Exploring the role of transtibial prosthetic use in deep tissue injury development: a scoping review

Abstract

Background: The soft tissue of the residual limb in transtibial prosthetic users encounters unique biomechanical challenges. Although not intended to tolerate high loads and deformation, it becomes a weight-bearing structure within the residuum-prosthesis-complex. Consequently, deep soft tissue layers may be damaged, resulting in Deep Tissue Injury (DTI). Whilst considerable effort has gone into DTI research on immobilised individuals, only little is known about the aetiology and population-specific risk factors in amputees. This scoping review maps out and critically appraises existing research on DTI in lower-limb prosthetic users according to (1) the population-specific aetiology, (2) risk factors, and (3) methodologies to investigate both. Results: A systematic search within the databases Pubmed, Ovid Excerpta Medica, and Scopus identified 16 English-language studies. The results indicate that prosthetic users may be at risk for DTI during various loading scenarios. This is influenced by individual surgical, morphological, and physiological determinants, as well as the choice of prosthetic componentry. However, methodological limitations, high inter-patient variability, and small sample sizes complicate the interpretation of outcome measures. Additionally, fundamental research on cell and tissue reactions to dynamic loading and on prosthesis-induced alterations of the vascular and lymphatic supply is missing. Conclusion: We therefore recommend increased interdisciplinary research endeavours with a focus on prosthesisrelated experimental design to widen our understanding of DTI. The results have the potential to initiate muchneeded clinical advances in surgical and prosthetic practice and inform future pressure ulcer classifications and guidelines.

Changes in Tissue Composition and Load Response After Transtibial Amputation Indicate Biomechanical Adaptation

“…10 There has been relatively little research into skin damage in individuals with lower limb amputations, despite the specific risk factors and high prevalence in this group. 18 Indeed the residual limbs are exposed to challenging biomechanical conditions, impaired load tolerance due to comorbidities, considerable variability in anatomy and surgical reconstruction, and the presence of scar tissue over vulnerable sites. 41 Tissue loading at the residuum-prosthesis interface is influenced by the socket design, with the prosthetist considering both the morphology of the local tissues and their load tolerance.…”

The Impact of Limited Prosthetic Socket Documentation: A Researcher Perspective

“…Whilst little is defined about good fit, much is known about the context of poor fit. Most literature refers to the medical consequences of ill-fitting sockets or inadequate distribution of load, e.g., skin breakdown and deep tissue injury (41)(42)(43)(44). Little is documented about the day-to-day impact on quality-of-life stemming from poor socket fit (3,45).…”

Methods to design bespoke sockets

“…This is well documented in lower limb prosthetic sockets, where pressure is off-loaded by the cyclic loading during the gait cycle ( 7,8 ), but remains an underexplored area within upper limb prosthetic design. Reducing shear pressure is critical for preventing deep tissue injury 9,10 . One method which prosthetists use to reduce socket pressures is to apply the principle of total contact socket design.…”