Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_921_Библиотеки_им_академика_М_И_Перельмана
.pdf
Section 1: General Topics
Figure 1
ter an open transtibial amputation. A negativepressure dressing covers the wound.
Photograph of a re sidual limb af-
the incision, but they do not provide
a substantial degree of wound protec-
1,2
tion.
Soft dressings are ubiquitous in
their use and inexpensive. Wrapping
gauze rolls over the end of the residual
limb frequently requires some expertise to ensure even distribution. Major
disadvantages of soft dressings are that
they tend to loosen and require reapplication as frequently as every 3 to 4
hours. These dressings may provide
padding when a compressive sleeve or
rigid dressing is required.
Petroleum-impregnated gauze is frequently applied to the incision site at
the conclusion of the surgical procedure, and it is then covered with regular gauze. Some form of wrap (often
a gauze roll or elastic wrap) is then applied. Many surgeons use these dressings instead of rigid dressings because
they prefer to view the incision site on a
daily basis, although it has been shown
that this is often unnecessary.
3
In 1980, Kane and Pollak4 reported
no statistical difference in narcotic
use among patients with amputations
Figure 2
after an open transfemoral amputation. A
negative- pressure wound dressing was applied
at the end of the rst-stage surgery.
Photograph of a residual limb
resulting from vascular causes who were
treated with soft dressings or those who
were fitted with an immediate postoperative prosthesis (IPOP). However, the
analgesic protocols at that time were
different from those in current use.
Nonetheless, wound necrosis developed
in 21% of the patients treated with the
IPOP, and infection occurred in another
21% of those patients. In the patients
treated with soft dressings, wound necrosis developed in 17% and infection
occurred in 33%, which was not statistically different from those treated with
rigid dressings. The authors noted that
56% of the patients managed with the
IPOP became prosthesis users compared
with 22% of the patients managed with
soft dressings. There were no reported
important beneficial or harmful effects
of the IPOP on early healing outcomes
after amputation.
Negative-Pressure
Wound Dressings
Negative-pressure wound dressings
(also known as vacuum-assisted closure
dressings) are becoming more widely
used and are commonly applied in
orthopaedic surgery for open wounds
associated with fractures, after wound
débridements, and before skin closure,
as well as for contaminated and infected wounds when closure is contraindicated (Figures 1 and 2). These devices
use open-pore foam to fill the wound
cavity, an occlusive wound dressing,
suction tubing, and a suction device.
A wound-healing mechanism of action
of negative-pressure wound dressings
is the bringing together of the wound
edges by the suction distributed through
the foam sponge.
5,6
Another healing
mechanism of action, which has been
determined by finite element computer
analysis, is the 5% to 20% strain that
negative-pressure wound dressings produce across the healing tissues. This
strain promotes cell division and proliferation, growth factor production, and
angiogenesis.6 Other reported benefits
of negative-pressure wound dressings
are removal of edematous fluid and exudate from the extracellular space and
removal of inflammatory mediators and
cytokines, whose prolonged effect can
hinder the ability of the microcirculation
to support damaged tissue. Another positive factor in wound healing is reduction of wound desiccation and enhanced
formation of granulation tissue. There
is convincing evidence to support the
hypothesis that the reduction of lateral
tension and hematoma, coupled with an
acceleration of the elimination of tissue
edema, are the main beneficial mechanisms of action of negative-pressure
wound therapy over the incision site.
7
Over the past several years, there
has been an increased frequency in
managing residual limb wounds with
negative-pressure dressings applied over
the incision site at the conclusion of surgery (Figures 3 and 4). Applying these
dressings to closed incisions reduces
the relative risk of infection.8 A randomized controlled trial demonstrated
a decrease in postoperative seromas after
the application of incisional negativepressure wound dressings after total hip
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
32
Chapter 3: General Principles of Postoperative Residual Limb Management
arthroplasty.
