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SAGITFAL INCISION FOR BELOW KNEE AMPUTATION IN ISCHAEMIC GANGRENE

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					             SAGITFAL                INCISION                         FOR               BELOW-KNEE                            AMPUTATION                                       IN
                                                        ISCHAEMIC                            GANGRENE

                                                     BJ#{246}RN      M.      PERSSON,             LUND,         SWEDEN




       Above-knee       amputation                   is still        preferred            by some             surgeons             in the                 treatment          of ischaemic
gangrene   because         of the frequency   of necrosis    in the anterior                                                    flap after conventional                                 below-
knee amputation.            To solve this problem     Romano      and Burgess                                                      (1971) used a technique                                  with
a posterior     flap only, as originally     described                                    by Ghormley     (1946),    and achieved     a 77 per cent
healing     rate with preservation       of the knee                                    in ischaemic    gangrene       with or without      diabetes.
There     seems     to be no parallel      comparison                                       between   a conventional        and a posterior         flap
technique  except         that     of S#{248}rensen (1970),   which                                showed    no               difference  in a small                                series.        It
may be supposed          that     the posterior    flap technique                                 would   prove                to be the better when                                compared
with    the conventional        if all other                   circumstances                     were       the same.
       This article    presents     another                    way to improve                     the       healing   possibilities                              by a technique             that
uses medial    and lateral  musculocutaneous                                        flaps.  This is termed                          the      sagittal                 technique,         and       it
resembles   the one independently         described                                  by Tracy   in 1966.


                                                                     CLINICAL               MATERIAL

       The   material     comprises                  all major              amputations                   of the        lower         limb                done        at the       University
Hospital     in Lund     from        1966        to 1971         .    Amputations                      for tumour             and         trauma                 have       been     excluded

                                                                                    TABLE          I

                           MAJOR           AMPUTATIONS                 OF THE           LOWER       LIMB      BELOW          THE     HIP         AT THE
                                  UNIVERSITY             HOSPITAL             OF LUNn            1966-71,       WITH         INDICATIONS



                                                         Diagnosis                                        Numberof                 Percentage


                                 Ischaemic            gangrene.                     .        .               172                            83

                                    Arteriosclerosis                    .           .        .                         92                             44

                                    Diabetes               .            .           .        .                         66                                 32

                                    Arterial          embolism                      .        .                         10                                  5

                                    Thromboangeitis                    obliterans            .                          4                                  2
                                 Malignant             tumours          .           .        .                21                            10

                                 Trauma.                   .            .           .        .                 10                                5

                                 Malformation                           .           .        .                     1                             05

                                 Osteomyelitis             .            .           .        .                  I                                    .5

                                 Other           .         .            .           .        .                  2                                1

                                                                                                             207                           100




because     here the selection       of level is not made  on the basis                                                     of the         potential     for healing.                           The
total   primary      material     is given   in Table I. In 207 patients                                                       172         limbs     were amputated                              for
ischaemic      gangrene       and form the basis of this study.

I 10                                                                                                            THE         JOURNAL              OF        BONE       AND    JOINT     SURGERY
                         SAGITTAL            INCISION           FOR     BELOW-KNEE                 AMPUTATION              IN ISCHAEMIC             GANGRENE                            111

                                                                      TECHNIQUE                OF        OPERATION

            A tourniquet                  is not     used.        The     skin       is cleaned          with   soap       and    then     with      iodine         solution.          The
skin incisions    are outlined                           with      blue ink (Fig. 1). The skin is not touched during  the operation.
Separation     of the layers                          during        incision is avoided. The tibia is sawn at a 45 degrees   angle                                                        in
one         cut ; the            fibula       is divided              only         1 centimetre             more        proximally.            For       ligature            of vessels
and         nerves            Supramid              is used.            The        muscles         are     united       from      side    to      side     over        the      oblique




                                            FIG. 2                                                                                        FIG. 3
The      sagittal         technique       for below-knee             amputation.            Figure   I-The             medial    and lateral     musculo-cutaneous                   flaps.
       Figure         2-The       45-degree      oblique          cut of tibia,         with myoplasty              from    side to side.     Figure     3-Plaster              shell.



bone end.     The fascia is closed   and the skin is closed     with interrupted      nylon    sutures.      Suction
drainage    is not used.     The wound     is covered   with cotton-wool         and a plaster      (Fig.   3).    The
plaster  is retained    for two weeks    unless   there are indications      for inspection.        Myodesis       and
osteoplastic       procedures   are                          considered                 to be unnecessary                for below-knee      amputation.                               The
patient      is got up on crutches                            the day              after operation      but            a prosthesis   is not used until                         four     to
six  weeks              have elapsed       and the wound       is soundly     healed.
       This             technique       was used in fifty-eight       cases of ischaemic         gangrene.    Another    forty-one
below-knee                  amputations      were done by the conventional            technique,     with or without  application
of plaster               after operation.       The posterior     flap technique        was not used in this series.


