Abstract
Aims
Lower limb amputation is associated with significant morbidity and mortality. Reflecting the predominance of vascular or diabetic disease as a cause for lower limb amputation, much of the available literature excludes lower limb amputation secondary to trauma in the reporting of complication rates. This paucity of literature represents a research gap in describing the incidence of complications in lower limb amputations due to trauma, which we aim to address.
Methods
A retrospective analysis was undertaken of a prospectively collected database of lower limb amputations secondary to trauma from a regional multidisciplinary amputee service in London. Clinical records were consulted for evidence of reoperation, infection, phantom limb pain, neuroma, and contralateral limb arthritis. A multivariable regression model was created to establish risk factors for reoperation. A total of 213 amputations (200 patients) were included in the final analysis.
Results
Mean age at amputation was 33 years (1 to 90), with a mean follow-up of 230 months (2 to 734). Overall, 35.2% of patients (n = 75) underwent reoperation, and 27.7% (n = 59) had at least one episode of infection. Of those who underwent reoperation, 44% (n = 33) had evidence of infection. Phantom limb pain and neuroma were reported in 39.9% (n = 85) and 10.8% (n = 23), respectively. Contralateral limb osteoarthritis was documented in 7%. Presence of infection is a statistically significant risk factor, conferring a 3.9 times increased risk of reoperation.
Conclusion
Lower limb amputations secondary to trauma exhibit higher rates of reoperation and infection compared to vascular or diabetic amputees. This is the first and largest study to provide high-quality data describing the incidence of complications in patients with lower limb amputations due to trauma in the UK.
Cite this article: Bone Jt Open 2026;7(3):442–447.
Keywords: Trauma, Amputation, Lower limb, Complication rates, Reoperation, Traumatic amputation, lower limb amputations, trauma, amputations, Infection, neuroma, limb amputations, limb osteoarthritis, retrospective analysis, morbidity
Introduction
Acute lower limb amputation following trauma is a life-changing event associated with significant morbidity and mortality. Unlike amputations predominantly caused by vascular or diabetic disease, traumatic amputations often result from high-energy injuries and disproportionately affect a younger, more active population. Despite this, lower limb amputations secondary to trauma are under-represented in the literature, which tends to focus on chronic conditions (notably, diabetes or vascular disease), or combine all amputee groups together, often masking key differences in aetiology and outcomes. In the UK, trauma accounts for 13.9% of all lower limb amputations, yet detailed, current data on this subset remain scarce.1
Some studies, many of which are historic, have primarily emphasized vascular and diabetic amputations, neglecting the specific challenges faced by young, medically well trauma patients.1-3 Higher rates of infection, phantom limb pain, neuroma formation, and contralateral limb arthritis have been anecdotally noted, but not systematically quantified.
Moreover, much of the available research arises from studies outside the UK, often failing to consider the unique context of regional multidisciplinary amputee services within which these patients are managed long-term. These services standardize rehabilitation and therapy, providing an opportunity to examine outcomes in a more consistent treatment setting.
This study sought to address this gap in the literature by analyzing a large cohort of patients with acute lower limb amputations secondary to trauma, managed within a regional multidisciplinary amputee service in London. This is one of the largest amputee rehabilitation units in the UK, encompassing multidisciplinary expertise delivered by orthopaedic and plastic surgeons, prosthetists, rehabilitation medicine doctors, physiotherapists, occupational therapists, psychologists, and pain specialists. By examining the incidence and predictors of complications such as infection, reoperation, phantom limb pain, and contralateral osteoarthritis, we aim to address this paucity of literature in UK demographic features of acute lower limb amputation due to trauma. This is the first study in the UK to evaluate these outcomes in a large cohort, bridging a critical gap in the literature and improving the field of trauma care.
Our objectives were to describe the rate of complications (defined as reoperation, infection, phantom limb pain, neuroma, and contralateral limb osteoarthritis) in acute lower limb amputations due to trauma in a UK-based regional multidisciplinary amputee service.
Methods
A retrospective analysis of a prospectively collected database of all acute traumatic lower limb amputations secondary to trauma was conducted. Data were collected at the regional multidisciplinary amputee service at Queen Mary’s Hospital, Roehampton. For the purposes of this study, acute amputation was defined as amputation within six weeks of initial trauma.
