Injury, Int. J.

Care Injured 42 (2011) 1474–1479

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Outcomes in lower limb amputation following trauma: A systematic review and

meta-analysis
Jowan G. Penn-Barwell 1,*
Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (RCDM), ICT Research Park, Vincent Drive, Edgbaston, Birmingham B15 2SQ, UK

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: Lower limb amputation (LLA) is life-changing surgery. Shorter residual limbs are known to
Accepted 7 July 2011 place greater physiological strain on patients than longer residual limbs; however, there is ongoing
debate as to whether through-knee amputations are preferable to above-knee amputations. This
Keywords: analysis aims to resolve this question by systematically collecting and pooling published and
Injury unpublished data on this subject.
Trauma Methods: An exhaustive search of Medline, Embase and Recal databases was made for outcome studies
Amputation
of patients with lower limb amputations following trauma. Studies concerned with amputations of the
Leg
Lower-limb
upper limb or foot and ankle were excluded as were papers reporting outcomes in a population of mixed
Outcomes trauma and non-trauma patients. Authors of studies published in the last 10 years were contacted for
Results unpublished details. Patients were then divided, according to amputation height, into four groups:
Rehabilitation below-knee amputation (BKA), through-knee amputation (TKA), above-knee amputation (AKA) and
Combat bilateral amputation. The primary outcome measure was Physical Component Score (PCS) of the short-
Wounds form-36 measure of quality of life and secondary outcomes were pain, employment, ability to walk
500 m and proportion of time that prosthesis is worn.
Results: As many as 27 studies were included, representing a total of 3105 patients, 1855 with a BKA, 104
with a TKA, 888 with an AKA and 258 bilateral amputees. There was progressive and significant lowering
of PCS (worsening outcomes) as unilateral amputation height became more proximal from BKA to TKA
and AKA. A significantly greater proportion of patients with a BKA or a TKA were able to walk 500 m than
those with an AKA or bilateral amputation (p = 0.0035). However, patients with a TKA wore their
prosthesis significantly less, and had significantly more pain than those with an AKA.
Conclusion: This study describes the impact of LLA of different levels on patients’ lives. The results
indicate that patients with a TKA have a better physical quality of life than those with an AKA and,
therefore, support the surgical strategy of maintaining maximum length and performing TKA in
preference to AKA, where possible.
ß 2011 Elsevier Ltd. All rights reserved.

Limb amputation is life-changing surgery. The extent of the
likely impact on a specific patient treated with lower-limb
amputation (LLA) will depend on a variety of factors, one of the
principal ones being the height of amputation.1 For surgeons to
answer their patients’ concerns about their future mobility,
symptoms, and lifestyles, they need accurate information about
the likely impact of different levels of LLA.
Whilst it has long been accepted that the more proximal an LLA,
the greater the resulting physiological demand,2 the precise nature
of the relationship between amputation height and mobility, pain
and quality of life is less well understood. Whilst most clinicians
* Tel.: +44 7810867555.
E-mail address: Jowan@doctors.net.uk.
1
On behalf of the Severe Lower Extremity Combat Trauma (SeLECT) study group.
might assume that outcomes are poorer with more proximal
amputations, there is uncertainty as to the strength of this
relationship, the significance of retaining the knee joint and
whether a patient with a through-knee amputation (TKA) ‘does
better’ than a patient with an above-knee amputation (AKA).1,3
Interpreting the literature in this area is challenging. Studies
often include patients with traumatic and nontraumatic causes for
their amputation and do not differentiate between different levels. A
further challenge is that the research on traumatic LLA is published
across a wide range of academic journals, from the core orthopaedic
and trauma publications to journals of military or rehabilitation
medicine and those representing the allied health professions.
The 2009 British Orthopaedic Association/British Association of
Plastic, Reconstructive and Aesthetic Surgeons (BOA/BAPRAS)
guidelines on open fractures argue against TKA in adults4 on the
basis of the results of the Lower Extremity Amputation Project

0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2011.07.005
 J.G. Penn-Barwell / Injury, Int. J. Care Injured 42 (2011) 1474–1479
(LEAP).5 This runs contrary to the experience of the Defence
Medical Services who anecdotally report positive results of TKA
compared to AKA. This discordance between guidelines and
clinical experience motivated this systematic examination of
published literature.
