{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T14:48:54Z","timestamp":1787755734529,"version":"build-2784847793"},"reference-count":35,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"17","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2021,9,1]]},"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>Selecting the best treatment for patients with severe terminal lower-limb injury remains a challenge. For some injuries, amputation may result in better outcomes than limb salvage. This study compared the outcomes of patients who underwent limb salvage with those that would have been achieved had they undergone amputation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>This multicenter prospective observational study included patients 18 to 60 years of age in whom a Type-III pilon or IIIB or C ankle fracture, a Type-III talar or calcaneal fracture, or an open or closed blast\/crush foot injury had been treated with limb salvage (n = 488) or amputation (n = 151) and followed for 18 months. The primary outcome was the Short Musculoskeletal Function Assessment (SMFA). Causal effect estimates of the improvement that amputation would have provided if it had been performed instead of limb salvage were calculated for the SMFA score, physical performance, pain, participation in vigorous activities, and return to work.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>The patients who underwent limb salvage would have had small differences in most outcomes had they undergone amputation. The most notable difference was an improvement in the SMFA mobility score of 7 points (95% confidence interval [CI] = 2.0 to 10.7). Improvements were largest for pilon\/ankle fractures and complex injury patterns.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>Amputation should be considered a treatment option rather than a last resort for the most complex terminal lower-limb injuries.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence:<\/jats:title>\n                    <jats:p>\n                      Therapeutic\n                      <jats:underline>Level II<\/jats:underline>\n                      . See Instructions for Authors for a complete description of levels of evidence.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.2106\/jbjs.20.01320","type":"journal-article","created":{"date-parts":[[2021,5,12]],"date-time":"2021-05-12T15:00:12Z","timestamp":1620831612000},"page":"1588-1597","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":30,"title":["Outcomes Following Severe Distal Tibial, Ankle, and\/or Mid\/Hindfoot Trauma"],"prefix":"10.2106","volume":"103","author":[{"name":"Major Extremity Trauma Research Consortium (METRC)","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2021,5,12]]},"reference":[{"issue":"24","key":"bib1-20250430","doi-asserted-by":"crossref","first-page":"1924","DOI":"10.1056\/NEJMoa012604","article-title":"An analysis of outcomes of reconstruction or amputation after leg-threatening injuries","volume":"347","author":"Bosse","year":"2002","journal-title":"N Engl J Med."},{"issue":"1","key":"bib2-20250430","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1097\/BOT.0b013e31825121b6","article-title":"The mangled foot and ankle: results from a 2-year prospective study","volume":"27","author":"Ellington","year":"2013","journal-title":"J Orthop Trauma."},{"issue":"5","key":"bib3-20250430","doi-asserted-by":"crossref","first-page":"e24","DOI":"10.2106\/JBJS.L.00003","article-title":"Risk factors for infection and amputation following open, combat-related calcaneal fractures","volume":"95","author":"Dickens","year":"2013","journal-title":"J Bone Joint Surg Am."},{"issue":"10","key":"bib4-20250430","doi-asserted-by":"crossref","first-page":"3002","DOI":"10.1007\/s11999-013-3382-z","article-title":"A model to predict limb salvage in severe combat-related open calcaneus fractures","volume":"472","author":"Bevevino","year":"2014","journal-title":"Clin Orthop Relat Res."},{"issue":"2","key":"bib5-20250430","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1302\/2046-3758.72.BJR-2017-0217.R2","article-title":"Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years","volume":"7","author":"Bennett","year":"2018","journal-title":"Bone Joint Res."},{"issue":"Suppl 1","key":"bib6-20250430","doi-asserted-by":"crossref","first-page":"S48","DOI":"10.1097\/BOT.0000000000000799","article-title":"Outcomes after severe distal tibia, ankle, and\/or foot trauma: comparison of limb salvage versus transtibial amputation (OUTLET)","volume":"31","author":"Bosse","year":"2017","journal-title":"J Orthop Trauma."