Scientific Abstract Presentations: Reconstructive 5 Friday, October 27 Fri, Oct 27 2:00-3:30 p.m. CDT

Purpose: Lower limb amputees with socket-based prostheses often have issues with mobility, skin breakdown, and nerve pain. Osseointegrated prostheses, in which a titanium implant is inserted directly into the bone to which the prosthesis is attached, are a novel solution to improve pain and mobility in those with poorly tolerated socket-based prostheses. Targeted muscle reinnervation (TMR) is often done concurrently to alleviate phantom limb pain and prevent painful neuromas from forming. Little is known about the incidence of, risk factors for, and management of neuromas in this unique patient population. Information on the role of TMR in preventing neuromas will aid physicians in determining how best to approach peripheral nerves in an osseointegrated limb.

Methods: A retrospective analysis was performed on all patients who received a single-stage lower-limb osseointegration at our institution between 2017 and 2022. Demographics, medical history, and postoperative complications were reviewed. Each patient included in the study had at least 12 months post-operative follow up. Pearson's chi-squared test and Student's t-tests were used to evaluate significance between categorical and continuous variables, respectively, using an alpha of 0.05.

Results: Our study included 20 females and 43 males with 38 transfemoral and 25 transtibial amputations for a total of 63 patients. 30 patients received TMR at the time of implantation; 25 had a history of painful neuroma with neuroma excision at implantation, and 5 received TMR prophylactically as implantation occurred at the time of initial amputation. 33 patients did not undergo TMR, as they had no history of neuromas and lacked suitable anatomy due to prior amputation. There were 11 postoperative neuromas, which occurred on average 438 days after implantation (range: 196-963). Sex, amputation level, and amputation etiology were not significant predictors of post-operative neuromas (p>0.05). Of the 11 patients, 5 had received concurrent TMR and 6 had not. There was no difference in post-operative neuroma rates between patients who did and did not undergo TMR (p>0.05). Of the patients who received TMR, there was no difference in rates between the indication for TMR surgery (p>0.05). However, patients who received TMR for prior neuroma developed post-operative neuromas at 261 days postoperatively on average, while patients who received TMR prophylactically developed post-operative neuromas at 718 days, and those who did not receive TMR developed neuromas at 434 days.

Conclusions: Plastic surgeons will increasingly oversee the management of soft tissue concerns, including neuromas, as osseointegration becomes more accessible to lower limb amputees. Our study showed that there was no difference in neuroma development between patients who received TMR and those who did not. Nor was there a difference in outcomes based on history of neuroma. However, our data demonstrated that patients with prior neuroma developed neuromas faster than patients who received TMR prophylactically. More long-term follow-up is needed to understand how best to both prevent and manage neuromas after implantation in this unique cohort.

