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Page 8 of 14 Evans et al. Plast Aesthet Res 2022;9:34 https://dx.doi.org/10.20517/2347-9264.2021.134

NOT ALL LIMBS NEED SALVAGE-A FOCUS ON FUNCTIONAL OUTCOMES AND PATIENT
QUALITY OF LIFE
Although innovations in microsurgery and skeletal stabilization have allowed surgeons to reconstruct
injuries that would otherwise be amputated, outcomes are not always favorable. Limb salvage often requires
several surgeries and prolonged physical therapy, often plagued by high cost, infection, and functional
complications [104-108] . In an effort to evaluate patient outcomes following limb salvage, literature has
demonstrated substantial physical, mental, and financial hardships that can follow these heroic attempts.
Thus, while early management of lower extremity injuries emphasized reconstructive options, the paradigm
has now shifted to focus on maximizing quality of life.

One of the most influential series investigating limb salvage versus primary amputation is the Lower
Extremity Assessment Project (LEAP) . As part of this multi-institutional series, a study published in 2009
[107]
demonstrated primary amputation after lower extremity trauma resulted in lower complication rates
compared to limb salvage, with no statistically significant difference in self-reported health status and
functional outcomes between both groups . A portion of the limb salvage group (4%) went on to
[106]
amputation as a result of complications (e.g., infection, osteomyelitis, non-union, etc.), compared to 5.4% of
patients in the primary amputation group that required a revision amputation surgery.

In analyzing long-term outcomes for these patients, a 7-year follow-up demonstrated no statistically
significant difference in return to work for primary amputation versus limb salvage patients. Moreover,
patients who received soft tissue only reconstruction and primary below-knee amputations reported lower
severity scores of their injuries than those who underwent both bone and soft tissue reconstruction for limb
[109]
salvage .
While the LEAP series does not objectively outline which patient should receive limb salvage versus primary
amputation, it does present comparable functional outcomes and subjective injury severity scores between
both groups [104,108-110] . Overall, it is evident that severe lower extremity trauma is debilitating for patients
regardless of attempted limb salvage or amputation. These injuries are often met with poor functional
outcomes, complication rates, and chronic pain. Reconstructive options have greatly improved in functional
limb salvage; however, it is apparent that greater emphasis is needed on post-operative care and patient
rehabilitation.

In addition to analyzing the quality of life for primary amputation versus limb salvage, healthcare-associated
[111]
costs should also be considered prior to reconstruction. In a study by MacKenzie et al. , it was estimated
that the cost of the first two years following injury was comparable between primary amputation ($91,105)
versus limb salvage ($81,996). In analyzing life-time cost, MacKenzie et al. determined primary
[111]
amputation costs to be substantially higher than limb salvage when factoring in costs for a new prosthesis,
maintenance, and medical care ($509,275 versus $162,28, respectively). Chung et al. , demonstrated
[112]
similar findings, with 40 years of life remaining cost estimated to be $350,465 for primary amputation and
$133,704 for limb salvage.

CONCLUSION
Lower extremity reconstruction has evolved tremendously in a short few decades. Innovations in
microvascular surgery, skeletal fixation, and patient management have contributed greatly to the ability to
care for patients with traumatic injuries. While operative techniques continue to expand, a greater emphasis
is needed on improving long-term outcomes in these patients. The authors believe that future efforts to
improve physical rehabilitation, chronic pain, and minimize costs, are key factors in preserving limb
function and patient quality of life following lower extremity trauma.