Transcript Amputation Stump Infection

Amputation Stump Infection
Prof Jai Kulkarni / Dr. Basu ST6
Disablement Services Centre
University Hospitals of South Manchester
May 2012
Is it an infected stump or not ?
Infection Continuum
• Wound Contamination: Presence of bacteria
within the wound but with no host reaction.
Does not delay wound healing.
• Wound colonisation: Presence of bacteria in
the wound which do multiply. No delay to
healing and no host reaction.
• Critical colonisation: Multiplication of bacteria
in a wound causing a delay in healing.
Increased pain with thick slough and
malodour. No cellulitis.
Wound Infection
•Multiplication of
bacteria in the wound
with host reaction
•Erythema
•Pain/heat/swelling
•Increase in exudates
•Asc lymphangitis and Prox
lymphadinopathy +/•Systemic symptoms
•Lower limb amputations account for the majority of all amputations in
the UK, with PVD and diabetes being the major reasons for surgery – 80%
•Within the population of patients with dysvascularity, major lower
extremity amputation results in significant peri-operative morbidity and
mortality.
•Potential wound-healing complications associated with lower limb
amputation stumps include infection, tissue necrosis, pain, problems with
the surrounding skin, scar adhesion, haematoma, stump oedema,
osteomyelitis and dehiscence.
•The highest rate of surgical site infection is associated with lower limb
amputations.
•Wound healing outcomes for amputees can be maximised by MDT
working.
•Wound healing complications associated with the stump of
an amputee are important because in some cases these
determine a patient's ability to walk with a prosthetic limb.
•Commonest stump-related complications were wound
infection and poor healing (70%), poorly fashioned stumps
(20%) and phantom pain (10%)
White SA, Thompson MM, Zickerman AM, Broomhead P, Critchley P, Barrie WW, et al. Lower limb amputation and
grade of surgeon. Br J Surg 1997; 84(4): 509-11.
•The healing rates for below- and above-knee amputations
vary considerably. It is thought that a total of 90% of aboveknee major amputations heal, 70% primarily, whereas for
below-knee amputations, primary healing rates range
between 30% and 92%, with a re-fashioning rate of up to
30%.
Dormandy J, Heeck L, Vig S. Major amputations: clinical patterns and predictors. Semin Vasc Surg 1999; 12(2): 154-61
Wound Healing
•Inflammation phase with haemostasis (approx 1-7 days):
1.Initially white blood cells are attracted to wound. Leucocytes get rid of the wound contaminants.
Neutrophils assist in destroying bacteria.
2.At 2-3 days macrophages assist in cleaning wound of bacteria
3.Slough common at this stage. As cells engulf bacteria they float to surface of wound and die = slough
•Proliferation phase (approx 4-24 days): Components are
a) Granulation (new wound matrix provides the scaffolding for new blood vessels). Macrophagescontinue to destroy bacteria - release growth factors to attract fibroblasts - stimulate fibroblasts to
produce collagen-send for endothelial cells to form new capillary loops. New capillary network formed
in wound bed as well as new connective tissue
b) Wound contraction: Myofibroblasts are produced. They congregate at the wound edges and contract
allowing the wound edges to come together.
c) Epithelialisation (resurfaces the wound): This is the re surfacing of the wound by new skin cells.
New cells multiply and migrate. Process aided by moist wound environment. Wound bed must be clean
and free from devitalised tissue
•Maturation phase (20days- 1 year):
Can take up to 1 year. Re modelling of collagen into a more structured tissue occurs. Wound becomes paler
and flatter as vascularisation decreases. Tensile strength improves
Unhealed stump is not always infected
“Unhealed” stumps often show healing at the
ends of the suture line. Unhealed over the bone.
When is an unhealed stump suitable for
prosthetic fitment?
No standard
Various centres use different regimes
Small wounds ok
Leave until fully healed
Early walking aid only
Can we apply force/friction to a dressed wound?
What are the benefits of exercise?
 Builds muscle
Helps claudication
Improves general fitness
Evidence
Early post-op rehabilitation results in improved functional outcomes
(Friedman 1990;Munin 2001).
 Compression and EWAs result in quicker progression to prosthetic rehabilitation
(Condie 1998).
Friedmann LW. (1990) Rehabilitation of the lower extremity amputee. In: Kottke FJ,
Lehmann JF, editors. Krusen’s handbook of physical medicine and rehabilitation (4th
edition) Philadelphia: WB Saunders Company p 1024-69.
Munin MC, Espejo-DeGuzman MC, Boninger ML, Fitzgerald SG, Penrod LE, Singh J
(2001) Predictive factors for success in early prosthetic ambulation amongst lower limb
amputees. Journal of Rehabilitation Research and Development 38(4): p 379-84.
Condie ME, Treweek SP, Ruclkey CV (1998). Trends in lower limb management: 3 year
results from a national survey. British Journal of Surgery 85 (supp1) 23.
