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reconstructive plan. Furthermore, the wide variety of etiologies responsible for producing the defect in
question informs the reconstructive approach in distinctive ways. Compared to adults, restoring form and
function in children often poses increased technical challenges and necessitates the reconstructive surgeon
account for future growth. In this article, we discuss the evaluation and management of soft tissue defects of
the leg in the pediatric population as well as important considerations inherent to this patient demographic.

MULTIDISCIPLINARY APPROACH TO CARE
The management of patients with extensive lower extremity defects is highly complex as patients often
require multiple surgical procedures, have prolonged hospitalizations, and frequently experience profound
psychosocial impairment. As is true with other forms of reconstructive surgery, multidisciplinary
collaboration between the reconstructive surgeon and other surgical and non-surgical specialists is essential
to optimize outcomes . Of multidisciplinary collaborations, none have had as transformative an impact on
[1-4]
patient outcomes as the orthoplastic approach. The orthoplastic approach to lower extremity reconstruction
entails extensive collaboration between orthopedic and plastic surgeons when evaluating lower extremity
[5,6]
defects and developing the surgical plan . Using this approach, the orthopedic surgeons typically perform
skeletal reconstruction whilst the plastic surgeons reconstruct the overlying soft tissue; however, the plastic
surgery team may become involved in skeletal reconstruction should free transfer of vascularized bone to be
incorporated into the reconstructive plan. Over time, this approach has evolved to include the expertise of
vascular surgeons, radiologists, infectious disease and pain management doctors, and physical therapists .
[6]
Several studies have validated the utility of this multidisciplinary approach in the trauma setting, noting
shorter time to bony healing, increased rates of free tissue transfer when indicated, decreased rates of bony
and soft tissue infections, and healing by secondary intention . Additionally, similar beneficial effects have
[7-9]
been observed in patients with chronic wounds and oncologic defects managed by a multidisciplinary care
team comprised of both orthopedic and plastic surgeons [10,11] .

In addition to optimizing reconstructive outcomes, it is important to address the psychological impact that
significant insults to the lower extremity can have on children and adolescents. Pediatric patients, in
particular, are highly susceptible to developing acute stress disorder and post-traumatic stress disorder
secondary to both the cause of lower extremity injury and its associated management [12-15] . As such, the
inclusion of psychologists and psychiatrists in the multidisciplinary care team and mindful postoperative
management is paramount to minimizing psychological morbidity.

PREOPERATIVE CONSIDERATIONS
Successful lower extremity reconstruction is dependent on meticulous preoperative planning based on a
comprehensive history and physical examination. When performing the initial assessment, the
reconstructive surgeon must identify risk factors that may preclude the use of some surgical options or
complicate wound healing following surgery. Children requiring lower extremity reconstruction typically
have fewer comorbidities than adults; however, it is prudent to assess for obesity, diabetes, congenital
pulmonary or cardiovascular diseases, coagulopathies, and malnutrition states. In cases of oncoplastic
reconstruction, it is imperative to discuss any neoadjuvant and adjuvant chemoradiation plans
preoperatively as this will inform the timeline and type of reconstruction performed [16,17] .

When evaluating the lower extremity defect, the orthoplastic care team must determine its size, depth,
location along the leg, along with the viability and laxity of surrounding tissue. Additionally, exposed,
damaged, and missing vital tissues including bone, neurovascular structures, and tendons, should also be
noted on examination. In trauma patients, aggressive debridement of non-viable tissue is needed to fully
ascertain the defect’s size and extent and decrease the risk of infection following surgery [18,19] . Additionally,