Early trans-tibial oedema control using polymer gel socks

Rigid dressings versus soft dressings for transtibial amputations

BACKGROUND

Dressings are part of the routine postoperative management of people after transtibial amputation. Two types of dressings are commonly used; soft dressings (e.g. elastic bandages, crepe bandages) and rigid dressings (e.g. non-removable rigid dressings, removable rigid dressings, immediate postoperative protheses). Soft dressings are the conventional dressing choice as they are cheap and easy to apply, while rigid dressings are costly, more time consuming to apply and require skilled personnel to apply the dressings. However, rigid dressings have been suggested to result in faster wound healing due to the hard exterior providing a greater degree of compression to the stump.

OBJECTIVES

To assess the benefits and harms of rigid dressings versus soft dressings for treating transtibial amputations.

SEARCH METHODS

In December 2018 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, EBSCO CINAHL Plus, Ovid AMED and PEDro to identify relevant trials. To identify further published, unpublished and ongoing studies, we also searched clinical trial registries, the grey literature, the reference lists of relevant studies and reviews identified in prior searches. We used the Cited Reference Search facility on ThomsonReuters Web of Science and contacted relevant individuals and organisations. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that enrolled people with transtibial amputations. There were no restrictions on the age of participants and reasons for amputation. Trials that compared the effectiveness of rigid dressings with soft dressings were the main focus of this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-text publications for eligible studies. Two review authors also independently extracted data on study characteristics and outcomes, and performed risk of bias and GRADE assessments.

MAIN RESULTS

We included nine RCTs and quasi-RCTs involving 436 participants (441 limbs). All studies recruited participants from acute and/or rehabilitation hospitals from seven different countries (the USA, Australia, Indonesia, Thailand, Canada, France and the UK). In all but one study, it was clearly stated that amputations were secondary to vascular conditions.Primary outcomes Wound healing We are uncertain whether rigid dressings decrease the time to wound healing compared with soft dressings (MD -25.60 days; 95% CI -49.08 to -2.12; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is not clear whether rigid dressings increase the proportion of wounds healed compared with soft dressings (RR 1.14; 95% CI 0.74 to 1.76; one study, 51 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Adverse events It is not clear whether rigid dressings increase the proportion of skin-related adverse events compared with soft dressings (RR 0.65; 95% CI 0.32 to 1.32; I² = 0%; six studies, 336 participants (340 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision.It is not clear whether rigid dressings increase the proportion of non skin-related adverse events compared with soft dressings (RR 1.09; 95% CI 0.60 to 1.99; I² = 0%; six studies, 342 participants (346 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. In addition, we are uncertain whether rigid dressings decrease the time to no pain compared with soft dressings (MD -0.35 weeks; 95% CI -2.11 to 1.41; one study of 23 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Secondary outcomesWe are uncertain whether rigid dressings decrease the time to walking compared with soft dressings (MD -3 days; 95% CI -9.96 to 3.96; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision. We are also uncertain whether rigid dressings decrease the length of hospital stay compared with soft dressings (MD -30.10 days; 95% CI -49.82 to -10.38; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is also not clear whether rigid dressings decrease the time to readiness for prosthetic prescription and swelling compared with soft dressings, as results are based on very low-certainty evidence, downgraded twice for very high risk of bias and once/twice for serious/very serious imprecision. None of the studies reported outcomes on patient comfort, quality of life and cost.

AUTHORS' CONCLUSIONS

We are uncertain of the benefits and harms of rigid dressings compared with soft dressings for people undergoing transtibial amputation due to limited and very low-certainty evidence. It is not clear if rigid dressings are superior to soft dressings for improving outcomes related to wound healing, adverse events, prosthetic prescription, walking function, length of hospital stay and swelling. Clinicians should exercise clinical judgement as to which type of dressing they use, and consider the pros and cons of each for patients (e.g. patients with high risk of falling may benefit from the protection offered by a rigid dressing, and patients with poor skin integrity may have less risk of skin breakdown from a soft dressing).

Prosthetic interventions for people with transtibial amputation: Systematic review and meta-analysis of high-quality prospective literature and systematic reviews

Considering transtibial amputation (TTA) rehabilitation costs and complexity, high-quality literature should inform clinical practice. Systematic reviews (SRs) suggest this is not the case. This article's purpose was to review the highest-quality evidence available to guide clinical practice for TTA regarding five prosthetic intervention areas. Six databases were searched for high-quality SRs and prospective clinical trials (randomized clinical trials [RCTs]). Reviewers screened, sorted, rated (i.e., methodologic quality, bias risk), and extracted article data. Meta-analyses were conducted when possible. Thirty-one references were included (25 RCTs and 6 SRs). Five topical areas emerged (alignment, feet and ankles, interface, postoperative care, pylons). Twenty-three evidence statements were supported by level 2 evidence and eight by level 1 evidence. All RCTs reported randomization and reasonable data presentation. Concealed allocation and blinding were not widely used. Mean attrition was 11%. SRs included no meta-analyses. Functional level was poorly reported. Grouping feet and ankle components by functional classification enabled meta-analyses, though variance was considerable given the small sample sizes. Prosthetic interventions are generally safe for TTAs. High-quality literature enabled formulation of evidence statements to support select clinical practice areas, though quantity was lacking. Thus, numerous topics related to TTA care lack rigorous evidence. Although blinding in prosthetic research requires increased funding and effort, it could greatly improve the methodologic quality of prosthetic research.