9
A study by Hansen et al10
confirmed that negative-pressure dressings reduced or eliminated incisional
drainage after hip arthroplasty, and no
adverse effects were reported. Negative
pressure set between 50 and 125 mm
Hg helps to reduce edema and decrease
incisional drainage.6 Negative-pressure
incisional dressings are kept in place
for 3 days and may be reapplied or discarded. If no additional fluid collects
in the canister over a 12-hour period,
it is recommended that the dressing be
discontinued. However, it is likely that,
because of the decreased wound edge
tension created by the negative-pressure
dressing, there is often no measurable
fluid accumulation in the collection
reservoir. Recent studies have noted
that the benefits of negative-pressure
dressings may be associated with edema reduction, increased blood flow,
and increased granulation tissue in the
wound.
6,7
After 3 to 5 days of postoperative negative-pressure wound therapy,
healing time may be reduced, and there
is evidence of a reduced incidence of
wound healing complications and a reduced frequency of infections.7 Karlakki
et al7 reported the existence of good evidence for incisional negative-pressure
wound therapy in orthopaedic surgery
because of the frequency of patient comorbidities and the substantial incidence of infection. Brem et al11 reported
that incisional negative-pressure wound
therapy may reduce the risk of delayed
wound healing and infection after severe
trauma and orthopaedic interventions.
In some instances, a rigid dressing may
be placed over the negative-pressure
wound dressing on the residual limb
for added protection.
12
Negative-pressure wound dressings
also can be used over open wounds before definitive skin closure in situations
such as traumatic amputations and in
the presence of infection when a two- or
three-stage amputation is planned.13 For
open wounds, a new negative-pressure
dressing is applied at the second-stage
Figure 3
after a transtibial amputation. An incisional
negative-pressure dressing was applied immediately postoperatively.
Photograph of a residual limb
surgery. Two studies reported good results with the application of a custom,
topical negative-pressure dressing for
open amputations.
14,15
Hydrofiber Dressings
Hydrofiber wound dressings consist of
soft nonwoven sodium carboxymethylcellulose fibers integrated with ionic
silver. This is a moisture-retention dressing, which forms a gel on contact with
wound fluid and has the antimicrobial
properties of ionic silver.
1,16
After the use of a negative-pressure
dressing, a hydrofiber with silver dressing may be applied over the incision
(Figure 5). This dressing can remain
in place for up to 7 days and may cover
sutures. Because the dressing is impervious to water, patients may shower with
the dressing in place. There has been
renewed interest and research in using
ionic silver (the oxidized active state of
silver) as a prophylactic antimicrobial
agent in wound dressings because of its
broad-spectrum antibacterial range.16
The gel promotes a moist woundhealing environment but absorbs any
wound exudate and contains it away
from the wound. Because of the antimicrobial effect of silver, this dressing
has the potential to reduce postoperative
infections.1 Cutting et al17 reported that
Figure 4
after a transfemoral amputation. An incisional
negative-pressure wound dressing was appli ed
at wound closure.
Photograph of a residual limb
the silver in the hydrofiber dressing provides a certain amount of resistance to
infection. In a randomized study of acute
surgical wounds in 100 patients, the
performance of hydrofiber and alginate
dressings was compared.18 Ninety-two
percent of patients randomized to the
hydrofiber dressing were found to experience less pain (mild or none) compared with 80% of those who received
alginate dressings. Similarly, 84% of
patients who had hydrofiber dressings
were pain free at 1 week postoperatively compared with 58% of those treated
with alginate dressings. Although statistical significance was not shown,
the authors concluded that hydrofiber
dressings consistently performed better
than the alginate dressings.
Compressive Dressings
Compressive dressings consist of elastic
and conforming dressings. The original compressive dressing was an elastic
bandage or sleeve. Newer materials have
been developed to apply more uniform
pressure over the residual limb. These
dressings apply a measure of compression to the limb and help control
postoperative edema.
sic compression dressing is the elastic
wrap, which should be applied in a figure-of-8 configuration, with the most
pressure applied distally to proximally
19,20
The most ba-
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
33
Section 1: General Topics
Figure 5
(A) and the incision site 10 days after surgery (B).
Photographs of a hydrober dressing in place over a transtibial amputation incision
(Figure 6). Applying uniform pressure
is difficult with this method, so the
wraps have to be reapplied every 4 to
6 hours. Volume reduction takes more
time in the first 2 weeks after surgery
with elastic compression dressings
compared with rigid dressings and is
not as effective.
