Limb salvage versus primary amputation in severe lower extremity trauma: a systematic review and meta-analysis.

Background: The optimal management of severe lower extremity trauma remains controversial, with debate between limb salvage and primary amputation. Recent evidence synthesis is needed to guide clinical decision-making. Objectives: To compare functional outcomes, quality of life, complications, and economic factors between limb salvage and primary amputation in severe lower extremity trauma. Data sources: Electronic searches of five databases (PubMed, Embase, Cochrane CENTRAL, Scopus, Web of Science) from January 2000 to January 2025, supplemented by hand-searching of reference lists. Study eligibility criteria participants and interventions: Eligible studies were randomized controlled trials and prospective and retrospective cohort studies with a minimum 12-month follow-up assessing severe lower limb trauma (Gustilo-Anderson IIIB/IIIC or MESS (Mangled Extremity Severity Score) ≥7). Interventions were limb salvage compared with primary amputation. Forty-seven studies involving 8742 patients (4318 limb salvage, 4424 amputation) were identified. Study appraisal and synthesis methods: Systematic review and meta-analysis conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. Risk of bias assessed using ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions); certainty of evidence evaluated using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. Results: Quality of life metrics showed no clinically meaningful differences at 2-year follow-up (Short Form-36 (SF-36) Physical Component Summary: standardized mean differences (SMD) 0.16, p=0.0001; EQ-5D: SMD 0.07, p=0.31). Functional outcomes were comparable between groups (SMD 0.12, p=0.09). Limb salvage demonstrated modestly higher return-to-work rates (risk ratio (RR) 1.08, p=0.03) but required 4.7 months longer recovery. However, limb salvage was associated with significantly higher complications: 2.5-fold increased infection rates (RR 2.54, p<0.001), 87% higher re-hospitalization (RR 1.87, p<0.001), and 34% increased chronic pain prevalence (RR 1.34, p<0.001). Secondary amputation occurred in 22.7% of salvage attempts. Initial healthcare costs were significantly higher for salvage (mean difference $28 600, p<0.001), converging over 15+ years. Psychological outcomes were comparable between groups. Limitations: The evidence base was predominantly observational, limiting causal inference, and residual confounding by injury severity and patient selection could not be excluded. Outcome measurement was heterogeneous across studies, and most studies originated from high-income countries, limiting generalisability to resource-limited settings. Conclusions or implications of key findings: Long-term functional outcomes and quality of life are comparable between limb salvage and primary amputation despite substantially higher complication burdens with salvage. Findings support a paradigm shift toward individualized, shared decision-making incorporating injury characteristics, patient preferences, and realistic outcome expectations.Systematic review registration number. Systematic review registration number: PROSPERO CRD420251236066.