Stump Wound Research Articles

Evaluation of Vacuum-Assisted Dressing on Treatment of Ischemic Above Knee Amputation Stump and the Rate of Healing of the Amputation Stump

Abstract Background AKA Amputation results in permanent disability and a significant alteration in the individual's life and performance. Vascular problems are the leading cause of Lower limb amputations (LLA s) in developed countries. Delayed wound healing particularly in difficult wounds and in elderly with co morbidities is a major concern. Aim of the Work The aim of the present study is to Asses healing time after using the vacuum assisted dressing therapy in wounds of ischemic above knee amputation (AKA) open stump. Also to Asses reintervention rates after using the vacuum-assisted dressing therapy as a dressing in ischemic AKA open stump wounds. Patients and Methods This is a prospective cohort study, conducted at Ain Shams University Hospitals and Nasser institute Hospital in Cairo on 55 patients with ischemic above knee amputation stump. Results All patients (55) had no femoral pulse and underwent AKA due to arterial disease, 33 patients underwent revasculrization with trial of angioplasty prior to amputation. 40 patients had occluded CIA, 15 of them didn’t obtain complete closure of the stump while the other 25(62.5 %) obtained complete closure, while 8(66.7%) of them needed reintervention with another session of amputation to go with a higher level of amputation(new stump length < or = 15 cm) in order to obtain complete closure. Only 2 patients of them didn’t obtain complete closure after the higher amputation level. There was a statistically significant positive correlation between new stump length and baseline stump length with r and p-value of (0.774 and 0.003) and also statistically significant positive correlation between weeks for complete closure with baseline length and TLC with r and p-value of (0.491 and 0.001) and (0.682 and 0.000) respectively. Any patient with stump length less than 15 cm either primarly or after reintervention achieved complete closure of the stump Which makes us to come to a conclusion of that VAC/NPWT Can be used in ischemic AKA stump wounds cautiously with negative pressure less than 125 mmhg intermittently with a stump length equal or less than 15 cm after good debridment of the wound from any necrotic tissues and good monitoring of the patients lab and TLC while giving patients good antibiotics after culture from the wound, While ischemic AKA stumps with stump length more than 15 cm, VAC proved to be non effective and not aiding the healing process. Conclusion VAC/NPWT Can be used in ischemic AKA stump wounds cautiously with negative pressure less than 125 mmhg intermittently with a stump length equal or less than 15 cm after good debridment of the wound from any necrotic tissues and good monitoring of the patients lab and TLC while giving patients good antibiotics after culture from the wound, While ischemic AKA stumps with stump length more than 15 cm, VAC proved to be non effective and not aiding the healing process.

PURULENT-NECROTIC COMPLICATIONS AFTER AMPUTATION OF THE LOWER EXTREMITIES: ISSUES OF TREATMENT AND PREVENTION

Transfemoral amputation of a limb performed by a patient with obliterating atherosclerosis with irreversible ischemia is a difficult, traumatic operation and is accompanied by high mortality. High mortality after amputation of a limb at the hip level is associated with the severity of the general condition of patients and complications of the postoperative period. As our studies have shown, the most common complication after limb amputation is an infection of the femoral stump wound, its development is directly related to metabolic disorders in patients, a decrease in the immune status, ischemia of the stump tissues and foci of secondary infection. The clinical picture of infection of the femoral stump wound is variable. It depends, first, on the patient's general condition, the process's spread, the trophism of the stump tissues, and the nature of the microflora. Improving the treatment results of patients who have undergone limb amputation is possible by performing all the necessary preventive measures regarding ischemia and stump infection in the prescribed volume and the development of infectious complications, as well as treatment by the requirements of modern purulent surgery.

НОВАЯ КОНЦЕПЦИЯ ПРОФИЛАКТИКИ И ЛЕЧЕНИЯ НЕСОСТОЯТЕЛЬНОСТИ ПОСЛЕОПЕРАЦИОННОЙ РАНЫ КУЛЬТИ АМПУТИРОВАННОЙ КОНЕЧНОСТИ

Postsurgical stump wound failure after limb amputation is the most frequent postamputation complication. The failure considerably worsens the results of the patient’s rehabilitation after amputation. The paper proposes a simple system to evaluate status of the patient.

