In Hong Kong, the incidence of major lower limb amputation is approximately 4.8 in 100,000 per year.1 Lower limb amputation is indicated for most persons because of infection, gangrene, chronic tibial osteomyelitis, acute lower limb ischemia,2–5 and trauma.2 In the past decades, the outcomes of amputation rehabilitation programs have been the main focus.6 Rarely, studies have been conducted on postoperative residual limb management, which is a crucial part of preparing the residual limb for prosthesis fitting.7,8
The aims of postoperative residual limb management for transtibial amputation include edema control and better shaping of residual limbs. These factors can facilitate better prosthesis fitting, which is essential for successful rehabilitation for self-care and mobility.3,9 Previous studies have demonstrated the effectiveness of different residual limb management techniques after transtibial amputation. Residual limb bandaging10–12 and elastic residual limb sock10,13 were two techniques recommended for persons with transtibial amputation to reduce edema and improve residual limb shape.12,13 The effects of both methods are well documented in the previous literature.14,15 Significant reduction in residual limb volume has been found for persons using either residual limb bandaging technique13,16 or residual limb sock.13
RESIDUAL LIMB BANDAGING
The figure-of-eight bandaging technique is the most often chosen technique for residual limb management after amputation.13,17 This technique consists of oblique turns that alternately ascend and descend after encircling the lower limb, making a figure of eight.18 The greatest pressure is applied at the distal end of the residual limb and allows several degrees of compression over the residual limb to control edema.11
Previous studies have shown that this technique is effective in reducing edema and better shaping of the residual limb.13,16 Besides, it is light in weight and washable.10 As proximal joint movements and the movement of residual limbs against bedclothes may cause the slipping down and wrinkling of the bandages, rewrapping is frequently needed.10 These wrinkles can create uneven pressure over the residual limb leading to skin abrasion and breakdown.10 It is also difficult to control the varied quality of elastic bandaging application by different persons.19 Poor technique can induce pressure that may provide adverse effect to the residual limb.20
ELASTIC RESIDUAL LIMB SOCK
The elastic residual limb sock, which is also called an elastic residual limb shrinker, is a sock-like garment that is conical in shape. One of the advantages of elastic residual limb sock application is easy donning and doffing. The use of residual limb socks can provide compression that helps reduce edema and gives light protection to the limb, as well as helps to shape it into a cylindrical shape for prosthesis fitting.13 However, its disadvantages are that it can be applied only after the sutures have been removed and the drainage has stopped.10 Frequently donning and doffing a residual limb sock may create excessive distracting pressure over the distal end of the residual limb, which can cause wound drainage that would soil the residual limb sock.10
Manella15 conducted a study to compare the effects of bandaging and residual limb socks on residual limb management for persons with transtibial amputation. It was found that the residual limb sock was more effective in decreasing the residual limb volume during a period of 4 weeks. Although the residual limb bandaging technique and the residual limb sock showed encouraging results in the residual limb management, there have been few recent studies conducted to compare the effects between these two techniques. This study objective was to compare the effectiveness of residual limb bandaging or residual limb sock use in terms of residual limb circumferential changes, shape, and firmness.
Inpatients who had undergone a transtibial amputation within a month in a local orthopedic rehabilitation unit were recruited by convenient sampling. The participants recruited were required to have Cantonese version of Mini-Mental State Examination (CMMSE)21 Scores 16 or above and no other medical complications or psychiatric illness.
The design was a prospective two-group experimental design in which pretest and posttests were applied to investigate whether residual limb bandaging or residual limb sock is more effective in reducing residual limb edema, increasing firmness, and improving shape. Ethical approval from the local rehabilitation setting was obtained beforehand.
When patients who fulfilled the recruitment criteria had entered the orthopedic rehabilitation unit, a detailed description of the study was provided. Then, written consents were collected before they participated in the study. The participants were randomly assigned to the residual limb bandaging group or the residual limb sock group by a clerical officer who was blinded to this study. The participants in the residual limb bandaging group were trained in the figure-of-eight bandaging technique by occupational therapists with clinical experience of 5 years or more. Ward nurses served as liaisons to provide cues or assistance to the participants if they forgot the residual limb bandaging skills. The participants were advised to follow the guideline for effective residual limb bandaging, as recommended by May10 and Brady,22 including 1) application of bandaging for more than 20 hr a day, 2) application of figure-of-eight bandaging with most tension placed on the distal part of residual limb, and 3) rewrapping the limb three times a day or as indicated. For the participants in the residual limb sock group, three tailor-made elastic residual limb socks were fabricated. They were advised to apply the residual limb sock for more than 20 hr a day during the 6-week time period and to regularly check to see whether the residual limb sock had slipped down from the residual limb. Case occupational therapists also closely monitored the size of the residual limb sock and revised the sock if indicated for maximizing the residual limb management effect.
All participants were provided with standard functional training according to the lower limb amputation rehabilitation protocol in the local rehabilitation setting. Circumferential residual limb measurement at tibial tuberosity, 5 and 10 cm distal to tibial tuberosity, together with five-point Visual Analogue Scales (VAS) on residual limb shape, residual limb solidity, and participants' satisfaction on residual limb appearance were obtained at baseline and the consecutive 5 weeks after the prescription of either residual limb bandaging or residual limb sock.
