117

General Surgical Principles for the Combat Casualty With Limb Loss

Chapter 8

GENERAL SURGICAL PRINCIPLES FOR 

THE COMBAT CASUALTY WITH LIMB 

LOSS

SCOTT B. SHAWEN, MD*; WILLIAM C. DOUKAS, MD†; JOSEPH A. SHROUT, MD‡; JAMES R. FICKE, MD§; BENJAMIN K. POTTER, MD¥

; ROMAN A. HAYDA, MD¶; JOHN J. KEELING, MD**; ROBERT R. GRANVILLE, MD††; and

DOUGLAS G. SMITH, MD‡‡

INTRODUCTION AND HISTORICAL PERSPECTIVE 

WOUND MANAGEMENT AT POINT OF INJURY

INDICATIONS AND TIMING FOR DEFINITIVE CLOSURE

MANAGEMENT OF SOFT TISSUE AND MUSCLE

MANAGEMENT OF NERVES

DRESSINGS

UPPER LIMB

LOWER LIMB

MULTIPLE INJURED LIMB AMPUTEE

DELAYED AMPUTATION VERSUS LIMB SALVAGE

CONCLUSION

*Lieutenant Colonel, Medical Corps, US Army; Orthopaedic Surgeon, Integrated Department of Orthopaedics and Rehabilitation, National Naval Medical 

Center/Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307

†Colonel (Retired), Medical Corps, US Army; Chairman, Integrated Department of Orthopaedics and Rehabilitation, National Naval Medical Center/

Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307

‡Lieutenant Colonel(P), Medical Corps, US Army; Orthopaedic Hand Surgeon, Department of Orthopaedics and Rehabilitation, Walter Reed Army 

Medical Center, Building 2, 6900 Georgia Avenue, NW, Washington, DC 20307; formerly, Chief, Department of Surgery and Special Care, Kimbrough 

Ambulatory Care Center, Fort George Meade, Maryland

§

Colonel, Medical Corps, US Army; Orthopaedic Consultant, US Army Surgeon General, Chairman, Department of Orthopaedics and Rehabilitation, 

Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, Texas 78234

¥

Major, Medical Corps, US Army; Musculoskeletal Oncology Fellow, Department of Orthopaedics and Rehabilitation, University of Miami School of 

Medicine (D-27), PO Box 016960, Miami, Florida 33101; formerly, Chief Resident, Integrated Department of Orthopaedics and Rehabilitation, Walter 

Reed Army Medical Center, Washington, DC

¶

Colonel, Medical Corps, US Army; Chief Orthopaedic Trauma, Residence Program Director, Department of Orthopaedic Surgery, Brooke Army Medical 

Center, 3851 Roger Brooke Drive, Fort Sam Houston, Texas 78234

**Commander, Medical Corps, US Navy; Director, Orthopaedic Trauma and Foot and Ankle Division, Department of Orthopaedics, National Military 

Medical Center, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, Maryland 20899 

††Colonel, Medical Corps, US Army; Orthopaedic Surgeon, Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, 3851 Roger 

Brooke Drive, Fort Sam Houston, Texas 78234; formerly, Director of Amputee Service, Department of Orthopaedics and Rehabilitation, Brooke Army 

Medical Center, Fort Sam Houston, Texas 

‡‡Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Washington, Harborview Medical Center, 325 Ninth Avenue, 

Seattle, Washington 98104
118

Care of the Combat Amputee

INTRODUCTION AND HISTORICAL PERSPECTIVE 

ing traumatic amputations often survive what might 

previously have been lethal injuries. 

Most near amputation injuries sustained during the 

current conflict are secondary to blast injuries from 

improvised explosive devices (IEDs). These injuries 

are universally grossly contaminated and often involve neurovascular compromise, frequently including 

damage to other extremities in addition to traumatic 

brain injury and other multisystem comorbidities. The 

physiologic status of the whole patient, not merely the 

mangled limb, must therefore be considered in the initial 

medical resuscitation and surgical management of the 

combat-injured patient, always insuring the salvage of 

life over limb. As of early 2008, over 700 patients have 

sustained major limb loss (nearly a quarter of which 

involve the upper extremity) during Operations Iraqi 

Freedom/Enduring Freedom (OIF/OEF), with approximately 20% having multiple limb involvement. Surgical 

management, therefore, must be tailored toward initial 

limb preservation and the utilization of length-sparing 

amputations when amputation is required, maximizing 

possible future reconstructive options and potentially 

offering injured service members the greatest opportunity for choice and eventual informed consent. 

The major amputation rate during the US Civil 

War was in excess of 12%; post-Vietnam, however, the 

rate in modern conflicts has remained fairly constant, 

ranging from 1.2% to 3.4%.1 Even this rate has resulted 

in thousands of survivors requiring long-term care, 

including delayed surgical revision and prosthetic 

modification, which often evolves based on patient experience and expectation. In the near future, functional 

outcome analyses, both physical and psychological (ie, 

evaluation of soldier self-efficacy), will be critical to 

the ongoing improvement of surgical treatment and 

rehabilitation protocols.

As Hippocrates eloquently stated, “War is the only 

proper school for a surgeon.” Surgeons following 

historical armies learned firsthand the care of complex, open orthopaedic injuries. Amputations have 

long been and remain common sequelae of warfare. 

During the US Civil War, nearly 20,000 amputations 

were performed on Union troops alone, with approximately 60% of these involving the lower extremities. 

World War II saw equally high numbers, leading the 

US Army to establish several “amputation centers” 

to provide longitudinal care to injured servicemen 

who had sustained major amputations. Because penetrating thoraco-abdominal and head injuries were 

almost universally lethal in earlier conflicts, survivable 

extremity injuries with open, contaminated wounds 

were often treated with amputation. Transosseous 

amputation proximal to the area of gangrene with 

the use of compression dressings and vessel ligation 

for hemostasis became commonplace, with cauterization used as a last resort. As surgical management of 

combat extremity injuries improved, circular amputation became popular during the Vietnam War and 

subsequently evolved to the currently recommended 

technique of length-preserving open amputations to 

aid with eventual coverage with traditional or atypical myofasciocutaneous flaps. With advances in both 

vascular and orthopaedic reconstructive surgery, limb 

salvage has frequently become an option for limbs that 

would previously have been amputated. The introduction of modern blood replacement, aseptic surgery, 

antibiotics, and primary vascular repair and external 

fixation techniques, in concert with rapid evacuation 

to well-equipped far forward surgical hospitals, has 

greatly improved opportunities for limb salvage. 

Nonetheless, amputation is still required in many 

cases of unsalvageable injury, and soldiers sustainWOUND MANAGEMENT AT POINT OF INJURY

Tourniquet Use

The combat surgeon frequently faces dramatic war 

wounds in multiply, and often extremely severely, 

wounded patients. In these situations, preservation of 

life must always take priority over salvage of a limb. 

Toward this end, the development of a practicable 

field tourniquet, its universal distribution, individual 

training in its application, and a paradigm shift away 

from considering the tourniquet as the last resort have 

greatly facilitated the survival of critically injured 

patients. Tourniquet use is a relatively safe and often 

critical adjunct in resuscitation with great potential to 

contribute to improved survival rates.2 On the modern 

battlefield tourniquet application rapidly corrects compressible hemorrhage and can be safely used during 

timely patient transport to a forward surgical facility. 

Limb Salvage Versus Amputation

When receiving a patient with a tourniquet, forward 

surgeons often face difficult choices with respect to 

limb salvage versus completion of an amputation. 

A variety of scoring systems have been developed 

to assist the surgeon in surgical decision-making. 

However, none of these have been shown to reliably 

predict the salvageability and functional viability of 

an injured limb.3,4
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General Surgical Principles for the Combat Casualty With Limb Loss

On the modern battlefield, a variety of factors 

critically impact these difficult decisions. First and 

foremost among these is the individual patient. Most 

injured soldiers are young and previously healthy but 

now have severe, often life-threatening, injuries. In a 

hemodynamically unstable patient, amputation may 

be critical in saving the soldier’s life. Additionally, 

when the limb is mangled, particularly if segmental 

concomitant vascular injury exists, provisional repair 

and reconstruction may be neither possible nor feasible 

with the available skill sets and resources in a combat 

theater. In the past, concomitant nerve injury had 

been considered an indication for early amputation. 

However, preliminary data from the Lower Extremity 

Assessment Project (LEAP) study (a multicenter study 

of severe lower extremity trauma in the US civilian 

population) recently demonstrated satisfactory 2-year 

results following tibial nerve injury and limb salvage 

with, in the absence of visualized transection, poor 

correlation between initial neurologic examination 

and final outcome.5 Therefore, isolated nerve injury 

should no longer be considered an indication, in and 

of itself, for amputation. The final individual factor for 

amputation versus limb salvage is the extent of muscle 

and skeletal damage. Because even severe open and 

segmental fractures with bone loss can be provisionally stabilized with external fixation, recent advances 

in limb salvage have been remarkable. The goal of 

limb salvage thus remains to provide a functional limb 

with reasonable sensation and mobility. The challenge, 

then, is to predict those limbs that have the potential 

for achieving this goal. The degree of muscle loss appears to be the best predictor of function. Massive loss, 

involving multiple compartments or an extensive zone 

of injury, carries a grim prognosis, and primary amputation is most likely the best decision in such cases.

Another aspect of combat amputations and surgical decision-making involves the larger spectrum of 

limited hospital resources. The acutely injured patient, 

initially managed by buddy aid (level-I casualty care), 

receives a tourniquet, hemorrhage control, and rapid 

evacuation. Level-II facilities, a battalion aid station or 

possibly a forward surgical team, provide advanced 

trauma life support, possibly including damagecontrol surgery, stabilization or open amputation, 

and approximately 10 to 20 units of blood. It should 

be noted that in civilian settings, the average trauma 

resuscitation requires around 30 units of blood. Most 

Army combat support hospitals (level III) typically 

have enough equipment to perform two to four simultaneous surgical procedures and maintain less 

than 100 units of blood, enough for two or possibly 

three major trauma resuscitations. Therefore, lengthy 

and extensive procedures may lead to surgical delays, 

which could have devastating consequences for incoming patients in dire need of surgical stabilization. The 

concept of “damage control surgery” in a combat zone 

or mass casualty situation demands brief, focused, 

initial stabilization for as many patients as possible. 

This applies to the soldier with a mangled limb as well. 

Often, salvage is questionable, and additional cases are 

waiting. This situation forces difficult choices: life must 

be favored over limb, and occasionally the decisionmaking process for an individual patient must also 

include assessment of patients in the holding area as 

well as those in the operating suite. Whenever possible, 

the optimal decision is to initially spare the limb, stabilize any surgical injuries, and establish conditions for 

subsequent reassessment and informed discussion.

Surgical Goals

Surgical goals during the initial treatment stage are 

to thoroughly excise contaminated wounds, retain 

viable tissue for subsequent reconstruction or amputation coverage, and ultimately leave the wounded 

warrior with the highest potential for a useful limb, 

either salvaged or with a prosthetic device. The three 

most critical principles to follow when combat wounds 

necessitate amputation are (1) to thoroughly debride 

the residual limb, (2) to preserve as much salvageable 

tissue as possible, and (3) to leave the wound open.6

Historically, war surgery often meant a “guillotine” 

amputation, in which the blade sliced through all 

tissues at the same level (Figure 8-1). This antiquated 

technique leaves no residual tissue for later closure, 

coverage of the bone, or potential for modern prosFigure 8-1. Open bilateral transfemoral guillotine amputations. The failure to leave any additional viable tissue for 

coverage limited subsequent reconstructive options, and the 

patient required substantial shortening of both residual limbs 

to achieve a functional myodesis and soft tissue coverage. 
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Care of the Combat Amputee

thesis management at the initially amputated level. 

