One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study. Skewflap versus long posterior flap in below-knee amputations: multicenter trial. Below-knee amputation for ischaemic gangrene. Prospective, randomized comparison of a transverse and a sagittal operative technique.
Although the two-stage amputation technique entails an additional operation, several authors have advocated this approach to deal with wet gangrene because it allows primary wound closure with a reduced chance of wound infection. To examine this issue, 47 patients with necrotizing wet gangrene of the foot were randomized prospectively to receive either a one-stage amputation (definitive below- or above-knee amputation with delayed secondary skin closure in 3 to 5 days) or a two-stage amputation (open ankle guillotine amputation followed by definitive, closed below- or above-knee amputation). Antibiotic coverage was standardized with clindamycin and gentamicin used in all patients. Preoperative blood cultures and intraoperative foot cultures were obtained, as well as cultures from the deep muscle and lymphatic area along the saphenous vein to determine the presence of bacteria at the level of initial amputation. Twenty-four patients (11 diabetic and 13 nondiabetic) were randomized to the one-stage procedure. Twenty-three patients (14 diabetic and nine nondiabetic) were randomized to the two-stage procedure. Five of 24 patients in the one-stage group (21%) had positive muscle cultures vs 10 of 23 patients in the two-stage group (43%). Two of 24 patients in the one-stage group (8%) had positive lymphatic cultures vs 7 of 23 patients in the two-stage group (30%). Five of 24 patients in the one-stage group (21%) had wound complications attributable to the amputation technique vs none of 23 patients in the two-stage group (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS) A multicenter trial of alternative techniques for below-knee amputation is described in which surgeons in 11 centers randomized 191 patients with end-stage occlusive vascular disease to two different methods of stump construction. The skewflap technique was performed in 98 and the long posterior flap was performed in 93. The two groups were well matched in respect to age, sex, smoking, diabetes, and indications for amputation. Early outcome was compared in terms of 30-day mortality rate: skew 11 (11%) deaths versus long posterior flap 16 (17%); the state of the wound at 1 week (primary healing 60% in both groups); the need for surgical revision at the same level 7 (7%) versus 7 (8%), and revision to a higher level 10 (10%) versus 7 (8%). Follow-up information at 6 months was available from records or by mailed questionnaire in 188 (98%) at 6 months, 20 died during that interval. It showed that a prosthetic limb was fitted to 64 (84%) of skew flaps and 50 (77%) of long posterior flaps. Walking, alone or with support, was achieved in 59 (78%) and 46 (71%), respectively. None of these differences reached statistical significance. It is concluded that the skew flap is just as effective as the long posterior flap and is an excellent option for below-knee amputation. In a prospective, randomized study a comparison was made of the results of primary below-knee amputation for ischaemic gangrene carried out by two methods: In 47 cases by the transverse technique with a long posterior musculo-cutaneous flap and in 41 cases by the sagittal technique using equally large medial and lateral musculo-cutaneous flaps--in both instances followed by 2 weeks in a half-open plaster cast with extended knee. The sex ratio and age distribution were the same in both groups. Minor differences in the vascular condition between the groups, assessed by the duration of rest pain, pulsation findings, extent of gangrene, and frequency of diabetes, wholly or partially equalized each other. The course of healing was the same in both groups, primary healing being attained in 38 per cent and 41 per cent, respectively (0.70 less than P less than 0.80). There was also no difference between the results as regards limb fitting, ambulation, occupational, or social status. It is concluded that the choice between the two methods can be based merely upon surgical skill and the ischaemic changes in the lower leg.
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.