Impact of Timing on Lower Extremity Amputations in Blunt Polytrauma : A Retrospective Analysis of Clinical Outcomes and Risk Factors

Impact of Timing on Lower Extremity Amputations in Blunt Polytrauma : A Retrospective Analysis of Clinical Outcomes and Risk Factors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Impact of Timing on Lower Extremity Amputations in Blunt Polytrauma : A Retrospective Analysis of Clinical Outcomes and Risk Factors Jinjoo Kim, Wanseon Choi, Wontae Cho, Jonghwan Moon This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3887741/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Mar, 2025 Read the published version in Scientific Reports → Version 1 posted 14 You are reading this latest preprint version Abstract Delayed amputation after failed limb salvage can lead to negative clinical and functional outcomes due to complications, including re-amputation. This study aimed to compare clinical outcomes and identify risk factors according to the timing of amputation. A retrospective review of managed lower-extremity injuries was conducted between January 2016 and December 2022 at a level 1 trauma center. Outcomes were compared between the early amputation and the delayed amputation groups (within and beyond 48 h after the time of injury, respectively). The primary outcome of interest was that the risk factors changed to a more proximal amputation level according to the timing of amputation. The secondary outcomes included trauma-related complications and clinical outcomes. The incidence of trauma-related complications was more common in the delayed amputation group with no significant differences in 30-day mortality. Delayed amputation and stump site deep surgical infection were associated with higher odds of changing to a more proximal level than initially predicted. The overall hospital stay was significantly longer in the delayed amputation group. Although patients and clinicians prefer the limb salvage strategy, delayed amputation could be a risk factor for shorter limb stumps due to re-amputation, and patients may experience more trauma-related complications and prolonged hospitalization. Health sciences/Medical research Health sciences/Risk factors Figures Figure 1 Figure 2 Introduction Historically, amputation has been regarded as the treatment for severe extremity trauma, and whether primary amputation or challenging limb salvage should be performed remains a topic of debate. [ 1 , 2 ] In the study of the prevalence of limb amputation in the United States, trauma accounts for 45% of extremity amputations. In South Korea, the most common cause of lower extremity amputation is trauma, accounting for over 75% of cases. [ 3 , 4 ] A large number of patients with mangled extremities are relatively young and healthy people. Therefore, given the nature of limb amputation as a “life-changing” operation, physicians and patients might want to avoid amputation. Thus, limb salvage can be attempted in most situations despite advances in reconstructive techniques and medical treatment. [ 5 , 6 ] Severe lower-extremity trauma is a life-threatening event. Trauma surgeons are faced with emergencies in which amputation should be considered for hemorrhagic control in the operating room as part of the initial resuscitation according to the Advanced Trauma Life Support (ATLS) guidelines. [ 7 ] In addition, the outcomes of challenging limb salvage are still debated. Previous studies, including the Lower Extremity Assessment Project (LEAP), insisted that limb salvage did not improve functional outcomes and showed a higher complication rate, resulting in prolonged hospital stays or multiple procedures. Delayed amputation, which involves limb salvage, was associated with more frequent major complications than early amputation. [ 8 – 10 ] The length of the residual limb is an essential outcome of treating the mangled extremity, which indicates the amputation level, and it may have a decisive effect on functional outcomes. Longer residual limbs have mechanical advantages and are associated with quality of life. However, re-amputation could be necessary because of the sequelae of postoperative complications, which cannot be handled through non-operative methods, and a shorter residual limb contributes to more significant physical strain. Therefore, re-amputation may affect functional outcomes in patients who have undergone previous amputations. [ 11 , 12 ] For trauma surgeons responsible for the initial resuscitation of patients with severe polytrauma, deciding the timing of amputation is vital for establishing a treatment strategy. Nonetheless, most previous studies have been conducted in trauma patients with relatively lower ISS, and studies on the association between the timing of amputation and re-amputation for severely injured patients are scarce. [ 8 , 13 – 15 ] We hypothesize that the timing of amputation could affect clinical outcomes and the rate of re-amputation, which may cause changes in amputation level. Therefore, this study aimed to compare clinical outcomes and the final amputation level and identify risk factors that change to a more proximal level according to the timing of the amputation. Materials and Methods We performed a retrospective study of patients presenting with a mangled lower extremity at a single level 1 trauma center over 7 years (2016–2022) using the electronic medical records (EMR) of the patients included in this study. We included adults aged 18 years or older with lower extremity injuries. According to a previously published approach, a mangled extremity injury is defined as (1) a severe crushing injury or (2) a major fracture combined with selected severe injuries to at least two or three of the following: soft tissue, artery, or nerve. [ 16 ] Patients who died on arrival or within 48 h of hospital presentation were also excluded because their cause of death could be associated with other severe trauma, such as thoracic or abdominal injury, rather than the timing of amputation. Patients who underwent only midfoot or toe amputation or amputation for nontraumatic causes were excluded. Patients with incomplete or missing data were excluded. After reviewing medical records, the following data were collected: patient demographics, injury characteristics, comorbidities, treatment courses, and complications. Injury characteristics were defined by injury mechanism, Injury Severity Score (ISS), and presence of concomitant severe head and neck, face, chest, abdomen, and/or pelvis injury, which is defined as an Abbreviated Injury Scale (AIS) score of > 3. We also assessed the presence of shock (a systolic blood pressure of less than 90 mmHg) and the Glasgow Coma Scale (GCS) score in the resuscitation area. Two trauma surgeons and two orthopedic surgeons evaluated lower extremity trauma regarding orthopedic, soft tissue, and vascular injury by reviewing medical records, clinical photography, radiography, and computed tomography (CT) and assessed the Mangle Extremity Severity Score (MESS). [ 17 ] The patients were divided into two groups according to the timing of amputation: early or delayed. Patients who underwent amputation within 48 h of injury were classified into the early amputation group. Delayed amputation was defined as any amputation that occurred 48 h after the injury with the intention of limb salvage. The predicted amputation level was defined as the expected amputation level if lower extremity amputation was performed within 48 h of injury and evaluated by four trauma specialists, including two orthopedic surgeons and two trauma surgeons. One of the two trauma surgeons is a cardiovascular specialist. Four trauma specialists retrospectively reviewed the EMR images, clinical photographs, and initial lower-extremity CT angiography. After the review, they discussed whether there were disagreements about the predicted amputation level among the specialists. Our primary outcome was to compare the final amputation level and identify the risk factors that changed to a more proximal amputation level according to the timing of the amputation. The secondary outcomes are the outcomes of patients with lower extremity mangled injury, including development of complications, mortality, hospital stay, and Intensive Care Unit (ICU) length of stay (LOS). The normality assumption was tested using the Shapiro–Wilk test. When departures from normality were significant, the Mann-Whitney U test was used as a non-parametric method. When the data followed a normal distribution, a two-sample t -test was used for the analysis. Continuous variables are presented as mean \(\text{±}\) standard deviation (SD) and median interquartile range (IQR). Dichotomous variables were compared using the chi-square test or Fisher’s exact test, as appropriate, and expressed as proportions. Considering the results of univariate analysis, the variables with P < 0.05 were included as candidates in the multivariable logistic regression analysis using a stepwise selection to identify the risk factors for changes at a more proximal amputation level than the predicted level. All statistical analyses were conducted using R software, version 4.1.2. A P-value < 0.05 was considered significant. The study was approved by the Institutional Review Board of our institution (IRB No. AJOUIRB-DB-2023-270), the requirement for informed consent was waived owing to the observational nature of this study. This study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Guidelines for Observational Studies. [ 18 ] Results A total of 199 patients were included in the analysis, of whom 132 (66.3%) underwent early amputation, and 67 (33.7%) were treated by delayed amputation. 24 patients were excluded from analysis (Fig. 1 ). The baseline characteristics of the patients are summarized in Table 1 . Most patients in both groups were male, with an average age of 53 years, and had similar initial systolic blood pressure and GCS scores. There were no significant differences in the proportions of smokers and underlying diseases, except for hypertension. All patients experienced blunt trauma, and the ISS and mechanism of injury were not significantly different between the two groups (Table 1 ). Table 1 Baseline characteristics of patients with mangled extremity underwent lower extremity amputation, subdivided by the time of amputation Variables Early amputation (n = 132) Delayed amputation (n = 67) p-value Age, mean ± SD (years) 53 ± 13.8 53.2 ± 18.5 0.949 Sex, n (%) 0.119 Male 102 (77.3) 58 (86.6) Female 30 (22.7) 9 (13.4) Mechanism of injury, n (%) 0.176 Free fall 4 (3) 1 (1.5) Motor vehicle accident 27 (20.5) 11 (16.4) Motorcycle accident 24 (18.2) 18 (26.9) Bicycle/Pedestrian 55 (41.7) 23 (34.3) Machinery 14 (10.6) 4 (6) Other blunt injury 8 (6.1) 10 (14.9) Arrived from, n (%) <0.001 Scene 107 (81.1) 36 (53.7) Outside Hospital 25 (18.9) 31 (46.3) Initial SBP, n (%) 0.203 < 90 mmHg 117 (88.6) 55 (82.1) ≥ 90mmHg 15 (11.4) 12 (3.4) Initial GCS, mean ± SD 13.7 ± 3 13.4 ± 3.4 0.629 Initial lactic acid (mmol/L), median (IQR) 3.8 (2.1, 5.2) 2.6 (1.7, 4.1) 0.011 Known associated injuries, AIS ≥ 3, n (%) Head and neck 14 (10.6) 8 (11.9) 0.777 Face 2 (1.5) 0 (0) 0.551 Chest 60 (45.5) 29 (44.3) 0.771 Abdomen 20 (15.2) 13 (19.4) 0.446 Pelvis 8 (6.1) 11 (16.4) 0.019 ISS, median (IQR) 19 (10,26) 18 (9, 24.5) 0.458 ISS < 15 39 (29.5) 27 (40.3) 0.128 ISS ≥ 15 93 (70.5) 40 (59.7) Underlying diseases, n (%) 45 (34.1) 28 (41.8) 0.287 Cardiovascular disease 4 (3) 0 (0) 0.303 Peripheral disease 0 (0) 2 (3) 0.112 Cerebrovascular disease 7 (5.3) 0 (0) 0.098 Diabetes Mellitus 23 (17.1) 11 (16.4) 0.859 CKD 0 (0) 1 (1.5) 0.337 Liver disease 2 (1.5) 1 (1.5) > 0.999 HTN 27 (20.5) 26 (38.8) 0.006 Current smoker, n (%) 60 (45.5) 29 (43.3) 0.771 SD, standard deviation; SBP, systolic blood pressure; GCS, Glasgow