Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XXI: Amputations
United States Department of Defense
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The open circular amputation, as described below, is the most acceptable type for combat conditions:
1. A circumferential incision is made through the skin and deep fascia at the lowest viable level. This layer is allowed to retract without further dissection (Figure 27A).
2. The muscle bundles exposed are then divided circumferentially at the new proximal level of retracted skin edge The incised muscle bundles will promptly retract, proximally exposing the bone beneath (Figure 27B).
3. The soft tissues are then manually retracted proximally to facilitate bone transection at a still higher level (Figure 27C). Periosteum should not be stripped. This technique has the appearance of a cone with the apex directed proximally.
4. The blood vessels are divided between clamps and are ligated as they are encountered. In addition, a transfixing suture is added to the cuff of large arteries. The artery supplying the sciatic nerve may require separate ligation. Temporary pressure, bone wax or thromboplastin is applied to the open medullary cavities of large bones to control oozing when necessary.
5. Major nerves are transected 2-3 inches above the amputation at the highest possible level without resorting to traction. Nerve stumps are neither ligated nor injected with alcohol or other chemical agents, but may be injected with a long-acting local anesthesic agent to reduce pain during the postoperative recovery period.
6. Since the amputation has been performed because of irreparable damage to a contaminated, if not grossly septic, extremity, the stump is never closed primarily.
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