The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of armed conflict and other situations of violence and to provide them with assistance. The ICRC also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the Geneva Conventions and the International Red Cross and Red Crescent Movement. It directs and coordinates the international activities conducted by the Movement in armed conflicts and other situations of violence.# FOREWORD
The International Committee of the Red Cross (ICRC) was founded in 1863; it promoted the Geneva Conventions which have been signed by 165 countries. These conventions protect victims of war, be they wounded, shipwrecked, prisoners of war or civilians. Furthermore, they protect the hospitals and the medical staff who care for the sick and wounded. Within a framework of these conventions, the mandate of the ICRC is to take action and propose humanitarian initiatives in armed conflicts. Bringing surgical care to victims of war, whether com batant or civilian, where there is little or no medical infrastructure, is an increasing part of the activities of the ICRC.
Over the last 10 years, the Medical Division of the ICRC has gained enormous experience of the management of war wounds, especially of those inflicted by antipersonnel mines. This review of amputation tech niques and related problems endeavors to record this experience for the benefit of others who care for victims of war.
Dr. Remi Russbach, ICRC Chief Medical Officer INTRODUCTION ln hospitals of the International Committee of the Red Cross (ICRC) surgical amputa tion of lower and upper limbs at every level is common. Many of the severe limb injuries and traumatic amputations result from antipersonnel mines which, in modern warfare, are widely used and remain after the conflict (1) (figure 1).
Failure to appreciate the disparities between amputation in war surgery and civilian practice results in unhealed stumps, bone exposure and serial proximal amputations; these are the most disheartening aspects of working in a hospital for war injured. These complications arise from the dilemma of having to amputate according to war surgery principles but with only civilian techniques at hand; the pathology and varia tion of the injuries may render these techniques inappropriate.
amputation for war wounds is difficult and different 1a. Victim of an antipersonnel mine with trau matic amputation of the left lower leg. 1b. Plastic string has been used as a makeshift tourniquet.
- c. The patient also had face injuries from the explosion.
- d. The stump is healed six weeks after gastrocnemius myo plastic amputation with delayed primary closure. 1e. A prosthesis has been fitted and manufactured in an ICRC orthopaedic workshop.
- f. The patient's face has hea led well with wound excision and primary closure.
The three objectives of primary amputation for war wounds, in order of priority, are:
iii) to excise dead and contaminated tissue; iii) to be able to perform delayed primary closure;
iii) to leave a stump that is acceptable for fitting a prosthesis i.e. prepara tion of the wounded part for a new function.
A primary amputation which achieves all three objectives avoids complications.
This booklet is aimed at the civilian surgeon with little experience of war wounds; it is intended to rationalize and facilitate surgical amputation for war wounds, whether immediate or after attempted limb salvage. ICRC surgeons treat a large number of war wounded and the same surgeons receive prompt feedback about their tech niques because, in contrast to military surgeons, the patients remain under their care. The standard texts give inconsistent advice about primary amputation (25).
Any surgeon who treats war wounded must recognise that some cultures take a dif ferent view of limb amputation (6). The patients may prefer a useless limb to a functioning prosthesis, whilst others may prefer to die from their wounds rather than suffer amputation. Such views must be accepted and accomodated in decision making.
the amputation must include all dead, contaminated and contused tissue

