Tisi P V, Callam M J
Department of Vascular Surgery, Bedford Hospital, Kempston Road, Bedford, Bedfordshire, UK, MK42 9DJ.
Cochrane Database Syst Rev. 2004(1):CD003749. doi: 10.1002/14651858.CD003749.pub2.
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.
Publications describing randomised controlled trials comparing different types of incision for below knee amputation were sought using the search strategy described by the Cochrane Review Group on Peripheral Vascular Diseases. This involved searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. 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) and/or diabetic foot sepsis were considered for inclusion. Patients undergoing below knee amputation for other conditions were excluded.
Three studies were included in the analysis: two-stage versus one-stage BKA; skew flaps BKA versus long posterior flap BKA; 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.
REVIEWER'S 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.
对于晚期严重肢体缺血或糖尿病足脓毒症患者，若没有其他治疗选择，膝下截肢（BKA）可能是必要的。对于哪种手术技术能实现最大康复潜力，目前尚无共识。
以残端愈合、伤口感染、再次截肢率和使用假肢的活动能力作为结局指标，研究比较不同BKA手术技术的证据。
使用Cochrane外周血管疾病综述小组描述的检索策略，查找描述比较不同类型膝下截肢切口的随机对照试验的出版物。这包括检索Cochrane对照试验中心注册库（CENTRAL）、MEDLINE和EMBASE。通过这些检索找到的论文的参考文献也进行了额外检索，并且还手动检索了相关期刊。
确定比较两种或更多种BKA皮肤切口类型的随机对照试验。所有下肢缺血（急性或慢性）和/或糖尿病足脓毒症患者均考虑纳入。因其他情况接受膝下截肢的患者被排除。
分析纳入了三项研究：两阶段与一阶段BKA；斜形皮瓣BKA与长后皮瓣BKA；矢状皮瓣BKA与长后皮瓣BKA。两位作者独立提取数据。
使用斜形皮瓣或矢状皮瓣的BKA与成熟的长后皮瓣技术相比没有优势。对于湿性坏疽患者，两阶段手术，先在踝关节处进行断头截肢，然后进行确定性的长后皮瓣截肢，比一阶段手术能带来更好的残端一期愈合。
证据表明，截肢技术的选择对结局没有影响，因此可能只是外科医生偏好的简单问题。可能影响这一选择的因素包括对特定技术的既往经验、坏死组织的范围以及先前手术瘢痕的位置。
