September 2008 • Vol. 4, No. 4
	Advancing Orthotic and Prosthetic Care Through Knowledge

Bilateral Transtibial Amputation and Delayed Wound Healing in Patient with Peripheral Vascular Disease: Walking with Prosthesis or Re-Amputation?

Anton Johannesson, CPO

Abstract

This article presents a case study to introduce an alternative to a re-amputation at a higher level when dealing with delayed wound healing after transtibial amputation in patients with peripheral vascular disease (PVD).

Despite a large wound after transtibial amputation, a prosthetic fitting was performed. By mobilizing the patient with a vacuum-suspended prosthesis and a total-surface-bearing (TSB) socket, the rehabilitation was started. This method provides an alternative to prolonged rehabilitation or re-amputation at a higher level, both with a risk of poor functional outcome.

Background

When a major amputation is unavoidable, it is essential to select the lowest level that will allow both healing and optimal function. Delayed or failed healing at more distal amputation levels is known to increase morbidity and prolong hospitalization. The choice of a more proximal amputation level benefits wound healing, but lowers the odds of the patient becoming a prosthetic user¹ . This may lead to more social isolation, less independence, and other negative effects regarding the quality of life of the patient². Traditionally, an individually made prosthetic socket is not provided until the wound is completely healed, especially in elderly PVD patients. Vacuum-assisted closure for chronic non-healing wounds is a well-known method of treatment today³. Creating sub-atmospheric pressure within a prosthetic socket is possible by using an airtight suspension sleeve. The weight of the prosthesis creates a negative pressure within the socket in the swing phase. During full load, a positive pressure is produced. It is hypothesized that this enhances the circulation at the distal end of the residuum and promotes the healing process.

Case Study and Methods

A left-side transtibial amputation was performed on a 65-year-old female with PVD. After rehabilitation with a TSB socket, good functional status was obtained, although circulation in the right leg was poor. One year later, after unsuccessful vascular surgery, a transtibial amputation was performed on the right side, leaving a short residual limb. The tissue cover was poor due to previous surgery, which resulted in a necrotic area distally around the suture line (12 x 8 centimeters). Fifty-five days after the surgery, the wound was clean and showed good signs of healing (figure 1). The cavity of the wound was filled with highly absorbing bandages and covered with thin plastic film. A silicone liner without a distal adapter was rolled on. A prosthesis was provided using a pressure casting socket (ICEX™, Ossur Inc., Reykjavik, Iceland) with a distal valve, lightweight pylon and foot. An airtight suspension sleeve was used to provide a vacuum suspension. The dressings were changed at intervals depending on the amount of leakage from the wound, to avoid wound fluid getting in contact with healthy skin. The amount of weight put on the leg and the walking distance was increased during this period, and the patient was in charge of the speed of progress. The prosthesis was used most of the day (minimum eight hours) and the patient stayed at home during the whole healing period. During the first three weeks the patient came in three times a week for wound inspection and training, after that, only once a week. After four weeks the size and the depth of the wound was reduced to half (figure 2). After eight weeks a three-ply sock was added for better fit and comfort (figure 3). After 12 weeks the wound was totally healed (figure 4).

Figure 1	Figure 3
Figure 3	Figure 4

Discussion

In this case, a higher-level amputation was not an option if walking ability was to be reestablished. The traditional practice of delaying the prosthetic fitting until the wound is completely healed would not only have prolonged the healing time but presumably the patient would have adjusted to a wheelchair, risking knee and hip contractures. This case study shows favorable results demonstrating that a TSB vacuum suspension socket can enhance the wound healing through better distal blood circulation. This shortens the rehabilitation time and helps avoid a re-amputation at a higher level. Further research is warranted to explore the approach. The author has now used this method for ten years in over 20 cases of delayed wound healing without any setbacks. The method requires a good teamwork between the doctor, the wound specialist nurse, the physiotherapist, the prosthetist, and most of all, the patient.

References

1. Johannesson A, Larsson GU, Oberg T. From Major Amputation to Prosthetic Outcome: A Prospective Study of 190 Patients in a Defined Population. Prosthet Orthot Int 2004 April;28(1):9-21.

2. Cutson TM, Bongiorni DR. Rehabilitation of the Older Lower Limb Amputee: A Brief Review. J Am Geriatr Soc 1996 November;44(11):1388-93.

3. Argenta LC, Morykwas MJ. Vacuum-Assisted Closure: A New Method for Wound Control and Treatment: Clinical Experience. Ann Plast Surg 1997 JUNE;38(6):563-76.

Anton Johannesson, CPO, is affiliated with the Department of Orthopaedics, Hässleholm/Kristianstad, S-281 25 Sweden.

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