Soft dressings traditionally have been used to cover the residual limb after surgery. Their role is to cover the suture line and wrap the limb to hold the incision dressings in place. Gauze wraps do not reduce edema, nor do they affect the shape of the residual limb. Residual limb shape is determined at the time of surgery and is affected by muscle, soft tissue, skin flaps, and, in certain areas, by the shape and length of the bones, such as the tibia and fibula or radius and ulna.

Soft dressings include cotton or polyester gauze pads and wrapping with cotton gauze rolls or conforming polyester rolls.¹ These dressings are used to hold wound and incision coverings in place, but they do not provide support for the residual limb. The dressings are
permeable and help absorb drainage from the incision, but they do not provide a substantial degree of wound protection.^1,2 Soft dressings are ubiquitous in their use and inexpensive. Wrapping gauze rolls over the end of the residual limb frequently requires some expertise to ensure even distribution of pressure being applied to the surgically created residual limb. Major disadvantages of soft dressings are that they tend to loosen and require reapplication as frequently as every 3 to 4 hours. These dressings may provide padding when a compressive sleeve or rigid dressing is required.

Petroleum-impregnated gauze is frequently applied to the incision site at the conclusion of the surgical procedure, and it is then covered with regular gauze. Some form of wrap (often a gauze roll or elastic wrap) is then applied. Many surgeons use these dressings instead of rigid dressings because they prefer to view the incision site on a daily basis, although it has been shown that this is often unnecessary.³

In 1980, Kane and Pollak⁴ reported no statistical difference in narcotic use among patients with amputations resulting from vascular causes who were treated with soft dressings or those who were fitted with an immediate postoperative prosthesis (IPOP); however, the analgesic protocols at that time were different from those in current use. They noted no statistical difference in wound necrosis and infection between the two methods. The authors noted that 56% of the patients fitted with the IPOP became prosthesis users compared with 22% of the patients treated with soft dressings; however, it is not known if there was a selection bias based on their perceived rehabilitation potential. They were not able to identify either beneficial or harmful effects of the IPOP on early healing or functional clinical outcomes after amputation.

Dressings Negative-pressure wound dressings (also known as vacuum-assisted closure dressings) are becoming more widely used and are commonly applied in orthopaedic surgery for open wounds associated with fractures, after wound débridements, and before skin closure, as well as for contaminated and infected wounds when closure is contraindicated (Figures 1 and 2). These devices use open-pore foam to fill the wound cavity, an occlusive wound dressing, suction tubing, and a suction device. A wound-healing mechanism of action of negative-pressure wound dressings is the bringing together of the wound edges by the suction distributed through the foam sponge.^5,6 Another healing mechanism of action, which has been determined by finite element computer analysis, is the 5% to 20% strain that negative-pressure wound dressings produce across the healing tissues. This strain promotes cell division and proliferation, growth factor production, and angiogenesis.⁶ Other reported benefits of negative-pressure wound dressings are removal of edema fluid and exudate from the extracellular space and removal of inflammatory mediators and cytokines, whose prolonged effect can hinder the ability of the microcirculation to support damaged tissue. Another positive factor in wound healing is reduction of wound desiccation and enhanced formation of granulation tissue. There is convincing evidence to support the hypothesis that the reduction of lateral tension and hematoma, coupled with an acceleration of the elimination of tissue edema, are the main beneficial mechanisms of action of negative-pressure wound therapy over the incision site.⁷

Over the past several years, there has been an increased frequency of managing residual limb wounds with negative-pressure dressings applied over the incision site at the conclusion of surgery (Figures 3 and 4). Applying these dressings to closed incisions reduces the relative risk of infection.⁸ A randomized controlled trial demonstrated a decrease in postoperative seromas after the application of incisional negative-pressure wound dressings after total hip arthroplasty.⁹ A study by Hansen et al¹⁰ confirmed that negative-pressure dressings reduced or eliminated incisional drainage after hip arthroplasty, and no adverse effects were reported. Negative pressure set between 50 and 125 mm Hg helps to reduce edema and decrease incisional drainage.⁶ Negative-pressure incisional dressings are kept in place for 3 days and may be reapplied or discarded. If no additional fluid collects
in the canister over a 12-hour period, it is recommended that the dressing be discontinued. However, it is likely that, because of the decreased woundedge tension created by the negative-pressure dressing, there is often no measurable fluid accumulation in the collection reservoir. Recent studies have noted that the benefits of negative-pressure dressings may be associated with edema reduction, increased blood flow, and increased granulation tissue in the wound.^6,7 After 3 to 5 days of postoperative negative-pressure wound therapy, healing time may be reduced, and there is evidence of a reduced incidence of wound healing complications and a reduced frequency of infections.⁷ Karlakki et al⁷ reported the existence of good evidence for incisional negative-pressure wound therapy in orthopaedic surgery because of the frequency of patient comorbidities and the substantial incidence of infection. Brem et al¹¹ reported that incisional negative-pressure wound therapy may reduce the risk of delayed wound healing and infection after severe trauma and orthopaedic interventions. In some instances, a rigid dressing may be placed over the negative-pressure wound dressing on the residual limb for added protection.¹²

Negative-pressure wound dressings also can be used over open wounds before definitive skin closure in situations such as traumatic amputations and in the presence of infection when a two- or three-stage amputation is planned.¹³ For open wounds, a new negative-pressure dressing is applied at the second-stage surgery. Two studies reported good results with the application of a custom, topical negative-pressure dressing for open amputations.^14,15

Hydrofiber wound dressings consist of soft nonwoven sodium carboxymethylcellulose fibers integrated with ionic silver. This is a moisture-retention dressing, which forms a gel on contact with wound fluid and has the antimicrobial properties of ionic silver.^1,16

After the use of a negative-pressure dressing, a hydrofiber with silver dressing may be applied over the incision (Figure 5). This dressing can remain in place for up to 7 days and may cover sutures. Because the dressing is impervious to water, patients may shower with the dressing in place. There has been renewed interest and research in using ionic silver (the oxidized active state of silver) as a prophylactic antimicrobial agent in wound dressings because of its broad-spectrum antibacterial range.¹⁶ The gel promotes a moist wound-healing environment but absorbs any wound exudate and contains it away from the wound. Because of the antimicrobial effect of silver, this dressing has the potential to reduce postoperative infections.¹ Cutting et al¹⁷ reported that the silver in the hydrofiber dressing provides a certain amount of resistance to infection. In a randomized study of acute surgical wounds in 100 patients, the performances of hydrofiber and alginate dressings were compared.¹⁸ Ninety-two percent of patients randomized to the hydrofiber dressing were found to experience less pain (mild or none) compared with 80% of those who received alginate dressings. Similarly, 84% of patients who had hydrofiber dressings were pain free at 1 week postoperatively compared with 58% of those treated with alginate dressings. Although statistical significance was not shown, the authors concluded that hydrofiber dressings consistently performed better than the alginate dressings.