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Special Surgical Considerations for the Combat Casualty With Limb Loss

Chapter 9

SPECIAL SURGICAL CONSIDERATIONS 

FOR THE COMBAT CASUALTY WITH 

LIMB LOSS

BENJAMIN K. POTTER, MD*; ROBERT R. GRANVILLE, MD†; MARK R. BAGG, MD‡; JONATHAN A. FORSBERG, MD§; 

ROMAN A. HAYDA, MD¥; JOHN J. KEELING, MD¶; JOSEPH A. SHROUT, MD**; JAMES R. FICKE, MD††; WILLIAM C. 

DOUKAS, MD‡‡; SCOTT B. SHAWEN, MD§§; and DOUGLAS G. SMITH, MD¥¥

INTRODUCTION

EVALUATION OF THE LESS-THAN-SUCCESSFUL AMPUTEE

History

Physical Examination

HETEROTOPIC OSSIFICATION

NEUROMA

MYODESIS FAILURE AND LACK OF SOFT TISSUE PADDING

Myodesis Failure in Transfemoral Amputation

Myodesis and Myoplasty Failure in Transtibial Amputation

Myoplasty Failure in the Transhumeral Amputation

Myodesis and Myoplasty Failure in Transradial Amputation

OSTEOMYOPLASTIC TRANSTIBIAL AMPUTATION: THE ERTL PROCEDURE

MANAGEMENT OF BURNS AND SKIN GRAFTS

Burn-Related Amputations

Skin Grafts

JOINT CONTRACTURES

Lower Extremity Contracture

Upper Extremity Contracture

MARQUARDT HUMERAL OSTEOTOMY

KNEE INSTABILITY

INFECTION

BURSITIS

SKIN PROBLEMS

CONCLUSION
154

Care of the Combat Amputee

*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, Department of Orthopaedics and Rehabilitation, Walter Reed Army 

Medical Center, 6900 Georgia Avenue, NW, Washington, DC

†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, 3851 Roger Brooke Drive, Fort Sam Houston, Texas

‡Chairman, Department of Orthopaedics and Rehabilitation,Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, Texas 78234 §

Lieutenant Commander, Medical Corps, US Navy; Orthopaedic Surgeon, Department of Orthopaedic Surgery, National Naval Medical Center, 8901 

Wisconsin Avenue, Bethesda, Maryland 20889

¥

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 

**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

‡‡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, 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

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

Seattle, Washington 98104
155

Special Surgical Considerations for the Combat Casualty With Limb Loss

INTRODUCTION

of amputees, with emphasis on late complications and 

patient complaints. Although no individual amputee will 

(hopefully) require operative intervention for all of the 

complaints, complications, and issues discussed herein, 

this chapter may serve as a guidepost in the long-term 

surgical management of the combat-related amputee.

The operative treatment of the combat casualty with 

limb loss is challenging, but can also be immensely rewarding. The previous chapter discussed general surgical 

principles to guide early treatment, prevent complications, and optimize outcomes. This chapter discusses 

special surgical considerations for specific subgroups 

EVALUATION OF THE LESS-THAN-SUCCESSFUL AMPUTEE

Even highly functioning posttraumatic amputees 

continue to suffer from perceived physical limitations 

and pain. Smith et al1 retrospectively reviewed a large 

cohort of transtibial amputees, finding that short form 

36 (SF-36) health status profile scores were significantly 

decreased from published normal aged-matched scores 

in the categories of physical function and role limitations because of physical health problems and pain. 

Similarly, Gunawardena and associates2 found that 

differences in profiles for combat-injured soldiers with 

unilateral transtibial amputations were largest in scales 

sensitive to physical health as compared to uninjured, 

age-matched controls. More proximal levels of amputation and problems with the residual limb and sound 

leg were significantly associated with poor physical 

and mental health scores.

When considering the myriad potential causes of 

amputation-related disability, it is critical to remember 

that, regardless of how well the operative surgeon 

perceives the technical success of the surgery, a painful 

prosthesis will not be used by the patient.3 To resolve 

this problem, a critical and systematic approach to 

the identification of residual disability, both real and 

perceived, is essential in the evaluation of amputees.

History 

As in much of medicine, an adequate and complete 

history is the first step in the evaluation process. Patient 

age, comorbidities, and histories of original injury, 

infection, and revision operative procedures should be 

explored and documented in appropriate detail. A history of recent trauma or progressively increasing pain 

should be sought. Daily prosthetic usage, recreational 

activities, age of the prosthesis, and frequency and 

types of adjustments should be noted. Pain, perhaps 

one of the most nebulous areas in all of medicine, 

is by far the most common presenting problem for 

amputees. Nonetheless, elucidation of the intensity, 

onset, and character of the pain is often revealing of 

underlying cause. Medications, doses, and utilization 

patterns should be reviewed and discussed.

Numerous types of postamputation pain have been 

reported. However, three main categories are generally 

accepted: (1) phantom sensations, (2) phantom limb 

pain, and (3) residual limb or “stump” pain. Phantom sensations are defined as nonpainful sensations 

referred to the missing limb. These are estimated to be 

present in 4% to 20% of congenitally absent limbs and 

in 53% to 100% of traumatically or surgically removed 

limbs. Within the limb, sensations of tingling, itching, 

pins and needles, or numbness can occur. Additionally, 

“super-added” phenomena such as the sensation of 

wearing a ring or sock may be present. The phantom 

limb may “telescope” in size over time, leaving a 

relatively small area of foot or digits perceived on the 

stump. These sensations are generally more of a nuisance or curiosity than an overt problem and usually 

stabilize within the first year following amputation.4

Phantom limb pain is nociceptive afferent pain from 

the amputated limb. The quality of phantom limb pain 

varies but is generally described as either a burning 

or throbbing sensation, or a discomfort ranging from 

a mild ache to excruciating and intolerable pain.5

Phantom limb pain occurs on some level in as many as 

50% to 80% of amputees. Symptomatic neuroma may 

present with neuropathic pain of similar characteristics, but can frequently be localized and distinguished 

based on symptom onset, exacerbations, and physical 

examination.

Residual limb or stump pain is discomfort within, 

localized to, and identified with the residual limb itself. 

Although invariably present in the early postoperative period, chronic stump pain generally exhibits a 

characteristic dull and nagging nature. It has been 

reported in 6% to 76% of amputees and is not thought 

to be related to the central neural axis, but rather to 

organic issues within the residual limb itself.4 Localized 

stump pain can be caused by skin disorders, delayed 

healing, infection, prosthetic fit and alignment issues, 

or fracture. Hirai et al6 noted that residual limb problems were seen in about 37% of lower extremity amputees, and identified specific patterns of stump pain 

associated with different levels and methods of lower 

extremity amputation, including abnormal keratosis 

in Syme amputation, equinus deformity in Chopart 
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Care of the Combat Amputee

amputation, reduced muscle power in transfemoral 

amputation, and knee joint dysfunction in transtibial 

amputation.

Physical Examination

Surgeons should attempt to develop a systematic 

approach to examination of a residual extremity that 

is efficient, complete, and reproducible to avoid overlooking potential problems. In general, examination 

should proceed gradually from benign maneuvers 

remote from the source of pain toward direct palpation of the source of discomfort to avoid “guarding” 

by the patient. Specifically, both passive and active 

range of motion of adjacent joints should be measured 

and recorded. Hip and knee flexion contractures are 

well-known problems associated with lower extremity 

amputation and may cause a functional limb length 

discrepancy and resulting problems. Stability, especially of the ankle, knee, shoulder, and elbow joints 

must be assessed with appropriate stress testing and 

provocative maneuvers. Strength of major muscle 

groups should be evaluated and documented as well 

as a complete sensory examination. Painful neuromas 

can sometimes be palpated directly, and reproducible 

symptoms can often be elicited during percussion 

testing for Tinel’s sign.

The patient should be asked to don and doff the 

prosthesis under direct observation and point with 

a single digit to specific areas of discomfort or skin 

breakdown. Brief observation of static standing and 

ambulation in the prosthesis is essential to evaluate 

gait abnormalities and malaligned or malfunctioning 

prosthetic components. Hoagland et al7 evaluated 251 

veterans with major traumatic amputation-related 

problems. They found that approximately half of all 

patients had socket problems that caused or contributed to their symptoms. Among this group, 59% of the 

transtibial and 78% of the transfemoral prostheses had 

inadequate socket fitting. Improper shaping of socket 

margins was the most frequently observed deficiency. 

Moreover, 41% of transtibial and 22% of transfemoral 

residual limbs demonstrated signs of mechanical 

skin irritation or skin breakdown. Faulty suspension 

and alignment, in addition to improper socket fit and 

construction, contributed to these problems. Excessive 

stiffness of solid ankle cushion heels was the most common prosthetic foot problem and contributed to gait 

abnormalities. Socket-related skin complications are 

less frequently observed in upper extremity amputees, 

but prosthesis fit and utilization should be evaluated 

in these patients as well. One of the most important 

components of patient rehabilitation is the ability to 

consult with a prosthetist frequently and make prosthetic modifications as needed to ensure proper fitting 

and pressure relief. A more complete discussion of 

prosthetic alternatives and available modifications is 

presented elsewhere in this text (Chapters 20–24). 

Skin disorders are frequent complaints among 

amputees due to the intimate and confined nature of 

the limb within the socket. Skin is challenged by both 

shear and loading forces delivered by the prosthesis to 

the residual limb during ambulation or prosthetic use. 

Furthermore, skin is taxed by the closed socket, which 

affects temperature regulation and creates a moist environment from sweat accumulation. When a socket 

is poorly fitted or an inadequate soft tissue envelope 

is present, chronic and recalcitrant skin changes may 

develop. Some of the more common skin disorders 

include verrucose hyperplasia, epidermoid inclusion 

cysts, contact dermatitis, stump edema, Marjolin’s 

ulcers, and, infrequently, squamous cell carcinoma 

related to chronic infection. Skin disorders are usually 

easily identified on visual inspection of the limb. 

Similarly, surgical scars may be symptomatic. The 

optimal surgical scar is linear and avoids bony prominences, the cut end of bone, and socket pressure points. 

Although ostensibly less of an issue with modern 

prosthetic liners and sockets, the scar or scars should 

ideally not lie directly over the terminal residual limb 

because of these problems. Unfortunately, achieving 

this scar position is not always possible or practicable 

in the setting of a posttraumatic or combat-related 

amputation. Nonetheless, the optimal scar should be 

freely moveable, soft, pliable, and insensitive. Scar 

adhesion to bone, in particular, renders the scar immobile and increases the risk of skin breakdown due 

to excessive shear forces at the skin-liner interface. 

The adherent scar thus often breaks down, necessitating discontinuance of the prosthesis until healing 

occurs. Frank wound dehiscence or inflammation, 

warmth, and persistent redness not relieved by rest 

and elevation around surgical scars usually heralds 

underlying infection and should be evaluated with 

routine laboratory testing of the white blood cell count 

with differential, erythrocyte sedimentation rate, and 

C-reactive protein, at a minimum. 

Plain radiographic examination of the residual 

limb is simple and inexpensive and can reveal many 

problems unique to the traumatic blast-injured 

amputee. Posttraumatic or age-related arthritis in 

adjacent joints may be present. Fracture within the 

residual limb following subsequent trauma or minor 

falls has been noted by several authors.8,9 Additionally, heterotopic ossification (HO) and bone spur 

formation complicate a large percentage of combatrelated amputations and can be a disabling source of 

localized pain.10 Likewise, nonunion of an attempted 
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Special Surgical Considerations for the Combat Casualty With Limb Loss

bone-bridging distal tibiofibular synostosis can be a 

potential source of continued pain. Both of these phenomena are discussed in greater detail in subsequent 

sections of this chapter. 

Weight-bearing radiographs taken in the prosthesis 

can be extremely beneficial for analyzing complications 

related to myodesis failure and residual limb control or 

occult soft tissue envelope deficiencies. Xeroradiography is an excellent technique in evaluating the fit and 

alignment of extremity prostheses. With these tools, 

the degree of contact achieved and attendant pressure 

problems, if any, can be precisely determined.11 More 

elusive problems thought to be associated with gaitrelated dynamic interface within the prosthesis can 

be further investigated in a gait laboratory or using 

videofluoroscopy, if available.12

Magnetic resonance imaging (MRI) has increased 

in popularity to aid in identification of inflammationrelated pathology including bursitis, localized soft 

tissue inflammation, and bone marrow edema.13 It 

is a sensitive tool for evaluation of infection and has 

demonstrated some utility in evaluation of neuroma 

formation in amputees.14 Local lidocaine and steroid 

injections can be both diagnostic and therapeutic in 

evaluating and treating these frequently encountered 

problems. 

HETEROTOPIC OSSIFICATION

HO is the formation of lamellar bone in nonosseous 

tissue. Although infrequently reported in previous 

modern conflicts, known reports of HO in combatrelated amputations date back to World War I15 and 

the US Civil War.16 Because of its apparently increased 

prevalence following injuries sustained in the recent 

conflicts in Iraq and Afghanistan, HO is now recognized as a common and not infrequently problematic 

development in the residual limbs of traumatic and 

combat-related amputees.10 

HO formation is thought to require cellular elements capable of osteogenesis, an inciting event, and 

an environment supportive of bone formation.17 The 

most accepted theory about this dysplastic process 

regards mesenchymal stem cells present in muscle, 

periosteum, and soft tissue as the cells of origin, with 

the inciting event in these cases being a blast injury 

or combat-related trauma.18 It is now clear that traumatized residual limbs represent a very conducive 

milieu for this process. Although, as will be discussed, 

the timing of various putative causative factors and 

prophylactic measures varies, the nucleus of this 

metabolic cascade lies at the point of injury. Indeed, 

clinically evident HO can develop very rapidly following injury (Figures 9-1 and 9-2), and ectopic bone due 

to any cause is reliably present and detectable in some 

quantity within 2 months of the instigating stimulus 

onset, although further growth and maturation may 

continue thereafter.19,20

At least 36% of all combat-related amputees from 

the current conflicts have radiographically proven 

HO in their residual limbs. The prevalence jumps to 

an astounding 63% when only limbs with adequate 

radiographic follow-up are assessed.10 Although this 

latter figure likely represents a degree of selection 

bias, because patients with palpable or symptomatic 

lesions are more likely to have follow-up radiographs 

performed, the actual prevalence likely approaches 

or exceeds 50%. The scope of the clinical problem 

is therefore vast and not merely a topic of academic 

discussion. 

