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344
Excisional
biopsy for
H&E
H. B. Pasieka et al.
sum vs. bacterial infection. Histopathology may
occasionally make a denitive diagnosis, however, frequently the biopsy provides more information, but not a denitive diagnosis and
therefore, the wound care provider should also
draw from clinical and historical clues to solidify
the diagnosis.
4mm punch
biopsy for DIF
4mm punch
biopsy for
bacterial, fungal,
AFB cultures
Fig. 24.20 Representative specimen sites for H&E, tissue culture, and DIF analysis
acid-fast bacilli. Tissue cultures need to be sent to
the lab as soon as possible for processing, ideally
within an hour or two of procurement. Unlike tissue placed in formalin, tissue cultures cannot be
placed on a shelf and await transport the following day.
A peripheral specimen for DIF should be
obtained from a new specimen under 24 h old
when concern for vasculitis exists. This should be
submitted in Michel’s/Zeus transport media for
direct immunouorescence to ascertain the presence of autoimmune skin disease or vasculitis.
Michel’s/Zeus transport media is a hyperosmolar sucrose solution which will allow any
immune components in the sample to remain
bound. It is important not to expose the peripheral specimen to formalin at all, as formalin will
instantly destroy antibodies and subsequent DIF
will return a false negative result. This inaccurate
reading will also require a second biopsy and
more tissue.
If possible, it is best to have stains read by a
board-certied dermatopathologist. There is frequent overlap in the histopathological ndings of
atypical wounds: for example, a surface-level
reading of “neutrophilic invasion present” does
not resolve the question of pyoderma gangreno-
Further Management
Pyoderma Gangrenosum
If an atypical wound is suspected, the patient
should be counseled to:
• Check wound frequently.
• Avoid disturbing the wound by picking/popping lesion.
• Use non-stick dressings to avoid pathergy
with dressing changes.
• Return to clinic in the event of pathergy/
enlarging wound.
Atypical Mycobacterial Infection
Atypical mycobacterial infections are difcult to
treat and require partnership with infectious disease to determine targeted systemic antimicrobial
therapy. The duration of treatment necessary is
often several months.
Fungal Infection
When weighing fungal vs. autoimmune wound
etiologies, it is important to never combine steroids and antifungal medications as this runs the
risk of Tinea incognito, as discussed in the fungal
infections section above.
Our recommendation is to trial topical anti-
fungals rst before attempting topical immunomodulatory agents.
24 Limb Wounds ofDermatologic Disease: Dermatopathology, Biopsy, andMedical Management
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345
Contact Dermatitis
Remove offending allergen with continued avoidance and consider alternative wound care modalities. Document the allergen and patient reaction
in the electronic medical record.
Malignancy
Marjolin’s ulcer and SCC should be preferably
excised via wide local excision.
Multinodal SCC deemed unresectable may be
managed by PD-1 inhibitory therapy.
Calciphylaxis
After a diagnosis of calciphylaxis, management
extends beyond routine wound care considerations such as removal of triggers, maximizing
blood ow and nutrition, preventing infection,
and promoting healing:
• Remove triggers.
– Warfarin can be changed to apixaban.
– Sources of exogenous calcium should be
replaced with alternatives such as low
Ca2+ dialysate or non-calcium phosphate
binders like Sevelamer.
• Check protein C and S levels.
• Assess venous and arterial insufciency on
lower extremities.
• Maximize blood ow with pentoxifylline,
compression.
• Maximize nutrition with high protein diet.
• Utilize medications to prevent calcium depo-
sition such as IL and/or IV sodium thiosulfate,
cinacalcet.
• Prevent infection with silver impregnated
dressings.
• Optimize wound healing with advanced
wound dressings, HBO.
• Pain management: gabapentin, Cymbalta,
opioids.
Clinical Pearls
Diagnostic pearls
• Violaceous border in pyoderma gangrenosum
suggests an actively expanding lesion.
• Retiform purpura with pain out of proportion
suggests calciphylaxis.