Application of Flow-through Anterolateral Thigh Perforator Flaps in Replantation of Complex Severed Limb

ObjectiveTo explore the clinical application value of flow-through anterolateral thigh perforator (ALTP) flaps in replantation of complex severed limbs. MethodsThirteen severe vascular, nerve injury, and skin or soft tissue defects in patients with complex severed limbs from August 2017 to January 2019 were enrolled in this retrospective study. The skin flap has covered the wound by using the flow-through ALTP flap technique. The main vascular defect was repaired by using the descending branch of the lateral circumflex femoral artery, and the blood supply of the transplanted limb was reconstructed. The blood supply of the flap and wound healing observed were observed after the operation. Regular follow-up was performed to observe the survival and functional recovery of the replanted limb. ResultsEleven cases of replanted limb and perforator flap survived completely. Limb shortening occurred in 3 patients owing to bone defects caused by distal amputation. After the second stage of bone transplantation, the limb length and function of those 3 patients recovered well. One case showed necrosis of the little finger after replantation of the severed palm. One case showed that the crushed forearm was severed completely. The anastomotic vascular inflammatory embolism was caused by infection and necrosis of soft tissue after replantation for 2 weeks, and then the stump wound was covered with a survived skin flap in the second stage. ConclusionThe flow-through ALTP flap technique has a good therapeutic effect on the functional reconstruction of complex severed limbs with severe skin and vascular injuries.

Case 5. Toe stump wound in arterial disease.

Case 5. Toe stump wound in arterial disease.

Prognosis of the development of purulent-necrotic complications in stump of the hip

Purpose of the study : to develop of method for prediction of development of purulent-necrotic complications in amputation stump of the hip. Material and methods. 90 disease histories of patients of both sexes were analyzed, aged 40–91 years old (mean age 65 (40; 91)), admitted to the hospital with a diagnosis of obliterating atherosclerosis of the vessels of the lower extremities, critical ischemia or gangrene of the foot. Patients were divided into two clinical groups: 1st group - 69 (76.7%) patients with a favorable course of the postoperative period; and 2nd group – 21 patients (23.3%) with a complicated postoperative period of infection of the thigh stump wound. Results . The original method developed includes the determination of the following risk factors: the systemic nature of atherosclerotic vascular damage; amputation at the level of the upper third of the hip; emergency surgery; hematoma in the early postoperative period; prothrombin time; INR; a quick prothrombin test: when receiving the sum of points 16 and more, a high risk of development is predicted, with the sum of points from 13 to 15 – moderate risk; and with a score of less than 12 – low risk of developing purulent-necrotic complications in amputation stump of the hip. Conclusion . Proposed method allows to objectively and quickly determine development of purulent-necrotic complications in amputation stump of hip, which further allows to correct starting therapy and in cases of high risk of development of complications, to prescribe enhanced antibacterial and detoxification therapy.

Amnioexcel® Plus Graft and its Prospective Benefits in Salvaging a Below- the- Knee- Amputation Stump Wound

Amnioexcel® Plus Graft and its Prospective Benefits in Salvaging a Below- the- Knee- Amputation Stump Wound

Use of the DermaBlade for Debridement of Hypergranulatory Wound Tissue.

Use of the DermaBlade for Debridement of Hypergranulatory Wound Tissue.

Is that a berry?

A 55-year-old male, smoker, with no other comorbidities, was referred to our hospital with signs and symptoms of acute left lower limb ischemia, which was not salvageable. He underwent an Above Knee Amputation [AKA] to avoid sepsis and relieve pain. He was discharged on therapeutic dose of Rivaroxaban as he had a past history of unprovoked venous thromboembolism. Post AKA, his stump wound was healthy. Two weeks post-op he reported to the emergency with history of swelling and pain on the stump edge. Upon examination, there was 2 by 2 cm collection on the lateral edge of his stump wound. Under local anesthesia, the collection was drained. This was thought to be an infected hematoma. He started regular physiotherapy once the incision site healed.

Dysvascular Transtibial Amputation Due To Artery Stenosis: A Case Report Study

Below-knee (BK) amputation is one of the most commonly performed actions in dysvascular cases, but rare caused by arterial stenosis. Those had significant impacts on clinical functions and affect the contralateral limb, so its need adequate supervision during rehabilitation programs. The report are to describe the stump wound healing of the patient after amputation surgery, stump preparation at pre-prosthetic phase, prevention of knee contracture, prosthetic preparation and use, gait training and evaluation of unaffected limb. A 44-years old female with right below-knee amputation caused by stenosis of right peroneal and dorsalis pedis artery, and the wound in the residual limb was not healed within 4 weeks. She got rehabilitation to accelerate stump healing and stump shaping, maintain knee flexibility, muscle strengthening, cardiovascular endurance, transfer and ambulation. She had good compliance to the programs and achieved independent ambulation using the prosthetic within 6 months. Improvement in residual limb healing within 6 weeks, pain reduction from VAS score 3 to zero, and stump shape changes from buldging to conical. And also in knee joint range of motion, transfer ability, gait pattern using BK prosthetic (by modifying shoe components), and the patient's ability to carry out ADL (BI score 75 to 100). Laser therapy, stump shaping, flexibility exercise, strengthening exercise, endurance exercise, ambulation exercise and prosthetic use on transtibial dysvascular amputation showed good results for ADL. Careful examination to the unaffected limb could identify early occurence of stenosis. Early intervention could prevent future ischaemia and amputation.

