Surgical revision for transtibial stump problems following war traumatic amputations: a 2016–2020 cohort from Aleppo, Syria

Armed conflicts often lead to a surge in traumatic amputations performed under emergency conditions with limited surgical standards. In Syria, over a decade of war has resulted in a high burden of residual limb complications among amputees, posing major barriers to prosthetic rehabilitation. Despite their clinical significance, long-term surgical outcomes of stump revision in such contexts remain scarcely documented. Between 2016 and 2020, a total of 1,450 lower-limb amputees presented to the Syrian Arab Red Crescent Orthopedic clinic in Aleppo. Of these, 110 patients (120 transtibial stumps) who were unable to achieve prosthetic fitting due to residual limb complications underwent surgical revision. Complications included symptomatic neuromas, bony overgrowth, chronic ulcers, scar contractures, and redundant soft tissue. Residual limb length was objectively categorized into five groups (very short, short, optimal, long, Syme), and associations between stump characteristics, trauma mechanism, and complication type were analyzed. All patients were followed prospectively using a standardized multidisciplinary protocol to assess rehabilitation progress. Bone spurs (45.8%) and symptomatic neuromas (22.5%) were the leading indications for revision surgery. Neuroma incidence was significantly higher in very short and short stumps (p < 0.01), while long and Syme-level stumps showed increased rates of bony overgrowth. Landmine and blast injuries were strongly associated with chronic ulcers (60%) and scar contractures (35%). Tailored surgical approaches, including nerve repositioning, bone contouring, and soft-tissue balancing, enabled successful prosthetic fitting in all cases. Functional reintegration was achieved within an average of 95–140 days post-revision. This prospective cohort highlights the predictable nature of stump complications based on residual limb length and injury mechanism in a war-injured population. Surgical revision, even with basic techniques, proved effective in restoring prosthetic use and function. These findings emphasize the critical importance of structured amputation protocols, optimal stump length preservation, and meticulous nerve handling to reduce long-term complications and achieve sustainable prosthetic rehabilitation in conflict zones and under-resourced surgical environments.