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Page 2 of 10 Othman et al. Plast Aesthet Res 2022;9:29 https://dx.doi.org/10.20517/2347-9264.2021.135

burden of lower extremity trauma, in particular, cannot be overstated. In 2005, it was found that 1.6 million
people living in the United States suffer from lower extremity loss, with the number projected to double in
[1]
[1]
the coming years . Nearly 50% of cases of lower extremity loss are due to traumatic etiology .
Furthermore, even in those with salvaged limbs, there exists a long-term functional deficit, with the
psychological burden to patients, and costs to both the patient and the health care system .
[2,3]
The role of the plastic surgeon in lower extremity reconstruction in larger centers largely centers upon
ensuring adequate soft-tissue coverage. This is often particularly challenging in the setting of traumatic
defects, as local soft-tissue can be limited, necessitating the utilization of free tissue transfer . Regardless,
[4,5]
selecting the optimal method per clinical scenario is a critical junction between limb salvage and the need
for amputation. The urgency in achieving limb salvage was highlighted by The 2002 Lower Extremity
Assessment Project, which showed that outcomes might be similar between those who undergo limb salvage
and those necessitating amputation . Thus, the question of salvage vs. amputation remains nuanced and
[6]
must be considered within the context of several factors. In 2009, the British Association of Plastic,
Reconstructive and Aesthetic Surgeons and British Orthopaedic Association published guidelines for open
limb fractures, though this has not been widely adopted as definitive . There remains very little objective
[7]
and widely applicable data regarding the appropriate treatment algorithm in relation to a patient-centered
[8]
approach . Furthermore, given the difficulty presented by many of these cases, some centers lack the
[9]
adequate means or personnel to appropriately treat the traumatic lower extremity .
Despite advances in the role of the plastic surgeon, as well as leaps made in wound care management, such
as the development of negative pressure wound therapy (NPWT), limb salvage remains a difficult clinical
scenario. The use of free tissue transfer for reconstruction has the highest flap failure and complication rates
of any anatomic region and may result in amputation secondarily . Failed limb salvage remains an
[10]
unfortunate outcome that results in functional deficits, psychological trauma, and an increasingly elevated
[3,6]
cost burden . Avoiding incorrect management is important, and is compounded by the fact that few
guidelines exist on appropriate treatment and patient counseling. This study aims to describe the authors’
experience at a large limb salvage center in order to further delineate management strategies.

DIAGNOSIS, MULTIDISCIPLINARY COLLABORATION, AND INITIAL APPROACHES
The general approach to lower extremity trauma requires a thorough examination and appropriate
diagnosis of deficits and treatment strategies. This is facilitated by experts of several disciplines, including,
but not limited to, trauma surgeons, vascular surgeons, orthopedic surgeons, and plastic surgeons. The ever-
growing orthoplastic approach, a term coined by Dr. L. Scott Levin and Dr. Sterling Bunnell, incorporates
philosophies of orthopedic and plastic surgeons for management of traumatic lower extremity injuries, and
has been shown to improve outcomes [11,12] .

At the authors’ institution, a thorough physical examination helps guide the next steps of management.
Every patient receives radiographic imaging to evaluate bony structure and stability. The role of vascular
imaging is less liberalized, indicated in the setting of an equivocal physical examination that introduces the
potential or suspicion for vessel injury. In this situation, the authors employ computer-topographic
angiography, outlining the presence of major vessel injury [i.e., anterior tibial, posterior tibial (PT), and
peroneal artery]. This serves the purpose of not only involving vascular surgeons, but also in the pre-
operative planning if microsurgical intervention is necessary for soft-tissue restoration.

In the case of obvious vascular injury, the vascular surgeon must emergently be consulted if not done so
already to avoid an ischemic limb. Even so, vascular injuries should promptly be identified as this also