Review Article

Limb salvage surgery

Dinesh Kadam
Department of Plastic and Reconstructive Surgery, A J Institute of Medical Sciences and A J Hospital and Research Centre,
Kuntikana, Mangalore, Karnataka, India

Address for correspondence: Dr. Dinesh Kadam, Professor and Head, Department of Plastic and Reconstructive Surgery,
A J Institute of Medical Sciences, A J Hospital and Research Centre, Kuntikana, Mangalore ‑ 575 004, Karnataka, India.
E‑mail: drkadam@yahoo.co.in

ABSTRACT

Ancaman kehilangan ekstremitas bawah terlihat umum pada cedera parah, ablasi kanker, diabetes,
penyakit pembuluh darah perifer dan neuropati. Tujuan utama dari limb salvage adalah untuk
memulihkan dan mempertahankan stabilitas dan ambulasi. Strategi rekonstruktif berbeda pada setiap
kondisi seperti: Debridement yang teliti dan penutupan dini pada trauma, mengganti unit fungsional yang
hilang pada ablasi kanker, meningkatkan vaskularisasi pada kaki iskemik dan menyediakan permukaan
jalan yang stabil untuk ulkus trofik. Keputusan untuk menyelamatkan anggota tubuh yang cedera kritis
adalah multifaktorial dan bersifat individual bersama dengan indikasi definitif yang ditetapkan. Penutupan
awal tetap menjadi standar perawatan, penutupan luka yang tertunda tidak selalu mempengaruhi hasil
akhir. Limb salvage lebih hemat biaya daripada amputasi dalam jangka panjang. Limb salvage adalah
pilihan utama prosedur daripada amputasi pada 95% sarkoma ekstremitas tanpa mempengaruhi
kelangsungan hidup. Flap majemuk dengan komponen jaringan yang berbeda, rekonstruksi kerangka;
transfer/rekonstruksi tendon membantu memulihkan fungsi. Radiasi ajuvan mengubah karakter jaringan
dan memerlukan modifikasi dalam rencana rekonstruktif. Ulkus neuropatik yang luas dan dalam sering
dipersulit oleh osteomielitis. Rekonstruksi flap gratis membantu penyembuhan lebih cepat dan
menyediakan permukaan superior untuk pembongkaran. Luka diabetes terutama disebabkan oleh
neuropati dan menyebabkan peningkatan enam kali lipat pada ulserasi. Pengendalian infeksi,
debridement agresif dan penutupan vaskular adalah andalan manajemen. Prosedur endovaskular
semakin penting dan telah mengurangi luasnya operasi dan meningkatkan periode kelangsungan hidup
bebas amputasi. Meskipun pendekatan standar tetap menggunakan pilihan terbaik di tangga
rekonstruksi, tren terbaru menunjukkan menurunnya tangga rekonstruksi dengan flap lokal baru yang
andal dan terapi tekanan luka negatif.

KEY WORDS
Limb salvage; limb trauma; lower limb reconstruction; foot ulcers

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265 Indian Journal of Plastic Surgery May-August 2013 Vol 46 Issue 2

 Kadam: Limb Salvage Surgery-unfavourable results
with the prosthetic limb ambulation. Variety of
conditions such as trauma, chronic infections, cancer
ablation, diabetes, peripheral vascular diseases (PVDs)
and so on afflicts the lower limb. Salvage of the limb
remains a challenging task due to distinct anatomical
factors such as close proximity of vital structures with
limited local coverage options. The vascularity of the leg
and foot is precarious and unlike in other regions the
skin over the leg and foot is non‑pliable even in elderly
individuals.
The limb salvage has advanced since the time of the Civil
War, when nearly all severely traumatised limbs were
amputated. After World War I, Winett Orr and later Trueta,
developed the technique of ‘closed plaster treatment’ of
open fractures, based on two important principles, which
are still remains the basis of current modern practice:
Debridement and Stabilisation. The major breakthrough
in limb salvage occurred with the introduction of
microsurgery from the 1960 onwards. Not only did it allow
replantation of amputated extremities, but also allowed
the transfer of vascularised tissue to repair large soft‑tissue
defects.[1] With further advances in microvascular tissue
transfer, advent of newer reconstructive options such as
perforator and propeller flaps, negative pressure wound
therapy (NPWT), endovascular procedures to improve
limb perfusion, advances in skeletal fixation, Ilizarov
bone lengthening for bony defects, growth factors for
the osseous healing and improvised podiatric care with
custom made footwear most limbs can now be salvaged.
The modern dilemma that reconstructive surgeons face
is no longer how to salvage an extremity, but knowing
whether or not attempting salvage is the best treatment
for the patient. Achieving stable bony union and adequate
soft‑tissue cover are cardinal in restoring function to enable
fitting normal footwear with protective plantar sensation.
The protracted course of limb salvage procedures with
its impact on psychosocial and economic status and the
final functional outcome determines the decision making
and should be individualised. Early amputations too are
not necessarily cost‑effective. Below knee stump salvage
procedures should be considered to preserve mobile
knee joint whenever the amputation becomes inevitable.
CONDITIONS OF LIMB SALVAGE
Various conditions can afflict limb survival such as:
• Trauma
• Stump salvage
Indian Journal of Plastic Surgery May-August 2013 Vol 46 Issue 2
• Cancer ablation
• Chronic infections
• PVDs
• Diabetic wound/non healing ulcers
• Exposed prosthesis
• Miscellaneous.
