Post-Operative Management

1. Soft/dry dressing should be applied around the amputation site and extremity. Circumferential wraps with gauze rolls and ace wraps must be applied in a figure eight fashion without excessive compression.
2. The limb may be placed in a splint or bivalved cast to prevent joint contractures and provide soft tissue support when necessary. There should be ample access for wound inspection.
3. In the event of the short skin flaps, skin traction to prevent soft tissue retraction is an option.
4. Avoid placement of pillows under the knee to prevent contractures when dealing with amputations below the knee.
5. Negative Pressure Wound Therapy (NPWT) device/ Vacuum Assisted Closure (VAC) dressing is recommended for management of appropriate amputation wounds, when available.8 The VAC device has been the primary NPWT device used within the DoD. Clinical studies support the use of the VAC as a soft tissue wound management adjunct in appropriately prepared wounds as a bridge to delayed closure, flap coverage, or coverage with a split thickness skin graft. In appropriately debrided and prepared wounds the VAC has been shown to increase the rate of granulation and decrease bacterial colonization leading to effective amputation coverage and or closure.8 Use of NPWT should be considered only after complete wound debridement and hemostasis have been achieved and only after the wound has had frequent debridements and demonstrated wound stability. More extensive and acute soft tissue wounds should have the VAC dressing removed with further irrigation and debridement on shorter intervals (every 24 hours) compared to less extensive wounds (greater than every 24 hours). Neurovascular structures should be covered with tissue or other barrier (white foam, Adaptic, or petroleum gauze) prior to applying the NPWT. The VAC sponge should cover the open wound bed and be set to 50-125 mm Hg continuous pressure. The use of NPWT dressings has been demonstrated to be safe in patients during strategic aeromedical evacuation. Consideration should be given to the placement of antibiotic beads, if available under the NPWT dressing to convert the wound to an antibiotic bead pouch in the event of vacuum dressing failure (seal leak or machine shutdown) during patient transport.8
6. Upon arrival to the next level of care, direct wound inspection needs to be completed by a surgeon.
7. Wounds in the early phase of management need frequent inspection to ensure infection control and no evolution of injury; however, NPWT/ reticulated open-cell foam dressings can be left in place for 48-72 hours if there are no concerns for infection or injury progression. Wounds with concern for ongoing infection and evolution of injury need daily inspection.
8. Coordinate dressing changes/repeat debridement with evacuation schedule to avoid extended periods without wound care or inspection. Given the extent of many soft tissue wounds, dressing changes and repeat debridements should be performed in the operating room affording the patient the comfort of conscious sedation or general anesthesia and the surgeon access to the full array of equipment necessary to perform adequate debridement. Also, reapplication of the VAC dressing may be more complete and effective if performed in the operating room with the support of operating room and anesthesia teams when possible.