Introduction: Autologous skin grafts, including full-thickness skin grafts (FTSG) and split-thickness skin grafts (STSG), are usually the coverage of choice for healing burns. However, cases of limited donor supply sites, donor site morbidity, and graft loss have prompted exploration of alternative solutions, such as skin substitutes. To date, no systematic review has extensively compared the existing skin substitutes within each category, highlighting key differences, benefits, or burn outcomes. This systematic review aims to fill this gap in the literature by providing an updated and extensive review of existing skin substitutes. This study critically assesses and analyzes current skin substitutes in the literature in hopes of improving burn coverage and healing outcomes for patients. Methods: This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. PubMed, Cochrane, Embase, Scopus, Ovid, and Web of Science were queried to identify relevant articles. English-language prospective and retrospective cohort studies, cross-sectional studies, randomized control trials, case-control, and case series were included. Case reports, review papers, studies reporting only qualitative data, studies published more than 10 years ago, and case series <10 patients were excluded. Results: Of all papers reviewed, 25 selected studies reported on patients who received skin substitutes. More than half (22/25) of these studies were conducted using a randomized controlled trial or randomized paired study design; the remaining studies consisted of (2/25) prospective cohort studies; (1/25) prospective case-control studies. Wound healing or graft take was measured in (20/25) of the included studies. There was variation in how wound healing and graft take were reported: healing percentage at specified time points, incidence of complete wound healing, incidence of % wound healing, ratio of areas of closed wounds to donor biopsies, percentage engraftment at specified time points, percentage epithelialization at specified time points, percent reduction in defect size, length of time until complete wound healing/re-epithelialization, and rate of complete graft take/re-epithelialization. Other common study outcomes included fibrosis, scar appearance, pain, and infection. With regard to types of skin substitute/grafts used, (12/25) studies used synthetic, while (12/25) studies used biologic, and (1/25) studies evaluated both synthetic and biologic grafts. The most commonly studied skin substitutes included Integra (5/25), fish skin (4/25), amniotic membrane (5/25), Stratagraft (2/25), and Matriderm (2/25). Discussion: Of the skin substitutes implemented, there was no clear superior substitute type, as studies did not consistently compare the same various options. Notably, however, study arms using amniotic membranes consistently provided statistically significant improvements in wound healing and epithelialization when compared to comparator groups. Given the variability in study designs, methodology, and skin substitutes included in our eligible studies, further prospective and randomized controlled research should be conducted to provide stronger evidence regarding optimal skin substitutes for skin grafts in burn patients. Future studies should seek to improve our understanding of these various alternatives to autologous skin grafting in hopes of improving treatment protocols and long-term outcomes and reducing morbidity and further skin disfigurement in burn patients.

Background: Hidradenitis suppurativa (HS) is a chronic, painful, and inflammatory disorder that causes abscesses and scarring of the skin. Conservative HS treatment consists of antibiotics, improved hygiene, and analgesia. Severe and refractory cases, however, may require surgical management. Despite the differences in risk factors (such as smoking and obesity) and HS chronicity between children and adults, the relative outcomes in these two populations has not been studied. Therefore, the aim of this study is to quantitatively assess the perioperative outcomes after HS excision in the adult and pediatric populations.

Methods: A retrospective cohort analysis was conducted using the National Surgical Quality Improvement Program (NSQIP) database and the Pediatric National Surgical Quality Improvement Program (P-NSQIP) database from 2012 to 2020. The databases were queried using the International Classification of Disease (ICD-9) code 705.83. Demographic and outcome data for all patients who underwent HS excision was collected and analyzed.

Results: Data from 1136 patients were analyzed. Seven hundred eighty-four (69.0%) patients were adults and 352 (31.0%) patients were children. Adults were more likely to be readmitted following surgery at 6.8% compared to pediatric patients, at 4.8 % (P<0.001). Similarly, they had higher rates of reoperation at 30 days, totaling 6.9% of patients versus 3.4% (P<0.001). Adults also exhibited a higher percentage of transfusions at 4.2% compared to 0 children (P<0.001), and deep incisional surgical site infections, 2.6% vs. 0.6% (P=0.025). Children had a higher rate of sepsis, 0.6%, compared to 0 adults (P=0.002).

Conclusions: Compared to children, adult patients who underwent surgery for HS were significantly more likely to be readmitted and to require reoperation within 30 days. This data suggests the need for closer postoperative monitoring for adult patients.

Burn injury causes a coagulopathy that is poorly understood. In the post-burn state, significant fluid losses are managed by aggressive resuscitation that can lead to hemodilution. These injuries are managed by early excision and grafting, which can cause significant bleeding and further decrease blood cell concentration. Tranexamic acid (TXA) is an anti-fibrinolytic that has been shown to reduce surgical blood losses; however, its use in burn surgery is not well established.