LIMB SALVAGE IN TRAUMA
Initial assessment
Trauma is most frequently encountered cause in the lower
extremity salvage surgery. High velocity trauma is often
associated potentially life‑threatening injuries, which
requires foremost attention. Quick and careful assessment
of the limb for the vascularity, sensibility, soft‑tissue and
skeletal loss grades the severity. With routine radiographs,
additional computed tomography angiogram or Doppler
evaluation is useful to rule out suspected vascular
compromise particularly in multilevel injuries. In a critically
injured limb, the decision of salvage versus primary
amputation continues to haunt the surgeons. Although
various scoring systems like the mangled extremity severity
score; the Limb Salvage Index; the Predictive Salvage Index;
the nerve injury, ischaemia, soft‑tissue injury, skeletal
injury, shock and age of patient score; and the Hannover
Fracture Scale‑98[1‑6] have been developed to assist the
clinician in decision making, it is seen that they are not good
predictors of limb amputation, salvage or the functional
recovery when salvaged.[7‑10] The criterion and the decision
to amputate must be individualised for each patient.
The limb salvage versus amputation
The indications for limb salvage are mainly two; (1) Any
limb injury in children and (2) adults with bony and
soft‑tissue loss with intact sensibility. Absolute indications
for primary amputation as described by Lange[11] with
open tibial fracture include (1) complete anatomical
disruption of posterior tibial nerve in adults and (2) crush
injuries with warm ischaemia time beyond six hours.
The relative indications for amputation are: Associated
life‑threatening comorbidities, severe ipsilateral foot
injury, multiple level injuries and anticipated protracted
course of soft‑tissue and skeletal reconstruction.
The high energy limb injuries requiring major
reconstruction and salvage procedures are generally falls
into type IIIB (exposed bone with periosteal stripping
with extensive contamination) and type IIIC (IIIB with
additional vascular injury) of the Gustilo‑Anderson
fracture classification.[12]
266
 Kadam: Limb Salvage Surgery-unfavourable results
It should be noted that closed or open injuries around
knee involving fractures of the tibia or femoral condyle
frequently associated with neurovascular injuries in the
popliteal region necessitating urgent exploration for
skeletal stabilisation and vascular repair. Strong clinical
suspicion, careful evaluation with expeditious imaging
studies is cardinal to detect such innocuous appearing
limb injuries.
Reconstructive strategy
The objective of reconstruction is to achieve long‑term
functional stability with a minimal morbidity in a short
time. This should result in skeletal union and stable
soft‑tissue coverage without persistence of sinus. The
reconstructive strategy following the decision to salvage
includes: Skeletal stabilisation, radical debridement,
restoration of neurovascular continuity ensuring
adequate limb perfusion, repair of soft‑tissue and early
wound coverage. Skeletal stabilisation with external
fixation is preferred in wounds with extensive soft‑tissue
and bone loss. The direction of the fixator pin placement
carefully planned to avoid access difficulties for flap
cover. The debridement should include removal of all
devitalised tissues and may be repeated several times
until the healthy bed. All distal muscular attachment of
the severed tendon is generally avascular and should be
excised preserving tendons. Wound may be kept covered
with collagen sheets while the definitive wound coverage
is planned. At no point of time, the site of vascular repair
is left exposed and providing an immediate flap cover is
essential to prevent both limb and life‑threatening blow
outs. The radical debridement and early tissue coverage
within 72 h emphasised by Godina in 1986 results in
the best outcome in terms of reducing flap failure rate,
wound infection, bone healing time, duration of hospital
stay and number of surgical procedures. The advantages
of early cover have been reemphasised in several
subsequent studies.[13‑16] However, a number of studies
have reported minimal flap failure and a low infection
rate even when wound coverage was provided at two
weeks following the injury[14,16,17] In addition, a study by
Kolker et al. has shown that the timing of reconstruction
had no influence on the ultimate outcome and it is even
safe to perform vascular anastomosis distal to the zone
of injury.[18] Thus, the timing of definitive wound cover
with free flaps should be individualised based on the
condition of the wound and fitness of the patient.[18,19]
Nevertheless, expeditious coverage of exposed vital
neurovascular structures, tendon, bone and hardware
remains a standard practice[20] [Figure 1a‑d].
267
Choice of recipient vessels
The ‘zone of injury’ following limb trauma is known to
exists beyond the limits of the wound and cited as a
principle cause of flap failure.[21] Thus, the conventional
practice is to select the recipient vessels away from this
zone preferably in the proximal site. However, it is shown
that the quality of the flow, pliability of the vessel wall
and the vascular status of the limb are more important
determinants in choosing the recipient vessel and
eventual success[21,22] [Figure 2a‑e]. This observation is
further supported by the success of super microsurgery
utilising perforators of this region for the anastomosis.[23]
Salvage of the stump
Whenever the amputation becomes inevitable the goal
is to preserve as much length of the limb as may be
possible, especially the functioning knee joint, which
reduces energy expenditure as well as provides superior
ambulation with below knee prosthesis.[24,25] Inadequate
tissue for the stump cover can be addressed by utilising
fillet flaps or microvascular free flaps.[26,27]
The outcome studies
The outcome of limb salvage versus amputation
was systematically evaluated for type IIIB and C
limb injuries.[28] In their review of 1947 articles and
28 observational studies, they found no evidence to
support superior outcomes of either limb salvage or
primary amputation for type IIIB and IIIC tibial fractures
in the current literature. Length of hospital stay was
56.9 days for salvage patients versus 63.7 days for
amputees. The most common complications after
salvage attempt were osteomyelitis (17.9%), non‑union
(15.5%), secondary amputation (7.3%) and flap failure
(5.8%). Rehabilitation time for salvaged patients was
reported as time to union (10.2 months) and time to full
weight‑bearing (8.1 months). The proportion of patients