Proven and statistically significant risk factors 

for HO formation in residual limbs of traumatic and 

combat-related amputees include a final amputation 

within, rather than above, the initial zone of injury 

(ZOI) and a blast (vs blunt, sharp, or even high-velocity 

gunshot) mechanism of injury (MOI). However, HO 

may also develop due to other, non-blast MOIs (Figure 

9-3). Final amputation level within the initial ZOI also 

appears to be predictive of HO magnitude and severity.10 In addition to these proven risk factors, a number 

of other potential causative or confounding factors for 

Figure 9-1. Photomicrograph (hematoxylin-eosin stain; 

original magnification × 20) of a specimen resected from the 

brachialis muscle of a transhumeral amputation at the time 

of definitive revision and closure just 15 days after injury. 

Abundant enchondral heterotopic ossification formation is 

evident immediately adjacent to normal skeletal muscle.
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Care of the Combat Amputee

the high recent prevalence of HO in residual limbs have 

been proposed or anecdotally reported. Chief among 

these is the potentially greater survival of otherwise 

grievously injured combatants afforded by modern 

body armor, rapid evacuation and treatment, and 

medical advances as compared to historical conflicts.

Other potential risk factors for ectopic bone growth 

within residual limbs include subatmospheric pressure dressings, moderate- to high-pressure pulsatile 

lavage irrigation systems, occult traumatic brain injury, 

chronic low-grade local infection, preinjury nutritional 

supplement use by allied combatants, and other as yet 

undetermined geographic environmental factors. With 

the data currently available, none of these has been definitively shown to increase the risk of HO formation in 

residual limbs.10 However, such confounding variables, 

most notably the severity of initial injury to the limb 

and other body systems, are difficult to adequately 

control for in statistical data analysis. Further study 

of these factors is warranted and ongoing. 

A wide variety of suppositional prophylactic agents 

and modalities to prevent HO have been studied, with 

varied levels of clinical and laboratory evidence of efficacy, in other patient populations with or at risk for 

HO. The only modalities definitively proven to prevent 

HO occurrence are nonsteroidal antiinflammatory 

drugs (NSAIDs) and local external beam radiation 

therapy.20–23 Local radiation therapy within the requisite time frame (24–72 hours of injury) is logistically 

infeasible in a combat environment, irrespective of 

concerns about irradiating open wounds and resulting 

local immunosuppression and inhibition of wound 

healing, as well as initial uncertainty about the final 

level of amputation. NSAIDs also have undesirable 

effects on platelet function, fracture healing, and the 

renal and gastrointestinal systems. However, in patients with essentially isolated amputations who are 

putatively able to systemically tolerate this modality, 

early prophylaxis is reasonable and should be continued for at least 2 and as long as 6 weeks postinjury. 

Other proposed prophylactic modalities include 

vitamin K antagonists, corticosteroids, colchicine, and 

calcitonin.24–27 Independent of concerns about coagulopathy, immunosuppression, and other untoward side 

effects, however, currently available evidence does not 

Figure 9-3. Anteroposterior radiograph of a right transfemoral amputation with severe, symptomatic heterotopic 

ossification following a crush injury sustained in a motor 

vehicle accident. The patient underwent excision of extensive 

heterotopic ossification with surgical revision of his residual 

limb with an excellent clinical result.

Figure 9-2. Radiograph of resected heterotopic ossification 

specimens from the soleus muscle belly of a transtibial amputee at the time of definitive amputation and closure 20 days 

after injury. Although wound vacuum-assisted closure and 

pulse lavage exposure have been theoretically implicated as 

potential causes of the apparently increasing prevalence of 

heterotopic ossification in modern combat-related amputees, 

the deep superficial compartment of this patient’s leg was 

protected from direct exposure to these devices. The patient 

underwent elective transtibial amputation for an unreconstructable soft tissue defect associated with a type-IIIB/C 

tibia fracture after free tissue transfer failed. 
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Special Surgical Considerations for the Combat Casualty With Limb Loss

support the routine use of any of these agents in the 

combat-injured amputee. The only agent that has been 

evaluated for late prophylaxis is the older bisphosphonate etidronate sodium.28 Enthusiasm for this agent 

is tempered by frequent symptomatic esophagitis, 

inhibition of concomitant long-bone fracture healing, 

and the potential for late “recurrence” of HO after discontinuation of therapy due to delayed mineralization 

of transiently inhibited ectopic bone. Some long-term 

benefit may be gained with this modality, however. If 

bisphosphonate therapy is pursued, etidronate should 

be used. Newer agents have not been evaluated in 

relation to HO treatment, and would likely be less 

efficacious due to greater selectivity and inhibition of 

osteoclasts, as opposed to the osteoblast suppression 

desired in HO prophylaxis. 

After HO is established within a residual limb, 

asymptomatic lesions do not require treatment. 

Particularly in asymptomatic patients in whom the 

radiographic HO is not palpable, repeated reassurance 

should be given that the lesion is not a true tumor, 

no treatment is required, and that asymptomatic HO 

seldom causes discomfort associated with prosthetic 

fitting. In dedicated rehabilitation centers where many 

amputees have HO and some of these have undergone 

excision, such discussions are critical to avoiding unnecessary and potentially complicated surgery. 

The initial treatment of all symptomatic amputees 

with HO is conservative. The authors have found HO 

excision with or without amputation revision to be 

fraught with wound-related and infectious complications. Because of these complications, an exhaustive 

attempt at nonoperative treatment is indicated prior 

to excision. This consists of brief periods of rest and 

activity modification concurrent with adjustments 

to pain medications, evaluation for alternate causes 

of residual limb pain (as discussed in the preceding 

section), and serial prosthetic alignment, socket, suspension, and liner modifications. Using this approach, 

most patients with symptomatic lesions can be treated 

conservatively. Of recent combat-related amputees 

with known HO, nearly 85% were asymptomatic or 

had been successfully treated conservatively, with only 

about 7% of all amputees requiring surgical excision 

of HO.10

Once conservative measures have been exhausted 

and surgery is planned, however, further new socket 

fitting and prosthesis component changes should be 

delayed until after the procedure; virtually all patients 

undergoing HO excision require entirely new sockets 

postoperatively. Indications for operative intervention include exposed bone, continued skin and soft 

tissue breakdown, and localizable pain, all of which 

should be proven refractory to local wound care and/

or repeated prosthetic modifications preoperatively. 

Patients contemplating an excisional procedure should 

be counseled that the incidence of wound-related and 

infection complications requiring additional surgery 

may approach 25%. 

Radiographically, HO may be graded in severity 

as mild, moderate, or severe based on whether the 

ectopic bone occupies less than 25%, 25% to 50%, or 

over 50%, respectively, of the cross-sectional area of the 

terminal residual limb on plain radiographs.10 Severe 

HO is more difficult to excise, requires more extensive 

surgery for complete excision (including frequent formal myodesis and amputation revision), and is more 

likely to demand creative soft tissue reconstruction to 

achieve adequate coverage of the residual limb. However, the shape and depth of heterotopic lesions may 

be a more critical factor in determining which lesions 

become symptomatic and require excision (Figures 

9-4 and 9-5).

The timing of HO excision has previously been a 

matter of substantial debate, with many advocates 

for delayed excision of HO to prevent unacceptable 

local recurrence rates.29 The authors have found assessment of historical markers of HO maturity such 

as bone scan activity and serum alkaline phosphatase 

to be unhelpful and unnecessary. Plain radiographic 

evidence of maturity is somewhat helpful (stable, 

mature cortical rind and no change in appearance on 

radiographs taken at least 1 month apart), but principally because mature, mineralized bone is technically 

easier to marginally but completely excise than its 

softer, cartilaginous precursor. With frequent utilization of adjunctive secondary recurrence prophylaxis 

(ie, radiotherapy and/or NSAIDs), good results have 

been obtained, with no clinical recurrences to date, in 

operations performed as early as 3 months postinjury. 

The authors therefore advocate excision as soon as 

required in patients with HO symptoms refractory 

to conservative measures, which generally take 3 to 4 

months to exhaust. At a maximum, 6 months appears 

to be a more than adequate observation interval from 

injury to excision for surgeons desiring a more conservative approach. 

Preoperative planning and detailed patient counseling are critical to ensuring optimal outcomes following 

HO excision from residual limbs. In addition to the 

potential for wound complications, any primary or 

contingency plans for myodesis takedown, residual 

limb shortening, or formal revision of the amputation 

concurrent with the excisional procedure should be 

discussed with patients preoperatively. All of these 

factors may affect both subsequent patient function 

and the postoperative rehabilitation schedule. Although direct data to support secondary HO recur-
160

Care of the Combat Amputee

rence prophylaxis are lacking due to a nearly absent 

control group, the authors advocate routine use of 

radiotherapy and/or NSAIDs postoperatively based 

on the potential residual limb compromise that may 

occur if repeat excision is required. This portion of the 

postoperative plan should also be discussed with the 

amputee preoperatively, emphasizing the importance 

of compliance with, and reporting of side effects related 

to, postoperative NSAID use. 

For relatively uncomplicated cases, orthogonal radiographs of the residual limb are all that is required. 

For larger, serpentine ectopic bone lesions and those 

that approach or envelope critical neurovascular 

structures, preoperative computed tomography scans 

with coronal, sagittal, and (ideally) three-dimensional 

reconstructions can be helpful for both preoperative 

planning and intraoperative reference (Figure 9-6). 

Overlying split-thickness skin grafts should be excised concurrently with the HO excisional procedure 

when practicable. However, soft tissue coverage 

is often difficult after extensive HO resection, and 

the majority of any concurrent soft tissue resection 

should be performed after the HO has been removed. 

In patients with focal, localizable symptoms or for 

whom complete excision would require revision with 

extensive limb shortening or loss of a functional joint 

level, partial excision of only the most symptomatic 

HO is a reasonable approach. No evidence indicates 

that partial excision of HO predisposes the patient to 

recurrence of the excised portion. A plan for the exact 

sequence of events during the excisional procedure, 

including soft tissue coverage and closure as well as the 

potential need to shorten the residual limb, is helpful 

in avoiding unsuspected problems. 

The authors attribute the relatively high incidence 

of postoperative infections and wound-related complications to compromised soft tissue envelopes, 

potentially latent chronic infections, and the frequent 

culture-positive nature of excised HO specimens. 

Given the high incidence of postoperative infection and 

wound-related complications, relatively short-term 

(~2 weeks) postoperative empiric and subsequently 

culture-specific antibiotics should be administered, in 

addition to routine empiric preoperative prophylaxis. 

Tissue from each resected HO specimen should be 

sent to microbiology for culture analysis. To further 

minimize complications, wounds should be irrigated 

Figure 9-4. Anteroposterior radiograph of a left transfemoral 

amputation demonstrating moderate heterotopic ossification 

with a prominent, symptomatic distal-lateral spike of ectopic 

bone. The patient’s symptoms were refractory to repeated 

prosthesis modifications, and he subsequently underwent 

heterotopic ossification excision through a direct lateral approach without myodesis takedown. 

Figure 9-5. Axial computed tomography scan of a left transfemoral amputee with diffuse heterotopic ossification about 

his terminal residual limb. Although the patient’s preoperative symptoms were greatest laterally, he desired compete excision of the heterotopic ossification. This required complete 

myodesis takedown and revision amputation concurrent 

with the heterotopic ossification excision. 
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Special Surgical Considerations for the Combat Casualty With Limb Loss

thoroughly following excision, meticulous hemostasis 

achieved, and layered closure performed over a surgical drain. 

Postoperatively, drains should be removed at the 

bedside generally within 72 hours as indicated by 

drainage output. Dressings should be changed daily 

starting on postoperative day 2, and patients should 

be transitioned back to compressive shrinker stockings as soon as feasible. Sutures should be removed 

at 2 to 3 weeks postoperatively. For patients with focal excisions and limited dissection, prosthetic fitting 

and wear may recommence as soon as wound status 

and comfort allow, in some cases even prior to suture 

removal. When formal myodesis and amputation revision has been performed, prosthetic rehabilitation 

should follow a standard protocol and progression 

similar to, but slightly accelerated from, that utilized 

for new amputees. New radiographs of the residual 

limb should be obtained immediately postoperatively, 

again at 2 to 3 months to assess for possible HO recurrence or myodesis failure, and as clinically indicated 

thereafter. 

NEUROMA

Neuroma formation in amputation surgery is inevitable—all transected nerves form neuromas. Currently 

no technique has been convincingly proven to prevent 

or ameliorate this process. However, not all neuromas 

are symptomatic. Persistent symptoms associated with 

neuromas have been reported in approximately 20% 

to 30% of amputations,30,31 and the majority of these 

can be managed without revision surgery. A discreet 

area of pain in the vicinity of a palpable nodule and the 

presence of Tinel’s phenomenon are clear indicators of 

the presence of a symptomatic neuroma. Evaluation 

of the residual limb with routine radiographs may 

provide useful information if HO or retained metallic 

fragments are near the neuroma, but computed tomography or ultrasound rarely provide any information 

that cannot be determined by a good history, examination, and standard radiographs. Careful evaluation 

of fine cut MRI scans can occasionally be helpful in 

identifying neuromas that are otherwise difficult to 

localize.14 Prosthetic socket modification is usually sufficient to relieve pressure causing persistent pain from 

a symptomatic neuroma. However, in recalcitrant cases 

a diagnostic injection of a local anesthetic at the point 

of maximal tenderness may help verify the diagnosis 

as well as provide some prognosis for improvement 

if surgical excision becomes necessary. 