• If an atypical wound is suspected, the wound care
provider should consider obtaining three
specimens:
– Main specimen from lesion >72h old, obtained
by elliptical wedge incision and submitted for
H&E analysis in formalin bottle.
– Tissue culture specimen submitted in sterile urine
cup/gauze and submitted for bacterial, fungal,
and acid-fast bacilli cultures.
– Peripheral specimen from lesion <24h old,
submitted for direct immunouorescence in
Michel’s/Zeus transport media.
Management pearls
• Counsel patient on wound care with low threshold
to return to clinic if concerned for pyoderma
gangrenosum.
• Neomycin is a common contact allergen, avoid if
possible.
• Do not combine antifungal and topical steroids due
to the risk of tinea incognito.
• Restore skin barrier function with topical
moisturizers containing ceramides.
• Domeboro compressions/soaks +40% urea as
astringent/antibacterial.
•Gentian violet as an antifungal agent.
Acknowledgment This chapter contains images that were
reproduced from the Michigan Medicine Department of
Pathology Virtual Slide Box Dermatopathology collection
(https://www.pathology.med.umich.edu/slides/search.php
?collection=DermPath&dxview=show) with permission
from the Regents of the University of Michigan.
Disclaimer The opinions and assertions expressed herein
are those of the author(s) and do not reect the ofcial
policy or position of the Uniformed Services University of
the Health Sciences or the Department of Defense.
Conicts of Interest None.
346
H. B. Pasieka et al.
References
1. Davis Mark DP, Moschella SL.Neutrophilic dermatoses. In: Bolognia JL, Schaffer JV, Cerroni L, editors.
Dermatology. 4th ed. Amsterdam: Elsevier Limited;
2018. p.453–471.e2.
2. Maverakis E, Ma C, Shinkai K, etal. Diagnostic criteria of ulcerative pyoderma Gangrenosum: a Delphi
consensus of international experts. JAMA Dermatol.
2018;154:461–6.
3. McClintock D.Slide 48552: Pyoderma gangrenosum.
In: University of Michigan Medicine Department
of Pathology Virtual Slide Box, Dermatopathology
Collection. https://www.pathology.med.umich.edu/
slides/oldlmstrip.php?loc=QXJwcyUyRkFycHMl
MjUyMHNsaWRlcyUyNTIwMzMwJTI1MjB0aHJ1
JTI1MjAzMzUlMkZIJTI2RV80ODU1Mm5sLnN2c
w==&myname=48552&stain=H%26E. Accessed 19
Dec 2021.
4. Tannenbaum R, Strunk A, Garg A.Overall and subgroup prevalence of pyoderma gangrenosum among
patients with hidradenitis suppurativa: a populationbased analysis in the United States. J Am Acad
Dermatol. 2019;80:1533–7.
5. McClintock D. Slide 63036: Bullous pemphigoid.
In: University of Michigan Medicine Department
of Pathology Virtual Slide Box, Dermatopathology
Collection. https://www.pathology.med.umich.edu/
slides/oldlmstrip.php?loc=RGVybVBhdGglMkZE
ZXJtUGF0aCUyNTIwQ29uZmVyZW5jZSUyRkF
uZGVhJTI1MjAyMDE2MDcyOSUyRkglMjZFXz
YzMDM2bmwuc3Zz&myname=63036&stain=H%
26E. Accessed 19 Dec 2021.
6. Bernard P, Borradori L. Pemphigoid group. In:
Bolognia JL, Schaffer JV, Cerroni L, editors.
Dermatology. 4th ed. Amsterdam: Elsevier Limited;
2018. p.510–526.e2.
7. Elman SA, Joyce C, Nyberg F, et al. Development
of classication criteria for discoid lupus erythematosus: results of a Delphi exercise. J Am Acad
Dermatol. 2017;77:261–7.
8. Aringer M, Costenbader K, Daikh D, et al. 2019
European league against rheumatism/American
College of Rheumatology classication criteria for
systemic lupus erythematosus. Arthritis Rheumatol.
2019;71:1400–12.