The aim of this study is to provide accurate information on the
likely outcome following LLA at specific levels by systematically
collecting published research and then pooling and analysing the
results by level of amputation.
Methods
The principal medical literature databases, Embase and Medline,
together with the RECAL database of physical medicine and
rehabilitation, were searched in December 2010 by using a series
of search strategies built on combinations of: injury, trauma,
amputation, leg, lower-limb, outcomes, results and rehabilitation,
in a number of combinations as both keywords and title words.
Abstracts of the search results were reviewed for relevance.
Abstracts that did not mention trauma or injury were excluded.
Published studies cited by or which referenced these articles were
also retrieved and similarly reviewed. Full copies of the publica-
tions were then acquired and reviewed in depth. Papers were
excluded if they did not contain quantitative examination of
either: mobility, function, quality of life, prosthesis use, employ-
ment, or pain. Studies concerned with amputations of the foot and
ankle were excluded as were papers reporting outcomes in a
population of mixed trauma and nontrauma patients or upper and
lower limb amputees, if they contained data presented in a form
that did not allow separate analysis of trauma LLA cohorts.
Authors of studies from the last 10 years were contacted for
their unpublished data in order that published results could be
further analysed, particularly with respect to amputation height,
defined in this study as trans-tibial or below-knee amputation
(BKA), TKA, AKA or bilateral amputation. Studies were then
reviewed to determine which outcomes could be meaningfully
pooled. Studies that did not present results in these outcomes in a
form that allowed data to be pooled according to amputation
height were then discarded. When several publications describe a
single project, all component papers were cited, but the work is
referred to as a single study.
Meta-analysis of data
Physical Component Scores (PCS) of the 36-item Short Form
(SF-36) scores and associated standard deviations (SD) were
pooled together. Due to insufficient studies providing SD for their
prosthesis use results, the largest SD within a set of data was
adopted for that whole group.
The ability to walk greater than 500 m was stated specifically in
some studies, derived from individual walking distances in others
or adapted from individual patient responses to an item in the SF-
36 questionnaire, indicating that they were unlimited in their
ability to walk several hundred yards, several blocks’ or ‘several
hundred metres depending on the translation.
Pain is part of a complex spectrum of unpleasant symptoms
and, as such, was examined in a variety of ways by different
studies: data were dichotomised and analysed as a single symptom
with a rate of prevalence. Similarly, employment was treated as a
binary variable in some studies, but categorical in others. In studies
that gave greater detail on employment, this was dichotomised by
regarding employment as only those in full-time employment and
as opposed to those in education or part-time employment, along
with those not working.
PCS and prosthesis use results were then analysed using a
two-tailed t-test. A Fisher’s variation of the chi-test was used to
1475
examine variation between employment, pain and mobility
rates.
Results
The number of studies that included outcomes in traumatic LLA
patients was 35. A review of these studies determined that the
outcome measures commonly used across the studies that could
be pooled were PCS, mobility (ability to walk 500 m), prevalence of
pain symptoms, prosthesis use and employment rate, with PCS
regarded as the principal outcome measure. Eight studies6–15 were
excluded for either not using these outcomes or for not including
published or unpublished results allowing amputation levels to be
analysed separately. The remaining 27 studies, listed in Table 1,
represent a total of 3105 patients, 1855 with a BKA, 104 with a TKA,
888 with an AKA and 258 bilateral amputees. Twelve of these
studies include patients with combat-type injuries, which included
civilians injured in armed conflict.16
Three types of studies were included: the majority were
retrospective cohort studies of patients identified from hospital or
rehabilitation centre databases and who either had their medical
records reviewed or were invited to a fresh review. Only one
prospective study was included, the Lower Extremity Amputation
Project (LEAP).5,17 The third group was case–control studies that
included outcome data on patients who had received LLA in
comparison with those who were managed with limb salvage
surgery.