Somewhat more recently, the concept of an open circular amputation has been advocated. This technique 

incises the skin, followed by skin retraction, then the 

muscle at a higher level, and, after muscle retraction, 

bone sectioning is conducted so that all planes roughly 

corresponded to a transverse amputation. Current consensus among war surgeons recommends removal of 

nonviable tissue at the lowest level, retaining irregular 

yet viable tissues (Figure 8-2). Rather than fashioning 

formal tissue flaps, this technique should include 

preservation of viable tissue to optimize later definitive 

closure and maximize ultimate residual limb length.

Orthopaedic surgeons often focus erroneously on 

the bone, whereas in most amputations the best predictor of length, final closure, and ultimate function is the 

soft tissue. A stable, well-padded residual limb with 

adequate soft tissue coverage is far more predictive 

of functional prosthetic use than simple residual limb 

length. In the immediate setting, preservation of bone 

length provides soft tissue support, minimizes edema, 

and seems to be least painful. It is not unreasonable to 

externally fixate fractures proximal to an amputation, 

as long as the nonviable soft tissue is completely debrided. In fact, when critical length can be maintained 

through proximal fracture fixation, this technique 

is warranted and should be advocated. All frankly 

devitalized skin, muscle, and fat must be removed. If 

there is question of viability, the authors recommend 

leaving skin, removing questionable fat and fascia, 

and applying the “four Cs” (developed during the 

Korean War) to muscle: color, consistency, circulation, 

and contractility.7 Residual devitalized deep tissue, left 

for subsequent surgeons throughout the evacuation 

chain, results in a risk of sepsis, myoglobinuria, and 

systemic inflammatory response, which can be fatal. If 

bone has periosteal attachments, it should be retained, 

and whenever possible externally stabilized.8

Nerve Management

The management of sectioned nerves remains a 

controversial aspect of amputation surgery. The free 

end of a divided nerve heals by forming a neuroma. 

Neuromas can frequently become symptomatic, and 

no described technique has been convincingly proven 

to prevent or ameliorate this process (neuroma preventative treatment and management is discussed later 

in this chapter). In the acute setting, even transected 

or injured nerves should be preserved in patients in 

whom limb salvage is attempted, potentially permitting later repair or reconstruction without creation 

of prohibitively large segmental defects. Transected 

nerve ends may be tagged with suture to assist in later 

identification for surgeons further up the evacuation 

chain. 

For traumatic amputations or limbs deemed unsalvageable and undergoing amputation at the initial 

point of operative care, the surgeon’s goal is to retain 

and employ as much useful nerve function in the residual limb as possible, just as with the conservation 

of muscle tissue in the residual limb. Nerves should 

be transected sharply under gentle tension and allowed to retract into viable soft tissues proximally. 

This process may prove to be definitive management 

of some nerves, and maximizes patient comfort during 

subsequent transport, dressing changes, or operative 

procedures. Sensory branches generally depart motor 

Figure 8-2. (a) Open, length-preserving transradial amputation. (b) The salvage of viable distal soft tissues permitted closure with an atypical flap of native tissues, not requiring flaps or grafts and retaining a functional transradial residual limb 

length. 

a b
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General Surgical Principles for the Combat Casualty With Limb Loss

nerves well proximal to their corresponding area of 

cutaneous innervation, but residual limb sensibility 

should not be compromised by overzealous nerve 

transection well proximal to the amputation. This consideration is important in segmentally injured limbs in 

which a nerve may be injured or exposed well proximal 

to the ostensible level of final amputation. 

Care should be taken not to perform group ligation 

of vessels and adjacent nerves. Likewise, inadvertent 

deinnervation of remaining viable muscle groups, 

which can compromise residual limb control or result 

in eventual muscle atrophy and inadequate resulting 

soft tissue padding, should be avoided. This consideration is particularly critical in the upper extremity, 

where myoelectric prostheses are frequently desired 

and utilized. Furthermore, several investigators are 

currently evaluating reinnervation, nerve transfers, 

and even the potential for neural-prosthetic interfaces. Thus, in upper extremity amputations, particularly those proximal to the elbow, it is reasonable to 

forgo traction-assisted nerve transection and salvage 

transected nerve length by simply burying the cut 

nerve end within or deep to adjacent muscle. 

Open Wound Management

Combat wounds must always be left open. A dry 

bulky gauze dressing, the historical standard, can be 

readily applied in all situations. Occasionally, skin 

traction can be applied, but the authors have not found 

this to be a strong contributor to accelerated functional 

limb closure. No strong evidence exists to support 

skin traction technique in contemporary war injuries 

subject to the stresses of evacuation. Rigid dressings 

or external fixation, as stated earlier, can stabilize soft 

tissue, and may assist with pain reduction during 

transport. Recent advances in open wound management have been applied to open amputations. Negative pressure wound therapy is an aggressive method 

to provide optimum wound-healing potential. This 

concept enhances vascularity, minimizes additional tissue necrosis and wound contamination, and has been 

widely used to temporize management between serial 

debridements.6,9 Currently, protocols are underway 

to investigate the safety and effectiveness of negative 

pressure wound therapy as the patient traverses the 

air evacuation chain. If these prove successful, the 

therapy’s application in theater is likely to eliminate 

any need for skin traction techniques.

Upper Versus Lower Extremity Considerations

The surgical considerations involving lower and 

upper extremity combat injuries are different. The 

weight-bearing nature of the lower extremity requires 

adequate soft tissue and a flexible and hopefully sensate residual limb, whereas the motion and intricate 

functional demands of the upper extremity are quite 

different. Additionally, prosthetic technology for upper 

and lower limb amputations is also vastly different. 

Lower limb prosthetic demands primarily involve 

durability and preserving energy expenditure during 

ambulation, whereas upper limb prosthetic demands 

are focused on lightweight devices that can adapt to 

multiple diverse functional activities. Therefore, in the 

upper extremity, surgical length often takes a higher 

priority than achieving robust soft tissue padding. In 

addition, definitive closure using partial thickness 

grafts is generally well tolerated for the upper limb. 

These differences in residual limb coverage and prosthetic management must be considered by the initial 

combat surgeon to maximize patient outcomes. 

INDICATIONS AND TIMING FOR DEFINITIVE CLOSURE

Wound closure is undertaken only when strict criteria for residual tissue viability are met. In the absence 

of better indicators, military practitioners should use 

the four Cs to judge the viability of muscle.7 Wounds 

cannot be closed over nonviable muscle, and it often 

takes several debridements for residual tissue to declare itself. This is particularly true in burn patients, 

who must have all nonviable and grossly contaminated 

tissue excised. In blast wounds, debris tracks proximally along fascial planes. This contamination may be 

masked by the elasticity of skin, and is easily missed 

in mass casualty situations. Once the patient arrives at 

a level-5 facility, the resources are available to ensure 

a calm, meticulous, and systematic surgical evaluation to determine the complete extent of the injury. 

Several additional debridements may be necessary to 

ensure that all nonviable tissue is excised. Fortunately, 

military resources allow for a less aggressive initial 

surgical approach than the treatment advocated by 

the International Committee of the Red Cross, which 

has published the most recent civilian discussion of 

treating war wounds, and is directed toward saving 

life over limb, especially in circumstances of limited 

resources.10

Negative pressure dressings are very useful during 

the period before wound closure, maintaining a favorable wound environment and promoting the formation of granulation tissue. When performing dressing 

changes using traditional bulky dry dressings, the 

presence of greenish drainage or some odor does not 
122

Care of the Combat Amputee

equate with infection, if the wound appears otherwise 

healthy. Similarly, growth on microbiologic cultures 

does not per se indicate infection. War wounds are 

often colonized without being “infected” and can be 

successfully closed when (a) the wound appears clean, 

(b) the patient shows no signs of systemic illness, and 

(c) no necrotic tissue remains. However, if the wound is 

colonized by multidrug-resistant organisms, antibiotic 

therapy is generally warranted. Empiric antibiotics 

should usually be continued for 72 hours after closure 

of wounds that are culture-negative or without gross 

evidence of infection. Topical wound care solutions 

can also decrease bacterial colonization for many severe open wounds. Although some topical solutions 

have fallen out of favor in most civilian wound care 

centers because they may slow granulation or epithelial cell growth, control of bacterial colonization must 

be achieved. In severe trauma, especially that seen in 

military combat, aggressive topical wound care solutions still have an important role.

Nutritional support plays a critical role in achieving 

successful wound closure and the ongoing resuscitation of wounded service members. The wound healing 

process has a catabolic effect on the individual, which 

combined with long transport times, sedating and 

nauseating medications, long periods of intubation, 

concurrent abdominal or facial injuries, and multiple 

returns to the operating room interrupting intake, 

nutritional deficits that impair wound healing develop 

rapidly and almost universally. Weight loss of 30 lb in 

2 weeks is not uncommon. Serum albumin and prealbumin levels should be monitored and maintained 

above 3.5 g/dL and 20 mg/dL, respectively, if at all 

possible. Gastric feeding is preferable to parenteral 

nutrition because it reduces the incidence of multisystem organ failure and parenteral nutrition-related 

complications.

Limbs that have sustained traumatic amputation 

in combat are frequently injured at multiple levels. 

Length and levels should be preserved whenever 

possible. The soft tissue injury dictates the final level 

of amputation, not the level of bony injury—a problematic transtibial amputation will likely function 

better than a long transfemoral amputation, and a long 

transfemoral amputation in the zone of injury usually 

functions better than a short transfemoral amputation 

above the zone of injury. It is important to keep an open 

mind, approaching each patient’s situation unencumbered by traditional concepts of “appropriate” fracture 

fixation and “standard” closures. In accordance with 

International Committee of the Red Cross guidelines, 

the authors advocate length-preserving amputation 

techniques with closure by nontraditional flaps whenever possible (Figure 8-3).11 Military surgeons have 

been successfully inventive in preserving length in the 

face of fractures and soft tissue defects. One example of 

this is the use of pediatric flexible intramedullary rods 

to fix fractures of the femoral diaphysis in transfemoral 

amputees (Figure 8-4).12 Similarly, rotational and free 

tissue flaps are used whenever possible to retain an 

otherwise unsalvageable level or critical diaphyseal 

length. Especially in the multiple injury patient, preserving a viable, but unsalvageable, extremity until 

the time for definitive closure allows the amputated 

Figure 8-3. Open, length-preserving transfemoral amputation in a bilateral transfemoral amputee (a), permitting 

eventual closure with atypical flaps (b) in an injury pattern 

that might otherwise have required hip disarticulation if a 

guillotine or open circular amputation had been performed 

in theater. 

a b
123

General Surgical Principles for the Combat Casualty With Limb Loss

part to serve as a source of autograft bone and skin 

to facilitate reconstruction of the other perhaps more 

functional residual limbs.

Retained bone must have soft tissue attachment and 

must bleed when ronguered. Exceptions are made if 

there is a large amount of articular cartilage on a dysvascular fragment, which may be initially retained in 

the interest of preserving articular congruity. However, 

in the face of deep wound infection, these fragments 

must be excised. Similarly, every attempt should be 

made to retain nerves and vessels, for without these 

structures, distal tissues will not survive with useful 

residual function.

Orthopaedic surgeons have long been taught, in 

treating civilian blunt trauma, that coverage must be 

achieved within 7 days to maximize patient outcome. 

This principle does not fully apply to combat wounds, 

where it is more important to have all nonviable tissue 

removed and no evidence of infection prior to definitive closure. Unfortunately, no objective criteria can 

reliably indicate the optimal timing for wound closure, 

so careful surgical judgment is needed. 

