The Role of Plastic Surgery in Limb Reconstruction – Medical and Medicolegal Challenges

Patients may require limb reconstruction following major trauma, such as a serious accident or natural disaster, or through diseases such as cancer. Regardless of the reason for it, limb salvage attempts to avoid amputation and improve quality of life, both physically and psychologically. While limb reconstruction is often considered to be a subspeciality of orthopaedic surgery, plastic surgeons also have a very important role to play. Once any broken bones have been stabilised, the main aims of limb reconstruction are to achieve full soft tissue coverage, maintain functional ability and ideally restore appearance. Injuries comprising an open fracture with soft tissue loss require a coordinated approach to achieve bone union, prevent infection and maximise function. Therefore, management of soft tissue injuries is vitally important for a successful outcome in major orthopaedic trauma.

One of the biggest challenges in limb reconstruction is to provide full soft tissue cover over an open wound. Sometimes this can be achieved by relatively simple procedures such as skin grafting. However, if there is a particularly large amount of tissue missing, a plastic surgeon will often use a procedure known as a flap. In a flap, skin, fat and/or muscle are taken from another part of the body, usually the thigh, stomach, back or forearm, and transplanted over the damaged area. This often involves microsurgery, to reconnect blood vessels. The choice of site from which the transplant is taken often determines the aesthetic outcome of the surgery. Tissue taken locally has the advantage of being of similar quality and colour to the affected site. In addition, the procedure is often less complex and thus shorter. Unfortunately, local tissue is often within the zone of trauma and so not suitable for transfer. Issues with soft tissue reconstruction include failure of the transplant (flap), infection and excessive scarring. There have also been reports of a decrease in donor site strength, particularly if the amount of tissue taken is large. There is some debate about the ideal timing of wound closure, but studies suggest that those receiving soft tissue reconstruction within 72 h of their original injury experience lower rates of infection and graft failure.

Peripheral nerve injuries are common in major limb trauma, but they are not necessarily a contra-indication to reconstruction. While it was formerly believed that a lack of sensation in the feet should always lead to amputation of the affected limb, results from the recent Lower Extremity Assessment Project (“LEAP”) showed that among patients who underwent lower limb reconstruction, sensation in the feet at two years post-operatively was similar regardless of the amount of sensation present before reconstruction took place. Nerves can be repaired by simply re-joining the two ends, if severed, or by using grafts, decompression techniques or transfers, although this latter procedure is mainly used only in upper limbs. In the leg, particularly, the location of the injury often determines the outcome: the best results are seen in injuries below the knee, followed by the thigh and then the buttock. Injuries to the tibial nerve have a better prognosis than those to the peroneal nerve. Wherever the injury occurs, prompt treatment is essential for a good outcome. An unjustified delay in treatment may lead to a claim for negligence.

Historically, orthopaedic and plastic surgeons have worked separately to salvage a limb. Nowadays, however, surgeons are increasingly approaching limb reconstruction using an orthoplastic approach. This combines the skills of both orthopaedic and plastic surgery, in a team of surgeons. In order to achieve the best outcome for the patient, it is vital that each surgeon understands the other’s role, and how it will jointly contribute towards the outcome. Consultation between the two specialities should take place as early as possible, so that a unified approach to treatment can be agreed. Therefore, it is usual for the plastic surgeon to assess soft tissue injuries either during fracture stabilisation or immediately afterwards.

The orthoplastic approach has many benefits and has been shown to increase the probability of a good outcome. Patients undergoing orthoplastic limb reconstruction show quicker bone union, lower failure rates of soft tissue transplants, less pain, better limb function and shorter hospital stays. Early collaboration means that cases can be treated on a more individual basis. Importantly, patient satisfaction is also higher using this approach, meaning that the risk of future litigation is reduced. However, this does not mean that amputation should never be considered. Sometimes a limb may be too badly damaged to salvage, or factors relating to the patient may make a good outcome unlikely. As well as the patient’s physical condition and situations where amputation can protect life, factors such as their lifestyle, wishes and attitudes, support system, and occupation all need to be considered.

The need for limb reconstruction can arise from both trauma and disease. As a result of the wide variation in aetiology and presentation, each case provides a unique challenge to surgeons. After initial fracture stabilisation, the aim should be to provide soft tissue reconstruction and wound closure as soon as possible. There is considerable evidence that an orthoplastic approach, in which orthopaedic and plastic surgeons work as part of a team, offers the most benefit to patients. Adopting this approach reduces the need for amputation and increases the possibility of a good outcome, thus reducing the risk of a future claim being made.

Further reading:

Crystal DT, Ibrahim AMS, Lin SJ. The role of plastic surgeons in extremity reconstruction following mass casualty incidents. Plast Aesthet Res 2019;6:1. http://dx.doi.org/10.20517/2347-9264.2018.69

Mendenhall, S. D., Ben-Amotz, O., Gandhi, R. A., & Levin, L. S. (2019). A Review on the Orthoplastic Approach to Lower Limb Reconstruction. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India, 52(1), 17–25. https://doi.org/10.1055/s-0039-1688095