A neuroma that is diagnosed and found to be resistant to all nonoperative measures is best treated with 

early resection to avoid the development of a “pain 

generator” and changes in the central neural axis 

that may result in chronic, refractory pain.32 The first 

surgical intervention to remove a painful neuroma is 

usually the most effective. Tupper and Booth33 found 

that in the treatment of 232 neuromas, 65% of patients 

improved following the first surgery, while only 13% 

showed improvement following a second operative 

procedure. Many of the principles outlined in the 

preceding chapter’s section on managing nerves during amputation surgery apply to neuroma surgery. A 

clean, sharp transection of the nerve proximal to the 

neuroma, with moderate tension applied, will allow 

the nerve to retract into the proximal soft tissues. If 

the surgeon decides to implant the freshly cut nerve 

end into a local muscle, it is imperative to avoid any 

tension on the nerve and place the implant in an area 

free from scar and socket pressure. 

Nerves that traverse a relatively superficial anatomic course deserve specific mention. Superficial 

radial nerve neuromas should be resected so that the 

remaining nerve end is well beneath the brachioradialis muscle.34 For neuromas of the peroneal nerve, the 

surgeon should consider a higher level of resection in 

the thigh to better insure that the nerve end is beneath 

the hamstring muscles, while the sural nerve should 

be allowed to retract deep to the gastrocnemius or into 

the distal popliteal fossa. When excising a symptomatic 

neuroma of the sciatic nerve in transfemoral amputees, 

it is important to remember not to excessively shorten 

Figure 9-6. Three-dimensional computed tomography scan 

reconstruction of an amputee with a blast-related right hip 

disarticulation through the initial zone of injury complicated 

by severe, diffuse heterotopic ossification. 
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Care of the Combat Amputee

the nerve, which may lead to pain with sitting and is 

often recalcitrant to repeated attempts at surgical revision. As mentioned previously, pulsatile, throbbing 

pain, particularly at rest, usually indicates a neuroma 

in proximity to a blood vessel. Revision surgery for 

this problem involves separation of the nerve and 

blood vessel, repeat ligation of the vessel, and a wellperformed traction neurectomy insuring that the nerve 

is no longer in proximity to the pulsing blood vessel. 

Adherence to these principles, both conservative and 

operative, will ensure acceptable relief for the vast 

majority of amputees with symptomatic neuromas. 

MYODESIS FAILURE AND LACK OF SOFT TISSUE PADDING

In response to an increasingly active amputee 

population, modern amputation techniques emphasize 

appropriate and durable bone covering as well as anatomic muscle and soft tissue stabilization. In addition 

to proper socket fit and training, the success and longevity of residual limbs, especially in a young, active 

population who place supraphysiologic demands on 

their residual limbs, depend heavily upon the adequacy 

of this muscular and soft tissue stabilization. Myodesis 

failure and loss of soft tissue padding are two potential complications facing modern amputees and may 

contribute significantly to long-term healthcare costs.35

Thus, it is critical that the treating physician be familiar 

with the signs and symptoms associated with failure of 

one or both of these important physiologic constructs.

The approach to the painful or ill-functioning 

prosthetic limb is multidisciplinary. Close consultation among the patient, orthopaedist, physiatrist, and 

prosthetist is required to help determine which conditions may respond to socket modifications and which 

may require further evaluation and surgical treatment 

(as described in the first section of this chapter). To 

address failure of myodesis, failure of myoplasty, 

or loss of soft tissue padding, history and physical 

examination, weight-bearing radiographs (in and out 

of the socket), and gait analysis are often successful at 

identifying the problem.

Myodesis Failure in Transfemoral Amputation

Myodesis of the adductor magnus to the residual 

femur is critical to restoring proper mechanical alignment and control of the lower extremity.36,37 Failure to 

achieve adequate myodesis or catastrophic subsequent 

rupture of the construct results in a 70% decrease in 

adduction strength due to a shortened effective movement arm of the weaker adductors longus and brevis 

(Figure 9-7).38 The femur, pulled into abduction by 

the relatively unopposed abductors, can no longer 

be held in anatomic alignment, even with aggressive 

socket modifications (Figure 9-8).37,39–41 The resulting 

problems, often debilitating, include residual limb 

pain and ulceration as well as a less-efficient gait 

cycle, leading to increased energy expenditure during 

ambulation.42

Patients may complain of anterolateral residual 

limb pain or ulceration despite socket modifications. 

Subjective weakness in the residual limb, or a decrease 

in gait velocity, with or without fatigue, often accompanies the discomfort. In highly functional amputees, 

history may reveal a previously well-functioning limb 

and well-fitting prosthesis prior to an uncontrolled 

fall or hyperabduction injury. This may indicate a 

catastrophic failure of the myodesis. An exaggerated 

side lurch or a circumduction gait is noticeable as 

the patient compensates for an inadequate adductor 

mechanism. 

Physical examination may reveal a flexed and abducted residual limb, as well as a bony prominence 

anterolaterally. An “adductor roll” may be present 

above the socket line medially, caused, in part, by the 

retracted adductor musculature. Strength and isometric testing would reveal weak adduction and extension, 

without a palpable contraction of the adductor longus 

or hamstring muscle bellies. Radiographic evaluation 

including weight-bearing anteroposterior and lateral 

radiographs of the residual limb would reveal an excessively flexed and abducted femur within the soft 

tissue envelope of the residual limb.

Once the diagnosis of myodesis failure or insufficiency has been made, it is important to assess the 

amputee’s level of functioning before committing to 

an elective surgical revision. Sedentary or otherwise 

low-demand patients without ulceration may respond 

to socket modifications and continue to function adequately despite an insufficient adductor mechanism.39,40

Most patients, however, may not respond adequately 

to socket modifications and may desire to achieve (or 

return to) a higher level of functioning. These amputees 

require a timely revision procedure to restore proper 

anatomic alignment to the residual femur. 

In these situations, revision or reconstruction of the 

adductor mechanism should be performed as soon 

after diagnosis as possible. Scarring and retraction of 

the adductors and hamstrings can make delayed repair 

more difficult. Also, some evidence suggests that within a residual limb, retracted muscles atrophy over time, 

losing up to 60% of their cross-sectional area (and thus 

the majority of their contractile strength), compared 

to muscles in which the length-tension relationship 
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Special Surgical Considerations for the Combat Casualty With Limb Loss

was preserved.43–45 Early rather than delayed repair 

of the adductor mechanism is therefore preferred to 

maximize potential restoration of the residual femur 

to anatomic alignment, as well as to minimize the difficulty of the reconstruction. 

Repair of the insufficient adductor mechanism is 

technically demanding and consists of meticulous 

identification of the adductor magnus and hamstring 

tendons. Previous incisions should be used, and the 

development of flaps minimized. If adequate tendon 

length is present, the myodesis is performed in much 

the same way as a primary transfemoral amputation. 

The authors recommend the technique described by 

Gottschalk38 as outlined in greater detail in the previous 

chapter. If the adductor and medial hamstring tendons 

are insufficient for this task, femoral shortening may 

be required and the patient should be counseled accordingly. In severe or unique cases, reconstruction of 

the adductor mechanism using soft tissue autograft, allograft, or xenograft may be necessary. Metal vascular 

clips may be attached to the adductor mechanism near 

its new insertion in an effort to provide a radiographic 

indicator of myodesis integrity. 

Figure 9-7. Diagram of the resultant forces of the adductor 

muscles. The relative insertion sites of the adductors are indicated. Progressive shortening of the residual femur results 

in increasing weakness in adduction as a result of progressive 

loss of adductor function. 

AB: adductor brevis

AL: adductor longus

AM: adductor magnus

Reproduced with permission from: Pinzur MS, Gottschalk 

FA, Pinto MAG, Smith DG. Controversies in lower-extremity 

amputation. J Bone Joint Surg Am. 2007;89:1118–1127, Figure 7.

Figure 9-8. Standing anterior-posterior radiograph of a transfemoral amputee in his prosthesis demonstrating failure of 

the adductor magnus myodesis. Due to the resulting deficiency in adductor strength, the residual femur is pulled into 

progressive abduction, altering the alignment of the residual 

femur versus the normal mechanical axis in the contralateral 

sound limb femur, producing a less efficient gait, and causing 

a focal pressure point against the distal lateral socket, which 

was a source of the patient’s discomfort. 
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Care of the Combat Amputee

Prolonged adductor pain is common in patients who 

have undergone revision myodesis. Adequate early 

pain control with judicious use of muscle relaxants and 

abduction precautions to protect the myodesis repair is 

important. Likewise, close consultation with a physical 

therapist in addition to the prosthetist is critical. After 

adequate early healing of the wound and myodesis, 

early rehabilitation should focus on active adduction 

and extension exercises before a return to prosthetic 

fitting and rehabilitation.

Inadequate myoplasty or soft tissue padding in 

the transfemoral amputation is rare, but can be a 

source of pain and disability. Although most cases 

result from an inadequate adductor myodesis as 

discussed above, some can be caused by failure of the 

quadriceps myoplasty itself. This can often be appreciated clinically via new anterior distal prominence 

of the residual femur as well as hypermobility of the 

anterior residual limb skin with active quadriceps 

contraction. Additionally, traumatic and combatrelated amputees may have a paucity of healthy and 

robust residual limb soft tissue due to appropriate 

early efforts to maintain maximal residual limb 

length in the setting of a broad ZOI. Short of revision with substantial shortening of the residual limb 

or free tissue transfer, both operative options of last 

resort, reconstructive alternatives may be quite limited in this setting. Fortunately, socket modifications 

can succeed in improving symptoms in the majority 

of cases, and it is thus important to maximize the 

benefits of nonoperative therapy prior to surgery. 

Revision of the quadriceps myoplasty is unlikely to 

be successful, especially in a high-demand patient, if 

the adductor myodesis is inadequate. Therefore, it is 

important to assess these two structures thoroughly 

and concurrently. 

Myodesis and Myoplasty Failure in Transtibial 

Amputation

Myodesis and/or myoplasty within the transtibial 

amputation provides the residual limb with a durable 

end-bearing muscle mass. Standard posterior (Burgesstype) flaps are perhaps the most durable and employ 

a myodesis technique.46,47 Sagittal, skew, and free 

flaps provide end-bearing bulk by myoplasty alone, 

or a combination of myoplasty and myodesis.48–51 The 

so-called “fishmouth” flap is used in rare cases to 

salvage bone length when the posterior musculature 

is inadequate. It is formed by two equal anterior and 

posterior fasciocutaneous flaps that provide little or 

no muscular coverage over the distal tibia suitable for 

end-bearing. For this reason it is not routinely used, 

but reserved for salvage cases only.

Loss of durable end-bearing musculature in the 

transtibial amputation causes pressure-related pain 

with prosthetic wear. Patients may complain of anterior residual limb pain or present with skin breakdown 

and ulceration. History may reveal a previously wellfunctioning limb and well-fitting prosthesis prior to 

a fall onto the residual limb, which may indicate an 

acute failure of the myodesis or myoplasty. 

Physical examination will reveal a prominent anterior and distal tibia. Depending on the type of flap 

used, retraction of the posterior musculature or a rent 

in the skew flap myodesis will be palpable. As with 

any amputation revision, nonoperative management 

including socket modifications may result in a functional and painless limb and should be exhausted 

preoperatively. For the same reasons listed above, 

however, most young, active amputees may not respond adequately to socket modifications and may 

desire a higher level of function and residual limb 

durability. This subset of patients requires a timely 

revision procedure to restore durable end-bearing 

muscle to the distal tibia. For overt myodesis failure 

presenting acutely, particularly if occurring relatively 

early in the soldier’s initial rehabilitation, immediate 

operative repair without a trial of nonoperative treatment is reasonable. 

Revision of the transtibial myodesis or myoplasty 

is challenging. In the acute setting, a simple myodesis or myoplasty repair may be possible; however, 

retracted posterior compartment muscles are often 

scarred and difficult to mobilize. Shortening of the 

residual tibia and fibula is almost always necessary to ensure an adequate, durable myodesis. Care 

must be taken, however, to avoid overtightening the 

myofascia of the posterior compartment, which may 

cause a knee flexion contracture and predispose the 

patient to early failure of the (revision) myodesis. 

The anterior bevel of the tibia should also be revised, 

if needed, and the myodesis performed with stout 

nonabsorbable sutures. It is important to note that the 

lateral gastrocnemius undergoes far less atrophy than 

its medial counterpart, and may contribute a more 

robust construct to the repair.52,53 Myoplasty repair, 

if indicated, may be performed with long-lasting absorbable suture, and consideration should be given 

to augment the repair with a myodesis technique to 

prevent recurrence. 

As in most amputation revision surgery, previous 

incisions should be utilized and the development of 

flaps minimized. Although the development of a knee 

flexion contracture is undesirable, residual limb rest 

with the knee in slight flexion for a few days postoperatively is reasonable to permit the muscles to adapt 

to their new resting length and minimize tension on 
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Special Surgical Considerations for the Combat Casualty With Limb Loss

the myodesis. Early rehabilitation should then focus 

on gentle passive knee extension and active-assisted 

knee range-of-motion exercises.

Myoplasty Failure in Transhumeral Amputation

In contrast to lower extremity amputations in which 

the myodesis and myoplasty form a durable endbearing pad, myoplasty techniques of the arm serve 

to stabilize the musculature and contain the residual 

humerus within the soft tissue envelope. Additionally, 

for high-demand amputees utilizing myoelectric prostheses, stable myodesis may be required for optimal 

residual limb and terminal device control. 