Delayed amputations secondary to chronic infection, nonunion, chronic pain, or other post-traumatic complications were excluded. Electronic patient records and paper file notes were consulted for evidence of reoperation (change of amputation level, soft-tissue procedures, debridement), infection (superficial or deep), phantom limb pain, neuroma, and evidence of contralateral osteoarthritis.
Patient characteristics
Baseline demographic characteristics are shown in Table I.
Table I.
Baseline demographic details.
| Characteristic | Value |
|---|---|
| Number of amputations | 213 |
| Number of amputees | 200 |
| Mean age at amputation, yrs (range) | 33.73 (1 to 90) |
| Mean follow-up, mths (range) | 227.72 (2 to 734) |
| Laterality (n = 213) | |
| Left | 88 |
| Right | 99 |
| Bilateral | 13 |
| Sex (n = 213) | |
| Male, n (%) | 176 (82.63) |
| Female, n (%) | 37 (17.37) |
Using the ‘Rehapp’ database (ReHapp; Enablement Foundation, the Netherlands) at Queen Mary’s Hospital of 3,622 amputations, 484 lower limb amputations secondary to trauma were identified (Figure 1). Of these, 190 had no records and 69 were excluded due being delayed, or planned, amputations (> six weeks post-trauma), or non-traumatic in nature.4 Overall, 213 acute lower limb amputations in 200 patients were included in the final data analysis. Demographic data were also collected, including sex, age, mechanism of injury, amputation level, and laterality.
Fig. 1.
Flowchart of amputations included in data analysis.
Statistical analysis
All data were coded in Microsoft Excel (Microsoft, USA) and the statistical analysis was conducted using Stata version 17 (StataCorp, USA). We established the association between prognostically relevant characteristics and multiple defined outcomes (including risk for reoperation, infection, neuroma, phantom limb pain, and contralateral osteoarthritis) using a multivariable regression model. All analyses adjusted for age at time of amputation, sex, amputation level, and mechanism of injury. Statistical significance was set at p < 0.05.
We established the association between prognostically relevant characteristics and multiple defined outcomes (including risk for reoperation, infection, neuroma, phantom limb pain, and contralateral osteoarthritis) using a multi-variable regression model. All analyses adjusted for age at time of amputation, sex, amputation level, and mechanism of injury.
Results
Records identified 213 lower limb amputations secondary to trauma in 200 patients, in a predominantly young, male population (mean age of 33.73 years at time of amputation (1 to 90)) with a mean follow-up of 227 months (2 to 734; Table I).
Road traffic accidents were the leading mechanism of injury (55.00%), followed by train accidents (10.50%) and blast injuries (9.50%) (Table II).
Table II.
Mechanism of original injury (total n = 200).
| Mechanism of injury | Value, n (%) |
|---|---|
| Road traffic accident | 110 (55.00) |
| Train | 21 (10.50) |
| Blast injury | 19 (9.50) |
| Unknown | 16 (8.00) |
| Firearms | 13 (6.50) |
| Workplace accident | 12 (6.00) |
| Jump from height | 5 (2.50) |
| Assault | 2 (1.00) |
| Fire/burns | 1 (0.50) |
| Degloving | 1 (0.50) |
The most common index amputation level was trans-tibial (52.11%), followed by trans-femoral (28.17%), through knee (13.62%), ankle (3.29%), hip (0.94%), and partial foot (1.88%), Figure 2. Overall, 6.57% amputations underwent change of amputation level, with trans-tibial to through knee the most prevalent (35.71%) (Table III).
Fig. 2.
Amputation levels.
Table III.
Change of amputation level.
| Change of amputation stump level | N = 14 |
|---|---|
| Trans-tibial to through knee | 5 |
| Trans-tibial to trans-femoral | 2 |
| Through knee to trans-femoral | 3 |
| Partial foot to ankle | 2 |
| Ankle to trans-tibial | 1 |
| Partial foot to trans-tibial | 1 |
Infection
Overall, 27.70% of patients had evidence of at least one episode of infection. This was defined as either superficial or deep infection, as deemed appropriate by clinical examination by the rehabilitation medicine doctors, requiring antibiotics (oral or intravenous), or return to theatre for debridement (Table IV).
