Download PDF
J Reconstr Microsurg 2021; 37(01): 042-050
DOI: 10.1055/s-0039-1695753
Original Article

Principles of Orthoplastic Surgery for Lower Extremity Reconstruction: Why Is This Important?

Saïd C. Azoury
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania
,
John T. Stranix
2   Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
,
Stephen J. Kovach
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania
3   Department of Orthopaedic Surgery, Penn Medicine University City, Philadelphia, Pennsylvania
,
L. Scott Levin
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania
3   Department of Orthopaedic Surgery, Penn Medicine University City, Philadelphia, Pennsylvania
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background Regardless of the antecedent etiology, lower extremity salvage and reconstruction attempts to avoid amputation, restore limb function, and improve quality of life outcomes. This goal requires a treatment team well versed in neurovascular pathology, skeletal and soft tissue reconstruction, and physical rehabilitation.

Methods A review was performed of historical milestones that lead to the development of orthoplastic extremity reconstruction, principles of current management and the evidence that supports an orthoplastic approach. Based on available evidence and expert opinion, the authors further sought to provide insight into the future of the field centered around the importance of a multidisciplinary management protocol.

Results Historically, orthopaedic and plastic surgeons worked separately when faced with challenging reconstructive cases involving lower extremity skeletal and soft tissue reconstruction. With time, many embraced that their seemingly separate skill-sets and knowledge could be unified in a collaborative orthoplastic approach in order to offer patients the best possible chance for success. First coined by the senior author (LSL) in the early 1990s, the collaborative orthoplastic approach between orthopaedic and plastic surgeons in limb salvage for the past several decades has resulted in a unique field of reconstructive surgery. Benefits of the orthoplastic approach include decreased time to definitive skeletal stabilization/soft tissue coverage, length of hospital stay, post-operative complications, need for revision procedures and improved functional outcomes.

Conclusion The orthoplastic approach to lower extremity reconstruction is a collaborative model of orthopaedic and plastic surgeons working together to expedite and optimize care of patients in need of lower extremity reconstruction. The implementation of protocols, systems, and centers that foster this approach leads to improve outcomes for these patients. We encourage centers to embrace the orthoplastic approach when considering limb salvage, as the decision to amputate is irreversible.