Coma Scale; IQR, interquartile ranges; AIS, abbreviated injury scale; ISS, injury severity scale; CKD, chronic kidney disease; HTN, hypertension Table 2 demonstrates the MESS score used to assess the severity of lower-extremity management injury. MESS was significantly higher in the early amputation group (7.1 \(\pm\) 1.5 vs. 6.0 \(\pm\) 1.5, P < 0.001). In the early amputation group, most patients were injured by a very high-energy injury mechanism, significantly higher than the delayed amputation group (88.6% vs. 47.8%, P < 0.001). Compared with the delayed amputation group, the early amputation group demonstrated a greater prevalence of severe limb ischemia, whereas the number of patients with ischemia longer than 6 h was notably higher in the delayed amputation group (Table 2 ). Table 2 Injury severity of lower extremity mangled injury according to MESS score Variables Early amputation (n = 132) Delayed amputation (n = 67) p-value MESS score, mean ± SD 7.1 ± 1.5 6.0 ± 1.5 <0.001 Injury mechanism (%) <0.001 Low energy 0 (0) 2 (3) Medium energy 5 (3.8) 15 (22.4) High energy 10 (7.6) 18 (26.9) Very high energy 117 (88.6) 39 (47.8) Limb ischemia (%) 6hrs (%) 11 (8.3) 18 (26.9) 90mmHg consistently 57 (43.2) 38 (56.7) Transient hypotension 46 (34.8) 17 (25.4) Persistent hypotension 29 (22) 12 (17.9) Age (%) 0.118 50yrs 73 (55.3) 46 (68.7) MESS, mangled extremity severity score; SBP, systolic blood pressure Delayed amputation was defined as any amputation that occurred more than 48 h after the injury; however, the mean time to amputation in this group was 11.9 \(\pm\) 7.3 days. Although the proportion of patients requiring packed red cell (PRC) transfusion units was not significantly higher in the early amputation group (89.4% vs. 79.1%, P = 0.079), the rate of massive transfusion was significantly higher in that group (54.5% vs. 32.8%, P = 0.004). Vascular procedures were more frequently performed in the delayed amputation group (10.6% vs. 26.9%, P = 0.003). In the delayed amputation group, the most commonly performed vascular procedure was vascular reconstruction, whereas ligation of the vessels was the most frequent procedure in the early amputation group. Ipsilateral fractures above amputation level were more common in the early amputation group (20.5% vs. 35.8%, P = 0.019). There were no statistically significant differences in the rates of re-amputation, predicted amputation level, final amputation level, and overall stump complications (Table 3 ). Table 3 Procedures, and complications related to lower extremity amputation Variables Early amputation (n = 132) Delayed amputation (n = 67) p-value Timing of definitive amputation, mean ± SD (days) 0.2 ± 0.7 11.9 ± 7.3 <0.001 Total numbers of operation 2.5 ± 1.8 4.4 ± 3.0 <0.001 PRC transfusion, n (%) 118 (89.4) 53 (79.1) 0.079 Transfusion within 24 hrs, median (IQR) 8 (4,15) 5 (3,15) 0.137 Massive transfusion, n (%) 72 (54.5) 22 (32.8) 0.004 Other orthopedic injury, n (%) 79 (59.8) 21 (31.3) < 0.001 Ipsilateral fractures above amputation level, n (%) 27 (20.5) 24 (35.8) 0.019 Vascular procedure to ipsilateral leg, n (%) 14 (10.6) 18 (26.9) 0.003 Thrombectomy only 1 (7.1) 1 (5.6) Reconstruction 4 (28.6) 12 (66.7) Vessel ligation 9 (64.3) 5 (27.8) Open amputation, n (%) 15 (11.4) 6 (9) 0.601 Re-amputation, n (%) 26 (19.7) 7 (10.4) 0.097 Predicted amputation level, n (%) 0.112 Transtarsal 2 (1.5) 1 (1.5) Below knee 54 (40.9) 39 (58.2) Through knee 27 (20.5) 13 (19.4) Above knee 47 (35.6) 14 (20.9) Hip 2 (1.5) 0 (0) Final amputation level, n (%) 0.703 Below knee 51 (38.6) 25 (37.3) Through knee 20 (15.2) 13 (19.4) Above knee 56 (42.4) 25 (37.3) Hip 5 (3.8) 4 (6) Stump complication, n (%) 71 (53.8) 35 (52.2) 0.836 Deep SSI 24 (18.2) 15 (22.4) 0.480 Superficial SSI 2 (1.5) 0 (0) 0.551 Dehiscence/wound breakdown 3 (2.3) 4 (6) 0.228 Tissue necrosis 58 (43.9) 17 (25.4) 0.011 Hematoma 3 (2.3) 5 (7.5) 0.122 SD, standard deviation: PRC, packed red cells; SSI, surgical site infection; IQR, interquartile ranges However, there was a significant change in the predicted and final amputation levels between the two groups. The delayed amputation group showed a significantly greater final amputation level change rate to a more proximal level than initially predicted (Fig. 2 ). Despite the lack of significant differences in the 30-day mortality rate between the two groups, the delayed amputation group experienced significantly more complications related to trauma and rhabdomyolysis (38.6% vs. 59.7%, p = 0.005, 38.2% vs. 55.2%, P = 0.022, respectively) (Table 4 ). The delayed amputation group experienced significantly more compartment syndrome on the injured limb (0% vs. 13.4%, P < 0.001) and decubitus ulcer (9.1% vs. 23.9%, P = 0.003). Osteomyelitis was observed more often in the delayed amputation group (0.8% vs. 7.5%, P = 0.017) (Table 4 ). Table 4 Patient outcomes Variables Early amputation (n = 132) Delayed amputation (n = 67) p-value 30-day mortality, n (%) 7 (5.3) 0 (0) 0.098 Hospital disposition, n (%) 0.070 Death 11 (8.3) 1 (1.5) Inpatient rehab 93 (70.5) 56 (83.6) Home with or without home care 28 (21.2) 10 (14.9) Received mechanical ventilation, n (%) 87 (65.9) 39 (58.2) 0.287 Mode of ambulation at discharge 0.828 Crutches 22 (18.2) 10 (15.2) Rolling walker 1 (0.8) 0 (0) Wheelchair 93 (76.9) 52 (78.8) Bed rest 5 (4.1) 4 (6.1) Prosthetic use, n (%) 0.563 Prosthetic use 77 (64.2) 43 (66.2) Follow up loss 30 (25) 18 (27.7) Rhabdomyolysis, n (%) 50 (38.2) 37 (55.2) 0.022 Complications related to trauma, n (%) 51 (38.6) 40 (59.7) 0.005 AKI, n (%) 9 (6.8) 5 (7.5) > 0.999 ARDS, n(%) 4 (3) 4 (6) 0.446 Cardiac arrest, n(%) 4 (3) 5 (7.5) 0.167 Decubitus ulcer, n (%) 12 (9.1) 16 (23.9) 0.005 Deep SSI, n (%) α 8 (6.1) 8 (11.9) 0.149 Superficial SSI, n (%) α 2 (1.5) 2 (3) 0.604 Compartment syndrome, n (%) b 0 (0) 9 (13.4) 0.999 Organ/Space surgical infection, n (%) α 0 (0) 1 (1.5) 0.337 Stroke, n (%) 0 (0) 2 (3) 0.112 Unplanned intubation, n (%) 2 (1.5) 3 (4.5) 0.338 Urinary tract infection, n (%) 3 (2.3) 6 (9.0) 0.063 CRABSI, n (%) 2 (1.5) 1 (1.5) > 0.999 Osteomyelitis, n (%) b 1 (0.8) 5 (7.5) 0.017 Unplanned return to OR, n (%) 10 (7.6) 9 (13.4) 0.184 Unplanned return to the ICU, n (%) 7 (5.3) 5 (7.5) 0.543 Severe sepsis, n (%) 7 (5.3) 7 (10.4) 0.240 Renal replacement therapy, n (%) 5 (3.8) 6 (9.0) 0.187 AKI, acute kidney injury; ARDS, acute respiratory distress syndrome; SSI, surgical site infection; DVT, deep vein thrombosis; VAP, ventilator associated injury; PTE, pulmonary thromboembolism; CRABSI, catheter related blood stream infection; OR, operation room; ICU, intensive care unit α Excluding the amputation site b Data related to the lower extremity amputation site only Between the two groups, ICU length of stay (LOS) (4 days [IQR, 2,9] vs. 7 days [IQR, 3,14], P = 0.060) was not significantly different, whereas ventilator days (3 days [IQR, 1,8] vs. 5 days [IQR, 2,13.5], P = 0.033) and hospital LOS (37.5 [IQR, 18,55.3] vs. 48 [IQR, 26.5,70.5], P = 0.005) showed significant differences (Table 5 a). A similar result was observed when patients were stratified according to an ISS 15, there were no significant differences between the two groups(Table 5 c). Table 5. ICU LOS, MV days and Hospital LOS (a) Entire population Early amputation (n = 132) Delayed amputation (n = 67) p value ICU LOS, days, median (IQR) 4 (2, 9) 7 (3, 14) 0.060 Ventilator days, median (IQR) 3 (1, 8) 5 (2, 13.5) 0.033 Hospital LOS, days, median (IQR) 37.5 (18, 55.3) 48 (26.5, 70.5) 0.005 CI, Confidence Interval; ICU, intensive care unit; LOS, length of stay; IQR, Interquartile range (b) ISS <15 ISS <15 Early amputation (n=39) Delayed amputation (n=27) P value ICU LOS, days, median (IQR) 3 (2, 4) 4 (2, 8.5) 0.097 Ventilator days, median (IQR) a 1 (1, 2) a 5 (4.3, 12.5) b <0.001 Hospital LOS, days, m edian (IQR) 21 (14.5, 35.5) 42 (25.5, 63) <0.001 CI, Confidence Interval; ICU, intensive care unit; LOS, length of stay; IQR, Interquartile range a n=20; b n=10 (c) ISS ≥ 15 Early amputation (n=93) Delayed amputation (n=40) P value ICU LOS, days, median (IQR) 6 (3, 13) 7.5 (3.8, 14.3) 0.114 Ventilator days, median (IQR) 4 (1, 13) a 5 (2, 13) b 0.416 Hospital LOS, days, median (IQR) 44 (20, 66) 49.5 (29.8, 72.5) 0.102 CI, Confidence Interval; ICU, intensive care unit; LOS, length of stay; IQR, Interquartile range a n=67; b n=29 Table 6 presents the risk factors for changes at a more proximal amputation level than the predicted level based on multivariate logistic regression analysis. The odds of delayed amputation after 48 h of injury were 2.95 times higher among the participants (adjusted odds ratio 2.95; 95% CI 1.38–6.24; P = 0.006). In addition, preexisting underlying disease and deep surgical site infection of the amputation stump were statistically significant risk factors for changes at a more proximal amputation level than the predicted level (Table 6 ). Table 6 Risk factors for changes at a more proximal amputation level than the predicted level Variables Odds Ratio 95% CI p-value Underlying disease 2.26 1.07–4.79 0.032 Presentation at the hospital 6 hours after trauma 2.04 0.78–5.20 0.138 Delayed amputation (48 hours) 2.95 1.38–6.42 0.006 Stump Deep SSI 3.56 1.58–8.07 0.002 SSI, surgical site infection; Discussion Despite significant advancements in limb salvage techniques, such as surgical stabilization, vascular repair, microsurgical free tissue transfer, and antibiotic therapy, the question of whether to amputate or attempt limb salvage remains. The treatment strategy depends on isolated lower extremity injury, polytrauma, or coexisting hemorrhagic shock. [ 19 , 20 ] Therefore, a multidisciplinary approach to mangled lower extremities, especially in collaboration with trauma surgeons, orthopedic surgeons, and plastic surgeons, is mandatory based on patients’ medical conditions to provide optimal treatment. However, previous studies have not demonstrated ISS. Furthermore, most studies have a relatively low ISS in the study population, and few studies have been conducted in patients with lower extremity mangled injuries combined with multiple severe traumas. [ 6 , 8 , 13 – 15 , 21 ] In this study, the majority (67%) of the population had an ISS > 15, indicating our study includes a relatively larger number of severely injured patients compared to previous studies. Although vascular injuries to the extremities are rare in civilian settings, blunt trauma is a major cause of vascular trauma and contributes to increased mortality and morbidity. Therefore, aggressive hemorrhage control should follow the ATLS guidelines, including resuscitation and surgical approaches. [ 22 , 23 ] In the present study, the early amputation group showed more severe limb ischemia, implying peripheral vascular injury; hence, massive transfusion was more frequently required, whereas vascular reconstruction was less likely to occur in the early amputation group. The LEAP study reported a higher incidence of complications in the late amputation group, including wound infection, osteomyelitis, and residual limb complications. In addition, the severity of soft tissue injury may be the most important factor in decision-making regarding amputation or limb salvage. [ 5 , 10 , 13 ] Urrechaga et al. suggested that the high-energy mechanism of blunt trauma is associated with a significant rate of limb loss. [ 14 ] A high-energy soft tissue injury stimulates the inflammatory process and microvascular cascade, which causes tissue hypoxia and further tissue injury. [ 22 ] Those crushing injuries induce muscle cell damage and release diverse substances, including creatine phosphokinase, myoglobin, and potassium, into the systemic circulation. This process is defined as rhabdomyolysis and can lead to various complications, such as compartment syndrome and acute kidney injury. [ 24 ] The