# PATHOLOGICAL ASPECTS OF THE LIMB INJURY
Severe limb injury or traumatic amputation produce different levels of tissue damage within the limb; skin, fat and muscle have variable resilience to injury. The most strik ing example is the extreme compartmental injury produced within the leg by anti personnel mines (figure 2); skin may be preserved distal to the muscle damage. Therefore, the wound excision element of the primary amputation is complicated; it is not achieved by amputating "throught viable tissue as distal as possible". A guillotine amputation may not even fulfil the first operative objective. Antibiotic prophylaxis is an essential part of the management but does not allow for leaving dead or contaminated tissue on the stump. All patients admitted with open wounds to an ICRC hospital initially receive 5 million units of benzyl penicillin intra venously; this antibiotic is the drug of choice because the more serious pathogens i.e. streptococci and clostridia, remain sensitive to it.
When there is a long delay in the patient reaching medical care, putrid wounds are common but clinical gas gangrene is rare (6) (figure 3). A common and dramatic syndrome is the fever, confusion and anaemia associated with infected wounds. This may be labelled "toxaemia" or "septicaemia" (7). It is rarely encountered outside war surgery and its lack of description in medical literature is due, not to its benign nature, but to the adverse conditions in which it arises. Incomplete excision of dead tissue at primary amputation results in the same syndrome and when overlooked, if not fatal, results in a higher amputation (figure 4).
- a. Three day old shelling injury of the forearm with clinical gas gangrene. Surgical emphysema was palpable in the arm. The patient had a sub capital humeral amputation.
- b. The radiograph shows the presence of gas in the tissues around the fracture.
Field tourniquets which have been applied to the proximal limb present the surgeon with a dilemma if they have been in place and completely occlusive for two hours or more. Does he release the tourniquet and risk renal failure from myoglobinaemia or does he amputate above the tourniquet? A reasonable guideline might be that if such a tourniquet has been in place for more than six hours, the limb should be amputated proximal to it. However, if less time has elapsed, the whole limb is still in danger; after surgery, the surgeon should observe the patient carefully and be prepared to perform proximal amputation at a later date.
First aid workers should be instructed to apply any tourniquet as distal as possible. 4. Victim of an antipersonnel mine three days after injury. The patient has suffered primary closure of an inadequate amputation with no attempt being made to excise the wound on his left thigh (note the ery thema around this wound). He subsequently required above knee amputation on the right with wound excision and delayed closure of the left thigh. His hospitalisation was prolonged and he required mult iple blood transfusions.
stump infection is very dangerous

# OPERATIVE CONSIDERATIONS general
The indications to amputate are well established (25) but the decision in individual cases can be difficult (8). A second opinion is invaluable and the prosthetic facilities should also be considered.
A pneumatic tourniquet is recommended to minimise blood loss during removal of the field dressing and the operation; recognition of viable tissue is not made difficult.
After the operation, it must be released and haemostasis achieved before the dressing is applied.

# the level and technique of amputation
One text advises that a guillotine amputation is performed proximal to the injury and the stump left open for subsequent closure by secondary intention or skin graft (5).
Whilst this amputation might be preferable for the untrained operator outside a surgi cal environment, it must be recognised that, first, it may miss dead muscle due to the compartmental nature of the injury; second, it is unsuitable for amputation through muscular parts, i.e. calf or thigh, because of subsequent swelling; third, it is likely to require revision; fourth, it results in an amputation that is higher than necessary. For these reasons, guillotine amputations are not performed in ICRC hospitals.