who returned to work was 63.5% for salvage patients and
73% for amputees. They conclude that when outcomes
are similar between two treatment strategies, economic
analysis that incorporates cost and preference (utility)
may define an optimal treatment strategy to guide
physicians and patients.[28]
It is seen that following limb salvage over one‑quarter
of patients who were working before a severe lower
extremity fracture do not returned to work by 12 months
after injury and a minority of patients still report
limitations at 30 months after injury, with one‑fifth not
returning to work.[29]
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 Kadam: Limb Salvage Surgery-unfavourable results

a b c d
Figure 1: (a) A 24‑year‑old lady with Gustilo IIIB injury with circumferential soft‑tissue loss and avascular tibial segment. Referred after failed attempts of
both gastrocnemius flap. (b) Harvesting of fibula 12 cm with skin paddle. (c) Reconstructed tibial defect and soft‑tissue following 1 year. (d) Osseous union of
vascularised fibula

a b

c d e
Figure 2: (a) Crush injury leg, Gustilo‑IIIB type with circumferential skin loss and loss of lower third of tibia and fibula in a 55‑year‑old lady. Circumferential raw
area was skin grafted and reconstruction planned with osteocutaneous free fibula flap. Posterior tibial artery was the only perfusing vessel. (b) Anastomosis end
to side in the zone of injury to the posterior tibial vessels. (c) Anastomotic site covered with skin paddle. (d) Well healed flap with normal ambulation and weigh
bearing without support at 22 months post surgery.(e) Stable osseous union at 38 months post reconstruction

It is generally believed that in comparison to the
complicated limb salvage procedures, early amputation
and prosthetic rehabilitation offers a faster recovery at
a lower cost. However, recent studies based on sickness
impact profile and the lower extremity assessment
project (study) have shown that there is no significant
difference in the outcome at 2 years and amputation
was more expensive and may be as high as three times
the limb salvage.[30‑33] While the overall cost of the limb
salvage and amputation remains similar, additional cost
of the prosthesis and its maintenance turns out to be
more expensive for amputation.[31,32] These study suggests
that limb salvage should be more aggressively pursued,
especially where amputation is not clearly indicated.
These studies however do not represent health care
system of developing counties where the prosthetic
rehabilitation is available at a subsided cost. Further,
the team of expertise for expeditious treatment is not
always available, which either prolongs the successful
reconstruction or fails to achieve the goal. Amputation
Indian Journal of Plastic Surgery May-August 2013 Vol 46 Issue 2
versus salvage needs to be individualised based on the
given circumstances of available standard of care and
affordability.
SOFT‑TISSUE SARCOMA
Sarcomas, a malignant component of the wide array of
soft‑tissue tumours are classified based on their mesoderm
origin and their resemblance to the differentiated
adult tissue. They present with a wide spectrum of
aggressiveness from low‑ to high‑grade and from local
destruction to distant metastasis. Lower limbs are most
commonly affected than the upper limb (74 vs. 26%)
and they represent 45% of overall sarcoma afflicting
the body.[34] Surgical excision remains the mainstay of
the treatment supported by the adjuvant radiation and
chemotherapy. The oncological clearance demands
wide excision including one or more compartments,
which were managed earlier with limb amputation. It is
established that limb amputation against limb salvage
268
 Kadam: Limb Salvage Surgery-unfavourable results
surgery has no better survival advantage over the
latter.[35] When the consideration for the limb salvage
from oncological point of view began in post‑World
War II, the reconstructive options were limited to
the pedicled, tube pedicled flaps and cross leg flap.
Following the integration of microsurgical techniques in
reconstruction, the limb salvage has become the standard
approach of the sarcoma management with better
patient acceptance, improved quality‑of‑life without
compromising the survival.[34‑36] Primary amputations as
the treatment choice in lower extremity sarcomas are
now reduced to <5% of all patients and <15% among
recurrences while demonstrating a comparable long‑term
survival.[34‑36] Primary amputation is however investable in
extensive circumferential limb sarcoma, multi component
proximal thigh tumours, extensive skeletal involvement,
compromised general condition for a longer procedure,
local unfavourable conditions like PVD or technically
difficult reconstructions.
The aim of limb salvage is thus to provide stability, weight
bearing capability and ambulation. A multidisciplinary
team approach with input from Oncologists, Pathologists
and resective and reconstructive surgeons is essential
to achieve such a goal.[37] The reconstruction however
is challenging in lower limbs due to the vicinity of
vital structures running close together, which are often
invaded by a relatively smaller tumour. Poor vascularity
of lower extremity, wound healing problems, prone for
infections, high venous pressure and poor nerve repair
or grafting results further hinders in achieving the goal.
Wide resection of the tumour entails sacrifice of considerable
skin, soft‑tissue, skeletal and neurovascular structures
leaving composite defects. In addition, pre‑operative
and adjuvant radiation along with chemotherapy alters
the conventional reconstructive options of a successful
coverage. While prior radiation deprives availability of
local tissue for the cover, adjuvant radiation demands
supple vascularised tissue to fill the defects and cover and
a b
Figure 3: (a) A young lady with soft‑tissue sarcoma resection defect of left groin. Tumour infiltrating the femoral artery was resected. Femoral artery reconstructed
with saphenous vein graft. (b) Reconstruction planned with vertical rectus abdominus flap based on inferior epigastric artery. (c) Prior to inset of flap, brachytherapy
ports inserted for radiotherapy. (d) Early post‑operative with well settled flap
269
protect exposed neurovascular structures and skeleton.
The objectives of soft‑tissue reconstruction include
obliteration of dead space, tension free skin closure,
supporting the preserved skin with underneath muscle
flaps and to provide adequate cushion for exposed bony
prominences or amputation stumps. Irradiated skin
precludes usage of local flaps or local perforator flaps
due to fibrosis and inelasticity of the surrounding skin.
