Trans-tibial prosthesization in large area of residual limb wound: Is it possible? A case report

Trans-tibial amputation is a common sequela of vascular complications caused by diabetes mellitus [1]. Using prosthesis is the only way for patients with lower-limb amputation to regain the ability to walk and acquire independence in activities of daily living (ADLs). According to Van Velzen [2], prior to fitting a prosthesis the residual limb has to meet certain criteria: the surgical wound must be healed; the oedema must be resolved; the residual limb should be conically shaped and mature. General measures, suggested for dysvascular patients with wound healing problems, include complete bed rest, optimization of diabetes control and adequate diet [3]. Many lower limb amputations do not heal in a primary fashion; therefore, it is not uncommon for patients referred to prosthetic rehabilitation to have small areas requiring secondary healing and a period of minor wound care [4]. Good residual limb health is one of the major determinants of mobility. Efforts must be made to minimize residual limb complications [5,6] and to avoid delayed prosthesis fitting, which is the main cause of increased rehabilitation costs after amputation [7]. Vacuum-assisted closure (VAC) for chronic and non-healing wounds is a well-known method of treatment today [8,9]. Armstrong and Lavery [10] reported that VAC could reduce the re-amputation risk in patients affected by recurrent skin lesions. However, some complications associated with VAC therapy include pain, skin irritation, tissue necrosis, bleeding, pressure from tubing, and infection [11]. We report the case of a patient with a trans-tibial amputation who, in spite of an open residual limb wound, was fitted with a vacuum-assisted socket system (VASS). Note that VASS is not a VAC device; in fact, with this system no foam or sponges are applied over the wound. VASS of Otto Bock HealthCare GmbH, Duderstadt, Germany was used to fit our patient. This device is able to provide the following: enhanced negative pressure during the swing phase through a one-way check valve with a vacuum pump, that draws fluid into the residual limb; reduce the positive pressure on the residual limb during the stance phase, so that less fluid is driven out of the limb [12,13].