                                                                                           RESULTS
       A comparison                         of the healing     after   below-knee     amputation        by the                                       sagittal          and       by the
conventional     method                       is shown   in Table    11. The differences      are significant                                        (sequential              analysis)
both        for        reamputation                 above       the      knee        and     for     the    total      figure     of primary             healing.             The      two
series          are    similar       but      not    identical.              The     mean      age was          the same         but     the proportion                of diabetics

VOL.       56 B,        NO.    1,   FEBRUARY          1974
112                                                                                                             B. M.          PERSSON


                                                                                                                       TABLE                  II
      A COMPARISON                   BETWEEN              THE        SAGITFAL                      AND         THE      CONVENTIONAL                              TECHNIQUES                    OF BELOW-KNEE                   AMPUTATION



                                                                         Number                                                 Incidence                          Reamputations                            Local                       Delayed
                 Technique               of                                    of                  Mean          age                  of                              to above-                           revision                      healing
        below-knee            amputation                                 patients                                                   diabetes                          knee    level                          only                          only


  Sagittal             .             .          .            .                 58                        739                          18/58                                     6/58                        3/52                          6/49

  (medial        and       lateral        flaps)                                                                              (31    per           cent)                (10    per      cent)           (6 per      cent)         (12     per     cent)

  Conventional                       .          .            .                 41                        737                         23/41                                     16141                        2/25                          6/23
  (anterior          and    posterior               flaps)                                                                    (56    per cent)                      (39        per cent)                (8 per cent)              (26    per cent)




                                                                                                                      TABLE                 III

                           REAMPUTATIONS                         FROM               BELOW-               TO      ABOVE-KNEE                         RELATED                   TO OPERATIVE                TECHNIQUE
                                                                         AND         THE       OCCURRENCE                           OF DIABETES                     MELLITUS



                                                                                                               Reamputations                            Reamputations                                    Total
                                         Operative               technique
                                                                                                                 in diatirs                            in non-diabetics

                             Sagittal                 .              .               .              .                    1/18                                            5/40                              6/58
                             (medial            and        lateral           flaps)                            (56       per        cent)                  (125          per    cent)             (10     per cent)

                             Conventional                            .               .              .                    6/23                                           10/18                             16/41
                             (anterior              and      posterior                    flaps)                (26      per cent)                         (56 per          cent)                 (39     per cent)




was      higher            in the             conventional                               group.                   If the              series                is divided                   between               diabetics                and       non-
diabetics     (Table      III) the advantage          of the sagittal    technique     is at least the                                                                                                                    same,           and        the
reamputation         rate in diabetics       was lower.
        To evaluate      the results  it is necessary    also to compare     the number     ofabove-knee                                                                                                                        amputations
done during                  the same period.                                   In Figure    4 the yearly   final                                                       numbers  of above-                            and below-knee
amputations                   are shown.      In                               Figure    5 both   the attempted                                                           and the finally                           achieved    relative
numbers             of below-knee                                amputations                               are demonstrated          for                                             each        year.    During    1971 the
sagittal         technique    only                        was      used and                             the attempted      below-knee                                                 ratio      was raised    to 93 per cent
of the total number                             of major     amputations                                            for ischaemic      gangrene.
      The mortality                            after  operation       for                                      ischaemic      gangrene      was                                           17 per           cent          for      above-knee
amputations                and            6 per           cent            for            below-knee                      amputations.                                    The         mean         primary              stay        in hospital
was thirty             days.

