Academic journal article Journal of Rehabilitation Research & Development

Skin Problems in Individuals with Lower-Limb Loss: Literature Review and Proposed Classification System

Academic journal article Journal of Rehabilitation Research & Development

Skin Problems in Individuals with Lower-Limb Loss: Literature Review and Proposed Classification System

Article excerpt


Problems with skin integrity can disrupt the daily use of a prosthetic limb and interfere with the independence and lifestyle of individuals with lower-limb loss. Biomechanical factors involved in the interaction between a prosthetic limb and skin interface, including distribution of weight, shear force, moisture, and temperature, can lead to skin problems [1-3].

Skin problems associated with prosthetic limb use are common. While a range of skin diagnoses, such as allergic contact dermatitis, epidermal hyperplasia, malignancies, and ulcerations, have been described [4], we found no consistency in the literature regarding how these problems are reported. Accordingly, we do not know the epidemiology of the residual-limb dermatologic issues faced by individuals with lower-limb loss. A recent literature review [5] cited only one study [6] with sufficient rigor to ascertain a prevalence of 16 percent for skin problems on the residual limb. However, the skin problems reported in that study were limited to abscesses and ulcers, a narrow subset of the whole spectrum of dermatologic issues that could affect prosthetic limb use and user satisfaction.

As a first step toward filling this gap in knowledge, we undertook a systematic review of the literature to better define the prevalence and types of skin problems on the residual limb related to prosthetic use. We use this information to propose a classification system that may be of use in future clinical studies.


We searched the literature published through 2008 using four databases: MEDLINE, EMBASE, CINAHL, and RECAL. MEDLINE is a biomedical database containing publications since the 1950s. EMBASE is a biomedical and pharmacological database containing publications since 1988. CINAHL is a nursing and allied health database containing publications since 1982. RECAL is an orthotics and prosthetics database containing publications from 1900 to 2007. Table 1 shows medical subject headings (MeSH) and free text words that we used to search MEDLINE, CINAHL, and EMBASE. MeSH are standardized terms defined by the National Library of Medicine and arranged in a hierarchical structure that allows searching at various levels of specificity. In RECAL, we used the free text words "skin" and "amputation" (MeSH not available). We restricted our search to the English language and humans in MEDLINE and EMBASE and to the English language in CINAHL (option to limit to human research not available).

We reviewed the title and abstract of all publications identified in our literature search. We selected articles if they discussed skin problems in adults (>18 years old) with lower-limb loss (transtibial, transfemoral, or knee disarticulation, but not foot, ankle, or hip disarticulation) who were fitted with a prosthesis. We excluded articles that discussed wound healing immediately postamputation. We removed duplicate articles obtained from different databases.

Our second selection process involved reviewing study research methodology. We selected articles if they included a description of the inclusion and exclusion criteria and the study population, identified the reason for amputation, identified the level of amputation, and reported both the prevalence and types of skin problems on a residual limb associated with prosthetic limb use. We excluded all case studies, case series, reviews, expert opinions, and letters to editors. We also excluded articles published before 1990 or with a sample size of fewer than 40 subjects.

Lastly, we reviewed the reference lists of these articles for publications related to skin problems in individuals with lower-limb loss (transtibial, transfemoral, or knee disarticulation). Relevant articles published after 1990 underwent the second selection process we mentioned previously.


Our initial search using MeSH and free text words yielded 777 articles: 313 from MEDLINE, 233 from EMBASE, 31 from CINAHL, and 200 from RECAL (Table 2). …

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