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Azoury et al. Plast Aesthet Res 2020;7:4 Plastic and
DOI: 10.20517/2347-9264.2019.44 Aesthetic Research

Review Open Access

Expanding the top rungs of the extremity
reconstructive ladder: targeted muscle

reinnervation, osseointegration, and vascularized
composite allotransplantation

Saïd C. Azoury , Andrew Bauder , Jason M. Souza , John T. Stranix , Sammy Othman , Christine
1
3
2
1
1
McAndrew , Scott M. Tintle , Stephen J. Kovach , Lawrence Scott Levin 1,4
4
2,4
1,4
1 Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania, PA 19104, USA.
2 Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.
3 Department of Plastic Surgery, University of Virginia, Charlottesville, VA 22908, USA.
4 Department of Orthopaedic Surgery, University of Pennsylvania, Pennsylvania, PA 19104, USA.
Correspondence to: Dr. Lawrence Scott Levin, FACS; Paul B. Magnuson Professor of Bone and Joint Surgery; Chairman,
Department of Orthopaedic Surgery; Professor of Surgery (Plastic Surgery); Penn Medicine University City; 3737 Market Street,
6th Floor, Philadelphia, PA 19104, USA. E-mail: scott.levin@pennmedicine.upenn.edu
How to cite this article: Azoury SC, Bauder A, Souza JM, Stranix JT, Othman S, McAndrew C, Tintle SM, Kovach SJ, Levin
LS. Expanding the top rungs of the extremity reconstructive ladder: targeted muscle reinnervation, osseointegration, and
vascularized composite allotransplantation. Plast Aesthet Res 2020;7:4. http://dx.doi.org/10.20517/2347-9264.2019.44
Received: 26 Oct 2019 First Decision: 16 Jan 2020 Revised: 17 Jan 2020 Accepted: 20 Jan 2020 Published: 12 Feb 2020

Science Editor: Matthew L. Iorio Copy Editor: Jing-Wen Zhang Production Editor: Jing Yu

Abstract

Osseointegration (OI), targeted muscle reinnervation (TMR), and vascularized composite allotransplantation
(VCA) are just a few ways by which our reconstructive ladder is evolving. It is important to recognize that
amputation does not necessarily denote failure, but surgeons should strive to find ways to provide these patients
with means for obtaining better satisfaction and quality of life postoperatively. TMR and OI have added options
for mutilating lower extremity injuries that necessitate amputation. More recently, the senior author (Levin LS)
described the “penthouse” floor of the reconstructive ladder being VCA. Despite the advances in VCA over the last
20 years, there are many challenges that face this discipline including indications for patient selection, minimizing
immunosuppressive regimens, standardizing outcome measures, establishing reliable protocols for monitoring, and
diagnosing and managing rejection. Herein, the authors review TMR, OI, and VCA as additional higher rungs of the
reconstructive ladder.

Keywords: Targeted muscle reinnervation, osseointegration, vascularized composite allotransplantation, salvage,
reconstruction

© The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made.

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