                                                                                                                DISCUSSION
        A number     of facts have now been collected                    concerning     the handling         of amputations         in
cases of ischaemic      gangrene      with or without          diabetes.        It has been shown         that the selection       of
level is to be determined          by clinical      estimation       of the condition         of the skin judgment           based
on colour     and temperature.           Pre-operative         determination          of arterial    pulsations      at different
levels and the character        of the arteriographic           picture      bear little correlation        to the potential      for
healing   in below-knee      amputation        (Sarmiento,        May, Sinclair,        McCollough         and Williams       1970;
Rornano       and Burgess      1971).     A plaster     shell during      the first two weeks        after  operation        has
been    shown      to be of considerable         importance       for successful       healing,   whereas     direct    fitting
with a prosthesis       in these      old people     can disturb     healing     (Sarmiento     and colleagues        1970) if
the loading      during  walking      is not limited    to 9 kilograms       (Romano        and Burgess    1971 ; Mooney,
Harvey,          McBride                  and         Snelson                       1971).               Considerable                              improvement                           in the         healing             of below-knee
stumps         has         been          achieved                 when                   these           points               have            been            carefully                 observed.                  The         total      number
of these          patients               is increasing                              (Hansson                          1964,         Tibell                 1971),              and        with          a preserved                    knee       joint
the     frequency               of prosthetic                            use is about                           doubled                  (Romano                          and          Burgess            1971).            Even          patients
who      are too           debilitated                    to walk                    have           the use of the                             knee           joint            for sitting,              turning               in bed         and         so

                                                                                                                                                                  THE         JOURNAL            OF     BONE       AND          JOINT      SURGERY
                    SAGITFAL                 INCISION                  FOR            BELOW-KNEE                         AMPUTATION                                IN        ISCHAEMIC                       GANGRENE                                 113

on.     Only when                there is a flexion                                   contracture                   of 30 degrees                              or more is below-knee                                                 amputation
contra-indicated                   in old people.                                     If more               knee       joints  are                            to be preserved    surgical                                              technique
must      be improved.
         A sagittal    technique                          similar                    to the           one         presented                   here                 has         been                described                  from        Australia
(Tracy       1966)       and          tried      in a routine                           series         (Jones              and           Burniston                           1970).                 The        possible              advantages


                                     50


                                                                                                                                                              I,         \                TOTALOF                    BELOW
                                                                                                                                                         ‘I                   %           AND            ABOVE          KNEE
                                      40
                                                                                                                                                   ‘I                             \       AMPUTATIONS

                                                                                                                                                                                          ‘I




                                     30                                                                                                                                                              BELOW            KNEE
                        (I)
                        I-
                        z                                                                                                           A


                                      20
                                                                              _.*-          -


                        U-
                        0

                                      10
                        aD
                                                                                                                                                                                                    ABOVE             KNEE
                        z


                                                    1966                        1967                    1968                      1969                    1970                          1971

                                                                                                                  FIG.       4
                                     Major       amputations                          for       ischaemic           gangrene                  1966-71.                       Final        levels             only.




                        -j
                        4                                                                                                                                               BELOW KNEE
                        1oo                                                                                                                                             RATIO ATTEMPTED                                       100
                                                                                                                                                                                                         A
                        U.                                                                                                                                                                           /                        go
                        080                                                                                                                                                                    /
                                                                                                                                                                                                                              80
                        Iii

                                 70                                                                                                                                                                                            70
                                 60                                                                                                                                                                                            60

                                                        I..-.                                                                                                                                                                  50
                        5o
                        aD       40                                                                                                                                                                                            40
                        -30                                                                                                                                                                                                    30
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                                     10                                                                                                                                                                                        10
                        0



                                                   1966                              1967                   1968                        i69                             1970                         1971

                                                                                                                  FIG.       5
                        Amputation                levels          attempted                     and    finally           achieved             in each               year.             Below-             and         above-
                                                                knee         amputations                    for     ischaemic                 gangrene                       only.



of     the   sagittal            technique                      in comparison                               with            the          posterior                           flap        technique                        are        as    follows:
1) The       skin        cut          reduces              effectively                          the    amount                  of vulnerable                                   pre-tibial                      skin           and     creates         an
angle in which    the                      tibia can easily be divided.    2) The theoretical risk                                                                                                  of flap necrosis                        depends
on the ratio between                         the length and the width ofthe flap. Two symmetrical                                                                                                      flaps should                       therefore
be better than  a long one                                      with the same width.     3) Two symmetrical                                                                                  flaps also allow the skin


                                 ,
to be cut as far as possible                                      from  an area of ischaemic   or infected                                                                               skin, with preservation     of