The treatment of retained fragments or foreign bodies also requires careful judgment. Injuries caused by 

explosively formed projectiles, IEDs, or antitank mines 

may lead to dozens of retained foreign bodies in the 

patient. Fragments may include pieces of the explosive 

device itself, spall from the interior of a vehicle, or soil 

and gravel from the surrounding site of the blast. Removal of every foreign body is often impractical due 

to the damage it would cause to the surrounding soft 

tissues. Many fragment wounds will heal uneventfully 

with only local wound care, and a scar will generally 

encapsulate the fragment. These wounds should generally be treated with “watchful waiting,” debriding only 

those fragments that become infected, are painful, or 

negatively impair function. Exceptions to this principle 

include intraarticular fragments, which may damage 

the joint mechanically or by the toxicity of heavy metals, and large, superficial fragments that may interfere 

with prosthetic fit.

Heterotopic ossification (HO) has been a significant 

Figure 8-4. Radiographs of a transfemoral amputation with 

a proximal fracture provisionally stabilized with external 

fixation (a) and after definitive revision and closure following 

stabilization with flexible intramedullary nails (b).

a b
124

Care of the Combat Amputee

problem for service members with an amputation from 

combat injuries sustained in OIF/OEF. It is believed 

that the greatest risk of HO formation occurs when 

the amputation is performed through the zone of injury. Revision surgery because of HO complications 

may occur in approximately 15% of patients.13 The 

pathophysiology, prevention, and optimal treatment of 

HO is currently under investigation. A more complete 

discussion of this topic can be found in Chapter 9, Special Surgical Considerations for the Combat Casualty 

With Limb Loss.

In summary, decisions regarding definitive closure 

are guided by established general principles, but best 

executed with the gestalt gained by experience. The 

soldier who sustains an amputation is best served by 

the surgeon who follows accepted general tenets of debridement, who is experienced enough to differentiate 

the subtleties between infection and colonization, and 

who is skillful enough to employ inventive techniques 

for fracture fixation and soft tissue coverage—allowing 

preservation of functional length and levels to achieve 

a sound, painless, durable residual limb.

MANAGEMENT OF SOFT TISSUE AND MUSCLE

Muscle

In the treatment of extremities injured by the various 

implements of war, the surgeon is often forced to use 

what muscle and fasciocutaneous tissues remain and 

are viable. However, the basic principles of amputation 

surgery remain the same, with the goal of providing a 

functional residual limb that can be fit by a prosthetic 

socket. To achieve this goal, the residual limb is best 

covered with muscle to provide padding and sometimes aid in control of the terminal extremity. An important component of this principle is defined by how 

the muscle is treated when closing the amputation. A 

muscle that is not secured under physiologic tension 

and does not have fixed resistance will atrophy over 

time, becoming weaker and providing less padding 

over the bony prominences. Many of the muscles used 

in amputation surgery cross a proximal joint (eg, adductors, quadriceps, and hamstrings in transfemoral 

amputations or the gastrocnemius in transtibial amputations), providing function and stability. Several 

different techniques for maximal muscle treatment 

have been utilized, each with relative benefits and 

deficiencies.

Myofascial Closure

To provide a soft tissue envelope over the distal 

bone via myofascial closure, the outer fascial envelope 

over the top of the muscles is approximated. This 

technique approximates only loose tissues, providing minimal tension and stability to the underlying 

muscles. In dysvascular patients the absence of muscle and tissue tension provides a possible benefit,14–16

and the technique is also thought to maximize the 

remaining blood flow to optimize healing. However, 

even in dysvascular and diabetic patients, the benefits 

of this technique are more theoretical than proven. 

Because of the loose attachment, myofascial closure 

alone does not generally provide a limb suitable for 

prosthetic fitting and use. Therefore, muscle stabilization is critical to a successful surgery and is almost 

always possible.

Myoplasty

Most amputations seen in war surgery are diaphyseal (mid-bone) in nature. Whether the muscles are 

severed at this level by the blast, fragments, or other 

projectiles or surgically transected, the muscle belly 

is often encountered in cross-section without distal 

fascia, aponeuroses, or tendons. This is seen in most 

transhumeral, transradial, transfemoral, and transtibial 

amputations. To provide closure with the myoplasty 

technique, the muscle from the opposing muscle 

groups (quadriceps and hamstrings in a transfemoral amputation) are sewn to each other, covering the 

transected bone end. Although this is much easier than 

attaching the muscle to bone and provides more stabilization of the muscle than a myofascial closure, it is not 

recommended for routine amputation closure. Unless 

the muscle firmly adheres to the underlying bone and 

tissues, the myoplasty unit may move with contraction 

of either opposing muscle group, and a painful bursa 

can develop either between the muscle and bone or 

muscle and overlying soft tissues. Faulty adhesion 

can be detected on physical examination by palpating 

the muscle motion over the bone with the accompanying crepitus from the problematic bursa. Likewise, 

deliberate or inadvertent contraction of the involved 

muscle groups may lead to motion and shifting of the 

overlying skin within a prosthetic socket, leading to 

irritation and friction-related complications. 

Myodesis

To avoid the complications associated with either 

myofascial closure or myoplasty, the muscle fascia of 

the padding or controlling muscle groups within a given 

residual limb should in most cases be attached to the end 
125

General Surgical Principles for the Combat Casualty With Limb Loss

of the bone, a technique termed myodesis. Myodesis 

prevents motion over the bone end and provides padding between the bone and overlying prosthetic socket. 

One of two methods is utilized to perform this part of 

the amputation procedure: (1) connection of the muscle 

to bone through drill holes, or (2) connection of the 

muscle to the periosteum (Figure 8-5). Once the myodesis is performed, the remaining muscle fascia can be 

approximated using the techniques described above for 

myofascial and myoplasty stabilizations (Figure 8-6). In 

the typical transfemoral amputation the muscle bellies 

are transected and only the muscle and investing fascia 

may be available to attach to bone, and getting suture to 

hold in the muscle tissue and overlying fascia can be difficult.17 In such cases, a muscle-grabbing suture technique 

can be used, achieving muscle-bone opposition under 

reasonable tension without undue tissue strangulation. 

Tenodesis

Depending on the level of amputation, tendon may 

be associated with the muscle intended for attachment 

to bone. The presence of such tendon provides the 

ability to achieve good purchase with suture, allowing for the most effective type of muscle stabilization. 

Unfortunately, most amputations require transection 

of the muscle belly, leaving no tendon associated 

with the remaining muscle to allow bony attachment. 

However, in disarticulations and some transtibial and 

transradial amputations, tendon may still be present 

at the level of the amputation. This tendon can then be 

directly connected to the transected bone, as is the case 

for knee disarticulations, where the patellar ligament 

may be sutured to the origin of the cruciate ligaments. 

Additionally, for long transtibial or Syme amputations 

the tendon of the gastrocnemius muscle may be connected to the posterior tibia.18 Lastly, for transradial 

amputations, several muscle groups may be utilized 

to perform multiple myodeses to bone, maximizing 

distal soft tissue and residual limb control. 

Muscle Tension

During stabilization, it is important to secure muscle 

under appropriate tension to ensure the maximum 

benefit. Appropriate tension may be difficult to determine in the operating room, because physiologic resting tension of the muscle is not studied in most surgical 

training programs. Experience gained from tendon 

transfers in the hand and foot can be a useful guide. 

Too much tension may cause pain because of persistent 

stretch on the muscle, and, in the absence of stable 

myodesis performed through robust, suture-holding 

tendon and fascia, lead to failure of suture fixation. 

Additionally, in instances where the muscle would 

normally cross two joints, proximal deformity and 

contractures may occur. For example, in transfemoral 

amputations overtensioning the quadriceps may lead 

to a hip flexion contracture because of the attachments 

above the hip joint. However, these instances are rare, 

and the surgeon should place a moderate amount of 

tension on all muscle attachments, especially when the 

muscle is important in stabilizing the residual limb (eg, 

adductor myodesis for transfemoral amputations). As 

a general rule, the surgeon should err on the side of 

too little rather than too much tension. 

Figure 8-5. Transfemoral amputation with atypical skin flaps 

demonstrating use of the myodesis technique through drill 

holes in the femur to attach the adductor magnus muscle 

to the bone.

Figure 8-6. The amputation in Figure 8-5 after myoplasty of 

the quadriceps and hamstring muscles over the adductor 

muscle previously attached to bone (myodesis).
126

Care of the Combat Amputee

Skin Traction

One of the basic tenets of amputation surgery 

is that residual limb length directly correlates with 

patient function. Although this concept is generally 

true,5 exceptions remain. For example, a very long 

transtibial amputation may limit the accommodation 

of advanced foot and ankle components. Similarly a 

very long transfemoral amputation may not accommodate more advanced knee components, thereby 

potentially limiting an individual’s ultimate functional 

capacity. Despite these exceptions, it still remains the 

surgeon’s goal to salvage as much of the limb as possible, especially when a joint is involved. 

As previously stated, most traumatic amputations 

caused by explosive ordinance do not leave an abundance of viable tissue to work with. In past conflicts, it 

was commonplace to perform an open circular or guillotine amputation above the zone of injury, often followed 

by skin traction techniques to slowly pull the skin and 

dermal tissues over the end of the bone. The primary 

benefits of this technique included length preservation 

of the residual limb and low infection rates. Essentially, 

the limb was maintained in traction with daily dressing 

changes that allowed for application of various topical 

agents (eg, Dakin solution) and provided an environment inconducive to bacterial infection. The primary, 

and very important, downside to this technique, however, was the formation of an adherent, scarred, and thin 

covering over the distal residual limb, causing difficulty 

for prosthetic fitting. Therefore, this technique is currently not advocated for routine use.19–21

A newer variation on the use of skin traction is 

currently being applied to the treatment of residual 

limbs. As discussed previously, to preserve as much 

length as possible, circular amputations should be 

avoided. As much bone and soft tissue as possible 

should be left after the debridement is performed, 

even if only atypical muscle and fasciocutaneous flaps 

remain. A thorough debridement, typically performed 

through the entire zone of injury, is utilized to remove 

any devitalized tissue. After each debridement the 

tissues are partially closed over a vacuum-assisted 

closure device sponge (VAC; KCI, San Antonio, Tex) 

with vessel loops or no. 2 nylon, providing tension 

over the end of the bone (Figure 8-7). This technique 

prevents the muscle and fasciocutaneous tissues 

from retracting. Antibiotic beads may be placed in 

the deep tissues if infection is a significant concern. 

These beads may be tailored to the bacteria isolated 

in previous cultures. When operating within the 

zone of injury, it is often unclear which tissues will 

remain viable; therefore, multiple debridements must 

be performed to ensure that all nonviable tissue is 

removed. When the amputation is ready for closure, 

typical myodesis and tenodesis techniques should be 

applied. Even when atypical skin flaps are present, 

the skin should be primarily closed, except when skin 

grafts are necessary.

Although the application of skin traction with the 

VAC saves length and amputation levels, it is not without complications or deficiencies. It is an extremely 

labor intensive technique, requiring multiple debridements and/or dressing changes under sedation every 

2 to 3 days. Additionally, the formation of HO may be 

associated with amputations through the zone of injury 

and the use of pulsatile irrigation or VAC dressings. 

Traditional skin traction techniques permitted dressing 

changes at the bedside, infrequent visits to the operating room, and a less frequently reported incidence of 

HO formation, but did not offer the ability to save as 

much residual limb length as today’s techniques.

Figure 8-7. Technique using the vacuum-assisted closure 

(VAC) device and vessel loops for skin traction over the 

remaining bone.
127

General Surgical Principles for the Combat Casualty With Limb Loss

MANAGEMENT OF NERVES

neurectomy. Management of the sciatic nerve, however, is unique because of its own intrinsic large blood 

vessel. This nerve requires ligation prior to transaction 

to prevent significant bleeding, which may be associated with critical blood loss, hematoma formation, or 

wound breakdown. 

