Amputation versus limb salvage after gunshot wounds and combat injuries: Considerations for an integrative concept of surgical care and rehabilitation therapy.

The management of complex limb injuries has evolved from a survival-focused approach to one emphasizing functional preservation, patient autonomy and reintegration. Historically, high amputation rates were due to limited vascular repair techniques and prolonged ischemia, particularly during World War II. Pioneering vascular interventions during the Korean and Vietnam Wars, coupled with advances in evacuation and early stabilization, significantly improved limb salvage outcomes. The advent of microsurgery and the orthoplastic approach further revolutionized treatment, facilitating early soft tissue coverage and biologically robust reconstructions. Despite these advancements, modern conflicts - especially those involving improvised explosive devices - present challenges of scale, resource constraints and delayed evacuations, necessitating flexible, phase-based care strategies. Contemporary decision-making increasingly involves patient-centered shared consent processes and must balance surgical feasibility with psychosocial and rehabilitative factors. Studies such as METALS and LEAP highlight that elective amputation may yield comparable, if not superior, outcomes in some cases, especially when supported by advanced prosthetic technologies. This review advocates for a strategic orthoplastic framework where early biological reconstruction, rather than anatomical perfection, guides decision-making. Rehabilitation is reframed as a parallel and integral process rather than a post-surgical adjunct, beginning from the acute phase and continuing iteratively throughout recovery. Utilizing ICF-based tools and patient-reported outcome measures allows individualized goal-setting and dynamic evaluation. Moreover, holistic rehabilitation - especially in military settings - demands interdisciplinary collaboration, early planning, and recognition of personal and environmental factors. Rehabilitation-specific counselling is crucial for both upper and lower extremity injuries, particularly given the psychological, functional, and social consequences of amputation or salvage. Ultimately, successful outcomes hinge not solely on surgical excellence but on the integration of rehabilitation planning, shared decision-making, and patient empowerment throughout the continuum of care.