Chapter 26 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
Skin Problems of the Amputee
S. William Levy, M.D.
Amputation is just the beginning and not the end of a treatment! The amputation surgeon and prosthetist have joined together to become the lifelong advisors to the amputee who will wear an artificial limb for the rest of his life. A dermatologist is capable of rendering valuable aid to not only the amputee but also other members of the rehabilitation team, for he is familiar with the problems of the skin that can result from the wearing of an artificial limb. Lower-limb amputees are frequently involved with skin problems since many have been subjected to anatomic loss of the lower limbs at widely varying levels, with each level subjected and reacting to different pressures. Amputation at any level is accompanied by distinct problems of functional loss, prosthetic fitting and alignment problems, and medical problems such as skin disorders that are secondary to the use of the artificial limb. Partial or total loss of an upper limb can also be associated with similar complaints. Amputees require the continued care of a prosthetist who constructs the artificial limb on which the amputee must depend for locomotion and, to a larger degree, for social and economic rehabilitation. Skin lesions, however minute they may appear, are nevertheless of great importance since they can be the beginning of an extensive skin disorder that may be mentally, socially, and economically disastrous to a given amputee. It is best to view any minor irritation as a potentially dangerous symptom and to deal with it as early as possible. This is especially true in diabetics.Once the skin problem has begun, it should not be ignored in the hope that it will heal of its own accord. Nothing can be more frustrating to the lower-limb amputee than to be told to remain off his prosthesis or to go onto crutches because he has neglected a minor skin eruption.
This chapter is devoted to the common skin problems and danger signals associated with the wearing of a lower-limb prosthesis. In working with numerous amputees over the years, specific information regarding the various clinical problems has been assembled and correlated in an effort to benefit the individual amputee. Stump and socket hygiene is important in relation to several clinical disorders of the skin, and accordingly, a specific hygienic program for care of the stump and socket has been developed. These will be mentioned subsequently. Some amputees will go for months or years without any skin complaint or irritation. In others, the skin is a weaker tissue for them, and frequent difficulties do arise. The orthopaedic surgeon, prosthetist, dermatologist, and other medical personnel concerned with amputees should be aware of certain conditions and danger signals that are frequently the forerunners of seriously incapacitating cutaneous disorders. Early recognition and treatment of these conditions can avert much mental anguish and avoid loss of social or economic activity. It should be remembered that once in a prosthesis, the amputee desires to continue, and it is of vital concern to the physician and prosthetist to prevent any disorder that may return the amputee to crutches or bed rest.
In the past decade there have been numerous advances in the development of prostheses for transtibial (below-knee) and transfemoral (above-knee) amputees. The strongly expressed desire of amputees to participate in sports with high physical demands has resulted in the development of lighter-weight, stronger prostheses with more dynamic action than was available in previous years. Many new designs are now reported to store energy during stance and release energy as the body weight progresses forward, thus helping to passively propel the limb. Numerous means to suspend prostheses have been developed, and diversity has resulted from attempts to fit individuals of differing physical characteristics and life-styles.
The skin of an amputee who wears a prosthesis is subject to numerous abuses. Most leg prostheses have a snugly fitting socket in which air cannot circulate freely, thereby trapping perspiration. The socket provides for weight bearing; uneven loading may cause stress on localized areas of the stump skin. Examples of such stress are intermittent stretching of the skin and friction from rubbing against the socket edge and interior surface. With certain prostheses, stump socks are worn for reduction of the friction. In the transfemoral amputee, pressure may be exerted on the adductor region of the thigh, the groin, and the ischial tuberosity, all points of contact with the socket rim. If suction is used for suspension, the stump is subjected to negative pressure as well. In the transtibial amputee, who usually has at least the upper third of the tibia remaining, pressures occur over the anterior portion of the tibia, the sides, and sometimes, the end of the stump. Additional pressures also occur from mechanical rub over the prepatellar and infrapatellar areas. In the older conventional transtibial prosthesis, constriction of soft tissues of the thigh by the thigh corset may cause significant obstruction to venous and lymphatic drainage of the leg. In addition to the effects of pressure and friction, an amputee's skin is vulnerable to the possible irritant or allergic action of the material used in the manufacture of his prosthesis or topical agents applied by the patient himself.
The state of the stump skin is of utmost importance in the amputees' ability to use a prosthesis. If the normal skin condition cannot be maintained despite daily wear and tear, the prosthesis cannot be worn, no matter how accurate the fit of the socket may be.