Table IV.
Complication rates following lower limb amputation due to trauma (total n = 213).
| Complications | Value, n (%) |
|---|---|
| Reoperation | 75 (35.21) |
| Infection | 59 (27.70) |
| Reoperation + infection | 33 (15.49) |
| Change of amputation level | 14 (6.57) |
| Neuroma | 23 (10.80) |
| Phantom limb pain | 85 (39.91) |
| Contralateral osteoarthritis | 15 (7.04) |
Reoperation
With regard to complication rates, 35.21% of lower limb amputations secondary to trauma underwent reoperation (defined as any return to theatre). Overall, 6.57% of amputations underwent change of amputation level. Of those which underwent reoperation, 44.0% also had evidence of at least one episode of infection.
Infection was a statistically significant risk factor for reoperation, with patients at 3.89 times increased risk of undergoing reoperation in the presence of infection (p = 0.001, Table V).
Table V.
Multivariable logistic regression model establishing risk factors for reoperation following limb amputation due to trauma.
| Variable | Odds ratio | Standard error | p-value | 95% CIs |
|---|---|---|---|---|
| Sex (male) | 0.85 | 0.37 | 0.700 | 0.36 to 1.98 |
| Age | 0.98 | 0.01 | 0.032 | 0.96 to 100 |
| Infection | 3.89 | 1.52 | 0.001 | 1.81 to 8.38 |
| Phantom pain | 1.62 | 0.56 | 0.167 | 0.82 to 3.19 |
| Neuroma | 0.93 | 0.54 | 0.901 | 0.30 to 2.88 |
Conversely, older age is a protective factor, such that each year increase is age is associated with a 2% decreased risk for reoperation (p = 0.032, Table V). This is likely due to the fact that the risk of living long enough for another complication to develop is reduced, and the functional demand on the amputation stump lessens, with increasing age.
There were no statistically significant findings with regard to mechanism of injury and amputation level as risk factors for reoperation (Supplementary Material). These results are adjusted for age, sex, presence of phantom limb pain, neuroma, amputation level, and mechanism of injury.
Neuroma
Overall, 10.80% of patients had documented evidence of painful neuroma confirmed clinically by the rehabilitation medicine team, or radiologically via ultrasound.
Phantom limb pain
Overall, 39.91% of patients demonstrated symptoms of phantom limb pain at any timepoint, defined by a diagnosis of phantom limb pain, or evidence of unpleasant and painful sensations (not attributable to neuroma or wound problems).
Osteoarthritis
Records identified 7.04% of patients had evidence of contralateral limb osteoarthritis. This was defined as radiological evidence of osteoarthritis on radiographs organized due to complains of joint pain.
Discussion
We describe the demographic of a predominantly young, male population with trans-tibial amputations accounting for 52.11% of amputation levels. Road traffic accidents are the most common cause for limb loss, with 55.00% of amputations due to this of mechanism of injury. Our data are similar to those reported by Low et al,5 with values of 46% and 61.25% for trans-tibial amputations and road traffic accidents, respectively.
Our data demonstrate a higher rate of infection (27.70%) in lower limb amputations due to trauma than those previously described in amputations due to vascular disease and/or diabetes (2.2% to 10.4%).2,3 We postulate that this is due to the mechanism of injury itself generating a greater zone of soft-tissue injury, and in the context of a dirty environment (e.g. road, train tracks), creating a contaminated wound with a high risk of infection.3 This is even more applicable to explosive injuries, which are subject to primary, secondary, tertiary, quaternary, and sometimes quinary blast injuries.6 The injury is further aggravated by the host’s immune response to trauma and tissue damage, in which innate immunity mechanisms can trigger systemic inflammatory response syndrome, upregulating anti-inflammatory mechanisms. This can proceed to a compensatory anti-inflammatory response syndrome, culminating in immunoparesis and higher susceptibility to infection.7 We report a higher reoperation rate compared to previously published data on vascular and/or diabetic amputees citing reoperation rates between 11.7% and 14.9%.2,3 Moreover, our reoperation rate is lower than that reported by Low et al5 of 41.8%. Interestingly, their dataset does not extrapolate further than discharge date; as such, ours has longer follow-up, yet a lower incidence of reoperation.