compartment syndrome develops with increased pressure within the osseofascial space, leading to microvascular compromise and tissue injury. [ 25 ] Interestingly, our study showed that delayed amputation was associated with a higher incidence of rhabdomyolysis and compartment syndrome in the injured extremities, and tissue necrosis on the stumps and osteomyelitis were more common. In the present study, there was no association between delayed amputation and mortality; however, delayed amputation increased the overall incidence of trauma-related complications. Although not statistically significant, the incidence of renal replacement therapy was higher in the delayed amputation group, which may have been due to the relatively increased incidence of rhabdomyolysis. Delayed amputation is also associated with the occurrence of decubitus ulcers. Applying plaster splints, immobilization of patients, and poor tissue perfusion results in medical conditions that could be important etiologies of decubitus ulcers, prolonging hospital length of stay and causing financial burden. [ 26 , 27 ] In addition, despite being statistically insignificant, the incidences of urinary tract infection and severe sepsis were relatively higher in the delayed amputation group in our study. Our study also revealed a tendency toward increased hospital LOS and mechanical ventilator days in the delayed amputation group, indicating that patients with delayed amputation may require a longer period for additional surgeries and handling of complications. When we stratified the results according to ISS, we observed a similar pattern for ISS 15. Tillmann et al. reported that the limb salvage strategy for mangled lower extremity patients could elevate the risk of AKI and prolong ICU and hospital stays; however, it did not affect mortality for multisystem injuries. [ 6 ] Although delayed amputation costs 2.5 times more than primary amputation, according to Bondurant et al. , this treatment strategy could provide additional time for patients and families with failed limb reconstruction to provide opportunities for psychological preparation, leading to satisfactory outcomes. [ 28 – 31 ] Shorter residual limbs are associated with physiological strain. Therefore, adequate soft tissue and stump lengths are essential for better functional outcomes. The selection of the anatomical level for amputation depends on the patient’s clinical status, including hemodynamics, vascular condition, soft tissue injury, and activity level. [ 12 ] Unfortunately, clinical decisions may not always be appropriate; re-amputation to a higher level is required for some patients with trauma, which can lead to worsening clinical and functional outcomes. Overall, 10.5% of patients required re-amputation in the present study due to trauma-related complications during the initial admission. There is a lack of studies on the re-amputation rate for mangled extremity injuries; it is surprising considering approximately 19% ipsilateral and contralateral re-amputation rates for patients with diabetes at one year. [ 32 ] Ebskov et al . suggested that ipsilateral re-amputation results from an inappropriate choice of the initial amputation level or postoperative complications, including infection. [ 11 ] Interestingly, our study demonstrated that the presence of deep surgical site infection and delayed amputation could be associated with re-amputation to a higher level. Our study had several strengths. We included a relatively large number of patients with severe multiple trauma compared to previous studies that considered ISS. Therefore, we hope that our study will help in the decision-making process for patients with severe polytrauma in level 1 or level 2 trauma centers. In addition, this study included only patients who were severely injured because of blunt trauma. Trauma specialists, including well-trained trauma surgeons, especially cardiovascular surgeons, were responsible for the primary survey and included initial resuscitation. Orthopedic trauma surgeons are also available for trauma resuscitation. Therefore, errors related to ineffective communication among specialties or unnecessary delays due to inappropriate procedures or imaging studies can be minimized. [ 33 ] However, this study had several limitations due to the data's retrospective nature. First, this was a single-center retrospective study; therefore, the generalizability of our results may be limited. Second, although this study was retrospective in design, assessing the predicted amputation level was difficult. To overcome this limitation, we retrospectively reviewed four trauma specialists based on all available clinical information, including EMR, clinical photographs, and CT angiography. In our trauma center, clinical photographs are routinely taken for all trauma patients as part of recording clinical information in the resuscitation area at the time of arrival. Third, we excluded patients who died within 48 h of hospital presentation because the cause of death could be other severe injuries such as traumatic brain injury or abdominal trauma. Fourth, our findings are representative of civilian trauma only. Long-term follow-up was not available due to the healthcare system; therefore, the results may not be generalizable to combat-inflicted injuries. Despite several limitations, this was the first study to assess the risk factors for changing the final amputation level. We found that delayed amputation and deep SSI on the stump could be important risk factors. Conclusion In our study, delayed amputation may have been a risk factor for shorter limb stumps due to re-amputation. Although we found no difference in overall mortality, delayed amputation to limb salvage could result in more trauma-related complications and prolonged hospital and ICU LOS. However, owing to the limitations of retrospective studies, there is a need for future multicenter prospective research on this topic. We expect our results to provide useful information for managing lower extremity injuries. Abbreviations ATLS Advanced Trauma Life Support LEAP Lower Extremity Assessment Project EMR Electrical medical records ISS Injury Severity Score AIS Abbreviated Injury Scale GCS Glasgow Coma Scale CT Computed tomography MESS Mangled extremity severity score ICU Intensive care unit LOS Length of stay IRB Intuitional Review Board PRC Packed Red Cell SD Standard deviation IQR Inter-quartile range SSI Surgical site infection Declarations Author Contribution J. K., W. C.1(Wanseon Choi), W. C.2 (Wontae Cho) and J. M. were involved in the conception and design of the study. All authors performed data collection and analysis. J. K. and J. M. performed interpretation, writing the manuscript, and critical revision. All authors approved the final manuscript. Data availability statement The datasets used and analyzed during the current study available from the corresponding author on reasonable request. Ethics decalarations The authors declare no competing interests. References Aldea, P. A. & Shaw, W. W. The evolution of the surgical management of severe lower extremity trauma. Clin. Plast. Surg. 13, 549-569 (1986). Schirò, G. R., Sessa, S., Piccioli, A. & Maccauro, G. Primary amputation vs limb salvage in mangled extremity: A systematic review of the current scoring system. BMC Musculoskelet. Disord. 16, 372 (2015). Bok, S. K. & Song, Y. Fact sheet of amputee 10-year trends in Korea: From 2011 to 2020. Ann. Rehabil. Med. 46, 221-227 (2022). Ziegler-Graham, K., MacKenzie, E. J., Ephraim, P. L., Travison, T. G. & Brookmeyer, R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch. Phys. Med. Rehabil. 89, 422-429 (2008). Huh, J., Stinner, D. J., Burns, T. C. & Hsu, J. R. Late amputation Study Team: Infectious complications and soft tissue injury contribute to late amputation after severe lower extremity trauma. J. Trauma 71(1), S47-S51 (2011). Tillmann, B. W. et al. The timing of amputation of mangled lower extremities does not predict post-injury outcomes and mortality: A retrospective analysis from the ACS TQIP database. J. Trauma Acute Care Surg. 91, 447-456 (2021). Surgeons ACo: 10th edition of the Advanced Trauma Life Support ® (ATLS ® ) Student Course Manual; 2018. Bosse, M. J. et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N. Engl. J. Med. 347, 1924-1931 (2002). Francel, T. J., Vander Kolk, C. A., Hoopes, J. E., Manson, P. N. & Yaremchuk, M. J. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: Timing of coverage and long-term functional results. Plast. Reconstr. Surg. 89, 478-487; discussion 488 (1992). Harris, A. M. et al. Complications following limb-threatening lower extremity trauma. J. Orthop. Trauma 23, 1-6 (2009). Ebskov, B. & Josephsen, P. Incidence of reamputation and death after gangrene of the lower extremity. Prosthet. Orthot. Int. 4, 77-80 (1980). Penn-Barwell, J. G. Outcomes in lower limb amputation following trauma: A systematic review and meta-analysis. Injury 42, 1474-1479 (2011). Swiontkowski, M. F., MacKenzie, E. J., Bosse, M. J., Jones, A. L. & Travison, T. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J. Trauma Acute Care Surg. 52, 641-649 (2002). Urrechaga, E. et al. Traumatic lower extremity vascular injuries and limb salvage in a civilian urban trauma center. Ann. Vasc. Surg. 82, 30-40 (2022). Williams, Z. F., Bools, L. M., Adams, A., Clancy, T. V. & Hope, W. W. Early versus delayed amputation in the setting of severe lower extremity trauma. Am. Surg. 81, 564-568 (2015). de Mestral, C., Sharma, S., Haas, B., Gomez, D. & Nathens, A. B. A contemporary analysis of the management of the mangled lower extremity. J. Trauma Acute Care Surg. 74, 597-603 (2013). Johansen, K., Daines, M., Howey, T., Helfet, D. & Hansen, S. T. J. Objective criteria accurately predict amputation following lower extremity trauma. J. Trauma 30, 568-572; discussion 572 (1990). von Elm, E. et al. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. BMJ 335, 806-808 (2007). Bumbaširević, M. et al. Mangled extremity- Modern concepts in treatment. Injury 52, 3555-3560 (2021). Prasarn, M. L., Helfet, D. L. & Kloen, P. Management of the mangled extremity. Strateg. Trauma Limb Reconstr. 7, 57-66 (2012). Doukas, W. C. 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. 95, 138-145 (2013). Liang, N. L. et al. Contemporary outcomes of civilian lower extremity arterial trauma. J. Vasc. Surg. 64, 731-736 (2016). Muckart, D. J., Pillay, B., Hardcastle, T. C. & Skinner, D. L. Vascular injuries following blunt polytrauma. Eur. J. Trauma Emerg. Surg. 40, 315-322 (2014). Chatzizisis, Y. S., Misirli, G., Hatzitolios, A. I. & Giannoglou, G. D. The syndrome of rhabdomyolysis: Complications and treatment. Eur. J. Intern. Med. 19, 568-574 (2008). McGee, D. L. & Dalsey, W. C. The mangled extremity: Compartment syndrome and amputations. Emerg. Med. Clin. North Am. 10, 783-800 (1992). Bhattacharya, S. & Mishra, R. K. Pressure ulcers: Current understanding and newer modalities of treatment. Indian J. Plast. Surg. 48, 4–16 (2015). Jiao, Y. et al. Incidence of pressure injuries in fracture patients: A systematic review and meta-analysis. J. Tissue Viability 31, 726-734 (2022). Bennett, J. Limb loss: The unspoken psychological aspect. J. Vasc. Nurs. 34, 128-130 (2016). 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 Acute Care Surg. 27, 817 (1987). Loucas, C. A., Brand, S. R., Bedoya, S. Z., Muriel, A. C. & Wiener, L. Preparing youth with cancer for amputation: A systematic review. J. Psychosoc. Oncol. 35, 483-493 (2017). van der Merwe, L., Birkholtz, F., Tetsworth, K. & Hohmann, E. Functional and psychological outcomes of delayed lower limb amputation following failed lower limb reconstruction. Injury 47, 1756-1760 (2016). Liu, R., Petersen, B. J., Rothenberg, G. M. & Armstrong, D. G. Lower extremity re-amputation in people with diabetes: A systematic review and meta-analysis. BMJ Open Diabetes Res. Care 9 (2021). Scalea, T. M. et al. Western Trauma Association Critical Decisions in Trauma: Management of the mangled extremity. J. Trauma Acute Care Surg. 72, 86-93 (2012). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3887741","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":270378992,"identity":"ac0074a2-e276-49dc-b2a9-41ef81dc279f","order_by":0,"name":"Jinjoo Kim","email":"","orcid":"","institution":"Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jinjoo","middleName":"","lastName":"Kim","suffix":""},{"id":270378993,"identity":"dea5f8a6-123c-4fa2-99c1-1ab97d13934a","order_by":1,"name":"Wanseon Choi","email":"","orcid":"","institution":"Department of Orthopedic Surgery, Ajou University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wanseon","middleName":"","lastName":"Choi","suffix":""},{"id":270378994,"identity":"1ad5ca2c-5b7a-4252-8a2e-e8365180d634","order_by":2,"name":"Wontae Cho","email":"","orcid":"","institution":"Department of Orthopedic Surgery, Ajou University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wontae","middleName":"","lastName":"Cho","suffix":""},{"id":270378995,"identity":"c53ec5f4-2850-4e86-8ded-9ac2b8d6b20a","order_by":3,"name":"Jonghwan Moon","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYLCChAobOX7StDw4k2Ys2UCKDsaHbYcTDQ4Qq1y+vcfwQQIbc4Lx7eZnEh/3MMjzixHQbHDmjLFBAg9bntmdY2aSM54xGM6cnUBAi0SOmUSCBE+x2Y0EY2OeAwwJBrcJaJGfAdJiIJG4eUb6Z+M/xGhhuAHSkmCQuEEix/AxAzFaDM4cKzZIOJBgLHEjp/BhzwEJwn6Rb2/e+PDnv/9y/DPSNxz4ccBGnl+akMMYOAyQeRKElIMA+wNiVI2CUTAKRsFIBgDyekVg+UquIgAAAABJRU5ErkJggg==","orcid":"","institution":"Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jonghwan","middleName":"","lastName":"Moon","suffix":""}],"badges":[],"createdAt":"2024-01-22 11:04:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3887741/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3887741/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-93322-9","type":"published","date":"2025-03-10T15:57:39+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":50578834,"identity":"11a7a309-0a29-4433-98fd-91f7502ca6ef","added_by":"auto","created_at":"2024-02-02 18:10:50","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":68619,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow chart of the Study Population\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure13.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3887741/v1/10b4335f2d36f5eb0455359e.jpg"},{"id":50579599,"identity":"ff55c3ef-8b70-45be-8553-c3229b866202","added_by":"auto","created_at":"2024-02-02 18:18:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":635093,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of the final amputation level to the predicted level\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure23.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3887741/v1/00868e9d83d844208405a8c9.jpg"},{"id":78688977,"identity":"753797bb-e101-42c3-a984-d2db458cf2ef","added_by":"auto","created_at":"2025-03-17 16:09:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1869499,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3887741/v1/a514d4fc-612a-4dc9-ade7-f4bf35d8d67f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Timing on Lower Extremity Amputations in Blunt Polytrauma : A Retrospective Analysis of Clinical Outcomes and Risk Factors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHistorically, amputation has been regarded as the treatment for severe extremity trauma, and whether primary amputation or challenging limb salvage should be performed remains a topic of debate.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e In the study of the prevalence of limb amputation in the United States, trauma accounts for 45% of extremity amputations. In South Korea, the most common cause of lower extremity amputation is trauma, accounting for over 75% of cases.\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e A large number of patients with mangled extremities are relatively young and healthy people. Therefore, given the nature of limb amputation as a \u0026ldquo;life-changing\u0026rdquo; operation, physicians and patients might want to avoid amputation. Thus, limb salvage can be attempted in most situations despite advances in reconstructive techniques and medical treatment.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSevere lower-extremity trauma is a life-threatening event. Trauma surgeons are faced with emergencies in which amputation should be considered for hemorrhagic control in the operating room as part of the initial resuscitation according to the Advanced Trauma Life Support (ATLS) guidelines.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e In addition, the outcomes of challenging limb salvage are still debated. Previous studies, including the Lower Extremity Assessment Project (LEAP), insisted that limb salvage did not improve functional outcomes and showed a higher complication rate, resulting in prolonged hospital stays or multiple procedures. Delayed amputation, which involves limb salvage, was associated with more frequent major complications than early amputation.\u003csup\u003e[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe length of the residual limb is an essential outcome of treating the mangled extremity, which indicates the amputation level, and it may have a decisive effect on functional outcomes. Longer residual limbs have mechanical advantages and are associated with quality of life. However, re-amputation could be necessary because of the sequelae of postoperative complications, which cannot be handled through non-operative methods, and a shorter residual limb contributes to more significant physical strain. Therefore, re-amputation may affect functional outcomes in patients who have undergone previous amputations.\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFor trauma surgeons responsible for the initial resuscitation of patients with severe polytrauma, deciding the timing of amputation is vital for establishing a treatment strategy. Nonetheless, most previous studies have been conducted in trauma patients with relatively lower ISS, and studies on the association between the timing of amputation and re-amputation for severely injured patients are scarce.\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e We hypothesize that the timing of amputation could affect clinical outcomes and the rate of re-amputation, which may cause changes in amputation level.\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to compare clinical outcomes and the final amputation level and identify risk factors that change to a more proximal level according to the timing of the amputation.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eWe performed a retrospective study of patients presenting with a mangled lower extremity at a single level 1 trauma center over 7 years (2016\u0026ndash;2022) using the electronic medical records (EMR) of the patients included in this study.\u003c/p\u003e \u003cp\u003eWe included adults aged 18 years or older with lower extremity injuries. According to a previously published approach, a mangled extremity injury is defined as (1) a severe crushing injury or (2) a major fracture combined with selected severe injuries to at least two or three of the following: soft tissue, artery, or nerve.\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e Patients who died on arrival or within 48 h of hospital presentation were also excluded because their cause of death could be associated with other severe trauma, such as thoracic or abdominal injury, rather than the timing of amputation. Patients who underwent only midfoot or toe amputation or amputation for nontraumatic causes were excluded. Patients with incomplete or missing data were excluded.\u003c/p\u003e \u003cp\u003eAfter reviewing medical records, the following data were collected: patient demographics, injury characteristics, comorbidities, treatment courses, and complications. Injury characteristics were defined by injury mechanism, Injury Severity Score (ISS), and presence of concomitant severe head and neck, face, chest, abdomen, and/or pelvis injury, which is defined as an Abbreviated Injury Scale (AIS) score of \u0026gt;\u0026thinsp;3. We also assessed the presence of shock (a systolic blood pressure of less than 90 mmHg) and the Glasgow Coma Scale (GCS) score in the resuscitation area. Two trauma surgeons and two orthopedic surgeons evaluated lower extremity trauma regarding orthopedic, soft tissue, and vascular injury by reviewing medical records, clinical photography, radiography, and computed tomography (CT) and assessed the Mangle Extremity Severity Score (MESS).\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe patients were divided into two groups according to the timing of amputation: early or delayed. Patients who underwent amputation within 48 h of injury were classified into the early amputation group. Delayed amputation was defined as any amputation that occurred 48 h after the injury with the intention of limb salvage. The predicted amputation level was defined as the expected amputation level if lower extremity amputation was performed within 48 h of injury and evaluated by four trauma specialists, including two orthopedic surgeons and two trauma surgeons. One of the two trauma surgeons is a cardiovascular specialist. Four trauma specialists retrospectively reviewed the EMR images, clinical photographs, and initial lower-extremity CT angiography. After the review, they discussed whether there were disagreements about the predicted amputation level among the specialists.\u003c/p\u003e \u003cp\u003eOur primary outcome was to compare the final amputation level and identify the risk factors that changed to a more proximal amputation level according to the timing of the amputation. The secondary outcomes are the outcomes of patients with lower extremity mangled injury, including development of complications, mortality, hospital stay, and Intensive Care Unit (ICU) length of stay (LOS).\u003c/p\u003e \u003cp\u003eThe normality assumption was tested using the Shapiro\u0026ndash;Wilk test. When departures from normality were significant, the Mann-Whitney U test was used as a non-parametric method. When the data followed a normal distribution, a two-sample \u003cem\u003et\u003c/em\u003e-test was used for the analysis. Continuous variables are presented as mean\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\text{\u0026plusmn;}\\)\u003c/span\u003e\u003c/span\u003e standard deviation (SD) and median interquartile range (IQR). Dichotomous variables were compared using the chi-square test or Fisher\u0026rsquo;s exact test, as appropriate, and expressed as proportions. Considering the results of univariate analysis, the variables with P \u0026lt; 0.05 were included as candidates in the multivariable logistic regression analysis using a stepwise selection to identify the risk factors for changes at a more proximal amputation level than the predicted level. All statistical analyses were conducted using R software, version 4.1.2. A P-value \u0026lt; 0.05 was considered significant.\u003c/p\u003e \u003cp\u003eThe study was approved by the Institutional Review Board of our institution (IRB No. AJOUIRB-DB-2023-270), the requirement for informed consent was waived owing to the observational nature of this study. This study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Guidelines for Observational Studies.\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 199 patients were included in the analysis, of whom 132 (66.3%) underwent early amputation, and 67 (33.7%) were treated by delayed amputation. 