An updated meta-analysis of prognostic factors for secondary amputation following surgical repair of lower-extremity vascular trauma in both civilian and military populations

BACKGROUND: Lower-extremity vascular trauma (LEVT) remains a major cause of limb loss. A thorough understanding of prognostic factors associated with secondary amputation is essential for guiding decision-making, patient counselling, and risk stratification. This study aimed to further our understanding by incorporating novel risk factors and distinguishing outcomes between contemporary military and civilian populations. METHODS: A systematic review was conducted to identify prognostic factors for amputation following LEVT repair. Bayesian meta-analysis was employed to calculate each factor’s absolute pooled proportion, odds ratio, and 95% credible interval for secondary amputation. RESULTS: Sixty-nine studies, describing 8,553 limbs, were included. The pooled secondary amputation rate was 12.6% (12.0% in civilian and 14.9% in military populations). The strongest predictors were prolonged ischemia, major soft-tissue injury, compartment syndrome, fracture or dislocation, multiple-level arterial injury, and shock. High-energy mechanisms, such as explosive and blunt trauma, were also associated with a greater risk than penetrating injury. Among treatment-related factors, interposition grafting was linked to higher amputation rates than primary repair, while temporary vascular shunt use and prophylactic fasciotomy showed a modest association, particularly in civilian populations. Prehospital tourniquet use was not significantly associated with amputation. Demographic variables, venous repair, and graft type were also not predictive. Notable differences were observed between civilian and military injuries. CONCLUSIONS: Secondary amputation remains common following LEVT repair, affecting approximately one in eight limbs. This meta-analysis reaffirms the prognostic importance of prolonged ischemia, shock, and compartment syndrome, alongside broader markers of injury severity. Emerging treatment-related factors likely reflect injury complexity rather than modifiable determinants. Differences between civilian and military cohorts highlight the need for tailored prognostic algorithms. Decision-making should prioritize early recognition of injury severity, rapid revascularisation, and anticipation of limb recovery trajectory. ( J Trauma Acute Care Surg. 2026;00: 000–000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level II.