21,22
Another form of
elastic dressing is an elastic shrinker
or sock, which has built-in elasticity
and is rolled onto the limb23 (Figure
7). The socks are available in various
sizes and materials, are provided by a
prosthetist, and may be kept in place
throughout the day and night for as long
as required. They are helpful at night
to reduce edema when a prosthesis has
been fitted and is doffed after daily use.
In shorter residual limbs, a suspension
belt may be required to hold the shrinker sock in place.
Compression devices to help reduce
edema include polymer gel socks and
thermoplastic and silicone liners
24,25
(Figures 8 and 9). These devices are
rolled onto the limb and stay in place
because of their compressive force and
associated evenly distributed shear friction. They are more effective in edema
reduction than elastic bandages. The
liners also are used within the prosthetic
socket and may provide suspension assistance in addition to padding.
A technique that is now rarely used
after amputations is the Unna paste
dressing, a mixture of zinc oxide, calamine, gelatin, and glycerin that is applied over successive layers of residual
limb bandages that have been applied in
a figure-of-8 configuration.
26,27
After 24
hours, a semirigid, inextensible dressing is formed that prevents edema. The
dressing may be used for any level of
amputation. This type of dressing was
previously used primarily by physical
therapists and physical medicine and rehabilitation physicians, but it has fallen
out of favor because of newer materials
and techniques.
Protective Dressings
Protective dressings include rigid and
semirigid dressings and pneumatic
postamputation mobility (PPAM) aids.
These dressings are designed to protect
the residual limb in the immediate postoperative period and are used only for
a limited time until edema of the residual limb has decreased and provisional
wound healing has occurred.
Figure 6
wrapped with a gure-of-8 elastic compressive
bandage after a transtibial amputation.
Figure 7
elastic sock rolled over a residual limb after a
transtibial amputation.
Photograph of a residual limb
Photograph showing a tubular
Rigid Dressings
Rigid dressings are recommended for
transtibial and more distal amputations
in the lower limb and for transradial and
more distal amputations in the upper
limb. Rigid dressings are kept in place
for 5 to 7 days by a suspension strap28
(Figure 10). A rigid dressing is applied
in the operating room by the surgeon or
prosthetist, with appropriate padding
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
34
Chapter 3: General Principles of Postoperative Residual Limb Management
Figure 8
and a tubular liner for a transtibial amputation (B).
Photographs of a thermoplastic liner in place over a transfemoral amputation (A)
over the bony prominences. The rigid
dressing is removed after 5 to 7 days,
and may be replaced if required. At
the time of removal, the wound can be
evaluated. In a review of the published
literature, Smith et al2 reported that
several studies demonstrated that patients treated with plaster cast dressings
had substantially quicker rehabilitation
times and less edema compared with
those treated with soft gauze dressings.
The authors also noted that patients
treated with prefabricated prostheses
had substantially fewer postoperative
complications and required fewer revisions to a higher level compared with
those treated with soft gauze dressings.
A retrospective study by Sumpio et al28
noted that transtibial amputations managed with a rigid dressing as opposed to
a soft dressing had significantly quicker
healing times (P = 0.02) as measured
by the time needed before prosthesis
casting. Of 151 patients analyzed, 60
were treated with soft dressings and
91 with rigid dressings. Patients with a
soft dressing had a statistically increased
prevalence of diabetes mellitus, hypertension, and chronic renal failure compared with the rigid dressing group. The
two groups did not show any significant
differences with regard to complications
caused by infection or cellulitis. Patients
with rigid dressings healed in a median
time of 76 days compared with 127 days
for the group treated with soft-dressings.
Fifty percent of patients treated with a
rigid dressing had an initial casting for
a prosthesis within 43 days compared
with 75 days for those receiving a soft
dressing.
A 2005 study reported an improvement in the time to delivery of the prosthesis when a rigid dressing was used.19
In comparison to the elastic bandaging
method, the use of a rigid dressing resulted in a statistically significant shorter
period from amputation to the delivery
of the first regular prosthesis (110 days
versus 50 days, respectively) and a decreased risk of knee flexion contracture.
Other studies have confirmed that rigid
dressings are preferable to soft dressings
for managing patients with transtibial
amputation and result in substantially
shorter times from amputation to casting or fitting of a prosthesis.