9. Maley AM, Arbiser JL.Gentian violet: a 19th century
drug re-emerges in the 21st century. Exp Dermatol.
2013;22(12):775–80. https://doi.org/10.1111/
exd.12257.
10. Hachem R, Reitzel R, Borne A, Jiang Y, Tinkey P,
Uthamanthil R, Chandra J, Ghannoum M, Raad
I. Novel antiseptic urinary catheters for prevention
of urinary tract infections: correlation of invivo and
in vitro test results. Antimicrob Agents Chemother.
2009;53:5145–9.
11. Ramos-e-Silva M, Ribeiro de Castro MC.
Mycobacterial infections. In: Bolognia JL, Schaffer
JV, Cerroni L, editors. Dermatology. 4th ed.
Amsterdam: Elsevier Limited; 2018. p.1296–318.
12. Rapini, R. P. Practical Dermatopathology, Third edition.; Elsevier: Philadelphia, PA, 2021.
13. Coerdt KM, Zolper EG, Starr AG, Fan KL, Attinger
CE, Evans KK. Cutaneous mucormycosis of the
lower extremity leading amputation in two diabetic
patients. Arch Plast Surg. 2021;48(2):231–6. https://
doi.org/10.5999/aps.2020.00549. Epub 2021 Mar 4.
PMID: 33657778; PMCID: PMC8007453.
14. Elewski BE, Hughey LC, Hunt KM, Hay RJ.Fungal
diseases. In: Bolognia JL, Schaffer JV, Cerroni L,
editors. Dermatology. 4th ed. Amsterdam: Elsevier
Limited; 2018. p.1329–63.
15. Sommer LL, Reboli AC, Heymann WR. Bacterial
diseases. In: Bolognia JL, Schaffer JV, Cerroni L,
editors. Dermatology. 4th ed. Amsterdam: Elsevier
Limited; 2018. p.1259–95.
16. Smart V, Alavi A, Coutts P, Fierheller M, Coelho
S, Linn Holness D, Sibbald RG. Contact allergens in persons with leg ulcers: a Canadian study
in contact sensitization. Int J Low Extrem Wounds.
2008;7:120–5.
17. DeKoven JG, Silverberg JI, Warshaw EM, etal. North
American contact dermatitis group patch test results:
2017-2018. Dermatitis. 2021;32:111–23.
18. DeKoven JG, Warshaw EM, Zug KA, et al. North
American contact dermatitis group patch test results:
2015-2016. Dermatitis. 2018;29:297–309.
19. Gehrig KA, Warshaw EM.Allergic contact dermatitis to topical antibiotics: epidemiology, responsible
allergens, and management. J Am Acad Dermatol.
2008;58:1–21.
20. McClintock D. Slide 51174: Invasive, well-differentiated squamous cell carcinoma. In: University of
Michigan Medicine Department of Pathology Virtual
Slide Box, Dermatopathology Collection. https://
www.pathology.med.umich.edu/slides/oldlmstrip.
php?loc=bmV3c2NhbnMlMkZIJTI2RV81MTE3N
G5sLnN2cw==,RGVybVBhdGglMkYyMDE1JTI
1MjBWU0IlMkZIJTI2RV81MjI5NW5sLnN2cw=
=&myname=51174,52295&stain=H%26E,H%26E.
Accessed 20 Dec 2021.
21. McClintock D. Slide 61317: Calciphylaxis. In:
University of Michigan Medicine Department of
Pathology Virtual Slide Box, Dermatopathology
Collection. https://www.pathology.med.umich.edu/
slides/oldfilmstrip.php?loc=RGVybVBhdGglMkZBbG9tYXJpLUd1dG1hcmslMjUyMENvbGxlY3Rpb24lMkZBbG9tYXJpX3JlcSUyNTIwMTM4N
l9KdW5lJTI1MjAyMDE2JTJGSCUyNkVfNjEzM
TdubC5zdnM=&myname=61317&stain=H%26E.
Accessed 5 Dec 2021.