Failure of the myoplasty is often characterized 

by the insidious onset of symptoms; catastrophic 

(or acute) failure is rare. Patients may complain of a 

painful snapping sensation with range of motion or 

pressure-related pain with prosthesis wear. Physical 

examination may reveal a painful bursa overlying an 

area of inadequate myodesis; however, palpating a 

defect (rent) in the myoplasty is the key to diagnosis. 

As with any amputation revision, nonoperative 

management must be exhaustive, including socket 

modifications, local wound care (if necessary), and 

prosthesis rest. Those amputees who do not improve 

with nonoperative management require surgical 

repair. In the authors’ experience, higher demand 

amputees are more likely to fail conservative management for these issues, which should be a consideration 

when selecting patients for surgery as well as timing 

the surgery. 

Repair of the myoplasty should be performed as 

soon as possible to minimize the effect of muscular 

contraction and scarring. The myofascia should be 

repaired with a mild amount of tension to restore 

the muscle bellies to resting length and tension. This 

ensures a maximum myoelectric signal generation for 

applicable prostheses.54 Shortening of the humerus 

is occasionally required, depending on the timing of 

the repair and general condition of the remaining soft 

tissues. As with other amputation revisions, previous 

incisions should be used, and the development of flaps 

minimized. Postoperative care and rehabilitation are 

similar to those in primary transhumeral amputations.

Myodesis and Myoplasty Failure in Transradial 

Amputation

Myodesis in the transradial amputation serves a 

similar purpose to that performed in a transhumeral 

amputation. Anterior and posterior muscle flaps are 

used to contain the residual radius and ulna within 

a durable, stable myofascial construct. Failure of the 

myoplasty is rare at this level but is characterized by a 

prominent distal radius or ulna. As in the transhumeral 

level, patients may also complain of a painful snapping 

within their residual limb as well as pressure-related 

pain with prosthesis wear. Physical examination will 

indicate an area of inadequate myoplasty and may 

reveal an overlying painful bursa. Once again, identifying a palpable rent in the myoplasty or new focal area 

of prominent bone is the key to diagnosis. 

Nonoperative management, including socket 

modifications, local wound care (if necessary), and 

prosthesis rest will likely provide symptomatic relief and should be exhausted prior to surgery. Those 

amputees who do not improve with nonoperative 

management require surgical repair. Again, as with 

all cases of suspected myodesis or myoplasty failure, 

conservative options should be pursued expeditiously 

to minimize muscle retraction and scarring in those 

cases requiring revision surgery. The myofascia or 

tendons should be repaired while keeping the muscle 

bellies at resting length and tension to maximize distal 

bone stability, residual limb control, and myoelectric 

signal generation.54 Shortening of the radius and ulna 

is sometimes required because more muscle mass is 

available proximally; however, progressive loss of residual forearm length directly correlates to a decrease 

in forearm rotation.55 This must be kept in mind when 

planning to shorten a transradial amputation, and the 

patient must be counseled accordingly. For more distal 

transradial amputations, retracted tendons can often 

be mobilized sufficiently via proximal dissection so 

that shortening is not required. Neuromata, if present, 

may also be addressed during the revision surgery. 

As with other amputation revisions, previous incisions should be used, and the development of flaps 

minimized. Postoperative care and rehabilitation are 

similar to those in primary transradial amputations. 

OSTEOMYOPLASTIC TRANSTIBIAL AMPUTATION: THE ERTL PROCEDURE

In 1939 Janos Ertl56 published a technique for transtibial amputation revision for problematic residual 

limbs, which he developed treating World War I amputees in Hungary.In 1949 he published his experience 

treating 6,000 amputees following World War II.57 His 

original technique calls for raising periosteum from the 

medial aspect of fibula with attached cortical chips and 

suturing it to the lateral tibial periosteum. A similar 

flap of periosteum is raised from the anteromedial 

tibia. The distal tibia and fibula are then cut at the same 

level, taking care to carefully bevel the tibial crest and 

round off all cortical edges. The tibial periosteum is 
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Care of the Combat Amputee

then sutured to lateral fibular periosteum. Anteriorly 

and posteriorly, the edges of the two periosteal flaps 

are sutured together, forming a tube of periosteum 

with opposed “cambrial” surfaces and viable bone 

chips. With time, a synostosis forms between the two 

bones, with a broad, smooth surface (Figure 9-9). Ertl 

felt this allowed end bearing in the socket, reducing 

pain and improving function. He also proposed that, 

by sealing the medullary canal, “normal bone physiology” was restored. 

The procedure continues to have proponents in 

Europe.58 In the United States, two generations of Ertl 

descendants have been proponents of the elder Dr 

Ertl’s techniques.59 During the Vietnam War, the technique was utilized at Valley Forge General Hospital, 

the Army’s amputee center at the time, for revision of 

problematic transtibial amputations.60 Deffer, Moll, 

and LaNoue60 reported a case series of 155 patients, 

giving their opinion that the technique allowed more 

reliably successful total-contact fitting in their young, 

active, patient population. In cases of short residual 

limb length, they successfully utilized free autograft, 

iliac crest, and rib to form the bone bridge. Pinto and 

Harris61 advocated the use of a fibular segment to form 

the distal tibiofibular synostosis, noting that approximately 7 cm of tibia must be resected to harvest an 

adequate amount of tibial periosteum. They advocate 

leaving the adjacent viable lateral compartment muscle 

attached, performing a closing wedge osteotomy to 

swing the fibular segment into a slot in the lateral 

tibial cortex, so the healing will more closely approach 

fracture healing.

Although the Ertl procedure has many proponents, 

most of the published literature on the subject consists 

of case series. A recent review of that literature found 

a single controlled outcome study.62 Pinzur and associates62 reported on 32 consecutive patients with 

modified Ertl transtibial amputations for a variety of 

diagnoses, compared to a historical “control” group of 

17 transtibial amputees who had been treated by the 

classic Burgess technique and who were considered to 

be highly functional. A validated outcome instrument, 

the prosthetics evaluation questionnaire, measuring 

“quality of life and functional demands in patients 

with lower extremity amputations,” was administered 

to the Ertl group at an average of 16.3 months and to 

the Burgess group and an average of 14.7 years. The 

Ertl group scored better in ambulation (P = 0.037) and 

frustration (P < 0.001) and lower in appearance (P = 

0.025). The results in the other six domains were similar 

between the two groups. The authors conclude that 

bone-bridging “may enhance patient-perceived functional outcomes.” No randomized or blinded studies 

Figure 9-9. Anterior-posterior radiograph after healing of 

a classic osteomyoplastic transtibial amputation utilizing 

the classic Ertl technique with strips of tibial and fibular 

periosteum. 
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Special Surgical Considerations for the Combat Casualty With Limb Loss

have been performed assessing function or outcomes.

The osteoplastic transtibial amputation technique 

has been performed on a limited number of amputees 

from the current wars in Iraq and Afghanistan. Because 

the current practice is to perform length-preserving 

amputations in the ZOI, fibular instability due to 

rupture of the interosseous membrane is not uncommon. There is a general consensus among military 

orthopaedic surgeons that synostosis is strongly indicated in this clinical situation. A variety of techniques 

have been used, with roughly an even split between 

the closing wedge technique and the use of a free segment of autograft fibula. In the latter case, the segment 

should be relatively short, because a narrower distal 

tibiofibular distance and osteoplasty length is thought 

to maximize osseous stability and be less likely to 

cause a symptomatic osseous prominence. The graft 

can be stabilized via one of several techniques. Often, 

a single 3.5-mm cortical screw is placed through the 

lateral fibular cortex, through the medullary canal of 

the graft segment, and through one or two cortices of 

the tibia (Figure 9-10). The graft can also be secured 

via intraosseous sutures utilizing devices designed for 

anterior cruciate ligament graft or syndesmotic stabilization (Figure 9-11). Alternatively, drill holes can be 

made in both the distal tibia and fibula and the graft 

secured with heavy, nonabsorbable suture in a fashion 

resembling a myodesis (Figure 9-12). 

If available, the periosteum of the anteromedial 

tibia, which is invariably thick and easily raised, is then 

Figure 9-10. Postoperative anterior-posterior radiograph 

demonstrating a distal tibiofibular synostosis in a transtibial 

amputation secured with a 3.5-mm cortical screw.

Figure 9-11. Anterior-posterior radiograph demonstrating a 

healed distal tibiofibular synostosis in a transtibial amputation secured with an intraosseous suture technique. 
168

Care of the Combat Amputee

sutured over the cut end of the tibia and to the lateral 

fibular periosteum. This speeds graft incorporation, 

and extensive remodeling of the synostosis has been 

noted over time, with its distal profile becoming gradually rounded off in both the anteroposterior and lateral 

planes. The authors have not noted any frequent problems with graft incorporation when viable periosteum 

was unavailable, as is the case in most revision cases; 

although nonunions do occasionally develop (Figure 

9-13), they are infrequently symptomatic. Occasionally percutaneous screw removal had to be performed 

when the screw head became prominent due to osseous remodeling. In revision cases without evidence 

of latent infection and in which both fibular autograft 

and tibial periosteum are unavailable without excessive residual limb shortening, use of tricortical iliac 

crest autograft or fibular allograft may be considered. 

Finally, as an alternative source of local autograft, the 

surgeon may perform a partial tibial osteotomy, hinged 

distally and utilizing a segment of lateral tibial cortex 

as graft, while maintaining the overall length of both 

the tibia and fibula. 

The use of the Ertl technique in other clinical situations remains controversial. Because of the risk of 

infection, many surgeons are reluctant to leave a 

devascularized fibular segment or a metal implant 

at the time of delayed primary closure of an amputation through the ZOI. Concern for infection is less in 

revision surgery above the ZOI, such as transtibial 

amputation following failed salvage of severe hindfoot 

injury. The patient with a painful residual limb, who 

on physical examination has pain with manipulation 

of the fibula or progressive splaying of the fibula on 

serial radiographs, may also benefit from synostosis. 

That said, the surgeon must exercise care to identify 

and address other causes of lateral residual limb pain, 

Figure 9-12. Anterior-posterior radiograph demonstrating 

a distal tibiofibular synostosis in a transtibial amputation 

utilizing fibular autograft and tibial periosteum and secured 

with tranosseous heavy, nonabsorbable sutures at both graft 

junctions. Early postoperative remodeling and healing is 

evident in this image obtained 8 weeks postoperatively. 

Figure 9-13. Anterior-posterior radiograph demonstrating a 

nonunion of a distal tibiofibular synostosis at nearly 1 year 

postoperatively. 
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Special Surgical Considerations for the Combat Casualty With Limb Loss

such as peroneal neuroma, or run the risk of a failed 

outcome and persistent symptoms despite the achievement of radiographic synostosis. Because of the lack 

of a convincing body of evidence for the superiority 

of the Ertl over the Burgess technique, synostosis is 

performed on the basis of surgeon preference and 

training. Studies are currently in progress that will examine both subjective and objective results comparing 

the two techniques using outcome instruments such 

as the SF-36, gait analysis, and videofluorscopy of the 

residual limb-prosthesis interface, which may provide 

an evidence-based choice of operative technique.

Much anecdotal advocacy for the Ertl appears on the 

Internet and in the prosthetic business community.63

Several patients have requested that highly functional 

Burgess amputations be revised to Ertls based on this 

promotional material, including patients successfully 

running long distances and playing cutting sports. The 

authors feel these requests are based on limited information, and strongly discourage them. Nonetheless, 

some patients have found civilian surgeons willing to 

revise their residual limbs following retirement from 

active duty.

In summary, the osteomyoplastic transtibial amputation offers the theoretical benefit of allowing distal 

end bearing, and is definitely indicated acutely in cases 

where the interosseous membrane has torn and the 

fibula is unstable. As a revision procedure, it is also 

useful in cases where fibular hypermobility can be 

identified as a pain generator. No strong evidence in 

the literature, however, shows a significant improvement in outcome over amputation without synostosis 

in patients with a stable fibula. Studies are underway 

that may further clarify this controversy. 

MANAGEMENT OF BURNS AND SKIN GRAFTS

Burn-Related Amputations

Burn injuries may occur due to chemical, electrical, or flash fire-type mechanisms.64 Burns sustained 

in combat-related injuries, with or without associated 

amputation, typically result from fires or thermal 

injuries secondary to conventional or improvised 

ordinance and thus fall into the latter category. Burns 

from volatile compounds such as white phosphorus 

or actual chemical weapons fortunately remain absent 

from the present battlefield environment. 

In the present conflicts, approximately 5% of all 

major injuries requiring evacuation from theater have 

been amputations.65 A similar proportion of amputees 

have had concomitant burn injuries, with burns involving the residual limb in nearly 75% of cases. Roughly 

6% of patients requiring burn center treatment were 

amputees, and the proportion of burn patients with 

multiple limb amputations has not been significantly 

different from that of amputees without burns. The 

average burn size has been 40% of total-body surface 

area (TBSA) involved in the burn amputee group, as 

compared to 16% TBSA in the entire burn cohort. 

In contrast to most combat-related amputations, 

which often occur as a direct result of the inciting trauma or during early surgical management, nearly 45% 

of burn-related amputations are ultimately performed 

at the definitive treatment facility due to early (15%) 

or late (30%) burn-related complications. Amputees 

with burn injuries have demonstrated a greater mortality rate (24%) than their nonamputee burn patient 

counterparts (6%). Thus, burns in the combat-injured 

amputee complicate treatment and rehabilitation 

and are associated with higher mortality. Half of the 

amputations were complete in theater, while 6% had 

unreconstructable fractures, and 9% required amputation due to progressive ischemia from required vasopressor support. In the delayed amputation group, 21% 

required amputation due solely to the severity of the 

burn. The remaining 9% had complications of infection 

or nonunion. These rates are in direct contradistinction to the available civilian literature on burn-related 

amputations: the rate of amputations among burn unit 

patients at civilian centers is 1% to 2%, with the vast 

majority of these amputations being performed in 

delayed fashion66 and burns being more likely to result 

in multiple limb amputations.67 Multiple studies have 

demonstrated a survival benefit to amputation in the 

management of severe burn patients.68,69

Initial in-theater management of the combat-related 

burn patient with or without amputation follows basic 

advanced trauma life support and burn protocols. 