VOL.     56 B,   NO.         I   FEBRUARY               1974
 114                                                                                                  B. M.            PERSSON


the       minimum                    length of bone.    4) The myoplasty                                                         from              side to          side gives better   coverage    of
the       bone end                  than a plasty  from posterior  to the                                                      anterior              fascia         only.   The oblique    cut of the
tibia        gives         good            support              to the             myoplasty,                      preventing                     it from          sliding             posteriotly.                  5) Good
spontaneous        drainage     without    tubes is allowed  because     of the elimination      of pocket                                                                                                        formation
as with     one posterior         flap.    The two symmetrical       flaps give from         the beginning                                                                                                          a stump
without     wrinkles       or ears.     The total  contact  socket,    irrespective     of its suspension                                                                                                          principle,
seenis        to give good                      function                 with any               position    of the scar,                                 so long as the scar is not adherent.
           It may be the                         sum of                  a number                  of refined    details                                 in the care of these   patients    that
accounts             for the reported                          success  of knee preservation    in different    published   series (Tracy     1966,
Sarmiento               and colleagues                           1970, Romano     and Burgess     1971).     The sagittal  technique     seems to
deserve             more   attention                         and it has qualities     that make    it worth     while to compare      it with the
posterior             flap          technique,               with         prophylactic                       antibiotics,              drainage,                 plastering               and          other      important
factors   statistically                       controlled                   throughout                    the study.                  The critical                  indication   for the amputation
(pain,  toxaemia,                          malfunction)                     must also                  be the same                   in different                   series if a valid  conclusion                                     is
to be drawn.

                                                                                                           SUMMARY

1 A sagittal
     .              technique                                 for      below-knee    amputation                                      for ischaemic                        gangrene                based        on medio-
lateral   musculo-cutaneous                                         flaps is described,      similar                                   to the one                       independently                      presented     by
Tracy   (1966).
2. The results                         with this method     are illustrated                                              by the evolution                        of the below-knee                              healing       rate
over six years                       in 172 patients    with ischaemic                                                 gangrene.
3.       A comparison                        between                sagittal         and         conventional                        flap techniques                       shows          a reamputation                      rate
of six out of fifty-eight                                   in the former    and sixteen     out                                       of forty-one in the latter.
4. The overall     relative                                 knee joint preservation      during                                         1971 was 82 per cent, and                                          the frequency
of attempted      below-knee       amputation      was 93 per cent.
5. It is concluded         that the sagittal      technique        has several       advantages       in comparison                                                                                                       to the
posterior    flap technique,      and that the potential           for healing      is on the same high level.
6. A fully controlled          comparison     between       different    techniques        is proposed.


                                                                                                           REFERENCES


GHORMLEY,                 R. K. (1946)               : Amputation                  in Occlusive                    Vascular          Disease.              In Peripheral                Vascular           Diseases.          First
         edition,         p. 783.           Edited          by E. V. Allen,                N.         W.     Barker          and     E. A. Hines,                Jun.       Philadelphia:                  W.     B. Saunders
         Company.
HANSSON,         J. (1964): The Leg Amputee.         Acta orthopaedica                                                           Scandinavica,               Supplementum                       69.
JONES,      R. F., and BURNISTON,        G. G. (1970): A Conservative                                                              Approach                to Lower-Limb                  Amputations.                    Medical
         JournalofAustralia,      2, 711.
MOONEY,             V.,    HARVEY,             J. P., Jun.,               MCBRIDE,              E.,        and     SNELSON,           R. (1971):             Comparison                  ofPostoperative                   Stump
         Management                   : Plaster       vs. Soft Dressings.                          Journal              ofBone        andJoint              Surgery,           53-A,       241.
ROMANO,              R.       L.,    and      BURGESS,               E.     M.       (1971):               Level         Selection           in     Lower          Extremity             Amputations.                     Clinical
         Orthopaedics                 and Related              Research,             74,    177.

SARMIENTO,                A.,       MAY,       B.     J.,     SINCLAIR,             W.      F.,        MCCOLLOUGH,                      N.         C.,     and     WILLIAMS,               E.         M.   (1970):        Lower-
         Extremity              Amputation.                   Clinical         Orthopaedics                      and     Related       Research,             68,     22.

S#{216}RENSEN, K. 1-I. (1970)                   :     Crus-         og     femuramputation                             ved   arteriosklerose.                  Nordisk  Medicin,      84, 1598.
TIBELL,        B.    (1971)          : Peripheral             Arterial           Insufficiency.              Acta orthopaedica                            Scandinavica,    Supplementum         I 39.
TRACY,         G.     D. (1966):              Below-Knee                  Amputation                   for Ischemic   Gangrene.                             Pacific Medicine     and Surgery,      74,                         251.




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