Risk Factors for and Results of Late or Delayed Amputation Following Combat-related Extremity Injuries

We studied patients with combat-related injuries that required delayed amputation at least 4 months after the initial injury due to dysfunction, persistent pain, and patient desires. Late amputations were performed 22 times in 22 patients (21 men, 1 woman) since 2003. Fourteen patients underwent transtibial amputation, 5 transfemoral amputations, 1 knee disarticulation, and 2 transradial amputations. The primary indications for late amputation were neurologic dysfunction in 6 patients, persistent or recurrent infection in 6, neurogenic pain in 3, non-neurogenic pain in 5, and a globally poor functional result in 2. Sixteen of 22 patients reported multiple indications for electing to undergo amputation, with an average of 2.1 specific indications per patient. At final clinical follow-up an average of 13 months after amputation, all patients reported subjectively improved function and reported that they would undergo amputation again under similar circumstances. When medically and functionally practicable, every effort is given to limb salvage following severe combat-related extremity injuries. There is no single risk factor that increases the likelihood of delayed amputation, but the combination of complex pain symptoms with neurologic dysfunction appears to increase the risk, particularly if the initial insult is a severe hindfoot injury or distal tibia fracture. With appropriately selected and counseled patients, elective late amputation results in a high degree of patient satisfaction and subjectively improved function.