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Page 2 of 11 Patterson et al. Plast Aesthet Res 2022;9:23 https://dx.doi.org/10.20517/2347-9264.2021.117

associated with contamination, skeletal injury, and functional impairment. A great deal of our knowledge of
the management and outcomes of severe extremity injuries has come from combat casualties in the past
half-century - a period in which there were lower rates of combat mortality due to prehospital care and,
subsequently, greater incidence of survivors with disabling extremity trauma. For example, extremity
injuries accounted for 39%-54% of all combat wounds sustained in the Global War on Terror between 2001-
[1]
2011 with 2037 necessitating major amputations and the remainder requiring significant treatment . The
frequency of limb-threatening, high-energy extremity trauma in the civilian population is difficult to
estimate. Worldwide, approximately 973 million individuals sustain injuries requiring healthcare per year,
accounting for 10.1% of the global burden of all diseases. Although severe soft tissue extremity injuries may
account for a small portion, such injuries are both unequivocally life-altering and a global healthcare
[2,3]
burden .
The extent of soft tissue damage associated with a skeletal injury correlates with limb survival, infection,
reoperation, function, mobility, independence, patient-reported outcomes, and mental health. Patients and
surgeons may initially find themselves at the crossroad of salvage vs. amputation, facing complex paths to
treatment and recovery along either route. Many algorithms have been proposed to guide the decision to
attempt limb salvage or to amputate a severely damaged limb. Large multicenter studies, including the
Lower Extremity Amputation Project (LEAP) and Military Extremity Trauma Amputation/Limb Salvage
(METALS), found that severity scores assessed at the time of injury do not fully predict the outcome with
[4,5]
either pathway . However, the LEAP and METALS studies both found that patient self-efficacy as well as
psychologic and social support structures are associated with superior patient outcomes independent of
limb salvage or amputation. These findings inform patient evaluation and shared decision making for severe
extremity trauma.

This review is intended for plastic surgeons working with an orthopedic colleague in the pursuit of limb
salvage for a damaged extremity. Management of the soft tissue component of extremity trauma is
improved by coordination and collaboration between plastic reconstructive surgeons and orthopedic
traumatologists. This “orthoplastics” approach involves multidisciplinary co-management by the two
subspecialties and has been shown to reduce the number of overall procedures as well as improve such
outcomes as pain, time to skeletal fixation and soft tissue coverage, length of inpatient stay, final functional
[6-8]
outcome, and the incidence of revision procedures . The purpose of this review is to provide a perspective
on the orthopedic trauma surgeon’s approach to soft tissue management. Understanding the orthopedic
surgeon’s priorities, concerns, interventions, and goals of care will facilitate communication and maximize
functional outcomes.

THE “ORTHOPLASTICS” APPROACH
Limb salvage and lower extremity reconstruction is not a modern surgical pursuit. With origins in
Hippocrates practice almost 2500 years ago and formal modern collaboration between plastic and
orthopedic surgeons traceable to World War I between Sir Harold Gillies and Sir W. Arbuthnot Lane, the
concept of an “orthoplastics” approach was a gradual development formally articulated by L. Scott Levin in
the early 1990s . The “orthoplastics” approach encompasses the “principles and practices of both specialties
[9]
applied to a clinical problem either by a single provider or teams of providers working in concern for the
benefit of the patient” [10-12] . This mode of reconstructive surgery has applications in trauma, oncology, and
the care of diabetic patients with underlying peripheral vascular disease . It has a far-reaching impact not
[9]
only on individual patients but also within society as these types of injuries affect a patient’s disability status
and psychological well-being .
[13]