Reconstruction Options for Lower Extremity Traumatic Wounds

Saïd C. Azoury, MD; Stephen J. Kovach, MD; L. Scott Levin, MD

Disclosures

J Am Acad Orthop Surg. 2022;30(16):735-746. 

In This Article

Abstract and Introduction

Abstract

The senior author first coined the "orthoplastic" approach to traumatic lower extremity reconstruction, by which multidisciplinary surgeons and specialists work together for optimal patient success. The goals of lower extremity salvage are to optimize limb appearance, restore unrestricted pain-free ambulation, and improve quality of life. Composite traumatic defects require an organized approach, and the reconstructive ladder is used for strategies of varying complexity for repair of soft-tissue wounds. The lower rungs of the ladder include simpler reconstructive options such as the use of skin grafts and local flaps, and the higher rungs represent complex techniques such as free tissue transfer. Although there is no notable difference between muscle and fasciocutaneous/perforator flaps in reconstructive outcomes, there has been a trend toward perforator flaps to minimize donor site morbidity.

Introduction

Trauma is one of the most common antecedent etiologies for lower extremity wounds, both acute and chronic. The care of traumatized lower extremity patients necessitates an orthoplastic approach, first coined by the senior author (L.S.L.), by which multidisciplinary surgeons and specialists all work together to ensure optimal patient success.[1] Early treatment of a patient sustaining severe lower extremity trauma at a specialized orthoplastic limb salvage center should be the standard of care, and the lower extremity guidelines for salvage should be widely embraced to expedite referrals.[2–4]

The goals of limb salvage are to optimize limb appearance, restore unrestricted pain-free ambulation, and improve quality of life. Our algorithm for the management of composite defects of the lower extremity below the knee has been previously described (Figure 1).[5,6] Blood flow should be restored, devitalized tissue débrided, bony defects or fractures stabilized, and missing soft-tissue implants replaced. When deciding the optimal tissue type for coverage, the reconstructive ladder is used: the lower rungs of the ladder include options such as skin grafts and local flaps and the higher rungs represent complex techniques such as microvascular free tissue transfer. The ladder is also expanding with options for the lower extremity amputee patient, including osseointegration, targeted muscle reinnervation, regenerative peripheral nerve interface, and even vascularized composite allotransplantation; however, these topics are out of the scope of this review. In this study, the authors review reconstructive options for lower extremity wounds, with a focus on soft-tissue coverage.

Figure 1.

Flow chart showing the authors' algorithm for orthoplastic management of composite defects of the lower extremity below the knee (borrowed from reference 4, figure 1, obtained with permission from Thieme publisher).

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