22. Kroshinsky D, Fairley JA. Calcifying and ossifying
disorders of the skin. In: Bolognia JL, Schaffer JV,
Cerroni L, editors. Dermatology. 4th ed. Amsterdam:
Elsevier Limited; 2018. p.784–792.e1.
23. Wetter DA, Dutz JP, Shinkai K, Fox LP.Cutaneous
vasculitis. In: Bolognia JL, Schaffer JV, Cerroni L,
24 Limb Wounds ofDermatologic Disease: Dermatopathology, Biopsy, andMedical Management
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
347
editors. Dermatology. 4th ed. Amsterdam: Elsevier
Limited; 2018. p.409–439.e3.
24. Valerio Marzano A, Raimondo MG, Berti E, Meroni
PL, Ingegnoli F. Cutaneous manifestations of
ANCA-associated small vessels vasculitis. Clin Rev
Allergy Immunol. 2016;53(3):428–38. https://doi.
org/10.1007/s12016-017-8616-5.
25. McClintock D. Slide 91398: Polyarteritis nodosa.
In: University of Michigan Medicine Department
of Pathology Virtual Slide Box, Dermatopathology
Collection. https://www.pathology.med.umich.edu/
slides/oldfilmstrip.php?loc=SCUyNkVfOTEzOT
hubC5zdnM=&myname=91398&stain=H%26E.
Accessed 15 Dec 2021.
26. Alibaz-Oner F, Koster MJ, Crowson CS, Makol A,
Ytterberg SR, Salvarani C, Matteson EL, Warrington
KJ.Clinical spectrum of medium-sized vessel vasculitis. Arthritis Care Res (Hoboken). 2017;69:884–91.
27. Weinstein S, Piette W.Cutaneous manifestations of
antiphospholipid antibody syndrome. Hematol Oncol
Clin North Am. 2008;22:67–77.
Prosthetics, Orthotics,
andAmputation Rehabilitation
BenjaminG.Higgs
25
Collaboration withMedstar
The Medstar Georgetown University Hospital
(MGUH) Center for Wound Healing (CWH) collaborates with a variety of specialists to create a
comprehensive environment for patient care,
providing an avenue for patients with at-risk
limbs to meet with an extensive limb salvage
team. A prosthetist in clinic is one part of this
team that also includes podiatry, vascular, plastic, orthopedic, hyperbaric, and rheumatoid specialties. At each clinic visit, the patient has an
opportunity to consult with several team members in an effort to provide an inclusive plan to
optimize care. Since this is a specialized limb
salvage team, the patient can rest assured knowing that the route of amputation either provides
optimum function above what would be obtained
when saving the limb or will occur as the last
result after other treatment modalities are
explored. This chapter will focus on the prosthetic and orthotic intervention assisting with
limb preservation or providing care throughout
the amputation process when limb salvage is no
longer the most practical option.
B. G. Higgs (*)
Hanger Clinic, Washington, DC, USA
e-mail: bhiggs@hanger.com
Preventative Measures
Comorbidities and other detrimental health outcomes for patients with diabetes are well documented, including neuropathy, dysvascularity,
and an increased susceptibility of limb loss [1].
As of 2020, there are 34.2 million Americans,
nearly 1in 10, living with diabetes mellitus (DM)
[2]. Furthermore, an individual with diabetes is
28 times more likely to receive an amputation
than an individual without diabetes, and twothirds of the 2.1 million Americans living with
limb loss have diabetes [1–3].
In diabetes related lower extremity amputations, 85%, are preceded by foot ulcerations [1,
4]. Each year, ulcerations develop in 5% of dia-
betic patients, and 1% require amputation.
Importantly, the ulcerative recurrence rate is 66%
in this patient population and the likelihood of
amputation rises from 1% to 12% with these subsequent ulcers [5]. The 5-year survival rate of a
major amputation is 50% [6]. Mortality is double
among diabetic patients with ulcerations than
that among diabetic patients without [1, 7].
Considering the time required in treating ulcerations, there is a great societal cost due to loss of
productivity and lesser quality of life for these
patients and their families. Chronic wounds
impact 6.5 million patients at a cost of $25 billion
annually [5].