# use a tourniquet for surgery
An alternative approach for the field surgeon is to amputate as distal as possible, through viable tissue and by techniques resembling civilian amputations (24). This approach may ensure that the first operative objective is achieved but does not take delayed primary closure of the stump into account. However, compared with guillo tine amputation, the resulting stumps are preferable as few need subsequent revision (2, 3).
Appropriate advice is: perform amputation of dead, damaged and contaminated soft tissue and then plan the bone section as distal as possible but ensuring that the remaining, viable soft tissue can be closed over the bone after a delay. ln practice, this approach involves: trimming of skin edges and fat; raising flaps, with fascia, either formally or as determined by the injury; examining the damaged muscle so exposed; making the muscle section proximal to it and then the bone section. The skin, and preferably muscle as well, should approximate easily at the end of the pri mory operation and so further bone shortening is unnecessary at delayed closure.
leave enough soft tissue to cover bone Most patients are young men with bulky muscles which swell considerably in the four or five days between amputation and closure (figure 5). Skin flaps that approximate at the primary operation may only do so under tension at delayed primary closure; should the wound break down the bone section is exposed (figure 6). Texts that advise delayed primary closure fail to recognise this problem which, if not accounted for, necessitates further bone shortening. An intact muscle left exposed swells much less, is more pliable and readily hoIds sutures; therefore, myoplastic amputations utilising complete muscles are recommended (9).
5. A below knee amputation in which the subse quent muscle swelling was not taken into account. Delayed closure was not possible; the stump had to be reamputated.
A below knee amputation where the skin edges have necrosed because of their closure over the bone section under tension. If this com plication does not necessitate reamputation, the resulting scar will be thin and tethered to the bone; a subsequent revision is likely.
do not underestimate muscle swelling
The section of vessels, nerves and bone are by standard techniques. Vessels should be transfixed with an absorbable suture and the nerves distracted before they are cut. The front of the tibial section should be bevelled and sharp edges of bone filed; bone wax is not used; the periosteum is cut at the level of bone section without proxi mal stripping. It is recommended that extruding intercompartmental fat is also exci sed just proximal to the level of muscle section. This ensures that exposed fat does not necrose and impede delayed closure.
The practice of placing a few large tension sutures to hold a compress between the skin flaps to prevent skin retraction is dangerous: it causes strangulation of skin and muscle.
never attempt primary closure of the stump dressing The primary amputation is rinsed with normal saline and dressed with a dry and non constrictive dressing with sufficient quantities of gauze and cotton wool to soak up the exudate of the first 48 hours (figure 7). Soaking the dressings in an antiseptic solution is strongly discouraged. A plaster of paris splint may be beneficial if the patient is to be transported. It is stressed that this dressing does not routinely need changing before the date set for delayed primary closure.
- a7c. Photographs of the recommended stump dressing being applied to a left below knee amputation (the assistants hand is on the left knee). Some small compresses are placed next to exposed tissue and two larger ones, each containg a generous layer of cotton wool, are placed crosswise over the end of the stump. The arrangement is held in place by a bandage. The bulk of the dressing should be noted.
