When faced with high-energy lower extremity trauma, the question of salvage versus amputation is one of the toughest decisions in reconstructive surgery. This episode breaks down the evidence and provides practical pearls for plastic surgery residents and trainees.

We walk through the landmark LEAP study and subsequent meta-analyses comparing functional outcomes between limb salvage and early amputation. We also review flap timing (Godina’s “within 72 hours” principle), the evolving role of negative pressure wound therapy, and flap selection strategies based on leg thirds. Importantly, we highlight cost-utility data and long-term functional results that shape how we counsel patients.

Key Takeaways:

• Injury severity scores should not be the sole factor in amputation decisions.

• Early flap coverage (<72 hrs) reduces infection risk, but negative pressure therapy can buy safe time.

• Limb salvage success rates approach 95% in modern free tissue transfer.

• Salvage and amputation yield similar long-term function, but salvage often carries higher complication and rehospitalization rates.

• Cost-utility analysis favors salvage for Gustilo IIIB/C fractures, especially in younger patients.

References:
Medina ND, Kovach SJ, Levin LS. An Evidence-Based Approach to Lower Extremity Acute Trauma. Plast Reconstr Surg. 2011;127(2):926-931. doi:10.1097/PRS.0b013e3182046a16

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