Appropriate early and subsequent attention must be 

paid to hypothermia, volume resuscitation, electrolyte 

imbalances, coagulopathy, infection, associated inhalational injuries, and tissue necrosis that may result in 

sepsis or renal failure.

Surgical principles followed for burn amputees are 

similar to those recommended for all combat-related 

amputations, with initial open management and length 

preservation. In the absence of ongoing sepsis and/or 

hypotension requiring vasopressors, which may result 

in additional tissue necrosis and ischemia, tissue viability is generally clinically evident within 4 to 7 days 

following injury.64 This time frame coincides with the 

average arrival time at definitive treatment facilities 

in the present conflicts. Thus, advanced techniques of 

tissue viability assessment, such as nuclear medicine 
170

Care of the Combat Amputee

scans, have not been routinely required in the authors’ 

experience. Amputees with burn injuries require, in 

general, a substantially greater number of operative 

procedures during their initial hospitalization than 

their counterparts without burns. 

Myodesis at the time of definitive treatment is typically performed. One particularly useful technique is 

to utilize extra-long muscle and/or skin flaps to cover 

bone and other structures, preserving length and even 

amputation levels. Even when the entire medial face 

of the tibia was exposed, a carefully designed very 

long posterior flap extending down to the plantar foot 

can preserve a transtibial level (Figure 9-14). Heroic 

attempts to salvage residual limb length or functional 

joint levels are indicated in some instances, particularly in multiple limb burn amputees who otherwise 

would be less likely to achieve independent function 

and ambulation.66 The results of such procedures can 

be extremely gratifying.70 However, flap coverage is 

best performed late, after tissue viability, physiologic 

status, and residual limb wounds have stabilized; flap 

failure has been significantly associated with early 

coverage in burn patients.71 Eventual skin grafting of 

residual limbs is routinely required in most patients 

with burns, and in most cases resulted in a functional 

residual limb72 (Figure 9-15).

Most of the civilian medical literature discussing 

amputations secondary to or associated with burn injuries is limited to case reports or small case series, many 

of which address electrical injuries. There is general 

agreement that amputee rehabilitation and prosthetic 

fitting is complex and frequently delayed secondary 

to additional surgeries, concomitant medical problems, open wounds and wound instability, edema, 

Figure 9-14. Intraoperative photographs of a transtibial amputation with burns of the residual limb. An extra long posterior 

flap was utilized to compensate for inadequate anterior soft tissue coverage, avoiding the need for a skin graft and salvaging 

an extremely functional final residual limb length.

a b
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Special Surgical Considerations for the Combat Casualty With Limb Loss

the need for skin graft maturation, hypertrophic and 

often painful scarring on the residual limb, and joint 

contractures.66,68,72,73 The average time to prosthetic 

fitting of burn amputees in the authors’ experience 

has been over 110 days, or nearly two to three times 

that of most nonburn amputees. Additionally, burn 

amputees who had larger burn surface injuries (> 40% 

TBSA) had a slightly higher average time to prosthetic 

fitting than burn amputees with less involvement. 

Due to lower shear forces placed on the residual limb 

at the skin-prosthesis interface, upper extremity burn 

amputees without rate-limiting concomitant injuries 

may be candidates for accelerated prosthetic fitting, 

training, and rehabilitation.74

Skin Grafts

When practicable, skin grafting of residual limbs 

is best avoided. Although satisfactory results can be 

achieved in most cases with the techniques described, 

concerns about chronic and recurrent complications 

ranging from minor patient discomfort to skin breakdown and ulceration or frank graft failure remain. 

Split-thickness skin grafts (STSGs) placed over terminal residual limbs or directly over bony prominences 

are particularly problematic. Current silicone liners, 

however, have decreased the rate of complications 

associated with skin grafting of the residual limb. In 

patients with adequate residual limb length, modest 

shortening to achieve adequate native myofasciocutaneous coverage is warranted. However, in many cases, 

the need for skin grafting cannot be avoided without 

substantial residual limb shortening or functional joint 

levels. Furthermore, most combat-related amputees 

have soft tissue and/or osseous injuries proximal to 

their residual limb, making shortening or revision to a 

more proximal level an even less appealing alternative. 

When necessary, the authors advocate slightly 

thicker than typical STSGs (12–16 thousands of an inch) 

to maximize final residual limb soft tissue durability. 

With adequate wound bed preparation, including the 

absence of active infection or nonviable tissue and 

evidence of early healing granulation tissue formation, failure of these grafts has not been a problem in 

our experience. However, thicker STSGs may not be 

possible in burn patients with large TBSA involvement, in whom repeat donor site harvest is sometimes 

necessary. 

Full-thickness pinch grafts can be useful to cover 

small areas, particularly over the terminal residual 

limb, but are more prone to early graft necrosis and 

failure than split-thickness grafts; when utilized, fullthickness grafts should be liberally perforated with a 

no. 15 blade in order to prevent seroma or hematoma 

accumulation and subsequent graft separation and 

failure. In patients undergoing skin grafting at the time 

of definitive amputation, skin that would otherwise 

be discarded can sometimes be harvested from the 

terminal limb or revised viable skin flaps. 

Every effort should be made to place grafts over 

viable underlying muscle, both to ensure graft survival and maximize ultimate function via adequate 

soft tissue padding. Grafts placed directly on fascia 

or periosteum, even when “successful,” are frequently 

problematic in the long term. The utilization of creative, atypical myofascial flaps and, occasionally, free 

flaps, is critical to avoid these problems. When such 

flaps are not possible, bioartificial dermal substitutes 

can be useful in restoring soft tissue contour or substituting for the absent native dermis.75,76 Placed in areas 

of exposed tendon or bone or otherwise inadequate 

soft tissue coverage, the grafts should be allowed to 

incorporate and mature with regular dressing changes 

for a period of 10 to 21 days, followed by planned, 

delayed STSG. Grafts can also be layered at 10- to 

14-day intervals in an effort to restore normal surface 

contour to particularly cavitary defects.76 Treatment 

with this method is time consuming and can be costly, 

but the authors have had generally favorable results in 

a few amputees and a number of nonamputee combatinjured service members. 

Myriad conventional graft bolstering techniques 

have been described in civilian settings. However, 

Figure 9-15. Clinical photograph of a healed bilateral transtibial amputee who presented with extensive burns of his 

residual limbs. Relatively long posterior flaps were utilized, 

minimizing the need for split-thickness skin grafting. The 

required skin grafts, which healed uneventfully and functioned well, were not placed over osseous prominences near 

the terminal residual limb, areas of relatively greater direct 

pressure and shear forces.
172

Care of the Combat Amputee

when feasible, the authors advocate placement of 

subatmospheric pressure dressings (VAC; KCI, San 

Antonio, Tex) to cover STSGs for the first 4 to 5 days 

postoperatively. Although military medical treatment 

allows managing these dressings in an inpatient setting 

in most cases, due to associated injuries, ongoing inpatient rehabilitation, or social concerns not often present 

in civilian trauma (as well as the general absence of 

third-party pressure to accelerate discharge), portable 

units are now available for outpatient use. Numerous 

series have demonstrated increased graft survival with 

VAC use compared to conventional techniques.77–79

After initial graft healing, careful transition to 

conventional shrinker compression stocking use can 

be initiated at 2 to 3 weeks postoperatively. A supplemental dressing beneath the shrinker is generally used 

initially to protect the graft and cover peripheral areas 

of ongoing granulation and healing by secondary 

intention. Prosthetic fitting and, in particular, use are 

delayed until more definitive graft maturation has 

occurred. Utilizing this and similar techniques, most 

amputees requiring skin grafting of their residual limbs 

can ultimately be fit with and operate a functional 

prosthesis.72

Late wound problems after skin grafting are best 

managed early and aggressively (albeit nonoperatively) via local wound care, transient activity modification, and prosthetic modification. Problematic grafts 

can often be treated with late excision and primary 

closure with adjacent fasciocutaneous advancement 

after early soft tissue healing and swelling subsidence, 

or concurrently with excision of symptomatic HO 

and salvage of redundant native skin. In other cases, 

catastrophic graft failures following multiple grafting 

attempts or as a result of prosthesis wear, in addition 

to patients chronically dissatisfied with their residual 

limb function or discomfort, may require discussion of 

more aggressive alternatives including tissue expanders, free tissue transfer, or residual limb shortening or 

revision to a more proximal level. 

JOINT CONTRACTURES

Lower Extremity Contracture

Contracture is a potential complication of any amputation including the lower extremity. Although very 

uncommon in traumatic amputees, severe contractures 

may be seen in amputees with neurological injury or 

vascular disease. Significant contracture can challenge 

prosthetic fitting and limit functional return. Contractures may also be associated with decubitus ulcers and 

complicate seating and patient positioning. For these 

reasons, prevention and aggressive management of 

contracture are very important in the rehabilitation of 

war-related amputee care. 

Contractures in amputees are caused by many factors. The resulting change in limb length sometimes 

allows one muscle group to dominate, due to injured, 

inefficient, or absent antagonist muscle groups, leading 

to contracture formation. Such a situation is observed 

in midfoot and hindfoot amputations, when a fixed 

equinus deformity develops because of unopposed 

pull of the gastrocsoleus complex, or in a transtibial 

amputee who developes a knee flexion contracture 

because of excessive pull of the hamstrings. Contractures are often also exacerbated by delayed prosthetic 

fitting and mobility training. In addition, pain can 

often inhibit range of motion of joints and contribute 

to contracture formation. In the hip, problems are often 

encountered with prolonged seating or semirecumbent positioning, with shorter residual limbs being at 

greater risk for contracture development.

The presence of injury proximal to the level of 

amputation may also be a cause of contracture. In the 

transtibial amputee, injury to the knee or the distal 

femur may cause quadriceps scarring, HO, and limited 

motion in flexion, leading to an extension contracture. 

Standing is not impaired, but the limitation of flexion 

makes sitting more difficult in a vehicle and limits 

high-level function such as running. In these situations, 

a quick connecting coupler to the prosthetic limb can 

be a simple solution to facilitate sitting.

The treatment of contracture should be initiated at 

the time of surgical amputation. It is recommended 

that midfoot and hindfoot amputation undergo 

lengthening or tenotomy of the Achilles along with 

preservation or tenodesis of the tibialis anterior and 

the peroneal musculature.80 Similarly, in transfemoral 

amputees, the myodesis of the adductor and hamstring 

in adduction and extension reduces the risk of a hip 

flexion and abduction contracture.81

Following surgery, dressings and patient positioning 

assist in preventing contracture. Hindfoot amputations 

should be splinted in maximal dorsiflexion. Transtibial 

amputees should be instructed to initiate active knee 

extension and range of motion exercises and avoid 

placing pillows under the knee, producing a flexed 

resting posture. The transfemoral amputee should be 

instructed on periodic prone lying, and active hip adduction and extension exercises. For patients unable to 

tolerate or participate in these activities, periodically 

lying completely flat in bed and placing a light sandbag 

on the residual limb to facilitate passive hip extension 

is an effective preventative measure for supine patients. 
173

Special Surgical Considerations for the Combat Casualty With Limb Loss

Rigid dressings for transtibial amputation have been 

advocated not only for maintenance of extension but 

also for edema and pain control.82,83 The use of rigid 

dressings was fairly standard in the treatment of war 

amputees in the Vietnam era. However, in the authors’ 

experience, soft dressings have been very effective 

in the postoperative management of combat-related 

amputations and permit regular wound monitoring. 

In compliant traumatic amputees with appropriate 

therapy, it has been our experience that amputees 

have not developed flexion contractures of the hip or 

knee. Dynamic splinting may be effective in transtibial 

flexion contracture if the tibial segment is long enough 

to allow such a device. Another option is to adapt the 

prosthetic socket in flexion to accommodate the contracture and facilitate mobility and progression with 

rehabilitation.64,84

Generally, surgery is not required in the management of contracture following amputation surgery. 

Appropriate surgical technique at the time of amputation surgery followed by diligent therapy and patient 

instruction will generally prevent this complication. 

In a hindfoot amputation equinus contracture, revision to a transtibial level can be an effective solution. 

Additionally, consideration can be given to converting a transtibial amputation to a through-knee or 

transfemoral level when other means of knee contracture treatment have failed.84,85 However, every 

effort should be made to save the knee, which has 

a significant impact on functional recovery. The 

authors’ experience with knee arthrofibrosis release 

and quadricepsplasty has been generally satisfactory 

in a few young, motivated amputees. Gas-sterilized 

custom sockets with attached shafts can be useful 

intraoperatively to assist in knee manipulation under 

anesthesia after contracture release (Figure 9-16). In 

the hip, contracture up to 25° can be accommodated by 

the socket. In the hip, as in the knee, a surgical release 

is difficult, requiring extensive dissection. In these 

instances, consideration may be given to a femoral 

corrective osteotomy to improve prosthetic function.

Burn amputees with extensive burns on their limbs 

represent a separate category of patients with distinct 

complications.86 When a skin graft is required, contracture develops slowly, often despite appropriate therapy 

and positioning.66,73,87 These contractures may respond 

to plastic procedures to release the scarred skin but 

may also require release of contracted muscle-tendon 

units. When other factors such as very delicate skin 

grafts make prosthetic wear unlikely, such methods 

should be avoided.