When pain and swelling of the proximal limb are accompanied by deterioration of his general condition, the patient should be taken to theatre, given an anaesthetic for the dressing to be taken down and have the amputation revised with the same ope rative objectives in mind. The decision to undertake reamputation in a seriously sick patient with multiple injuries can be difficult. An offensive dressing alone is not a rea son to suspect stump infection (10).
The use of skin traction needs clarification (3,4,11). It may help skin closure of the indurated and open stump where delayed primary closure has failed; further opera tion is avoided. The disadvantages are that the patient is confined to bed for a long period and that the resulting scar is tethered to the bone; a subsequent stump revi sion is likely. When the primary amputation is performed correctly there is no need for skin traction; it does not help routine delayed primary closure.

# delayed primary closure
All texts agree that the stump must be left open, permitting exudation of blood and serum and decompression of divided muscle. Primary closure should be performed between three and seven days later and only then if the stump is clean (2,3,4,9). The original operative dressing adheres to the fibrin coagulum that covers a clean wound; as it is peeled off, the divided muscles contract away in a characteristic manner. At this time skin and muscle are pliable. Fine absorbable sutures hold a myoplasty in place; skin flaps are closed independently by interrupted sutures incor porating deep fascia. Vacuum drainage of the stump is recommended for 48 hours after closure.
When the skin flaps are deficient, but the bone section is covered with muscle, a split skin graft can be applied (9). Should this subsequently interfere with prosthetic fitting, it can be excised after some months when the oedema has settled, the muscles have wasted and the skin has regained its normal elasticity.
An open stump which is not clean when the dressing is removed usually needs fur ther excision of soft tissue and possibly bone. This is a difficult and bloody operation and contributes further to the patient's anaemia. Alternatively, repeated antiseptic dressings may clean the wound but closure becomes more difficult with time as the soft tissue of the stump becomes indurated. These unsatisfactory measures affirm the importance of correct primary amputation.
the myoplastic amputations ln this text, three myoplastic amputations are shown (pages 17, 20 and 23) for three levels of amputation; each involves the whole muscle (as opposed to transected muscle) being left at the end of the operation. They fulfil the operative objectives des cribed above as they take the pattern of injury and the swelling of muscle between amputation and delayed closure into account. Additional advantages are: the result ing stump may be longer; stump infection and subsequent breakdown is minimised because the bone section is covered by muscle; the skin flaps, often determined by the injury, are closed independently; the myoplasty can be left exposed when there is insufficient skin to close the stump (figure 8).
There is the theoretical advantage of the myoplasty bringing proprioception to the stump.
- a. A patient with a gastrocnemius myoplastic below knee amputation in which the myoplasty was left exposed because the skin was deficient medially. Photograph taken one week after delayed closure.
- b. The stump two weeks after delayed closure. Note that, as the swelling subsides, the defect closes rapidly. A long stump has been achieved.