Nerves frequently run parallel with major pulsating blood vessels, and the surgeon performing the 

amputation should take great care to prevent group 

ligation of nerves and blood vessels. Although no definitive proof exists, it seems logical that the presence 

of a pulsating vessel adjacent to a neuroma could lead 

to the throbbing pain reported by many amputees. In 

such situations, a revision surgery aimed at separating 

the nerve and artery vessel, re-ligating the vessel, and 

performing a better traction neurectomy, will allow 

the nerve to separate from the pulsating vessel and 

alleviate these symptoms.

A new and innovative technique in the management of nerves in amputation surgery, called targeted reinnervation, is now being investigated.25–29

Preliminary results are very promising when the 

technique is applied to transhumeral and shoulder 

disarticulation amputees. The technique involves 

the dennervation of specific nonessential muscle 

bellies located within the residual limb, followed 

by the transfer of a freshly transected major mixed 

nerve of the upper extremity into the motor end 

point of the freshly dennervated muscle. Reinnervation of the muscle occurs very predictably with the 

transferred nerve, and the brain signals associated 

with the intuitive activation of that nerve lead to 

specific patterns of muscle contraction in the newly 

innervated muscle belly. 

This procedure has been employed to achieve an 

increased number of surface myoelectric sites with 

more intuitive control. Thinning the adipose tissue 

under the skin also improves myoelectrical recording 

capability. Subsequent mapping of the contraction 

patterns associated with specific upper extremity 

functions, and wiring these surface electrodes to 

certain advanced myoelectric prosthetics, allows the 

use of an upper extremity prosthesis with multiple 

degrees of freedom at the shoulder, elbow, wrist, 

and digits. The end result can be far more efficient 

in performing fluid motion and manipulative tasks 

than previous generations of myoelectric prostheses. Although additional research is needed before 

this technique can be recommended for widespread 

application, the early results are promising and 

compelling. 

When performing an amputation at any level, the 

surgeon is faced with the decision of how to manage the transected nerves, with the primary goal of 

preventing a symptomatic neuroma. Every transected 

nerve will heal by forming a neuroma, which has the 

potential to become a source of pain in the residual 

limb with stimuli such as pressure, stretching, vascular 

pulsation, or other types of physical or physiologic 

irritation to the terminal neuroma bulb. Numerous 

techniques to minimize symptoms associated with 

neuroma formation have been described, but none 

have proven to be superior to any of the others, and 

the choice of technique remains a controversial aspect 

of amputation surgery. 

Traction neurectomy involves identifying and 

isolating all major nerves in the limb, then applying 

moderate tension prior to dividing them. The nerves 

are then allowed to retract proximal to the wound 

into the muscles of the residual limb. This technique 

provides a technically simple way to move the 

eventual neuroma away from the expected areas of 

scarring, pressure, and pulsating blood vessels. Surgeons occasionally implant the end of the transected 

nerve into muscle or bone in an attempt to “give the 

nerve something to do.”22 Although both of these 

techniques have had good results reported when 

dealing with painful neuromas in nonamputated 

limbs,23 their application in primary amputation 

surgery is not well documented. When performing 

an amputation, the latter technique, implanting the 

cut nerve into muscle or bone, involves transecting relatively less of the nerve so that the surgeon 

can perform a tensionless attachment of the nerve 

end into the muscle or bone, although usually still 

within the amputation wound. Because the nerve 

cannot retract as far proximally as it could with a 

well-done traction neurectomy, this technique may, 

in fact, contribute to the development of a painful 

postsurgical neuroma. Nerves within wounds are 

exposed to tension, pressure, anoxia, infection, and 

delayed wound healing, have been found to have 

increased amounts of connective tissue, and may be 

prone to painful neuroma formation.24 Additionally, 

because of the nerve proximity to the end of the 

residual limb, they may be more prone to pressure, 

friction, and tension from a prosthetic socket. 

Other described techniques for managing transected 

nerves include cauterization of the nerve end, ligation, nerve capping, and end loop anastomosis, but 

no definitive evidence exists demonstrating that these 

are more effective than a carefully performed traction 
128

Care of the Combat Amputee

DRESSINGS

compression or a possible tourniquet effect, particularly near joints. With a transtibial or transradial amputation, the elastic bandage can act as a tourniquet, 

particularly at the joint level as the patient flexes and 

extends the joint immediately proximal to the amputation. In the perioperative phase, abundant padding 

with Webril (Kendall Company, Mansfield, Mass) or 

similar material under the elastic dressing, as well as 

extending the dressing well above the knee or elbow, 

helps to avoid this complication. Transition to a shrinker sock should be initiated as soon as possible. 

Although soft dressings provide easy access to the 

wound, many surgeons feel that they do not provide 

sufficient compression or support to the residual limb 

to promote proper healing through soft tissue rest. 

No studies have shown a clear advantage of one type 

of dressing over another, but several have shown a 

trend toward better healing with rigid dressings.30–36

However, soft dressings may facilitate unencumbered 

early mobilization of patients and allow focused early 

rehabilitation of more proximal muscles and joints 

within the residual limb. As stated above, dressing 

selection is very dependent on the surgeon as well as 

regional and hospital preferences.

Rigid Dressings

The dressing of choice for most surgeons for the 

transtibial amputation has traditionally been the rigid 

dressing, either in the form of a splint or cast. Early 

in its history this type of dressing was modified to 

include IPOP, which will be discussed in the next section. It is generally believed that injured tissues heal 

more consistently and with less pain when placed at 

rest. The three basic principles applied here are immobilization, application of gentle distal pressure, and 

infrequent dressing changes. These principles have 

Most surgeons are a product of their cumulative 

experiences, and when a clear standard has not been 

convincingly established through evidence-based 

medicine, multiple treatments are frequently recommended and rendered for any given condition. Such is 

the case with postoperative dressings after amputation 

surgery—while one surgeon may prefer a splint or cast, 

another would use padding and an elastic bandage 

on the same residual limb. The basic considerations 

for postoperative dressings are soft dressings, rigid 

dressings, and immediate postoperative prosthesis 

(IPOP). Each dressing technique has its own benefits 

and limitations.

Balanced compression of the residual limb is 

important, particularly in the early postoperative 

period. This helps to control swelling, which further 

minimizes postoperative pain and promotes a stable 

limb volume. Support of soft tissues is also important 

because the muscle and skin flaps require a tension-free 

environment for optimal healing. Some combination of 

compression and support is provided by each category 

of dressing.

Soft Dressings

A soft dressing is commonly applied in the care of 

the young combat amputee. Often first applied in the 

operating room, it provides a sterile dressing covered 

by an elastic bandage. The classic application of the 

elastic bandage is in the “figure 8” pattern. While using 

one hand to support the myofascial and fasciocutaneous flap, the bandage is applied with care taken to 

evenly distribute compression and to relieve tension 

on the flap and suture line (Figure 8-8). This type of 

dressing, with modifications, can be applied to any 

residual limb. 

Careful application is paramount to avoid over1. 2. 3. 4. 5. 6.

Figure 8-8. Application of a typical “figure 8” dressing. This provides support to the underlying tissues as well as compression.
129

General Surgical Principles for the Combat Casualty With Limb Loss

been shown over time to be effective in the treatment 

of residual limbs.37

During the application of this type of dressing, 

several technical tips are warranted. Failure to follow 

the tenets of splint or cast application can lead to significant adverse complications. Extra padding should 

be placed over the patella when placing rigid dressing 

for transtibial amputations to prevent skin irritation 

and pressure necrosis in that area. Alternatively, the 

patella can be omitted entirely from the splint, with 

distal compression provided through a combination 

of plaster and soft dressing while the splint material 

assists in flexion contracture prevention (Figure 8-9). 

Although less of an issue and less frequently utilized 

for transradial amputations, the olecranon should also 

be meticulously padded for the same reason. The distal 

end should be well padded to maintain balanced pressure and gentle circumferential compression. Closedcell foam or other similar material can be used for this 

purpose. A supracondylar mold is necessary to keep 

the dressing in place, avoiding distal migration of the 

cast or splint. With loss of distal-to-proximal pressure, 

unrelenting terminal edema can occur, resulting in 

severe wound complications. Patients and staff must 

be educated to avoid this situation and can assist by 

placing distal pressure with a looped towel or pulling 

up the dressing during straight leg raises.

One drawback of rigid dressing application actually contradicts one of the stated benefits, which is the 

need for infrequent dressing changes. In the combat 

amputee with an amputation performed through the 

zone of injury, the possibility of infection is a major 

concern. Many times the patient has undergone multiple thorough debridements, with healthy-appearing 

tissue prior to closure. Nonetheless, in these cases the 

authors have seen a high incidence of wound infections 

at 3 to 5 days after closure. Early detection of these 

cases is paramount to preventing tissue necrosis and 

salvaging soft tissue and possibly amputation level. 

Frequent dressing changes are therefore necessary, 

and rigid dressings have often been avoided for this 

reason. However, after the immediate postoperative 

period, soft dressings can be transitioned to rigid ones 

and wounds can generally be monitored via attentiveness to fluctuations in patient signs (eg, fever) and 

symptoms (eg, increasing pain).

Immediate Postoperative Prosthesis 

A frequently cited source of controversy in amputee 

care has been the IPOP. The concept of early weight 

bearing through a rigid dressing was proposed by 

Wilson shortly after the end of First World War.38 Many 

others have used and modified this technique over 

Figure 8-9. Lateral radiograph of a well-padded transtibial 

amputation in a posterior splint designed to prevent knee 

flexion contracture but avoid potential patella-related complications. 

the years, especially following the Second World War, 

Korean War, and Vietnam War.39–42 This evolution has 

included modifications ranging from casts with lower 

extremity components applied in the operating room to 

padded prefabricated sockets with distal components. 

This technique can be utilized with almost any level of 

amputation in either the upper or lower extremity.

Regardless of the type of IPOP used, many benefits have been demonstrated. These range from the 

psychological benefit of having a prosthesis in place 

immediately after the amputation, with less perceived 

loss of function, to shorter hospital stays, fewer revisions, and faster time to initial prosthetic fitting.31,35,43,44 

However, most of these studies have been performed 

in patients who have undergone amputation for nonreconstructible ischemia or infection.

Despite these reported benefits, this technique has 
130

Care of the Combat Amputee

been infrequently used in the current treatment of 

combat amputees because of the extent of soft tissue 

and other remote injuries. Given the tenuous nature 

of zone-of-injury tissue damage and frequent use of 

flaps and skin grafts, early ambulation may compromise healing. Additionally, many of the other injuries 

sustained from combat, particularly blast injuries (eg, 

multiple other extremities, intra-abdominal) prohibit 

early mobilization. Most importantly, however, the 

authors have recognized that when the definitive 

amputation is performed in a setting where the patient will receive his or her rehabilitation, the patient 

has immediate contact with the rehabilitation team 

as well as other individuals going through amputee 

rehabilitation, making it much easier to see what the 

patient’s potential function will be. This situation 

largely outweighs the potential psychological benefit 

of IPOP use. 

UPPER LIMB

Amputations in the upper extremities from combat 

wounds generally involve massive trauma due to blast 

munitions, with a large resulting zone of injury. The 

decision to attempt limb salvage should be based on 

the technical feasibility of doing so and on the chance 

of providing a limb that maintains some useful function. Unlike the lower extremity, the upper extremity 

is nonweight bearing, generally allowing it to function 

very well despite decreased sensation. When addressing limb salvage versus amputation or residual limb 

length decisions in an individual with severe upper 

limb trauma, it is most important, however, to focus 

on the potential functional rehabilitation of the entire 

patient, especially giving significant considerations 

to the impact of other commonly associated severe 

injuries. In general, the goals of amputation surgery 

in the upper extremity should be the following: (a) 

preservation of functional length, (b) preservation of 

useful sensibility, (c) prevention of symptomatic neuromas, (d) prevention of adjacent joint contractures, (e) 

minimal and short morbidity, (f) early prosthetic fitting 

(where applicable), and (g) early return of patient to 

work and recreation.45

Hand and Carpus

The severity of amputations involving the hand 

ranges from single digit tip amputations to multiple 

digit amputations, loss of the thumb, and partial hand 

amputations. For most digital amputations distal to 

the flexor digitorum superficialis (FDS) insertion, 

skeletal shortening with primary closure or allowing 

the wound to heal secondarily will provide for early 

mobilization of the digit and yield a durable tip with 

excellent sensation and an acceptable appearance. 

