Abstract
Sir: Please find below our response to the letter you received following the publication of our article in the December 2006 issue of Prosthetics and Orthotics International (Vol. 30, No. 3).
We would like to state at the onset that we set out an observational study based on our clinical practice. Further progression on this work will be a pilot study to test some of the issues raised with eventual progression to a randomized controlled trial. The interest generated on this topical issue is welcomed and we anticipate that multicentre collaboration would be required to further explore this.
We acknowledge that only limited information is available concerning the nature of socket adjustments. This reflects the observational nature of our study. In general, adjustments were made to socket volume and contour to offload areas of skin with pressure ulcers and to address volume mismatch.
We have already stated that limb usage was simply recorded as ‘less’, ‘more’ or ‘as usual’ and acknowledge that more detailed information would be helpful. However, we did note that a similar approach had been used in a previous study (Datta et al. 1996) and believe this was realistic and practical in a clinic consultation scenario, which was the setting for our report.
We appreciate that many different definitions of skin ulceration have been used. Again, our choice of ‘a break in stump skin of at least 0.25 cm in diameter’ was based on practical considerations in our large observational study. We felt it was necessary to specify minimum diameter to differentiate ulcers from puncture skin lesions, which may, for example, occur in allergic or irritant dermatitis.
We agree that ulcer depth measurement is an important factor to consider in wound healing. However, routine clinical practice does not entail this but an estimation of the involved tissue plane (subcutaneous, deep-fascia, muscle etc.). A reduction in ulcer size is certainly an acceptable measure of healing with face validity.
Meulenbelt and Geertzen have drawn attention to the fact we have not specified ulcer type. However, there are many methods of classification often based on aetiology. Stump ulcers are multi-factorial in causation with mechanical factors, peripheral vascular disease and diabetes mellitus frequently contributing. Part of our recommendations is that further studies explore these issues.
Data concerning delayed healing of the surgical wounds and development of ulcers were pooled, as both in essence are breaches of the stump skin (Coleman 2000) which might potentially affect prosthetic limb usage. Whilst their aetiologies differ, in this study we were primarily concerned with the impact of both on prosthesis use and hence mobility and lifestyle of the amputee.
Regarding limb use, we wrote that five patients were advised to discontinue limb use as part of the clinical management and that ulcer deterioration was noted in two. We would like to confirm that the ulcers in the remaining three improved.
Finally, we appreciate the interest shown in this very important issue in rehabilitation of amputees and share Meulenbelt and Geertzen's views that more in-depth knowledge is needed if we are to manage our patients optimally.