We performed a systematic review and meta-analysis to investigate the influence TXA may have on burn surgery outcomes. A PubMed and Cochrane Library literature search was conducted on November 13th, 2022, for articles written since January 1st, 2012 that included data on the use of TXA in burn surgery. Eight papers were included, with outcomes considered in a random-effects model meta-analysis. Effects discussed within the articles included the following: intraoperative fluid administration, blood loss, change in hemoglobin levels, change in hematocrit levels, transfusion administration, length of hospital stay, VTE events, graft take, and mortality. RevMan 5.4 software was used for our statistical analysis and forest plot generation.1

Overall, when compared to the control group, TXA significantly reduced total volume blood loss (mean difference (MD) = -192.44; 95% confidence interval (CI) = -297.73 to -87.14; P = 0.0003), the ratio of blood loss to burn injury total body surface area (TBSA) (MD = -7.31; 95% CI = -10.77 to -3.84; P < 0.0001), blood loss per unit area treated (MD = -0.59; 95% CI = -0.97 to -0.20; P = 0.003), and the number of patients requiring a transfusion intraoperatively (risk difference (RD) = -0.16; 95% CI = -0.32 to -0.01; P = 0.04). Additionally, there were no noticeable differences in venous thromboembolism (VTE) events (RD = 0.00; 95% CI = -0.03 to 0.03; P = 0.98) and mortality (RD = 0.00; 95% CI = -0.03 to 0.04; P = 0.86).

In conclusion, TXA significantly reduces blood loss and the need for transfusions in burn surgery without increasing the risk of VTE events or mortality.

1. Review Manager (RevMan) [Computer program]. Version 5.4. The Cochrane Collaboration, 2020.

Introduction: Radiation therapy is a promising modality for treating keloids after surgical excision. However, it is currently not standard practice among physicians due to concern surrounding the risk of radiation induced secondary cancers, especially among pediatric patients. There is minimal research assessing the complications for radiation therapy in keloid management.

Aim: The goal of this study was to determine radiation oncologists' perspectives about the utility and appropriateness of radiation therapy for keloid management in both adult and pediatric patients. This study also aimed to characterize radiation modality, dose, fractionation, and secondary complications observed by providers.

Methods: An electronic survey was delivered to 3102 members of the American Society for Radiation Oncology. The survey subjects were radiation oncologists who are currently practicing in the United States. Rates of responses were analyzed.

Results: A total of 114 responses from practicing radiation oncologists were received. Of these, 113 providers (99.1%) supported radiation therapy for keloid management in adults; while only 54.9% supported radiation therapy for pediatric patients. Out of 101 providers that treated adults in the past year, the majority used external beam: electrons (84.2%), applied three fraction regiments (54.4%), and delivered radiation within 24 hours post-excision (45.5%). In pediatric patients, only 42 providers reported treating at least one patient. The majority used electron beam radiation (76.2%), applied three faction regimens (65%), and delivered radiation on the same day of keloid excision (50.0%) The main concern when treating pediatric patients were risk of secondary malignancy (92.1%).

Conclusion: While radiation therapy appears to be a widely accepted adjuvant treatment option for adults with keloids, the use of radiation therapy for pediatric patients is less widely accepted due to concerns regarding secondary malignancy. The findings suggest additional studies need to be carried out to assess the risk of those complications.