Circumferential residual limb measurement was taken by using soft measuring tape, as advised by Krouskop et al.23 At each measurement, the residual limb was positioned on a foam block to keep the knee joint in 60° of flexion, as recommended by Persson and Liedberg24 in a standardized residual limb assessment protocol. Circumferential measurements at tibial tuberosity, 5 and 10 cm distal to tibial tuberosity along the long axis of the residual limb, were taken with an aim of collecting information about the volume changes of the residual limb in accordance to the suggestion of Zheng et al.25
Three five-point VAS rating scales were used to investigate residual limb shape, solidity, and participants' satisfaction with the limb's appearance in the 6-week assessment time period. The development of the VAS rating scales of residual limb shape and residual limb solidity was based on the previous literature on residual limb inspection.24 To enhance the interrater reliability of the rating scales, all investigators of this study participated in briefing sessions on how to rate the residual limbs with the VAS rating scales. Besides, pilot use of the rating scales was conducted for 10 persons with transtibial amputation before launching the main study.
All data collected were analyzed with the use of the Statistical Package for the Social Science (SPSS version 12.0 for Windows; SPSS, Chicago, IL). With an aim to prove the homogeneity of the two groups of participants, chi-square statistics were used to compare sex, diagnosis, amputation cause, and residual limb skin flap types between the groups. An independent t-test was then used to compare age, residual limb length, and admission CMMSE Scores between the groups.
Repeated measure analysis of variance with CMMSE scores, residual limb flap types, and residual limb characteristics as covariates were used to investigate the difference of outcome measures within and between the groups across the six-week time interval.
A total of 81 participants were recruited in this study. Four patients were unable to complete the protocol and were excluded from data analysis. The reasons for not continuing their study were due to either their deaths during the program or unwillingness to perform residual limb bandaging on their own. As a result, a total of 77 participants were used for data analysis, with 39 and 38 of them randomly allocated to the bandaging group and residual limb sock group, respectively. Participants' ages ranged from 30 to 93 years (mean age 67.14 years; standard deviation 13.07). Forty-nine of them were men (63.6%) and 28 were women (36.4%). Seventy-four (96.1%) participants had medical-induced causes for amputation, whereas the remainder of the amputations were due to trauma (3.9%). Forty-six participants (59.7%) had amputations with sagittal flap, whereas the rest of them had amputations with long posterior skin flap. Their mean admission CMMSE was 22.67 (SD 5.64).
Chi-square statistics and independent t-test showed that there were no significant differences over age, CMMSE scores, residual limb length, skin flap type, and amputation causes between the groups (p > 0.05). The demographics are summarized in Table 1.
To investigate the difference between residual limb bandaging and residual limb sock in reducing residual limb circumference, improving shape, residual limb solidity, and participants' satisfaction with the residual limb's appearance, repeated measures analysis of variance with CMMSE scores, residual limb flap types, and residual limb characteristics as covariates were conducted across the 6-week time interval (Tables 2–13).
Results showed that there was significant reduction in the circumferential measurement at the tibial tuberosity, 5 and 10 cm distal to the tibial tuberosity for both the residual limb bandaging group (F (1, 38) = 0.02–18.56, p < 0.05) and residual limb sock group (F(1, 37) = 3.12–27.16, p < 0.05). Only the bandaging group showed significant improvement on residual limb shape (F(1, 38) = 1.00–5.5, p < 0.05).
When comparing the outcome measures between the groups, significant differences were found on residual limb circumferential measurement at 5 cm distal to tibial tuberosity (F (1, 36) = 5.69–7.23, p < 0.05) at week 3 to 5. There were also statistical significant difference found on the residual limb solidity (F(1, 36) = 7.77–7.99, p < 0.05) at week 1 to 2 and week 4 to 5 between the groups. Significant association with age and CMMSE scores were detected on residual limb circumferential measurement and residual limb solidity between the groups (p < 0.05). However, no significant difference was found on the participants' satisfaction on residual limb appearance (p > 0.05).
The study showed that that both bandaging and residual limb sock techniques were effective in reducing edema and improving the residual limb's shape and firmness. Unlike the result in the study by Manella,15 this study showed that the residual limb bandaging group had more reduction on residual limb circumferential measurement and residual limb firmness across the 6-week time period. The results also showed that increasing age and poor mental function of patients are limiting factors for applying the residual limb bandaging technique. It could be explained by the theory that increasing age may hinder the ability of participants to learn the bandaging technique.26,27 This was similar to the study by Visser,28 which showed that education and skills reinforcement are needed for facilitating the residual limb bandaging technique. The use of residual limb socks could be recommended as an alternative residual limb management technique for persons with fair hand and cognitive functions.
There were several limitations in this study. First, the small sample size may have limited investigators in detecting possible effects of the different treatment modalities. Besides, the rating scales used in the study were only objective measures for assessing residual limb shape and residual limb solidity. To improve the quality of outcomes collected, more subjective instruments are recommended; for example, spiral x-ray computed tomography imaging and a specifically designed cylindrical tank for assessing residual limb shape.29,30 The limited skill in applying the residual limb bandaging was also a factor that influenced the overall results of this study.28 In the future, an education booklet together with hands-on practice and supervision of residual limb bandaging are recommended for further improving the bandaging skills of persons with transtibial amputation.28
This study shed light on the residual limb management of persons with transtibial amputation before prosthesis fitting. As occupational therapists, it is important for us to provide sufficient training and guidance on residual limb management for our patients so as to facilitate prosthetic fitting and improve the outcomes of amputation rehabilitation.
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