Full length article| Volume 48, ISSUE 2, P364-370, February 2017

Complications and revision amputation following trauma-related lower limb loss

Published:November 18, 2016DOI:



      Trauma-related amputations are a common cause of limb loss in the United States. Despite the military and public health impact of trauma-related amputations, distributions of various lower limb amputations and the relative frequency of complications and revision amputations have not been well described. We used the National Trauma Data Bank (NTDB) in order to investigate the epidemiology of trauma-related lower extremity amputations among civilians in U.S. trauma centers.

      Materials and methods

      We conducted a secondary data analysis of the 2011–2012 NTDB research data sets, using means and frequencies to characterize the patient population and describe the distribution of major lower extremity amputations. Multivariable regression models were fit to identify predictors of major post-surgical complications, revision amputation, length of hospitalization, and in-hospital mortality.


      A total of 2879 patients underwent a major lower extremity amputation secondary to a trauma-related lower limb injury, representing 0.18% of all NTDB trauma admissions from 2011 to 2012. 80.4% were male and 67.6% were white. The three most frequent definitive amputations preformed included trans-tibial (46%), trans-femoral (37.5%), and through foot (7.6%). The average length of hospitalization for all amputees was 22.7 days. Patients with at least one revision amputation stayed in the hospital approximately 5.5 days longer than patients not needing a revision amputation. 1204 patients (41.8%) required at least one revision amputation. 27.5% of amputees experienced at least one major post-surgical complication. African Americans experienced a 49% higher major post-surgical complication incidence and stayed, on average, 2.5 days longer in the hospital compared to whites. Injury severity score, age, hospital teaching status, presence of a crush injury, fracture location, presence of compartment syndrome, and experiencing a major post-surgical complication were all significant predictors of revision amputation.