Quality of life
The SF-36 score is a measure of health-related quality of life
generated from a patient questionnaire. It allows calculation of
overall and separate physical and emotional component scores,
each expressed as a value between 0 and 100 with a high score
representing a better quality of life.18 There was a progressive and
significant lowering of PCS as unilateral amputation height became
more proximal from BKA to TKA and AKA (see Fig. 1). Unexpect-
edly, patients with bilateral lower-limb amputations had a score of
55.9, implying a higher quality of life than patients with an AKA or
TKA; this score was lower but statistically similar to those with a
BKA (p = 0.0673).
Mobility
Approximately three-quarters of patients with a BKA or TKA
could walk at least 500 m. The proportion of patients with a TKA
able to walk 500 m was greater than those with either an AKA or
bilateral amputations (p = 0.0035) (see Fig. 2). There was no
significant difference between patients with an AKA and those
with bilateral amputations (p = 0.8).
Employment
Returning to work is one of the main goals of rehabilitation. This
was achieved approximately in 70% of all patients with a LLA,
regardless of height (see Fig. 3). In the sub-group of military
patients, only 59 of 366 (16%) patients with a BKA returned to duty
in the military: this was achieved by 31 of the 283 (11%) with an
AKA. These rates were statistically similar (p = 0.1114). None of the
nine patients with a TKA or the 65 patients with a bilateral
amputation returned to duty.
Prosthesis use
Patients with a BKA wore their prosthesis significantly more
than those with an AKA. Patients with a TKA wore their prosthesis
1476 J.G. Penn-Barwell / Injury, Int. J. Care Injured 42 (2011) 1474–1479

Table 1
Studies included in meta-analysis and which elements they contributed to.

Study n FU Mobility SF-36 Employment Painful Prosthesis

(years) PCS rate stump use
symptoms

Reiber VA/DoD LLA Study: 135 BKA 19 TKA 118 AKA 50 Bilateral 37  
Vietnam (31–34) Combat
Reiber VA/DoD LLA Study: 133 BKA 13 TKA 106 AKA 42 Bilateral 3  
OIF/OEF31–34 Combat
RTD
Stinner35 Combat 142 BKA 89 AKA 65 Bilateral 2+ RTD
Taghipour36 Combat 60 BKA 38 TKA 43 AKA 22    
Ebrahmizad37,38 Combat 96 BKA 31 AKA 18   
Tekin39 Combat 10 BKA 4  
Rotter40 Civilian 45 BKA 34 AKA 9   
Gunawardena41 Combat 413 BKA 48 AKA 6 Bilateral 4   
Graham, 200616 Combat 16 BKA 25 AKA 15 Bilateral 22  
Herbert42 Civilian 20 BKA 12 AKA U/K 
Geertzen43 Civilian 70 BKA 11 TKA 18   
50 AKA 7 Bilateral
5,17
LEAP Civilian 81 BKA 16 TKA 2   
27 AKA 10 Bilateral
Dougherty44–46 Combat 72 BKA 46 AKA 23 Bilateral 28   
Hoogendoorn47 Civilian 18 BKA U/K 
Atesalp48 Combat 29 Bilateral 3 
Dagum49 Civilian 14 BKA 4 
Burger50 Civilian 115 BKA 2 TKA 30 
102 AKA
Hertel51 Civilian 18 BKA 7   
Smith52 Civilian 20 BKA 6    
Dahl53 Civilian 30 BKA 7  
Kishbaugh54 Combat 131 BKA 79 AKA U/K RTD
Walker55 Civilian 47 BKA 26 AKA 7 Bilateral 15   
Fairhurst56 Civilian 12 BKA 1+ 
Livingston57 Civilian 21 BKA 5 AKA 4 Bilateral 2 
Pederson58 Civilian 14 BKA 4 TKA 4 AKA 9 
Purry59Civilian 25 BKA 8    
Groom60 Combat 18 BKA 1 TKA 2 RTD
9 AKA
Hoaglund15 Mixed 77 BKA 38 AKA 21 

FU, follow-up time given as a mean or minimum when followed by a ‘‘+’’; RTD, Return to duty (military); VA, veterans administration (US); DoD, department of defence (U.S.);
OIF/OEF, operation Iraqi freedom/operation enduring freedom, conflicts in Iraq and Afghanistan, 2001 present.

significantly less than either of the other two unilateral groups (see
Fig. 4). Patients with bilateral LLAs wore their prosthesis the least
(p < 0.0001).