All patients with contractures should undergo 

exhaustive conservative attempts to increase motion 

and function prior to considering operative intervention. Postoperatively, amputees undergoing any 

contracture release require early mobilization and 

aggressive physical therapy to maintain and maximize operative gains. Toward this end, indwelling 

regional anesthesia catheters, continuous passive 

motion machines, and static and dynamic splinting 

can be particularly useful. When combined with an 

appropriately motivated patient, satisfactory results 

can be achieved in most cases through nonoperative 

and, in carefully selected patients, operative treatment of contractures. However, it cannot be overemphasized that the primary and most important 

contracture treatment in combat-related amputees 

is prevention. 

Figure 9-16. Intraoperative photographs of manipulation under anesthesia of a transtibial amputee following knee extension contracture release and quadricepsplasty utilizing a sterilized custom socket. Satisfactory motion was achieved and 

maintained postoperatively through aggressive rehabilitation. 

a b
174

Care of the Combat Amputee

Upper Extremity Contracture

Among combat-injured personnel with upper extremity amputations, symptomatic contractures are 

rare. In the absence of additional risk factors, no amputees from the current conflicts have required surgical 

management or significant modification of prosthetic 

devices, to the authors’ knowledge. Exceptions to this 

include burn patients, whose injuries may lead to contractures of the elbows and shoulders, patients with 

concomitant ipsilateral intraarticular elbow fractures, 

and patients developing HO about the elbow adjacent 

to short transradial amputations. 

In the evaluation and treatment of upper extremity 

amputees with contractures, decision-making is determined by the condition and function of the terminal 

limb, the involved joint, and the individual patient’s associated injuries as well as his or her real and perceived 

functional limitations. Consideration for contracture 

release in burn patients with contracted amputations 

should be based on the experience gained in the 

treatment of burn patients without amputations. This 

may involve capsular release, excision of HO, plastic 

management of contracted skin (Z-plasty, expanders, 

and tissue transfer).88–90 Wound-healing complications 

are common and often only modest improvements in 

function are observed. 

When HO is limiting functional motion around the 

elbow, with or without associated fracture, surgical 

excision and release can be undertaken after conservative measures have been exhausted. A waiting period 

of 3 to 6 months is recommended to permit initial HO 

and wound maturation, but longer waiting periods 

are not necessary.10,91–93 Typically, at least this much 

time will transpire while conservative modalities are 

pursued, patients adapt to their new lives as amputees, functional limitations that cannot be overcome or 

compensated for become evident, and most patients 

would even contemplate an additional, elective surgical procedure. The authors advocate standard techniques of scar revision/excision and circumferential 

capsular release with simultaneous HO excision, followed by postoperative radiotherapy and/or NSAIDs, 

with aggressive physical therapy.91–93 Some evidence 

shows that results of elbow contracture release may be 

superior in patients with HO compared to those with 

non-HO posttraumatic fibrosis.94

Symptomatic functional loss of shoulder range of 

motion has not been a frequent problem in the authors’ experience, particularly for amputations distal 

to the elbow. Some patients with short transhumeral 

amputations likely have markedly decreased shoulder 

range of motion secondary to a protracted time course 

of restricted mobility because of multiple surgeries or 

adjacent soft tissue injury. However, this is seldom if 

ever bothersome to the amputee; most transhumeral 

amputees who use functional prostheses seldom 

use them for overhead activities. For amputees with 

symptomatic loss of shoulder motion, we recommend 

standard arthroscopic releases followed by manipulation under anesthesia, soft tissue envelope permitting.95 Patients in whom the shoulder girdle tissues 

are too compromised to permit arthroscopy would 

ostensibly be at dramatically increased risk of wound 

complications if an open procedure were attempted. 

Open release should therefore be reserved for patients 

with a reasonably intact shoulder soft tissue envelope 

and who fail an attempt at arthroscopic release and 

manipulation, due to extraarticular causes (eg, subscapularis contracture).

As with most complications, primary treatment of 

amputation-associated upper extremity contractures is 

prevention via early motion and therapy as soon after 

injury as soft tissue and osseous injuries permit. Unique 

considerations in upper extremity amputation contractures include compromised soft tissue envelopes, 

which may limit soft tissue healing and durability after 

operative treatment; shortened lever arms, which may 

make early passive and active-assisted therapy more 

difficult; and the patient’s desire to return to early 

prosthetic fitting and use after surgery. Postoperatively, 

aggressive physical therapy and early return to regular 

prosthetic use is necessary to maintain operative gains 

and maximize ultimate patient function. Modalities 

such as indwelling postoperative nerve catheters, 

continuous passive motion, and static or dynamic 

splinting remain relatively unproven with regard 

to efficacy but can serve as useful adjunctive rehabilitation measures, particularly for patients in whom 

postoperative pain is too great or motivation too little. 

MARQUARDT HUMERAL OSTEOTOMY

Successful prosthesis use by the unilateral transhumeral amputee is by no means guaranteed, despite 

the availability of the most advanced prosthetic technology and occupational therapy services. Many patients find single-limb strategies for activities of daily 

living preferable to using a transhumeral prosthesis, be 

it body-powered, hybrid, or myoelectric. Additionally, 

many transhumeral amputees who are regular prosthesis users utilize their prostheses only for very specific 

tasks, and may wear their limbs only for an hour or 

two per day, a couple of days per week. Among the 

common reasons cited by patients for low prosthetic 

use are prosthetic weight and limited functional range 

of motion. Many suspension systems utilize shoulder 
175

Special Surgical Considerations for the Combat Casualty With Limb Loss

caps that are hot and uncomfortable and can chafe 

and restrict motion. Likewise, suction suspensions on 

cylindrical residual limbs have limited resistance to 

torque in the axial plane. 

In 1972 Marquardt96 published a case report of a 

pediatric patient utilizing a new technique in which a 

distal angulation osteotomy was performed. He noted 

improved suspension with unrestricted shoulder motion and improved rotational control in flexion and 

abduction, giving a much larger functional range for 

prosthetic use. In 1974 Marquardt and Neff97 published a case series of adults and children who had 

undergone the procedure, noting that, in addition to 

improved motion and control, the incidence of terminal 

overgrowth in pediatric patients was reduced by the 

procedure. With the angulation osteotomy, therefore, 

transhumeral amputation acquired most of the beneficial attributes of elbow disarticulation—without 

the limitations of external-hinge elbow units needed 

to keep relative arm and forearm length normal in the 

disarticulation patient.

The authors have used this technique in selected 

combat-related amputees. The ideal candidate is a 

successful prosthetic user who is dissatisfied with a 

shoulder cap suspension, or who needs greater range 

of motion or improved rotational control for specific 

desired bimanual tasks. Most of these transhumeral 

patients have undergone “length-preserving” amputations closed with nontraditional flaps, and an 

appropriate portion of the initial closure is utilized. 

The procedure is performed as a revision only. The 

risk of placing fixation hardware in these initially 

highly contaminated wounds is considered too high 

to be justified until the wound has declared itself and a 

rehabilitation problem has been identified. Utilizing a 

portion of the wound closure scar, a 5-cm portion of the 

distal humerus is exposed. Concomitant revision procedures such as neuroma or HO excision are performed 

as appropriate. A 70° wedge is then cut anteriorly, 

with the posterior periosteum preserved as a hinge, if 

possible. The osteotomy is then closed and fixed with 

a single 3.5-mm cortical screw placed in compression 

from distal to proximal (Figure 9-17). (This represents a 

deviation from Marquardt’s original technique, which 

was performed through a separate posterolateral incision and fixed from proximal to distal.)

Postoperative management includes edema prevention, initially with figure-of-eight elastic wraps, and 

progressing to a stump shrinker as soon as the patient 

tolerates application. The patient is transitioned to a 

Silastic (Dow Corning Corporation, Midland, Mich) 

liner at about 2 weeks postoperatively. Prosthetic wear 

is resumed after 3 weeks to allow for early osteotomy 

healing. The authors have not encountered any problems with nonunion or loss of fixation by resuming 

Figure 9-17. Anterior-posterior radiograph of a transhumeral 

amputee with a healed Marquardt angulation osteotomy.
176

Care of the Combat Amputee

prosthetic wear early and, in spite of some stress at the 

osteotomy site caused by the prosthesis suspension, 

the prosthetic socket provides some external, bracelike support. An unexpected benefit is that patients 

universally perceive a decrease in the weight of their 

prosthesis (Figure 9-18). We attribute this to the decrease in shear forces on the residual limb soft tissues. 

The weight of the prosthesis appears to be transferred 

to the bone, which is better able to tolerate it than the 

patient’s often compromised soft tissues and skin.

Although the best suspension solution for the transhumeral amputee may be direct skeletal attachment 

(osseointegration), the Marquardt angulation osteotomy is a useful technique for certain patients until the 

difficulties of the prosthesis/skin interface and loosening associated with osseointegration are resolved. 

Figure 9-18. Clinical photographs of a transhumeral amputee demonstrating prosthetic use with improved range of 

motion and prosthesis suspension following a Marquardt 

angulation osteotomy.

a b

KNEE INSTABILITY

The open, length-preserving amputation technique 

advocated in this textbook, with amputation frequently 

carried out through the ZOI, is sometimes associated 

with ligamentous injury to adjacent joints. Two recurrent clinical situations have presented in high-demand 

transtibial amputees that require ligament reconstruction or repair: (1) anterior cruciate ligament (ACL) deficiency and (2) the short residual limb with an unstable 

fibula. Although both can be successfully treated with 

standard surgical techniques, making the correct diagnosis can be challenging. In ACL deficiency, symptoms 

of “giving way” may be masked by problems with 

prosthetic fit, weakness, or gait training. The length 

of the residual limb may make it difficult to perform 

a Lachman maneuver, and make a classic pivot shift 

test nearly impossible to perform. Retained ferrous 

fragments may preclude or obstruct MRI. The symptomatic unstable fibula can be confused with other 

causes of lateral residual limb pain, such as peroneal 

neuroma. Careful physical examination, evidence of 

fibular splaying on plain radiograph, and peroneal 

nerve block in the thigh will assist in the diagnosis.

In the authors’ experience, high-demand transtibial 

patients with ACL-deficient knees have not been satisfied with prosthesis modification, incorporating 

polyaxial hinges in the socket similar to current sports 

braces used to treat ACL-deficient athletes nonoperatively. Single-bundle ACL reconstruction, however, 

has had good results. Allograft bone-tendon-bone, 

Achilles, or tibialis posterior tendons are preferable in 

reconstructing the ACL-deficient knee in the transtibial 

amputee, rather than using autograft bone-tendonbone or semitendinosis/gracilis from the ipsilateral 

or contralateral knee. Both lower extremities have 

frequently been severely injured, and the slight delay 

in incorporation of allograft outweighs the additional 

insult of autograft harvest. These patients are fitted 

with hinged, double-upright socket extensions fab-
177

Special Surgical Considerations for the Combat Casualty With Limb Loss

ricated by prosthetists to protect the reconstruction 

for 12 weeks postoperatively, allowing early return to 

prosthetic use. Full weight bearing without ambulatory aides is allowed at 12 weeks, and running and 

cutting activities are permitted when the quadriceps 

and hamstrings are within 85% of the contralateral 

side by Biodex (Biodex Medical Systems, Shirley, NY) 

testing, usually at about 5 to 6 months.

Patients with extremely short transtibial amputations have achieved high-level functioning: many with 

amputations 2 or 3 cm distal to the tibial tubercle are 

runners, and several patients with these short transtibial amputations who have a contralateral transfemoral amputation are able to run and play cutting 

sports. The function achieved by these young men 

and women defies conventional wisdom, and speaks 

volumes about their courage and tenacity.

Some patients with short transtibial amputations, 

however, have painful, unstable residual fibulas. Frequently, this can be elucidated on physical examination or on plain radiographs. A residual fibula shorter 

than 5 cm should raise the suspicion that insufficient 

interosseous membrane remains for fibular stability. 

Patients with longer residual limbs who have fibular 

instability can be treated with revision to an Ertl-style 

amputation with a synostosis between the distal tibia 

and fibula, but this technique is not easily done in patients with short residual limbs. These patients respond 

well to fibular excision with repair of the posterolateral 

corner. In this procedure, the lateral collateral ligament 

(LCL) and biceps femoris tendon insertion are elevated 

as a sleeve and fixed to the lateral tibia with a screw 

and washer at the tibial facet of the proximal tibialfibular joint, after excision of the articular cartilage. The 

repair is protected for 6 weeks with a custom clamshell 

brace before range of motion and active strengthening 

against resistance are resumed.

If fibulectomy of a very short residual fibula is 

performed early in a patient’s postinjury treatment to 

facilitate soft tissue closure and prosthetic fitting, the 

authors advocate securing the released biceps tendon 

and LCL to the isometric point on the residual tibia 

with periosteal sutures, suture anchors, or drill holes 

through bone. However, several early patients in 

whom this was not performed have not experienced 

symptomatic instability as a result. For amputees presenting with late LCL/posterolateral corner instability 

after early fibulectomy, allograft reconstruction using 

conventional techniques, securing the graft to the residual tibia via a biotendodesis screw, is a reasonable 

approach. 

Elbow or shoulder instability above transradial 

or transhumeral amputations has not been a common problem in upper extremity amputees. Stiffness 

of these joints is a more common complaint, due to 

adjacent fractures, frequent proximate soft tissue 

injury, and the difficulty of performing early range 

of motion exercises above an often open or otherwise 

compromised residual limb. However, in the event 

that these issues are encountered, standard open and 

arthroscopic-assisted reconstructive techniques would 

be indicated.