24 patients were excluded from analysis (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The baseline characteristics of the patients are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Most patients in both groups were male, with an average age of 53 years, and had similar initial systolic blood pressure and GCS scores. There were no significant differences in the proportions of smokers and underlying diseases, except for hypertension. All patients experienced blunt trauma, and the ISS and mechanism of injury were not significantly different between the two groups (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline characteristics of patients with mangled extremity underwent lower extremity amputation, subdivided by the time of amputation\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEarly amputation\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;132)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDelayed amputation\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.2\u0026thinsp;\u0026plusmn;\u0026thinsp;18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.949\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.119\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102 (77.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (86.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMechanism of injury, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.176\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFree fall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMotor vehicle accident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMotorcycle accident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBicycle/Pedestrian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMachinery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther blunt injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (14.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArrived from, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eScene\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e107 (81.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (53.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOutside Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (46.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInitial SBP, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.203\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;90 mmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117 (88.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (82.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;90mmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInitial GCS, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.629\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInitial lactic acid (mmol/L), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.8 (2.1, 5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.6 (1.7, 4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.011\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKnown associated injuries, AIS\u0026thinsp;\u0026ge;\u0026thinsp;3, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHead and neck\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.777\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.551\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (44.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.771\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbdomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.446\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePelvis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.019\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eISS, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (10,26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (9, 24.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.458\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eISS\u0026thinsp;\u0026lt;\u0026thinsp;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (40.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.128\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eISS\u0026thinsp;\u0026ge;\u0026thinsp;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93 (70.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (59.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnderlying diseases, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (41.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.287\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiovascular disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.303\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeripheral disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.112\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCerebrovascular disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.098\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes Mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.859\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCKD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.337\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLiver disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026gt;\u0026thinsp;0.999\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (38.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.006\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCurrent smoker, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.771\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eSD, standard deviation; SBP, systolic blood pressure; GCS, Glasgow Coma Scale; IQR, interquartile ranges; AIS, abbreviated injury scale; ISS, injury severity scale; CKD, chronic kidney disease; HTN, hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates the MESS score used to assess the severity of lower-extremity management injury. MESS was significantly higher in the early amputation group (7.1\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\pm\\)\u003c/span\u003e\u003c/span\u003e1.5 vs. 6.0\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\pm\\)\u003c/span\u003e\u003c/span\u003e1.5, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In the early amputation group, most patients were injured by a very high-energy injury mechanism, significantly higher than the delayed amputation group (88.6% vs. 47.8%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Compared with the delayed amputation group, the early amputation group demonstrated a greater prevalence of severe limb ischemia, whereas the number of patients with ischemia longer than 6 h was notably higher in the delayed amputation group (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eInjury severity of lower extremity mangled injury according to MESS score\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEarly amputation\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;132)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDelayed amputation\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMESS score, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInjury mechanism (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow energy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedium energy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (22.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh energy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVery high energy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117 (88.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLimb ischemia (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReduced pulse but normal perfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (55.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePulseless, paresthesia, slow capillary refill\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (14.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCool, paralysis, numb/insensate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (29.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLimb ischemia for \u0026gt;\u0026thinsp;6hrs (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShock (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.190\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSBP\u0026thinsp;\u0026gt;\u0026thinsp;90mmHg consistently\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (56.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransient hypotension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersistent hypotension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.118\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;30yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30-50yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (14.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;50yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73 (55.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (68.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eMESS, mangled extremity severity score; SBP, systolic blood pressure\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eDelayed amputation was defined as any amputation that occurred more than 48 h after the injury; however, the mean time to amputation in this group was 11.9 \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\pm\\)\u003c/span\u003e\u003c/span\u003e 7.3 days. Although the proportion of patients requiring packed red cell (PRC) transfusion units was not significantly higher in the early amputation group (89.4% vs. 79.1%, P = 0.079), the rate of massive transfusion was significantly higher in that group (54.5% vs. 32.8%, P\u0026thinsp;=\u0026thinsp;0.004). Vascular procedures were more frequently performed in the delayed amputation group (10.6% vs. 26.9%, P\u0026thinsp;=\u0026thinsp;0.003). In the delayed amputation group, the most commonly performed vascular procedure was vascular reconstruction, whereas ligation of the vessels was the most frequent procedure in the early amputation group. Ipsilateral fractures above amputation level were more common in the early amputation group (20.5% vs. 35.8%, P\u0026thinsp;=\u0026thinsp;0.019). There were no statistically significant differences in the rates of re-amputation, predicted amputation level, final amputation level, and overall stump complications (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eProcedures, and complications related to lower extremity amputation\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEarly\u003c/p\u003e\n \u003cp\u003eamputation\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;132)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDelayed\u003c/p\u003e\n \u003cp\u003eamputation\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTiming of definitive amputation, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal numbers of operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePRC transfusion, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118 (89.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 (79.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.079\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransfusion within 24 hrs, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (4,15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3,15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.137\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMassive transfusion, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (32.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.004\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther orthopedic injury, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79 (59.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIpsilateral fractures above amputation level, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (35.