Pain symptoms
The prevalence of pain associated with the patient’s stump was
similar in patients with a BKA and an AKA (p = 0.0082). Pain was
significantly more common in patients with TKA (p < 0.0001). Pain
was significantly less common in patients with bilateral LLA (see
Fig. 5).
Discussion
Meta-analysis of the results of these studies consistently
demonstrates a significantly better outcome in patients with a
BKA than those with an AKA across all measures. With respect to
the principal outcome measure, SF-36 PCS patients with a TKA
have significantly superior outcomes than those with an AKA.
Meta-analysis was originally developed to pool results of
prospective, interventional trials.19 The application of this
technique to observational studies does raise methodological
issues but is still regarded as valid.20 Due to the nature of literature

Fig. 1. SF-36 Physical Component Scores by amputation height with error bars
showing standard deviation and size of diamond corresponding to group size. p- Fig. 2. Ability to walk 500 m by amputation level with significant difference is
values between groups are shown. shown.
 J.G. Penn-Barwell / Injury, Int. J. Care Injured 42 (2011) 1474–1479
Fig. 3. Employment rate by amputation height; differences between groups are not
statistically different.
in this area, it was decided that vigorous exclusion of papers on
methodological grounds, e.g., because of poor inclusion criteria,
would lead to excessive exclusion. This study benefits from the
large number of patients included and the use of unpublished data
from published studies, allowing significantly more precise
conclusions to be reached.
There is no consensus on the most appropriate outcome
measure for patients with a lower-extremity amputation, and a
wide array has been used in previous studies.21 The outcome
measures included in this study were used solely because they best
allowed the pooling of data. The SF-36 PCS is the only outcome
measure in this analysis that is well validated and that
incorporates physical functioning, role limitation, energy, pain
and perception of health22 and is therefore regarded as the
principal outcome measure. Pain and employment require little
explanation; the ability to walk 500 m and the duration of daily
prosthesis are less obvious measures. The ability to walk a distance
equivalent to approximately 500 m has been identified as a key
threshold to enable independent living23 and was used as it was
possible to collate data across a range of studies, unlike the wide
range of other measures of mobility that were also used. Prosthesis
use is widely regarded as an outcome measure because it is
believed to be a surrogate marker of the extent of rehabilitation
and stump health but has not been validated as such.6,24,25
Amputation due to injury is relatively rare and is the cause of
only 10–20% of lower-limb loss in the developed world.
Approximately 55% of civilian LLA for trauma are BKA, 40% AKA,
less than 5% TKA and 1% bilateral amputations.26 Because of the
low incidence of TKA and bilateral amputation, most studies
recruit low numbers of these amputees. Even well-designed
studies like LEAP that recruited patients over 40 months from eight
U.S. level-1 trauma centres only recruited 18 patients with TKA.
LEAP was a prospective study with minimal selection bias
whilst the methodology of many of the other studies included in
this analysis may introduce bias. For example, a significant
Fig. 4. Mean prosthesis use in mean hours/day by amputation height. Error bars
showing standard deviation and size of diamond corresponding to group size.
Significance of differences betweens groups is shown.
1477
Fig. 5. Painful symptoms associated with stump by amputation height; statistical
differences are shown.
proportion of the patients with a TKA in this analysis were from
Taghipour and Moharamzad’s 2009 study. They recruited patients
from Iran’s tertiary prosthesis centre who, by definition as a cohort,
had greater difficulties than the wider LLA population.
Aside from the dependency of this analysis on retrospective
studies, an unavoidable weakness of this project was the need to
regard outcomes that were defined and examined slightly
differently as being consistent. This was most apparent with
walking distance data that were collated from studies that had
collected and handled those data in different ways.
The amputation height groups will clearly not be homogeneous.
This will be most pronounced in the bilateral amputation group,
which regards patients with two BKAs as the same those with two
AKAs. This is a potential weakness, but necessary in order to allow
meaningful comparisons to be made.