# SPECIFIC AMPUTATIONS IN RELATION TO WAR WOUNDS foot and ankle amputations
Formal forefoot or Symes amputations are rarely performed in war surgery. Forefoot injuries do not always necessitate a transverse section; it may be possible to salvage the medial or the lateral portion of the foot. They require wound excision and skin closure by routine methods. Few wounds for which a Symes amputation is possible from the bone point of view have enough soft tissue remaining to cover the distal tibia.

# below knee amputation
There are two appropriate below knee amputations; they are determined by the injury. Whichever is used, the front corner of the tibial section must be bevelled and the fibula cut 3 cm shorter.
i) The lower (case A), through the middle third of the tibia, is only possible when there has been irreparable damage to the foot but the leg is unaffected. ln this case, a soleus muscle flap with independent skin closure is possible; this leaves the intact, musculotendinous part of the calf muscles exposed before delayed closure. The result is a long and well covered stump.
ii) More commonly, a below knee amputation through the proximal third of the tibia is necessary because the injury extends above the ankle (case B). The surgeon may have difficulty maintaining a tibial stump of acceptable length. The compartmental nature of the injury makes the primary amputation more difficult and swelling of the greater muscle bulk higher in the leg may hinder delayed closure. Under these cir cumstances a gastrocnemius myoplastic amputation is best (9). The gastrocnemius muscle, because it is not contained in a tight compartment and has a proximal blood supply, tends to be preserved in severe leg injuries. The technique of using the full length of the medial gastrocnemius muscle takes the compartmental pattern of injury and subsequent swelling into account whilst permitting both good cover of the stump and skin closure by flaps determined by the injury.
A long posterior myocutaneous flap is rarely possible as the tip of the proposed flap is usually affected by the injury.
case a soleus myoplastic below knee amputation.
i) Traumatic amputation of the left foot by an antiper sonnel mine. There appeared to be little damage to the leg.
ii) Equal anterior and posterior skin flaps have been cut and reflected. This exposed proximal contusion in the anterolateral compartment of the leg (the dark muscle held in the forceps). The muscle section was made proximal to this in the affected compartment. The bone section should not be much below this level.
iv) The anterior corner is filed to smoothness.
iii) The tibial section in process. Note the cutting angle of the wire saw to produce the bevelling of the anterior edge. The soft tissue is being held clear by the assistant.
v) The amputation at the end of primary surgery. The intact soleus was the only muscle left distal to the tibial section.
vii) A bulky and dry gauze and cotton wool dressing was applied.
vi) The soft tissues should approximate easily at the end of initial surgery (note not closed with sutures).
viii) The gauze of the original operative dressing after four days when the patient came to the operat ing theatre for delayed closure. Note that the blood and serum which has exuded into the dressing has begun to dry.
ix) The original operative dressing during remo val; this shows how the gauze adheres to the fibrin coagulum on the surface of the muscle. The stump was clean and ready for closure.
x) The soleus myoplasty sutured to the perios teum of the anterior tibial border.
xi) The skin flaps were closed independantly. A vacuum drain was placed beneath the skin flaps and the lateral part of the wound closed.
xii) A bulky dry dressing was applied over the closed stump. The vacuum drain was removed, without taking the dressing down, after 48 hours. The date set for taking the dressing down on the ward can be marked on the dressing (five to seven days after closure).
xiii) The amputation seen at the first dressing change on the ward. This was a well covered and long stump. The sutures were removed after 12 days. 20 case b medial gastrocnemius myoplastic below knee amputation.
i) Antipersonnel mine injury of the right leg; there is traumatic amputation of the leg with half of the tibial shaft exposed.
iii) The surgeon is demonstrating with the forceps that the medial gastrocnemius muscle has survived the injury; the deeper muscles have been contused.
ii) The lateral side of the leg; more skin has been preserved medially.
iv) Medial gastrocnemius myoplastic below knee amputation has been performed. A medial skin flap, as determined by the injury, has been fashioned; the tip of the intact gastrocnemius muscle is held in the forceps in the surgeon's right hand. Note that some of the deeper muscles have been divided just above the level of the tibial section.
vi) The surgeon is demonstrating how the gastroc nemius myoplasty easily covers the tibial section. It was sutured in place to periosteum.
viii) The stump seen at the first dressing change, five days after delayed closure. The sutures were remo ved after 12 days.
v) The stump at delayed closure (five days). Note how the transected muscles have swollen yet the intact gastrocnemius muscle has swollen much less.
vii) The skin flap remaining, easily covers the myo plasty.
through knee amputation
This amputation is rarely performed in ICRC hospitals. It is not suited to closure after a delay because it exposes the large cartilagenous surface of the femoral condyles or their more complex bone section. It is only suitable as a rapid amputation when the patient has multiple injuries and, invariably, it has to be converted to a low femoral section. Basic prosthetic facilities do not readily provide for an end bearing prosthesis.

