ISPO UK ASM 2023 - Poster Exhibition

Outcomes from the early mobilisation of transtibial amputees with unhealed amputation wounds

 

Presenter:  Kath Crawford, Specialist Nurse, Manchester University NHS Foundation Trust

E-mail:  helen.locke@mft.nhs.uk

Other authors:  Claire Fleming (Rehabilitation Assistant); Helen Locke (Consultant in Rehabilitation Medicine)

Introduction:
The Early Mobilisation Protocol (EMP) was established at The Specialised Ability Centre (SAC) following a clinical trial (Van Ross et al, 2009) which recruited patients with unhealed transtibial wounds who were keen to progress with prosthetic rehabilitation. Prior to this trial, gait training was not commenced until full healing of the residual limb had been achieved. Outcomes of the trial demonstrated that patients with unhealed transtibial wounds could simultaneously undergo gait training and prosthetic fitting whilst achieving wound healing. Data over the last 5 years has now been collated to give an update on clinical outcomes of the EMP at SAC.

Methods:
Patients attending SAC with unhealed transtibial wounds are assessed at their primary appointment by the specialist nurses or are referred later along their care pathway. The protocol is discussed with patients and they are issued with an information booklet so that they can give fully informed consent. The patients attend a weekly physiotherapy session at SAC where their wound is also reviewed by the specialist nurses. Wound care plans are communicated with the patient’s local community nursing teams to ensure continuity of care and the wounds are photographed at regular intervals. Liaison with local physiotherapy teams occurs if patients are also having appointments in their local areas. A compression sock is issued to all patients to help manage residual limb oedema. Casting and measuring for a primary prosthesis takes place as appropriate despite patients having unhealed wounds. The nursing team keeps a database of patients that are signed to the protocol in order to collate accurate outcome data.

This poster presents data from 2018, 2020, 2021 and 2022 (data from 2019 was excluded due to interruptions to usual care provision during the covid pandemic). Results: The total number of patients consenting to the protocol in this time period was 77. Of these, dysvascularity was the cause of amputation in 59 patients (76%), infection in 9 (12%), trauma in 5 (6%), neurological conditions in 2 (3%), and neoplasia in 2 (3%). 46 (60%) of patients were diabetic. In total, 67 patients (87%) achieved wound healing, with an average time to healing of 111 days. Non wound healing outcomes included death (5%), failure to attend (3%), medical conditions preventing further rehabilitation (3%), non-healing (1%) and an on-going wound in one patient (1%) which required revision to a more proximal level of amputation. 69 patients (90%) went on to receive a prosthetic limb.

Conclusions:
Our results confirm that early mobilisation in the presence of an unhealed transtibial wound is not detrimental to healing, even in patients with vascular disease or diabetes. Patients on the EMP can commence early gait training with the benefit of preventing deconditioning and disuse atrophy. Our data also demonstrates favourable outcomes in terms of mobility with a high number of patients receiving a primary prosthesis and low complications rates.

Reference: 
Van Ross E.R. et al. (2009) ‘Effects of early mobilisation on unhealed dysvascular transtibial stumps: a clinical trial’, Arch Phys Med Rehabilitation, 90(4), 620-617.