Keywords

lower extremity - reconstruction - orthoplastic - flap - free flap


Publication History

Received: 10 June 2019

Accepted: 18 July 2019

Article published online:
27 August 2019

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Suh HS, Lee JS, Hong JP. Consideration in lower extremity reconstruction following oncologic surgery: Patient selection, surgical techniques, and outcomes. J Surg Oncol 2016; 113 (08) 955-961
    CrossrefPubMedGoogle Scholar
  • 2 Lerman OZ, Kovach SJ, Levin LS. The respective roles of plastic and orthopedic surgery in limb salvage. Plast Reconstr Surg 2011; 127 (Suppl. 01) 215S-227S
    CrossrefPubMedGoogle Scholar
  • 3 Bell B. A brief review and estimate of the professional writings of Benjamin Bell, F.R.C.S.E., F.R.S.E., Author of “A System of Surgery,” and other works. Edinburgh Med J 1868; 14 (05) 408-433
    PubMedGoogle Scholar
  • 4 Lister J. On a new method of treating compound fracture. 1867; 89 (2274): 387-389
    PubMedGoogle Scholar
  • 5 Friedlaender GE, Friedlaender LK. Art in science: the Gross Clinic by Thomas Eakins. Clin Orthop Relat Res 2014; 472 (12) 3632-3636
    CrossrefPubMedGoogle Scholar
  • 6 Huntington TW. The classic: Case of bone transference. Use of a segment of fibula to supply a defect in the tibia. 1905. Clin Orthop Relat Res 2012; 470 (10) 2651-2653
    CrossrefPubMedGoogle Scholar
  • 7 Stark WJ. The use of pedicled muscle flaps in the surgical treatment of chronic osteomyelitis resulting from compound fractures. J Bone Joint Surg Am 1946; 28: 343-350
    PubMedGoogle Scholar
  • 8 Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses. A clinical technique. Plast Reconstr Surg 1973; 52 (02) 111-117
    CrossrefPubMedGoogle Scholar
  • 9 Colen DL, Colen LB, Levin LS, Kovach SJ. Godina's principles in the twenty-first century and the evolution of lower extremity trauma reconstruction. J Reconstr Microsurg 2018; 34 (08) 563-571
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Hong JPJ, Colen LB. How has Dr. Marko Godina influenced us?. Plast Reconstr Surg 2017; 140 (03) 641-642
    CrossrefPubMedGoogle Scholar
  • 11 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
    CrossrefPubMedGoogle Scholar
  • 12 Levin LS. The reconstructive ladder. An orthoplastic approach. Orthop Clin North Am 1993; 24 (03) 393-409
    CrossrefPubMedGoogle Scholar
  • 13 Zenn MR, Levin LS. Microvascular reconstruction of the lower extremity. Semin Surg Oncol 2000; 19 (03) 272-281
    CrossrefPubMedGoogle Scholar
  • 14 Levin LS, Erdmann D. Primary and secondary microvascular reconstruction of the upper extremity. Hand Clin 2001; 17 (03) 447-455 , ix
    CrossrefPubMedGoogle Scholar
  • 15 Mathews JA, Ward J, Chapman TW, Khan UM, Kelly MB. Single-stage orthoplastic reconstruction of Gustilo-Anderson Grade III open tibial fractures greatly reduces infection rates. Injury 2015; 46 (11) 2263-2266
    CrossrefPubMedGoogle Scholar
  • 16 Ly TV, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ. LEAP Study Group. Ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. J Bone Joint Surg Am 2008; 90 (08) 1738-1743
    CrossrefPubMedGoogle Scholar
  • 17 Bosse MJ, MacKenzie EJ, Kellam JF. et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am 2001; 83 (01) 3-14
    CrossrefPubMedGoogle Scholar
  • 18 Sbitany H, Au AF, Kovach SJ, Levin LS. Orthoplastic approach to composite tissue loss. In: Pu LLQ, Levine JP, Wei FC. eds. Reconstructive Surgery of the Lower Extremity. St. Louis, MO: Quality Medical Publishing Inc; 2013: 1025-1045
    Google Scholar
  • 19 Suh YC, Kushida-Contreras BH, Suh HP. et al. Is reconstruction preserving the first ray or first two rays better than full transmetatarsal amputation in diabetic foot?. Plast Reconstr Surg 2019; 143 (01) 294-305
    CrossrefPubMedGoogle Scholar