20,2 9,30
Vigier et al31 noted that rigid dressings helped promote healing in open
wounds of residual limbs associated
with transtibial amputations for vascular disease, as well as leading to shorter
Figure 9
silicone liner with rings for vacuum suspension.
Figure 10
with an outer covering of berglass on a residual limb after a transtibial amputation. The
device for the suspension strap is seen at the
anterior brim.
Photograph of a transfemoral
Photograph of a rigid dressing
hospital stays. In 2010, Johannesson
et al25 evaluated outcomes using rigid
dressings and silicone compression liners in a standardized surgical and rehabilitation program for 217 individuals
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
35
Section 1: General Topics
who had undergone transtibial amputation for peripheral vascular disease.
The authors reported a reduction in
morbidity in patients treated by a dedicated team using a protocol requiring
a rigid dressing for 5 to 7 days postoperatively and subsequent incremental
applications of a silicone liner to apply
residual limb compression. Prosthetic
fitting was achieved in 119 of the patients (55%), and 76 of those patients
(64%) achieved good function. Of the
217 patients in the study, 51% had
diabetes, more than 75% could walk
before amputation, and approximately 50% were living in an elderly care
nursing home. The reamputation rate
(amputation to a higher level) during
the first year was 8.2%.
The use of rigid dressings may be
limited by application difficulties and
gaining access to the incision. In a 2008
study, Johannesson et al32 compared the
use of a removable vacuum-formed rigid
dressing and a conventional rigid plaster
of Paris dressing in 27 patients treated
with transtibial amputation. The authors
found that a vacuum-formed removable
rigid dressing appears to achieve results
similar to those of a conventional rigid
dressing regarding time to prosthetic
fitting and a patient’s function with a
prosthesis.
Removable Rigid Dressings
Removable rigid dressings are most
frequently used after transtibial amputations and are easy to apply and use
(Fig ure 11). A removable rigid dressing
is a transtibial cast that is suspended
using an outer layer of stockinette and
held by a supracondylar femoral cuff.
This technique is an effective method
for postoperative, preprosthetic, and
prosthetic care of transtibial amputees.33
Removal rigid dressings allow additional
shrinker socks to be applied as edema
in the residual limb decreases.34 The removal rigid dressing is used for 2 to 3
weeks in preparation for fitting with a
preparatory prosthesis.
Figure 11
applying a supracondylar femoral suspension
strap over an outer stockinette.
Photographs of an individual
A 2005 randomized controlled study
of 50 dysvascular transtibial amputees
reported that primary wound healing
of the residual limb occurred approximately 2 weeks earlier in patients
treated with a removable rigid dressing compared with those treated with a
standard soft dressing.35 Both dressing
types were applied immediately postoperatively and were only removed for
wound dressing changes. There were no
significant differences in the two groups
in time to prosthetic fitting, length of
hospital stay, incidence of residual limb
breakdown, and time needed for volume
stabilization of the residual limb. The
authors proposed that removable rigid
dressings protect the new residual limb
from trauma while permitting regular
wound access, care, and assessment.
Although upper limb amputations
are less frequent than those for the
lower limb, removable rigid dressings
have a place in the management of these
patients. The principles of wound care
are the same, and timely healing is a
major goal.
IPOP Fitting
IPOP use has been recommended for
mobilizing patients immediately after
amputation surgery. A rigid dressing
is applied after an incisional dressing has been placed. Adequate padding over bony prominences (such
as the fibular head, tibial crest, and
Figure 12
postoperative prosthesis made using a plaster
cast and prosthetic foot.
Photograph of an immediate
patella) is essential, and a pylon and foot
are incorporated below the cast30 (Fig-
ure 12). A prosthetist should ensure
correct alignment of the IPOP, and patient mobilization should be supervised
by a therapist. Initially, partial weight
bearing is permitted for a few minutes
at a time, with a gradual increase as the
patient is able to cooperate and regain
strength. Cast changes are necessary
when edema has decreased and there
is a volume discrepancy between the
residual limb and the cast. For patients
to be considered for an IPOP fitting,
certain requirements should be met,
including preoperative ambulatory status, no evidence of active infection, good
motivation, willingness to comply with
the required postoperative protocol, and
good healing potential.30 Incision breakdown with the IPOP fitting technique
has been noted, and its use has become
less popular. One study reported that
skin breakdown was higher in the IPOP
group of patients than in the non-IPOP
group, but the need for revision surgery
was lower.30 The current practice is to
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
36
Chapter 3: General Principles of Postoperative Residual Limb Management
ensure wound healing in a 2- to 4-week
timeframe and then begin prosthetic fitting and supervised therapy.