Similarly, when radiation is planned following surgery, skin
grafts or muscle flap covered with skin grafts are avoided
due to their poor tolerance for radiation. Perforator or
fasciocutaneous flaps are superior to skin grafts, but
inadequate to cover large defects and donor site skin
graft in the immediate vicinity is a disadvantage. As most
sarcoma are located in the proximal limb, pedicled flap
based on deep inferior epigastric artery system either
vertical [Figure 3a‑d] or transverse myocutaneous flap
offers an excellent choice. Superior or inferior gluteal
artery flap from the buttock is another option available
for the proximal limb defects. All these flaps can also be
converted into free flaps if pedicle length limits adequate
coverage. The microsurgical reconstruction offers a
superior tailored flap to the defects from various donor
sites. It is essential to ensure patency of recipient vessels
preferably chosen away from the irradiated areas.
Immediate reconstruction though is a preferred choice,
but not always obligatory unless neurovascular cover or
reconstruction is involved. All major vascular defects are
reconstructed simultaneously to ensure limb viability with
a mandatory soft‑tissue cover. Vascular continuity can be
achieved with interpositional vein grafts or alloplastic
material. It should be noted that autologous vein grafts
have higher chances of thrombosis in oncosurgical
reconstruction than in for traumatic conditions possibly
due to longer length.
Skeletal defects following resection of primary osseous
sarcoma or bony invasion of STS calls for a multidisciplinary
approach involving orthopaedic and plastic
c d
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 Kadam: Limb Salvage Surgery-unfavourable results
surgeons.[38] Modern orthopaedic techniques include
expandable and non‑expandable tumour prostheses,
resection arthroplasties, distraction osteogenesis,
segment transport or total joint replacements. In
combination with such procedures, vascularised bone
and soft‑tissue cover is mandatory for long lasting desired
outcomes. Free bone grafts are not useful whenever
irradiation is planned are limited to the defects <4 cm
with adequate soft‑tissue envelop. Ipsilateral pedicled
fibula transfer, free latissimuss dorsi muscle with scapular
bone up to 11 cm or parascapular flap have been utilised
for augmenting the prosthetic skeletal reconstruction and
obliteration of the dead space. For large bony defects,
vascularised fibula and Iliac crest offers an excellent
choice though discrepancy in bony diameter exists. They
are dynamic, hypertrophies with walking stress, relatively
infection and radiation resistant.[39]
Prognosis of patients with extremity STS, has not
changed over the past 20 years, indicating that current
therapy has reached the limits of efficacy.[34] Limb salvage
with microvascular reconstruction is safe and reliable in
lower extremity STS reconstruction, which has avoided
amputation in most patients.[40,41]
TROPHIC ULCERS
Trophic ulcers (Neuropathic or plantar ulcers) on
the sole have been described as the scourge to the
insensitive foot.[42] These ulcers initiate a vicious cycle
of progressive infection and deformity associated with
crippling morbidity. They bear a multi‑factorial aetiology
that ranges from diabetes, Hansen’s disease to spinal
injury and spina bifida. Chronicity and recalcitrance to
local and systemic treatment are the hallmarks of these
lesions. Many of these patients if left untreated develop
complications and eventually undergo amputation.
An understanding of the contributory factors and
addressing them is essential to ensure successful limb
salvage. The natural history of the disease is initiated by
the high biomechanical stresses that develop on walking
with an insensate foot. However, the onset of peripheral
neuropathy removes the protective mechanism against
excessive pressure and pain and initiates the breakdown
of plantar skin, which proceeds to alter the biomechanics
of the foot with regard to ankle kinematics, gait
distribution and gait kinetics.[43] A complex interplay of
neurologic, autonomic and vascular damage advances
the disease over time.
Indian Journal of Plastic Surgery May-August 2013 Vol 46 Issue 2
The main treatment principles are (1) radical debridement,
particularly the osteomyelitic bones; (2) wound coverage
with adequate bulk and (3) podiatric support for
offloading. Additional measures include endovascular
procedures to improve foot perfusion, neural
decompression for sensory recovery and optimisation of
physical condition. Most challenging aspect of treatment
however would be reconstruction of the plantar defect.
The heel and the forefoot represent the weight bearing
zones and contribute to 95% of locations of these ulcers.
Satisfactory functional reconstruction of these ulcers
need a flap with adequate bulk, provide shock absorption
and remain stable and durable against shearing forces
of ambulation. In addition, the transferred tissue should
deliver enough vascularity to the bed to clear the infection
as well as retain normal foot contour to fit footwear. Perry
has calculated the shearing and pressure forces during
walking to be around 9.3 kg/cm2 in an average individual,
which would translate to forces around 60 tons/foot
when walking a mile.[44] Thus, the most superior mode
of reconstruction needs to be used to ensure optimum
rehabilitation of the patient.
Local flaps undeniably satisfy the physical properties of
the weight bearing plantar region as the skin is glabrous,
sensate (in otherwise normal foot) and has qualities
superior to distant tissue transfer thus replacing ‘like with
like’. However, the local skin conditions of a neuropathic
foot are vastly different. Peripheral neuropathy renders
the skin insensate and brittle, which breaks down easily
even with normal shearing force thus losing the advantage
over the transferred tissue. A local flap, when chosen, is
mostly from a non‑weight bearing area and leaves the
donor defect skin grafted and this skin grafted area is not
ideal for weight bearing during offloading.
A smaller looking ulcer generally has a wide base often
with an exposed bone in the floor surrounded by callous
skin edges resulting from both chronic inflammation
and the neuropathy. Radical debridement invariably
necessary until a healthy fat pad margin is obtained.