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.019\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVascular procedure to ipsilateral leg, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.003\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThrombectomy only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReconstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVessel ligation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (64.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOpen amputation, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.601\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRe-amputation, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (19.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.097\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePredicted amputation level, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.112\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTranstarsal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBelow knee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54 (40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (58.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThrough knee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbove knee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (35.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (20.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinal amputation level, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.703\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBelow knee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (38.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThrough knee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbove knee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56 (42.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStump complication, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 (53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.836\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeep SSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (22.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.480\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuperficial SSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.551\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDehiscence/wound breakdown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.228\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTissue necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (43.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.011\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHematoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.122\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eSD, standard deviation: PRC, packed red cells; SSI, surgical site infection; IQR, interquartile ranges\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eHowever, there was a significant change in the predicted and final amputation levels between the two groups. The delayed amputation group showed a significantly greater final amputation level change rate to a more proximal level than initially predicted (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eDespite the lack of significant differences in the 30-day mortality rate between the two groups, the delayed amputation group experienced significantly more complications related to trauma and rhabdomyolysis (38.6% vs. 59.7%, p\u0026thinsp;=\u0026thinsp;0.005, 38.2% vs. 55.2%, P\u0026thinsp;=\u0026thinsp;0.022, respectively) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). The delayed amputation group experienced significantly more compartment syndrome on the injured limb (0% vs. 13.4%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and decubitus ulcer (9.1% vs. 23.9%, P\u0026thinsp;=\u0026thinsp;0.003). Osteomyelitis was observed more often in the delayed amputation group (0.8% vs. 7.5%, P\u0026thinsp;=\u0026thinsp;0.017) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePatient outcomes\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEarly amputation\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;132)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDelayed amputation\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30-day mortality, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.098\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital disposition, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.070\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInpatient rehab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93 (70.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56 (83.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHome with or without home care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (21.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (14.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReceived mechanical ventilation, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87 (65.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (58.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.287\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMode of ambulation at discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.828\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCrutches\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRolling walker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWheelchair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93 (76.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52 (78.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBed rest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProsthetic use, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.563\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProsthetic use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77 (64.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (66.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFollow up loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (27.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRhabdomyolysis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (55.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.022\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplications related to trauma, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (38.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (59.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.005\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAKI, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026gt;\u0026thinsp;0.999\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eARDS, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.446\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiac arrest, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.167\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDecubitus ulcer, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (23.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.005\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeep SSI, n (%)\u003csup\u003e\u0026alpha;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.149\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuperficial SSI, n (%)\u003csup\u003e\u0026alpha;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.604\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCompartment syndrome, n (%)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDVT, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.149\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFlap failure, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.112\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVAP, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.706\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePTE, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026gt;\u0026thinsp;0.999\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOrgan/Space surgical infection, n (%)\u003csup\u003e\u0026alpha;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.337\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStroke, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.112\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnplanned intubation, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.338\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrinary tract infection, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.063\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCRABSI, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026gt;\u0026thinsp;0.999\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteomyelitis, n (%)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.017\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnplanned return to OR, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.184\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnplanned return to the ICU, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.543\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSevere sepsis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.240\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRenal replacement therapy, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.187\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eAKI, acute kidney injury; ARDS, acute respiratory distress syndrome; SSI, surgical site infection; DVT, deep vein thrombosis; VAP, ventilator associated injury; PTE, pulmonary thromboembolism; CRABSI, catheter related blood stream infection; OR, operation room; ICU, intensive care unit\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e\u0026alpha;\u003c/sup\u003e Excluding the amputation site\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e Data related to the lower extremity amputation site only\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eBetween the two groups, ICU length of stay (LOS) (4 days [IQR, 2,9] vs. 7 days [IQR, 3,14], P\u0026thinsp;=\u0026thinsp;0.060) was not significantly different, whereas ventilator days (3 days [IQR, 1,8] vs. 5 days [IQR, 2,13.5], P\u0026thinsp;=\u0026thinsp;0.033) and hospital LOS (37.5 [IQR, 18,55.3] vs. 48 [IQR, 26.5,70.5], P\u0026thinsp;=\u0026thinsp;0.005) showed significant differences (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003ea). A similar result was observed when patients were stratified according to an ISS\u0026thinsp;\u0026lt;\u0026thinsp;15 (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003eb). On the contrary, among patients with an ISS of \u0026gt;\u0026thinsp;15, there were no significant differences between the two groups(Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003ec).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eICU LOS, MV days and Hospital LOS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(a) Entire population\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEarly amputation\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;132)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDelayed amputation\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eICU LOS, days, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2, 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (3, 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.060\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVentilator days, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (1, 8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (2, 13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.033\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital LOS, days, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.5 (18, 55.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (26.5, 70.