RESPONSES- "DOG EARS"

RESPONSES- "DOG EARS"

Benveniste, David Mark

3/10/2011

Thank you for your responses

Original post


As prosthetists we see amputations with dog ears all the time and assure
the pt they will eventually go away and hopefully without too much
wrinkling.

My suspicion is that dog ears could be avoided if the surgery is done
with more care. Time may be an important factor in some cases so I can
understand that may be a factor. I have seen these dog ears from
amputations done by multiple surgeons from multiple hospitals over the
years as we all have.

I have seen new amputations that did not have dog ears so I know it can
be done. I think fitting and shaping would be faster without the 'ears'
and the pt may appreciate the way it looks immediately post op.

Am I missing something or am I correct?
I would especially like to hear from surgeons.


Mark Benveniste CP




I have on surgeon in particular who's transtibial suture line looks like
a big sad upside down U. No matter how bulbous the limb is post-op,
there are no dog ears whatsoever. The other surgeons still do the
straight across suture line and dog ears result. So disappear over time,
some don't...

Only one answer Look at any legs done by Ertl and you will never see any
dog ears. I was once told by the doctor they were left like that to
control rotation LOL

Regarding your post, the ability to trim or reduce dog ears is
certainly possible as illustrated by the attached pics of a fresh BK
amputation.(NOT ATTACHED FOR THE LIST SERVE) What's interesting about
this photo is that it was a learning case in that one side was closed
by a vascular surgeon experienced in amputations while the other side
was closed by the resident. Can you guess which is which? Dog Ear 1
shows the contrast the best. Dog Ear 2 illustrates what the incision
looks like after the dog ear is trimmed.

I am not 100% sure how this is accomplished, only that it is possible
and something that can certainly be taught. I'm guessing that it takes
a bit of skill and practice in order to accomplish this and is not
standardized due to a general lack in experience with amputations
amongst surgeons. I may be wrong? I do know that it has certainly been
something that our surgeons in Dayton have been open to discussing in
order to benefit the amputee.

If there is any question re the vascularity of the flap, you MUST leave
dog-ears or may get partial necrosis! (from a surgeon)

I took the online course on post amputation care and I think they
attributed some of the dog ear cause to be solved by removable rigid
dressings and rigid dressings because swelling is deceased along that
section of the suture line. But maybe I am wrong....

Mark, I have gotten myself into trouble complaining about the surgeries
I see, one Dr. chewed me out because a Patient came to us requesting
information regarding amputation procedures.

Mark - YOU ARE ABSOLUTELY, MOST DEFINITELY RIGHT-ON! As you know, I too
have seen the result of many surgeons talent/or lack thereof, in
treating limb tissues during amputation.
The result is manifest at the immediate and early postoperative period,
and subsequently in late effect residual-limb problems - the least of
which could arguably be dog-ears of soft tissue; the worst of which
would include nerve, muscle, fascia, and bone; and less known late
effect problems involving secondary nerve, centralized pain, and
emotional conditions often referred for psychiatric treatment. This is a
very sensitive topic with me and forgive me for being so immediately
direct and sharp in my criticism. This is directed to surgeons, AND the
prosthetists that provide absolutely NO FEEDBACK to the surgeon! And,
In my conversations with SURGEONS in the past, They have expressed that
very few people in government or other hospitals there had any interest
in doing the amputation in a better way, even though these techniques
exist.


I refer to elective surgical amputation (i.e. due to PVD) - you're lucky
if dog ears are all that is of concern. How about the larger issues of
excessive distal soft tissue, unnecessarily short amputation and
incorrect anterior closure in the case of TT amputation (i.e. too distal
resulting in a prime site for distal soft tissue adhesion to the cut end
of tibia).

The above events will continue to occur whilst surgical amputation of
limbs is performed by junior vascular surgeons (i.e. in training -
registrars). Added to which is the predisposition for the vascular
group to book amputation surgery at the end of an operating theatre list
which indicates the relative importance of the procedure. Orthopaedic
Surgeons used to perform more of these elective procedures and in my
opinion presented us with a superior residual limb. I believe that's
because Ortho's routinely deal with biomechanical issues involving
muscle & bone. Also, the procedure is not regarded in the same way as
the vascular group and they tend to involve us earlier; including
pre-surgical planning.

Perhaps it's time for amputation surgery to become a sub-specialty of
Orthopaedics.

Mark when I have seen this condition it usually was from a surgeon that
does not routinely do amputations and usually is cases where the
vascular condition of the skin is felt to be compromised. The surgeon
is worried about the viability of the limb and usually does not do any
type of rigid dressing so he/she can look at the stump.


Whilst I realize there are a few surgeons who are willing to listen to
this sort of advice, good luck with the majority of them!! You can't
tell a vascular surgeon how to do their job!!

I assist surgeons with Amputations all the time. I have always wondered
about Dog Ears. One time we made careful attention to the closure and
tried not to create Dog Ears. That was the only time we got problems
with healing the suture site. I say leave them alone.

Mark, the ears help them hear our instructions better when they are new
amputees.