Some amputees fail to adequately wash either the stump or the socket, and hence maceration and mal-odor can result. There has been no unanimity of opinion as to exactly what measures should be used routinely, and some amputees have come to us with varied and often strange ideas about their own hygiene. Poor hygiene may be an important factor in producing some pathologic conditions of the stump skin. If a routine cleansing program is not employed, bacterial and fungal infections, nonspecific eczematization, intertrigo, and persistence of infected epidermoid cysts can eventuate. We have suggested a simple hygienic program with the use of a bland soap or sudsing detergent, and this has often had a preventive or therapeutic effect on a cutaneous disorder. For example, such a simple regimen has been curative for some persistent eczematoid eruptions of the stump skin. Soaps or detergents that contain bacteriostatic or bactericidal agents in addition to their cleansing action help to reduce the possibility of infection. Amputees should be advised in a program and asked to purchase a plastic squeeze container of a liquid detergent containing chlorhexidine gluconate, triclosan, or hexachlorophene. These are relatively inexpensive and available in drugstores throughout the world with and without a prescription. Some amputees prefer to use a cake or bar soap containing similar agents or triclocarban and should be fully informed as to their use for cleansing both the stump skin and/or the wall of the socket. The cleansing routine should be followed nightly or every other night, depending on the rate of perspiration, the degree of malodor, and the bathing habits of the person. The season of the year may also dictate the frequency of cleansing. The stump should not be washed in the morning unless a stump sock is worn because the damp skin may swell, stick to the socket, and be irritated by friction during walking. For the same reason, the best time to cleanse the socket is also at night. Some amputees prefer to use witch hazel or rubbing alcohol compound for the wall of the socket. If a stump sock is worn, it should be changed daily and should be washed as soon as it is taken off before perspiration is allowed to dry in it. If the sock does dry with a "dog-ear," a plastic or rubber ball can be inserted into the base of the sock to give it the correct shape.
STUMP EDEMA SYNDROME
When an amputee first starts to wear a prosthesis with suction suspension, his skin must adapt to an entirely new environment. Similarly, a transtibial amputee wearing a total-contact socket must adapt to the heat, rub, and perspiration generated within the socket. The amputee can expect mild edema and a reactive hyperemia or redness when first becoming accustomed to the prosthesis. These changes are the inevitable result of the altered conditions that are now forced on the skin and subcutaneous tissues of the stump. In the majority of instances, they are relatively innocuous, do not usually require therapy, and can be minimized by gradual compression of the stump tissues postoperatively with an elastic bandage or "shrinker" sock prior to use of the prosthesis. An incorrectly fitted socket may predispose the leg amputee to these problems by imposing a pressure distribution that can disturb local circulation.
If the amputee continues to wear a malfitting prosthesis, edematous portions of the skin of the distal part of the stump may become pinched and strangulated within the socket, and this may cause ulceration or gangrene as a result of the impaired blood supply. The pigmentary changes so often seen on the distal portion of the stump of amputees is due to hemosiderin or blood pigment deposited within the distal stump skin (Plate 7.). It is thought that this disorder is vascular in origin, a venous and lymphatic congestion producing edema and hemorrhage. Superficial erosion of the distal stump skin is not uncommon, and in rare instances deep ulcers can result from continued mechanical injury and poor skin nutrition. Here, therapy by the dermatologist requires teamwork with the orthopaedic surgeon and prosthe-tist. This includes elimination of all mechanical factors contributing to the edema, such as choking by the socket or lack of total contact distally.
Continued uneven mechanical rub can produce thickened, lichenified areas on the skin or weeping superficial erosions (Plate 8., Plate 9., and Plate 10). Occasional use of an oral diuretic and a shrinker sock will be advantageous. Excessive negative pressure in a socket can also contribute to circulatory congestion and edema. Treatment should be directed toward better support of the distal soft tissues by restoring distal tissue contact, perhaps by making a pad in the bottom of the socket. Cutaneous disorders common to lower-limb amputees have been classified as well as evaluated and treated in numerous individual cases. Out of the studies, improved methods of treatment are continuing to evolve. The man-machine interface is critical to wearing an inert prosthetic substitute for the limb loss. Every amputee who wears a prosthesis experiences the skin adaptations and problems incident to this intimate interface. Much of the skin involving the interface is not designed physiologically to withstand the environment and the variety of pressures that are inherent in prosthetic wearing. The disorders that follow are not only seen in lower-limb amputees but are also seen in upper-limb amputees as well. Newer plastics and metals developed through the United States Space Program are now utilized in the manufacture of prostheses. Although improvements in technology continue, certain cutaneous problems associated with the wearing of a prosthesis continue to occur quite commonly.
