Stump management after trans-tibial amputation: a systematic review.

In order to achieve stump healing after trans-tibial amputation, various methods are applied, such as soft dressings followed by elastic wrapping of the stump, rigid dressings, semi-rigid dressings, and more recently the application of silicon or gel-liners. A systematic literature search was performed to identify the optimal post-amputation management. The methodological quality of the studies was systematically evaluated by using a predefined list of criteria. Only 11 controlled studies were identified and evaluated for their methodological quality. From these studies, no studies were classified as A-level studies, whereas three were classified as B-level, and 8 were classified as C-level studies. Relevant literature appears heterogeneous with respect to patient selection, intervention and outcome measures. Despite the large variability of included studies, this review reveals a trend in favour of rigid and semi-rigid dressings for achieving stump healing and reduction of stump volume. No conclusions can be drawn with regard to the effect on functional outcome. The literature is not conclusive on the effects of early weight bearing on stump healing, volume reduction, and functional outcome. More research is needed for the development of evidence-based clinical practice guidelines concerning management after transtibial amputation.

Gating of sensation and evoked potentials following foot stimulation during human gait.

To investigate how gait influences the perceived intensity of cutaneous input from the skin of the foot, the tibial or sural nerves were stimulated at the ankle during walking or running on a treadmill. As compared to standing, the detection threshold for these stimuli was raised by more than 30% during the locomotion tasks. During walking, there was a phase-dependent modulation in perceived intensity of suprathreshold stimuli (1.5, 2, or 2.5 x PT). Stimuli given just prior to footfall were perceived as significantly above average (Wilcoxon signed-rank test). In contrast there was a significant phasic decrease in sensitivity for shocks delivered immediately after ipsi- and contralateral footfall. The amplitude of somatosensory evoked potentials (P50-N80 complex), simultaneously evoked from pulse trains to the sural nerve and recorded at scalp level, was, on average, 62% of the level during standing. During gait, the amplitude of this complex was significantly smaller just after footfall than the amplitude during late swing (MANOVA). It is suggested that the reduced sensation and the decreased evoked potentials after touchdown may be due to occlusion or masking by concomitant afferent input from the feet. On the other hand, the phasic increase in sensitivity at the end of swing is thought to result from a centrally generated facilitation of sensory transmission of signals in anticipation of foot-placing.