Local advancement or pedicled soft-tissue flaps have 

limited application in the combat amputee for treatment of fingertip and distal amputations of digits. The 

adjacent tissue has usually also been injured to some 

extent by the blast, and attempting to mobilize it for 

wound coverage may lead to necrosis and further soft 

tissue loss. Additionally, these techniques usually require the restriction of adjacent joint and/or adjacent 

digit motion during the first 3 to 4 weeks following 

the flap procedure, risking the development of contracture and stiffness, and further limiting the use of 

the upper extremity in early phases of the patient’s 

rehabilitation. 

When a digit is severely injured proximal to the 

FDS insertion, the surgeon should make every attempt 

to salvage the important proximal interphalangeal 

joint. A stable skeletal core and functional arc of joint 

motion under active flexor/extensor control, with a 

viable, sensate, and durable soft tissue covering, are 

the desirable end points. However, when the degree 

of injury is too severe to salvage the proximal interphalangeal joint, the surgeon is faced with the decision 

of amputation through the proximal phalanx versus 

metacarpophalangeal joint (MCPJ) disarticulation or 

metacarpal ray amputation. Preservation of as much 

proximal phalanx as possible is desirable, because the 

remaining segment will be under the control of the 

intrinsic muscles and the extensor digitorum communis. Active flexion of the proximal phalanx up to 

45° is possible with the intrinsics, and the remaining 

digit can participate in grasping and holding within 

those limitations. 

If a relatively long portion of the proximal phalanx 

can be preserved, a flexor tendon tenodesis (FDS 

and/or flexor digitorum profundus) to the A2 pulley 

under normal resting tension of the muscle-tendon 

unit (if possible) can give extrinsic flexor control to the 

remaining proximal phalanx, and make MCPJ flexion 

up to 90° possible. This adds significant capability for 

grasping and holding small objects within the palm. 

If, however, the amputation occurs near the base of the 

proximal phalanx, the ability of the remaining segment 

to participate in meaningful grasp and hold is minimal, 

and the resulting gap (particularly when the long or 

ring finger is involved) often allows small objects to fall 

out of the palm. In this situation, consideration should 

be given to MCPJ disarticulation or more proximal 

metacarpal ray amputation. 

The decision between MCPJ disarticulation and ray 
131

General Surgical Principles for the Combat Casualty With Limb Loss

amputation is more complex, involving factors such 

as which digit is injured, palm breadth and strength 

(particularly grip and pronation), cosmetic appearance, 

thumb web space impedance, and gap presence. This 

decision is individualized, and should be based on total 

rehabilitation needs (ie, other injuries), occupational 

demands, hand dominance, and psychological impact 

of hand appearance. It is important to remember that 

most metacarpal ray amputations are rarely indicated 

in the acute setting and are performed under elective 

conditions. 

Because of the vital importance of the thumb in 

grip, pinch, and opposition, every attempt should be 

made to preserve as much length as possible in thumb 

amputation. For amputations distal to the interphalangeal joint, it is extremely important to attain sensate, 

durable, soft tissue and skin coverage. Failure to do 

so will result in a hypesthetic, dysesthetic, or tender 

thumb tip, which the patient would likely exclude in 

performing activities with the hand. For amputations 

distal to the interphalangeal joint where no bone is 

exposed, healing by secondary intent gives the most 

reliable outcome for the demands of the thumb. If this 

method cannot be used, then cross-finger flaps or radially innervated fasciocutaneous sensory flaps should 

be considered. For more proximal injuries, the surgeon 

should attempt preservation of thenar musculature and 

all remaining joints practicable for later reconstruction 

efforts, which may include metacarpal lengthening, 

index pollicization, or toe-to-thumb transfer.

Combat-related injuries to the hand almost always 

involve more than a single digit, however. In amputations involving multiple digits or partial hand amputations, it is extremely important to save all viable 

tissue by whatever means possible and preserve it for 

later reconstructive efforts. Similarly, when traumatic 

amputations occur through the carpus, the surgeon 

should preserve all viable tissue at the time of injury to 

maximize residual limb length and function. Although 

prosthetic socket design and terminal device availability for amputations at this level are problematic, 

many patients find the ability to flex and extend the 

wrist to be very useful for holding and carrying objects 

against the body, without the need for a prosthesis. 

Other patients experience significant frustration with 

the limited terminal devices available for carpus-level 

amputations and desire the ability to pinch and grasp 

with a standard terminal device available for transradial amputations. Patients rarely have the ability to 

make an informed decision about these issues at the 

time of injury. The surgeon should therefore preserve 

everything salvageable and allow the patient to evaluate his or her resulting function before proceeding to 

a more proximal amputation.

Wrist and Forearm

Wrist disarticulation continues to be a controversial procedure. Advantages include retention of most 

forearm pronation and supination, due to preservation 

of the distal radioulnar joint, and improved suspension of the prosthetic device, due to the radial styloid 

flare. Disadvantages include an excessively long and 

wide prosthetic socket, difficulty fitting in a wrist 

component, and fewer choices for the terminal device. 

Additionally, when myoelectric devices are used, there 

is little room at the distal end of the socket to conceal 

the electronics and batteries with wrist disarticulation 

compared to transradial amputations. In performing 

a wrist disarticulation, it is important to avoid injury 

to the triangular fibrocartilage and distal radioulnar 

joint, because preservation of these structures is vital to 

preserving the potential advantages of the disarticulation versus a transradial amputation.

When performing a transradial (below-elbow) 

amputation, attempts should be made to preserve as 

much length as possible because residual pronation 

and supination of the forearm is directly proportional 

to the length of remaining radius and ulna. Retaining 

as much of this function as possible can have a significant impact on the amputee’s ability to position 

the prosthetic terminal device for functions involving 

pinch and grasp. For individuals with combat wounds, 

the level of amputation is dictated by the integrity of 

the soft tissue. Bony length should not be spared at 

the expense of providing a durable, stable, soft-tissue 

covering. In very proximal forearm amputations, all 

efforts should be made to preserve the elbow joint. In 

this situation, detaching the biceps tendon from the 

radius and reattaching it to the proximal ulna may allow the surgeon to excise the radius and gain a larger 

soft-tissue envelope for closure (Figure 8-10). At the 

very least, this technique preserves elbow flexion and 

may provide for easier prosthetic fitting at very proximal levels—even 5 cm of ulnar bone length is sufficient 

to permit transradial prosthetic fitting. Because of the 

significant advantage of retaining residual elbow flexion, the use of pedicle or free tissue transfers to provide 

durable soft tissue coverage over a preserved elbow 

joint is considered by most surgeons and prosthetists to 

be preferable to elbow disarticulation or transhumeral 

amputation.

Elbow and Humerus

Disarticulation of the elbow, like disarticulation 

of the wrist, is a controversial treatment option and 

amputation level. Its advantages include better suspension and control of the prosthesis, as well as improved 
132

Care of the Combat Amputee

function of the residual limb when not wearing the 

prosthesis due to the longer lever arm and preserved 

myotendinous units secured to the distal humerus 

with a tenodesis. The main disadvantages of elbow 

disarticulation involve prosthetic fitting and appearance. The prosthetic socket is larger than a traditional 

transhumeral prosthetic socket, and the placement 

of the prosthetic elbow joint is, by necessity, several 

centimeters distal to the anatomic joint, creating a 

disproportionate appearance to the upper extremities. 

This can be a difficult body image for some patients to 

accept. Despite the disadvantages of elbow disarticulation, better function and control with and without 

a prosthesis lends most surgeons and prosthetists to 

prefer this level over the more proximal transhumeral 

amputation when adequate soft tissue coverage can 

be attained.

Transhumeral (above-elbow) amputations should 

be performed with the goal of preserving as much 

bone length as possible. The circumferential nature 

of muscle around the humerus, as well as the fact 

that it is not, generally, a weight-bearing extremity 

allows even the use of split-thickness skin grafting over adequate subcutaneous tissue to maintain 

humeral length. Traumatic amputations, particularly from blast-related wounds, generally have more 

proximal levels of skin and subcutaneous tissue loss 

than bone loss, but the surgeon should approach a 

Figure 8-10. Radiograph of a short transradial amputation. The radius was excised due to a comminuted proximal fracture 

and inadequate available local soft tissue for closure, and the biceps tendon was transferred to the proximal ulna, providing 

the patient with satisfactory elbow flexion and extension.
133

General Surgical Principles for the Combat Casualty With Limb Loss

more proximal bone transection to achieve primary 

closure with caution. The shorter the residual humeral 

length, the less control the amputee will have over the 

prosthesis. 

Additionally, it is important to remember that the 

biceps and triceps both work across the glenohumeral 

joint, and a secure myodesis of these muscles distally is 

essential to retain their function in glenohumeral motion. Amputations at the level of the axillary fold and 

higher function effectively as shoulder disarticulations 

because essentially all useful glenohumeral motion is 

lost. At this level, it is important whenever possible to 

retain the humeral head, which can improve shoulder 

contour and the fit of clothing as well as prosthetic 

suspension systems. Some surgeons have even recommended arthrodesis of the glenohumeral joint in 

extremely short transhumeral amputations to prevent 

the abduction and flexion contracture that occurs in 

many of these patients and to provide further prosthesis stability. Although results of this procedure can 

be gratifying, internal fixation for formal arthrodesis 

is best performed in delayed, elective fashion in the 

setting of a contaminated, blast-related wound. 

Shoulder disarticulations are generally performed 

in emergency situations when the patient’s life is at 

stake due to severe proximal trauma. Once hemostasis 

is obtained and the patient’s life is no longer in jeopardy, the clavicle and scapula should be retained if at 

all possible. Although not necessary or advocated at 

the initial point of care, the surgeon should strongly 

consider internally fixing fractures of the clavicle to 

retain the rigid strut suspending and supporting the 

scapula and maintain shoulder contour. Because the 

disfigurement of forequarter amputations is so severe 

and the fit of clothing so difficult for these patients, 

extreme measures to save the clavicle and scapula 

should be undertaken in this circumstance. These injuries, particularly in combat wounds, should not be 

closed primarily, and the abundance of muscle from the 

latissimus, deltoid, and pectoralis major make coverage and salvage of the clavicle and scapula possible 

in the vast majority of instances. 

Handling of the median, radial, and ulnar nerves in 

transhumeral and shoulder disarticulation patients is 

gaining importance as research on targeted reinnervation definitively proves the potential of this technique 

in the management of shoulder disarticulation patients. If the surgeon, physiatrist, and prosthetist believe a particular patient to be a good candidate for this 

protocol, then it becomes important to leave adequate 

length of these nerves until the definitive transfer is 

performed. This approach does entail the risk of leaving the transected nerve ending relatively superficial 

within the scar, where a symptomatic neuroma may 

develop. However, this problem can be definitively 

addressed on an elective basis regardless of whether 

or not targeted nerve transfer is ultimately attempted. 

This approach at least preserves an alternative for the 

patient until that alternative can be discussed and an 

appropriate determination made. 