An amputee can have an acute or chronic skin inflammatory reaction caused by contact with an irritant or allergenic substance. The irritant form of contact dermatitis is the most common and can result from contact of the skin with strong chemicals or other known irritants. Although some elderly amputees have a less pronounced inflammatory response to standard applied irritants than do younger patients, chronic irritant dermatitis is nonetheless frequently seen in older amputees. Allergic contact dermatitis may arise from the application of medicaments by the patient or the physician or possibly from agents used in the manufacture of the prosthetic socket by the prosthetist. The socket wall in itself can also produce such allergic contact dermatitis. Amputees may develop delayed hypersensitivity to a variety of substances that come into contact with the skin. Although older patients are less readily sensitized to experimental allergens, they can develop allergic contact dermatitis from a variety of contactants and complain of intense itching or burning of the skin when using their prosthesis. Common sensitizers include nickel, chromates (used in leathers), wool fats and especially lanolin found in many moisturizers and skin creams, rubber additives, topical antibiotics such as neomycin, and topical anesthetics such as ben-zocaine or lidocaine. Areas of eczema appearing at the site of contact with an irritant or allergen may be acute, with small blisters and swelling or oozing of the skin, or more often chronic, with scaling and mild redness or erythema.
A number of patients with contact dermatitis of the skin of the stump have been observed. In these, the disorder was usually caused by contact of the skin with chemical substances that acted either as a primary irritant or drying agent or as a specific allergic sensitizer to the skin (Plate 11.). Varnishes, lacquers, plastics, and resins are frequently used in finishing the inner lining of the socket of leg prostheses. One has to learn about the materials used in the manufacture of prostheses in order to understand and treat the problem adequately. One also has to analyze the different conditions of heat, humidity, and friction within the socket since these are interrelated with the intensity of the reaction. Plastic resins, if incompletely cured in their manufacture, may produce a primary irritant reaction or even cause a specific allergic sensitization. Some amputees will use a foam rubber cushion, others a plastic-covered pad on the bottom of the socket, which can also produce allergic sensitization over a period of time. Many cements and volatile substances used to repair prostheses are also capable of producing either an irritant reaction or allergic sensitization. Any of these agents are capable of producing a contact dermatitis of the stump skin after weeks, months, or even years of continued use. In some patients, only a carefully taken history will reveal that the use of a new cream, lotion, lubricant, or cleansing agent coincided with the onset of the dermatitis. In other patients we found that over-the-counter topical antibiotics or skin-"toughening" agents will produce a dermatitis. When contact dermatitis is suspected or diagnosed, every attempt should be made to determine the contactant in order to avoid future complaints. Patch tests are most informative in pinpointing specific substances as the cause of a dermatitis. Since patch testing with strong concentrations of known primary irritants will result in reactions on almost any skin, solutions of such substances are first diluted according to published lists in order to prevent a false-positive reaction and possible continued injury to the skin. We have investigated a number of contact dermatitis cases, and some have been due to neomycin, epoxy resins, various cements, Naughahyde, waxes and polishes, and even adhesive tape. Removal of a suspected contactant has resulted in a cure, and subsequent patch testing has identified the offending agent after the acute process subsided. In those instances of contact dermatitis where the irritant has not been obvious and where patch test results have been inconclusive, temporary symptomatic therapy has always alleviated these symptoms. Cool or cold compresses, bland anti-itch lotions, and the topical application of corticosteroids or similar preparations have been beneficial in controlling the process and allowing for improvement. Once an agent causing a given reaction has been identified, it should be avoided as much as possible. All documented skin allergies should be carefully noted on a patient's record since systemic exposure to chemically related compounds may result in systemic allergic reactions.
Nonspecific eczematization of the stump has been seen in a variety of instances as an acute or chronic persistent, weeping, itching area of dermatitis over the distal portion of the stump. The lesions at times can be dry and scaly (Plate 12.), while at other times they become moist without apparent reason. The condition often fluctuates over a period of months or years and may be the source of much anxiety to the amputee. It appears in some patients to be seasonal and in others to be related to continued standing or unusually active episodes.