Postoperative Pneumatic Systems
The initial popularity and enthusiasm of pneumatic systems seen in the
1980s has substantially declined, and
there have been no scientific articles
published in the past 10 years regarding their routine use. Pneumatic sleeves
are not used in the United States but still
see sporadic use in the United Kingdom,
Europe, and Australia.
In the early 2000s, a pneumatic IPOP
system was advocated for the mobilization of lower limb amputees. This
prefabricated pneumatic system was
applied in the operating room at the
time of wound closure.35 The average
time to custom prosthetic limb fitting
was 8.1 weeks (range, 4 to 16 weeks).
Another study reported on a removable,
adjustable, prefabricated IPOP with
pneumatic air bladders inflated to 20 to
30 mm Hg.36 In a study by Schon et al,37
19 patients managed with an IPOP were
compared with a retrospective matched
control group of 23 patients managed
with soft dressings. Eleven patients in
the soft dressing group required revision procedures, whereas no patients in
the IPOP group required surgical revision. The pneumatic systems were used
until the wound was healed; a custom
prosthesis was then applied at an average of approximately 3 months after
the amputation surgery. For a variety
of reasons, 11 patients were able to use
the temporary device for only 14 days or
less; however, this was not considered a
failure of the technique.
Although the PPAM aid is not used in
the United States, the device is used in
select Scottish, Scandinavian, and Australian settings.38 The PPAM aid helps
to reduce residual limb edema; allows
reeducation of postural reactions, balance, and gait; and prepares the residual
limb for a standard prosthetic socket. It
can be placed over a soft dressing, an
elastic wrapping, or a plaster cast. It is
initially used for a very limited amount
of time on a daily basis and under the
supervision of a therapist. The PPAM aid
is designed for partial weight bearing.
With progress, use of the PPAM aid is
increased over time to achieve longer
weight bearing periods in the early
postoperative period. The PPAM aid is
suitable for individuals with knee disarticulations and transtibial and long
transfemoral amputations. A disadvantage of the PPAM aid is that it does not
allow a transtibial amputee to flex or
extend the knee during walking.38 An
alternative device was developed that
allows for knee flexion; however, no
functional differences between the two
devices was noted.
38
Pneumatic devices were purported to
be superior to rigid cast IPOP because
they are lighter in weight, allow for better compression control, and permit easy
removal for incision inspection.2 Despite
these early claims, they are infrequently
used and have been superseded by modern postoperative amputation dressings.
Summary
Because soft dressings for amputation
wounds do not provide adequate protection, the use of dressings that are more
compressive and protective is generally recommended. With the advent of
improved materials and techniques,
rigid and removable rigid dressings are
considered superior for the immediate postoperative care of patients with
transtibial and transradial amputations.
Negative-pressure wound therapy is
valuable for the first few days after surgery and is followed by an appropriate
alternative dressing. Modern dressings
reduce edema, enhance wound healing,
and facilitate early mobilization. This allows for accelerated, definitive prosthetic
fitting and initiation of gait training. In
individuals with an upper limb amputation, postoperative residual limb management is vital to early prosthetic fitting
and subsequent daily use of a prosthesis.
In the United States, current postoperative residual limb management after
amputation involves the use of modern
treatment techniques, removable rigid
devices, systems for edema control and
wound protection, and no or protected
weight bearing until incision and wound
healing are achieved.
References
1. Sood A, Granick MS, Tomaselli NL:
Wound dressings and comparative
eectiveness data. Adv Wound Care
(New Rochelle) 2014;3(8):511-529.
