Study: Female and Transtibial Amputees Most Likely to Use Cosmetic Covers

Patients with transtibial amputation are likely to use prosthetic coverings to combat body image issues, according to recently published data.

Non-cosmetically finished prostheses that are visible to others, including bulky interfaces, lack of symmetry and abrupt transitions, play a role in those issues and could even reduce societal engagement for some patients, M. Jason Highsmith, PhD, PT, DPT, CP, FAAOP, told O&P News.

His research shows cosmetic covers can assist in prosthesis acceptance, promote functional recovery and positively affect patient-perceived comfort and outcomes.

“But what is most surprising, was that no one had previously taken time to look at different trends in the cosmetic covers themselves,” he said. “We were curious to see how many folks in a lower limb amputee population used covers, [and] the differences based on level of amputation, gender, age, type of insurance and other demographic factors.”

Finding insight

Highsmith and a team at the University of South Florida used a cross-sectional study design to review outpatient records from a Tampa-based prosthetic practice. A total of 294 transtibial and transfemoral amputees who received a prosthesis within a 2-year period were included.

M. Jason Highsmith

Use and type of cosmetic cover within the study period were examined. Payment source, nominal and continuous data were also collected.

Using logistic regression models, researchers explored comparisons to determine whether differences existed between the type of cover delivered and demographics of the patient.

Results showed that regardless of amputation level, women were significantly more likely to use a cover, as 56% of female participants used one compared with 31% of males.

Patients with transtibial amputation were also more likely to use a cover than transfemoral amputees. This could be due to a heightened sense of body image at more proximal amputation levels, Highsmith said. It could also be that transfemoral covers must factor in knee articulation and flexibility, which may wrinkle with movement or simply not be covered at all, he said.

Additionally, the researchers found that patients who chose to use cosmetic covers preferred pull-up skin covers, as they satisfied multiple criteria including high utility, durability, affordability and were rated more aesthetically pleasing than nylon stockings.

Insurance type did not affect whether or not a cover was used, but Medicare comprised the largest percentage of reimbursement for cosmetic covers, the researchers found.

Limitations and future direction

There were some limitations with the research, Highsmith said. Only third-party reimbursement records were attainable, making it difficult to determine whether any patients paid out-of-pocket for cosmetic covers.

Also, the analysis was conducted in a warm, tropical geographic region. Results may differ in other parts of the world based on varying climates, Highsmith noted.

“We are in Florida … so [for much] of the year, people wear shorts,” he said. “Will that translate to a study out of New York, or Alaska or some other part of the world? I do not know, because aspects of the cover and its visibility are going to be different based on geographic region and other factors.

“There is also a bit of limitation because a given practice may prefer to provide certain types of covers or use completely different technical fabrication strategies. We would like to see bigger and more robust samples,” he said. “There is definitely still some work that needs to be done in this area.”

Research is moving in that direction. Highsmith suggested new studies expand sample size and geographic reach. Researchers should also look into ways to make cosmetic covers more accessible to transfemoral amputees and further examine the role insurance, gender and cover type play in outcomes.

“We should try to match demographic and psychosocial aspects with actual delivery and utilization,” he said. “I am not certain we can pursue this as a major research emphasis area, but I hope to take the necessary next steps to continue.” – by Shawn M. Carter


Highsmith MJ, et al. Prosthet Orthot Int. 2015;doi:0309364614564024.

Disclosure: Highsmith reports no relevant financial disclosures.

Leave a Reply

Your email address will not be published.