This results in a much larger defect than apparently
visible. Concomitant osteomyelitis farther complicates
the wound and demands a good vascular tissue cover to
obliterate the dead space and to promote healing. Thus,
a larger sized defect, insensate local tissue, associated
osteomyelitis and need of preserving the non‑weight
bearing areas for the purpose of offloading favours free
tissue transfer for the better and long‑term outcome
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 Kadam: Limb Salvage Surgery-unfavourable results
of these ulcers. The prerequisite however is adequate
vascularity of the affected limb, which is assessed
clinically by palpable distal pulsations. Commonly used
free flaps for sole reconstruction are fasciocutaneous
flaps such as the anterolateral thigh (ALT) flap, radial
forearm flap [Figure 4a‑d], lateral arm flap, parascapular
flap. Among this ALT flap offers an ideal choice as defect
can be obliterated with desired thickness, additional
muscle can be included and flap harvesting possible in
the same position. Muscle flaps like gracilis or latissimus
dorsi with split skin grafts are good vascular tissue fitting
to the defect, but provide inferior surface for the walking.
Although free vascularised tissues are arguably superior
form of reconstruction, the decision needs to be
individualised as it is technically demanding and is subject
to local conditions and physical fitness of the patient.
Debilitating illness, poor cardiac status, associated PVD
and uncooperative or noncompliant patients should be
excluded. Local conditions like extensive subcutaneous
fibrosis due to repeated cellulitis and chronic suppurative
arthritis generally results in unfavourable outcomes.
Infected charcoit (neuropathic) joints with unstable
and insensate foot should be evaluated cautiously and
realistic decision should be taken between the salvage
and the prosthesis in conjunction with the patient.
DIABETIC FOOT
Diabetic patients have multitude of problems such
as microvascular angiopathy, poor metabolic control,
neuropathy and nephropathy leading to chronic bacterial
colonisation, ischaemic wounds, osteomyelitis with
recurrent cellulitis and bony deformity.[45‑48] About 15% of
them during their lifetime develop leg ulceration and they
constitute two‑third of all amputation performed.[49,50]
Diabetic neuropathy is a single most major cause for foot
ulceration and more than 80% of diabetic foot ulcers have
some form of neuropathy. About 80‑85% of amputations
a b
Figure 4: (a) A 58‑year‑old lady with insensate foot with trophic ulcer of 8 years duration due to Hansen’s disease. (b) Reconstruction planned with radial
artery forearm free flap with posterior tibial as end to side recipient vessel. (c) 2 years post‑reconstruction with well‑settled flap. (d) Flap without excessive bulk,
contoured to the foot
271
are preceded by non‑healing ulcers in patients with
neuropathy.[51,52] Involvement of medium sized vessels
is well‑known in the infrapopliteal region,[53] however
the peripheral neuropathy is the primary cause of foot
ulceration leads to 6 times higher chances of ulceration.[52]
A multidisciplinary team is essential for a holistic approach
and success of reconstructive procedures. Treatment
strategies include optimising the patient, correction
of vascular insufficiency, aggressive debridement and
providing a well‑vascularised tissue cover.
The risk factors for lower extremity amputation (LEA)
in diabetic patients are peripheral sensory neuropathy,
PVD, foot ulcers (particularly if they appear on the
same side as the eventual LEA), former amputation
and treatment with insulin.[54] Half of them undergo
reamputation leading to eventual death within 3 years
especially patients presenting with gangrene of the foot
in insulin‑dependent diabetes mellitus.[55]
Diabetic foot reconstruction using free flaps reported to
have more than 91% success which significantly increases
the 5‑year limb salvage rate (86%). Risk factors such as
peripheral arterial diseases, history of angioplasties in
the extremity and using immunosuppressive agents after
transplant likely to increase the flap loss.[56]
LIMB ISCHAEMIA WITH INTRACTABLE LEG
ULCERS
Ischaemic ulcers present as painful non healing wounds
with extreme threat to the limb and disproportionally
cause severe rest pain. Unless limb perfusion is improved,
proximal limb amputation is inevitable. The most
common cause is atherosclerosis and diabetes followed
by Buerger’s disease, vasculitis and thromboembolic
disease. Doppler evaluation showing a monophasic flow
warrants treatment, which should be initiated prior
c d
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 Kadam: Limb Salvage Surgery-unfavourable results
to any surgical management. Unless a wet gangrene,
necrotising fasciitis or ascending cellulitis exists, the
initial surgical debridement is delayed to avoid any loss
of potentially salvageable tissue. To improve perfusion
both bypass‑surgery and endovascular procedures have
been employed. The results of Endovascular procedures
such as balloon angioplasty and stenting are comparable
to the invasive bypass surgery in terms of amputation free
survival.[57,58] Endovascular procedures in combination
with surgical bypass reduces the extent of surgery and
the length of grafts required particularly in surgically high
risk individuals. With such procedures the limb salvage
rate of 87% at 2 years has been reported.[59]
EXPOSED PROSTHESIS
Espoused hardware and prosthesis poses risk of not only
the implant loss, but also the limb causing considerable
setback to the patient in terms of suffering, disability
and financial burden. Basic principles of management
include irrigation, debridement, antibiotics and removal
of hardware itself. However, several factors should be
taken into account before considering removal such as
location of the hardware, microbiological flora, duration
of infection, duration of exposure of hardware and
hardware loosening. In a retrospective review by Viol
et al., they concluded that if hardware is clinically stable,
time of exposure is <2 weeks, infection is controlled and
the location of the hardware is for bony consolidation;
then, it may increase the likelihood of salvage of hardware
using the surgical soft‑tissue coverage.[60]
Exposed vascular grafts present life‑ and limb‑threatening
complications. It requires urgent intervention and early
debridement and muscle flap coverage to salvage the
graft. Synthetic grafts a source of bacterial colonisation
preferably are replaced with an autologous graft. Local
muscle flaps such as gracilis, sartorius or tensor fascia lata
are invaluable in achieving cover and obliteration of the
dead space. Exposure of vein graft should also be managed
in the similar manner after ensuring the graft patency.
