Outcomes Following Soft-Tissue Reconstruction for Traumatic Lower Extremity Defects at an Orthoplastic Limb Salvage Center: The Need for Lower Extremity Guidelines for Salvage (L.E.G.S.)

ABSTRACT INTRODUCTION Approximately 160-180,000 adults suffer limb loss annually, often due to trauma. The Penn Orthoplastic Limb Salvage Center enables concerted orthopedic/plastic (orthoplastic) surgery care and microvascular expertise for optimal outcomes. The authors review their experience and propose guidelines to facilitate early transfer for lower extremity salvage. METHODS A review (2002-2019) was performed of patients who underwent free-flap reconstruction (as a proxy for severity) for lower extremity traumatic injuries. Demographics, risk factors, imaging, operative details, and perioperative outcomes were analyzed. Further analyses were performed comparing patients transferred to our limb salvage center - transfers - and those admitted to our institution first following their trauma – direct admits. RESULTS 178 patients (62.4% transfers, 37.6% direct admits) met inclusion criteria. Osteomyelitis was higher among transfers (46.1% vs. 22%, p=0.006). There was a greater delay in soft tissue coverage in transferred patients (p=0.016). On multivariate analysis, flap within 30 days was protective of osteomyelitis (Odds Ratio (OR) = 0.233, 95% Confidence Interval (CI): 0.085-0.639). Limb salvage rates were 94% and 91.8% for the direct admits and transferred patients, respectively (p=0.584), at median follow-up of 941.5 days. Overall, full weight-bearing status was achieved in 77% of patients, with no difference between groups (p=0.163). CONCLUSION Despite microvascular advances, delay in referral for salvage contributes to unnecessary patient morbidity. Microsurgery/flap success is independent of timing, likely attributable to specialized care at a limb salvage center.Similar to American Burn Association guidelines for transferring burn injuries to specialized centers, the authors propose the Lower Extremity Guide for Salvage (L.E.G.S.).