Influence of prior activity on residual limb volume and shape measured using plaster casting: results from individuals with transtibial limb loss

The purpose of this research was to determine whether prior activity affected the shape of a plaster cast taken of a transtibial residual limb. Plaster casts were taken twice on one day in 24 participants with transtibial limb loss, with 5 s between doffing and casting in one trial (PDI-5s) and 20 min in the other trial (PDI-20m). The ordering of the trials was randomized. The mean +/- standard deviation radial difference between PDI-20m and PDI-5s was 0.34 +/- 0.21 mm when PDI-5s was conducted first and -0.02 +/- 0.20 mm when PDI-20m was conducted first. Ordering of the trials had a statistically significant influence on the mean radial difference between the two shapes (p = 0.008). The result shows that prior activity influenced the residual limb cast shape. Practitioners should be mindful of prior activity and doffing history when casting an individual's limb for socket design and prosthetic fitting.

Residual limb volume change: systematic review of measurement and management

Management of residual limb volume affects decisions regarding timing of fit of the first prosthesis, when a new prosthetic socket is needed, design of a prosthetic socket, and prescription of accommodation strategies for daily volume fluctuations. This systematic review assesses what is known about measurement and management of residual limb volume change in persons with lower-limb amputation. Publications that met inclusion criteria were grouped into three categories: group I: descriptions of residual limb volume measurement techniques; group II: studies investigating the effect of residual limb volume change on clinical care in people with lower-limb amputation; and group III: studies of residual limb volume management techniques or descriptions of techniques for accommodating or controlling residual limb volume. We found that many techniques for the measurement of residual limb volume have been described but clinical use is limited largely because current techniques lack adequate resolution and in-socket measurement capability. Overall, limited evidence exists regarding the management of residual limb volume, and the evidence available focuses primarily on adults with transtibial amputation in the early postoperative phase. While we can draw some insights from the available research about residual limb volume measurement and management, further research is required.

Inter- and intra-observer reproducibility and validity of an indirect volume measurement in transtibial amputees

The objective of the study was to assess the measurement properties of an indirect volumetric measurement using segmental circumferential measurements fitted into a formula of a truncated cone (Sitzia's method) in long-term transtibial amputees. Twenty-eight participants with a transtibial amputation >1 year participated in the study. Two observers measured stump volume twice, two weeks apart, using both Sitzia's method and the water displacement volumetric method (criterion standard test). The mean differences and upper and lower limits of agreement between the water displacement volumetric method and Sitzia's method, between the first and second assessment, and between both assessors were calculated. Intra-class correlation coefficients (ICCs) were derived from random-effects two-way analysis of variance. Inter-observer agreements of both methods were high and ranged from 86-96%. Intra-observer agreement ranged between 57% and 71%. In both methods the inter- and intra-observer differences were not significant. ICCs ranged from 0.88-0.99 and were better for inter-observer compared to intra-observer reproducibility. Lower stump volumes were observed in Sitzia's method compared to water displacement volumetric method, with high ICC's (0.92-0.95) between both methods. Although Sitzia's method systematically underestimates stump volume, it is a reliable and feasible alternative to the criterion standard test. To determine its validity to detect (longitudinal) differences in stump volume, follow-up research is needed in participants with recent amputations.

Removable rigid dressings versus soft dressings: a randomized, controlled study with dysvascular, trans-tibial amputees

This study compares a standard soft dressing (SSD) with a removable rigid dressing (RRD) in a randomized, controlled trial using 50 dysvascular trans-tibial amputees. Both dressing types were applied immediately post-operatively and were only removed for wound dressing changes. Half the subjects were allocated prospectively by ballot to either the RRD group or the SSD group. There was a strong trend indicating that primary wound healing of the stump occurred almost 2 weeks earlier in subjects using the RRD (RRD = 51.2 days +/- 19.4; SSD = 64.7 days +/- 29.5; P= 0.07; RRD: n =17; SSD: n = 14.) There were no significant differences between the other parameters measured which included time to prosthetic fitting, length of hospital stay, incidence of stump breakdown, and time taken for stump volume to stabilize. The incidence of stump damage due to falls was also recorded, the results indicating that RRDs may protect the new stump from trauma.