Jorge Fabregas, MD, of Children’s Health Care of
Atlanta, has encountered numerous patients who struggle with their residual
limb due to
wound complications such as infection, medical history, poor
socket fit and poor nutrition. Fabregas discussed
complications in wound healing in healthy adults and children at this
year’s
Association of Children’s Prosthetic-Orthotic Clinics Annual
Meeting in Park City, Utah.
“In pediatrics, some people say there are just
congenital,
trauma,
tumors and
infections,” Fabregas said. “I wish it was that
simple. We deal with malnutrition, dirty wounds in the tissue and allergic
reactions. Just like adults, after an amputation, pediatric patients do have
sections that are insensate.”
How does a practitioner know a wound is infected?
“All wounds have bacteria. The question is how does
a bacteria behave within that wound?” he asked adding that healing
problems are one tell-tale sign of infected wounds. “Maybe the wound has
healed, but it keeps opening up.”
Wounds can be classified as acute or chronic problems.
Everything starts with prevention. Good pre-operative planning, identifying
what is required for the wound to heal and what the practitioner needs to
optimize the health of the patient, are some ways to prevent wound
complications.
“Some things we can change, some things we can
foresee,” Fabregas said. “Pre-operative planning involves knowing
what surgical technique to employ, the exact location of the incision and
anticipating how you will close the wound. Incisions on the distal [residual
limb] are more prone to having problems. You must plan where you want that
incision located.”
Planning is only part of the equation. Host resistance
from the patient is the most important determining factor of wound healing.
Good wound healing needs quality vascular flow, fine nutritional status and a
strong immune system.
“Optimizing the patient involves nutrition.
It’s not just eating right. Even with kids, we talk about smoking. I have
had patients who are 15 and 16 [years old] and they are already smoking,”
Fabregas said.
Many patients scheduled for amputation have had previous
health complications and it is important to know what medications the patient
is currently taking or was taking in the past. Do they have any past history of
wound infection? Knowing the details of the patient’s history may
determine the surgeon’s surgical technique.
“Depending on the medication, you may have to wait
weeks or sometimes a month before performing that surgery,” he said.
“We talk about trauma, malnutrition and infection, but it all goes back to
surgical technique, how you are closing the wound and optimizing the
patient.”
Fabregas discussed one of his transtibial amputee
patients with a long-standing history of wound complications.
“He has had multiple critical revisions for
multiple wounds and has been completely worked up,” he said.
“Everything comes back negative. His skin changes indicate possible
diabetes ... but the tests indicate that he is not diabetic. We modified his
prosthesis, drained the wound and it opened up ... We still have not gotten the
right answer yet. He’s undergone multiple debridements, as well as a toe
amputation. He has something but we are just unable to identify it so
far.”
Fabregas recommended that all practitioners optimize
each patient, be meticulous with their surgical techniques, identify early
issues and be as aggressive as possible.
“Why do we worry? Fabregas asked. “Patients can fall into
depression. There is a decreased upright and activity time. The multiple
fittings, hospitalizations, surgeries and treatments cost the patient both
physically and financially.” — by Anthony Calabro
The biggest problem with O&P is that practitioners
do not follow up with these patients. They have to follow up. I have noticed
that a lot of practitioners will hand the patient a sheet of paper and say,
“call me if you have any problems.” But if the patient is
neuropathic, the patient will not know if they have any problems. There has to
be scheduled follow-ups where you actually take the sock off and look at the
foot.
We use infrared thermometers if we see a possible
problem. When you see one area that is three or four degrees hotter than the
surrounding areas, the practitioner needs to offload that before there is an
ulcer. Offloading must be done underneath the insert. If you see the heat and
you can offload it, you will not get the ulcer.
— Nancy Elftman, CO, CPed
Clinical
specialist, Hands on Foot Inc.
and member, O&P Business News
Industry Advisory Council