Use of a Novel Dual Compression System for the Management of Edema-Related Dehiscence in Amputation Sites
Lower-extremity amputations result in serious complex wounds. There are a multitude of reasons why amputations take place. A few of the most common reasons are peripheral vascular disease, infection (common in diabetes), and trauma.1 Even without the presence of pre-amputation edema, surgical amputation can be expected to produce edema levels that can range from mild to severe. When lower extremity swelling exists before amputation, the problem is accentuated. The preexisting edema is amplified, in our experience, in the amputated limb, especially in a below-the-knee amputation.
When edema is uncontrolled, the resultant swelling can interfere with wound healing, cause wound dehiscence, and cause tissue destruction, leading to a delay in wound healing and a need for additional surgical interventions, such as further surgical debridement and associated morbidity.2 Edema control before and after amputation appears to be a good clinical solution to address further complications to the amputation site. Multilayer compression therapy is the gold standard for managing venous insufficiency and other edema-associated disease processes that lead to lower extremity swelling and associated ulcer formation.3,4 In our practice, the dual compression system (DCS) (UrgoK2 Compression Bandage, Urgo Medical) is the standard of care for venous reflux/ulcers. Success in this area gave us the confidence to attempt the control of edema before and after amputation to solve a problem that has previously not had a satisfactory clinical solution for us. Our clinical sense was that a patient who could have confident pre-amputation compression for edema and post-amputation compression for amplified surgical edema would have the best wound healing outcome. Without such pre- and post-amputation edema control, the likelihood of wound dehiscence and complications are amplified based on our clinical experience.
METHODS
This article describes a method that has produced beneficial results in managing wound dehiscence after amputation. We present 3 cases of wound dehiscence management and establishment of healing, or a pathway to healing, using engineered compression wraps. In these cases, the dehiscence was due to uncontrolled post-amputation edema before these patients presented to our clinic. We monitored amputation site edema in all 3 patients.
Our edema management system to bring wound dehiscence under control and prevent further complications consisted of compressing the limb/stump with a DCS bandage. This bandage is associated with evidence that it can provide consistent, continuous, and comfortable compression for venous leg ulcers, but the system seems to work equally well for managing post-amputation edema.5-7
The cases consist of patients with wound dehiscence caused mainly by postsurgical edema and in whom the edema and health of the amputated limb, and thus wound health, was managed effectively with the DCS bandage. For each patient, the bandage was applied using the tension indicators on the bandage, as it would be on lower limb venous insufficiency. In short, the “oval” indicators (in both layers) became “circles” during application, and that provided the desired clinical results. The wound bed for the dehisced wound was managed with advanced moist wound healing techniques and exudate control using hydroconductive dressings (Drawtex, Urgo Medical).
CASE REPORTS
Case 1. A 48-year-old male with diabetes was seen 4 days after amputation due to a foot ulcer and necrotizing infection. The surgery required a left guillotine amputation followed by formalization of below-the-knee amputation. Wound dehiscence developed. Negative pressure wound therapy (NPWT) was attempted, but there was difficulty in applying the NPWT device. The patient was seen in the clinic with dehiscence of the amputation incision line and edema in the lower leg. The DCS bandage was applied with a hydroconductive dressing to control drainage and edema. This was changed twice a week. As the wound contracted in dimension, the frequency of dressing/compression change was decreased to once a week until closure.
Case 2. A 69-year-old male with diabetes, foot ulcer, and critical limb ischemia was seen 1 week after surgery for edema management and lateral wound dehiscence of the amputation site. The DCS bandage was used with an alginate dressing to control drainage. This was done until the incision line was completely closed after 6 weeks of compression therapy with weekly bandage changes.
Case 3. A 61-year-old female with diabetes and amputation of the leg due to a necrotizing foot ulcer and critical limb ischemia (that was originally managed via vascular surgery) had an amputation site connected to an NPWT system. NPWT was continued with serial debridement. After the wound became superficial and the patient refused a skin graft, treatment transitioned to the DCS compression bandage with a hydroconductive dressing, and the dressing/bandage was changed twice a week. Treatment was eventually transitioned to weekly changes until closure.
RESULTS
Images of amputation sites over time (Figure 1, Figure 2, and Figure 3) show affected limbs and wound closure after compression application. They also demonstrate that each patient’s edema was managed and lowered to levels at which wound healing was achieved and dehiscence was reversed. Tension caused by the edema on the wound sites was reduced, leading to wound closure without further surgical intervention.