INFECTION

Despite aggressive medical and surgical care (including serial debridements, judicious use of antibiotics, and local wound adjuvant therapies), as many as 

20% to 40% of combat-injured amputees may develop 

deep infection requiring inpatient care or surgery following attempted definitive revision and closure.10,98,99

Specific recommendations on point-of-injury care, antibiotic therapy, serial debridements, and the timing and 

technique of definitive closure for infection prevention 

are discussed in Chapter 8, General Surgical Principles 

for the Combat Casualty With Limb Loss. Additionally, 

combat casualties frequently become malnourished in 

the postinjury setting because of limited oral intake 

and high metabolic demands. Nutrition has been 

repeatedly demonstrated to play a critical role in the 

wound-healing potential and immunocompetence of 

diabetic and dysvascular amputees,100 and the importance of adequate and supplemental nutrition cannot 

be overemphasized in the care of combat-injured 

personnel as well.

Given the demonstrated high incidence of early 

and/or late infectious complications in combat-related 

and traumatic amputations, appropriate counseling 

on patient expectations is critical. The probability 

and likelihood of infection requiring further antibiotic 

and/or operative treatment should be discussed with 

patients and families before an infection develops so 

that the psychological and physical setback of an infection, should one develop, is preemptively tempered. 

Similar to the portrayal of the amputation itself as a 

reconstructive procedure (rather than an ablative procedure or necessarily a failure of salvage treatment), 

viewing infection in this setting as an unfortunate but 

frequently necessary step in the rehabilitative process 

can prevent both patient and clinician from becoming 

unnecessarily discouraged. 

Once an infection develops, important treatment 

information can be inferred from both the timing 

and apparent chronicity of the process. Infections in 

residual limbs should thus be classified as early (< 6 
178

Care of the Combat Amputee

weeks from closure) or late, and further classified as 

acute or chronic. The latter distinction is influenced 

by the duration and type of symptoms or a history of 

prior infection with the same organism, and frequently 

this determination cannot be made until after the initial 

operative debridement permits direct inspection of 

deep tissues and operative cultures. Acute infections 

typically present with more fulminant collections 

of purulence and wound drainage, whereas chronic 

infections are generally less virulent and may involve 

well-formed abscesses or slow, gradual destruction of 

deep tissues or bone. Early infections typically result 

from bacteria already present and active within the 

residual limb at the time of definitive closure. Late 

infections may result from reactivation of a latent 

process dormant in the deep tissues for long periods, 

hematogenous seeding of persistent or new fluid 

collections, or extension of cutaneous infections aggravated by prosthetic wear (eg, cellulitis or folliculitis). Most early infections are acute and most chronic 

infections are late, but this is not always the case. The 

timing and chronicity of the infection, as well as the 

virulence and antibiotic susceptibility of the organism 

or organisms, are important in determining the need 

for operative irrigation and debridement, as well as 

the duration and type of antibiotic therapy. All types 

of residual limb infections may require one or more 

operative debridements, but relatively shorter durations of antibiotic therapy are typically required for 

early, acute infections. 

The history and physical examination of a patient 

with an infected residual limb should include reassessment of mechanism and ZOI, history of prior infections, chronologic relationship with wound closure 

and prosthetic use, and systemic symptoms, as well 

as recent exposures, procedures, and antibiotic use. 

In the authors’ experience, most patients with early 

or acute infections present with a febrile history, but 

(as is the case in chronic osteomyelitis)101 fever is less 

reliably present in late, chronic infections. Patients with 

focal pain and swelling and symptoms associated with 

a recent change in activity or prosthesis should have 

bursitis included in their differential diagnosis. This 

distinction is important because the treatment of bursitis, particularly aseptic bursitis (discussed in greater 

detail in the following section), differs substantially 

from that for abscesses and deep wound infections. 

When infection is present, most patients present 

with an erythematous, swollen, and painful residual 

limb, with difficulty or inability to tolerate prosthesis 

wear. The presence or history of a draining sinus 

should be noted and is strongly suggestive of chronic 

deep infection (Figure 9-19). Likewise, the presence, 

quantity, and quality of recent incisional wound drainage should be assessed and noted (Figure 9-20). Any 

palpable fluid collections should be assessed for size, 

location, tenderness, transillumination, and fluctuance. 

Routine culture of sinus tracts or draining incisions is 

not advocated because the results of these cultures are 

frequently polymicrobial and unreliably indicative of 

the actual infecting organism.101,102 If complete evaluation (including laboratory values and imaging studies) 

is strongly suggestive of infection versus bursitis, bedside aspiration of small palpable fluid collections under 

sterile conditions is reasonable in the rare instance that 

this may obviate the need for operative intervention; 

however, in most cases abscesses should be treated 

surgically, and multiple operative tissue cultures are 

preferred to bedside aspirates even under optimal 

circumstances.

All patients should undergo laboratory evaluation consisting, at a minimum, of blood cultures, 

complete blood count with manual cell differential, 

and inflammatory parameter (Westergren erythrocyte sedimentation rate and C-reactive protein level) 

assessment. Orthogonal radiographs of the residual 

limb should be obtained with particular attention to 

soft tissue swelling, osseous changes or new interval 

bone destruction, and HO. Although the relationship 

Figure 9-19. Clinical photograph of a transtibial amputation 

complicated by superficial skin necrosis, eschar formation, 

and a large draining sinus that probed to bone. The limb was 

salvaged with serial irrigation, debridements, and vacuumassisted closure dressing changes followed by delayed 

split-thickness skin grafting after the excised sinus tract had 

granulated appropriately.
179

Special Surgical Considerations for the Combat Casualty With Limb Loss

with infection remains unclear, a high percentage of 

resected HO specimens from combat-related amputations are culture-positive.10,102 Advanced imaging 

modalities are not frequently required, but in patients 

with equivocal findings, MRI, ultrasound, and indium111 tagged white blood cell scans can provide useful 

information.13,103–105 Isolated technetium-99 three-phase 

bone scans can remain positive for a prolonged period 

following revision and closure and may never return to 

normal in residual limbs due to osseous stress reactions 

from prosthesis wear,103 and therefore are generally less 

helpful in the absence of a paired indium scan.104,105 

Most residual limb infections should be initially 

managed with hospital admission. For patients without abscess, fluid collection, or overt wound drainage 

or draining sinuses, initial treatment should consist 

of parenteral antibiotics, elevation, adjacent joint and 

complete prosthetic rest, and continued use of compressive shrinker stockings. Operative intervention 

should be withheld pending failure to appropriately 

respond to these conservative measures. Toward this 

end, patients should be kept non per os (NPO) after 

midnight for the first 1 or 2 days of admission pending treatment response. This can assist in expediting 

operative treatment when required, and patients 

responding appropriately can resume a normal diet 

without missing any meals following reassessment on 

early morning rounds. 

Patients with active drainage or fluid collections 

generally require early operative exploration with 

formal tissue cultures and thorough irrigation and 

debridement. In these instances, to maximize culture 

accuracy and yield, empiric antibiotic therapy should 

be withheld until operative tissue cultures are obtained. When possible, prior surgical incisions and 

scars should be utilized, but draining sinuses should 

be excised and some superficial abscesses distant from 

other incisions are best managed with a direct longitudinal approach, local anatomy permitting. All purulent 

material and nonviable tissue should be removed and 

the wound should be thoroughly irrigated. Mixed data 

regarding the efficacy of gravity, bulb syringe, and 

pulsatile lavage irrigation preclude a recommendation 

of a specific irrigation technique,106–108 which remains 

a matter of surgeon preference. 

Although some patients can be adequately treated 

with a single irrigation and debridement, closure over 

a surgical drain, and subsequent systemic antibiotic 

therapy, the authors prefer a staged approach for most 

patients. Wounds should be managed in a provisional 

closure or open fashion, and a return to the operating 

room for a second look planned. This is performed 2 or 

3 days following the initial procedure and permits reassessment of compromised tissue and overall wound 

status after operative culture speciation and antibiotic 

susceptibilities have been completed, permitting appropriately tailored subsequent antibiotic therapy. 

Consultation with an infectious disease specialist is 

helpful in deciding which antibiotic to use, as well as 

in determining duration of therapy and monitoring 

for side effects of antibiotic treatment. Patients who 

are systemically ill or have locally aggressive infections may require early return to the operating suite 

within 24 hours. Likewise, patients with ongoing tissue destruction on repeat irrigation and debridement 

may require further serial irrigation and debridement 

procedures until the infection is controlled.

In addition to narrowing the antibiotic spectrum 

while avoiding undertreatment of resistant organisms, a staged approach to infection management 

may also allow for judiciously less aggressive initial 

debridement in patients with marginal soft tissue 

coverage or preexisting suboptimal residual limb 

length. As a general rule, patients and limbs are best 

served with eradication of infection via aggressive 

debridement. In rare instances substantial shortening 

of the residual limb or even revision to a higher level 

may be required to both control infection and permit 

reconstruction of an adequate soft tissue envelope to 

allow high-demand prosthetic use. Issues of possible 

limb shortening should be carefully discussed with 

the patient preoperatively. 

Figure 9-20. Intraoperative photograph of a bilateral transtibial amputee with a deep infection of the right residual 

limb. Abundant purulence and necrotic tissue is present 

along the incision line, which dehisced following intraoperative suture removal. The infection was eradicated with two 

irrigation and debridement procedures with concomitant 

antibiotic-bead and vacuum-assisted closure dressing use 

followed by closure over a drain and 2 weeks of parenteral 

antibiotic therapy. 
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Care of the Combat Amputee

A number of local wound adjuncts are available to 

assist in the staged management of infected residual 

limbs. Developed in World War I, Dakin moist-to-dry 

dressing changes are useful for provisional wound 

management in patients with superficial wounds 

and others able to tolerate frequent bedside dressing 

changes. The solution has strong antimicrobial properties without excessive untoward effects on healthy 

patient tissues, and has been used to good effect in both 

recent and historical combat-related wounds.109,110 In 

some cases of small, superficial abscesses, healing by 

secondary intention with serial Dakin dressing changes 

is a reasonable course of action. Subatmospheric pressure VAC dressings encourage vascular ingrowth and 

granulation tissue formation while removing excess 

fluid from the wound, reducing soft tissue edema, 

and preventing excessive soft tissue retraction. These 

devices also obviate the need for frequent dressing 

changes and have been utilized with good temporizing and, in some cases, definitive wound management 

results in both the authors’ experience and in the recent 

open fracture literature.111–113

Antibiotic-impregnated polymethylmethacrylate 

beads achieve supratherapeutic bacteriocidal local 

antibiotic concentrations with minimal systemic effects and have been utilized with good success in 

both arthroplasty and fracture-related infections.114–116

The beads may be placed deep to VAC dressings, in 

open wounds under an occlusive dressing, or inside 

provisionally closed residual limbs. A relatively large 

number of heat-stable antibiotics have been utilized 

successfully with bone cement, allowing microbespecific local therapy. Finally, silver-impregnated antimicrobial dressings may be utilized alone or in combination with the aforementioned techniques. These 

dressings have been repeatedly demonstrated to have 

good local antimicrobial properties,117,118 but reports 

of their use are lacking in the orthopaedic literature. 

In the authors’ experience, antibiotic-bead–associated 

exudate and silver residue may need to be irrigated 

from the wound at the time of the repeat procedure 

prior to wound assessment. Each of these modalities, 

used appropriately, may putatively assist in the local 

control of infection in residual limbs. Although useful in infection control, they should not be viewed as 

a substitute for adequate debridement, voluminous 

irrigation, and systemic antimicrobial therapy. 

Regardless of the adjuvant wound treatments used, 

it is prudent to provisionally tag critical structures (eg, 

released myodesis tendons, skin, and muscle flaps) 

with monofilament suture and secure them near their 

intended final locations between staged infection 

control procedures. This prevents excessive retraction, 

fibrosis, and scarring, which may make definitive 

revision and closure of the infected residual limb difficult or impossible days or weeks later. Maintaining 

as much residual limb length as practical following 

infection treatment is desirable, but when necessary, 

freshening the terminal bone end with an oscillating 

saw and redrilling myodesis holes is useful in achieving satisfactory coverage and closure. Skin closure of 

previously infected wounds should be performed with 

nonabsorbable monofilament suture over a closed suction drain and a compressive dressing applied. Drains 

should be left in place for 1 to 3 days depending on 

quantity and quality of output and then removed at 

the bedside. Dressings should be changed daily starting on postoperative day 2, and wound status closely 

monitored for evidence of recurrent infection. Patients 

should be transitioned back to compressive shrinker 

stockings as soon as wound drainage, patient comfort, and edema permit. Sutures should be removed 

at 2 to 3 weeks postoperatively, after adequate initial 

wound healing has been achieved and infection-related 

swelling has subsided. Patients can then be allowed to 

gradually resume prosthetic fitting, wear, and rehabilitation. Close clinical follow-up is required for several 

weeks up to and after the completion of systemic antibiotic therapy to monitor for recurrence of infection. 

As noted, the duration, type, and route of long-term 

antibiotic therapy are best determined in consultation 

with an infectious disease specialist. 

BURSITIS

Bursitis is a common and likely underreported problem in the residual limbs of amputees with functional 

pain, especially that which waxes with prolonged 

prosthetic use and wanes with subsequent rest.13,119 It 

can be a disabling and recalcitrant problem in residual 

limbs, and its treatment can be a matter of great frustration for patient, prosthetist, and physician alike. 

By definition, synovial (or true) bursae are formed in 

utero over tendinous or osseous areas of friction or 

dissimilar motion. In contrast, adventitious bursae 

develop postnatally within superficial connective tissues in response to chronic pressure, irritation, and 

friction. This latter group accounts for the majority of 

bursae within residual limbs. When these bursae are 

serially exposed to external stresses that exceed the 

physiologic tolerance of the involved tissues, they may 

become inflamed and bursitis results. In the residual 

limbs of amputees, the majority of symptomatic lesions 

develop in the subcutaneous tissues, but deep bursitis 

can develop between a patient’s myodesis and the 
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Special Surgical Considerations for the Combat Casualty With Limb Loss

adjacent terminal bone end as well. 

