The gauze sponges are removed, and all bleeding points are clamped. Only those on the proximal side are tied, while the clamps on the distal side, which are to be removed, may be left in place. A circular incision is made through the periosteum of the femur (Figure 7), and the periosteum is pushed downward only for several centimeters with a periosteum elevator (Figure 8). During this procedure, the muscle of the upper flap may be retracted upward by means of a sterile towel or bandage placed over the muscle surface. Retraction and covering of the muscle are maintained while the femur is divided with a saw at the desired level (Figure 9). The amputated part is removed from the surgical field.
The sharp margins of the bone at the site of amputation are beveled off with a rongeur or rasp (Figure 10). If a tourniquet has been used, it is now removed, and any additional bleeding points are clamped and tied. The muscle surface is washed with warm isotonic saline until the surgeon is assured that there is good hemostasis and all bone fragments are washed away. Hip flexion is avoided during the surgical procedure, because if the hip is flexed when the distal portion of the wound is sutured, there is a tendency for the soft tissue to hold the hip in flexion.
The deep investing fascia to the muscles in the anterior and posterior flaps is approximated with interrupted sutures over the end of the femur (Figure 11). After all dead space has been obliterated by the careful approximation of the muscle layers, the fascia over the muscles in the anterior and posterior flaps is approximated with interrupted absorbable sutures (Figure 11). With adequate hemostasis drainage should be unnecessary, but if serious infection existed distal to the site of amputation, it may be advisable to institute drainage. A closed-system Silastic suction catheter may be placed at the base of the flaps, and the muscles may be closed over it. If a guillotine type of amputation was carried out, the wound is left open to be closed later in a delayed manner, or the limb may be reamputated at a higher level to permit primary closure.