      We report a high rate of complications and revision amputations among trauma-related lower limb amputees, and identify predictors of surgical outcomes that have not been described in the literature including African American race. Compartment syndrome is a significant predictor of major post-surgical complications, revision amputation, and length of hospitalization.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Dillingham T.R.
        • Pezzin L.E.
        • MacKenzie E.J.
        Limb amputation and limb deficiency: epidemiology and recent trends in the United States.
        South Med J. 2002; 95: 875-883
        • Johannesson A.
        • Larson G.-U.
        • Ramstrand N.
        • Turkiewicz A.
        • Wirehn A.-B.
        • Atroshi I.
        Incidence of lower-limb amputation in the diabetic and nondiabetic general population a 10-year population-based cohort study of initial unilateral and contralateral amputations and reamputations.
        Diabetes Care. 2009; 32: 275-280
        • Dillingham T.R.
        • Pezzin L.E.
        • MacKenzie E.J.
        Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study.
        Arch Phys Med Rehabil. 1998; 79: 279-287
        • Ephraim P.L.
        • Dillingham T.R.
        • Sector M.
        • Pezzin L.E.
        • MacKenzie E.J.
        Epidemiology of limb loss and congenital limb deficiency: a review of the literature.
        Arch Phys Med Rehabil. 2003; 84: 747-761
        • Ebskov L.B.
        Trauma-related major lower limb amputations: an epidemiologic study.
        J Trauma. 1994; 36: 778-783
        • Doukas W.C.
        • Hayda R.A.
        • Frisch M.
        • Andersen R.C.
        • Mazurek M.T.
        • Ficke J.R.
        • et al.
        The military extremity trauma amputation/limb salvage (METALS) study outcomes of amputation versus limb salvage following major lower extremity trauma.
        J Bone Joint Surg Am. 2013; 95: 138-145
        • Morrison J.J.
        • Hunt N.
        • Midwinter M.
        • Jansen J.
        Associated injuries in casualties with traumatic lower extremity amputations caused by improvised explosive devices.
        Br J Surg. 2012; 99: 362-366
        • MacKenzie E.J.
        • Bosse M.J.
        • Kellam J.F.
        • Burgess A.R.
        • Webb L.X.
        • Swiontkowski M.F.
        • et al.
        Characterization of patients with high-energy lower extremity trauma.
        J Orthop Trauma. 2000; 14: 455-466
        • Matityahu A.
        • Elson J.
        • Morshed S.
        • Marmor M.
        Survivorship and severe complications are worse for octogenarians and elderly patients with pelvis fractures as compared to adults: data from the national trauma data bank.
        J Osteoporos. 2012; : 475739
        • MacKenzie E.J.
        • Jones A.S.
        • Bosse M.J.
        • Castillo R.C.
        • Pollak A.N.
        • Webb L.X.
        • et al.
        Health-care costs associated with amputation or reconstruction of a limb-threatening injury.
        J Bone Joint Surg Am. 2007; 89: 1685-1692
        • Rispoli D.M.
        • MacKenzie E.J.
        Extremity war injuries VII outcomes panel. Orthopaedic outcomes: combat and civilian trauma care.
        J Am Acad Orthop Surg. 2012; 20: S84-S87
        • Izumi Y.
        • Satterfield K.
        • Lee S.
        • Harkless L.B.
        Risk of reamputation in diabetic patients stratified by limb and level of amputation: a 10-year observation.
        Diabetes Care. 2006; 29: 566-570
        • Aulivola B.
        • Hile C.N.
        • Hamdan A.D.
        • Sheahan M.G.
        • Veraldi J.R.
        • Skillman J.J.
        • et al.
        Major lower extremity amputation: outcome of a modern series.
        Arch Surg. 2004; 139: 395-399
        • Cruz C.P.
        • Eidt J.F.
        • Capps C.
        • Kirtley L.
        • Moursi M.M.
        Major lower extremity amputations at a Veterans Affairs hospital.
        Am J Surg. 2003; 186: 449-454
        • Ploeg A.J.
        • Lardenoye J.W.
        • Vrancken Peeters M.P.
        • Breslau P.J.
        Contemporary series of morbidity and mortality after lower limb amputation.
        Eur J Vasc Endovasc Surg. 2005; 29: 633-637
        • Nehler M.R.
        • Coll J.R.
        • Hiatt W.R.
        • Regensteiner J.G.
        • Schnickel G.T.
        • Klenke W.A.
        • et al.
        Functional outcome in a contemporary series of major lower extremity amputations.
        J Vasc Surg. 2003; 38: 7-14
        • Stone P.A.
        • Flaherty S.K.
        • Hayes J.D.
        • AbuRahma A.F.
        Lower extremity amputation: a contemporary series.
        W V Med J. 2007; 103: 14-18
        • Abou-Zamzam Jr., A.M.
        • Teruya T.H.
        • Killeen J.D.
        • Ballard J.L.
        Major lower extremity amputation in an academic vascular center.
        Ann Vasc Surg. 2003; 17: 86-90
        • Schofield C.J.
        • Libby G.
        • Brennan G.M.
        • MacAlpine R.R.
        • Morris A.D.
        • Leese G.P.
        Mortality and hospitalization in patients after amputation: a comparison between patients with and without diabetes.
        Diabetes Care. 2006; 29: 2252-2256
        • Pezzin L.E.
        • Dillingham T.R.
        • MacKenzie E.J.
        Rehabilitation and the long-term outcomes of persons with trauma-related amputations.
        Arch Phys Med Rehabil. 2000; 81: 292-300
        • Franklin H.
        • Rajan M.
        • Tseng C.L.
        • Pogach L.
        • Sinha A.M.
        Cost of lower-limb amputation in U.S. veterans with diabetes using health services data in fiscal years 2004 and 2010.
        J Rehabil Res Dev. 2014; 51: 1325-1330
        • Belmont Jr., P.J.
        • Davey S.
        • Orr J.D.
        • Ochoa L.M.
        • Bader J.O.
        • Schoenfeld A.J.
        Risk factors for 30-day postoperative complications and mortality after below-knee amputation: a study of 2,911 patients from the national surgical quality improvement program.
        J Am Coll Surg. 2011; 213: 370-378
        • Bondurant F.J.
        • Cotler H.B.
        • Buckle R.
        • Miller-Crotchett P.
        • Browner B.D.
        The medical and economic impact of severely injured lower extremities.
        J Trauma. 1988; 28: 1270-1273
        • Wetterhall S.F.
        • Olson D.R.
        • DeStefano F.
        • Stevenson J.M.
        • Ford E.S.
        • German R.R.
        • et al.
        Trends in diabetes and diabetic complications, 1980–1987.
        Diabetes Care. 1992; 15: 960-967
        • Lavery L.A.
        • van Houtum W.H.
        • Ashry H.R.
        • Armstrong D.G.
        • Pugh J.A.
        Diabetes-related lower-extremity amputations disproportionately affect Blacks and Mexican Americans.
        South Med J. 1999; 92: 593-599
        • Lavery L.A.
        • Ashry H.R.
        • van Houtum W.
        • Pugh J.A.
        • Harkless L.B.
        • Basu S.
        Variation in the incidence and proportion of diabetes-related amputations in minorities.
        Diabetes Care. 1996; 19: 48-52
        • van Houtum W.H.
        • Lavery L.A.
        Methodological issues affect variability in reported incidence of lower extremity amputations due to diabetes.
        Diabetes Res Clin Pract. 1997; 38: 177-183
        • Huber T.S.
        • Wang J.G.
        • Wheeler K.G.
        • Cuddeback J.K.
        • Dame D.A.
        • Ozaki C.K.
        • et al.
        Impact of race on the treatment for peripheral arterial occlusive disease.
        J Vasc Surg. 1999; 30: 417-425
        • Tunis S.R.
        • Bass E.B.
        • Klag M.J.
        • Steinberg E.P.
        Variation in utilization of procedures for treatment of peripheral arterial disease. A look at patient characteristics.
        Arch Intern Med. 1993; 153: 991-998
        • Harris M.I.
        • Flegal K.M.
        • Cowie C.C.
        • Eberhardt M.S.
        • Goldstein D.E.
        • Little R.R.
        • et al.
        Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988–1994.
        Diabetes Care. 1998; 21: 518-524
        • Feinglass J.
        • Kaushik S.
        • Handel D.
        • Kosifas A.
        • Martin G.J.
        • Pearce W.H.
        Peripheral bypass surgery and amputation: northern Illinois demographics, 1993 to 1997.
        Arch Surg. 2000; 135: 75-80
        • Bosse M.J.
        • MacKenzie E.J.
        • Kellam J.F.
        • Burgess A.R.
        • Webb L.X.
        • Swiontkowski M.F.
        • et al.
        An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.
        N Engl J Med. 2002; 347: 1924-1931