LOWER LIMB

The location of the most severe injury sustained 

by a traumatized limb usually determines the level of 

amputation in extremity blast trauma.46 Optimizing 

functional outcome is the goal when deciding upon 

definitive amputation or revision level. Improved 

function is usually associated with levels that require 

less energy consumption, which generally equates 

to preservation of length. Moreover, preservation of 

joint function should be attempted to improve a limb’s 

mechanical advantages and preserve the benefits of 

articular and distal limb proprioception for the amputee. More proximal amputations are associated with 

increased energy consumption (Table 8-1).47,48

Traditionally, more functional amputation levels, in 

order of decreasing length, are transmetatarsal, Syme, 

transtibial, knee disarticulation, transfemoral amputation, hip disarticulation, and hemipelvectomy.49 Lisfranc (tarsometatarsal) and Chopart (tarsotarsal) amputations may be the exception to improved outcome 

with preserving length. In many cases, these amputations have the disadvantage of causing progressive 

TABLE 8-1

ENERGY EXPENDITURE FOR AMPUTATION 

 Oxygen

Amputation Energy Above Speed Cost

Level Baseline (%) (m/min) (mL/kg/m)

Long transtibial 10 70 0.17

Average transtibial 25 60 0.20

Short transtibial 40 50 0.20

Bilateral transtibial 41 50 0.20

Transfemoral 65 40 0.28

Wheelchair 0–8 70 0.16

Data sources: (1) Waters RL, Perry J, Antonelli D, Hislop H. Energy 

cost of walking of amputees: the influence of level of amputation. J 

Bone Joint Surg Am. 1976;58(1):42–46. (2) Czerniecki JM. Rehabilitation in limb deficiency: gait and motion analysis. Arch Phys Med 

Rehabil. 1996;77:S3-S8.
134

Care of the Combat Amputee

equinus and inversion foot deformities that result from 

difficulties obtaining proper muscle balance and overpull of the Achilles tendon. Additionally, difficulties 

can accompany fitting some energy storage feet for 

high-activity-level amputees who have received a very 

long transtibial or Syme amputation. 

Closure

Because of the contaminated nature of traumatic 

extremity injury sustained in battle, most traumatic 

amputations are left open, preferably as a tissuesparing and length-preserving amputation in which 

nontraumatized, viable soft tissue, muscle, and skin 

flaps are retained to aid in delayed definitive revision 

and closure. In either case, following serial irrigation 

and debridement, a plan for bony level and soft tissue 

closure should be formulated considering the local 

“flaps of opportunity.” Because preservation of joint 

function is paramount, attempts to save an amputation level with use of skin grafting for local soft tissue 

coverage are warranted. Historically, skin grafts did 

not often withstand shear forces after prosthetic fitting 

in the lower extremity, and a plan for tissue expansion 

and eventual coverage with native skin was often 

required.50,51 However, gel liners and improved prosthetic interface materials have improved the results of 

prosthetic fitting for amputated limbs with skin grafts 

in many individuals injured in the OIF/OEF conflicts. 

Additional challenges in closure of traumatic blast 

wounds have been reported from the military centers 

treating returning blast victims. Amputation closure 

within the zone of injury approaches a 67% wound 

complication rate.52 Additionally, approximately 63% 

of blast-related amputations are complicated by the formation of HO, which is most closely correlated with closure through the zone of injury.13 These considerations 

must be factored into the decision-making process and 

included in patient and family counseling discussions.

Preoperative prophylactic antibiotics should be 

administered. In the absence of frank wound infection in which culture-specific antibiotics are preferred, 

antibiotic selection should be standard perioperative 

prophylaxis for a noninfected surgery. In an effort to 

prevent the formation of chronic postoperative phantom and stump pain, many centers continue to employ 

the techniques of preemptive epidurals and early regional nerve blocks, although these procedures are not 

completely supported by available controlled trials.53

The use of a pneumatic tourniquet has been shown 

to reduce blood loss and transfusion requirements 

during elective amputation and may have the extra 

benefit of a reduced rate of revision due to the resultant 

hemostasis and easier visualization.54,55 In the management of combat-related amputees, in whom multiple, 

repeated surgical procedures and multisystem trauma 

is the rule rather than the exception, judicious tourniquet use may further limit the need for serial transfusions with their attendant immunosuppression and 

other potential systemic complications. An assessment 

of perfusion without the tourniquet inflated should, 

however, be performed at least once before definitive 

closure to ensure both adequate hemostasis and residual tissue viability via capillary bleeding. 

During secondary closure, the skin should be closed 

without tension. The scar should be placed to avoid 

adhesion to bone and trauma from pressure points 

in the prosthesis. Bone should be beveled distally to 

prevent a sharp end from causing discomfort or soft 

tissue breakdown with prosthetic wear. As mentioned 

previously, myodesis or myoplasty should be performed to provide better muscle balance and prevent 

atrophy.56 Nerves should be sharply transected after 

gentle distal traction and allowed to retract into the 

deep padded soft tissue. Individual wound closure 

techniques will be discussed by section; however, all 

combat-related amputations should be managed with 

deep drains at the time of definitive closure to prevent 

postoperative hematoma formation and subsequent 

wound complications or infection.

Partial Foot Amputation

The transmetatarsal amputation can produce a 

highly acceptable functional and cosmetic amputation 

level. A healthy, durable soft tissue envelope is more 

important than a specific anatomic amputation level, 

so bone should be shortened to allow soft tissue closure 

without tension, rather than to a specific, described 

surgical level. Bone contouring to replicate the anatomic forefoot cascade is desirable for weight bearing, 

and the bone ends should be beveled to prevent bony 

prominence. A long plantar flap is preferable (Figure 

8-11), but equal dorsal and plantar flaps can function 

Figure 8-11. Healed transmetatarsal amputation with long 

plantar skin flap.
135

General Surgical Principles for the Combat Casualty With Limb Loss

well when adequate viable plantar tissue is absent. 

Lisfranc-level amputation (tarsometatarsal) can 

provide adequate functional outcomes as well. 

However, careful evaluation should be made of the 

muscle balance around the foot, with specific attention to heel cord tightness and function of the tibialis 

anterior and peroneal muscles. Midfoot amputations 

significantly shorten the lever arm of the foot, so 

prophylactic Achilles tendon lengthening should be 

considered intraoperatively. Furthermore, tibialis anterior and peroneal muscle insertions should be reattached under appropriate tension, if they are released 

during bone resection, to prevent muscle imbalance, 

which will inevitably lead to foot deformity followed 

by eventual difficulty with prosthetic fitting and 

decreased function. Postoperative casting can help 

prevent deformities by preventing Achilles tendon 

contractures, allowing tendon reattachments time to 

heal, controlling residual limb edema, and preventing 

wound problems.

The Chopart (transverse tarsal) amputation removes 

the forefoot and midfoot while preserving the talus 

and calcaneus. Achilles tendon lengthening and tibialis and peroneal tendon reattachment and balancing 

are essential to prevent equinus and varus deformities at this level (Figure 8-12). Although described in 

the literature, tendon reattachment and balancing at 

this level can be quite humbling, with many patients 

progressing to hindfoot deformity necessitating further revision for functional limitations.57 If available, 

plantar weight-bearing skin is best utilized as a flap 

for closure, with special attention paid to fastening 

the flap to bone to prevent shear and bursa formation. Postoperative casting is necessary to allow for 

tendon healing to bone. Although precise indications 

for revision to a Syme or transtibial amputation are 

Figure 8-12. Intraoperative photograph of Chopart amputation. A Penrose drain is being utilized to pass the residual tibialis 

anterior tendon beneath a skin bridge to facilitate tenodesis distally.
136

Care of the Combat Amputee

lacking, a lengthy discussion with patients regarding 

rehabilitation and functional expectations is indicated 

prior to the decision to pursue a Lisfranc- or Chopartlevel amputation. 

Syme and Long Transtibial Amputation

Described by Syme58 in 1843 and subsequently reviewed by Harris,59 ankle disarticulation requires that 

the calcaneus and talus be removed. Care should be 

taken while dissecting out the calcaneus to preserve 

the heel skin and fat pad. The heel skin and fat pad are 

subsequently utilized as a durable end-bearing organ 

for ambulation, sometimes even without a prosthetic 

for short distances. It is important to stabilize the fat 

pad distally to prevent posterior and medial migration, 

which can compromise function. This can be accomplished several ways, including tenodesis of the Achilles tendon to the posterior margin of the tibia through 

drill holes, transfer of the tibialis anterior and extensor 

digitorum tendons to the anterior aspect of the fat pad, 

or removal of the cartilage and subchondral bone to 

allow scarring of the fat pad to bone.18,60 Subsequently, 

the medial and lateral malleoli must be removed and 

contoured to allow prosthetic fitting. An effort to retain 

some moderate malleolar flare should be made to allow 

for self-suspension of the prosthesis. 

A long transtibial amputation is an uncommonly 

used level for several reasons. Although it offers the 

potential advantages of improved lever arm and proproceptive control similar to the Syme level, the distal 

leg skin and lack of soft tissue for padding can be 

problematic. Patients with this amputation level generally cannot ambulate without a prosthesis, despite the 

putative benefits of a Syme amputation. Because the 

malleoli are absent, prosthetic fitting may not allow 

self-suspension. Moreover, similar to the Syme level, 

high-activity, athletic users often have difficulty fitting 

energy-storing feet typically used for running without 

cumbersome and heavy specialty attachments. This 

makes these levels less attractive in this particular 

patient population.

Transtibial Amputation 

Arguably the most appealing level of amputation 

from a functional outcome perspective in the young 

active military population, the transtibial amputation 

(TTA) level has many advantages from a surgical perspective. Historically, many soldiers have been treated 

with this type of amputation. During World War II, from 

January 1, 1943, to May 1, 1944, five medical centers 

reported 627 TTAs and 550 transfemoral amputations, 

35.7% and 31.3% of all amputations, respectively.61

Anteroposterior, lateral, and lateral oblique radiographs of the extremity should be obtained preoperatively. The lateral oblique radiograph allows 

assessment of preoperative tibiofibular distance to 

ensure that this distance remains constant during a 

bone-bridging procedure, if chosen. This view also 

allows for radiographic assessment of excessive 

distal tibiofibular diastasis, an indicator of proximal 

instability, which is an indication for either proximal 

stabilization or a distal bone-bridging procedure. A 

guideline of 2.5 cm for each 30 cm of height provides 

the appropriate residual limb length for the patient’s 

stature. Typically, 12.5 to 17.5 cm below the tibiofemoral joint line is used as the final tibia length for nonischemic limbs.62 For non-bone-bridging amputation, 

the fibula should be resected 1 to 2 cm proximal to 

the tibia. Definitive internal and external fixation 

of fractures has been used to preserve length in the 

traumatic amputee. Even segmental fractures can be 

stabilized to proximal segments, thereby preserving 

length. Amputation through the level of the highest 

fracture is not required, provided an adequate soft 

tissue envelope is present.46

Currently, most TTAs are performed utilizing a long 

posterior myocutaneous flap, which is based off the 

blood supply from the gastrocnemius muscle (Figure 

8-13). A recent metaanalysis showed that the choice of 

Figure 8-13. Gastrocnemius and soleus myodesis to the 

anterior tibia during definitive revision and closure of a 

transtibial amputation using conventional posterior myofascial and skin flaps.
137

General Surgical Principles for the Combat Casualty With Limb Loss

amputation skin flap, including skew flaps and sagital 

flaps, had little impact on outcome when compared to 

the posterior myocutaneous flap.63 A myodesis to bone 

holes of the gastrocnemius to the beveled distal tibia 

should be performed, with the knee in full extension to 

prevent flexion contracture. If the long posterior flap is 

compromised, available “flaps of opportunity” should 

be used to save length and level, including myodesis 

or myoplasty of anterior and/or lateral compartment 

musculature over the distal tibia to provide adequate 

distal soft tissue padding.

