Burden of Injury (Non-Limb Specific Injury - Time 0 and Time 1)
In the absence of reliable evidence, the workgroup suggests the physician team should prioritize patient survival in the limb reconstruction vs. amputation decision. Limb specific damage control (i.e. temporizing) measures or immediate amputation should be considered when further attempts at definitive salvage will increase risk of mortality.
Limb Salvage or Early Amputation
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: AOFAS, OTA



There is limited evidence that the poly-trauma patient with combined lower extremity injuries require limb salvage attempts. In the study from Webster (2018), in a military population of high ISS greater than 26 and bilateral and unilateral amputation, patients with pelvic fractures had increased mortality. Additionally, those with bilateral lower extremity amputations had a higher risk of death.

In Allami (2017), in veterans with ankle-foot injuries, having additional injuries was a determinant of poorer mental health and poorer PCS scores. In the study from Laferrier (2010) in a population of military polytrauma patients, an increasing number of combat injuries (including bilateral limb loss, traumatic brain injury) is associated with higher odds of wheelchair use. Laferrier also found that in patients with bilateral lower-limb loss compared to those with unilateral limb loss, there was also a higher odds of wheelchair use. In the study by Hutchison (2014) in subjects with military related amputees, having multiple amputations was associated with an increased odds of PE and VTE. Additionally, in the study by Bennett (2018) in a military population with injuries to the foot and ankle, having coexisting talar and calcaneal fractures was found to be associated with lower AAOS F&A scores but the same was not seen for fractures of the mid-foot.


In the acute setting, standard ATLS trauma resuscitation, and operative or non-operative management of the trauma patient injuries is paramount. The patient’s injuries are triaged based on addressing life-threating injuries (providing a stable airway, oxygenation) and stopping bleeding. Initial “Damage Control” trauma techniques are deployed (Damage Control Trauma Surgery and Damage Control Resuscitation). Damage control trauma and orthopedic surgery in the setting of a lower extremity injury may require re-establishing blood flow to the extremity, which can be a temporary vascular shunt, and external fixation.


The priority at this point is survival of the patient.


The cost of survival is high. The cost of a survivor with an amputation is higher.






This injury pattern is not amenable to randomized control study as it would be considered unethical to attempt limb salvage in a patient who is dying from another injury.


*Strength of Recommendation Upgraded. Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High” quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed in the EtD framework.


The Future of OrthoGuidelines


The OrthoGuidelines Process