In almost every instance we have tried to find the cause of this recurrent dermatitis through a complete study of the patient: history, physical examination, laboratory tests, and subsequent observation of the clinical course of the condition. In some we have noted the use of a new drug taken orally or some unusual dietary changes. We have been able at times to elicit a significant history of recurrent, allergic eczema and in others to demonstrate active eczematous lesions on other portions of the body to account for the eruption on the stump skin. In other patients, the eczema has been secondary to poor fit or alignment of the prosthesis or to edema and congestion of the terminal portion of the stump so that only with the improvement of these fitting problems has the condition cleared. Here again, temporary symptomatic topical therapy with hydrocortisone or other topical corticosteroid preparations is effective, but the condition frequently recurs unless its cause can be eliminated.
A number of authors have described the appearance of multiple cysts, frequently called post-traumatic epidermoid cysts, in the skin of amputees' stumps in association with the wearing of an artificial limb. These occur most frequently in transfemoral amputees in the areas covered by the upper medial margins of the prosthesis, but they have also been seen in other areas and in transtibial amputees. Usually the cysts do not appear until the patient has worn a prosthesis for months or years (Plate 13., Plate 14., and Plate 15.).
Characteristically, in the transfemoral amputee, small follicular keratin plugs develop in the skin of the inguinal fold and/or the skin of the adductor region of the thigh along the brim of the prosthesis. Similar plugs may appear over the inferior portion of the buttock where the posterior brim or ischial seat of the prosthesis rubs. Through the process outlined below, some of these plugs may become deeply implanted and develop into small or large cysts. Some lesions may become as large as 5 cm in diameter. They are seen as round or oval swellings deep within the skin, and with gradual and continued enlargement, they become sensitive to touch or pressure. The skin may break down and erode or ulcerate. If irritation by the prosthesis is allowed to continue, the nodular swelling may suddenly break and discharge a purulent or serosanguineous fluid. The sinus discharge may become chronic and thus make it impossible for the patient to use his prosthesis effectively. Frequently, scars can remain after the cysts have eventually healed. If the break takes place within the deeper portion of the skin, subcutaneous intercommunicating sinuses may develop.
From our studies it appears that the condition is one in which the surface keratin and the epidermis become invaginated and act as a "foreign body." Under the continued influence of friction and pressure from the prosthesis, the keratin plug and its underlying epidermis are displaced into the corium. The result is a production of nonspecific inflammation and implanted epidermoid cysts. These cysts can remain quiet for a long period or can, with secondary bacterial invasion by Staphylococcus or Streptococcus, become abscessed and produce the characteristic clinical picture.
Either incision and drainage or excision of the chronic, isolated, noninfected nodule may give temporary relief, but there is no completely satisfactory method of treatment. In the acutely infected phase, hot compresses and topical or oral antibiotics selected through bacterial studies and sensitivity tests of the cystic fluid are indicated. As the cyst localizes, incision and drainage may be temporarily beneficial. The chronic problem can, in some patients, be improved or successfully eliminated through evaluation by the prosthetist, followed by proper fit and alignment of the prosthesis.
We are currently applying various topical preparations in an effort to prevent or retard the inflammation that follows formation of the keratin plug, which may be the precursor of the epidermoid cyst. We have attempted to develop a stump sock or adductor rim sock for use with the suction suspension prosthesis to prevent cyst formation. Various substances have been tried as socket liners for reduction of friction over the pressure areas, especially over the brim of the socket. Poly-tetrafluoroethylene film (Teflon) has been found satisfactory for this purpose. Cortisone or its derivatives have been injected into the cysts and their channels to reduce the inflammatory reaction. Topical application of corticosteroids in areas of maximum friction have also been tried. Although this reduces inflammation, it provides only temporary symptomatic relief. In our own experience, there is still no completely satisfactory method of treatment, and each and every patient is a therapeutic challenge.
BACTERIAL AND FUNGAL INFECTIONS
Bacterial folliculitis and furuncles or boils are often encountered in amputees with hairy, oily skin, with the condition aggravated by sweating and rub from the socket wall. It is usually worse in the late spring and summer when increased warmth and moisture from perspiration promote maceration of the skin within the socket, which in turn favors invasion of the hair follicle by bacteria. Ordinarily this process is not serious, but sometimes, especially in diabetics, it can progress to furuncles, cellulitis, or an eczematous weeping, crusted, superficial, impetiginized pyoderma (Plate 16. and Fig 26-1.). Folliculitis and furuncles can also be the result of poor hygiene of the stump and/or the socket. In some of our amputees, the skin bacterial flora of the residual limb was compared with the flora of the opposite normal limb. All subjects wore prostheses and followed a satisfactory routine of skin hygiene. The stump skin was found to harbor bacterial flora more abundant than that of the skin of the intact leg. Chronic recurrent folliculitis can be cured by having an amputee adhere to the routine hygienic program previously described. In still other patients, therapy may require a wet compress, incision and drainage of boils after localization and oral or parenteral use of antibiotics, and local application of bacteriostatic or bactericidal agents.
