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Meta-Analysis
. 2014 Apr 8;2014(4):CD003749.
doi: 10.1002/14651858.CD003749.pub3.

Type of incision for below knee amputation

Paul V Tisi  1 , Mary M Than
Affiliations
Meta-Analysis

Type of incision for below knee amputation

Paul V Tisi et al. Cochrane Database Syst Rev. .

Abstract

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. This is the third update of the review first published in 2004.

Objectives: To assess the effects of different types of incision on the outcome of BKA in people with lower limb ischaemia or diabetic foot sepsis, or both. The main focus of the review was to assess the relative merits of skew flap amputation versus the long posterior flap technique.

Search methods: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched 28 March 2013) and CENTRAL (2013, Issue 2).

Selection criteria: Randomised controlled trials comparing two or more types of skin incision for BKA were identified. People with lower limb ischaemia (acute or chronic) or diabetic foot sepsis, or both, were considered for inclusion. People undergoing below knee amputation for other conditions were excluded.

Data collection and analysis: One review author identified potential trials. Two review authors independently assessed trial quality and extracted the data. Additional information, if required, was sought from study authors.

Main results: Three studies with a combined total of 309 participants were included in the review. One study compared two-stage versus one-stage BKA; one study compared skew flaps BKA versus long posterior flap BKA; and one study compared sagittal flaps BKA versus long posterior flap BKA. Overall the quality of the evidence from these studies was moderate. BKA using skew flaps or sagittal flaps conferred no advantage over the well established long posterior flap technique (primary stump healing was 60% for both skew flaps and long posterior flap (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.71 to 1.42) and primary stump healing was 58% for sagittal flaps and 55% for long posterior flap (Peto odds ratio (OR) 1.04, 95% CI 0.45 to 2.43). For participants with wet gangrene, a two-stage procedure with a guillotine amputation at the ankle followed by a definitive long posterior flap amputation led to better primary stump healing than a one-stage procedure (Peto OR 0.08, 95% CI 0.01 to 0.89). Post-operative infection rate or wound necrosis, reamputation, and mobility with a prosthetic limb were similar in the different comparisons.

Authors' conclusions: There is no evidence to show a benefit of one type of incision over another. However, in the presence of wet gangrene a two-stage procedure leads to better primary stump healing compared to a one-stage procedure. The choice of amputation technique can, therefore, be a matter of surgeon preference taking into account factors such as previous experience of a particular technique, the extent of non-viable tissue, and the location of pre-existing surgical scars.

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Conflict of interest statement

None known

Figures

1
1
Long posterior (Burgess) flap.
2
2
Skew flap.
3
3
Study flow diagram.
4
4
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
5
5
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Two‐stage amputation versus one‐stage amputation, Outcome 1 Failed primary stump healing.
1.2
1.2. Analysis
Comparison 1 Two‐stage amputation versus one‐stage amputation, Outcome 2 Post‐operative infection rate.
1.3
1.3. Analysis
Comparison 1 Two‐stage amputation versus one‐stage amputation, Outcome 3 Reamputation at same level.
1.4
1.4. Analysis
Comparison 1 Two‐stage amputation versus one‐stage amputation, Outcome 4 Reamputation at higher level.
1.5
1.5. Analysis
Comparison 1 Two‐stage amputation versus one‐stage amputation, Outcome 5 Mobility with prosthetic limb.
2.1
2.1. Analysis
Comparison 2 Skew flaps amputation versus long posterior flap amputation, Outcome 1 Failed primary stump healing.
2.2
2.2. Analysis
Comparison 2 Skew flaps amputation versus long posterior flap amputation, Outcome 2 Post‐operative wound necrosis.
2.3
2.3. Analysis
Comparison 2 Skew flaps amputation versus long posterior flap amputation, Outcome 3 Reamputation at same level.
2.4
2.4. Analysis
Comparison 2 Skew flaps amputation versus long posterior flap amputation, Outcome 4 Reamputation at higher level.
2.5
2.5. Analysis
Comparison 2 Skew flaps amputation versus long posterior flap amputation, Outcome 5 Fitted with prosthetic limb.
2.6
2.6. Analysis
Comparison 2 Skew flaps amputation versus long posterior flap amputation, Outcome 6 Mobility with prosthetic limb.
2.7
2.7. Analysis
Comparison 2 Skew flaps amputation versus long posterior flap amputation, Outcome 7 30‐day mortality.
3.1
3.1. Analysis
Comparison 3 Sagittal flaps amputation versus long posterior flap amputation, Outcome 1 Failed primary stump healing.
3.2
3.2. Analysis
Comparison 3 Sagittal flaps amputation versus long posterior flap amputation, Outcome 2 Reamputation at same level.
3.3
3.3. Analysis
Comparison 3 Sagittal flaps amputation versus long posterior flap amputation, Outcome 3 Reamputation at higher level.
3.4
3.4. Analysis
Comparison 3 Sagittal flaps amputation versus long posterior flap amputation, Outcome 4 Fitted with prosthetic limb ‐ overall.
3.5
3.5. Analysis
Comparison 3 Sagittal flaps amputation versus long posterior flap amputation, Outcome 5 Fitted with prosthetic limb ‐ below knee prosthesis.
3.6
3.6. Analysis
Comparison 3 Sagittal flaps amputation versus long posterior flap amputation, Outcome 6 Fitted with prosthetic limb ‐ PTB prosthesis.
3.7
3.7. Analysis
Comparison 3 Sagittal flaps amputation versus long posterior flap amputation, Outcome 7 Mortality at 3 months.
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Update of

References

References to studies included in this review

Fisher 1988 {published data only}
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Ruckley 1991 {published data only}
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