[Breast amputation].

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 STRATEGY: 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. 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) and/or diabetic foot sepsis 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; 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. 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.

Amputation, Surgical↗

PubMed2004

Prescription of prosthetic ankle-foot mechanisms after lower limb amputation.

BACKGROUND: A correct prosthetic prescription can be derived from adapting the functional benefits of a prosthesis to the functional needs of the prosthetic user. For adequate matching, the functional abilities of the amputees are of value, as well as the technical and functional aspects of the various prosthetic ankle-foot mechanisms. There seems to be no clear clinical consensus on the precise prescription criteria for the various prosthetic ankle-foot mechanisms related to the functional abilities of amputees. OBJECTIVES: To obtain information about aspects of prosthetic ankle-foot mechanisms and daily functioning of amputees with a prosthesis, for appropriate prosthetic prescription criteria. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register of trials (April 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 1, 2003), MEDLINE (1966 to April 2003), EMBASE (1983 to April 2003), CINAHL (1982 to April 2003) and reference lists of articles. No language restrictions were applied. SELECTION CRITERIA: All randomised controlled trials and quasi-randomised controlled trials comparing different prosthetic devices for lower limb amputation in adults. No language restrictions were applied. DATA COLLECTION AND ANALYSIS: Two reviewers independently identified potential articles from the literature search. Methodological quality was assessed using a checklist comprising 13 criteria. The reviewers extracted data using pre-defined extraction forms. MAIN RESULTS: Twenty-three trials were included, with a total of 217 participants. The methodological quality was moderate. Only one study was of high quality. No classical RCT's were identified, yet, all included studies used cross-over designs allowing sufficient control for confounding. In high activity transfemoral amputees, there is limited evidence for the superiority of the Flex foot during level walking compared with the SACH foot in respect of energy cost and, gait efficiency. This benefit has only been confirmed in transtibial amputees during decline and incline walking and increased walking speeds. REVIEWER'S CONCLUSIONS: There is insufficient evidence from high quality comparative studies for the overall superiority of any individual type of prosthetic ankle-foot mechanism. In high activity transfemoral amputees, there is limited evidence for the superiority of the Flex foot during level walking compared with the SACH foot in respect of energy cost and, gait efficiency. This benefit has only been confirmed in transtibial amputees during decline and incline walking and increased walking speeds. In prescribing prosthetic-ankle foot mechanisms for lower-limb amputees, practitioners should take into account availability, patient functional needs, and cost.

Amputation, Surgical↗