The majority of patients that require care
through the CWH is part of this neuropathic, dys-
© Springer Nature Switzerland AG 2023
C. E. Attinger, J. S. Steinberg (eds.), Functional Limb Salvage,
https://doi.org/10.1007/978-3-031-27725-2_25
349
350
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B. G. Higgs
vascular, diabetic patient population. Due to the
associated comorbidities and considering the
mortality rate, prevention is the utmost priority—
beginning with gait salvage. The challenge lies in
how to salvage gait and improve mobility. Many
of the above-mentioned complications are compounded when a patient is stagnant and immobile. Pressure ulcers are a localized injury to the
skin and/or underlying tissue as a result of pressure or pressure combined with shear or friction
forces. Skin integrity is weakened and deconditioned without frequent stresses, thus leaving a
non- ambulatory patient at higher risk for ulcerations. Coincidentally, an ulcerative compromised limb is also a limiting factor in the ability
to ambulate. It is proven that increased activity is
benecial in the treatment of the at-risk foot.
However, a sudden increase in loading the foot
might explain why a foot ulcer could develop,
unable to tolerate the additional stresses [8]. In
order to maintain skin integrity and optimize the
success of this patient population, pressure distribution combined with a slow re-introduction of
pressure and shear forces is imperative [9].
Mitigating the chance of ulceration formation
would have a cascade effect of reducing the
comorbidity amputation potential. A prosthetist
in clinic allows the provision of prompt care
when preventative measures are needed in treating contractures and deformations leading to
wounds. There are a number of orthotic modalities that can help accomplish this task [10, 11]:
Total Contact Cast (TCC): provided by technicians within the clinic. It has been identied that
ulcer healing is signicantly better when irremovable devices like the TCC are used [12]. It
mitigates noncompliance and is sufciently padded to ofoad wounds appropriately. However,
there are a number of circumstances where a
TCC is no longer appropriate, ideal, or preferred.
Access to monitor the limb is challenging.
Hygiene is problematic. Limited weight bearing,
mobility, and possibility of lesser quality of life
are factors to be considered.
Diabetic Healing Shoe (DH Shoes): Typically
intended for short-term use, DH shoes are
designed to distribute pressure across the plantar
surface of the foot. These lightweight shoes
accommodate mild contractures or deformations
of the foot that can create excessive pressure and
hot spots leading to skin breakdown and provides
ample space to accommodate soft dressings.
They lack any signicant composition to stabilize
to ankle and are a basic means of plantar pressure
distribution.
Diabetic Healing Boot (DH Boot): Also
designed to distribute pressure across the plantar
surface of the foot. The DH boot provides
increased integrity and leverage when compared
to the DH shoe. This taller design accommodates
or corrects contractures of both the foot and the
ankle, promotes enhanced ankle stability, and
further ofoads the plantar surface utilizing proximal compression of the shank.
Pressure Relief Ankle Foot Orthosis:
(PRAFO): Available as several designs both offthe-shelf (OTS) or custom fabricated versions.
The PRAFO family of ankle foot orthoses (AFO)
ideally maximize pressure distributions and
accommodate or correct mild to severe deformations or contractures while either in seated or
supine positions, or for ambulation.
Advancements in the ambulatory design include
an adjustable tibial shell which accommodates
edematous uctuations or soling cutouts for optimal forefoot or hindfoot ofoading. One such
robust design is also known as a Charcot Restraint
Orthotic Walker (CROW) due to the severe deformation associated with the Charcot joint and the
common need of this AFO design to help accommodate it. Total contact, depressions of the midfoot, and a rocker bottom soling help facilitate
movement while stabilizing the joint and mitigating plantar pressure that could otherwise cause
ulcerations or wounds.