Medline DOI
2. Smith DG, McFarland LV, Sangeorzan BJ, Reiber GE, Czerniecki JM:
Postoperative dressing and management strategies for transtibial amputations: A critical review. J Rehabil
Res Dev 2003;40(3):213-224. Medline
3. Barnes R, Souroullas P, Chetter IC: A
survey of perioperative management
of major lower limb amputations:
Current UK practice. Ann Vasc Surg
2014;28(7):1737-1743. Medline DOI
4. Kane TJ III, Pollak EW: e rigid
versus so postoperative dressing
controversy: A controlled study in
vascular below-knee amputees. Am
Surg 1980;46(4):244-247. Medline
5. Putnis S, Khan WS, Wong JM:
Negative pressure wound therapy:
A review of its uses in orthopaedic
trauma. Open Orthop J 2014;8:142-
147. Medline DOI
6. Huang C, Leavitt T, Bayer LR, Orgill
DP: Eect of negative pressure
wound therapy on wound healing.
Curr Probl Surg 2014 ;51(7):301-331.
Medline DOI
7. Karlakki S, Brem M, Giannini S,
Khanduja V, Stannard J, Martin R:
Negative pressure wound therapy for
management of the surgical incision
in orthopaedic surgery: A review
of evidence and mechanisms for an
emerging indication. Bone Joint Res
2013;2(12):276-284. Medline DOI
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
37
Section 1: General Topics
8. Stannard JP, Gabriel A, Lehner B: Use
of negative pressure wound therapy
over clean, closed surgical incisions.
Int Wound J 2012;9(suppl 1):32-39.
Medline DOI
9. Stannard JP, Volgas DA, McGwin G
III, et al: Incisional negative pressure
wound therapy aer high-risk lower
extremity fractures. J Orthop Trauma
2012;26(1):37-42. Medline DOI
10. Hansen E, Durinka JB, Costanzo
JA, Austin MS, Deirmengian GK:
Negative pressure wound therapy
is associated with resolution of
incisional drainage in most wounds
aer hip arthroplasty. Clin Orthop
Relat Res 2013;471(10):3230-3236.
Medline DOI
11. Brem MH, Bail HJ, Biber R: Value of
incisional negative pressure wound
therapy in orthopaedic surgery.
Int Wound J 2014;11(suppl 1):3 -5.
Medline DOI
12. Sumpio BJ, Cordova1 AD, Mahler D,
Sumpio BE: Use of negative pressure
wound therapy in healing below
knee amputation in patients with
chronic venous insuciency and/or
Charcot disease. Angiol Open Access
2013;1(2):1-3.
13. Stannard JP, Volgas DA, Stewart
R, McGwin G Jr, Alonso JE: Negative pressure wound therapy aer
severe open fractures: A prospective
randomized study. J Orthop Trauma
2009;23(8):552-557. Medline DOI
14. Guyver PM, Mountain AJ, Jeery SL:
Application of topical negative pressure for traumatic amputations. Ann
R Coll Surg Engl 2013;95(3):226-227.
Medline DOI
15. Penn-Barwell JG, Fries CA, Street
L, Jeery S: Use of topical negative
pressure in British servicemen with
combat wounds. Eplasty 2011;11:e35.
Medline
16. Barnea Y, Weiss J, Gur E: A review
of the applications of the hydrober
dressing with silver (Aquacel Ag) in
wound care. er Clin Risk Manag
2010;6:21-27. Medline
17. Cutting K, White R, Hoekstra H:
Topical silver-impregnated dressings and the importance of the
dressing technology. Int Wound
J 2009;6(5):396-402. Medline DOI
18. Foster L, Moore P, Clark S: A
comparison of hydrobre and
alginate dressings on open acute
surgical wounds. J Wound Care
2000;9(9):442-445. Medline
19. van Velzen AD, Nederhand MJ,
Emmelot CH, Ijzerman MJ: Early
treatment of trans-tibial amputees: Retrospective analysis of
early tting and elastic bandaging.
Prosthet Orthot Int 2005;29(1):3-12.
