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Zhang et al. Plast Aesthet Res 2019;6:30 I http://dx.doi.org/10.20517/2347-9264.2019.040 Page 3 of 11

Figure 1. A: adult male struck by motor vehicle. Resulting degloving injuries included exposure of right femoral head, visible peroneal
nerve, exposure of right metatarsals, and exposure of left proximal tibia; B: immediate reconstruction with lateral gastrocnemius pedicled
flap with STSG to proximal right leg, free rectus abdominus flap with STSG to dorsal right foot, and free anterolateral thigh flap to proximal
left leg. Dorsal left foot covered with integra, and subsequently skin grafted; C: patient six weeks after initial reconstruction. STSG: split
thickness skin graft

lost, etc., which are ostensibly essential in the characterization of the injury. However, using a dataset of
[11]
over 500 patients with lower extremity trauma, Bosse et al. prospectively analyzed seven commonly used
injury severity scales and found these scales to have limited utility in predicting amputation versus salvage.
Each of these scales demonstrated adequate sensitivity, but limited specificity, in which low scores were
concordant with salvage potential, but increasing values provided no indication regarding the likelihood of
amputation in injuries thought to be more severe. This work serves to cement the salience of individualized
assessment and care tailored to the unique circumstances of the patient.

The Gustilo-Anderson classification of open fractures remains a relevant and commonly used assessment
tool, to grade open fractures in the setting of lower extremity injury. The classification system, and
subsequent modification subdivide severity of injury into three categories, each with ascending level
with increasing involvement of soft-tissue, and ultimate vascular injury [12,13] . This classification system,
however, was devised to assess risk of subsequent infection and does not aim to predict likelihood of
amputation. Nonetheless, the Gustilo classification is an effective scale with demonstrated intra-observer
[14]
reproducibility .
The determinants of a patient’s prognosis following reconstruction are multiple, varied, and not solely
dependent on the wound itself, timing of reconstructions, or approach to treatment; as observed in
the LEAP trial, most independent risk factors for poor functional outcomes and amputation include
socioeconomic circumstance of the patient’s and not the treatment plan initially employed . Again, the
[3]
decision to proceed with reconstruction versus amputation is dependent on the gestalt of the patient
and injury. Patients must not only overcome modifiable risk factors, and pathophysiologic sequelae of
systemic disease; public perception and stigma regarding amputation continue to complicate the personal
decision of whether to proceed with amputation, as well as the support network of the patient during their
[15]
recovery .