Definitive surgical interventions for transtibial amputation

BACKGROUND
1.6 million people with limb loss were living in the USA in 2005 and the number is expected to rise to 3.6 million by the
year 2050, with similar trends expected across the world (1). The goal of amputation surgery is to provide a functional
residual limb with the fewest adverse effects (2). Despite the expected increase in number of amputations, there is
currently no consensus regarding the most appropriate transtibial amputation technique.
AIM
To review current literature and compare Long Posterior Flap (LPF), Skew Flap (SF), Bone Bridge (BB) amputations and
Transtibial Osseointegration (TOI) in regards to definitive perioperative, postoperative (acute) and functional outcomes.
METHOD
A literature review was performed in September 2020. The following databases were searched: PubMed, Science Direct,
Knowledge Network, Web of Science and Embase. Studies published between 2000- 2020 were included in the literature
review.
Studies with patients over the age of 18, describing at least one of the surgical techniques and reporting on at least one of
the outcome measures were included.
Full text studies were assessed using “The Criteria List for the Methodological Quality Assessment” by Cochrane
Collaboration Back Review Group (3). The quality of the studies was assessed and the data of each outcome measure
reviewed.
RESULTS
The perioperative outcomes reviewed showed significantly longer operative and operative tourniquet use periods in BB
amputations compared to the LPF amputations. There is not enough data to compare other surgical techniques.
The postoperative data showed no significant difference between LPF and SF amputations based on one available study.
Only one study reported significantly greater complication rates between BB and LPF amputations. There is not enough
data to make comparison between any other techniques.
The functional outcomes only showed significantly better Orthotics and Prosthetics Users Survey scores for LPF
amputations compared to SF amputations. Recent studies found significantly improved Sit-to-Stand times and improved
total limb work in BB groups compared to LPF groups. There are no studies comparing TOI to any other amputation
technique.
DISCUSSION AND CONCLUSION
There is not enough objective data comparing described amputation techniques, because most functional outcome
measures described in the studies are based on patient input. None of the included studies compared more than two
amputation techniques. There is a need for prospective control trials comparing a number of surgical techniques to
provide the answer for the most appropriate definitive transtibial amputation.
Currently, there is not enough research data to compare described amputation techniques in regards to perioperative,
postoperative and functional outcomes.