Fluid collections are exceedingly common in the 

early postoperative period following elective amputation or definitive revision and closure of open residual 

limbs.120 The majority of these collections undergo 

biologic resorption and resolve spontaneously. Prior 

to initiation of regular prosthetic training and rehabilitation, these perioperative collections are unlikely 

to represent bursae and should be considered hematomas, seromas, or abscesses until proven otherwise. 

After initial prosthetic fitting and rehabilitation have 

commenced, a bursa may develop under any area of 

increased friction or pressure within or near the edge 

of the prosthetic socket. 

Treatment of bursitis begins with prevention. Amputation and wound closure techniques are discussed 

elsewhere and are therefore beyond the scope of this 

section. However, bursitis may develop due to either 

inadequate or redundant mobile soft tissue coverage of a terminal residual limb or bony prominence. 

Hence, both should be avoided. Likewise, problems 

with prosthetic alignment, fitting, padding, or suspension may incite or aggravate bursitis and require due 

diligence on the part of both patient and prosthetist 

to avoid inadequate prosthetic modifications. Once 

formed, asymptomatic bursae should be considered 

part of a normal adaptive physiologic response and do 

not necessarily require treatment, but socket and liner 

modifications may be considered to reduce friction in 

these areas and decrease the potential for bursitis to 

subsequently develop.

Potential conundrums in bursitis management begin with the frequently difficult diagnosis. The chief 

differential diagnoses in symptomatic patients include 

aseptic bursitis, septic bursitis, abscess, and cellulitis. 

Aseptic bursitis is thus notoriously difficult to distinguish from infection.121–123 The medical history should 

include focused questioning about recent changes in 

activity or wear of the prosthesis or to the prosthesis 

or liner itself. The duration of symptoms, presence of 

any constitutional symptoms or fever, and relationship 

of these to prosthetic wear should be elucidated. 

On physical examination, the degree of tenderness, 

fluctuance, erythema, transillumination, and relative 

cutaneous warmth122 of the affected site can be helpful in distinguishing aseptic, mechanical bursitis from 

septic bursitis or abscesses. A complete blood count 

with manual cell differential and inflammatory parameters may provide reassurance on the diagnosis of 

aseptic bursitis or, conversely, guide more aggressive 

diagnostic and therapeutic modalities for a probable 

infectious process. Orthogonal radiographs of the 

residual limb should be obtained, with attention to 

cystic degeneration of bone, bone spurs, or HO deep 

to the symptomatic bursa. Advanced imaging modalities (including ultrasound, MRI, and technetium-99 

bone scans) have been advocated.13,119 However, the 

appreciation of a fluid collection with adjacent edema 

is expected, and reciprocal osseous changes may occur in the absence of a septic process; therefore, the 

utility of these studies in cases of suspected bursitis 

is limited in the absence of a florid deep infection or 

overt osteomyelitis. 

Diagnostic or therapeutic aspiration should be 

performed only if sufficient clinical suspicion of 

septic bursitis or abscess persists following the initial 

evaluation. There is little evidence that aseptic bursitis 

outcomes are improved with aspiration alone, and 

the potential exists for cutaneous fistula formation 

or bacterial contamination and creation of iatrogenic 

septic bursitis. Aspiration should therefore not precede more conservative measures in aseptic bursitis 

patients. At minimum, Gram stain, bacterial cultures, 

and cell count with differential should be sent from 

any aspirate.123,124 If adequate fluid is obtained, additional studies worthy of consideration include 

aspirate protein, glucose, and lactate dehydrogenase, 

with corresponding serum levels. Confirmed cases 

of septic bursitis or abscess should be managed with 

empiric and subsequently culture-specific antibiotics. 

The determination of initial intravenous versus oral 

treatment is predicated upon the severity of the infection and the patient’s clinical status. However, when 

in doubt, initial intravenous therapy with conversion 

to oral treatment following a positive clinical response 

is reasonable. The decision to proceed to the operating 

suite for formal irrigation and debridement of septic 

bursitis depends on the adequacy of the aspiration 

and the initial response to antibiotic treatment. Frank 

abscesses generally require operative intervention for 

adequate treatment and evacuation. 

For cases of suspected aseptic bursitis, initial treatment is conservative and should generally not include 

antibiotic therapy. Although complete resolution of 

inflammation and symptoms may require a prolonged 

period, failure to see tangible early and stepwise improvement within a few days should alert the clinician to a possible underlying infectious process and 

prompt further evaluation. Conservative treatment 

should consist of complete prosthetic rest and the required activity modifications, continued compression 

stocking wear, elevation, ice, and nonsteroidal antiinflammatory medication. Concurrently, investigation 

should continue in an effort to identify and modify any 

prosthesis- or activity-related inciting factors. Failure 

to do so will result in probable and predictable future 

recurrence of bursitis. Toward this end, particular 

attention should be paid to relieving pressure and 
182

Care of the Combat Amputee

friction over the involved area and prevention of limb 

pistoning. As symptoms become quiescent, prosthetic 

wear may gradually be resumed. 

For patients with recurrent or refractory aseptic 

bursitis, further treatment is required. Invasive treatment should be considered only after repeated and 

exhaustive efforts at prosthetic modification have been 

completed. Although the results of injection or operative treatment of bursitis are frequently gratifying, the 

potential complications can be disastrous.121,123–126 The 

success of aspiration in aseptic bursitis has been demonstrated only when utilized concurrently with other 

conservative measures,123 and only anecdotally noted 

in amputees.119 Conversely, corticosteroid injection, 

while found effective in a small randomized trial of 

olecranon bursitis patients,125 may result in atrophy 

of overlying fat and soft tissue, which is particularly 

undesirable in amputees with suboptimal soft tissue 

coverage. Steroid injection is therefore advocated 

only in patients with a robust soft tissue envelope, 

and simple aspiration should be the initial invasive 

treatment of others. Complications of aspiration and 

injection include tissue atrophy, iatrogenic infection, 

needle track fistulas, and recurrence of bursitis. 

Operative treatment of aseptic bursitis is even more 

contentious. The difficulties in treating nonamputees 

with more typical olecranon and prepatellar bursitis 

have been well documented. Amputees must eventually resume prosthetic wear and, in spite of the benefit 

of prosthetic modifications, place direct pressure and/

or shear on their previously symptomatic sites. This 

complicates treatment further and may predispose 

amputees to recurrences in spite of initially successful treatment. Therefore, the authors do not advocate 

surgical bursectomy for aseptic bursitis in the absence 

of concurrently modifiable external (eg, prosthesis or 

activity) or internal (eg, bone spur or HO excision) factors. Regardless of operative technique, completeness 

of excision, and avoidance of complications, failure to 

identify and address these factors will reliably lead to 

early symptomatic recurrence.121

Once operative drainage and bursectomy are considered, a preoperative plan should be formulated 

accounting for the location of the bursitis, the patient’s 

soft tissue envelope, and preexisting surgical incisions, 

scars, and skin grafts. In contrast to abscess drainage, 

incisions directly over the involved bursa are illadvised. Such incisions violate already compromised 

soft tissue in an area of known chronic irritation and 

stress, and may be more prone to chronic drainage as 

well. Therefore, the patient’s prior incisions should 

be utilized when practicable, avoiding skin grafts 

and flaps if possible. If the local anatomy renders this 

approach infeasible, a longitudinal incision adjacent 

to, but not immediately overlying, the involved bursa 

is recommended. A complete bursectomy should be 

performed without causing undue damage to uninvolved tissue, and the use of a surgical drain strongly 

considered. Using these techniques in nonamputees, 

most authors report favorable results in over 90% of 

patients,123,124,126 but wound drainage problems and 

recurrences in up to 27% and 22% of patients, respectively, have been reported.121 Endoscopic bursectomy 

has been reported with limited favorable results but 

cannot be advocated for routine use in amputees on 

the basis of the available evidence.127

SKIN PROBLEMS

The traumatic amputee who becomes a successful 

prosthesis user is likely to face lifelong challenges at the 

skin-prosthesis interface. The skin is subject to many 

stresses and factors unique to an enclosed and superficial environment. Modern socket liners and suspension 

have made tremendous progress toward eliminating 

many of these challenges. However, the surgeon is occasionally called to address issues ranging from wound 

healing to infections, and even flap failure early in the 

rehabilitation process. Late sequelae can also occur, 

such as verrucous hyperplasia, epidermoid cysts or 

suture abscesses, contact dermatitis, chronic drainage, 

and even the unlikely development of squamous cell 

carcinoma after many years of draining sinus tracts or 

chronic irritation from the prosthetic socket.128 Most of 

these conditions, and even more transient problems 

like hyperhidrosis, terminal limb edema, callus formation, folliculitis, hidradenitis, and fungal infections, can 

be successfully managed nonsurgically by a skilled 

team including the therapist, prosthetist, physiatrist, 

dermatologist, and surgeon.

When the combat amputee eventually undergoes 

definitive wound closure, it is nearly universal to experience terminal edema. While routine management 

includes carefully applied dressings and subsequent 

shrinker appliances, this edema generally resolves 

once the patient begins socket wear. Whenever a socket 

is removed for prolonged periods of time edema can 

return and must be managed accordingly. Over the 

first several months edema generally stabilizes to a 

steady state and rarely requires treatment. Similarly 

with socket wear, issues like hyperhidrosis and maceration improve with hygiene, stump sock use, and, 

infrequently, topical application of drying materials. 

The treating physician should regularly monitor for 

fungal infections or contact dermatitis associated with 
183

Special Surgical Considerations for the Combat Casualty With Limb Loss

chronic maceration or reaction to chemicals associated 

with socket manufacture. 

Another condition often associated with prosthetic 

fit, underlying vascular injury, or chronic bacterial 

infection is verrucous hyperplasia (Figure 9-21). Verrucous hyperplasia, in keeping with its nomenclature, 

has a wart-like appearance, often in areas of limited 

socket contact. While the condition poses superficial 

hygienic challenges, and pain when associated with 

skin breakdown, it is best managed with shrinker 

socks, or socket modification that equalizes the contact 

pressures throughout the limb.

Chronic conditions that often require surgical intervention are not common. One such condition is an 

epidermoid cyst, a pocket or invagination of keratinproducing cells, either as a result of overgrowth at the 

margin of the original amputation incision, or from the 

original wound closure. These cysts present as localized masses, intermittently draining or painful, and 

should be excised when recurrent.

Another condition, related to chronic recurring 

draining fistulae or sinus tracts but reported in amputees with recurrent skin breakdown, is squamous cell 

carcinoma or Marjolin’s ulcer. This condition typically 

presents years or decades after the original trauma, 

and is always heralded by a new-onset painful, often 

malodorous, ulceration at the site of a recurrent sinus 

tract.

Finally, many combat amputees lack adequate soft 

tissue coverage to permit closure of native myofascial 

layers and skin over their terminal residual limbs. 

Techniques to avoid this problem, including lengthpreserving initial amputation, subatmospheric pressure dressing use, skin traction, and creative skin 

flap creation, were discussed earlier. Nonetheless, 

some patients require split-thickness skin grafting to 

achieve definitive closure and coverage. Particularly 

in the lower limb, these grafts may not physiologically withstand high-demand prosthesis use (Figure 

9-22). For this reason, somewhat thicker than typical 

split-thickness skin grafts are advocated. Although the 

treatment process is lengthened by this intervention 

and the authors have only anecdotal experience in 

amputees, in cases of profoundly deficient subcutaneous tissue, dermal substitutes, commonly utilized 

in burn patients, can be a useful means to achieving 

an increased thickness of collagenous tissue between 

prosthesis liner, skin, and bone.75 Patients experiencing 

recurrent breakdown of necessary skin grafts are best 

managed with a truly exhaustive series of conservative measures, including activity, liner, and prosthesis 

modification. In rare instances, edema subsidence or 

underlying HO excision may permit delayed skin graft 

excision and closure with native skin. Some patients, 

particularly transfemoral amputees with relatively 

Figure 9-22. Clinical photograph of a transtibial amputee 

with recurrent skin breakdown of a terminal split-thickness 

skin graft complicated by underlying heterotopic ossification.

Figure 9-21. Verrucous hyperplasia in a 22-year-old soldier, 

18 months after definitive prosthesis. Note the maceration 

and fissuring within the invaginations.
184

Care of the Combat Amputee

more adjacent soft tissue, may benefit from plastic 

surgery consultation and tissue expander use. However, most cases requiring operative treatment will 

ultimately require free tissue transfer, residual limb 

shortening, or even revision to a higher level. 

Skin conditions are common and require awareness 

and management with a multidisciplinary approach. 

Although the majority of these conditions can be successfully managed without surgery, the surgeon may 

encounter them in the normal postoperative phase 

and must be prepared to recognize them to direct appropriate management.

CONCLUSION

The surgical management of the combat-related amputee, and amputations in general, remains an elusive 

and constantly evolving art and science. This chapter 

and the previous one represent a summary of both 

the best available published evidence on specific techniques and the sum of the authors’ combined clinical 

experiences in managing hundreds of amputees from 

the current conflicts in the global war on terrorism. 

Although specific techniques, such as osseointegration 

and target nerve transfer or reinnervation, as well as 

the development of newer and better modern prosthetics, may alter the art of amputation management 

in future years and conflicts, the general principles 

described are intended to guide the treating surgeon 

in making the best operative (and nonoperative) treatment decisions possible for each uniquely complex 

case and patient. Adherence to these often timeless 

and proven techniques and principles, coupled with 

creative thinking, a current knowledge of the available 

literature, and frequent consultation with experienced 

peers, will help to ensure the optimal results for both 

surgeon and patient. 

Acknowledgment

The authors gratefully acknowledge Donald A. Gajewski, MD, LTC, for his contributions to this chapter.

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