Background: Patients are counseled to reduce body mass index (BMI) prior to ventral hernia repair (VHR) due to associated risks of poor outcomes, including hernia recurrence. Ideal weight loss targets have not been established, nor has the impact of clinically significant weight loss (CWL) on postoperative outcomes. The study aim was to assess the influence of CWL on postoperative complications following abdominal wall reconstruction for VHR. Methods: A single-center retrospective review of patients who underwent abdominal wall reconstruction with the component separation technique for VHR from November 2008 to January 2023 was performed. Cohorts were stratified by presence of CWL (reduction > 5%) from baseline BMI at preoperative consultation. Data regarding comorbidities, perioperative details, and postoperative complications was compared between cohorts. Results: Of 180 total patients, 40 (22.2%) achieved CWL. Mean age and follow-up was 59.6 ± 11.2 years and 49.7 ± 23.4 months, respectively. Mean BMI was higher in the CWL cohort (33.6 vs. 31.7 kg/m2, p=0.076). Patients in the CWL cohort were more often obese compared to non-CWL (80.0% vs. 56.4%, p=0.007). There were no significant differences in demographic and surgical history between cohorts. The CWL cohort had a higher proportion of patients in Ventral Hernia Working Group (VHWG) classification II (82.5% vs. 63.6%) while the the non-CWL cohort had more VHWG classification III/IV (20.0% vs. 10.0%, p=0.078). There were no significant differences between concurrent procedures, hernia defect size, and mesh location and type. Complications including 30- and 90-day surgical site occurrence (SSO), return to operating room, readmission, and hernia recurrence, (CWL: 5.0% vs. non-CWL 1.4%, p=0.179) were comparable between cohorts. Multivariate analysis demonstrated BMI was an independent predictor of any complication (OR 1.07, p=0.044) and 90-day SSO (OR 1.10, p=0.043) while CWL did not independently predict postoperative outcomes. A post-hoc analysis was performed to better characterize and assess the influence of CSWL by BMI thresholds on rates of postoperative complications. When isolating patients with a BMI > 35 kg/m2, only 30.8% achieved CSWL (n=16) prior to index ventral hernia repair. There were no significant differences in complications including SSO, readmission, RTOR, or hernia recurrence. When analyzing patients with a BMI > 30 kg/m2, 28.8% achieved CSWL (n=32). Patients who achieved CSWL experienced a higher postoperative complication rate (31.3% vs. 17.7%) although this was not clinically significant (p=0.117). The CSWL cohort amongst obese patients had a significantly higher rate of hematoma (6.3% vs. 0%, p=0.008). Similarly, there were no significant differences in SSO, readmission, RTOR, or hernia recurrence. Conclusion: Clinically significant weight loss prior to ventral hernia repair utilizing component separation techniques does not independently influence post-reconstruction complications. Delaying surgical intervention for weight reduction in non-obese patients likely offers no benefit. However, surgeons should counsel obese patients to reduce BMI prior to surgery to lower associated risks of SSO.

Background: Advancing age is often considered a risk factor for postoperative complications.1-2 However, the effect of advanced age on outcomes following ventral hernia repair (VHR) using the component separation technique (CST) remains unclear. Thus, the study aim was to assess the influence of advanced age on short- and long-term postoperative complications following VHR using CST. Methods: A single-center retrospective review of patients who underwent abdominal wall reconstruction with the CST for VHR from November 2008 to January 2023 was performed. Cohorts were stratified by presence of advanced age (age ≥ 60 years). Data regarding comorbidities, perioperative details, and postoperative complications was compared between cohorts and analyzed via a multiple linear regression model. Results: Of 219 total patients, 114 met criteria for advanced age. Mean age and follow-up was 59.1 ± 11.3 years and 9.9 ± 21.8 months, respectively. Mean body mass index (BMI) was lower in the advanced-age cohort (30.8 vs. 33.2 kg/m2, p=0.004), and patients in this group were obese less often (54.4% vs. 72.4%). Chronic obstructive pulmonary disease (COPD) was more prevalent among the advanced-age cohort (8.8% vs. 1.9%, p=0.035). Intraoperatively, the advanced-age cohort underwent concurrent procedures less frequently (p<0.001), and received composite mesh (p<0.001) of a smaller size (p<0.001) more often. Controlling for these differences via multivariate analysis demonstrated BMI was an independent predictor of any complication (OR 1.1, p=0.002), dehiscence (OR 1.2, p=0.004), any surgical site occurrence (SSO; OR 1.1, p=0.026), and 90-day SSO (OR 1.1, p=0.015). A history of COPD was positively associated with seroma development (OR 20.1, p=0.012), while advanced age did not independently predict postoperative outcomes, including hernia recurrence (OR 0.8, p=0.766). Conclusion: VHR utilizing CST is generally safe to perform in patients of advanced age. Conversely, a patient's comorbidity profile, including BMI or COPD history, should be thoroughly assessed preoperatively, as these factors appear to have a stronger independent effect on postoperative outcomes.

