Furunculosis in a Transtibial Amputee

Case Report

Phys Med Rehabil Int. 2014;1(3): 4.

Furunculosis in a Transtibial Amputee

M Jason Highsmith1*, Scott Cummings2 and James T Highsmith3

1University of South Florida, USA

2Next Step Bionics and Prosthetics, USA

3Total Skin and Beauty Dermatology Center, University of Alabama at Birmingham, USA

*Corresponding author: M Jason Highsmith, School of Physical Therapy & Rehabilitation Sciences, Morsani College of Medicine, University of South Florida, USA

Received: August 27, 2014; Accepted: September 23, 2014; Published: September 25, 2014


Dermatoses are present in 15-41% of persons with lower limb amputation. Cysts are reportedly the third most prevalent dermatologic condition in this population whereas folliculitis and furuncles are not hierarchically ranked. This case report describes the post-transtibial amputation course of a man with recurrent development of furuncles. Management included recurrent periods of prosthetic disuse and cutaneous surgery. It is likely that self-management of prosthetic factors and hygiene were contributors to his skin maladies as he was undergoing significant residual limb volume change, learning to use his prosthesis, care for himself, and cope with limb loss.

Keywords: Amputee; Cyst; Dermatoses; Folliculitis; Furunculosis; Prosthesis


There are approximately 1.8M persons with amputation living in the U.S. Of these, approximately 378,000 have transtibial amputation[1]. Persons with amputation who utilize prostheses require ongoing care of prosthetists to fabricate, fit, align and maintain their artificial limbs to maximize mobility, function and quality of life. Even with regular prosthetic care to maintain device fit and function, dermatoses are prevalent in this population [2-4]. The prevalence of skin maladies among lower limb amputees reportedly ranges from 15 to 41%. There is no consensus regarding the type and frequency of specific dermatoses affecting persons with amputation. A recent study of 745 prosthesis users found cysts to be ranked as the third most prevalent dermatologic diagnosis affecting the residual limb while folliculitis and furunculosis were not specifically ranked[5]. Evidence to guide practitioners in the management of these diagnoses in persons with amputation is lacking. This report presents a case that was initially diagnosed as folliculitis, then with cystic lesions, and finally as furunculosis demonstrating specific treatment management options that can be applied to patients with similar findings.

Case Presentation

In 2009, a 30 year-old male (height: 1.85m; mass: 70.3kg) sustained a crush injury to his right foot-ankle while employed as a truck driver and manual laborer. He underwent partial-foot amputation and secondarily experienced rapid onset of complex regional pain syndrome (CRPS) affecting the right ankle and foot. Partial-foot prosthesis, including a lower-leg orthotic section was provided. However, due to the severity of his CRPS symptoms, an elective transtibial amputation (TTA) with traditional long posterior flap closure was performed 1year after the primary amputation. The TTA resulted in a residual limb that was 30% of the sound leg length with good soft tissue coverage distally. The patient's goals were to return to work and be able to enjoy outdoor activities.

Six days post-TTA, the patient was fit with an adjustable, customfit preparatory prosthesis. Physical therapy commenced including ambulation with prosthetic side partial weight-bearing. Eight weeks post-TTA, his residual limb had matured sufficiently and his functional level plateaued with the preparatory prosthesis so he was fit with a definitive, endoskeletal prosthesis. The prosthesis included a custom molded, total surface bearing socket with a cushion gel liner, energy storing foot and suction sleeve suspension. The prosthetist instructed the patient in daily stump and prosthetic cleansing to include soap and water. Rubbing alcohol was substituted two times per week to disinfect the liner and sleeve.

Six weeks following definitive prosthesis fitting, the patient was wearing the limb full-time daily and ambulating independently. Due to daily volume-loss and fluctuations, he used 13-18 sock plies to optimize socket fit. The patient began to remark that material bulk of the combined liner, socks, and suspension sleeve reduced comfort with knee flexion. The patient also reported odor build-up in the liner and sleeve. Therefore, he self-initiated use of a prosthetic cleanser (i.e. water-based detergent with ammonium) to mitigate the problem.

Over the next 8 months (3.5-11.5 months post-TTA), the patient's residual limb volume and shape changed sufficient to require fitting of two replacement sockets. Following successful fitting of the second socket replacement, the patient began to complain of posterior knee irritation. This included development of elevated, folliculocentric masses in the popliteal region. Suspecting folliculitis, the prosthetist recommended conservative, over-the-counter (OTC) antibiotic ointment applied in accordance with product instructions. Combined OTC ointment and short-duration, episodic prosthetic disuse, enabled activity continuance. A new prosthesis including powered ankle, cushion liner, and sleeve suspension was fit several months after the first outbreak of component odor, knee discomfort and elevated popliteal masses. After 10 additional months of wearing various prostheses (11.5-21.5 months post-TTA) including a water prosthesis, the powered prosthesis, and the aforementioned socket replacements, the patient began to experience skin issues over the entirety of his residual limb. Particularly problematic were recurrent elevated, erythemic popliteal masses. The OTC antibiotic ointment was continued as needed in selected locations. Barrier cream (i.e. A&D Ointment. Merck & Co., Inc. Whitehouse Station, NJ. USA.) was utilized for generalized areas of irritation.

For the next 10 months (21.5-31.5 months post-TTA), bouts of residual limb dermatoses occurred interspersed with periods of healing partially attributable to prosthetic discontinuance and possibly with topical antibiotics. He then developed a cystic lesion in the popliteal region so painful that prosthetic use was not optional. The patient was referred to a dermatologist for consultation. The dermatologist formally diagnosed the condition as furunculosis and performed incision, drainage and biopsy. Cultures revealed a bacterial infection and the patient was treated with oral antibiotics.

At this point, the prosthetist changed the socket design to include a pin system, thereby eliminating the suspension sleeve and decreasing the amount of skin surface area contacting gel materials. Despite the prosthetic change, the patient's dermatologic problems increased in frequency and severity. A second furuncle formed which was also incised, drained and cultured and a wick placed. Prosthetic use was discontinued to permit healing. Cultures were negative for infection and healing continued over the next two weeks at which time the prosthesis was progressively re-integrated. The patient returned to function until a third bout of furuncles (i.e. carbuncles) emerged.

At 3 years following the fitting of his first definitive prosthesis, the patient's skin ulcerated in the distal hamstring area and furuncles formed again along the anterior and posterior aspects of the residual limb. Prosthetic use was discontinued again. Anterior and posterior furuncles were incised and drained and the residual limb was placed in a semi-rigid stump protector for 6 weeks post-operatively to permit healing. A total period of 7 months of prosthetic disuse was necessary, with the first portion involving use of the stump protector. Immediately prior to prosthetic re-integration, a second prosthetist and dermatologist team were consulted to objectively assess the case. At the extreme end of assessment, predisposition to furuncle development as a reaction to material irritants was considered. However the repeated furuncle development without introduction of new chemicals matched a diagnosis of furunculosis (or carbuncles) quite well. Further, review of the photographic history revealed linear excoriations and xerotic skin suggesting other factors contributing to dermatoses, inflammation, and skin breakdown. Therefore, hygiene, tissue hydration and prosthetic self-management (i.e. volume change, perspiration management) were determined to be worthy focal points of management. See Figure 1 for the post-amputation timeline of development of dermatoses, management and follow up.

Citation: Highsmith MJ, Cummings S and Highsmith JT. Furunculosis in a Transtibial Amputee. Phys Med Rehabil Int. 2014;1(3): 4. ISSN:2471-0377