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120 HIGHSMITH ET AL. RESIDUAL LIMB ULCER MANAGEMENT IN LEG AMPUTEES 121

and 6.3 cm (control/suction socket group) compared DISCUSSION for prosthetists to educate patients regarding the risk unilateral transtibial patients (five male, one female,
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with mean initial wound areas of 3.6 cm in estab- The purpose of this review was to determine of developing an ulcer as well as numerous methods mean age = 66.5 years, mean weight = 94.6 kg) of
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lished prosthesis users and 3.1 cm in new prosthesis the quantity, quality, and consistency of available of preventing and managing them should they arise, vascular (n = 5) and traumatic (n = 1) etiology pre-
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users reported by Salawu et al. (9,10). Further, these evidence to formulate evidence statements support- including proper device utilization and volume man- scribed VASS prostheses upon presentation with an
wound area measures were made using vastly different ing treatment methods for prosthesis-related RL agement. Specifically, skin ulcers reportedly develop open RL wound (20). Subjects had several comor-
methodologies. For instance, there were manual mea- ulcers. The review identified five articles (Table 3) in nearly 27% of diagnosed skin problems in pros- bidities, including Diabetes Mellitus Type 1 and 2,
surements (10) and scaled on-screen measurements that described the treatment of RL ulceration in 117 thetic users (14). The responsibility for preventing peripheral vascular disease, Charcot joint disease,
taken in software (9). These differences in wound area amputee subjects. With the exception of four bilat- and managing ulcers in the residual limbs of pros- retinopathy, hearing impairment, dermatillomania,
measurement methodologies further complicate the erally involved individuals, subjects had a history thetic users is shared between the prosthetist, who and history of chronic alcohol and tobacco use. All
ability to aggregate data for meta-analyses. of unilateral transtibial amputation of vascular or provides a properly fit device and educates the patient, subjects received physiatrist-prescribed wound care
Ultimately, prosthetic continuance or prosthetic unknown etiologies. The subjects were mostly elderly and the patient, who should practice diligent self-care and were instructed to continue prosthetic use “as
discontinuance were the predominant interven- and had multiple comorbidities, including Type 2 and compliance. much as possible given any pain they may experi-
tion options available to manage RL ulcers related Diabetes Mellitus, coronary artery disease, hyperten- Controversy exists as to whether continued ence and not to limit their activities” (20). Vacuum
to prosthetic use. Multiple adjuvant interventions sion, hyperlipidemia, chronic venous insufficiency, prosthetic use is indicated for amputees with RL pump and prosthetic foot type were not controlled.
were included within the themes of prosthetic con- neuropathy, anemia, post-herpetic neuralgia, pru- ulcerations because ambulation has many physio- Wound size (determined by software analysis of ulcer
tinuance (i.e., use) or discontinuance (i.e., disuse). ritus, and chronic smoking. All subjects received logical benefits that improve wound healing (15), photographs) and time to complete wound closure
These adjunct interventions included: such as increased circulation (16), tissue oxygenation were primary outcome measures. Wound surface
modification of prosthetic use, including restriction (16,17), and fluid filtration (17). Prolonged inactiv- area was 2.17 ± 0.65 cm (initially) and mean time
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1. Prosthetic modification or adjustment and disuse, as an intervention. ity, which is often associated with prosthetic disuse, is to wound closure was 117 ± 113 d (range: 40 to 380
2. Planned progressive prosthetic re-introduction The first empirical evidence statement (EES) associated with several deleterious effects on health, d). During that period, one subject was non-com-
3. Patient education addressed development of an ulcer relative to including reduced functional capacity, respiratory pliant with proper use protocols for a short time
4. Continued prosthetic use (VASS, suction, or improper volume management and utilization of function, skin integrity, and oxygen transportation (≈20 d), another had a hole in the sealing sleeve that
usual suspension) with wound care (during interface components (Table 4). Scenarios that can (17) as well as muscle atrophy (18). This list is not required repair (at ≈100 d), and a third subject suf-
disuse periods or scheduled) contribute to ulceration include weight gain or loss, inclusive of negative psychological effects of inactiv- fered a fall requiring surgery and rehabilitation (at
changes in activity, medication and physiologic ity, such as depression, anxiety, and psychosomatic
Finally, three evidence statements were synthesized changes, componentry damage, patient compliance ≈30 d). Authors concluded VASS prostheses may be
from the results. The topics addressed were 1) ulcer fatigue (19). used while managing RL wounds in transtibial ampu-
etiology, 2) continued prosthetic use, and 3) cessa- issues, and improper patient education. Confidence In the event that an ulcer develops, there are tation patients. Results further suggest a well-fitting
in this statement was moderate. It is standard practice
tion of prosthetic use (Table 4). numerous management options, including pros- VASS socket does not preclude RL wound healing
thetic use or disuse. EES 2 (Table 4) indicates that, and closure in compliant users even without activity
in the absence of comorbidities that may delay healing limitation (20). This recently published data sup-
and impair cognition, patient education and modi- ports EES 2 and suggests that continued prosthetic
Table 4. Empirical Evidence Statements fied prosthetic use with or without elevated vacuum use without activity restrictions may be possible in
Table 4. Empirical Evidence Statements
suspension is safe, can reduce ulcer size, and result the presence of common diabetic-related complica-
Level of
Empirical Evidence Statement Supporting Studies Category in limited but continued function during healing. tions when VASS is utilized. It further suggests that,
Confidence
Improper volume management and utilization of Bruno & Kirby (2009) [Moderate] Conversely, EES 3 (Table 4) indicates that prosthetic on a per-case basis, comorbidities do not preclude
interface components can result in ulceration to the Highsmith & Highsmith (2007) Moderate Ulcer etiology disuse with or without alternative interventions such
skin of the residual limb. [Moderate] continued prosthetic use in the presence of a resid-
as surgery or systemic antibiotics may be indicated ual limb ulcer.
Following development of an ulcer, in the absence of Bruno & Kirby (2009) [Moderate] in the case of residual limbs that ulcerate in the pres-
comorbidities that delay healing and impair Highsmith & Highsmith (2007)
cognition, patient education and modified prosthetic [Moderate] ence of chronic heavy smoking, intractable pain, rapid Limitations
use with or without elevated vacuum suspension is Salawu et al. (2006) [High] Moderate Continued prosthetic use volume and weight change, history of chronic ulcer- Though most included articles demonstrated
safe, can reduce ulcer size, and result in limited but Trabellesi et al. (2012) [High]
continued function during healing. ation, systemic infections, or advanced dysvascular moderate to high internal validity and high exter-
Prosthetic disuse and/or alternative interventions Karakos (2006) [Moderate] etiology. The confidence in both statements is mod- nal validity, only one randomized control trial was
such as surgery or systemic antibiotics, may be Highsmith & Highsmith (2007) erate based on available evidence. included. This indicates substantial need for more
indicated in the case of residual limbs that ulcerate in [Moderate]
the presence of chronic heavy smoking, intractable Moderate Cessation of prosthetic use An additional case series, published after conduct- high-quality research including more randomized
pain, rapid volume and weight change, history of ing this review, reported on continued prosthetic use control trials to determine the optimal treatment
chronic ulceration, systemic infections, or
dysvascular etiology. in ulcerative care. Hoskins et al. described six (n = 6) methods to reduce wound healing time and increase