Loading & Wound Care

The skin and soft tissue of the residual limb are particularly susceptible to damage and breakdown. Scarring from the amputation surgery may complicate prosthetic fitting with adhesions or areas of invagination. Tissue may be further affected by other comorbidities, such as dysvascularity and in the event of breakdown, which prevents prosthetic use, there will be a serious impact on the individual’s quality of life.

It is reported that 41% of lower limb amputees experience residual limb skin and soft tissue problems, including ulcers, wounds and dermatitis38,39. Resolving socket comfort issues has the potential to drastically reduce the required number of clinic visits, while at the same time increasing the amount of time the user is able to wear their prosthesis, improving their quality of life.

Unnatural Loading

Of the reported residual limb skin problems, 25% are pressure ulcers38. The residual limb is particularly vulnerable to loading. Naturally, this part of the body would not be loaded in this way. Additionally, post-amputation, scar tissue is susceptible to damage due to its inelastic nature, especially if it is adherent. As a consequence, successful prosthetic rehabilitation should aim to reduce the magnitude of the loads at the residuum interface, as well as the rate at which these loads are applied.

While studies have found no significant difference in the peak positive pressure during stance phase between pin-lock and suction suspension40, EV has been shown to reduce mean interfacial peak pressures by 4% and reduce mean pressure impulses by 7.5%, compared to suction41. In a survey of world-leading prosthetists, 71% agreed that EV reduced interface pressure, compared to other suspension methods, while 91% agreed it improved comfort for the patient21. This may explain why Socket Comfort Score (SCS) improves when using EV42.

Changes elsewhere in the prosthetic limb can have a knock-on effect to the forces transferred to the residual limb. For example, the viscoelastic movement of hydraulic ankles, plantarflexing at heel strike, helps to attenuate the load transferred to the residuum. It reduces the peak pressure transferred to the residual limb by up to 81% and decrease the rate of loading by up to 87%, compared to rigidly attached prosthetic feet43. These reduced loads may be protective against the development of pressure ulcers and other skin damage.

It is important to remember that it is not just the residual limb, but the whole body that is subjected to unnatural loads. Gait compensations will affect the residual knee contact forces also, but research has shown that EV reduces this impact, compared to suction suspension44. Hydraulic ankles also reduce the demand placed on the sound limb while walking45,46 and standing47. Additionally, they have been shown to reduce peak plantar-pressure under the contralateral foot48 – something that may be of particular benefit to dysvascular amputees to protect against foot ulcers and a second contralateral amputation.

Wound Management

Residual limb health issues are by no means limited to ulcers38. Skin irritation and blisters can develop into wounds, which become painful, are susceptible to infection and may limit prosthetic use. This has severe implications for the user’s mobility and quality of life49.

Negative Pressure Wound Therapy (NPWT) is a common technique in medicine to promote faster healing of wounds50,51. The effectiveness of this technique to heal wounds following amputation surgery has been demonstrated52. Patients treated with NPWT have shown significantly higher frequencies and rates of wound healing than control subjects52.

The evidence in prosthetics literature points towards EV having a similar effect. Many studies have looked at patients with existing residual limb wounds, reporting that the use of EV has allowed wearers to continue using their prosthesis whilst their wound healed53,54 and, as an added bonus, wounds tended to heal at a faster rate when compared to alternative suspension systems55. Expert opinion21 and clinical case studies56 agree that EV is less painful than other suspension methods. As a consequence of these findings, many patients are more comfortable and more satisfied wearing their prosthesis57,58.

Healthier Tissue

By creating a vacuum around it, blood is drawn into the residual limb, providing better circulation. This makes the tissue healthier by bringing in a better supply of nutrients and improving the removal of waste products. Non-invasive probing techniques have been used to demonstrate how EV preserves skin health on the residual limb59. EV improved tissue oxygenation during walking, decreased transepidermal water loss and attenuated reactive hyperaemia, compared to other prosthetic suspension methods. The researchers who performed the study suggested that decreasing trans-epidermal water loss preserves the skin barrier function, which protects against ulcer formation.


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