  • 20 Suh YC, Suh HP, Lee JS, Chang JS, Hong JPJ. Reconstruction using a perforator free flap after malignant melanoma resection of the ankle and foot. J Surg Oncol 2017; 116 (07) 862-869
    CrossrefPubMedGoogle Scholar
  • 21 Nguyen T, Rodriguez-Collazo ER. Healing heel ulcers in high-risk patients: Distally based peroneus brevis muscle flap case series. J Foot Ankle Surg 2019; 58 (02) 341-346
    CrossrefPubMedGoogle Scholar
  • 22 Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976; 58 (04) 453-458
    CrossrefPubMedGoogle Scholar
  • 23 Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984; 24 (08) 742-746
    CrossrefPubMedGoogle Scholar
  • 24 Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg Am 1990; 72 (02) 299-304
    CrossrefPubMedGoogle Scholar
  • 25 Stranix JT, Lee ZH, Jacoby A. et al. Not all Gustilo type IIIB fractures are created equal: arterial injury impacts limb salvage outcomes. Plast Reconstr Surg 2017; 140 (05) 1033-1041
    CrossrefPubMedGoogle Scholar
  • 26 Chummun S, Wright TC, Chapman TWL, Khan U. Outcome of the management of open ankle fractures in an ortho-plastic specialist centre. Injury 2015; 46 (06) 1112-1115
    CrossrefPubMedGoogle Scholar
  • 27 Hong JPJ, Goh TLH, Choi DH, Kim JJ, Suh HS. The efficacy of perforator flaps in the treatment of chronic osteomyelitis. Plast Reconstr Surg 2017; 140 (01) 179-188
    CrossrefPubMedGoogle Scholar
  • 28 Tintle SM, Levin LS. The reconstructive microsurgery ladder in orthopaedics. Injury 2013; 44 (03) 376-385
    CrossrefPubMedGoogle Scholar
  • 29 KhourI RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps. J Trauma Inj Infect Crit Care 2006; 29: 1086-1094
    CrossrefPubMedGoogle Scholar
  • 30 Samaha FJ, Oliva A, Buncke GM, Buncke HJ, Siko PP. A clinical study of end-to-end versus end-to-side techniques for microvascular anastomosis. Plast Reconstr Surg 1997; 99 (04) 1109-1111
    CrossrefPubMedGoogle Scholar
  • 31 Serafin D, Voci VE. Reconstruction of the lower extremity. Microsurgical composite tissue transplantation. Clin Plast Surg 1983; 10 (01) 55-72
    CrossrefPubMedGoogle Scholar
  • 32 Stranix JT, Borab ZM, Rifkin WJ. et al. Proximal versus distal recipient vessels in lower extremity reconstruction: a retrospective series and systematic review. J Reconstr Microsurg 2018; 34 (05) 334-340
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 Fang F, Chih-Hung L. Lower extremity reconstruction. In: Wei FC, Mardini S. eds. Flaps and Reconstructive Surgery. 2nd ed. London: Elsevier; 2016: 255-274
    Google Scholar
  • 34 Ruedi TP, Buckley RE, Moran CG. AO Principles of Fracture Management. 2nd ed. New York: Thieme; 2007
    Google Scholar
  • 35 Lowenberg DW, Buntic RF, Buncke GM, Parrett BM. ; D.W. L. Long-term results and costs of muscle flap coverage with Ilizarov bone transport in lower limb salvage. J Orthop Trauma 2013; 27 (10) 576-581
    CrossrefPubMedGoogle Scholar
  • 36 Steiert AE, Gohritz A, Schreiber TC, Krettek C, Vogt PM. ; A.E. S. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy-worse or worth?. J Plast Reconstr Aesthet Surg 2009; 62 (05) 675-683
    CrossrefPubMedGoogle Scholar
  • 37 Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery 2008; 28 (08) 632-634
    CrossrefPubMedGoogle Scholar
  • 38 Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg 2011; 127 (Suppl. 01) 205S-212S
    CrossrefPubMedGoogle Scholar
  • 39 Mastorakos DP, Disa JJ, Athanasian E, Boland P, Healey JH, Cordeiro PG. Soft-tissue flap coverage maximizes limb salvage after allograft bone extremity reconstruction. Plast Reconstr Surg 2002; 109 (05) 1567-1573
    CrossrefPubMedGoogle Scholar
  • 40 Gebhardt MC, Flugstad DI, Springfield DS, Mankin HJ. The use of bone allografts for limb salvage in high-grade extremity osteosarcoma. Clin Orthop Relat Res 1991; 181-196
    PubMedGoogle Scholar