Art, craft and science of limb amputation Part 2. Сraft of amputation: from Ambroise Pare to Pierre Dionis (late XVI century – early XVIII century)

Since the XVI century until the beginning of the XVII century an operation of limb amputation has undergone changes and improvements that have affected all its aspects: preparation for carrying out, the technique of performing and postoperative treatment of patients. The invention of the ligature (1552) and the tourniquet (1674) became revolutionary. Wet and dry gangrene, extensive trauma to soft tissues and bones, traumatic limb amputation and osteomyelitis were considered of indications for amputation. The deontological and legal framework for amputation was developed, including the patient’s consent to the operation and the awareness of relatives about its outcomes. The article presents an instrumental and dressing apparatus of the XVII century for the operation; medicines used for general and local treatment of the patient before and after truncation of the stump; sedation and pain relief issues; technique of circular and one soft tissue flap (1679) amputation; the choice of tissue dissection level; methods of stopping bleeding (astringents, pressure bandage, cauterization, ligation and stitching of blood vessels); a method of stitching a stump wound, applying a bandage on it and strengthening it; postoperative management (regimen and diet, dressing change, staged wound treatment, complications); the phenomenon and causes of “phantom limbs”.

Follow Up Case of Left Knee TKR: Case Review

Poor wound healing following a major lower limb amputation can result in poor rehabilitation outcomes, which can be further worsened if the patient has recurrent falls and stump trauma during the wound healing stage. Direct trauma to the stump can result in bony fractures at the margins of the residual bones, and loose bony fragments may form inside the stump. These bony fragments can hinder the process of stump wound healing and interfere with prosthetic limb use and rehabilitation.

Development of Core Outcome Sets for Patients Undergoing Major Lower Limb Amputation for Complications of Peripheral Vascular Disease

Introduction: Despite advances in techniques for revascularisation, around 5000 patients each year undergo major lower limb amputation (MLLA) in the UK alone. Despite this, the evidence for optimal management of these patients is weak. Core Outcome Sets attempt to capture consensus on the most important outcomes for a patient cohort to improve the efficiency of future research. The aim of this work was to establish consensus on Core Outcomes Sets for studies involving patients undergoing MLLA. Methods: A list of outcomes was developed by systematic review to establish previously reported outcomes; and supplemented by focus groups involving healthcare professionals, patients and carers to identify additional areas which have not previously received research attention. Topics from these were then taken forward to a three-round Delphi consensus process, where outcomes were rated on a Likert scale from 1 (unimportant) to 9 (critical). Outcomes were rated for both short-term studies, with primary outcomes in the region of 30 days, and medium-term studies, with primary outcomes measured between a few months and 2 years following surgery. Results of the Delphi survey were then discussed at a face-to-face meeting of stakeholders, and recommendations made for Core Outcome Sets. Results: The systematic review revealed 444 distinct outcomes from 440 included studies involving a total of 442885 patients. Of these, 281 outcomes were reported by only a single study. These were reduced to a set of 44 broad themes to carry forward to the consensus survey. Focus groups revealed a further six themes which were felt to be important by participants, but which had not previously been reported in the research literature. The consensus survey received responses from 123 participants in round 1, and 91 individuals completed all three rounds. In the final round, stump wound infection and wound healing were rated as 'core' for both short-term and medium-term studies. Mortality; cause of death; effectiveness of analgesia; need for re-admission; need for additional operations; perioperative complications; and effective communication between patients, carers and healthcare professionals were rated as 'core' for short-term studies. Pain in the residual limb/stump/phantom; supply of a prosthetic limb; prosthetic limb use, comfort and fitting; level of independent mobility; participation in work and social activities; independent living; and quality of life were rated as 'core' for medium-term studies. The face-to-face stakeholder meeting ratified inclusion of all outcomes from the Delphi and suggested that deterioration of the other leg and psychological morbidity should also be reported for both short- and medium-term studies; length of hospital stay should also be reported for short-term studies, and that mortality should also be reported for medium-term studies. Conclusion: Studies concerning patients undergoing MLLA have historically been highly in-efficient, with huge numbers of different outcomes reported and little overlap between studies. We have established consensus on 9 core outcomes for short- and medium-term studies. Three additional outcomes were proposed at a face-to-face stakeholder meeting for each time period. We recommend that all future studies involving patients undergoing MLLA should report these outcome sets. Disclosure: Nothing to disclose