The significantly superior PCS in patients with a TKA compared
to an AKA, revealed by the large numbers of pooled patients in this
analysis, has implications for clinical practice. The high PCS
amongst patients with a bilateral amputation is unexpected. Over
half of the patients from this pooled group come from Dougherty’s
study of Vietnam veterans who had a mean PCS of 68.5 compared
to the rest of the group, which was 39. In a personal communica-
tion, Dr. Dougherty suggested that this was likely to be due to a
combination of relief at having survived such significant trauma
and eligibility for maximum Veteran’s Administration benefits
allowing for a reasonable quality of life.
Those patients with more distal amputations were more mobile
than those with an AKA or bilateral amputation is not surprising,
given the mechanical advantage of a longer residual limb stump
and this is consistent with previous biomechanical research.2 The
finding that patients with a TKA have significantly more stump
pain and wear their prostheses significantly less than other
unilateral amputees’ results suggests that there might be difficul-
ties associated with prosthetic fitting for patients with a TKA.
Indeed, TKA prostheses are essentially designed for AKAs, but in a
TKA, the axis of the ‘knee’ joint is lower than the contra-lateral real
knee, complicating gait training.27 This appears to negate the
postulated theory that the femoral condyles provide a superior
load-bearing surface than a transosseous amputation.28 It is
reasonable to speculate whether this effect might be due in part to
prosthetic services’ lack of experience with caring for patients with
a TKA, given the relative rarity of amputations at this level.26 The
reluctance to perform through-knee amputations has been
commented on by other authors, and may be due to the high
rate of revision to AKA when performed for vascular indica-
tions.29,30
Of recent studies on this subject, LEAP remains the most
significant because of its robust methodology. The main conclu-
sions drawn by this study and LEAP are consistent; i.e., patients
with a BKA are likely to have a better outcome than those with an
1478 J.G. Penn-Barwell / Injury, Int. J. Care Injured 42 (2011) 1474–1479
AKA. The findings comparing outcomes in patients receiving a TKA
or an AKA differ. Whilst LEAP found that a TKA is associated with a
lower quality of life, less mobility but less pain, this analysis
demonstrated a better quality of life and more mobility but
significantly more pain.
It is possible to interpret the findings regarding the relative
outcomes associated with TKA and AKA in light of the stump of the
residual limb. Soft tissue coverage can be sub-optimal at this level,
and it may possibly result in greater pain and therefore less
prosthesis use. However, the extra length of the stump or the
residual limb provides a superior lever arm, likely related to the
superior mobility compared to a more proximal amputation and
therefore less impact on the quality of life. The findings of this
meta-analysis indicate that TKA should be considered in prefer-
ence to AKA where appropriate, outcomes might be further
improved with more attention focused on the design of prosthesis
specifically tailored to TKAs. It also supports ‘stump-salvage’
where plastic surgical techniques are used to maximise stump
length in circumstances where there is sufficient bone but
inadequate soft tissue to achieve a more distal amputation level.
Conclusions
This study describes the impact of LLA of different levels on
patients’ lives. The results indicate that patients with a TKA have a
better quality of life than those with an AKA and therefore support
the surgical strategy of maintaining maximum length and
performing TKA in preference to AKA where possible.
The opinions or assertions contained herein are the private
views of the authors and are not to be construed as official or as
reflecting the views of the Ministry of Defence or Her Majesty’s
Government.
No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the
subject of this article.
Acknowledgements
James K. Aden PhD, Statistician, US Army Institute of Surgical
Research, San Antonio, Texas, Ms. Otilia Sánchez, M.A., Medical
Writer/Editor, U.S. Army Institute of Surgical Research, Prof Jon
Clasper MBA DPhil DM FRCSEd(Orth), Col L/RAMC, Defence
Professor Trauma & Orthopaedics, Mr Mike Rowe and his Staff
at the Defence Medical Library Services, Whittington Barracks, UK.
The following authors who generously shared unpublished
elements of previously published studies and assisted with further
analysis of their work:
Prof Gayle E. Reiber MPH PhD, VA Puget Sound Health Care
System and University of Washington, Washington, USA.
Capt Daniel Stinner MD, Brook Army Medical Centre, San
Antonio, Texas, USAProf Nalika Gunawardena MD, University of
Colombo, Sri Lanka, Dr Hamidreza Taghipour MD and Dr Yashar
Moharamzad MD, Baqiyatallah Medical Sciences Centre, Iran, Dr
Lorraine Graham FRCP, Musgrave Park Hospital, Northern Ireland,
UK, Prof Jan Geertzen and Prof Pieter Dijkstra, University Hospital
Groningen, The Netherlands.