Medline DOI
20. Alsancak S, Köse SK, Altınkaynak
H: Eect of elastic bandaging and
prosthesis on the decrease in stump
volume. Acta Orthop Traumatol Turc
2011; 45(1):14-22. Medline DOI
21. Punziano A, Martelli S, Sotgiu V,
et al: e eectiveness of the elastic
bandage in reducing residual limb
volume in patients with lower limb
amputation: Literature review [Italian]. Assist Inferm Ric 2011;30(4):208-
214. Medline
22. Nawijn SE, van der Linde H,
Emmelot CH, Hofstad CJ: Stump
management aer trans-tibial
amputation: A systematic review.
Prosthet Orthot Int 2005;29(1):13-26.
Medline DOI
23. Manella KJ: Comparing the eectiveness of elastic bandages and shrinker
socks for lower extremity amputees.
Phys er 1981;61(3):334-337. Medline
24. Graf M, Freijah N: Early trans-tibial oedema control using polymer
gel socks. Prosthet Orthot Int
2003;27(3):221-226. Medline DOI
25. Johannesson A, Larsson GU, Ramstrand N, Lauge-Pedersen H, Wagner
P, Atroshi I: Outcomes of a standardized surgical and rehabilitation
program in transtibial amputation
for peripheral vascular disease: A
prospective cohort study. Am J Phys
Med Rehabil 2010;89(4):293-303.
Medline DOI
26. MacLean N, Fick GH: e eect
of semirigid dressings on below-knee amputations. Phys er
1994 ;74(7):668-673. Medline
27. Wong CK, Edelstein JE: Unna and
elastic postoperative dressings: Comparison of their eects on function of
adults with amputation and vascular disease. Arch Phys Med Rehabil
20 00;81(9):1191-1198. Medline DOI
28. Sumpio B, Shine SR, Mahler D, Sumpio BE: A comparison of immediate
postoperative rigid and so dressings for below-knee amputations.
Ann Vasc Surg 2013;27(6):7 74-780.
Medline DOI
29. Churilov I, Churilov L, Murphy
D: Do rigid dressings reduce the
time from amputation to prosthetic tting? A systematic review
and meta-analysis. Ann Vasc Surg
2014;28(7):1801-1808. Medline DOI
30. Ali MM, Loretz L, Shea A, et al: A
contemporary comparative analysis
of immediate postoperative prosthesis placement following below-knee
amputation. Ann Vasc Surg
2013;27(8):1146-1153. Medline DOI
31. Vigier S, Casillas JM, Dulieu V,
Rouhier-Marcer I, D’Athis P,
Didier JP: Healing of open stump
wounds aer vascular below-knee
amputation: Plaster cast socket
with silicone sleeve versus elastic compression. Arch Phys Med
Rehabil 1999;80(10):1327-1330.
Medline DOI
32. Johannesson A, Larsson GU, Öberg
T, Atroshi I: Comparison of vacuum-formed removable rigid dressing
with conventional rigid dressing aer
transtibial amputation: Similar outcome in a randomized controlled trial involving 27 patients. Acta Orthop
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
38
Chapter 3: General Principles of Postoperative Residual Limb Management
33. Taylor L, Cavenett S, Stepien JM,
Crotty M: Removable rigid dressings:
A retrospective case-note audit to
determine the validity of post-amputation application. Prosthet Orthot Int
2008;32(2):223-230. Medline DOI
34. Wu Y, Keagy RD, Krick HJ, Stratigos
JS, Betts HB: An innovative removable rigid dressing technique for
below-the-knee amputation. J Bone
Joint Surg Am 1979;61(5):724-729.
Medline
35. Deutsch A, English RD, Vermeer TC,
Murray PS, Condous M: Removable
rigid dressings versus so dressings:
A randomized, controlled study with
dysvascular, trans-tibial amputees.
Prosthet Orthot Int 2005;29(2):193-
200. Medline DOI
36. Pinzur MS, Angelico J: A feasibility
trial of a prefabricated immediate
postoperative prosthetic limb system.
Foot Ankle Int 2003;24(11):861-864.
Medline
37. Schon LC, Short KW, Soupiou O,
Noll K, Rheinstein J: Benets of early
prosthetic management of transtibial
amputees: A prospective clinical
study of a prefabricated prosthesis.
Foot Ankle Int 2002;23(6):509 -514.