Bilateral pulmonary embolism and ilio-femoral DVT associated with recent amputation of lower limb, long distance air travel and suspected thrombophilia.

We present a 36 years old Bangladeshi male, known smoker, while working in Bahrain, suffered from arterial thromboembolism on left lower extremity resulting in gangrene of left leg. He underwent above knee amputation of the affected limb. After 16 days stay in the hospital with an open amputated stump wound, he was sent back to Bangladesh by air. While in the airplane, he complained of chest discomfort about two hours before landing at Dhaka airport of Bangladesh. Following disembarkation he was admitted into local cardiac hospital where a diagnosis of left ventricular failure with unstable angina was made. Five days later he was transferred to ICU of Ibn Sina Hospital for better management. Patient had high serum D-dimer level and fibrin degradation products (FDP) level. negative antinuclear antibody (ANA) test, negative anti-cardiolipin antibody test, normal troponin I, Homocysteine, antithrombin III, protein S, & protein C levels. Initial X-ray chest showed left lower zone wedge shaped density. ECG showed sinus tachycardia. CT angiogram of chest showed bilateral pulmonary embolism (PE) and large left pleural effusion. Contrast CT abdomen showed bilateral iliac vein thrombus extending to lower inferior vena cava. Left pleural effusion was found to be grossly hemorrhagic. Patient was treated with low molecular weight heparin and warfarin. As thrombolysis was not feasible, he was advised to have thrombo-embolectomy. He refused surgical option and left hospital against medical advice. This case illustrates that multiple risk factors can be responsible for PE, and appropriate & timely interventions are always needed to prevent morbidity and or mortalityBangladesh Crit Care J March 2016; 4 (1): 46-50

The regenerating antler blastema the derivative of stem cells resident in a pedicle stump

Antlers of the deer are the only mammalian organs that can fully grow back once lost from their pedicles, hence offer the only opportunity to learn how nature has bestowed mammalian epimorphic regeneration. Investigations have demonstrated that it is the proliferation and differentiation of pedicle periosteal cells (PPCs), but not dedifferentiation of the local differentiated cells, that give rise to the antler blastema. PPCs express key embryonic stem cell markers and can be induced to differentiate into multiple cell lineages, so are termed antler stem cells. Further research has found that PPCs can initiate antler regeneration only when they have interacted with cells of the pedicle skin. Histologically, the process of early antler regeneration resembles that of healing of a mouse leg stump wound. However what sets these two apart is the difference in proliferation potential between the PPCs and the periosteal cells of the long bone. We believe that if we can impart a greater proliferation potential to the long bone periosteal cells, we might be able to achieve the dream of regenerating limbs in mammals.

Treatment of stump complications after above-knee amputation using negative-pressure wound therapy

The stump wound complications after above-knee amputation lead to other problems, such as prolonged rehabilitation, delayed prosthetic restoration, the increase in total treatment cost and high mortality rates. To evaluate the safety and outcomes of negative-pressure wound therapy (NPWT) using Vacuum-Assisted Closure (VAC®) therapy in patients with stump complication after above-knee amputation (AKA). From January 2011 to July 2014, AKA was performed in 137 patients at the University Cardiovascular Clinic. Nineteen (12.4%) of these patients (mean age 69.3 ± 9.2 years) were treated with NPWT. The following variables were recorded: wound healing and hospitalization time, rate of NPWT treatment failure, and mortality. AKA was performed in 17 (89.5%) patients after the vascular or endovascular procedures had been exhausted, while urgent AKA was performed in two (10.5%) patients due to uncontrolled infection. The time before NPWT application was 3.1 ± 1.9 days and the duration of the NPWT use ranged from 15 to 54 days (mean 27.95 ± 12.1 days). During NPWT treatment, operative debridement was performed in 12 patients. All the patients were kept on culture-directed intravenous antibiotics. The average hospital length of stay was 34.7 days (range 21–77 days). There were four (20.9%) failures during the treatment which required secondary amputation. During the treatment, one (5.3%) patient died due to multi-organ failure after 27 days. The use of NPWT therapy in the treatment of AKA stump complication is a safe and effective procedure associated with low risk and positive outcome in terms of wound healing time and further complications.