Diabetic Shoes and Pedorthic Care: A key
modality in preventative measures. Off-the-shelf
(OTS) shoes, custom molded shoes, and custom
foot orthoses are all options designed to provide
long-term protection of the at-risk limb as a physical barrier to foreign objects and through reduction of pressure and friction. Shoes should have
few to no internal stitches, mitigating any contact
points that could breakdown the skin [13]. Wear
and tear or stretching of the shoe upper material
and gradual deterioration of soling along with
25 Prosthetics, Orthotics, andAmputation Rehabilitation
351
insole compression is expected as with any shoe
frequently used. Annual replacement is encouraged to replace degraded shoes and insoles in
order to maintain optimal foot protection.
With neuropathy, or a lack of sensation,
impact does not always register as pain and therefore indicate a problem. Trauma to the foot arises
from ill-tting footwear, undetected foreign
objects inside the shoes, and accidental injury
through impact. Poor vascularity can delay healing, allowing for infection to cultivate and propagate. Over half of ulcers with vascular origin are
infected on presentation [12, 14]. Infections precede about two-thirds of lower extremity amputations [15]. Appropriate education along with
donning/dofng procedures will help mitigate
these issues [16]. However, less than one-third of
those with appropriately tting footwear actually
use these items [17]. Diabetic foot disease is a
lifelong condition predisposing the patient to risk
of a new ulcer, amputation, or early death. A
holistic treatment approach is required for optimal prevention and wound management.
The primary objective of the integrated team
at Wound Center is mobility and functionality
obtained via gait salvage—typically accomplished with preventative measures in an effort to
preserve the limb. The prosthetist’s clinical presence opens the lines of communication and
enables discussion in mapping out current
orthotic treatments to aide in wound closure. Gait
salvage and limb salvage are not mutually exclusive. While limb salvage is typically an appropriate approach, in order to meet the primary
objective, gait salvage, early amputation, and setting realistic expectations might be a more viable
solution for an active patient [18].
Pre-amputation Consultation
cess, due to the undeniable physical and
psychological toll. Many patients experience limb
loss in the same fashion as the loss of a loved
one—progressing through the phases of grief, particularly lingering in depression [20–22].
Individuals with diabetes are at increased risk for
psychological distress due to a lack of psychological support and contending with comorbidities
prior to amputation [23]. There is limited research
on the psychological aspects for patients with diabetes, particularly for those also experiencing limb
loss [20]. While an ideal treatment modality would
include the addition of a psychiatrist to the interdisciplinary team [21], the ability for prosthetists,
peer supporter, and a specialized Amputee Care
Coordinator (ACC) to meet with patients in
advance provides patients with additional
resources to aide their recovery. See Fig.25.1 for
General Rehabilitation Timeline [24].
Prosthetist Consultation
Unlike patients with traumatic amputation, those
with diabetes and dysvascularity typically have
an opportunity to prepare for surgery and the
associated lifestyle changes. A pre-amputation
consultation with a prosthetist is the rst time a
patient discusses denitive next steps surrounding the prosthesis. While the discussions of this
encounter vary, it is common to share and set
realistic expectations, inclusive of both short- and
long-term recovery. This is also the initial opportunity for the patient to convey thoughts and concerns, to ask questions, and to discuss functional
design options with their prosthetist. An open
dialogue is important to bridge the gap between
potentially divergent patient desires and initial
prosthetists assessments.
Approximately two million people in the USA live
with limb loss and 185,000 amputations occur
yearly in the USA [3]. Amputation etiology
includes neuropathic and vascular 81.9%, trauma
16.4%, cancer 0.9%, and congenital 0.8% and is a
life changing event for a patient [19]. Each etiology presents challenges during the recovery pro-
Peer Support
An often overlooked, yet vital role in an amputee’s recovery is peer support. While prosthetists
work with amputees daily, most have not experienced the event of an amputation. Only a fellow
amputee can truly appreciate and understand the
352
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B. G. Higgs
Fig. 25.1 General rehabilitation timeline
journey and obstacles that lie ahead. This does
not negate the ability for a prosthetist to successfully provide clinical care; however, connecting
amputees to one another provides a valuable
resource that can be monumental in the outcomes
and success of a patient [20, 22].
