A 35-year-old woman injured in an explosion in Gaza had lost a substantial portion of her tibia. Her foot was still functioning, with preserved circulation and neurologic function. She had also sustained fractures of the hand and a depressed skull fracture. She did not want her leg amputated.

In a well-resourced hospital, a limb with preserved circulation and function might be considered for complex reconstruction. But Richard Villar, a UK consultant orthopedic surgeon on his third visit to Gaza, was working in an overcrowded hospital with rudimentary surgical equipment, high infection risk, and active fighting just 2 km away. “As a doctor, you know what you could do for a patient,” Villar said. But in unusual conditions such as in Gaza, the treatment a doctor can provide might depend entirely on what is available.

When the Injury Is Only Part of the Equation 

In civilian trauma practice, the decision to salvage or amputate a severely injured limb depends on the extent of bone, vascular, nerve, and soft-tissue damage; the degree of contamination; ischemia; and the patient’s overall condition. But the feasibility of reconstruction also depends on what happens after the initial operation.

A patient with a mangled extremity may require repeated debridement, vascular repair, fracture stabilization, soft-tissue coverage, antibiotics, and several subsequent procedures. Without access to these interventions, a limb that might be salvageable in a major trauma center may present a very different risk-benefit calculation.

In Gaza, even basic investigations can be difficult to obtain, Villar told Medscape News Middle East. “You don’t have any of the support services, really. If you’re lucky, you have an x-ray; most don’t, and probably only one view is all they’re going to give you.”

Limited imaging complicates assessment and operative planning. Surgeons don’t know whether the patient can return to the operating theatre for further debridement, definitive fixation, or soft-tissue coverage. The absence of microbiology means antimicrobial treatment cannot be tailored to the present pathogens, and even when surgeons know which treatment is indicated, antibiotics may be unavailable, Villar said. 

The International Committee of the Red Cross (ICRC), in its War Surgery manual, recognizes that limb salvage can be particularly difficult in resource-poor settings. Its guidance emphasizes meticulous debridement, delayed primary closure, and fracture stabilization techniques appropriate to the resources available.

A May 2026 WHO report indicated that there have been more than 5000 amputations since the war, with a fifth of these conducted in children. Another report showed that 1 in 4 injured people had sustained potentially life-changing injuries, including major limb injuries, spinal cord injuries, severe burns, and traumatic brain injuries.

When Salvage Threatens Survival

War injuries frequently involve extensive soft-tissue destruction and heavily contaminated open fractures. Christian Schamberg-Bahadori, an orthopedic and trauma surgeon who has worked in Gaza and Ukraine, said these injuries carry an exceptionally high risk for infection. Compartment syndrome, a life-threatening condition that occurs when pressure builds up inside enclosed muscle spaces and cuts off blood and oxygen flow to nerves and tissues, is also common, he told Medscape News Middle East.

For Shehan Hettiaratchy, a UK-based consultant plastic, hand, and reconstructive surgeon who served in Afghanistan, Gaza, and Ukraine, the immediate priority is removing infected, nonviable tissue. “If you don’t, infection can kill,” he said.

However, the risk for infection alone does not necessarily justify amputation. Staged treatment, with initial debridement and temporary stabilization followed by reassessment and reconstruction, may allow surgeons to preserve a viable limb. The difficulty arises when subsequent treatment cannot be assured. Repeated operations, persistent infection, inadequate soft-tissue coverage, and deteriorating patient physiology can turn an attempt at salvage into a prolonged and potentially dangerous course of treatment.

The ICRC’s war-surgery guidance addresses these constraints, recognizing that the resources, expertise, and postoperative care available must inform the decision between salvage and amputation.

For surgeons in mass-casualty settings, the calculation may also extend beyond the individual patient. Operating time, blood products, nursing capacity, and the ability to perform repeat procedures may be needed to treat other casualties.

Do Conventional Scoring Systems Still Apply? 

Schamberg-Bahadori said he uses scoring systems, including the Mangled Extremity Severity Score (MESS) and the Ganga Hospital Open Injury Score, to assess severely injured limbs. But scores designed to characterize injury severity do not necessarily capture the conditions under which treatment must occur, Villar cautioned. Patients who have experienced prolonged malnutrition may be physiologically less resilient than those treated in civilian trauma centers, a factor that conventional scores do not adequately reflect, he said.

The American Academy of Orthopaedic Surgeons’ clinical practice guideline on limb salvage or early amputation advises against using extremity injury scores alone to determine treatment or predict outcomes after high-energy, lower-extremity trauma. The scores also cannot establish whether a hospital has the reconstructive expertise, surgical capacity, or follow-up services required to complete a salvage attempt. 

“Various armed forces will have their own clinical protocols and guiding principles, but because the condition on the ground is so dynamic, teaching hard-and-fast rules may not be what is truly required,” Hettiaratchy said. “Rather, what is important is to ensure that there are broad principles in place that can be used even in difficult, constrained, and fast-changing environments.”

“You do whatever is possible. If you say, ‘I need an x-ray,’ and someone tells you there isn’t one that day, you think of something else. You just have to be what I call a ‘real doctor.’ Ultimately, that’s it. A war zone is a war zone. Everything has gone, so you need to adapt,” Villar said. 

Schamberg-Bahadori, Hettiaratchy, and Villar reported no relevant financial relationships.

Ryner Lai’s work examines local and regional health developments within the broader context of global policy trends and emerging ideas. His areas of interest include rare diseases, mental health, and international health policymaking.