Lower Extremity Guide (l.e.g.) For Trauma Transfer: Regionalization Of Lower Extremity Trauma To Orthoplastic Limb Salvage Centers Impacting Outcome
Said Azoury, MD, John Stranix, MD, Sammy Othman, BA, Rotem Kimia, BS, Liza Wu, MD, Suhail Kanchwala, MD, Joseph M. Serletti, MD, Samir Mehta, MD, Jaimo Ahn, MD PHD, Derek Donegan, MD, L. Scott Levin, MD, Stephen J. Kovach, MD.
University of Pennsylvania, Philadelphia, PA, 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. Common etiologies were motor vehicle collision (71, 39.9%), crush (50, 28.1%), and fall (26, 14.6%). Osteomyelitis was higher among transfers (44.8% vs. 20.8%, p=0.002) and chronic vs. acute cases (46.7% vs. 16.1%, p<0.001). 9 (5.1%) patients suffered total 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 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 for salvage.
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