The distal bone bridge synostosis technique offers 

the theoretical advantage of providing a more endbearing residual limb and has recently been shown 

to have some tangible benefits over traditional TTA 

in terms of prosthetic functional outcome.64 Furthermore, the technique is valuable to treat a patient with 

tibiofibular instability, which can cause prosthetic 

fit issues from fibula widening and translation with 

weight bearing. For bone-bridging procedures, several 

modifications of the original Ertl technique can be 

performed to create a bone bridge between the tibia 

and fibula with either a fibula strut graft and/or a 

periosteal sleeve (Figure 8-14).65,66 Distal bone bridging 

and modifications of the Ertl procedure are discussed 

in greater detail in Chapter 9. 

Contemporary prosthetic sockets and suspension 

systems allow fitting and function of even the shortest 

functional TTA, up to and including levels just below 

the tibial tubercle. Occasionally, however, these levels 

prove difficult to manage and patient frustration with 

an inability to regain adequate control of the prosthetic limb warrants additional strategies. Attempts 

at lengthening short residual limbs with either monoplanar or Ilizarov fixators have proven successful and 

should be discussed with the patient as an option prior 

to resorting to a higher level amputation.67,68 Due to 

concerns about wound healing and infection, however, 

these techniques should generally not be employed 

until after wound healing is complete and initial prosthetic fitting and rehabilitation has been attempted. At 

present, there are no indications for salvaging a short 

TTA in the absence of the tibial tuberosity or, at least, 

a reconstructible extensor mechanism. 

Postoperative care following TTA has traditionally 

been a rigid dressing in the form of a splint or cast. It 

is generally believed that injured tissues heal more 

consistently and with less pain when placed at rest. 

Furthermore, rigid immobilization affords the added 

benefit of preventing knee flexion contracture.57 Howa b

Figure 8-14. Demonstration of distal bone bridging technique for transtibial amputation utilizing a fibular autograft strut 

(a), which is then covered with a periosteal sleeve from the anteromedial tibia (b). 
138

Care of the Combat Amputee

ever, as mentioned earlier, rigid dressings have not 

been widely utilized during the current conflict due 

to concerns about early postoperative infection and 

the need for frequent wound examination during the 

period when such dressings would be most beneficial. 

Early postoperative rehabilitation should emphasize 

full knee and hip range of motion, including prone 

lying and stretching. Avoidance of pillows under the 

knee or a chronically flexed hip is critical to prevent 

functional limb length discrepancy associated with 

contractures.

Through-Knee and Transfemoral Amputation 

Above-knee amputation includes amputations 

through the knee (knee disarticulation) and transfemoral amputations (TFAs). Although knee disarticulation 

is often avoided due to the drawbacks of knee level 

disparity, unsatisfactory soft tissue padding and patient function, the procedure’s putative advantages 

include a simpler surgical technique, which potentially 

lessens operating room time and blood loss. The thigh 

musculature is not disrupted during the procedure 

and all muscle attachments remain, resulting in better functional control and biomechanics for walking.69

Additionally, this level can provide direct end-bearing 

characteristics for the residual limb and improved selfsuspension, with a resulting decrease in socket length. 

Previously, knee disarticulation created problems for 

prosthetic components because of the knee height 

difference compared to the uninjured side, but newer 

components, especially in knee designs, have largely 

solved these problems. Particularly with bilateral 

through-knee or transfemoral amputees, knee height 

disparity is not an issue.70

A posterior skin flap has traditionally been described for wound closure; however, recently the use 

of a long posterior myocutaneous flap has become 

popular because of the added padding of the gastrocnemius muscle and its associated contributory blood 

supply to the skin flap.71 Furthermore, the LEAP study5

demonstrated that through-knee amputations may not 

function as well as conventional transfemoral amputations, particularly if the gastrocnemius padding is 

absent. Thus, for an optimal through-knee amputation, 

nearly as much intact posterior myocutaneous tissue is 

required as for a short transtibial amputation. If both 

adequate proximal tibial bone and posterior soft tissue 

are present, the patient may be better served with a 

short transtibial amputation, potentially salvaging a 

functional knee joint. 

To complete a through-knee amputation, the distal 

extremity is removed sharply through the knee joint 

capsule. Care should be taken to resect the patellar tendon off the tibial tubercle. The patella should 

be sharply dissected from the encasing quadriceps 

mechanism to decrease the risk of future patellafemoral pain and patella prominence. Additionally, 

the remnants of the cruciate ligaments should be left 

attached to their femoral origins. Excessively bulbous 

lateral and medial femoral condyles may be modestly 

trimmed with a sagittal saw. Posterior condylectomy 

may be required to advance muscle coverage, but is not 

routinely needed. Finally, the patella ligament should 

be sutured to the remnants of the cruciate ligaments 

for quadriceps balance, and the posterior muscle flap 

brought forward and sutured to the thick anterior joint 

capsule, prior to tension-free skin closure.

Traumatic amputation through the femur can happen at any level. As the level migrates closer to the hip 

joint, function is compromised due to the decreased 

lever arm available for function and fitting, increasing disruption of the muscular attachments for thigh 

control and increasing the necessity for more complex 

proximal suspension systems for prosthetic use. When 

the skeletal muscle attachments are divided during 

amputation, muscle loses its mechanical abilities. Stabilization of the distal insertion of muscle can improve 

residual limb function. As noted, myodesis is the most 

effective technique to stabilize strong antagonistic 

muscle forces. 

Care must be taken during transfemoral amputation 

to correctly identify the cross-sectional anatomy, which 

can be difficult because the thigh is usually externally 

rotated. A good reference point is the linea aspera on 

the posterior femur. Once the anatomy is identified, 

it is important to remember that the large adductor 

magnus inserts onto the femur as a direct posteromedial structure. The most critical step during myodesis 

is to place the femur across midline adduction without 

hip flexion while suturing the adductor muscle mass 

to the distal femur through bone holes. If this process 

is not performed correctly, postoperative control of the 

limb will be compromised during ambulation due to 

over-pull of the abductors. 

The remaining muscle closure is usually performed 

as a series of myodeses or a hamstring-to-quadriceps 

myoplasty. Care must be taken to avoid excessive 

shortening of hip flexor musculature due to the position of the limb during surgery, which may result 

in a hip flexion contracture. The hamstrings and/

or quadriceps may be further stabilized by adding a 

nonabsorbable suture to the adductor myodesis. This 

technique helps prevent shifting of the adductor myodesis over the distal femur with use, and can function as 

a myodesis-by-proxy of the hamstrings or quadriceps 

if additional attachments through drill holes for each 

muscle group are not made in the distal femur. At a 

minimum, the authors recommend formal myodesis 
139

General Surgical Principles for the Combat Casualty With Limb Loss

of the semimembranosus, which is the strongest hamstring and typically the most robust muscle belly present at any transfemoral level. The quadriceps apron, if 

available, should be swung over the distal aspect of the 

remaining femur, for both stabilization and padding, 

as the last muscle layer closed.

Similar to length preservation in traumatic TTA, a 

proximal femur fracture can be stabilized to allow an 

eventual longer lever arm for TFA or knee disarticulation (Figure 8-15). Amputation through the level of 

the highest fracture is not required.12 Additionally, 

lengthening of a particularly short TFA residual limb 

a b

Figure 8-15. Radiographs of a through-knee amputation with external fixation of a proximal femur fracture. Due to soft tissue compromise and other injuries limiting potential early rehabilitation, the patient was treated definitively in this fashion 

until sufficient callous had formed to allow ambulation, with some additional support provided externally by the prosthetic 

socket. 
140

Care of the Combat Amputee

can be accomplished with monoplanar fixation following corticotomy. If bone injury occurs proximal 

to the lesser trochanter, control of the limb is severely 

compromised and hip disarticulation or fusion of the 

short proximal femur to the acetabulum are usually 

the only remaining practicable options.

To avoid hip flexion contracture, postoperative rehabilitation with prone lying and stretching should begin 

early. Additionally, placement of pillows between the 

legs with abduction at the hip should be avoided to 

prevent less than optimal adductor control of the limb 

or early strain on the adductor myodesis.

Hip Disarticulation and Hemipelvectomy

Hip disarticulation and, in particular, hemipelvectomy, are amputations of last resort. Despite the historically dismal functional prognosis associated with these 

proximal levels, modern prosthetics and suction-fit 

suspension mechanisms have resulted in remarkable 

function in some of these patients. Therefore, attention 

to a few key points is warranted to maximize patient 

outcomes. 

Hip disarticulation has traditionally been performed 

utilizing a posterior or posterolateral flap based on the 

gluteal musculature. The femoral and obturator vessels 

are identified, isolated, and double-ligated proximally 

as they exit the true pelvis. After removal or arthrodesis 

of the remaining (typically short or absent) proximal 

femur, the abductor musculature and/or pectineus 

can be sutured to the residual joint capsule or inserted 

directly into bone, filling the acetabular deadspace and 

reducing the risk of postoperative hematoma, seroma, 

and infection. Care is warranted to avoid dissection 

into the sciatic notch and violation of the gluteal vessels 

exiting there, which could compromise flap viability. 

The gluteus maximus tendon is then mobilized and 

sutured anteriorly to the inguinal ligament, resulting 

in a robust myofasciocutaneous flap over the residual 

hemipelvis. 

Hemipelvectomy is rarely required in a posttraumatic or combat-related setting—most patients with 

traumatic amputations at this level do not survive, 

even on the modern battlefield, and in most surviving 

patients a hip disarticulation can be salvaged. When 

required, efforts to salvage as much of the residual 

ilium and ischium as possible are warranted, given 

the importance of these osseous supports for prosthetic support and sitting balance, respectively. The 

soft tissue management and techniques are essentially 

the same as those for hip disarticulation, except that 

greater vessel dissection is required. In males, all three 

blood supplies to the testicle travel within the spermatic cord, which should be salvaged, or a unilateral 

orchiectomy should be performed concurrently. The 

corresponding round ligament of the uterus in females 

can be sacrificed without sequelae. 

For cases in which the gluteal musculature and 

skin are violated or absent, alternate coverage techniques are required. If possible, a femoral artery-based 

quadriceps anterior-posterior flap should be used.72

The availability of this flap in a posttraumatic setting 

clearly relies on the initial performance of an open, 

length- and tissue-preserving amputation, which illustrates the critical importance of this technique. A 

modified abdominoplasty advancement fasciocutaneous flap can also be utilized for soft tissue coverage, 

although this flap lacks the muscle padding desired 

under optimal circumstances.73 The authors have also 

had some success with rectus abdominus rotational 

flaps to augment soft tissue coverage in this region 

(Figure 8-16). Finally, in contradistinction to other 

lower extremity amputation levels, which are typically subjected to greater frictional and end-bearing 

forces with ambulation, split-thickness skin grafts can 

be utilized with relatively good anticipated results in 

this location. 

Wound complication rates after either hip disarticulation or hemipelvectomy are quite high, even in an 

elective setting. Therefore, early rehabilitation consists 

largely of early patient mobilization to prevent secondary complications such as decubitus, thromboembolic 

phenomena, pulmonary dysfunction, and general deconditioning. Prosthetic fitting is typically delayed until 

wound healing is complete. However, as noted, recent 

advancements have made resultant function in some 

amputees at these levels quite surprising and gratifying. 

Figure 8-16. Clinical photograph of a hip disarticulation in 

which soft tissue closure and coverage of the femoral vessels 

was facilitated by use of a rectus abdominis flap and partial 

thickness skin grafting. 
141

General Surgical Principles for the Combat Casualty With Limb Loss

MULTIPLE INJURED LIMB AMPUTEE

bilateral lower extremity injury to amputate the more 

severe limb and attempt salvage of the other through 

whatever means available (circular frames, free tissue 

transfer, etc). If function in the salvaged limb is not satisfactory after reconstructive and rehabilitative efforts 

are exhausted, consideration for elective amputation 

may be entertained in a careful, deliberate fashion. 