Medline
38. Scott H, Condie ME, Treweek SP,
Sockalingam S: An evaluation of
the Amputee Mobility Aid (AMA)
early walking aid. Prosthet Orthot Int
2000;24(1):39-46. Medline DOI
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
39
Chapter 4
General Principles of Limb Salvage
Versus Amputation in Adults
Christopher Bibbo, DO, FACS David J. Polga, MD Samir Mehta, MD Stephen J. Kovach III, MD
Abstract
e decision to attempt limb salvage of an injured or diseased limb requires good clinical judgment, knowledge of the pathologic process that put the limb in jeopardy, and an
understanding of the social and psychological prole of the patient. Each patient must be
treated as an individual based on his or her current medical and physiologic status. A few
of the factors that require consideration are the patient’s premorbid conditions, psychosocial
factors, desires and expectation, social support network, and accessibility to reconstruction
services. Knowledge of the general principles of limb salvage versus amputation will aid in
providing optimal treatment for these patients.
Keywords: amputation; diabetes; extremity; flaps; infection; limb
salvage; trauma; tumor; vascular disease
Introduction
A limb (primarily a lower limb) that is
at risk for amputation and being considered for salvage may be simplistically
categorized to primarily possess a vascular, infectious, tumorous, or traumarelated etiology. In reality, however,
these categories often overlap, increasing the degree of difficulty to achieve
limb salvage; unfortunately, difficulties
in healing and recovery after an amputation can escalate concurrently.
The general principles of limb salvage
versus amputation in adults mandate
that the first consideration is always life
over limb. Dire circumstances are most
commonly encountered in patients with
Dr. Polga or an immediate family member is a member of a speakers’ bureau or has made paid
presentations on behalf of Synthes. Dr. Mehta or an immediate family member has received research
or institutional support from Amgen, Medtronic, and Smith & Nephew; is a member of a speakers’
bureau or has made paid presentations on behalf of Smith & Nephew, Zimmer, and AO North
America; serves as a paid consultant to or is an employee of Smith & Nephew and Synthes; and
serves as a board member, owner, ocer, or committee member of the Pennsylvania Orthopaedic
Society. Dr. Kovach or an immediate family member has received research or in stitutional support
from KCI and is a member of a speakers’ bureau or has made paid presentations on behalf of Davol.
Neither Dr. Bibbo nor any immediate family member has received anything of value from or has
stock or stock options held in a commercial company or institution related directly or indirectly to
the subject of this chapter.
serious infections or multiple traumatic
injuries. If limb salvage is contemplated,
the surgical team must weigh whether the treatment required for salvage is
worse than the condition or the disease
state. For example, if salvage of a limb
with extensive tibial osteomyelitis is being considered in a patient who is frail,
elderly, and diabetic, the possibility of
organ failure, irreversible functional
decline, and a stiff nonfunctional limb,
may indicate amputation as the prudent
option. The adage of “burn no bridges”
is especially important for the at-risk
limb. Any procedure must be executed
with deference to subsequent surgical
interventions: how step one will affect
steps two, three, and so forth. An essential component to the overall treatment
strategy is that backup management
plans must be in place in the event of a
change in the patient’s condition.
The principles of limb salvage versus
amputation in adults—whether in acute,
chronic, or staged settings—mandate
the assessment of several key issues that
immediately and secondarily surround
the patient’s symptoms, including the
patient’s physiologic reserve and medical
comorbidities; arterial, venous, and lymphatic patency (vascular status); neurologic and psychological/psychiatric
statuses; functional potential and quality of life; surgical site considerations
and surgical procedures available from
the surgical team(s); and the availability of multidisciplinary resource teams
during the immediate perioperative and
rehabilitative phases of treatment. The
key assessments in all patients are physiologic reserve, medical comorbidities,
and vascular status.
Physiologic Reserve and
Medical Comorbidities
A patient must have adequate physiologic reserve to withstand limb salvage. Moreover, all correctable organ
system pathologies (for example, renal,
endocrine, cardiac, and hepatic) must
be addressed to maximize healing of
both limb salvage and amputation procedures. The most commonly encountered conditions are acute metabolic and
cardiac issues resulting from the circumstances of acute settings, as well as
age-related conditions. A patient’s nutritional health and immune competence
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
41
Соседние файлы в папке Библиотека им академика М.И. Перельмана