EVOLVING CONCEPTS FROM COMPLEX
TO SIMPLER APPROACHES IN
RECONSTRUCTION
The successful limb salvage over the past five decades has
evolved in parallel with the advances in soft‑tissue and
skeletal reconstructions. From a limited option of tube
Indian Journal of Plastic Surgery May-August 2013 Vol 46 Issue 2
pedicled flaps of then to the super‑microsurgery of today the
newer concepts continue to emerge. The extensive, complex
defects are being reconstructed from a single flap option to
a more versatile compound flaps with superior functional
and aesthetic results. Exploiting multiple perforators from
a single vascular source, various flap designs with different
tissue components to suit the anatomical defect has been
successful. These flaps include composite flaps (multiple
tissue components served by single vascular source),
conjoined flap (multiple flap territory with physical
interconnections each retaining independent vascular
supply) and chimeric flap (multiple flap territory without
interconnections, receiving independent blood supply).
Sequential flaps are two different flaps linked together
with their pedicles and anastomosed to a single recipient
vessel. A flow through flap acts as a conduit to re‑establish
vascular continuity and provides simultaneous soft‑tissue
cover. All these flap modifications and in combination with
available conventional flaps have enormously increased the
microsurgical coverage options of composite defects.
While reconstructing such defects with microsurgery has
been undisputedly practiced as a preferred option, there is
an evolving trend to explore newer local coverage options
for the same purpose based on improved understanding
of leg vascularity and angiosomes. Such local flaps
successfully employed include Keystone flap, propeller
perforator and free style perforator flaps/free flaps.[61‑64]
Keystone/perforator flaps
Described by Behan in 2003 the keystone flap is based on
fasciocutaneous perforators, is reliable and expeditious
to execute by local rearrangement of the tissues.[61] A high
success rate of 97% in large lower extremity and trunk
defect reconstruction is reported. Several advantages
include robust vascularity based on the axial or bunch of
perforators, ease of harvest, primary closure of the defect,
and superior aesthetic appearance by utilising adjacent
skin. It provides robust vascularity of a perforator flap
without technical difficulties of a perforator flap and it
also obviate need of free flaps in select cases.[62]
Although technically more challenging to perform, free
style perforator free flaps have endless donor site and
recipient vessel option without disturbing the vascularity
of the foot. Further advantages include minimal
donor‑site morbidity, reliable coverage and improved
contour. This represents a paradigm shift in flap selection
however demands a surgical proficiency in flap dissection
technique and anstomosis.
272
 Kadam: Limb Salvage Surgery-unfavourable results
NPWT
Further down in the reconstruction ladder from super
microsurgery to local flaps, the downward trend
continues to ‘downsize’ the defect with increasing
acceptance of the role of NPWT. Reduction of oedema
and wound surface area, rapid granulation growth and
lesser infection rate has prompted usage of NPWT in
more complex wounds such as exposed tendon, bone or
fractures sites. Successful coverage has been achieved
even in Gustilo type III wounds with delayed closure, skin
grafting or local flap cover. This is cost‑effective, avoids
complex surgical procedures and its complications.[65‑67]
CONCLUSIONS
Limb salvage should be aimed at providing stability
and function. While the objective remains common,
strategies of reconstruction differ such as: Early
coverage in trauma, replacing lost functional units in
cancer ablation, improving vascularity in ischaemic leg
and providing stable walking surface for trophic ulcers.
The decision to salvage the critically injured limb is
multifactorial and should be individualised along with
laid down definitive indications. Though the limb salvage
is claimed cost‑effective than amputation in a long run,
no data available from developing counties. The advent
of microsurgery has salvaged critically injured limbs,
with early and versatile reconstructive options including
combined flaps and perforator free flaps. Recent trend
also shows running down the ladder of reconstruction
with newer reliable local flaps and NPWT. Endovascular
procedures have given scope for further reconstructive
attempts in ischaemic limbs thus prolonging the
amputation free survival.
REFERENCES
1. Ong YS, Levin LS. Lower limb salvage in trauma. Plast Reconstr
Surg 2010;125:582‑8.
2. Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage
versus amputation. Preliminary results of the mangled extremity
severity score. Clin Orthop Relat Res 1990;256:80‑6.
3. Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW,
Koman LA, et al. Salvage of lower extremities following combined
orthopedic and vascular trauma. A predictive salvage index. Am
Surg 1987;53:205‑8.
4. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr.
Objective criteria accurately predict amputation following lower
extremity trauma. J Trauma 1990;30:568‑72.
5. Russell WL, Sailors DM, Whittle TB, Fisher DF Jr, Burns RP.
Limb salvage versus traumatic amputation. A decision based on
a seven‑part predictive index. Ann Surg 1991;213:473‑80.
6. Krettek C, Seekamp A, Köntopp H, Tscherne H. Hannover
fracture scale ‘98: Re‑evaluation and new perspectives of an
273
established extremity salvage score. Injury 2001;32:317‑28.
7. Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring
of mangled lower extremities. J Trauma 1993;34:99‑104.
8. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX,
Swiontkowski MF, et al. A prospective evaluation of the clinical
utility of the lower‑extremity injury‑severity scores. J Bone Joint
Surg Am 2001;83‑A:3‑14.
9. Durham RM, Mistry BM, Mazuski JE, Shapiro M, Jacobs D.
Outcome and utility of scoring systems in the management of
the mangled extremity. Am J Surg 1996;172:569‑73.
10. 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;90:1738‑43.
11. Lange RH. Limb reconstruction versus amputation decision
making in massive lower extremity trauma. Clin Orthop Relat
Res 1989;243:92‑9.
