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American Association of Plastic Surgeons

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Lower Extremity Guide for Salvage (L.E.G.S.): Regionalization of Severe Lower Extremity Trauma to Orthoplastic Limb Salvage Center
Said Azoury, MD1, John T. Stranix, MD2, Sammy Othman, MD1, Rotem Kimia, BS1, Liza Wu, MD1, Suhail Kanchwala, MD1, Joseph M. Serletti, MD1, Samir Mehta, MD1, Jaimo Ahn, MD PHD1, Derek Donegan, MD MBA1, L. Scott Levin, MD1, Stephen Kovach, MD1.
1University of Pennsylvania, Philadelphia, PA, USA, 2University of Virginia, Charlottesville, VA, USA.

PURPOSE: Approximately 185,000 adults suffer limb loss annually. The Penn Orthoplastic Limb Salvage Center (POLSC) enables concerted orthopedic/plastic (orthoplastic) surgery care and microvascular expertise for optimal outcomes. The authors review their experience, strategies, and propose guidelines to facilitate early transfer for lower extremity salvage.
METHODS: A review (2002-2018) 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, complications, length of stay, and readmission/reoperations were analyzed.
RESULTS: 178 patients (62.4% transfer, 37.6% non-transfer/primary) met inclusion criteria. Etiologies included motor vehicle collision (71, 39.9%), crush (50, 28.1%), and fall (26, 14.6%). Osteomyelitis was more common among transfers (44.8% vs. 20.8%, p=0.002). Transfers also had a greater delay in flap coverage (p<0.05). Overall, nine (5.1%) patients suffered flap failure and 41 (23%) had other complications. Limb salvage rates were 94% and 91.9% for the primary and transferred patients, respectively (p=0.584), at median follow-up of 598 days.
CONCLUSION: Despite microvascular advances, delay in referral for salvage contributes to unnecessary patient morbidity. Similar to American Burn Association guidelines for transferring burn injuries to specialized centers, the authors propose the Lower Extremity Guide (L.E.G.) for Trauma Transfer of patients with severe lower extremity injuries to specialized centers, as the decision to amputate is irreversible (Table). Future efforts are directed towards validaton of transfer criteria and earlier transfer.


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