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RESIDUAL LIMB ULCER MANAGEMENT IN LEG AMPUTEES 121

for prosthetists to educate patients regarding the risk unilateral transtibial patients (five male, one female,
of developing an ulcer as well as numerous methods mean age = 66.5 years, mean weight = 94.6 kg) of
of preventing and managing them should they arise, vascular (n = 5) and traumatic (n = 1) etiology pre-
including proper device utilization and volume man- scribed VASS prostheses upon presentation with an
agement. Specifically, skin ulcers reportedly develop open RL wound (20). Subjects had several comor-
in nearly 27% of diagnosed skin problems in pros- bidities, including Diabetes Mellitus Type 1 and 2,
thetic users (14). The responsibility for preventing peripheral vascular disease, Charcot joint disease,
and managing ulcers in the residual limbs of pros- retinopathy, hearing impairment, dermatillomania,
thetic users is shared between the prosthetist, who and history of chronic alcohol and tobacco use. All
provides a properly fit device and educates the patient, subjects received physiatrist-prescribed wound care
and the patient, who should practice diligent self-care and were instructed to continue prosthetic use “as
and compliance. much as possible given any pain they may experi-
Controversy exists as to whether continued ence and not to limit their activities” (20). Vacuum
prosthetic use is indicated for amputees with RL pump and prosthetic foot type were not controlled.
ulcerations because ambulation has many physio- Wound size (determined by software analysis of ulcer
logical benefits that improve wound healing (15), photographs) and time to complete wound closure
such as increased circulation (16), tissue oxygenation were primary outcome measures. Wound surface
(16,17), and fluid filtration (17). Prolonged inactiv- area was 2.17 ± 0.65 cm (initially) and mean time
2
ity, which is often associated with prosthetic disuse, is to wound closure was 117 ± 113 d (range: 40 to 380
associated with several deleterious effects on health, d). During that period, one subject was non-com-
including reduced functional capacity, respiratory pliant with proper use protocols for a short time
function, skin integrity, and oxygen transportation (≈20 d), another had a hole in the sealing sleeve that
(17) as well as muscle atrophy (18). This list is not required repair (at ≈100 d), and a third subject suf-
inclusive of negative psychological effects of inactiv- fered a fall requiring surgery and rehabilitation (at
ity, such as depression, anxiety, and psychosomatic ≈30 d). Authors concluded VASS prostheses may be
fatigue (19). used while managing RL wounds in transtibial ampu-
In the event that an ulcer develops, there are tation patients. Results further suggest a well-fitting
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
fied prosthetic use with or without elevated vacuum use without activity restrictions may be possible in
suspension is safe, can reduce ulcer size, and result the presence of common diabetic-related complica-
in limited but continued function during healing. tions when VASS is utilized. It further suggests that,
Conversely, EES 3 (Table 4) indicates that prosthetic on a per-case basis, comorbidities do not preclude
disuse with or without alternative interventions such continued prosthetic use in the presence of a resid-
as surgery or systemic antibiotics may be indicated ual limb ulcer.
in the case of residual limbs that ulcerate in the pres-
ence of chronic heavy smoking, intractable pain, rapid Limitations
volume and weight change, history of chronic ulcer- Though most included articles demonstrated
ation, systemic infections, or advanced dysvascular moderate to high internal validity and high exter-
etiology. The confidence in both statements is mod- nal validity, only one randomized control trial was
erate based on available evidence. included. This indicates substantial need for more
An additional case series, published after conduct- high-quality research including more randomized
ing this review, reported on continued prosthetic use control trials to determine the optimal treatment
in ulcerative care. Hoskins et al. described six (n = 6) methods to reduce wound healing time and increase