  • 41 Boriani F, Ul Haq A, Baldini T. et al. Orthoplastic surgical collaboration is required to optimise the treatment of severe limb injuries: A multi-centre, prospective cohort study. J Plast Reconstr Aesthet Surg 2017; 70 (06) 715-722
    CrossrefPubMedGoogle Scholar
  • 42 Gans I, Baldwin KD, Levin LS. et al. A lower extremity musculoskeletal and vascular trauma protocol in a children's hospital may improve treatment response times and appropriate microvascular coverage. J Orthop Trauma 2015; 29 (05) 239-244
    CrossrefPubMedGoogle Scholar
  • 43 Stammers J, Williams D, Hunter J, Vesely M, Nielsen D. The impact of trauma centre designation on open tibial fracture management. Ann R Coll Surg Engl 2013; 95 (03) 184-187
    CrossrefPubMedGoogle Scholar
  • 44 Sommar P, Granberg Y, Halle M, Skogh ACD, Lundgren KT, Jansson KÅ. Effects of a formalized collaboration between plastic and orthopedic surgeons in severe extremity trauma patients; a retrospective study. J Trauma Manag Outcomes 2015; 9: 3
    CrossrefPubMedGoogle Scholar
  • 45 Fernandez MA, Wallis K, Venus M, Skillman J, Young J, Costa ML. The impact of a dedicated orthoplastic operating list on time to soft tissue coverage of open lower limb fractures. Ann R Coll Surg Engl 2015; 97 (06) 456-459
    CrossrefPubMedGoogle Scholar
  • 46 Jenkinson RJ, Kiss A, Johnson S, Stephen DJG, Kreder HJ. Delayed wound closure increases deep-infection rate associated with lower-grade open fractures: a propensity-matched cohort study. J Bone Joint Surg Am 2014; 96 (05) 380-386
    CrossrefPubMedGoogle Scholar
  • 47 Bosse MJ, MacKenzie EJ, Kellam JF. et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002; 347 (24) 1924-1931
    CrossrefPubMedGoogle Scholar
  • 48 MacKenzie EJ, Bosse MJ, Kellam JF. et al; LEAP Study Group. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma 2002; 52 (04) 641-649
    CrossrefPubMedGoogle Scholar
  • 49 MacKenzie EJ, Bosse MJ, Kellam JF. et al. Early predictors of long-term work disability after major limb trauma. J Trauma 2006; 61 (03) 688-694
    CrossrefPubMedGoogle Scholar
  • 50 Trickett RW, Rahman S, Page P, Pallister I. From guidelines to standards of care for open tibial fractures. Ann R Coll Surg Engl 2015; 97 (06) 469-475
    CrossrefPubMedGoogle Scholar
  • 51 Carter JE, Neff LP, Holmes IV JH. Adherence to burn center referral criteria: are patients appropriately being referred?. J Burn Care Res 2010; 31 (01) 26-30
    CrossrefPubMedGoogle Scholar
  • 52 Rymer B, Dimovska EOF, Chou DTS, Choa R, Davis B, Huq S. A representative assessment of the management of open fractures of the lower limb within UK orthoplastic centres: A two-centre audit of compliance with national standards. Injury 2017; 48 (10) 2266-2269
    CrossrefPubMedGoogle Scholar
  • 53 Perkins ZB, Yet B, Glasgow S. et al. Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma. Br J Surg 2015; 102 (05) 436-450
    CrossrefPubMedGoogle Scholar
  • 54 Helgeson MD, Potter BK, Burns TC, Hayda RA, Gajewski DA. Risk factors for and results of late or delayed amputation following combat-related extremity injuries. Orthopedics 2010; 33 (09) 669
    CrossrefPubMedGoogle Scholar
  • 55 Dickens JF, Kilcoyne KG, Kluk MW, Gordon WT, Shawen SB, Potter BK. Risk factors for infection and amputation following open, combat-related calcaneal fractures. J Bone Joint Surg Am 2013; 95 (05) e24
    CrossrefPubMedGoogle Scholar
  • 56 Topal AE, Eren MN, Celik Y. Lower extremity arterial injuries over a six-year period: outcomes, risk factors, and management. Vasc Health Risk Manag 2010; 6: 1103-1110
    CrossrefPubMedGoogle Scholar
  • 57 McNutt R, Seabrook GR, Schmitt DD, Aprahamian C, Bandyk DF, Towne JB. Blunt tibial artery trauma: predicting the irretrievable extremity. J Trauma 1989; 29 (12) 1624-1627
    CrossrefPubMedGoogle Scholar
  • 58 Kurup HV. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. J Bone Joint Surg Br 2007; 89 (04) 562-562 , author reply 562–563
    CrossrefPubMedGoogle Scholar