Not surprisingly, given the implications of
ulceration treatment and its adverse effects on
mobility, coupled with the feelings of anger and
resentment [5], depression is 2x more likely in
patients with DM [25]. Pairing the patient with a
peer in a similar demographic can improve
morale and condence while aiding in the recovery and outcomes post-amputation. According to
Reichmann, 92% of amputees reported improved
outlook after meeting with their peer visitor. An
additional 50% requested an additional visit
while in rehabilitation. This was of particular
interest to bilateral amputees or amputees over
the age of 60years. Peer support yields positive
psychosocial value that contributes to positive
outcomes in a patient population already experiencing increased psychological distress [26].
Resources like the Amputee Coalition of
America’s Certied Peer Visitor (CPV) and
Hanger Clinic’s AMPOWER are two such mentorship programs that are currently available to
help amputees connect. Goals include fostering a
25 Prosthetics, Orthotics, andAmputation Rehabilitation
353
community of inclusion, education, and mentorship in an effort to support amputees and their
families throughout their recovery [27, 28].
Amputee Care Coordinator
A unique role implemented at the MGUH CWH to
further synergize the coordinated care is the ACC.
This position ensures continuity of patient care
from initial pre-amputation consultation through
receiving denitive prosthesis. Similar to a case
manager, the ACC tracks each patient in the CWH
documenting date of amputation. Based on date of
amputation, prosthetist and peer support are scheduled. Discharge plans are monitored and patient
status updates are relayed to the Wound Center for
continued coordinated care. Healthcare costs rise
as time to prosthetic delivery increases; therefore,
it is essential to keep patients engaged through
ambulation [29]. The follow-up provided by the
ACC means patients at MGUH CWH experience a
care pathway designed to improve outcomes, similar to other case manager platforms [30].
Traumatic Amputee
Much of the focus on amputee care in this chapter
surrounds patients with diabetes and dysvascularity. The ability to initiate a care plan in advance of
the amputation is always preferred. However, due
to the inherent nature of traumatic amputations,
this patient population unfortunately lacks the
ability to have the pre- amputation consultation in
its entirety as outlined above. Nevertheless, the
traumatic amputee requires these resources and
benets from the same level of prosthetist, peer
support, and ACC meetings. When a pre-amputation consultation is not an option, post-amputation
peer support is proven along with the support of
family, friends, and the workplace organization to
play an integral role in developing condence and
motivation in these patients [22]. Fortunately for
traumatic amputees, despite the inability to plan
and prepare for amputation, they are often more
successful with their prosthetic recovery when
compared to their diabetic counterparts [31].
Immediate Post-operative
Prosthetic Care
Recovery begins immediately post-surgery. The
body initiates its regeneration process upon surgical trauma. The surgical team provides general
medical and wound care dressings to tend to the
sutures and the edematous limb. There are four
common approaches in caring for a patient immediately following amputation: soft dressings,
rigid dressings, immediate post-operative prosthesis (IPOP), and removable rigid dressings
(RRD). The objectives in utilizing these modalities include mitigating pain and contractures,
limb protection, and controlling edema to optimize limb volume and shape in preparation for
prosthesis usage [11, 32].
Soft Dressings: Inclusive of wound dressings,
ACE wrap, Tubigrip, or shrinkers. Soft dressings
are cost-effective and readily available peri- and
post-surgery and are an appropriate means to
control edema. Care must be taken to ensure
sutures are protected from friction during donning and dofng. ACE bandages require methodical donning to ensure appropriate pressure
gradient and to mitigate excessive proximal compression which could create a tourniquet effect,
resulting in a bulbous limb shape, thereby negating the intended purpose of the dressing.
