Abstract
Sir: In the December 2006 issue of Prosthetics and Orthotics International Salawu et al. provide us with very important information regarding stump ulcers. Stump ulcers are a frequently seen problem in amputees wearing prosthesis. These ulcers can disrupt daily activities and can therefore interfere with activities and participation of amputees. A study into whether prosthesis can be worn despite having ulcers is indeed important. The authors came to a very important conclusion, namely that allowing amputees with stump ulcers to continue using their prostheses is safe. This is, however, also a study which may lead to controversy, because no evidence is available in medical literature which supports one of the mentioned solutions namely leaving the prosthesis off until proper healing has occurred compared with continuing use of the prosthesis (with adding liners or socks).
We have some remarks on this conclusion.
As the authors state, their measure of prosthetic limb usage was (too?) crude and the registration of appropriate socket modifications was insufficient. It is our opinion that correction of this would be the first appropriate step in treating stump ulcers whether or not in combination with continuing use of the prosthesis.
The second remark concerns the definition of the ulcers. Ulcers are often seen in amputees using prosthesis (Meulenbelt et al. 2006, 2007). The definition of an ulcer used by the authors is not a worldwide used definition (Berke 2004). There is, however, no accepted definition. In this study primary and secondary problems in wound healing are compared to the development of an ulcer. Further on in this paper both problems are grouped together. An average surface area of the ulcer was measured to evaluate the possible effect of the intervention. It is uncertain this measurement of average surface should be used as an outcome measure of the success of an intervention because delayed wound healing and the development of ulcers are pooled together and some patients had several ulcers. As the authors already stated in their discussion as a weakness of their study, the depths of the ulcers were not measured, while this is an important measure in classification of ulcers (Wagner 1981). Finally the type of ulcer was not described.
The last remark is related to the categorization of limb used during the survey period. This subject is not elaborated in this paper. Only five patients were advised to discontinue prosthetic limb use; they continued to use their prosthesis which in two cases led to deterioration of the ulcer. What about the other three cases? In the meantime new patients received new prostheses or received socket adaptations.
With respect to Salawu et al.'s findings which touch on a very important issue in the rehabilitation of amputees, clarification to our remarks will help us better understand their results.