References: 1. Pessaux P, Lermite E, Blezel E, et al; French Associations for Surgical Research. Predictive risk score for infection after inguinal hernia repair. Am J Surg. 2006 Aug;192(2):165-71 2. Lindmark M, Strigård K, Löwenmark T, Dahlstrand U, Gunnarsson U. Risk Factors for Surgical Complications in Ventral Hernia Repair. World J Surg. 2018 Nov;42(11):3528-3536

Background: Tissue expansion is a well-established approach to soft tissue reconstruction in the pediatric population, owing to its technical versatility and optimized aesthetic outcomes. Lower extremity tissue expansion has thus become the standard of care for the reconstruction of soft-tissue defects in children, particularly within the lower limb, buttocks, and perineum. Despite the broad applications of tissue expanders in children, reported complication rates range from 19% to 40%. General complications associated with tissue expansion include infection and implant extrusion, leading to premature expander removal and delays in reconstruction. In particular, the pediatric population has been a difficult cohort to treat. These challenges have prompted this investigation on categorizing risk factors for lower extremity tissue expander placement in the pediatric population.

Methods: A retrospective study of pediatric patients who underwent tissue expander placement in the lower extremity by the senior author (R.J.R) was performed over a 16-year period. Patient charts were reviewed to categorize baseline characteristics and operative characteristics. Primary outcome variables were surgical-site infection (SSI), expander extrusion, and expander deflation. Secondarily, any potential associations between patient baseline characteristics and operative characteristics were investigated. Univariate and multivariate logistic regressions were performed, as well as Pearson's chi-square analysis, Wilcoxon's ranked sum test, and student's t-tests (alpha <0.05).

Results: The overall complication rate in this study cohort was 27.1% with an overall 77.2% successful reconstruction rate. Greater number of expanders placed during one operation [2 (2-3)] are associated with 2.5 increased odds of having any complication including surgical-site infection, expander extrusion, and premature explantation and are associated with 0.4 decreased odds of having a successful reconstruction. Additionally, there is a near-significant association with three times increased odds for having expander extrusion. Incisions made in scar tissue for expander placement appear to be associated with a greater than seven times increased odds of readmission.

Conclusion: Reconstruction of soft tissue defects using lower extremity tissue expanders in the pediatric population is an effective, yet challenging technique. Extra care should be taken with patients who require multiple expanders in the same location and with choosing the location and incision of expander placement.

Purpose: Muscle flap closure can reduce wound complications in high-risk spine patients. Nevertheless, accurate risk stratification remains a challenge. We sought to identify predictors of wound complications after open spine procedures and compare to commonly used general surgical risk scores in a national quality-improvement database.

Methods: The ACS-NSQIP database (2011–2021) was queried for CPT codes representing open spine procedures with a posterior approach. Patients were stratified by whether they received a concurrent pedicled flap. Clinical variables, including 5-factor modified frailty index (mFI-5 score), were extracted to determine covariates associated with development of a wound complication in non-flap patients. Univariate and multivariate analyses were performed.

Results: 511,737 patients underwent open spine procedures and 2,501 (0.5%) received concurrent muscle flaps. Flap use has increased annually from 0.3% to 0.8% of annual cases from 2011 to 2021 (p<0.001). Non-flap patients who experienced a wound complication were older (p=0.007), female (p<0.001), black or other race (p<0.001), frailer (p<0.001) and had a greater burden of comorbidities. On regression analysis, high frailty index was independently predictive of wound complications (OR 1.26, 95% CI 1.19-1.34, p<0.001). However, factors, such as female gender, race, BMI >35, ASA Class 4-5, smoking history, and Albumin < 3.5 mg/dL, remained more strongly associated when adjusting for other covariates (p<0.001).

