This is not the most recent version of the article. View current version (8 APR 2014)
Type of incision for below knee amputation
Editorial Group: Cochrane Peripheral Vascular Diseases Group
Published Online: 26 JAN 2004
Assessed as up-to-date: 22 JUL 2008
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Tisi PV, Callam MJ. Type of incision for below knee amputation. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003749. DOI: 10.1002/14651858.CD003749.pub2.
- Publication Status: New search for studies and content updated (no change to conclusions)
- Published Online: 26 JAN 2004
This is not the most recent version of the article. View current version (08 APR 2014)
Below knee amputation (BKA) may be necessary in patients with advanced critical limb ischaemia or diabetic foot sepsis in whom no other treatment option is available. There is no consensus as to which surgical technique achieves the maximum rehabilitation potential.
To look at the evidence comparing different surgical techniques for BKA using stump healing, wound infection, reamputation rate, and mobility with a prosthetic limb as outcome measures.
The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register for randomised controlled trials (RTCs) comparing different types of incision for below knee amputation (last searched July 2008) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched 2008, Issue 3). Additional searches were made of bibliographies of papers found through these searches and also by handsearching relevant journals.
Randomised controlled trials comparing two or more types of skin incision for BKA were identified. All patients with lower limb ischaemia (acute or chronic), diabetic foot sepsis, or both were considered for inclusion. Patients undergoing below knee amputation for other conditions were excluded.
Data collection and analysis
Three studies were included in the analysis: two-stage versus one-stage BKA; skew flaps BKA versus long posterior flap BKA; and sagittal flaps BKA versus long posterior flap BKA. Data were extracted independently by both authors.
BKA using skew flaps or sagittal flaps conferred no advantage over the well established long posterior flap technique. For patients with wet gangrene, a two-stage procedure with a guillotine amputation at the ankle followed by a definitive long posterior flap amputation leads to better primary stump healing than a one-stage procedure.
Evidence suggests that the choice of amputation technique has no effect on outcome and can, therefore, be a simple matter of surgeon preference. Factors which might influence this include previous experience of a particular technique, the extent of non-viable tissue, and the location of pre-existing surgical scars.
Plain language summary
Type of incision used for below knee amputation to create a skin flap that maximises healing
Below knee amputation may be necessary for people with critical limb ischaemia caused by advanced vascular disease or diabetic foot infection (sepsis) where no other treatment option is possible. Keeping the knee joint gives a better chance of walking using an artificial leg or prosthesis and social independence after the amputation. The surgical technique is important. Bone and deep tissues are generally treated in a similar way but the type of skin incision varies between techniques. A skin flap is designed to go over the stump where the main consideration is to maximise blood supply and healing. A long posterior skin flap and unequal (skewed) anterior and posterior muscle and skin (myocutaneous) flaps are most often used, although other techniques have been described.
Three randomised controlled studies were identified. They were reported on between 1977 and 1991 and involved a total of 309 patients. Each reported on different comparisons. Below knee amputation using skew flaps or sagittal flaps provided no advantage over the long posterior flap technique on primary stump healing, which approached 60% for all groups. In the third study, involving 30 patients with wet gangrene, a two-stage procedure with a guillotine amputation at the ankle followed by long posterior flap amputation led to better primary stump healing than a one-stage procedure with delayed skin closure. Post-operative infection rate or wound necrosis, reamputation and mobility with a prosthetic limb were similar in the different comparisons.
Nearly all the surgeons in the study that looked at skew flap amputation versus the long posterior flap technique were new to the skew flap operation and so were on a learning curve. Factors which might have influenced the findings include previous experience of a technique, the extent of non-viable tissue and location of pre-existing surgical scars.
當患者出現嚴重的肢體缺血或是糖尿病足部敗血症，且沒有其他可以選用的治療方法時，便可能需要進行膝下截肢術(Below knee amputation，BKA)，目前對於應該使用種手術方式可以達到最佳復原效果並沒有共識。
以Cochrane Review Group on Peripheral Vascular Diseases所闡述的搜尋策略尋找比較不同種類的膝下截肢切口的隨機對照試驗。搜尋包括Cochrane Central Register of Controlled Trials (CENTRAL)、MEDLINE及EMBASE。並利用透過這些搜尋策略所找到的文章中的參考文獻從事額外的搜尋；再者也利用人工搜尋相關期刊。
有3個研究被納入進行分析：比較兩階段膝下截肢術和一階段膝下截肢術、比較斜交皮瓣膝下截肢術(skew flaps BKA)和長厚皮瓣膝下截肢術(long posterior flap BKA)；比較縱向皮瓣膝下截肢術(sagittal flaps BKA)和長厚皮瓣膝下截肢術。由2名作者分別取出數據。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。