References
1. Pinzur MS, Gottschalk FA, Pinto MA, Smith DG. Controversies in lower-extrem-
ity amputation. J Bone Joint Surg Am 2007;89(May (5)):1118–27.
2. Waters RL, Perry J, Antonelli D, Hislop H. Energy cost of walking of amputees:
the influence of level of amputation. J Bone Joint Surg Am 1976;58(January
(1)):42–6.
3. Perry J. Below-the-knee compared with above-the-knee amputation. J Bone
Joint Surg Am 2005;87(May (5)):1162–3. author reply 3.
4. Nanchahal J, Nayagam S, Khan U, Moran C, Barrett S, Sanderson F, et al. Standards
of the management of open fractures of the lower limb. 1 ed. London: Royal Society of
Medicine Press; 2009.
5. MacKenzie EJ, Bosse MJ, Castillo RC, Smith DG, Webb LX, Kellam JF, et al.
Functional outcomes following trauma-related lower-extremity amputation.
J Bone Joint Surg Am 2004;86-A(August (8)):1636–45.
6. Dillingham TR, Pezzin LE, MacKenzie EJ, Burgess AR. Use and satisfaction
with prosthetic devices among persons with trauma-related amputations:
a long-term outcome study. Am J Phys Med Rehabil 2001;80(August (8)):
563–71.
7. Pezzin LE, Dillingham TR, MacKenzie EJ. Rehabilitation and the long-term
outcomes of persons with trauma-related amputations. Arch Phys Med Rehabil
2000;81(March (3)):292–300.
8. Dillingham TR, Braverman SE, Belandres PV. Persian Gulf War amputees:
injuries and rehabilitative needs. Mil Med 1994;159(October (10)):635–9.
9. Lange RH, Bach AW, Hansen Jr ST, Johansen KH. Open tibial fractures with
associated vascular injuries: prognosis for limb salvage. J Trauma 1985;25(March
(3)): 203–8.
10. Millstein S, Bain D, Hunter GA. A review of employment patterns of industrial
amputees—factors influencing rehabilitation. Prosthet Orthot Int 1985;9(August
(2)):69–78.
11. Hutchins PM. The outcome of severe tibial injury. Injury 1981;13(November
(3)):216–9.
12. Melcer T, Walker GJ, Galarneau M, Belnap B, Konoske P. Midterm health and
personnel outcomes of recent combat amputees. Mil Med 2010;175(March
(3)):147–54.
13. Hagberg K, Branemark R, Gunterberg B, Rydevik B. Osseointegrated trans-
femoral amputation prostheses: prospective results of general and condi-
tion-specific quality of life in 18 patients at 2-year follow-up. Prosthet Orthot
Int 2008;32(March (1)):29–41.
14. Burger H, Marincek C, Jaeger RJ. Prosthetic device provision to landmine
survivors in Bosnia and Herzegovina: outcomes in 3 ethnic groups. Arch Phys
Med Rehabil 2004;85(January (1)):19–28.
15. Hoaglund FT, Jergesen HE, Wilson L, Lamoreux LW, Roberts R. Evaluation of
problems and needs of veteran lower-limb amputees in the San Francisco Bay
Area during the period 1977–1980. J Rehabil R D 1983;20(July (1)):57–71.
16. Graham L, Parke RC, Paterson MC, Stevenson M. A study of the physical
rehabilitation and psychological state of patients who sustained limb loss as
a result of terrorist activity in Northern Ireland 1969–2003. Disabil Rehabil
2006;28(June (12)):797–801.
17. Smith JJ, Agel J, Swiontkowski MF, Castillo R, Mackenzie E, Kellam JF. Functional
outcome of bilateral limb threatening: lower extremity injuries at two years
postinjury. J Orthop Trauma 2005;19(April (4)):249–53.
18. Ware Jr JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I.
Conceptual framework and item selection. Med Care 1992;30(June (6)):473–83.
19. Egger M, Smith GD, Phillips AN. Meta-analysis: principles and procedures. BMJ
1997;315(December (7121)):1533–7.
