Determinants of healing and readiness for prosthetic fitting after transtibial amputation: Integrative literature review.

BACKGROUND: Healing after an amputation is a critical step in the recovery process. Delayed wound healing can lead to deconditioning and flexion contractures which reduce a patient's ability to use a prosthesis, ambulate independently, and return to community participation. The purpose of this integrative literature review was to determine the evidence-based physiological factors, comorbidities, postoperative management, and outcome measures associated with healing after transtibial amputation and address how these factors clinically guide readiness for prosthetic intervention. METHODS: Authors completed Google Scholar searches to identify the most effective search terms to locate salient publications. Authors also completed literature searches of Ovid MEDLINE and Epub Ahead of Print, In-Process, and Other Nonindexed Citations and Daily <1946 to August 6, 2020>; Embase Classic + Embase <1947 to August 6, 2020>; and CINAHL Complete <1946 to August 6, 2020> databases using the following search terms: "transtibial," "trans-tibial," "below knee," "BKA," "amputation," amputation stump," "amputee," "wound healing," and "heal/s/ed/ing." The authors decided to include all levels of evidence to capture the maximum number of articles related to the determinants of healing and readiness for prosthetic fitting after transtibial amputation. RESULTS: The searches identified 2067 potential articles for review, and after removing articles not relevant to the topic, authors completed full-text assessment on 20 articles. These included review and synthesis on three randomized controlled trials and 12 cohort studies. CONCLUSION: Preamputation assessment is most critical in patients who present with a longer list of comorbidities and suboptimal physiologic factors known to predict wound complications. Clinical judgment is most subjective when determining the degree of healing over time. Readiness for prosthetic treatment need not wait for complete healing of the residuum. Future research is needed to assess transcutaneous oxygen profusion along with other noninvasive measures of blood flow and perfusion as a more objective way to track progression of healing over time. This objective methodology would quantify healing, reduce subjectivity, and promote research to compare different enhanced recovery after surgery protocols for their impact on healing after amputation.

Comparing Temporospatial Performance During Brisk and Self-Paced Walking by Men With Osteomyoplastic Transfemoral Amputation and Controls Using Pressure and Muscle Activation Peak Times.

Background: The aim of osteomyoplastic transfemoral amputation (OTFA) is to produce sustained, robust prosthetic gait performance by residuum reconstructing. A better understanding of residuum-socket interface pressures (RSI) and residuum muscle activation should uniquely reveal gait stability to better inform long-term rehabilitation goals. Objectives: The objectives of this study are to characterize RSI pressures and residuum muscle activation in men with OTFA while walking at two speeds and compare temporospatial muscle activation with intact controls. Methods: In this study, we observed and compared healthy men with OTFA and controls during 2-min gait trials at brisk and self-paced speeds, two visits, and 1 year apart. RSI pressures and hip adductors, hamstrings, and quadriceps activation were recorded for those with OTFA. OTFA temporospatial muscle activation patterns were compared with the controls. Within the extracted strides, heel-strike and toe-off events and EMG activation peak times were characterized and compared. Peak times for pressure and EMG activity were examined in individual muscles and antagonist muscles of residual and intact limbs. Results: Six men with OTFA exhibited adductor, hamstring, and quadriceps co-contraction within intact and residual limbs, regardless of walking speed or trial. Co-contraction within their intact limb occurred throughout the gait cycle. Within the residuum, co-contraction occurred during weight transference. The 75% most likely RSI peaks occurred during stance. EMG peaks were 75% most likely to occur during early stance, terminal stance-initial swing, and terminal swing. Conclusion: Participants with OTFA demonstrated adductors-hamstrings-quadriceps co-contraction in the intact thigh and residuum with corresponding RSI pressure increase, primarily during transitions between stance and swing, indicating gait instability, demonstrating the need to explicitly address these deficits continuously in rehabilitation and wellness settings.

MANAGEMENT OF PODODERMATITIS WITH AN ORTHOTIC BOOT IN A SOUTHERN ISABELA GIANT TORTOISE (CHELONOIDIS VICINA).

A 62-yr-old male Southern Isabela giant tortoise (Chelonoidis vicina) had a 1-yr history of chronic, reoccurring pododermatitis on the palmar surface of the left forelimb. Aggressive wound management was instituted and included surgical debridement, vacuum-assisted closure, and orthotic boot support during healing. A custom fabricated, carbon fiber clamshell Charcot Restraint Orthotic Walker walking boot was utilized to reduce focal pressure over the wound during weight bearing and promote a more normal gait. Distal padding was used to distribute pressure on the palmar surface of the left forelimb, with a focal depression in the padding preventing pressure directly over the wound. The design and trim lines were adjusted to allow shoulder and elbow motion without impingement. The clamshell design allowed relatively easy removal for wound inspection and dressing changes. The wound ultimately resolved after 9 wk of management with the orthotic boot, with no reoccurrence over the next 3 yr.

Non-invasive methods to maintain cervical spine position after pediatric tracheal resections.

OBJECTIVES: To present our experience with two methods of neck stabilization after pediatric tracheal resection with primary anastomosis as possible alternatives to the traditional chest-chin suture. METHODS: Children undergoing tracheal resection and/or cricotracheal resection with anastomosis under tension were placed in cervical spine flexion postoperatively with either a chest-chin (Grillo) suture, an Aspen cervical collar or Trulife Johnson cervical-thoracic orthosis (CTO). A retrospective chart review of tracheal resections performed between 2005 and 2016 was completed to evaluate the positive and negative factors associated with each neck flexion technique. RESULTS: Of the 20 patients, there were 13 patients with the Grillo suture, 4 with the Aspen collar and 3 patients with the Johnson CTO. There were 13 tracheal resection procedures and 7 cricotracheal resections, all of which had anastomosis under tension. One major anastomosis dehiscence was noted with the Grillo suture technique which required reoperation. Two patients with the Grillo suture experienced skin breakdown at the suture site. The Aspen cervical collar, which fixed the cervical spine and prevented lateral and rotational motion, was limited in several cases in that it placed the spine in slight hyperextension. The Johnson CTO provided the most support in a flexed position and prevented cervical spine motion in all directions. No anastomosis complications were noted with the Aspen collar or the Johnson CTO, however, several patients sustained minor cutaneous wounds. CONCLUSION: In this series the Aspen cervical collar and Johnson CTO were used successfully as non-Grillo alternatives to postoperative neck stabilization in pediatric tracheal resections. Modifications to both devices are proposed to minimize cutaneous injuries and increase immobilization of the cervical spine in the desired flexed position. Although these devices appear to be safe and may be better tolerated, further innovation is needed to improve the design and fit of these devices.