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Page 2 of 11 Zhang et al. Plast Aesthet Res 2019;6:30 I http://dx.doi.org/10.20517/2347-9264.2019.040

by reconstruction of these complex anatomic and functional deficits. Clinical decision-making should be
guided by our developing understanding of tissue physiology, orthopedic reconstructive principles, and
developing technology used to guide preoperative planning and intraoperative decision making. When
effective, limb reconstruction can confer a close approximation of pre-morbid functionality. However,
the calculus of when, how, and on whom to intervene remains incompletely defined and often plagued
by equivocation. Fortunately, the tools used to assess the severity and distribution of injury, including
expanding use of novel imaging techniques, as well as refinement of reconstructive approaches continue
to develop. This review focuses on the advances made regarding approaches in surgical management and
perioperative assessment of complex lower-extremity injuries. Advances in orthopedic fixation, as well
as advances in the provision of soft-tissue reconstruction, guided by long-standing principles of surgical
management continue to drive the functional, aesthetic, and patient-centered outcomes conferred by limb-
salvage.

INITIAL ASSESSMENT AND DECISION TO PROCEED WITH LIMB SALVAGE
The inclination to salvage a mangled extremity, by any means necessary, is an understandable reflex
for patients and physicians alike. This inclination, however, belies the utility of amputation in restoring
functionality of patients. Data from the landmark, Lower Extremity Assessment Project (LEAP) group,
published in 2002, provide the most thorough analysis to date of lower extremity trauma treatment and
outcomes, including demographic data of the civilian population who suffer these injuries as well as
[2]
their ultimate functional status and variables surrounding their recovery . The study found comparable
functional outcomes among individuals who had undergone reconstruction versus those who had
undergone amputation. Roughly one half of all patients followed for the duration of the study exhibited
significant disability as objectively assessed by the Sickness Impact Profile score. The sobering conclusion
gleaned from this multi-center study was that reconstruction conferred no functional benefit when
compared with amputation, and outcomes from both groups were poor; little more than 30% of patients
exhibited return to functionality compared with uninjured age-matched counterparts, and fewer than 60%
of patients had returned to work at seven years post-injury. These conclusions, however, should be weighed
critically, as subsequent analyses highlight the impact of socioeconomic factors, as opposed to treatment
[3,4]
course, as predictors of ultimate outcomes . It should be emphasized that the LEAP trial focused on
civilian patients. Much of the literature regarding advances in lower extremity reconstruction following
high-energy trauma has been gleaned from the arena of combat. As such, treatment guidelines taken from
one patient population, while informing of the other, cannot be translated without qualification, given
[5]
distinct mechanisms of injury, concurrent trauma/injury, treatment setting, etc. . Despite the multitude of
wound assessment and grading scales (discussed in more detail below), there remain no hard and fast rules
regarding when a severely damaged limb should be amputated [Figure 1]. Despite previous orthodoxy,
damage to posterior tibial nerve, and an insensate foot are no longer absolute contra-indications for limb
[6,7]
salvage . Instead, reconstruction should be evaluated and approached on a case by case basis and must be
in line with the ultimate goals of the patient.

ASSESSMENT OF INJURY AND PROGNOSIS OF RECONSTRUCTION
Multiple validated grading scales exist for the purposes of assessing extremities following traumatic injury
and attempt to guide treatment accordingly. Unfortunately, all have demonstrated limited utility when
applied in the clinical setting, and there remains no gold standard of a translatable universally applicable
injury assessment tool. Nevertheless, the injury assessment scales, including the Mangled Extremity
[8]
[9]
[7]
Severity Score , Predictive Salvage Index , Limb Salvage Index , and the Nerve Injury, Ischemia, Soft
Tissue Injury, Skeletal Injury, Shock, and Age of the Patient score, provide an objective and structured
[10]
assessment of complex injuries. Each purportedly identifies unique variables predictive of ultimate
amputation, including level of arterial injury, timing from injury to index operation, volume of soft tissue