The lower extremity amputee with severe upper 

extremity injury deserves special mention. Depending on the functional outcome of the lower extremity 

amputation, the upper extremities may be required 

for mobility and ambulation assistance in both the 

short and long terms. Although obviously desirable, 

regaining full function of the upper extremity is often 

not possible. In such a circumstance, stability and relatively painless upper extremity function become more 

important, because the upper limbs are required for 

transfers and wheelchair use. Deliberate arthrodesis or 

permissive ankylosis of the wrist, elbow, or shoulder 

may be preferred to an unstable or painful limb that 

is more mobile. 

The blind upper extremity amputee presents particular and unique challenges. Due to the lack of tactile 

feedback, current prosthetic technology requires vision 

for control of the terminal devices of upper extremity prostheses. A Krukenberg procedure, despite its 

cosmetic limitations, may allow for improved upper 

extremity function in these patients because of the 

presence of sensation in the terminal limb. If desired, 

a cosmetic limb may be provided for patient use in 

social settings.

It is not possible to cover the complete array of injury combinations that may present as a result of wartime trauma. However, decisions can be made based 

on the specific injury and patient needs. The surgeon 

and the rehabilitation team, working cooperatively 

with the patient and family, must make careful and 

considerate individual decisions based on multiple 

factors to arrive at optimal solutions in each case.

The combat amputee often has injuries to multiple 

extremities as well as other organ systems, including 

eyesight. Additional injuries and more proximal levels 

of amputation can have a profoundly negative impact 

on functional capacity. Even in an era of great technologic and prosthetic advancements, the multiple limb 

amputee has challenges with prosthetic donning, fit, 

wear, and sustained use. In the traumatic amputee, 

the oxygen consumption of the bilateral transtibial 

amputee approaches that of a unilateral transfemoral 

amputee, while the bilateral transfemoral amputee 

requires double the oxygen consumption to maintain 

60% of normal walking speed.74

A bilateral transfemoral amputee is difficult to 

fit effectively with bilateral ischial-bearing sockets. 

The high sockets impinge upon one another not only 

when walking but also when seated. For this reason, 

if it is possible to maintain one side at a through-knee 

level, the comfort of prosthetic wear may be greatly 

enhanced. An even more appealing alternative would 

be to maintain a single knee joint, even if it is a very 

short transtibial level, to obviate the need for a knee 

hinge75,76; balance and control are greatly enhanced 

in this circumstance. It is even reasonable to consider 

a free tissue transfer for coverage of a transtibial or 

through-knee amputation level to avoid bilateral 

transfemoral amputations, depending on the patient’s 

condition.

Traumatic lower extremity injuries, especially in 

combat, often result in bilateral transtibial amputations. Fortunately, current prosthetic technology 

coupled with rehabilitative training has allowed for a 

high level of function in many patients. In fact, some 

unilateral lower extremity amputees with severe injuries of the contralateral limb have requested elective 

amputations of the remaining limb to improve functional level and reduce pain. The long-term outcomes 

of these individuals have not yet been determined, and 

it is still generally preferable in a patient with severe 

DELAYED AMPUTATION VERSUS LIMB SALVAGE

The decision to proceed with limb salvage or 

amputation in the patient with a severely injured 

extremity or extremities will be a source of continued 

debate. Progress has been made every year in each 

of these areas, making it possible to save limbs that 

were previously unsalvageable as well as to provide 

more advanced prostheses with greater functional 

capacity. Another evolving concern is the cost of each 

treatment, although this factor may be a less significant consideration for the military amputee because of 

guaranteed lifelong care through military and Veterans 

Affairs healthcare systems. The most recent published 

cost analysis has demonstrated equivocal 2-year costs 

between the two groups, but a three-fold increase was 

shown for the lifetime cost of the amputee group.77

Physicians have a responsibility to become knowledgeable about each of these areas to best advise patients 

and help them make these very difficult decisions. To 

be effective, physicians must learn to use a variety of 

tools and discussion points.
142

Care of the Combat Amputee

Partners/Mentors

Most surgeons have not managed every type of 

injury or situation during training or regular practice 

to prepare them for the patient facing limb salvage 

or amputation. Even among experienced trauma 

surgeons, a specific patient’s injuries, dilemmas, and 

considerations are usually unique. The collective 

knowledge of peers and consultants is important when 

faced with treating this type of injury and patient. 

Fortunately, today’s digital media and communication 

allows advice to be sought quickly and securely, even 

across thousands of miles.

Amputee Counselors/Visitors

Peer visitors and certified counselors should be 

available at every major military treatment facility; 

they can be a tremendous assistance when treating 

patients in this situation. Many of these individuals 

have faced similar dilemmas and can provide specific 

insight that may not be readily apparent to the treating 

a b

Figure 8-17. Example of proximal tibia fracture above distal 

amputation. Limited internal fixation allowed preservation 

of a good length for the residual limb.
143

General Surgical Principles for the Combat Casualty With Limb Loss

physician. Patients may discuss concerns with a fellow 

service member in similar circumstances that they may 

not express to the physician. Examples include how 

each treatment will affect the soldier’s military career, 

relationships with spouses and family, recreational 

activities, and acceptance within society at large.

Surgical Considerations

When planning an amputation after attempted limb 

salvage, one of the most important considerations is the 

level at which the amputation should be performed. 

Multiple factors must be considered, including the 

condition of the soft tissues, presence of bone defects, 

injury to and function of proximal joints, vascular injury, and the presence of contralateral injuries. Each of 

these factors affects the level and type of amputation, 

c

a b

d

Figure 8-18. Clinical photograph (a) and radiograph (b) at 

presentation of a patient with a segmental distal tibial defect, near circumferential soft tissue injury, and contralateral 

transtibial amputation. Acute shortening was performed to 

facilitate wound closure and opposition of the bone ends 

(c, d).
144

Care of the Combat Amputee

a

b

Figure 8-19. Open bilateral lower extremity injuries secondary to an improvised explosive device blast. (c and d on opposite 

page)
145

General Surgical Principles for the Combat Casualty With Limb Loss

as well as the ultimate function anticipated.

The condition of soft tissue may have a dramatic 

effect on the level of amputation. If soft tissue is not 

adequate to cover the residual limb, or it is extremely 

tenuous, amputation at a higher level is likely warranted. For example, through-knee patients considered in a study by MacKenzie et al78 did not function 

as well as either transtibial or transfemoral patients. 

Lesser function was primarily observed in patients 

with poor soft tissue coverage, whereas patients with 

a good soft tissue envelope did comparably well 

with their transfemoral and transtibial counterparts. 

Although the results of this study do not support 

avoiding through-knee amputations, they illustrate the 

importance of achieving the optimal level to enhance 

patient outcomes.

Bone defects or persistent nonunion of fractures 

can play a significant role in both upper and lower 

extremity amputations and limb salvage, particularly 

in the lower limb because of its requirement for weight 

bearing. Consideration should therefore be given to 

performing the amputation through the bone defect 

or higher, provided that this will give the patient an 

adequate amputation level. Fixation of fractures above 

the amputation can be done in many cases, providing 

length to the amputation (Figures 8-17 and 8-18). However, for late amputations after failed attempts at limb 

salvage, little evidence suggests that an unresolved 

bone or soft tissue problem will fare any better within 

the residual limb after amputation, despite the external support and soft tissue padding that a prosthetic 

component may afford. 

Injuries to joints above the level of amputation 

should be evaluated closely. Reconstructible joints 

should always be salvaged with the amputation 

performed below. A functional joint will always be 

beneficial to the patient in the long run. Total knee 

arthroplasty has been performed successfully in 

transtibial amputees, with restoration of independent 

ambulation.79 Salvaging joints is even more important 

in patients with above-knee amputations, because hip 

disarticulation is much more disabling than almost any 

length of functioning residual femur.

Vascular injury can easily preclude the salvage of 

the lower extremity. Every attempt should be made 

to assist the general and vascular surgeons with these 

patients. Given the almost inevitable future amputation in these patients if vascular injury is not resolved, 

the relative benefits of vascular reconstruction far 

outweigh the risks in this patient category, provided 

that the patient is physiologically stable.

Limb Salvage Versus Bilateral Amputation

Injury to the contralateral limb may have strong 

influences on decision-making for limb salvage versus 

amputation. When one limb has sustained a traumatic 

amputation, in most cases every effort should be made 

to salvage the contralateral limb. In these situations, 

acute shortening of the involved limb for closure of soft 

tissue defects may be necessary. Achieving equal limb 

lengths is not a concern in this situation, because the 

c d
146

Care of the Combat Amputee

a b

Figure 8-20. Right foot after reconstructive surgery for an open calcaneus fracture. The patient was unable to bear weight 

secondary to severe dysasthesias in the right foot, and elected to undergo late transtibial amputation. 

a b

Figure 8-21. Follow-up radiographs of the foot and ankle 

of the patient in Figure 8-20 prior to elective late transtibial 

amputation. 
147

General Surgical Principles for the Combat Casualty With Limb Loss

prosthesis for the contralateral limb can be adjusted 

to compensate for any shortening. Today’s soldiers 

may be eager to undergo elective amputation given 

the advances in prosthetics and their desire to return 

to functional independence and higher activity levels 

more rapidly.

Injury to bilateral lower extremities with traumatic 

amputation on one side strongly, and appropriately, 

influences the caregiver to recommend initial limb 

salvage. Surgeons are reticent to proceed directly 

to amputation when any possibility of limb salvage 

remains, even in the direst circumstances. Although 

contralateral salvage may prolong the hospital stay and 

rehabilitation course of the patient, it remains the recommended course of action. Some patients with severe 

injuries unpredictably go on to near full functionality 

with an amputation and a marginal contralateral limb, 

while others with a seemingly good limb and amputation are severely disabled. Each individual patient has 

impairments from his or her unique injuries, but the 

final level of residual disability depends on multiple 

physical, psychological, and social factors. Salvaging 

the remaining limb allows the patient the opportunity 

and time to make an informed decision regarding 

future amputation. In the authors’ experience, those 

who have attempted limb salvage and decide for late 

amputation have done very well.

A sample case is a 24-year-old patient who was sitting in the back of a Stryker combat vehicle when it 

was hit by a powerful IED. He sustained a right open 

subtrochanteric femur fracture, right open patella fracture, left tibial pilon fracture, bilateral open calcaneus 

and talar fractures, and multiple soft tissue wounds 

(Figure 8-19). Treatment of the right femur consisted 

of multiple debridements followed by intramedullary 

nail fixation, and skin grafting of the lateral thigh. The 

left lower extremity fractures were severe, requiring an 

early amputation. Multiple debridements were necessary to treat the right open calcaneus fracture and talar 

injuries. After several months, he remained unable to 

place weight on the right lower extremity secondary 

to severe neuropathic pain (Figures 8-20 and 8-21). A 

transtibial amputation was performed at the patient’s 

request 9 months following the injury. Since that time 

he has returned to full activities including golf, work, 

and school.

CONCLUSION

Both early and late care of the combat casualty with 

limb loss remain challenging endeavors. Optimal early 

treatment, including initial decisions on limb salvage, 

open length-preserving amputations, thorough debridements, and provisional fracture stabilization techniques 

can dramatically influence reconstructive alternatives 

for surgeons at higher echelons of care as well as final 

patient outcomes. Subsequent treatment decisions are no 

less difficult, but can often be made with the assistance 

of physiatrists, prosthetists, therapists, patients, and 

families, as well as peers and the medical literature. By 

making informed, systematic determinations regarding 

final amputation level, nerve handling, and soft tissue 

reconstruction and closure in this fashion, satisfactory 

and occasionally excellent outcomes can ultimately be 

achieved for even the most challenging patients. 

Acknowledgment

The authors gratefully acknowledge Lieutenant Colonel Donald A Gajewski, MD, for his contributions to 

this chapter.

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