DISCUSSION
Using a compression bandage to manage amputation/arthroplasty surgery related–edema to prevent complications has been discussed sporadically in the literature.8-10 In-depth research in this area is sparse. In our practice, we have previously attempted to control postsurgical edema using commonly available bandages or wraps that are not designed to, and rarely provide, consistent and continuous compression. Thus, our success using this concept has been limited, which is consistent with the mediocre results observed in earlier publications.8-10 The DCS compression bandages that we describe here seem to provide a consistent, continuous, and comfortable therapeutic compression needed for reduction of edema, associated with conditions such as diabetes, after amputation.
As described in the literature,5-7 this DCS system can provide accurate therapeutic levels of compression, leading to edema reduction of lower extremity wounds. Based on the presented cases and our continuing experience with the DCS system, even when the principles of edema reduction before and after amputation have not been applied, and patients present to our wound center with post-amputation wound dehiscence, aggressive edema reduction with the DCS compression wrap can be achieved. This, in our experience, was successful in preventing further tissue destruction during dehiscence management, allowing facile progression to healing. The other benefit observed was that by reducing edema in the post-amputation limb, early remodeling of the amputated leg was achieved, allowing quicker transition to the use of a compression sock and an earlier and better-fitting prosthesis.
When a major adverse event, such as post-amputation wound dehiscence occurs, due to unmanaged postsurgical edema, we demonstrate here how a novel and engineered DCS can adress the situation effectively.
CONCLUSION
This bandage, when applied the same way as for venous insufficiency, was successful in managing presurgery edema and postsurgical amputation-related edema to prevent dehiscence.
Pearls for Practice is made possible through the support of Urgo Medical, Fort Worth, TX (www.urgomedical.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of Urgo Medical, Wound Management & Prevention, or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process and is based on a poster presented at the Symposium of Advanced Wound Care, Spring, 2021.
REFERENCES
1. Pran L, Harnanan D, Baijoo S, et al. Major lower limb amputations: recognizing pitfalls. Cureus. 2021;13(8):e16972. doi:10.7759/cureus.16972
2. Harris CL, Kuhnke J, Haley J, et al. Best practice recommendations for the prevention and management of surgical wound complications. In: Foundations of Best Practice for Skin and Wound Management. A Supplement of Wound Care Canada; 2017. www.woundscanada.ca/docman/public/health-care-professional/bpr-workshop/555- bpr-prevention-and-management-of-surgical-wound-complications-v2/file
3. Bar L, Brandis S, Marks D. Improving adherence to wearing compression stockings for chronic venous insufficiency and venous leg ulcers: a scoping review. Patient Prefer Adherence. 2021;15:2085-2102. doi:10.2147/PPA.S323766
4. Todd M. Venous disease and chronic oedema: treatment and patient concordance. Br J Nurs. 2014;23(9):466, 468-470. doi:10.12968/bjon.2014.23.9.466
5. Lazareth I, Moffatt C, Dissemond J, et al. Efficacy of two compression systems in the management of VLUs: results of a European RCT. J Wound Care. 2012;21(11):553-554, 556, 558 passim. doi:10.12968/jowc.2012.21.11.553
6. Jünger M, Ladwig A, Bohbot S, Haase H. Comparison of interface pressures of three compression bandaging systems used on healthy volunteers. J Wound Care. 2009;18(11):474, 476-480. doi:10.12968/jowc.2009.18.11.45000
7. Hanna R, Bohbot S, Connolly N. A comparison of inferface pressures of three compression bandage systems. Br J Nurs. 2008;17(20):S16-S24. doi:10.12968/bjon.2008.17.Sup9.31661
8. Christensen LMR, Arnesen CE, Möller S, Hyldig N. The effect of compression therapy on post-surgical swelling and pain after total knee arthroplasty. Int J Orthop Trauma Nurs. 2021;41:100815. doi:10.1016/j.ijotn.2020.100815
9. Munk S, Jensen NJ, Andersen I, Kehlet H, Hansen TB. Effect of compression therapy on knee swelling and pain after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):388-392. doi: 10.1007/s00167-012-1963-0
10. Goldberg T. Postoperative management of lower extremity amputations. Phys Med Rehabil Clin N Am. 2006;17(1):173-180. doi:10.1016/J.PMR.2005.10.009
