Risk Factors for Limb Amputations in Modern Warfare Trauma: New Perspectives

Shachar Shapira; Sharon Goldman; Adi Givon; Eldad Katorza; Israel Dudkiewicz; Danny Epstein; Dan Prat

doi:10.5435/JAAOS-D-24-00935

Risk Factors for Limb Amputations in Modern Warfare Trauma: New Perspectives

J Am Acad Orthop Surg. 2025 Jan 3. doi: 10.5435/JAAOS-D-24-00935. Online ahead of print.

Authors

Shachar Shapira¹, Sharon Goldman, Adi Givon, Eldad Katorza, Israel Dudkiewicz, Danny Epstein, Dan Prat

Affiliation

¹ From the Israel Defense Forces, Medical Corps, Kiryat Ono (Shapira, and Epstein), the Faculty of Medicine, The Hebrew University, Jerusalem (Shapira), the Sheba Medical Center, Tel Hashomer, Ramat Gan (Shapira), the Israel National Center for Trauma and Emergency Medicine Research, Gertner Institute of Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan (Goldman, Givon, and Katorza), the Arrow Program for Medical Research Education, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan (Katorza), the Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv (Katorza, Dudkiewicz, and Prat), the Rehabilitation Division, Sheba Medical Center, Tel Hashomer, Ramat Gan (Dudkiewicz), the Critical Care Division, Rambam Health Care Campus, Haifa (Epstein), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa (Epstein), and the Department of Orthopaedic Surgery, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel (Prat).

PMID: 39804819
DOI: 10.5435/JAAOS-D-24-00935

Abstract

Background: In modern conflicts, extremities are mainly affected, with limb amputations required for approximately 5% of severely injured combatants and 7% of those with serious limb injuries. Amputations are some of the most challenging injuries endured by survivors, significantly affecting the patients and the healthcare system. This study aims to describe the rates, characteristics, and risk factors of limb amputations in patients with serious extremity trauma during the 2023 conflict in Israel.

Methods: This nationwide retrospective cohort study, based on the Israel National Trauma Registry, includes all patients with serious extremity injuries (abbreviated injury score ≥3) from October 7 to December 31, 2023. Demographic and clinical characteristics, as well as outcomes of patients with limb amputations were compared with those who were not amputated. Multivariable logistic regression was used to identify risk factors for amputations.

Results: Among the 1,815 combat-related casualties, 1,318 (72.6%) sustained extremity injuries, and 451 (24.8%) had serious limb injuries. Most patients with severe limb injuries were young males, with 287 of 451 being soldiers. 150 of 451 were injured by explosions, and 158 of 451 had severe and critical injuries (ISS ≥16). Of 451 patients, 52 (11.5%) underwent limb amputations (43 lower limbs, eight upper limbs, and one both). Amputees were significantly more likely to be injured by explosions (76.9% vs. 27.6%, P < 0.001), have an ISS of ≥16 (75.0% vs. 29.8%, P < 0.001), and have polytrauma (46.1% vs. 27.1%, P = 0.004). Independent risk factors for amputation included explosions (adjusted odds ratio [aOR] 9.74, 95% confidence interval [CI] 4.83 to 21.32, P < 0.001), fasciotomy (aOR 8.51, 95% CI 2.82 to 25.74, P < 0.001), and polytrauma (aOR 1.98, 95% CI 1.03 to 3.78, P = 0.04). Vascular injuries were not associated with amputations (aOR 0.87, 95% CI 0.39 to 1.85, P = 0.72).

Conclusions: In recent conflicts, amputation rates have risen, likely due to increased tissue destruction from modern weaponry and improved survival rates among severely injured patients. Those with multiple severe injuries, blast injuries, or requiring fasciotomies face a higher risk of amputation.