Superficial fungal infections such as tinea corporis and tinea cruris can appear on any part of the residual limb enclosed by the socket. The diagnosis of a nonspecific scaling, erythematous eruption can be confirmed through culture and/or microscopic demonstration of the fungus filaments in scales or tiny vesicles removed from a given lesion (Fig 26-2.). Chronic recurrent fungal infections are especially common on the stumps of individuals who perspire freely and easily. Once the diagnosis has been made, therapy consists of the application of fungistatic creams and powders for an extended period of time. The newer antifungal agents, applied once nightly, can be curative. In those patients where topical antifungal agents are not effective, oral antifungal antibiotics can be helpful and curative. Griseoful-vin, ketoconazole, or fluconazole given orally for several weeks can be curative in these resistant patients. It should be noted, however, that superficial fungus infections of the stump skin may be difficult to eradicate completely because of continued moisture, warmth, and maceration within the prosthetic socket.
At the present state of knowledge, bacterial and fungal infections are usually short-lived if the diagnosis is made early and correct therapy is administered. Fortunately, the majority of patients respond to topical medications.
Intertriginous dermatitis is an irritation of skin surfaces that are in constant apposition, and between which there is hypersecretion and retention of sweat. The condition usually occurs in the inguinal or crural areas, but on occasion it occurs in the folds at the end of the stump where two surfaces of skin rub against each other and where the protective layer of keratin is removed by friction. Continued friction and pressure from the socket may result in lichenified or pigmented skin. The thickened skin may subsequently itch or burn depending upon the rub. A chronic disorder may develop with deep, painful fissures and secondary infection along with eczematization. Hygienic measures to cleanse the apposing folds and the use of drying powders or mild drying lotions can be beneficial. Frequently the problem can be corrected by proper prosthetic fit and alignment.
OTHER SKIN DISORDERS
Over many years numerous chronic dermatoses have been observed, and some have localized on the stump skin. We have seen patients with acne vulgaris of the face and back develop acne lesions on the stump. We have seen similar localization in patients with seborrheic dermatitis, folliculitis, and eczema. Localization on the stump skin following a generalizing eruption is not unusual. We have seen, and there are recorded instances of psoriasis (Plate 17.) as well as lichen planus developing on the stump skin, with few lesions being present elsewhere on the body. Here it is important to diagnose and treat the generalized cutaneous disorder in order to improve the local process. An accurate diagnosis is of utmost importance.
Diabetic skin is especially prone to chronic disorders that can be serious and disabling. Bacterial and fungal infections are common in those amputees where the diabetic metabolic process is uncontrolled. A high blood sugar content may be reflected as a folliculitis on the stump skin or even elsewhere on the body of the diabetic. Ulcerations or erosions of the skin in diabetics must be diagnosed and treated early to prevent serious infection. The painful deep ulcers and edematous processes can be chronic and disabling. Candidal or yeast infections are not uncommon in the groin and on the stumps of diabetic amputees following a course of antibiotics for some other disorder. Diabetic dermopathy can be seen as bullae or blisters from prosthetic rub against the skin and require several weeks for healing (Plate 18.).
Tumors of the stump skin can be benign or malignant. Viral verrucae or warts have been seen frequently on the stump skin and are treated by cauterization. Simple cutaneous papillomas (Fig 26-3.) are easily removed, and we have seen numerous cutaneous horns on stump skin. All of these are treatable by using a local anesthetic and superficially removing the lesion. Seldom does this require a large surgical excision, and cauterization on the skin following removal of a lesion usually will heal within 2 weeks.
Basal and squamous cell carcinomas have been removed without incident when they were small, and healing has been successful. However, we have had several patients where amputation was necessary for lymphangioma, and these resulted in recurrence with subsequent lymphangiosarcoma and death. Here again, an accurate diagnosis is of utmost importance.
Chronic ulcers of the stump may result from bacterial infection or from poor cutaneous nutrition secondary to edema or to an underlying vascular disorder. In some instances localized pressure from a poorly fitting prosthesis can produce erosion followed by ulceration (Fig 26-4.).