# above knee amputation
There are two appropriate above knee amputations; both of which are determined by the injury. The first and more common is when the injury is confined to the leg but successful below knee amputation is impossible (case C). An amputation utilising a vastus medialis myoplasty is suitable. This amputation gives a long stump with good cover of the femoral section. The higher above knee amputation, necessary when the thigh muscles are involved in the injury, is performed along the general guidelines. It may or may not be possible to leave one of the muscles intact for later myoplasty.
The swelling of the thigh muscles is considerable and the skin flaps should be cut as long as possible to permit delayed closure. The release of a thigh tourniquet after pri mary amputation causes the skin to elongate and the muscle to retract. This must be accounted for when planning the levels of bone, muscle and skin section. A pitfall in either above knee amputation is that oedema fluid, haematoma or pus travel proxi mally around the sciatic nerve and a seemingly clean amputation can prove disas trous if this is not accounted for. Examination of fat in the track of the divided nerve is recommended; the author excises this routinely.

# hand, forearm and arm amputations
The upper limb is easier than the lower to amputate without complication. This is prob ably because of the less bulk of the muscle compartments. The amputations are per formed along the general guidelines described above. Only the first two operative objectives have to be reached as the stump will not carry a weight bearing prosthesis.

# limb disarticulation and quarter amputations
Hip and shoulder disarticulations and forequarter amputations may be necessary with severe, infected proximal injuries. They are disfiguring and dangerous in a sep tic patient; if successful, delayed skin closure is rarely a problem. By policy, hind quarter operations are not performed in ICRC hospitals.
case c vastus medialis myoplastic above knee amputation.
i) A patient with traumatic amputation of the right leg. The dressings were applied in the field.
iii) Standard equal "fishmouth" skin incisions were made commencing at the upper border of the patella. Care must be taken not to extend the inci sion into the vastus medialis muscle.
ii) Below knee amputation was commenced but the damage to the leg muscles was extensive; shredded muscle and deep fascia is evident. This was aban doned for above knee amputation.
iv) The vastus medialis muscle was separated from its insertion into the quadriceps tendon. To do this, the distal skin has to be reflected down. The surgeon's index finger is shown here deep and medial to this muscle.
vi) The femoral vessels were clamped and transfixed individually. The exposed intercompartmental fat next to the vessels and the sciatic nerve is obvious here.
viii) After the release of the tourniquet, haemostasis was achieved. The intact vastus medialis muscle easily covers the bone section. The open stump was washed with saline and dressed.
v) The section of all other muscles and the femur were made where the femoral shaft begins to flare into the condyles. The assistant keeps the soft tissue clear of the saw.
vii) The intercompartmental fat was excised.
ix) The patient in theatre for delayed closure. Some of the exudate had reached the surface of the dres sing but was dry by this time.
xi) The vastus medialis myoplasty was sutured in position to lateral thigh muscles and fascia. (It can also be sutured to the periosteum.)
x) The stump was clean and ready for closure.
xii) A vacuum drain was placed beneath the skin flaps which were then closed over the myoplasty.
xiii) The dressings were changed after six days and the sutures removed after 12 days.
xiv) The patient was mobilised on crutches after a week. Photograph taken three weeks after injury. He has a long well covered stump.

# STUMP REVISION
Revision of a stump, months or years after skin closure, is commonly requested to facilitate the fitting of or weight bearing on a prosthesis. The common indications are: neuroma; a painful scar tethered to bone; chronic sinus from a non absorbable suture or sequestrum; in the case of below knee amputations, a long fibular section (figure 9); a tibial section without anterior bevelling or a bone spike from the resid ual periosteum.
ln children, the bone ends continue to grow and so may eventually protrude through the scar; this is particularly common in forearm amputations.
The aim of the revision is to remove the cause of the problem and to leave a stump as long as possible which is well covered by soft tissue. The myoplastic amputations described above are rarely appropriate for stump revision unless reamputation at a much higher level is being considered.
Revision for neuroma involves only excision of the neuroma and distraction of the nerve before its higher division.
The operation should be performed after a single intravenous dose of benzyl penicil lin and with a tourniquet on the limb. Both muscle and bone are wasted in any stump and so both are more easily cut. The stump can be closed primarily as long as the revision was not undertaken for an infected sinus. Vacuum drainage of the closed stump is recommended if the revision has involved division of bone or muscle.
- a. A right below knee amputation one year after injury. The fibula has been left too long (indicated) and the patient was unable to weight bear with a prosthesis. The fibula was shortened by four centi metres and the tethered scar revised.
- b. Radiograph of the stump.

# PHYSIOTHERAPY AND REHABILITATION
Following both primary amputation and delayed closure the stump should be ele vated on a traction frame, pillows (Iower limb) or a bedside sling (upper limb) for 48 hours. It is not necessary to confine the patient to bed if he can sit in a wheel chair with the stump above hip level.
Gentle active physiotherapy can be commenced three days after injury. This physio therapy should not disturb the operative dressing nor strain or compress the open stump. Particular attention should be paid to knee extension with isometric contrac tion of the quadriceps in patients with below knee amputation and hip extension for those with above knee amputation. Exercising the amputated limb can become rapidly more vigorous after a week.
Stump bandaging to help the swelling subside and shaping of the stump is only use ful after skin closure has been achieved. Traditional stump bandaging may only harm the stump if commenced too early.
The patient can usually be fitted with a prosthesis after six or eight weeks from skin closure. ln this time attention must be paid to exercising the limb and education of the patient; he should be introduced to other amputees and reintroduced to his family (figure 10).
10. War injured Afghan amputees in the ICRC orthopaedic centre in Peshawar. The centre undertakes their rehabilitation and manufactures pros theses.