20. Egger M, Schneider M, Smith DG. Spurious precision?. Meta-analysis of obser-
vational studies. BMJ 1998;316(January (7125)):140–4.
21. Condie E, Scott H, Treweek S. Lower limb prosthetic outcome measures: a
review of the literature 1995–2005. J Prosthet Orthot 2006;18(6):13–45.
22. Hays RD, Hahn H, Marshall G. Use of the SF-36 and other health-related quality
of life measures to assess persons with disabilities. Arch Phys Med Rehabil
2002;83(December (12 Suppl. 2)):S4–9.
23. van der Schans CP, Geertzen JH, Schoppen T, Dijkstra PU. Phantom pain and
health-related quality of life in lower limb amputees. J Pain Symptom Manage
2002;24(October (4)):429–36.
24. Pohjolainen T, Alaranta H, Karkkainen M. Prosthetic use and functional and
social outcome following major lower limb amputation. Prosthet Orthot Int
1990;14(2):75–9.
25. Gauthier-Gagnon C, Grise M-C, Potvin D. Predisposing factors related to pros-
thetic use by people with a transtibial and transfemoral amputation. J Prosthet
Orthot 1998;10(4):99–109.
26. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency:
epidemiology and recent trends in the United States. South Med J 2002;95(Au-
gust (8)):875–83.
27. Mensch G. Physiotherapy following through-knee amputation. Prosthet Orthot
Int 1983;7(August (2)):79–87.
28. Pinzur MS, Gottschalk F, Pinto MA, Smith DG. Controversies in lower extremity
amputation. Instr Course Lect 2008;57:663–72.
29. Jensen JS, Poulsen TM, Krasnik M. Through-knee amputations. Acta Orthop
Scand 1982;53(June (3)):463–6.
30. Newcombe JF, Marcuson RW. Through-knee amputation. Br J Surg 1972;59(April
(4)):260–6.
31. Dougherty PJ, McFarland LV, Smith DG, Esquenazi A, Blake DJ, Reiber GE.
Multiple traumatic limb loss: a comparison of Vietnam veterans to OIF/OEF
servicemembers. J Rehabil Res Dev 2010;47(4):333–48.
32. Epstein RA, Heinemann AW, McFarland LV. Quality of life for veterans and
servicemembers with major traumatic limb loss from Vietnam and OIF/OEF
conflicts. J Rehabil Res Dev 2010;47(4):373–85.
33. Gailey R, McFarland LV, Cooper RA, Czerniecki J, Gambel JM, Hubbard S, et al.
Unilateral lower-limb loss: prosthetic device use and functional outcomes in
servicemembers from Vietnam war and OIF/OEF conflicts. J Rehabil Res Dev
2010;47(4):317–31.
34. Reiber GE, McFarland LV, Hubbard S, Maynard C, Blough DK, Gambel JM, et al.
Servicemembers and veterans with major traumatic limb loss from Vietnam
 J.G. Penn-Barwell / Injury, Int. J. Care Injured 42 (2011) 1474–1479
war and OIF/OEF conflicts: survey methods, participants, and summary find-
ings. J Rehabil Res Dev 2010;47(4):275–97.
35. Stinner DJ, Burns TC, Kirk KL, Ficke JR. Return to duty rate of amputee soldiers in
the current conflicts in Afghanistan and Iraq. J Trauma 2010;68(June (6)):1476–9.
36. Taghipour H, Moharamzad Y, Mafi AR, Amini A, Naghizadeh MM, Soroush MR,
et al. Quality of life among veterans with war-related unilateral lower extremity
amputation: a long-term survey in a prosthesis center in Iran. J Orthop Trauma
2009;23(August (7)):525–30.
37. Ebrahimzadeh MH, Hariri S. Long-term outcomes of unilateral transtibial
amputations. Mil Med 2009;174(June (6)):593–7.
38. Ebrahimzadeh MH, Fattahi AS. Long-term clinical outcomes of Iranian veterans
with unilateral transfemoral amputation. Disabil Rehabil 2009;31(22):1873–7.
39. Tekin L, Safaz Y, Goktepe AS, Yazycyodlu K. Comparison of quality of life and
functionality in patients with traumatic unilateral below knee amputation and
salvage surgery. Prosthet Orthot Int 2009;33(March (1)):17–24.