Conclusion: The use of muscle flaps in high-risk patients during open spine procedures is rare but increasing. While mFI-5 is predictive of wound complications in non-flap patients, other clinical factors were significantly more associated. A novel risk score could identify high-risk spine patients who may benefit from enhanced closure.

Background: The 5-factor modified Frailty Index (mFI-5) has been shown to be an effective risk-stratification tool in predicting 30-day postoperative complications and mortality following major lower extremity (LE) amputation. However, its prognostic value for long-term mortality is unknown. The study aim was to assess whether a high mFI-5 score relates to long-term mortality following major LE amputation for chronic wounds.

Methods: A retrospective review of patients >60 years who underwent major LE amputation from 2017 to 2021 was performed. Data regarding patient demographics, comorbidities, perioperative factors, amputation type, and postoperative surgical and 30-day medical complications was collected and mFI-5 was calculated. Survival predictors were analyzed using Cox regression. Youden index of receiver operating characteristic curves was used to determine the discriminatory value of mFI-5 in predicting overall mortality. Survival analysis was performed with Kaplan-Meier curves and differences were assessed with Log-Rank test.

Results: Of 72 patients identified, the majority of patients were male (n=112, 65.1%) and African American (n=92, 54.1%). Mean age and follow-up was 70.7 + 8.0 years and 17.5 + 15.9 months, respectively. The mean mFI-5 score was 2.9 + 1.0 with 43.0% of patients (n=74) having a score of 3, 25.6% (n=44) with a score of 2, and 22.7% (n=39) with a score of 4. Median time to ambulation was 3.7 months (IQR 4.0). The Youdens´ Index of the ROC curve for mFI-5 and overall mortality was found to be 3.5 with an AUC of 0.61. Thus, the cutoff value was determined to be 4.

Ambulatory rate was 51.7% (n=89), overall mortality 36.0% (n=62), one-year mortality 14.0% (n=24), and three-year mortality 27.9% (n=48). Patients with an mFI-5 of >4 (26.7%, n=46) had a higher rate of overall mortality (52.2% vs. 30.2%, p=0.008), one-year mortality (23.9% vs. 10.3%, p=0.023), and three-year mortality (45.7% vs. 21.4%, p=0.002). Multivariate analysis demonstrated mFI-5 >4 remained a significant predictor of three-year mortality (OR 2.35, p=0.043), while overall mortality trended towards significance (OR 2.01, p=0.091). One-year mortality was no longer associated with increased mFI-5 scores.

The Kaplan-Meier overall survival probability was different between the mFI-5 cohorts by log-rank test (X2 = 8.501, P =0.004). Patients who were ambulatory at final follow-up were less likely to be deceased at all time points for both cohorts (OR 0.33 95% CI: 0.20–0.56, p<0.001). Patients who underwent AKA compared to BKA were more likely to be deceased at all time points for both cohorts (OR 2.72 95% CI: 1.43–5.15, p=0.002).

Conclusion: At a threshold of four or greater, the mFI-5 demonstrated utility in predicting long-term mortality. The value of this prognostic indicator is in its preoperative application of assessing risk of mortality, which should be utilized in conjunction with other measures.

PURPOSE: Free flap reconstruction of lower extremity defects frequently occurs with unpredictable timing; however, the association of operative time of day and outcomes is unknown.

METHODS: A retrospective review was performed of all lower extremity free flap reconstructions performed between 2013-2021 for a single surgeon at a single institution. Primary outcomes included complications and flap success. Secondary outcomes included procedure length, reoperations, readmissions, and time to definitive coverage. Cases performed within the hours of 7 AM and 7 PM were defined as daytime surgery; overnight surgery was defined as cases occurring outside that window. Primary outcomes were analyzed using a multivariable logistic regression adjusting for demographics, comorbidities, surgical technique, and time of day. Secondary outcomes were evaluated using chi-square or Fisher's exact tests.

