{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T14:51:42Z","timestamp":1787755902121,"version":"build-2784847793"},"reference-count":21,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"4","license":[{"start":{"date-parts":[[2025,10,1]],"date-time":"2025-10-01T00:00:00Z","timestamp":1759276800000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>The decision to reconstruct or amputate a limb after high-energy lower extremity trauma is influenced by time-dependent factors including evolution of the extent of injury and complications. The purpose of this study was to introduce a time-dependent classification of limb condition and assess its association with amputation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>This was a secondary analysis of OUTLET, a multicenter study of participants aged 18 to 60 with a Gustilo-Anderson Type III pilon, talar, calcaneal, IIIB or C ankle fracture, or an open or closed blast\/crush foot injury. The primary outcome was amputation within 18 months. The Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) was modified to score the evolving condition of the injured limb postoperatively throughout the treatment course to create a time-dependent OFC (OFC-P). Cox proportional hazards models were fit to estimate the hazard of amputation associated with OFC-P domains over time and compared with models using the baseline OTA-OFC.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>568 participants comprised the study sample, of which 99 underwent amputation. The average age was 38, 33% female, and 68% White. Using the least injured state (score = 1) as the referent, the highest adjusted hazard ratios for amputation were estimated for 2-point changes in the skin (6.1-fold; 95% confidence interval [CI]: 3.1-12.0), muscle (28-fold; 95% CI: 6.8-117), arterial (12.9-fold; 95% CI: 7.1-23.2), and contamination (7.2-fold; 95% CI: 2.9-18.0) domains of the OFC-P. When the relationship of the OFC-P with amputation was allowed to change after 2 weeks from injury, further improvements in model fit were found for skin (p = 0.03) and muscle domains (p = 0.005). The time-dependent models outperformed baseline models, with the largest effect sizes observed within 14 days after injury.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>A longitudinal modification of the OTA-OFC is more strongly associated with amputation, especially among skin and muscle domains. Dynamic, quantitative limb viability assessment more accurately reflects clinical practice and patient management but requires prospective validation.<\/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.oa.25.00270","type":"journal-article","created":{"date-parts":[[2025,12,10]],"date-time":"2025-12-10T19:00:23Z","timestamp":1765393223000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Time-Dependent Limb Assessment of High-Energy Lower Extremity Trauma Improves Prediction of Amputation"],"prefix":"10.2106","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0441-5433","authenticated-orcid":false,"given":"Christopher C.","family":"Stewart","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5373-9197","authenticated-orcid":false,"given":"Lisa","family":"Reider","sequence":"additional","affiliation":[{"name":"Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3194-6184","authenticated-orcid":false,"given":"Austin R.","family":"Thompson","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3212-748X","authenticated-orcid":false,"given":"Aaron Wolfe","family":"Scheffler","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2943-9546","authenticated-orcid":false,"given":"Nikan K.","family":"Namiri","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4296-7389","authenticated-orcid":false,"given":"Julie","family":"Agel","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert V.","family":"O'Toole","sequence":"additional","affiliation":[{"name":"Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5694-4524","authenticated-orcid":false,"given":"Madhav A.","family":"Karunakar","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8771-0317","authenticated-orcid":false,"given":"Benjamin K.","family":"Potter","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7484-5282","authenticated-orcid":false,"given":"Michael J.","family":"Bosse","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8847-8919","authenticated-orcid":false,"given":"Saam","family":"Morshed","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"METRC","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2025,10]]},"reference":[{"issue":"5","key":"R1-20251210","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 Jt 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