12. 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;24:742‑6.
13. Godina M. Early microsurgical reconstruction of complex trauma
of the extremities. Plast Reconstr Surg 1986;78:285‑92.
14. Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN,
Yaremchuk MJ. Microvascular soft‑tissue transplantation for
reconstruction of acute open tibial fractures: Timing of coverage and
long‑term functional results. Plast Reconstr Surg 1992;89:478‑87.
15. Organek AJ, Klebuc MJ, Zuker RM. Indications and outcomes
of free tissue transfer to the lower extremity in children: Review.
J Reconstr Microsurg 2006;22:173‑81.
16. Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR, Poka A,
Weiland  AJ. Acute and definitive management of traumatic
osteocutaneous defects of the lower extremity. Plast Reconstr
Surg 1987;80:1‑14.
17. Heller L, Levin LS. Lower extremity microsurgical reconstruction.
Plast Reconstr Surg 2001;108:1029‑41.
18. Kolker AR, Kasabian AK, Karp NS, Gottlieb JJ. Fate of free flap
microanastomosis distal to the zone of injury in lower extremity
trauma. Plast Reconstr Surg 1997;99:1068‑73.
19. Karanas YL, Nigriny J, Chang J. The timing of microsurgical
reconstruction in lower extremity trauma. Microsurgery
2008;28:632‑4.
20. Arnez ZM. Immediate reconstruction of the lower extremity: An
update. Clin Plast Surg 1991;18:449‑57.
21. Isenberg JS, Sherman R. Zone of injury: A valid concept in
microvascular reconstruction of the traumatized lower limb? Ann
Plast Surg 1996;36:270‑2.
22. Park S, Han SH, Lee TJ. Algorithm for recipient vessel selection
in free tissue transfer to the lower extremity. Plast Reconstr Surg
1999;103:1937‑48.
23. Hong JP. The use of supermicrosurgery in lower extremity
reconstruction: The next step in evolution. Plast Reconstr Surg
2009;123:230‑5.
24. Dormandy J, Heeck L, Vig S. Major amputations: Clinical patterns
and predictors. Semin Vasc Surg 1999;12:154‑61.
25. Gonzalez EG, Corcoran PJ, Reyes RL. Energy expenditure in
below‑knee amputees: Correlation with stump length. Arch Phys
Med Rehabil 1974;55:111‑9.
26. Kasabian AK, Colen SR, Shaw WW, Pachter HL. The role of
microvascular free flaps in salvaging below‑knee amputation
stumps: A review of 22 cases. J Trauma 1991;31:495‑500.
27. Kadam D. Secondary reconstruction of below knee amputation
stump with free anterolateral thigh flap. Indian J Plast Surg
2010;43:108‑10.
28. Saddawi‑Konefka D, Kim HM, Chung KC. A systematic review of
outcomes and complications of reconstruction and amputation
Indian Journal of Plastic Surgery May-August 2013 Vol 46 Issue 2
 Kadam: Limb Salvage Surgery-unfavourable results
for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg
2008;122:1796‑805.
29. Butcher JL, MacKenzie EJ, Cushing B, Jurkovich G, Morris J,
Burgess A, et al. Long‑term outcomes after lower extremity
trauma. J Trauma 1996;41:4‑9.
30. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX,
Swiontkowski MF, et al. An analysis of outcomes of reconstruction
or amputation after leg‑threatening injuries. N Engl J Med
2002;347:1924‑31.
31. Chung KC, Saddawi‑Konefka D, Haase SC, Kaul G. A cost‑utility
analysis of amputation versus salvage for Gustilo type IIIB and
IIIC open tibial fractures. Plast Reconstr Surg 2009;124:1965‑73.
32. MacKenzie EJ, Jones AS, Bosse MJ, Castillo RC, Pollak AN,
Webb LX, et al. Health‑care costs associated with amputation or
reconstruction of a limb‑threatening injury. J Bone Joint Surg Am
2007;89:1685‑92.
33. Williams MO. Long‑term cost comparison of major limb salvage
using the Ilizarov method versus amputation. Clin Orthop Relat
Res 1994;301:156‑8.
34. Weitz J, Antonescu CR, Brennan MF. Localized extremity soft
tissue sarcoma: Improved knowledge with unchanged survival
over time. J Clin Oncol 2003;21:2719‑25.
35. Papagelopoulos PJ, Mavrogenis AF, Mastorakos DP, Patapis P,
Soucacos PN. Current concepts for management of soft tissue
sarcomas of the extremities. J Surg Orthop Adv 2008;17:204‑15.
36. Daigeler A, Lehnhardt M, Khadra A, Hauser J, Steinstraesser L,
Langer S, et al. Proximal major limb amputations: A retrospective
analysis of 45 oncological cases. World J Surg Oncol 2009;7:15.
37. Heller L, Kronowitz SJ. Lower extremity reconstruction. J Surg
Oncol 2006;94:479‑89.
38. Chang DW, Robb GL. Recent advances in reconstructive surgery
for soft‑tissue sarcomas. Curr Oncol Rep 2000;2:495‑501.
39. Chen CM, Disa JJ, Lee HY, Mehrara BJ, Hu QY, Nathan S, et al.
Reconstruction of extremity long bone defects after sarcoma
resection with vascularized fibula flaps: A 10‑year review. Plast
Reconstr Surg 2007;119:915‑24.
40. Barner‑Rasmussen I, Popov P, Böhling T, Tarkkanen M, Sampo M,
Tukiainen E. Microvascular reconstruction after resection of soft
tissue sarcoma of the leg. Br J Surg 2009;96:482‑9.
41. Topham NS. Reconstruction for lower extremity limb salvage in
soft tissue carcinoma. Curr Treat Options Oncol 2003;4:465‑75.