Bacterial contamination in a special care baby unit of a tertiary hospital in Jos, Nigeria

Nosocomial infections pose a great challenge on healthcare systems. Although surfaces in neonatal wards, umbilical stump wounds and catheter are responsible for a high number of nosocomial infections due to bacteria. The aim of this study was to determine the bacterial profile of air and surface contamination in the special care baby unit of a tertiary hospital in Jos, Nigeria.Surface and air samples were cultured and antibiotic susceptibility of isolated bacteria were determined.The bacterial profile of air and surface samples showed that Klebsiella was the most common bacteria followed by Staphyllococcus; while the least was Escherichia. Most of the bacteria were isolated from the out-born term area of the special care baby unit. All the bacteria isolated were susceptible to ceftriaxone and meropenem.This study showed that all areas of the special care baby unit of the hospital have bacterial, indicating that these are a potential source of cross-infection from healthcare workers to the neonatal patients.

Application of homemade stump wound fixed sets for amputees

Objective To discuss the clinical effect of homemade stump wound fixed sets for amputees. Methods From January 2010 to November 2013 we treated sixty eight cases of patients with smashed wound, who received emergency amputation surgery.We randomly selected thirty five cases of using homemade stump wound fixed sets as experimental group, and chosenthirty three cases of using the U-shaped plaster dressingmethodto dress outside wound as control group, comparing two groups with postoperative wound drainage, local swelling, stump skin pressure sores, wound infection, joint function close to the situation. Results In the experimental group, the infection rate was 5.71%, skin necrosis rate 8.57%, incidence of swelling 28.57%,while those rate in the control group were 18.18%,15.15% and 54.55% respectively, the differences were statistically signifcant （χ2 =3.81,3.34,4.79, respectively;P〈0.05）.In the experimental group, the wound drainage averaged （46.8.0 ±12.35） ml, and the activities degrees of neighboring joint was （145.68 ±13.20）°;meanwhile in the control group the wound drainage averaged （89.81 ±10.61）ml, and the activities degrees of neighboring joint was （112.46 ±9.21）°, the differences were statistically significant （t=24.721,11.330,P〈0.05）.Conclusions It is a commendable approach to promote homemade stump wound fixed sets for amputees, because it can significantly reduce postoperative bleeding, promote swelling, reduce skin pressure sores, and can contribute the function exerciseof the neighboring jointearlier. Key words: Innovation to promote; Wound fixed sets; Amputation

Outcomes After 294 Transtibial Amputations With the Posterior Myocutaneous Flap

The transtibial amputation is a common operation for which there is little agreement regarding which technique provides the most reliable and resilient outcomes. We performed a retrospective chart review of all transtibial amputations performed by a single surgeon between 2004 and 2011 using the posterior myocutaneous flap with triceps surae myodesis technique. A stepwise logistic regression analysis was performed to evaluate the association between independent variables and dependent outcome variables. A total of 270 patients with 294 transtibial amputations were identified. Ambulation data were available for 192 patients with a mean follow-up 18.4 months. This cohort had an overall ambulation rate of 75%, a 12% incidence of stump wounds, 24% operative revision rate and only 2% required conversion to a transfemoral amputation. The posterior myocutaneous flap provides durable and reliable soft tissue coverage in the setting of a transtibial amputation.

A Case of Nonisland Pedicled Foot Fillet Flap for Below-Knee Amputation Stump Wound: Treatment Option for Compartment Syndrome after Fibular Free Flap Surgery

Despite the frequent use of the fibular free flap, there have been no reports of severe compartment syndrome of the donor leg that necessitated limb amputation. A 66-yr-old man had a fibular osseous free flap transfer from the left leg to the mandible that was complicated by postoperative compartment syndrome. An extensive chronic leg wound resulted, which was treated with multiple debridements and finally with below-knee amputation. Successful coverage of the below-knee amputation stump was accomplished with a nonisland pedicled foot fillet flap. Various foot fillet flaps may be used acutely as a free or an island pedicled flap, but dissection of the vascular pedicle may be difficult in a chronically inflamed wound because of inflammation and adhesions to surrounding tissue. The nonisland pedicled foot fillet flap may be considered as a useful option for treatment of a chronically inflamed stump wound after below-knee amputation.