Van Ross ERE, Abbott CA, Johnson S (2009) Effects of early mobilisation on unhealed
dysvascular transtibial amputation stumps:A clinical trial Arch Phys Med Rehab
90(4):610-17.
Advantages of Transtibial Amputations
•Improved function
•Lower energy requirement for
• mobilisation
•Easier to don/doff
•Reduced chance of prosthetic
• abandonment
•Improved survival
•Lower dependency on family/state
•Cheaper to rehabilitate
Benefits of early mobilisation protocol:
Promote TT instead of TF amputation.
Prevent joint contractures/muscle wasting.
Psychological boost for pts.
Rehab and wound healing occur simultaneously.
Optimal functional outcomes.
Infection of Stump
Dermatological infection: 30% of cases
• Allergic Contact Dermatitis ( ACD ) frequently appears as a macular, papular,
erythematous rash that is often pruritic. The liner, socks, and suspension mechanism are
the usual culprits for contact dermatitis. Occurs in 1/3 rd of these cases.
•Cysts and sweating can be signs of excessive shear forces and components that are
improperly fitted; sweating can also result from the loss of surface area
•Tinea infections are caused by excessive moisture – Fungal culture and treatment
•Skin maceration
•Folliculitis is an infection of the hair follicles caused by poor hygiene, sweating, and poor
socket fit; treatment includes use of antiseptic cleaner and topical ointments; socket
modification may be required to avoid high-pressure areas
•An epidermoid cyst (hydradinitis Suppurativa) is a sebaceous gland that is plugged with
keratin; treatment includes the use of topical or oral antibiotics, as well as incision and
drainage or excision
Is it an infected Stump
Verrucose hyperplasia that
has developed after choke
syndrome. Choke syndrome
develops when
• tight proximal socket
impairs venous return and
• lack of total contact occurs
between the residual limb
and the prosthetic socket.
Acutely, significant edema
leads to weeping and
blistering skin. As the choke
becomes chronic, the tissues
become thickened and
indurated. Hemosiderin
deposition causes
hyperpigmentation of the skin
Infection of Stump
Soft Tissue and Bony Infection
•Bursitis
• FB like - Bone wax
Infected thrombosed Vascular graft
Management of infection of major amputation stumps after failed femorodistal grafts. Rubin JR, Yao JS, Thompson RG, Bergan
JJ; Surgery 1985; Oct .
Delayed stump healing was noted to occur more commonly in the group who had undergone previous bypasses as opposed to
those who had undergone primary amputation (34.8% versus 14.3%). Fourteen graft infections developed in 89 patients after
amputation (15.7%), which is significantly higher than the overall 1.4% incidence of lower-extremity bypass infections that
occurred during the same interval in patients with intact extremities. In addition, it was found that when infected grafts in
amputated limbs were completely removed, stump healing without recurrent wound and graft sepsis was better than when
treated locally or with partial graft removal. We therefore recommend removal of a thrombosed graft with an infected wound or
an infected graft at the time of major limb amputation to decrease the incidence of wound complications and graft infection.
Bony fragments
• Breakage of adhered scar with secondary infection
• Bony infection and Osteomyelitis
A Story
Stump infection with chronic discharging sinus for 8
months following amputation
•There is extensive diffuse high
signal in the vastus medialis,
intermedius and the lateralis and
distal rectus femoris muscles.
(also adductor magnus )
Suspicious of muscle infection
(pyomyositis).
•Poor outline of cortical margins
of the femur
in the distally (approximately 6 cm),
some enhancement is seen along
especially within the marrow on
post gadolinium images
• A few low signal foci probably
representing bony fragments
There is probably a small collection
at the end of the stump shown
A small sinus tract is seen at the
anterolateral aspect of the stump
After Re-fashioning of stump
Immediately after surgery
Recent Picture – healing by 2*
intension
What about this!!!
After long term conservative
treatment and EMP
Post Re-fashioning
Still it is below knee amputation.
Good Surgical technique and Oedema management prevents stump
infection
•De-bulk flap to give ideal stump shape
which allows earlier casting
•Anterior beveling of tibia
•Allow for oedema in closure to prevent
tension on suture line
•Interrupted skin closure to allow
drainage
•Sutures not clips to allow for early
compression
• Post operative management with early
Compression stockinet (Not with skin clip)
or Rigid Removable Dressing (RRD)
-Volume control
-Better wound healing
-Protection of stump (fall)
-Lowers the risk of knee contracture
-Reduces hospital stay and Prosthesis fitting time
Management
Treat Stump infection early and prompt
•As it may lead to stump dehiscence and higher amputation
•It can cause serious systemic infection
•Delays the Prosthetic rehabilitation
•Prosthetic modification is immensely important for the
holistic management.
Thank You