42. Lang‑Stevenson AI, Sharrard WJ, Betts RP, Duckworth T.
Neuropathic ulcers of the foot. J Bone Joint Surg Br
1985;67:438‑42.
43. Bacarin TA, Sacco IC, Hennig EM. Plantar pressure distribution
patterns during gait in diabetic neuropathy patients with a history
of foot ulcers. Clinics (Sao Paulo) 2009;64:113‑20.
44. Perry J. Anatomy and biomechanics of the hindfoot. Clin Orthop
Relat Res 1983;177:9‑15.
45. Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS,
Karchmer AW, et al. Diagnosis and treatment of diabetic foot
infections. Plast Reconstr Surg 2006;117:212S‑38.
46. Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW,
Karchmer AW. Assessment and management of foot disease in
patients with diabetes. N Engl J Med 1994;331:854‑60.
47. Dargis V, Pantelejeva O, Jonushaite A, Vileikyte L, Boulton AJ.
Benefits of a multidisciplinary approach in the management of
recurrent diabetic foot ulceration in Lithuania: A prospective
study. Diabetes Care 1999;22:1428‑31.
48. Jolly GP, Zgonis T, Blume P. Soft tissue reconstruction of the
diabetic foot. Clin Podiatr Med Surg 2003;20:757‑81.
49. Block P. The diabetic foot ulcer: A complex problem with a simple
treatment approach. Mil Med 1981;146:644‑6.
50. Wrobel  JS, Mayfield  JA, Reiber  GE. Geographic variation
of lower‑extremity major amputation in individuals with and
Indian Journal of Plastic Surgery May-August 2013 Vol 46 Issue 2
without diabetes in the medicare population. Diabetes Care
2001;24:860‑4.
51. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb
amputation. Basis for prevention. Diabetes Care 1990;13:513‑21.
52. Ollendorf DA, Kotsanos JG, Wishner WJ, Friedman M, Cooper T,
Bittoni M, et al. Potential economic benefits of lower‑extremity
amputation prevention strategies in diabetes. Diabetes Care
1998;21:1240‑5.
53. LoGerfo FW, Coffman JD. Current concepts. Vascular and
microvascular disease of the foot in diabetes. Implications for
foot care. N Engl J Med 1984;311:1615‑9.
54. Adler AI, Boyko EJ, Ahroni JH, Smith DG. Lower‑extremity
amputation in diabetes. The independent effects of peripheral
vascular disease, sensory neuropathy, and foot ulcers. Diabetes
Care 1999;22:1029‑35.
55. Kono Y, Muder RR. Identifying the incidence of and risk factors for
reamputation among patients who underwent foot amputation.
Ann Vasc Surg 2012;26:1120‑6.
56. Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free
flaps increases 5‑year‑survival rate. J  Plast Reconstr Aesthet
Surg 2013;66:243‑50.
57. Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF,
et al. Bypass versus angioplasty in severe ischaemia of the
leg (BASIL): Multicentre, randomised controlled trial. Lancet
2005;366:1925‑34.
58. Ino K, Kiyokawa K, Akaiwa K, Ishida M, Furuyama T, Onohara T.
A team approach to the management of intractable leg ulcers.
Ann Vasc Dis 2013;6:39‑45.
59. Masaki H, Tabuchi A, Yunoki Y, Kubo H, Nishikawa K, Yakiuchi H,
et al. Collective therapy and therapeutic strategy for critical limb
ischemia. Ann Vasc Dis 2013;6:27‑32.
60. Viol A, Pradka SP, Baumeister SP, Wang D, Moyer KE, Zura RD,
et al. Soft‑tissue defects and exposed hardware: A review
of indications for soft‑tissue reconstruction and hardware
preservation. Plast Reconstr Surg 2009;123:1256‑63.
61. Behan  FC. The keystone design perforator island flap in
reconstructive surgery. ANZ J Surg 2003;73:112‑20.
62. Khouri JS, Egeland BM, Daily SD, Harake MS, Kwon S,
Neligan PC, et al. The keystone island flap: Use in large defects
of the trunk and extremities in soft‑tissue reconstruction. Plast
Reconstr Surg 2011;127:1212‑21.
63. Georgescu AV, Matei IR, Capota IM. The use of propeller
perforator flaps for diabetic limb salvage: A retrospective review
of 25 cases. Diabetic Foot & Ankle, North America, 2012;3.
Available from: http://diabeticfootandankle.net/index.php/dfa/
article/view/18978. [Last accessed on 21 Apr 2013].
64. Rinaldi S, Piperno A, Toscani M, Tarallo M, Cigna E, Fino P,
et al. Free-style perforator fl aps in the reconstruction of the
lower limb. Ann Ital Chir 2013;84. Available from: http://www.
annaliitalianidichirurgia.it/PDF/ONLINE/10_04_2013.pdf [Last
accessed on 21 Apr 2013].
65. Nazerali RS, Pu LL. Free tissue transfer to the lower extremity:
A paradigm shift in flap selection for soft tissue reconstruction.
Ann Plast Surg 2013 [Epub ahead of print]
66. Parrett BM, Talbot SG, Pribaz JJ, Lee BT. A review of local and
regional flaps for distal leg reconstruction. J Reconstr Microsurg
2009;25:445‑55.
67. DeFranzo AJ, Argenta LC, Marks MW, Molnar JA, David LR,
Webb LX, et al. The use of vacuum‑assisted closure therapy
for the treatment of lower‑extremity wounds with exposed bone.
Plast Reconstr Surg 2001;108:1184‑91.
How to cite this article: Kadam D. Limb salvage surgery. Indian J
Plast Surg 2013;46:265-74.
Source of Support: Nil, Conflict of Interest: None declared.
274
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