Dressing Choice—The dressing chosen for a residual limb also is of paramount importance following amputation. The personalized and dynamic management of postamputation wounds and skin involves achieving optimal healing through a dressing that sustains appropriate moisture levels, addresses edema, helps prevent contractures, and safeguards the limb.38 From the start, using negative pressure wound dressings after surgical amputation can decrease wound-related complications.39
Topical oxygen therapy following amputation also shows promise. In a retrospective case series by Kalliainen et al,40 topical oxygen therapy applied to 58 wounds in 32 patients over 9 months demonstrated positive outcomes in promoting wound healing, with 38 wounds (66%) healing completely with the use of topical oxygen. Minimal complications and no detrimental effects were observed.40
Current recommendations suggest that non–weight-bearing removable rigid dressings are the superior postoperative management for transtibial amputations compared to soft dressings, offering benefits such as faster healing, reduced limb edema, earlier ambulation, preparatory shaping for prosthetic use, and prevention of knee flexion contractures.41-46 Similarly, adding a silicone liner following amputation significantly reduced the duration of prosthetic rehabilitation compared with a conventional soft dressing program in one study (P<.05).47
Specifically targeting wound edema, a case series by Hoskins et al48 investigated the impact of prostheses with vacuum-assisted suspension on the size of residual limb wounds in individuals with transtibial amputation. Well-fitting sockets with vacuum-assisted suspension did not impede wound healing, and the results suggest the potential for continued prosthesis use during the healing process.48 However, a study by Johannesson et al49 compared the outcomes of transtibial amputation patients using a vacuum-formed rigid dressing and a conventional rigid plaster dressing, finding no significant differences in wound healing, time to prosthetic fitting, or functional outcomes with the prosthesis between the 2 groups. When comparing elastic bandaging, pneumatic prosthesis, and temporary prosthesis on postoperative stump management, temporary prosthesis led to a decrease in stump volume, quicker transition to a permanent prosthesis, and improved quality of life compared with elastic bandaging and pneumatic prosthetics.50
The type of material in dressings may contribute to utility in amputation wounds. Keratin-based wound dressings show promise for wound healing, especially in recalcitrant vascular wounds.51 There also are numerous proprietary wound dressings available for patients, at least one of which has particularly thorough data. In a retrospective study of more than 2 million lower extremity wounds across 644 institutions, a proprietary bioactive human skin allograft (TheraSkin [LifeNet Health]) demonstrated higher healing rates, greater percentage area reductions, lower amputations, reduced recidivism, higher treatment completion, and fewer medical transfers compared with standard of care alone.52
Postamputation Dermatologic Concerns
After the postamputation wound heals, a notable concern is the prevalence of skin diseases affecting residual limbs. The stump site in amputees, marked by a delicate cutaneous landscape vulnerable to skin diseases, faces challenges arising from amputation-induced damage to various structures.53
When integrated into a prosthesis socket, the altered skin must acclimate to a humid environment and endure forces for which it is not well suited, especially during movement.53 Amputation remarkably alters normal tissue perfusion, which can lead to aberrant blood and lymphatic circulation in residual limbs.27,53 This compromised skin, often associated with a history of vascular disease, diabetes mellitus, or malignancy, becomes immunocompromised, heightening the risk for dermatologic issues such as inflammation, infection, and malignancies.53 Unlike the resilient volar skin on palms and soles, stump skin lacks adaptation to withstand the compressive forces generated during ambulation, sometimes leading to skin disease and pain that result in abandonment of the prosthesis.53,54 Mechanical forces on the skin, especially in active patients eager to resume pre-injury lifestyles, contribute to skin breakdown. The dynamic nature of the residual limb, including muscle atrophy, gait changes, and weight fluctuations, complicates the prosthetic fitting process. Prosthesis abandonment remains a challenge, despite modern technologic advancements.