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.005\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eCI, Confidence Interval; ICU, intensive care unit; LOS, length of stay; IQR, Interquartile range\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(b) ISS \u0026lt;15\u003c/strong\u003e\u003c/p\u003e\n \u003ctable style=\"border: none;width:432.35pt;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:175.05pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 4.95pt 0in 4.95pt;height:17.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eISS \u0026lt;15\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:106.35pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 4.95pt 0in 4.95pt;height:17.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;'\u003eEarly amputation\u003cbr\u003e\u0026nbsp;(n=39)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:85.05pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 4.95pt 0in 4.95pt;height:17.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;'\u003eDelayed amputation\u003cbr\u003e\u0026nbsp;(n=27)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:65.9pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 4.95pt 0in 4.95pt;height:17.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eP\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003evalue\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:175.05pt;padding:0in 4.95pt 0in 4.95pt;height: 18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eICU LOS, days, median (IQR)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:106.35pt;padding:0in 4.95pt 0in 4.95pt;height: 18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e3 (2, 4)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:85.05pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e4 (2, 8.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:65.9pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family: \"Times New Roman\",serif;'\u003e0.097\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:175.05pt;padding:0in 4.95pt 0in 4.95pt;height: 18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eVentilator days, median (IQR)\u003c/span\u003e\u003csup\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003ea\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:106.35pt;padding:0in 4.95pt 0in 4.95pt;height: 18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e1 (1, 2)\u003c/span\u003e\u003csup\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;a\u0026nbsp;\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:85.05pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e5 (4.3, 12.5)\u003c/span\u003e\u003csup\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;b\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:65.9pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family: \"Times New Roman\",serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:175.05pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eHospital LOS, days,\u0026nbsp;\u003c/span\u003e\u003cspan style=\"font-size:15px;\"\u003em\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eedian (IQR)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:106.35pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e21 (14.5, 35.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:85.05pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e42 (25.5, 63)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:65.9pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 4.95pt 0in 4.95pt;height:18.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:center;font-size:10.0pt;font-family:\"Malgun Gothic\",sans-serif;line-height:normal;'\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family: \"Times New Roman\",serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eCI, Confidence Interval; ICU, intensive care unit; LOS, length of stay; IQR, Interquartile range\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e n=20; \u003csup\u003eb\u0026nbsp;\u003c/sup\u003en=10\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(c)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eISS\u003c/strong\u003e\u003cstrong\u003e\u0026ge;\u003c/strong\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"580\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.13793103448276%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"23.96551724137931%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEarly amputation\u003cbr\u003e\u0026nbsp;(n=93)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.20689655172414%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelayed amputation\u003cbr\u003e\u0026nbsp;(n=40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.689655172413794%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.13793103448276%\"\u003e\n \u003cp\u003eICU LOS, days, median (IQR)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.96551724137931%\"\u003e\n \u003cp\u003e6 (3, 13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.20689655172414%\"\u003e\n \u003cp\u003e7.5 (3.8, 14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.689655172413794%\"\u003e\n \u003cp\u003e\u003cem\u003e0.114\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.13793103448276%\"\u003e\n \u003cp\u003eVentilator days, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.96551724137931%\"\u003e\n \u003cp\u003e4 (1, 13)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.20689655172414%\"\u003e\n \u003cp\u003e5 (2, 13)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.689655172413794%\"\u003e\n \u003cp\u003e\u003cem\u003e0.416\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.13793103448276%\"\u003e\n \u003cp\u003eHospital LOS, days,\u0026nbsp;median (IQR)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.96551724137931%\"\u003e\n \u003cp\u003e44 (20, 66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.20689655172414%\"\u003e\n \u003cp\u003e49.5 (29.8, 72.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.689655172413794%\"\u003e\n \u003cp\u003e\u003cem\u003e0.102\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eCI, Confidence Interval; ICU, intensive care unit; LOS, length of stay; IQR, Interquartile range\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e n=67; \u003csup\u003eb\u0026nbsp;\u003c/sup\u003en=29\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e presents the risk factors for changes at a more proximal amputation level than the predicted level based on multivariate logistic regression analysis. The odds of delayed amputation after 48 h of injury were 2.95 times higher among the participants (adjusted odds ratio 2.95; 95% CI 1.38\u0026ndash;6.24; P\u0026thinsp;=\u0026thinsp;0.006). In addition, preexisting underlying disease and deep surgical site infection of the amputation stump were statistically significant risk factors for changes at a more proximal amputation level than the predicted level (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eRisk factors for changes at a more proximal amputation level than the predicted level\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOdds Ratio\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnderlying disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.07\u0026ndash;4.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.032\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresentation at the hospital 6 hours after trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.78\u0026ndash;5.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e0.138\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDelayed amputation (48 hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.38\u0026ndash;6.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.006\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStump Deep SSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.58\u0026ndash;8.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cem\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:red;'\u003e0.002\u003c/span\u003e\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eSSI, surgical site infection;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eDespite significant advancements in limb salvage techniques, such as surgical stabilization, vascular repair, microsurgical free tissue transfer, and antibiotic therapy, the question of whether to amputate or attempt limb salvage remains. The treatment strategy depends on isolated lower extremity injury, polytrauma, or coexisting hemorrhagic shock.\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e Therefore, a multidisciplinary approach to mangled lower extremities, especially in collaboration with trauma surgeons, orthopedic surgeons, and plastic surgeons, is mandatory based on patients\u0026rsquo; medical conditions to provide optimal treatment.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eHowever, previous studies have not demonstrated ISS. Furthermore, most studies have a relatively low ISS in the study population, and few studies have been conducted in patients with lower extremity mangled injuries combined with multiple severe traumas.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e In this study, the majority (67%) of the population had an ISS\u0026thinsp;\u0026gt;\u0026thinsp;15, indicating our study includes a relatively larger number of severely injured patients compared to previous studies.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAlthough vascular injuries to the extremities are rare in civilian settings, blunt trauma is a major cause of vascular trauma and contributes to increased mortality and morbidity. Therefore, aggressive hemorrhage control should follow the ATLS guidelines, including resuscitation and surgical approaches.\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e In the present study, the early amputation group showed more severe limb ischemia, implying peripheral vascular injury; hence, massive transfusion was more frequently required, whereas vascular reconstruction was less likely to occur in the early amputation group.\u003c/p\u003e\u003cp\u003eThe LEAP study reported a higher incidence of complications in the late amputation group, including wound infection, osteomyelitis, and residual limb complications. In addition, the severity of soft tissue injury may be the most important factor in decision-making regarding amputation or limb salvage.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e Urrechaga \u003cem\u003eet al.\u003c/em\u003e suggested that the high-energy mechanism of blunt trauma is associated with a significant rate of limb loss.\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e A high-energy soft tissue injury stimulates the inflammatory process and microvascular cascade, which causes tissue hypoxia and further tissue injury.\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e Those crushing injuries induce muscle cell damage and release diverse substances, including creatine phosphokinase, myoglobin, and potassium, into the systemic circulation. This process is defined as rhabdomyolysis and can lead to various complications, such as compartment syndrome and acute kidney injury.\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e The compartment syndrome develops with increased pressure within the osseofascial space, leading to microvascular compromise and tissue injury.\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e Interestingly, our study showed that delayed amputation was associated with a higher incidence of rhabdomyolysis and compartment syndrome in the injured extremities, and tissue necrosis on the stumps and osteomyelitis were more common.