40. Rotter KP, Robles K, Fuentes M, Carbonell C. Traumatic lower extremity ampu-
tees of the hospital del trabajador I. Laboral and functional aspects [Spainish].
Ciencia and Trabajo 2008;10(28):63–7.
41. Gunawardena NS, Seneviratne Rde A, Athauda T. Functional outcomes of
unilateral lower limb amputee soldiers in two districts of Sri Lanka. Mil Med
2006;171(April (4)):283–7.
42. Hebert JS, Ashworth NL. Predictors of return to work following traumatic work-
related lower extremity amputation. Disabil Rehabil 2006;28(May (10)):613–8.
43. Geertzen JH, Bosmans JC, van der Schans CP, Dijkstra PU. Claimed walking
distance of lower limb amputees. Disabil Rehabil 2005;27(February (3)):101–4.
44. Dougherty PJ. Long-term follow-up of unilateral transfemoral amputees from
the Vietnam war. J Trauma 2003;54(April (4)):718–23.
45. Dougherty PJ. Transtibial amputees from the Vietnam war twenty-eight-year
follow-up. J Bone Joint Surg Am 2001;83-A(March (3)):383–9.
46. Dougherty PJ. Long-term follow-up study of bilateral above-the-knee amputees
from the Vietnam war. J Bone Joint Surg Am 1999;81(October (10)):1384–90.
47. Hoogendoorn JM, van der Werken C. Grade III open tibial fractures: functional
outcome and quality of life in amputees versus patients with successful
reconstruction. Injury 2001;32(May (4)):329–34.
1479
48. Atesalp AS, Erler K, Gur E, Koseglu E, Kirdemir V, Demiralp B. Bilateral lower
limb amputations as a result of landmine injuries. Prosthet Orthot Int
1999;23(April (1)):50–4.
49. Dagum AB, Best AK, Schemitsch EH, Mahoney JL, Mahomed MN, Blight KR.
Salvage after severe lower-extremity trauma: are the outcomes worth the
means? Plast Reconstr Surg 1999;103(April (4)):1212–20.
50. Burger H, Marincek C, Isakov E. Mobility of persons after traumatic lower limb
amputation. Disabil Rehabil 1997;19(July (7)):272–7.
51. Hertel R, Strebel N, Ganz R. Amputation versus reconstruction in traumatic
defects of the leg: outcome and costs. J Orthop Trauma 1996;10(4):223–9.
52. Smith DG, Horn P, Malchow D, Boone DA, Reiber GE, Hansen Jr ST. Prosthetic
history, prosthetic charges, and functional outcome of the isolated, traumatic
below-knee amputee. J Trauma 1995;38(January (1)):44–7.
53. Dahl B, Andersson AP, Andersen M, Andersen GR, Ebskov LB, Reumert T.
Functional and social long-term results after free tissue transfer to the lower
extremity. Ann Plast Surg 1995;34(April (4)):372–5.
54. Kishbaugh D, Dillingham TR, Howard RS, Sinnott MW, Belandres PV. Am-
putee soldiers and their return to active duty. Mil Med 1995;160(February
(2)):82–4.
55. Walker CR, Ingram RR, Hullin MG, McCreath SW. Lower limb amputation
following injury: a survey of long-term functional outcome. Injury 1994;25(Au-
gust (6)):387–92.
56. Fairhurst MJ. The function of below-knee amputee versus the patient
with salvaged grade III tibial fracture. Clin Orthop Relat Res 1994;(April
(301)):227–32.
57. Livingston DH, Keenan D, Kim D, Elcavage J, Malangoni MA. Extent of disability
following traumatic extremity amputation. J Trauma 1994;37(September
(3)):495–9.
58. Pedersen P, Damholt V. Rehabilitation after amputation following lower limb
fracture. J Trauma 1994;36(February (2)):195–7.
59. Purry NA, Hannon MA. How successful is below-knee amputation for injury?
Injury 1989;20(January (1)):32–6.
60. Groom AF, Coull JT. Army amputees from the Falklands—review. J R Army Med
Corps 1984;130(June (2)):114–6.