Rigid Dressings: Proven over the past several
decades to be the optimal clinical approach for
post-operative care. Rigid dressings provide a
level of compression needed to continue to shape
the limb and reduce volume. The rigid design
prevents the knee from exing, protects the
sutures from post-surgical strain, and prevents
contracture formation while also providing a
high level of protection against falls. Fall prevalence is high post-operatively with injuries resulting in extended hospital stays or revision surgeries
[33]. Rigid dressings demonstrated signicantly
decreased healing time for transtibial amputation
to initial casting for a prosthesis when compared
to soft dressing [34–36]. Additionally, the use of
removal rigid dressings (RRD) is shown to reduce
acute care length of stay [35]. Reduced healing
time and shorter time spent in acute care both
benet the amputee patient and potential pros-
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B. G. Higgs
thetic intervention. While utilization of RRDs did
not reduce fall incidents, RRDs did reduce number and prevalence of injuries [37].
IPOP: A rigid dressing that is tted with a
prosthetic pylon and foot, suspended with a belt
strap. IPOPs provide patients with a visual reference to assist in overcoming the psychological
aspect of amputation. It also permits the patient
to initiate weight bearing. However, care must be
taken to ensure maintaining suture protection
while developing skin tolerance. It can be difcult for patients to grasp toe-touch or light pressure, compared to full body weight. Although
indicated for a traumatic amputee, IPOP is contraindicated for patients with at-risk dysvascular
limbs due to poor blood ow and increased susceptibility of further skin breakdown. Utilizing
an IPOP allows for low level function while healing from time of amputation, through wound closure and suture removal. Upon removal of the
sutures, the patient’s skin is typically no longer a
limiting factor in providing a prosthesis.
RRD: Offer the same features and outcomes
of the rigid dressing with the signicant added
benet of being readily removable. Standard
rigid dressings require the use of a cast saw for
removal, which typically occurs every few days.
In comparison, RRDs enable a caregiver to readily remove the dressing, provide the opportunity
to monitor the skin, and change soft dressings
easily or address other issues with limb recovery
on a more frequent basis. According to a metaanalysis by Churilov, the RRD reduces the number of days it takes to t the rst prosthesis [36].
The RRD should be the new standard of care,
combining the ability for frequent limb observation and protection to optimize recovery while
expediting the time to initial ambulation.
Preparatory Prosthesis
A new amputee will undergo a multitude of
changes during limb healing and maturation.
Most notably, volume and shape are impacted.
Regardless of cause, an amputation is a traumatic
event to the body, with common side effects such
as edema, redness, inammation, and uid retention. As outlined earlier, post-operative dressings
are designed to assist the recovery by controlling
edema and optimizing limb shape in preparation
for a prosthesis. An IPOP might be initiated,
while sutures remain and the wound is closing in
an effort to begin weight bearing. Upon closure
of the wound and suture removal, a preparatory
prosthesis may be provided for total weight bearing. A preparatory prothesis is different than an
IPOP in its material, suspension method, and
when it is provided. The preparatory prosthesis is
fabricated out of a durable polymer or carbon
ber and utilizes a gel liner with a pin or suspension sleeve rather than a waist belt. It is provided
promptly after wound closure and suture removal
rather than immediately post-operatively. The
preparatory prosthesis is nearly identical to a
denitive prosthesis; however, it is designed and
fabricated with the understanding the limb will
undergo signicant changes in the early months
and patient functionality is likely to change.
The rst several months post-surgery are crucial to a patient’s success [29, 38]. The provision
of a preparatory prosthesis provides an avenue
for the limb to mature. Perhaps more importantly,
the preparatory prosthesis grants time for a
patient to intrinsically evaluate themselves and
re-evaluate their initial wants and needs. With an
entry level prosthetic design, the patient will have
a better sense of what they can and cannot accomplish while using this prosthesis and more accurately validate their Medicare dened K-Level
(Table 25.1) [39]. Often starting with, but not
restrictive to, K2 components, the majority of
basic activities of daily living can be practiced. It
allows physical therapy and gait training to
broaden beyond pre-prosthetic training. While
not typically providing the highest levels of functionality, the preparatory prosthesis enables early
ambulation, serving as a diagnostic tool. If a
patient cannot accomplish a more complex goal
such as climbing stairs or running, the prosthetist
will evaluate if the prosthesis is a limiting factor
or work in collaboration with the patient care
team to determine if there are other physiological
or psychological considerations to be addressed.
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