During a 20-year period from 1973 to 1992, 109 patients underwent early operation for acute popliteal artery trauma. Clinical variables were analyzed for their association with amputation. Gunshot wounds accounted for the majority of injuries (73%), followed by shotgun wounds (18%), stab wounds (6%), iatrogenic injuries (2%), and lacerations (1%). Fasciotomies were performed selectively in 41% of patients. Seven patients (6%) lost the injured extremity despite arterial repair. The mean time from injury to arterial repair was not significantly different for patients with or without subsequent amputation (8.6 +/- 3.6 and 9.7 +/- 7.4 hours, respectively; p = 0.69). Delay in diagnosis longer than 6 or 12 hours after the injury did not increase the risk of amputation. Other factors not associated with limb loss were preoperative ischemic neurologic deficit or compartmental hypertension, concomitant fracture, and popliteal vein injury. Severe soft tissue injury (p < 0.0001) or postoperative wound sepsis (p < 0.0001) substantially increased the risk of amputation. Delayed fasciotomies were uncommon (4%) but were associated with a significantly increased risk of amputation (p < 0.0001). Vein grafting for arterial repair (p = 0.0017) and shotgun injuries (p < 0.0001) were associated with amputation to the extent that they were related to severe soft tissue injury. The degree of soft tissue trauma and subsequent infection of devitalized tissue limits the success of popliteal arterial repair. Changes in the mechanism of trauma, liberal use of four-compartment fasciotomies, and aggressive management of soft tissue injury resulted in a significant decline in the amputation rate from 21% (4/19) in the first 5 years to 0% (0/39) in the last 5 years of the study.