},{"issue":"Suppl 1","key":"bib7-20250430","doi-asserted-by":"crossref","first-page":"S63","DOI":"10.1097\/BOT.0000000000000791","article-title":"METRC. Transtibial Amputation Outcomes Study (TAOS): comparing transtibial amputation with and without a tibiofibular synostosis (Ertl) procedure","volume":"31","author":"Bosse","year":"2017","journal-title":"J Orthop Trauma."},{"issue":"S1","key":"bib8-20250430","doi-asserted-by":"crossref","first-page":"10","DOI":"10.7205\/MILMED-D-16-00138","article-title":"Major Extremity Trauma Research Consortium (METRC). Military and civilian collaboration: the power of numbers","volume":"182","author":"Stinner","year":"2017","journal-title":"Mil Med."},{"issue":"Suppl 1","key":"bib9-20250430","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1097\/BOT.0000000000001063","article-title":"Fracture and dislocation classification compendium-2018","volume":"32","author":"Meinberg","year":"2018","journal-title":"J Orthop Trauma."},{"issue":"4","key":"bib10-20250430","doi-asserted-by":"crossref","first-page":"453","DOI":"10.2106\/00004623-197658040-00004","article-title":"Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses","volume":"58","author":"Gustilo","year":"1976","journal-title":"J Bone Joint Surg Am."},{"issue":"9","key":"bib11-20250430","doi-asserted-by":"crossref","first-page":"1245","DOI":"10.2106\/00004623-199909000-00006","article-title":"Short Musculoskeletal Function Assessment questionnaire: validity, reliability, and responsiveness","volume":"81","author":"Swiontkowski","year":"1999","journal-title":"J Bone Joint Surg Am."},{"issue":"1","key":"bib12-20250430","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1186\/s13643-017-0577-5","article-title":"The validity and reliability of the Four Square Step Test in different adult populations: a systematic review","volume":"6","author":"Moore","year":"2017","journal-title":"Syst Rev."},{"issue":"1","key":"bib13-20250430","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1016\/j.apmr.2006.10.027","article-title":"The reliability and validity of the Four Square Step Test for people with balance deficits secondary to a vestibular disorder","volume":"88","author":"Whitney","year":"2007","journal-title":"Arch Phys Med Rehabil."},{"issue":"2","key":"bib14-20250430","doi-asserted-by":"crossref","first-page":"176","DOI":"10.1123\/ijspp.4.2.176","article-title":"Validity of a squash-specific test of change-of-direction speed","volume":"4","author":"Wilkinson","year":"2009","journal-title":"Int J Sports Physiol Perform."},{"issue":"7","key":"bib15-20250430","doi-asserted-by":"crossref","first-page":"951","DOI":"10.1682\/JRRD.2012.05.0096","article-title":"Comparison of three agility tests with male servicemembers: Edgren Side Step Test, T-Test, and Illinois Agility Test","volume":"50","author":"Raya","year":"2013","journal-title":"J Rehabil Res Dev."},{"issue":"11","key":"bib16-20250430","doi-asserted-by":"crossref","first-page":"3205","DOI":"10.1519\/JSC.0b013e318234e59f","article-title":"Test-retest reliability of the Five-Repetition Sit-to-Stand Test: a systematic review of the literature involving adults","volume":"25","author":"Bohannon","year":"2011","journal-title":"J Strength Cond Res."},{"issue":"10","key":"bib17-20250430","doi-asserted-by":"crossref","first-page":"1034","DOI":"10.1093\/ptj\/85.10.1034","article-title":"Clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the Five-Times-Sit-to-Stand Test","volume":"85","author":"Whitney","year":"2005","journal-title":"Phys Ther."},{"issue":"Suppl 1","key":"bib18-20250430","doi-asserted-by":"crossref","first-page":"S42","DOI":"10.5435\/JAAOS-20-08-S42","article-title":"Physical performance assessment in military service members","volume":"20","author":"Wilken","year":"2012","journal-title":"J Am Acad Orthop Surg."},{"issue":"4","key":"bib19-20250430","doi-asserted-by":"crossref","first-page":"228","DOI":"10.1136\/bjsm.27.4.228","article-title":"Maximal shuttle running over 40 m as a measure of anaerobic performance","volume":"27","author":"Baker","year":"1993","journal-title":"Br J Sports Med."},{"issue":"2","key":"bib20-20250430","first-page":"129","article-title":"Pain assessment: global use of the Brief Pain Inventory","volume":"23","author":"Cleeland","year":"1994","journal-title":"Ann Acad Med Singap."},{"issue":"1","key":"bib21-20250430","doi-asserted-by":"crossref","first-page":"60","DOI":"10.1249\/00005768-199301000-00010","article-title":"Measurement of physical activity to assess health effects in free-living populations","volume":"25","author":"Paffenbarger","year":"1993","journal-title":"Med Sci Sports Exerc."},{"issue":"3","key":"bib22-20250430","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1080\/03093640308726682","article-title":"Development and measurement properties of the Orthotics and Prosthetics Users\u2019 Survey (OPUS): a comprehensive set of clinical outcome instruments","volume":"27","author":"Heinemann","year":"2003","journal-title":"Prosthet Orthot Int."