Effects of Early Mobilization on Unhealed Dysvascular Transtibial Amputation Stumps: A Clinical Trial

VanRoss ER, Johnson S, Abbott CA. Effects of early mobilization on unhealed dysvascular transtibial amputation stumps: a clinical trial. Arch Phys Med Rehabil 2009; 90:610-7. Objective: To observe the effects of early mobilization on unhealed transtibial (TT) amputation stump wounds of dysvascular etiology. An unhealed stump was defined as having a wound greater than 1cm X 1cm at least 3 weeks after surgery. Design: An observational cohort study. Setting: This center receives about 250 new lower-limb amputees a year from over 50 surgeons working in 16 hospitals. Over 35% are unhealed. Participants: Sixty-six consecutive new TT amputees (age 62.8 +/- 10.8y) of dysvascular etiology (diabetes 50%) with unhealed stumps were recruited. Sixty-one percent were current or past smokers. The mean +/- SD stump wound size was 7.7 +/- 2.7cm X 3.2 +/- 2.0cm. Interventions: The wound size was measured, and stump transcutancous oxygen (TcPO(2)) and transcutaneous carbon dioxide (TcPCO(2)) were measured. Wounds were debrided and dressed by using a standard protocol. Mobilization using a Pneumatic Post-Amputation Mobility (PPAM) Aid for approximately 3 weeks was followed by provision of a TT prosthesis. A standard physiotherapy walking training program was performed. Main Outcome Measures: Stump wound healing, time to achieve healing, and resting transcutaneous oxygen pressure pre- and posttherapy. Results: Of the 66 amputees, 4 did not start. Sixty-two started; 6 withdrew, and 56 completed the trial. Complete wound healing was achieved in 74% (46/62) over a mean of 141 (87-270) days. The mean SD stump TcPO(2) at baseline was 41.3 +/- 19.8mmHg and increased significantly to 50.6 +/- 21.9mmHg (P<02) after 97 (34-185) days of mobilization. Nine of 46 required revision plastic surgery. Five subjects, whose wounds were healing, became unwell, dropped out, and later deceased. Five subjects, all current smokers, did not heal and underwent higher amputation. Conclusions: Patients with large unhealed TT stump wounds can simultaneously undergo walking training by using a prosthesis and can achieve wound healing. Seventy-four percent of subjects achieved full wound healing. The small minority of patients who did not heal were current smokers whose TcPO(2) levels did not improve throughout the trial. Rising levels of stump TcPO(2) were associated with wound healing.