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Three Part Question

In [diabetic patients with a foot resection] does
[weight bearing / mobilising] have [an impact on wound healing]?

Clinical Scenario

A multi disciplinary team working with diabetic and non diabetic patients who have had a lower limb amputation. A challenging area for the team is whether the diabetic patients can mobilise/weightbear after a partial foot resection. Situations have arisen in the past where consultant teams have had opposing views over the weightbearing status of the patient; non weight bearing or partial weight bearing with appropriate footwear.

Search Strategy

Embase 1980 to present
Cinahl 1981 to present
Medline 1981 to present
Amed 1985 to present search tool used.
Title and abstract
partial resection& amputation & foot, toe amputation and/or transmetatarsal amputation and/or,and/or diabetic and/or weight bearing, and/or mobilising and/ or wound healing and/ or granulation.
Manual search was essential due to the limited number of papers found through using the athens search mechanism.

Search Outcome

The search only produced one articlefound on cinahl that met the criteria of the search. A review and a retrospective article were obtained through a manual search of the data.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mueller M.J, Sinacore D.R November 1994 USA	Diabetic patients who have had a transmetatarsal amputation.	A clinical perspective on the problems associated with rehabilitation following a transmetatarsal amputation.	Reduction of foot pressures.	They felt that by changing the walking pattern of patients and providing appropriate footwear the pressures placed upon the foot can be reduced by 58%. The article stated that further research was needed into whether early exercise and footwear can reduce skin breakdown.
Kadukammakal.John, Yau Sydney, Urbas William 2012 USA	48 Patients who had diabetes mellitus who had had partial first ray resections. 30 patients were non insulin dependent and 18 were insulin dependent.	A retrospective study of patients after partial first ray amputation. They hypothesised that first ray resections that require furtehr surgery can lead to poor biomechanics when walking and a need for further amputation.	The level of surgery selected can influence the effectiveness of distributing the weightbearing forces and controlling the risk of ulceration. The partial ray amputation is a good method of prolonging a patients ability to mobilise.	52% of their patients had successful surgery and did not have to go on to have further surgery. The partial foot amputation is beneficial in maintaining a patietns mobility although the success of this surgery is variable.	A retrospective study so the care given and protocols followed may have varied between patients, this may have impacted on their wound healing. The follow up was only based on 4 months as not all patients received follow up care due to non attendance or were lost and could not be contacted.

Comment(s)

Although the papers do not fully answer the question posed they do provide evidence that appropriate footwear and gait traiing can have a positive impact on reducing the pressures that can cause a wound to deteriorate or ulcerate in other areas of the foot. This helps to prevent the need for further amputation to a higher level. This means that as therapists the appropriate footwear should be considered through discussion with the podiatrist.

Clinical Bottom Line

The articles sourced do not fully answer our three part clinical question as to whether a patient weight bearing immediately post toe rescetion/amputation has an impact on wound healing.

References

1. Lavery.L.A,Lavery.D.C, Quebedeax-Farnham T.L Increased foot pressures after great toe amputaion in diabetes. Diabetes Care volume 18, number 11, November 1995
2. Mueller M.J, Sinacore D.R Rehabilitation factors following transmetatarsal amputation. Physical Therapy. Journal of the American Physical Therapy Association 1994 vol 74 no 11 1027-1033 November 1994
3. Kadukammakal.John, Yau Sydney, Urbas William Assessment of partial first-ray resections and their tendency to progress to transmetatarsal amputations. A retrospective study. journal of American Podiatric Medical Association. vol102 No5 September/October 2012