},{"issue":"2","key":"bib23-20250430","first-page":"756","article-title":"An introduction to G methods","volume":"46","author":"Naimi","year":"2017","journal-title":"Int J Epidemiol."},{"issue":"4","key":"bib24-20250430","doi-asserted-by":"crossref","first-page":"707","DOI":"10.1214\/14-STS493","article-title":"Structural nested models and G-estimation: the partially realized promise","volume":"29","author":"Vansteelandt","year":"2014","journal-title":"Stat Sci."},{"issue":"3","key":"bib26-20250430","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1080\/10543409508835115","article-title":"A useful testing strategy in phase III trials: combined test of superiority and test of equivalence","volume":"5","author":"Morikawa","year":"1995","journal-title":"J Biopharm Stat."},{"issue":"6","key":"bib27-20250430","doi-asserted-by":"crossref","first-page":"821","DOI":"10.1002\/acr.20449","article-title":"Estimation of minimum clinically important difference for pain in fibromyalgia","volume":"63","author":"Mease","year":"2011","journal-title":"Arthritis Care Res (Hoboken)."},{"issue":"4","key":"bib28-20250430","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1097\/00005131-200404000-00002","article-title":"Open fractures of the calcaneus: a review of treatment and outcome","volume":"18","author":"Berry","year":"2004","journal-title":"J Orthop Trauma."},{"issue":"5","key":"bib29-20250430","doi-asserted-by":"crossref","first-page":"e25","DOI":"10.2106\/JBJS.K.01666","article-title":"Outcomes of IED foot and ankle blast injuries","volume":"95","author":"Ramasamy","year":"2013","journal-title":"J Bone Joint Surg Am."},{"issue":"10","key":"bib30-20250430","doi-asserted-by":"crossref","first-page":"1524","DOI":"10.1016\/j.apmr.2010.07.009","article-title":"Weight-bearing asymmetry in relation to measures of impairment and functional mobility for people with knee osteoarthritis","volume":"91","author":"Christiansen","year":"2010","journal-title":"Arch Phys Med Rehabil."},{"issue":"11","key":"bib31-20250430","doi-asserted-by":"crossref","first-page":"1566","DOI":"10.1053\/apmr.2002.35469","article-title":"A clinical test of stepping and change of direction to identify multiple falling older adults","volume":"83","author":"Dite","year":"2002","journal-title":"Arch Phys Med Rehabil."},{"issue":"20","key":"bib32-20250430","doi-asserted-by":"crossref","first-page":"1781","DOI":"10.2106\/JBJS.18.00213","article-title":"Multisite evaluation of a custom energy-storing carbon fiber orthosis for patients with residual disability after lower-limb trauma","volume":"100","author":"Potter","year":"2018","journal-title":"J Bone Joint Surg Am."},{"issue":"11","key":"bib33-20250430","doi-asserted-by":"crossref","first-page":"1205","DOI":"10.1177\/1071100716660821","article-title":"Skeletal Trauma Research Consortium (STReC). Effect of custom orthosis and rehabilitation program on outcomes following ankle and subtalar fusions","volume":"37","author":"Sheean","year":"2016","journal-title":"Foot Ankle Int."},{"issue":"10","key":"bib34-20250430","doi-asserted-by":"crossref","first-page":"3017","DOI":"10.1007\/s11999-014-3609-7","article-title":"Skeletal Trauma Research Consortium (STReC). Can an integrated orthotic and rehabilitation program decrease pain and improve function after lower extremity trauma?","volume":"472","author":"Bedigrew","year":"2014","journal-title":"Clin Orthop Relat Res."},{"issue":"Suppl 1","key":"bib35-20250430","doi-asserted-by":"crossref","first-page":"S56","DOI":"10.1097\/BOT.0000000000000795","article-title":"Patient response to an integrated orthotic and rehabilitation initiative for traumatic injuries: the PRIORITI-MTF study","volume":"31","author":"Hsu","year":"2017","journal-title":"J Orthop Trauma."},{"key":"bib36-20250430","article-title":"Clinical practice guideline for limb salvage or early amputation","author":"Trauma","year":"2019","journal-title":"Adopted by the American Academy of Orthopaedic Surgeons (AAOS) Board of Directors December 6,"}],"container-title":["Journal of Bone and Joint Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.2106\/JBJS.20.01320","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T13:47:18Z","timestamp":1787752038000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.2106\/JBJS.20.01320"}},"subtitle":["Comparison of Limb Salvage and Transtibial Amputation (OUTLET)"],"short-title":[],"issued":{"date-parts":[[2021,5,12]]},"references-count":35,"journal-issue":{"issue":"17","published-print":{"date-parts":[[2021]]}},"URL":"https:\/\/doi.org\/10.2106\/jbjs.20.01320","relation":{},"ISSN":["0021-9355","1535-1386"],"issn-type":[{"value":"0021-9355","type":"print"},{"value":"1535-1386","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,5,12]]}}}