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn the present study, there was no association between delayed amputation and mortality; however, delayed amputation increased the overall incidence of trauma-related complications. Although not statistically significant, the incidence of renal replacement therapy was higher in the delayed amputation group, which may have been due to the relatively increased incidence of rhabdomyolysis. Delayed amputation is also associated with the occurrence of decubitus ulcers. Applying plaster splints, immobilization of patients, and poor tissue perfusion results in medical conditions that could be important etiologies of decubitus ulcers, prolonging hospital length of stay and causing financial burden.\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e In addition, despite being statistically insignificant, the incidences of urinary tract infection and severe sepsis were relatively higher in the delayed amputation group in our study.\u003c/p\u003e \u003cp\u003eOur study also revealed a tendency toward increased hospital LOS and mechanical ventilator days in the delayed amputation group, indicating that patients with delayed amputation may require a longer period for additional surgeries and handling of complications. When we stratified the results according to ISS, we observed a similar pattern for ISS\u0026thinsp;\u0026lt;\u0026thinsp;15, whereas early amputation did not have an advantage for ICU LOS and hospital LOS for ISS\u0026thinsp;\u0026gt;\u0026thinsp;15. Tillmann \u003cem\u003eet al.\u003c/em\u003e reported that the limb salvage strategy for mangled lower extremity patients could elevate the risk of AKI and prolong ICU and hospital stays; however, it did not affect mortality for multisystem injuries.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e Although delayed amputation costs 2.5 times more than primary amputation, according to Bondurant \u003cem\u003eet al.\u003c/em\u003e, this treatment strategy could provide additional time for patients and families with failed limb reconstruction to provide opportunities for psychological preparation, leading to satisfactory outcomes.\u003csup\u003e[\u003cspan additionalcitationids=\"CR29 CR30\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eShorter residual limbs are associated with physiological strain. Therefore, adequate soft tissue and stump lengths are essential for better functional outcomes. The selection of the anatomical level for amputation depends on the patient\u0026rsquo;s clinical status, including hemodynamics, vascular condition, soft tissue injury, and activity level.\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e Unfortunately, clinical decisions may not always be appropriate; re-amputation to a higher level is required for some patients with trauma, which can lead to worsening clinical and functional outcomes. Overall, 10.5% of patients required re-amputation in the present study due to trauma-related complications during the initial admission. There is a lack of studies on the re-amputation rate for mangled extremity injuries; it is surprising considering approximately 19% ipsilateral and contralateral re-amputation rates for patients with diabetes at one year.\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e Ebskov \u003cem\u003eet al\u003c/em\u003e. suggested that ipsilateral re-amputation results from an inappropriate choice of the initial amputation level or postoperative complications, including infection.\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e Interestingly, our study demonstrated that the presence of deep surgical site infection and delayed amputation could be associated with re-amputation to a higher level.\u003c/p\u003e \u003cp\u003eOur study had several strengths. We included a relatively large number of patients with severe multiple trauma compared to previous studies that considered ISS. Therefore, we hope that our study will help in the decision-making process for patients with severe polytrauma in level 1 or level 2 trauma centers. In addition, this study included only patients who were severely injured because of blunt trauma. Trauma specialists, including well-trained trauma surgeons, especially cardiovascular surgeons, were responsible for the primary survey and included initial resuscitation. Orthopedic trauma surgeons are also available for trauma resuscitation. Therefore, errors related to ineffective communication among specialties or unnecessary delays due to inappropriate procedures or imaging studies can be minimized.\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, this study had several limitations due to the data's retrospective nature. First, this was a single-center retrospective study; therefore, the generalizability of our results may be limited. Second, although this study was retrospective in design, assessing the predicted amputation level was difficult. To overcome this limitation, we retrospectively reviewed four trauma specialists based on all available clinical information, including EMR, clinical photographs, and CT angiography. In our trauma center, clinical photographs are routinely taken for all trauma patients as part of recording clinical information in the resuscitation area at the time of arrival. Third, we excluded patients who died within 48 h of hospital presentation because the cause of death could be other severe injuries such as traumatic brain injury or abdominal trauma. Fourth, our findings are representative of civilian trauma only. Long-term follow-up was not available due to the healthcare system; therefore, the results may not be generalizable to combat-inflicted injuries. Despite several limitations, this was the first study to assess the risk factors for changing the final amputation level. We found that delayed amputation and deep SSI on the stump could be important risk factors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn our study, delayed amputation may have been a risk factor for shorter limb stumps due to re-amputation. Although we found no difference in overall mortality, delayed amputation to limb salvage could result in more trauma-related complications and prolonged hospital and ICU LOS. However, owing to the limitations of retrospective studies, there is a need for future multicenter prospective research on this topic. We expect our results to provide useful information for managing lower extremity injuries.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eATLS Advanced Trauma Life Support\u003c/p\u003e\n\u003cp\u003eLEAP Lower Extremity Assessment Project\u003c/p\u003e\n\u003cp\u003eEMR Electrical medical records\u003c/p\u003e\n\u003cp\u003eISS Injury Severity Score\u003c/p\u003e\n\u003cp\u003eAIS Abbreviated Injury Scale\u003c/p\u003e\n\u003cp\u003eGCS Glasgow Coma Scale\u003c/p\u003e\n\u003cp\u003eCT Computed tomography\u003c/p\u003e\n\u003cp\u003eMESS Mangled extremity severity score\u003c/p\u003e\n\u003cp\u003eICU Intensive care unit\u003c/p\u003e\n\u003cp\u003eLOS Length of stay\u003c/p\u003e\n\u003cp\u003eIRB Intuitional Review Board\u003c/p\u003e\n\u003cp\u003ePRC Packed Red Cell\u003c/p\u003e\n\u003cp\u003eSD Standard deviation\u003c/p\u003e\n\u003cp\u003eIQR Inter-quartile range\u003c/p\u003e\n\u003cp\u003eSSI Surgical site infection\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ. K., W. C.1(Wanseon Choi), W. C.2 (Wontae Cho) and J. M. were involved in the conception and design of the study. All authors performed data collection and analysis. J. K. and J. M. performed interpretation, writing the manuscript, and critical revision. All authors approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData availability statement\u003c/h2\u003e \u003cp\u003eThe datasets used and analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n \u003ch2\u003eEthics decalarations\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e "},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAldea, P. A. \u0026amp; Shaw, W. W. The evolution of the surgical management of severe lower extremity trauma. \u003cem\u003eClin. Plast. Surg.\u003c/em\u003e 13, 549-569\u003cem\u003e \u003c/em\u003e(1986).\u003c/li\u003e\n\u003cli\u003eSchir\u0026ograve;, G. 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Trauma Acute Care Surg.\u003c/em\u003e 72, 86-93\u003cem\u003e \u003c/em\u003e(2012).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3887741/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3887741/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDelayed amputation after failed limb salvage can lead to negative clinical and functional outcomes due to complications, including re-amputation. This study aimed to compare clinical outcomes and identify risk factors according to the timing of amputation. A retrospective review of managed lower-extremity injuries was conducted between January 2016 and December 2022 at a level 1 trauma center. Outcomes were compared between the early amputation and the delayed amputation groups (within and beyond 48 h after the time of injury, respectively). The primary outcome of interest was that the risk factors changed to a more proximal amputation level according to the timing of amputation. The secondary outcomes included trauma-related complications and clinical outcomes. The incidence of trauma-related complications was more common in the delayed amputation group with no significant differences in 30-day mortality. Delayed amputation and stump site deep surgical infection were associated with higher odds of changing to a more proximal level than initially predicted. The overall hospital stay was significantly longer in the delayed amputation group. Although patients and clinicians prefer the limb salvage strategy, delayed amputation could be a risk factor for shorter limb stumps due to re-amputation, and patients may experience more trauma-related complications and prolonged hospitalization.\u003c/p\u003e","manuscriptTitle":"Impact of Timing on Lower Extremity Amputations in Blunt Polytrauma : A Retrospective Analysis of Clinical Outcomes and Risk Factors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-02 18:10:45","doi":"10.21203/rs.3.rs-3887741/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-19T11:03:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-13T10:01:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-11T14:52:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282927215148952553414073896884283986602","date":"2024-06-09T01:40:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108866687031402712056891811732061773193","date":"2024-06-06T23:26:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-08T17:03:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2e22cbf2-65da-4238-9346-b6b6a9727def","date":"2024-04-12T14:34:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-21T11:57:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301bde76-b749-4896-b621-70857eba62e9","date":"2024-03-12T07:01:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-27T02:13:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-27T01:58:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-02-01T04:36:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-01T04:32:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-01-22T11:03:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e6bb643-4707-44ae-b150-1f066148d889","owner":[],"postedDate":"February 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":28498906,"name":"Health sciences/Medical research"},{"id":28498907,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2025-03-17T16:01:29+00:00","versionOfRecord":{"articleIdentity":"rs-3887741","link":"https://doi.org/10.1038/s41598-025-93322-9","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-03-10 15:57:39","publishedOnDateReadable":"March 10th, 2025"},"versionCreatedAt":"2024-02-02 18:10:45","video":"","vorDoi":"10.1038/s41598-025-93322-9","vorDoiUrl":"https://doi.org/10.1038/s41598-025-93322-9","workflowStages":[]},"version":"v1","identity":"rs-3887741","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3887741","identity":"rs-3887741","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}