Continued edema of the distal stump skin must be corrected early in order to avoid ulceration. Malignant ulcers can develop within old, persistent stump ulcerations; therefore, every effort should be made to treat the process before it becomes chronic. With repeated infection and ulceration of the skin, the amputation scar may become adherent to the underlying subcutaneous tissues, a process that invites further erosion and ulceration (Plate 19.). The continued wear and tear from the use of a prosthesis may then necessitate surgical revision in order to free the scar in the bound area and allow for effective use of a prosthesis. In every instance one must ascertain the cause of the stump ulceration and discuss corrective therapy with the amputation surgeon and prosthetist.
A warty or verrucose condition of the skin of the distal portion of the stump has been seen in many instances. The disorder has been described by some as the common wart virus invading the skin, while others have thought that the condition was associated with malignancy.
In our experience, we have found only one such instance among numerous patients with verrucose hyperplasia; in all other cases the process has been entirely reversible. In our malignant instance, a 40-year-old physician had extensive ulceration and infection of the stump skin with verrucose hyperplasia of long standing (Plate 20.). A squamous cell carcinoma ultimately developed in the distal skin and extended into the bone. The patient subsequently died in a matter of months from metastases to the lungs.
Verrucose hyperplasia of the stump skin can be present for months or years and can be associated with ulceration in addition to edema (Plate 21. and Plate 22.). Patients with this condition have made the rounds of general practitioners, orthopaedists, dermatologists, pros-thetists, therapists, and others dealing with amputees. Many have been treated with topical preparations and by other forms of therapy without effect. At the best, treatments had been of only temporary benefit. It was only through trial and error that we found external compression in combination with adequate control of bacterial infection and edema to be the best method of treatment. In the transtibial amputees we have reviewed who had this process, the distal part of the stump was edematous and dangled without distal support in the socket. When support of the end was provided in the socket by means of a temporary platform built up with cushions or compression, the warty condition was slowly reduced. The greater the compression on the distal skin, the more immediate and lasting was the improvement. As a result of our investigation, the engineers and prosthetists then modified a prosthetic design to provide backpressure for the tissues at the end of the stump. After several weeks' use of the modified prosthesis, the verrucose condition disappeared and did not recur as long as the compression was continued. The successful treatment of this disorder again serves as another example of the need for cooperation by various professionals to provide the maximum benefit to the individual amputee.
This hyperplastic condition appears to be secondary to an underlying vascular disorder related to poor prosthetic fit and alignment and, possibly, bacterial infection. Although these factors may be present in combination, it is clear from our studies that the poor pressure gradient, which tends to drive fluids into the distal tissues, plays an especially important role. It occurs whenever there is an increase of proximal over distal pressure on the tissues. In an amputation stump with redundant, unsupported tissues, there is likely to be edema before prosthetic treatment because of the lack of support and pressure for the terminal tissues and the absence of any pumping action by the muscles.A shrinker sock used continuously until prosthetic fitting and thereafter whenever a prosthesis is not employed is distinctly advantageous. If the amputee is then fitted with a prosthesis that distributes pressure properly, the edema will subside. However, if his prosthesis produces greater proximal than distal pressures, the edema will be increased.
Amputation surgeons, prosthetists, and engineers are applied scientists from whom great technical assistance is expected. Through their efforts, we have made great strides in our knowledge and technical ability to produce the finest of prostheses, but their skills must be combined with the contributions of the dermatologist in the solution of the many skin problems of the amputee. The importance of early recognition and treatment of the common skin disorders of residual limbs, as described in this chapter, cannot be overemphasized.
- Allende MF, Barnes GH, Levy SW, et al: The bacterial flora of the skin of amputation stumps. J Invest Dermatol 1961;36:165-166.
- Allende MF, Levy SW, Barnes GH: Epidermoid cysts in amputees. Acta Derm Venereol (Stockh) 1963; 43:56-67.
- Fisher AA: Contact Dermatitis. Philadelphia, Lea & Fe-biger, 1986.
- Gillis L: Amputations. London, Heinemann, 1954.
- Golbranson FL, Asbelle C, Strand D: Immediate post surgical fitting and early ambulation: A new concept in amputee rehabilitation. Clin Orthop 1968; 56:119-131.
- Jelinek JE: The Skin in Diabetes. Philadelphia, Lea & Fe-biger, 1986.
- Levy SW: Skin Problems of the Amputee. St Louis, Warren H. Green Inc, 1983.
- Wirta RW, Golbranson FL, et al: Analysis of below-knee suspension systems: Effect on gait. J Rehabil Res Dev 1990; 27:385-396.
Chapter 26 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles