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Application of the Orthoplastic Reconstructive Ladder to Preserve Lower Extremity Amputation Length

Fleming, Mark E. DO, MC, USN; CDR*†; O’Daniel, Anthony MD, MC, USN; LCDR*; Bharmal, Husain MD, MC, USA; CPT*; Valerio, Ian MD, MC, USN; LCDR†‡

doi: 10.1097/SAP.0b013e3182a638d8
Reconstructive Surgery

Background A primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation.

Methods A series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length.

Results Soft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with split-thickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle flaps or adjacent tissue rearrangements and free tissue transfers.

Conclusions The preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.

From the *Department of Orthopaedics, Walter Reed National Military Medical Center; †Uniformed Services University of the Health Sciences; and ‡Plastic and Reconstructive Service, Walter Reed National Military Medical Center, Bethesda, MD.

Received March 28, 2013, and accepted for publication, after revision, July 19, 2013.

Conflicts of interest and sources of funding: none declared.

Reprints: CDR Mark E. Fleming, DO, MC, USN, Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889. E-mail:

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of Defense, nor the US Government

© 2014 by Lippincott Williams & Wilkins