Effects of prosthetic rehabilitation interventions for patients with major lower limb amputation due to diabetes or peripheral arterial disease: A systematic review
Restricted accessReview articleFirst published online 2026
Effects of prosthetic rehabilitation interventions for patients with major lower limb amputation due to diabetes or peripheral arterial disease: A systematic review
This systematic review evaluates the effects of prosthetic rehabilitation interventions including post-amputation stump management techniques, microprocessor assisted foot or knee prosthesis and functional mobilization procedures on stamp healing, prosthetic adaptation time, functional mobility, balance and mortality in patients with a major lower limb amputation due to diabetes mellitus or peripheral arterial disease.
Methods
PubMed, Cochrane, Science Direct, Scopus, PEDro, and Web of Science databases were systematically searched from their inception until February 2025 using combinations of keywords and MeSH terms related to diabetes mellitus, lower limb amputation, and rehabilitation interventions, including stump management techniques, physical therapy and prosthetic equipment. Studies published in peer-reviewed journals in English or French were included. The data extracted included information regarding study provenance and design, as well as patient-specific variables, the nature of the rehabilitation interventions, and the resulting clinical outcomes.
Results
From 4426 identified records, 11 studies were selected, including a total of 2227 patients. The included studies comprised five randomized controlled trials and six observational studies. Nine studies had moderate risk of bias. The most used prosthetic rehabilitation interventions were rigid, semi-rigid dressings, silicone liner and prostheses with microprocessor-controlled knees. Stump healing, prosthesis fitting time, functional mobility and mortality were the most examined effects.
Conclusion
Rigid, semi-rigid dressings and silicone liners improve stump healing and reduce time to prosthetic fitting compared with soft dressings; microprocessor-controlled knee or foot also improve functional mobility compared with conventional prostheses. A biopsychosocial approach is strongly recommended to support the rehabilitation process of this population.
KumarDSinghSShantanuK, et al.Need of revision of lower limb amputations in a north Indian tertiary care centre. J Clin Diagn Res2015; 9: RC01–RC03. https://doi.org/10.7860/JCDR/2015/16385.6886
BarnesJAEidMACreagerMA, et al.Epidemiology and risk of amputation in patients with diabetes mellitus and peripheral artery disease. Arterioscler Thromb Vasc Biol2020; 40: 1808–1817. https://doi.org/10.1161/ATVBAHA.120.314595
7.
BeckmanJACreagerMALibbyP. Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA2002; 287: 2570–2581. https://doi.org/10.1001/jama.287.19.2570
8.
Ziegler-GrahamKMacKenzieEEphraimP, et al.Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil2008; 89: 422–429. https://doi.org/10.1016/j.apmr.2007.11.005
9.
NewhallKSpanglerEDzebisashviliN, et al.Amputation rates for patients with diabetes and peripheral arterial disease: the effects of race and region. Ann Vasc Surg2016; 30: 292–298. https://doi.org/10.1016/j.avsg.2015.07.040
10.
Danielle MincSBudiSThibaultD, et al.Opportunities for diabetes and peripheral artery disease-related lower limb amputation prevention in an Appalachian state: a longitudinal analysis. Prev Med Rep2021; 23: 101505. https://doi.org/10.1016/j.pmedr.2021.101505
UelgerÖTopuzSBayramlarK, et al.Risk factors, frequency, and causes of falling in geriatric persons who has had a limb removed by amputation. Top Geriatr Rehabil; 26: e85533. https://doi.org/10.1097/tgr.0b013e3181e85533
15.
SchaffalitzkyEGallagherPMaclachlanM, et al.Understanding the benefits of prosthetic prescription: exploring the experiences of practitioners and lower limb prosthetic users. Disabil Rehabil2011; 33: 1314–1323. https://doi.org/10.3109/09638288.2010.529234
CummingJCOBarrSHoweTE. Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation. Cochrane Database Syst Rev2006; 4: CD005260.
18.
PageMJMcKenzieJEBossuytPM, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ2021; 372: n71. https://doi.org/10.1136/bmj.n71
19.
SterneJAHernánMAReevesBC, et al.ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ2016; 355: i4919. https://doi.org/10.1136/bmj.i4919
20.
SterneJACSavovićJPageMJ, et al.RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ2019; 366: l4898. https://doi.org/10.1136/bmj.l4898
21.
WurdemanSStevensPCampbellJ. Mobility analysis of AmpuTees (MAAT 5): impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng; 6: 2055668318820784. https://doi.org/10.1177/2055668318820784
22.
WurdemanSMillerTStevensP, et al.Stability and falls evaluations in AMPutees (SAFE-AMP 1): microprocessor knee technology reduces odds of incurring an injurious fall for individuals with diabetic/dysvascular amputation. Assist Technol2023; 35: 205–210. https://doi.org/10.1080/10400435.2021.2010147
23.
WongCKEdelsteinJE. Unna and elastic postoperative dressings: comparison of their effects on function of adults with amputation and vascular disease. Arch Phys Med Rehabil2000; 81: 1191–1198. https://doi.org/10.1053/apmr.2000.3780
24.
WongCKRheinsteinJSternMA. Benefits for adults with transfemoral amputations and peripheral artery disease using microprocessor compared with nonmicroprocessor prosthetic knees. Am J Phys Med Rehabil2015; 94: 804–810. https://doi.org/10.1097/PHM.0000000000000265
25.
ChinTTodaM. Results of prosthetic rehabilitation on managing transtibial vascular amputation with silicone liner after wound closure. J Int Med Res2016; 44: 957–967. https://doi.org/10.1177/0300060516647554
26.
DeutschAEnglishRDVermeerTC, et al.Removable rigid dressings versus soft dressings: a randomized, controlled study with dysvascular, trans-tibial amputees. Prosthet Orthot Int2005; 29: 193–200. https://doi.org/10.1080/03093640500224295
27.
MayerATihanyiJBretzK, et al.Adaptation to altered balance conditions in unilateral amputees due to atherosclerosis: a randomized controlled study. BMC Muscoskelet Disord2011; 12: 118. https://doi.org/10.1186/1471-2474-12-118
28.
VigierSCasillasJMDulieuV, et al.Healing of open stump wounds after vascular below-knee amputation: plaster cast socket with silicone sleeve versus elastic compression. Arch Phys Med Rehabil1999; 80: 1327–1330. https://doi.org/10.1016/s0003-9993(99)90038-2
29.
VanRossEJohnsonSAbbottC. Effects of early mobilization on unhealed dysvascular transtibial amputation stumps: a clinical trial. Arch Phys Med Rehabil2009; 90: 610–617. https://doi.org/10.1016/j.apmr.2008.10.026
30.
JohannessonALarssonGRamstrandN, et al.Outcomes of a standardized surgical and Rehabilitation program in transtibial amputation for peripheral vascular disease A prospective cohort study. Am J Phys Med Rehabil2010; 89: 293–303. https://doi.org/10.1097/PHM.0b013e3181cf1bee
31.
WoodburnKRSockalinghamSGilmoreH, et al.A randomised trial of rigid stump dressing following trans-tibial amputation for peripheral arterial insufficiency. Prosthet Orthot Int2004; 28: 22–27. https://doi.org/10.3109/03093640409167921
32.
TurnerAPWegenerSTWilliamsRM, et al.Self-management to improve function after amputation: a randomized controlled trial of the VETPALS intervention. Arch Phys Med Rehabil2021; 102: 1274–1282. https://doi.org/10.1016/j.apmr.2021.02.027
33.
HidvégiT. Patient education: an indispensable element of care of patients with diabetes mellitus. Orv Hetil2011; 152: 1941–1948. https://doi.org/10.1556/OH.2011.29262
LiuRPetersenBJRothenbergGM, et al.Lower extremity reamputation in people with diabetes: a systematic review and meta-analysis. BMJ Open Diabetes Res Care2021; 9: e002325. https://doi.org/10.1136/bmjdrc-2021-002325
39.
SobtiNParkACrandellD, et al.Interdisciplinary care for amputees network: a novel approach to the management of amputee patient populations. Plastic Reconstr Surg, Glob Open2021; 9: e3384. https://doi.org/10.1097/GOX.0000000000003384
40.
RothEVPezzinLEMcGinleyEL, et al.Prosthesis use and satisfaction among persons with dysvascular lower limb amputations across postacute care discharge settings. Pharm Manag PM R2014; 6: 1128–1136. https://doi.org/10.1016/j.pmrj.2014.05.024
41.
AlsancakSKöseSKAltınkaynakH. Effect of elastic bandaging and prosthesis on the decrease in stump volume. Acta Orthop Traumatol Turcica2011; 45: 14–22. https://doi.org/10.3944/AOTT.2011.2365
42.
PastarIOjehNGlinosGD, et al.Physiology and pathophysiology of wound healing in diabetes. In: VevesAGiuriniJMGuzmanRJ (eds). The Diabetic Foot: Medical and Surgical Management. : Springer International Publishing, pp. 109–130.
43.
MohsinFJavaidSTariqM, et al.Molecular immunological mechanisms of impaired wound healing in diabetic foot ulcers (DFU), current therapeutic strategies and future directions. Int Immunopharmacol2024; 139: 112713. https://doi.org/10.1016/j.intimp.2024.112713
44.
ByrneRLNicholsonMLWoolfordTJ, et al.Factors influencing the healing of distal amputations performed for lower limb ischaemia. Br J Surg2005; 79: 73–75. https://doi.org/10.1002/bjs.1800790125
45.
VishwanathNHuDRaoV, et al.Refining treatment strategies in patients with fingertip wounds and end-stage renal disease. Handb Neuropsychol N2024; 19: 814–822. https://doi.org/10.1177/15589447231151261
46.
BurgessEMTraubJEWilsonAB, et al.Immediate postsurgical prosthetics in the management of lower extremity amputees. In: Prosthetic and sensory aids service, veterans administration. ■■■, 1967.
47.
WongAYWHooiNMFYeoBSY, et al.Improving diabetic wound-healing outcomes with topical growth factor therapies. J Clin Endocrinol Metab2024; 109: e1642–e1651. https://doi.org/10.1210/clinem/dgae128
48.
Martinez-HernandezM-H. Repair, regeneration, and fibrosis. Essent Pathol1995: 47–63.
49.
NawijnSEvan der LindeHEmmelotCH, et al.Stump management after trans-tibial amputation: a systematic review. Prosthet Orthot Int2005; 29: 13–26. https://doi.org/10.1080/17461550500066832
50.
ChurilovIChurilovLMurphyD. Do rigid dressings reduce the time from amputation to prosthetic fitting? A systematic review and meta-analysis. Ann Vasc Surg2014; 28: 1801–1808. https://doi.org/10.1016/j.avsg.2014.05.002
51.
ReichmannJPStevensPMRheinsteinJ, et al.Removable rigid dressings for postoperative management of transtibial amputations: a review of published evidence. Pharm Manag PM R2018; 10: 516–523. https://doi.org/10.1016/j.pmrj.2017.10.002
52.
SmithDGMcFarlandLVSangeorzanBJ, et al.Postoperative dressing and management strategies for transtibial amputations: a critical review. J Rehabil Res Dev2003; 40: 213–224.
HordacreBBirksVQuinnS, et al.Physiotherapy rehabilitation for individuals with lower limb amputation: a 15-year clinical series. Physiother Res Int J Res Clin Phys Ther2013; 18: 70–80. https://doi.org/10.1002/pri.1529
55.
BaarsECTGeertzenJHB. Literature review of the possible advantages of silicon liner socket use in trans-tibial prostheses. Prosthet Orthot Int2005; 29: 27–37. https://doi.org/10.1080/17461550500069612
56.
TriebKLangTStulnigT, et al.Silicone soft socket system: its effect on the rehabilitation of geriatric patients with transfemoral amputations. Arch Phys Med Rehabil1999; 80: 522–525. https://doi.org/10.1016/s0003-9993(99)90192-2
57.
BreuerRTriebK. Silicone soft socket system for the treatment of geriatric transtibial amputees. Wien Klin Wochenschr2021; 133: 216–221. https://doi.org/10.1007/s00508-020-01643-8
58.
ErnstMAltenburgBSchmalzT, et al.Benefits of a microprocessor-controlled prosthetic foot for ascending and descending slopes. J Neuroengineering Rehabil2022; 19: 9. https://doi.org/10.1186/s12984-022-00983-y
59.
AgrawalVGaileyRSGaunaurdIA, et al.Comparison between microprocessor-controlled ankle/foot and conventional prosthetic feet during stair negotiation in people with unilateral transtibial amputation. J Rehabil Res Dev2013; 50: 941–950. https://doi.org/10.1682/JRRD.2012.05.0093
60.
HunterSWBatchelorFHillKD, et al.Risk factors for falls in people with a lower limb amputation: a systematic review. Pharm Manag PM R2017; 9: 170–180.e1. https://doi.org/10.1016/j.pmrj.2016.07.531
61.
ChenPLinTChenI. Hybrid viabahn-assisted bypass for long femoro-popliteal occlusive disease - midterm results -. Circ J2018; 82: 2160–2164. https://doi.org/10.1253/circj.CJ-18-0163
62.
KannenbergAZachariasBPröbstingE. Benefits of microprocessor-controlled prosthetic knees to limited community ambulators: systematic review. J Rehabil Res Dev2014; 51: 1469–1496. https://doi.org/10.1682/JRRD.2014.05.0118
HamnerSNarayanVRappinN, et al.ReMotion knee: scaling of an affordable prosthetic knee for developing countries. In: HostettlerSHazbounEBolayJ-C (eds). Technologies for Development. : Springer International Publishing, 2015, pp. 137–151.
65.
Impact of Kinesiotherapy and Hydrokinetic Therapy on the Rehabilitation of Balance. Gait and functional capacity in patients with lower limb amputation: a pilot study. Stomatology2022; 11: 4108.
66.
ShutzeWGableDOgolaG, et al.Prosthetic outcomes after amputation and the impact of mobility level on survival. J Vasc Surg2024; 80: 873–881. https://doi.org/10.1016/j.jvs.2024.04.046
67.
BurgessEMRomanoRL. The management of lower extremity amputees using immediate postsurgical prostheses. Clin Orthop1968; 57: 137–146.
BrånemarkRBerlinOHagbergK, et al.A novel osseointegrated percutaneous prosthetic system for the treatment of patients with transfemoral amputation: a prospective study of 51 patients. Bone Jt J2014; 96-B: 106–113. https://doi.org/10.1302/0301-620X.96B1.31905
BuiKMRaugiGJNguyenVQ, et al.Skin problems in individuals with lower-limb loss: literature review and proposed classification system. J Rehabil Res Dev2009; 46: 1085–1090. https://doi.org/10.1682/jrrd.2009.04.0052
73.
PotterBKBurnsTCLacapAP, et al.Heterotopic ossification following traumatic and combat-related amputations. Prevalence, risk factors, and preliminary results of excision. J Bone Joint Surg Am2007; 89: 476–486. https://doi.org/10.2106/JBJS.F.00412
CiminoSRVijayakumarAMacKayC, et al.Sex and gender differences in quality of life and related domains for individuals with adult acquired lower-limb amputation: a scoping review. Disabil Rehabil2022; 44: 6899–6925. https://doi.org/10.1080/09638288.2021.1974106
76.
FereydooniAPatelJDossabhoySS, et al.Racial, ethnic, and socioeconomic inequities in amputation risk for patients with peripheral artery disease and diabetes. Semin Vasc Surg2023; 36: 9–18. https://doi.org/10.1053/j.semvascsurg.2023.01.005
77.
QuigleyMDillonMPFatoneS. Development of shared decision-making resources to help inform difficult healthcare decisions: an example focused on dysvascular partial foot and transtibial amputations. Prosthet Orthot Int2018; 42: 378–386. https://doi.org/10.1177/0309364617752984
78.
AhoukarMATakhdatKMounirA, et al. Supplementary data of the review ‘Effects of prosthetic rehabilitation interventions for patients with major lower limb amputation due to diabetes or peripheral arterial disease: A systematic review’[Data set]. Epub ahead of print 27 June 2025. https://doi.org/10.5281/zenodo.15754416.
