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Intervention Review

Type of incision for below knee amputation

  1. Paul V Tisi*,
  2. Michael J Callam

Editorial Group: Cochrane Peripheral Vascular Diseases Group

Published Online: 26 JAN 2004

Assessed as up-to-date: 22 JUL 2008

DOI: 10.1002/14651858.CD003749.pub2


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.

Author Information

  1. Bedford Hospital, Department of Vascular Surgery, Bedford, Bedfordshire, UK

*Paul V Tisi, Department of Vascular Surgery, Bedford Hospital, Kempston Road, Bedford, Bedfordshire, MK42 9DJ, UK. pvtisi@rcsed.ac.uk.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 26 JAN 2004

SEARCH

This is not the most recent version of the article. View current version (08 APR 2014)

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

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.

Objectives

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.

Search methods

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.

Selection criteria

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.

Main results

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.

Authors' conclusions

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

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

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.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

膝下截肢的切口種類

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。

目標

比較不同膝下截肢術的手術方法,著眼在殘端癒合、傷口感染、再截肢率、和使用義肢活動力等為預後評估。

搜尋策略

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。

選擇標準

進行膝下截肢術,比較兩種或兩種以上的皮膚切口方式的隨機性對照試驗。所有的病患都具有下肢缺(急性或慢性)和/或糖尿病足部敗血症,排除病患因為其他狀況而進行膝下截肢術的試驗。

資料收集與分析

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。

主要結論

使用斜交皮瓣膝下截肢術或矢向皮瓣膝下截肢術並沒有辦法產生比長厚皮瓣膝下截肢術更好的效果。有濕性壞疽的病患,先在腳踝處進行截斷、再進行長厚皮瓣膝下截肢這樣兩階段的程序,會比一階段的程序在斷肢處獲得更良好的復原效果。

作者結論

證據推測截肢技術的選擇對於治療成果上並沒有影響,這可能只是醫師喜好的簡單問題。可能產生影響的因子包括有對於特定技術的先前經驗、沒有活力之組織的範圍、和先前的手術傷疤等。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

不同的膝下截肢術手術技術對於治療預後並沒有產生影響。當患者腿部的動脈被阻斷時(因為動脈硬化)或是因為糖尿病導致腿部受到嚴重感染時,有時必須進行腿部截肢。膝下截肢提供了患者仍有辦法透過義肢行走的機會,對於這種截肢來說有不同的手術技術。本回顧中的試驗發現並沒有強烈的證據顯示不同的膝下截肢術會為預後造成影響,例如截肢處的癒合復原或是使用義肢行走的能力都沒有影響。