The incidence of reported phantom limb pain in this study (39.91%) is less than reported values of 59% to 64% for the general population of lower limb amputees.8-10 In the context of non-traumatic amputations, phantom limb pain can be primed by existing damage to peripheral nerves due to dysvascular disease. The upregulation of peripheral nociception leads to central sensitization and ‘pain memories’, which can manifest as phantom limb pain once the limb has been amputated.4 In, fact, preoperative pain is a documented risk factor the development of phantom limb pain.11 Modulation of the nociceptive pathways prior to amputation does not occur in acute amputations secondary to trauma, which we hypothesize accounts for the reduced rate of phantom limb pain we report.
The available literature describes neuroma rates between 15% to 19% for lower limb amputations, which is higher than the value of 10.80% we report in this study.12
Overall, 7.04% of amputees had documented evidence of contralateral limb osteoarthritis, confirmed radiologically only if the patient had volunteered a history of pain in that joint. Higher values of between 16.7% and 23% have been reported in radiological studies.13,14 This difference can possibly be accounted by self-selection bias, in that only amputees reporting pain had radiographs done, instead of systematically imaging all amputees for evidence of osteoarthritis.
There are limitations to consider when reviewing our data. As a retrospective review of clinical records (mostly paper notes), our data are limited by the quality of the clinical notes. For this reason, we have binarily coded our data to reflect the presence or absence of the outcomes in the notes. To counter this, most amputees remain under the care of the same rehabilitation centre for a long time, presenting with any amputation-related complication, which accounts for the long length of follow-up in this study.
In conclusion, our data demonstrate that acute lower limb amputations secondary to trauma exhibit higher rates of reoperation and infection compared to those for diabetic or vascular amputations, with infection as a significant risk factor for reoperation. Conversely, lower rates of neuroma and phantom limb pain are reported in lower limb amputations due to trauma when compared to non-traumatic amputations. This is the first UK study to provide high-quality data in a large series describing the incidence of complications in acute lower limb amputations secondary to trauma.
Take home message
- This UK study provides evidence that acute lower limb amputations following trauma carry high rates of complications, particularly reoperation and infection, in a younger and more active patient population.
- It identifies infection as a key risk factor for reoperation, supporting the need for aggressive early infection control and optimization of surgical management.
Author contributions
A. J. Trompeter: Methodology, Writing – original draft, Writing – review & editing
C. Brookes: Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing
S. Dardak: Data curation, Formal analysis, Writing – review & editing
E. Allen: Data curation, Investigation, Writing – review & editing
B. Cho: Data curation, Formal analysis, Writing – review & editing
J. Lohn: Writing – review & editing
V. Kolli: Methodology, Project administration, Writing – review & editing
Funding statement
The author(s) disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: APC funded by Queen Mary's Hospital.
ICMJE COI statement
A. J. Trompeter reports royalties from Oxford University Press and Stryker Trauma, consulting fees and speaker payments from Stryker, Orthofix, and Meshworks Orthosolutions, and payment for expert testimony from AK Medicons Ltd, all of which are unrelated to this study. A. J. Trompeter is also a member of the BOA Trauma Committee, BOA Clinical Standards Committee, BLRS Executive Committee, and The Bone & Joint Journal and Bone & Joint Open editorial boards. J. Lohn reports educational consultancy payments from Orthofix, unrelated to this study.
Data sharing
All data generated or analyzed during this study are included in the published article and/or in the supplementary material.
Acknowledgements
We would like to thank Dr. Brittany Dennis for her invaluable guidance and support with the statistical analysis.
Ethical review statement
This project was registered as a service evaluation with our local audit office (registration number AUDI002131), and therefore did not require ethics approval.
Open access funding
The open access fee for this article was funded by Queen Mary's Hospital.
Supplementary material
Multivariate regression models establishing mechanism of injury and amputation level as risk factors for reoperation.
Social media
Follow C. Brookes on X @cebrookes92
© 2026 Trompeter et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
Data Availability
All data generated or analyzed during this study are included in the published article and/or in the supplementary material.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analyzed during this study are included in the published article and/or in the supplementary material.