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Patterson et al. Plast Aesthet Res 2022;9:23 https://dx.doi.org/10.20517/2347-9264.2021.117 Page 3 of 11

From the plastic surgery perspective, limb salvage frequently requires one or more soft tissue coverage
procedures from the “soft tissue reconstructive ladder”. In general, the lowest complexity and lowest risk
intervention on the soft tissue reconstructive ladder that can adequately cover the defect and provide a
[9]
functional limb is the best choice . An orthopedic trauma surgeon can contribute to soft tissue
reconstruction as a partner in planning and timing interventions, guiding or performing debridement,
reconstructing the underlying skeletal framework, preparing soft tissues for definitive coverage, prescribing
post-operative therapy plans and restrictions, and assessing return to occupational and recreational
activities. A combined evaluation by plastic and orthopedic surgeons is helpful for developing treatment
plans for each individualized patient and positively influences outcomes. Multidisciplinary orthoplastics
care has been shown to decrease time to bony fixation, use of negative pressure wound therapy, risk of
wound infection or osteomyelitis, and is associated with greater use of free flap tissue transfers compared to
uncoordinated care .
[14]
ORTHOPAEDIC PRIRORITIES IN MANAGING EXTERMITY SOFT TISSUE TRAUMA
Orthopedic trauma surgeons share the patient’s best interest with reconstructive plastic surgery colleagues.
Philosophically, orthopedic trauma priorities can seem aligned with the Bauhaus school of design: aesthetics
and form follow function for everyday use. Orthopedic objectives in the care of the injured patient include
minimizing disability and restoring limb function for the purpose of improving quality of life. An
understanding of the orthopedic trauma perspective will facilitate communication and may improve patient
care.

Orthopedic traumatologists think about an extremity soft tissue injury in terms of how the injury will
impact our ability to restore function. We approach the traumatic soft tissue problem with a hierarchy of
priorities - an “orthopedic reconstruction” framework that is akin to the “soft tissue reconstruction
ladder” . These include:
[9]

1. Can and should the limb be salvaged?

2. Early intervention to prevent infection.

3. Skeletal reconstruction.

4. How “functional” would the best possible outcome be for the patient?

5. Monitored rehabilitation to optimize the outcome.

6. Orthotics and bracing to maintain or enhance function, prevent contractures, and prevent secondary
wounds.

7. Cosmesis.

Can and should the limb be salvaged?
The assessment of limb salvage vs. amputation begins with early, thoughtful, and, when possible, shared
decision making with the patient and/or family to either amputate a threatened limb or begin a pathway of
limb salvage. The possibility of a failed limb salvage resulting in delayed amputation due to infection,
compartment syndrome, flap failure, nonunion, unsatisfactory function, or pain must be discussed to set
treatment expectations [15-17] . Access to post-operative care, a stable living situation, self-efficacy and