RESULTS: 148 free flaps were included for analysis: 88 daytime, and 60 nighttime free flaps. Free flap indications and technique did not differ between groups. Overnight flaps were associated with a significantly shorter operative time (p=.006), but significantly more reoperations during admission (p=.045). Overall, vein grafting was independently predictive of an increased risk of complications (OR=8.4, 95% CI 2.0 to 36.2). There were no differences in flap success, readmissions, or time to definitive coverage between daytime and overnight operations. Early vs. late career (learning curve) had no impact on time-of-day outcomes.

CONCLUSION: Overnight lower extremity free flaps were associated with increased reoperations but were not associated with long-term differences in readmission or flap success. Increasingly complex cases requiring vein grafting are likely best performed during daytime hours.

Background: Orthoplastic surgery, coined by Dr. Scott Levin over twenty years ago, has become an increasingly sophisticated practice with techniques derived from both plastic and reconstructive surgery and orthopedic surgery (1). It has been suggested that the techniques employed by orthoplastic teams such as microvascular bypasses, free tissue transfers, replantation, nerve grafting, nerve transfers, targeted muscle reinnervation, and microlymphatic surgery can lead to better patient outcomes (2-4).

Purpose: Our study had two goals: First, to assess differences in outcome between the orthoplastic team approach vs. the traditional approach via a systematic literature review. Second, to gauge exposure to orthoplastic surgery in integrated plastic surgery residency programs nationally.

Methods: In the first part of our study, we investigated outcomes of various procedures as performed by orthoplastic vs. non-orthoplastic teams via a systematic literature review to determine whether there were significant post-operative differences for complex extremity cases. The indications we reviewed included limb salvage for (1) traumatic upper and (2) lower extremity injuries, (3) chronic osteomyelitis, (4) diabetic foot infections, (5) chronic deformity and congenital malformations, and (6) oncologic complications such as osteosarcomas and soft tissue neoplasms. In the second part, we distributed a 16-item anonymous survey to all directors of integrated plastic surgery residency programs. Information about the program, its affiliated hospitals, and curriculum related to hand and orthopedic surgery were collected.

Results: Our systematic review demonstrates superior outcomes, regardless of indication for limb salvage, when operatively managed by orthoplastic teams. We show decreased number of amputations, better skin healing, and better long-term gait recovery in a wide range of clinical scenarios when orthoplastic techniques are employed. Our survey data showed that out of 86 Integrated Plastic Surgery programs, 16 of which responded to our survey (19%), only one program had an orthoplastics center, at which residents rotate for 1 month. The estimated proportion of institutional case volume involving orthoplastic collaboration varied from 1% to 30%.

Conclusion: The orthoplastic approach demonstrates superior outcomes to the traditional non-orthoplastic approach in all measured indications. Yet, resident exposure to orthoplastic surgery training remains extremely limited. Increasing medical awareness of orthoplastic principles, specifically in medical education, will help advancements in a wide range of reconstructive scenarios.

1. Levin L.S. The reconstructive ladder. An orthoplastic approach. Orthop Clin N Am. 1993;24:393–409.
2. Naique S.B., Pearse M., Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Jt Surg. 2006;88:351–357.
3. Yang, Xu, C., Zhu, Y.-G., Li, J., Wu, Z.-X., Zou, J.-W., Xue, B.-B., Miao, D.-M., Shang, L., & Zhao, G.-Y. (2021). Radical treatment of severe open fractures of extremities by orthoplastic surgery: a 10-year retrospective study. Journal of Orthopaedic Surgery and Research, 16(1), 1–340. https://doi.org/10.1186/s13018-021-02479-2
4. Boriani F., Ul Haq A., Baldini T. Orthoplastic surgical collaboration is required to optimize the treatment of severe limb injuries: a multi-centre, prospective cohort study. J Plast Reconstr Aesthet Surg. 2017;70:715–722.

Purpose: Limb salvage post-traumatic lower extremity (LE) injury often necessitates blood transfusion for adequate tissue perfusion. Appropriate transfusion decision-making can maximize limb preservation opportunities. This study examines perioperative blood transfusion implications on amputation status in traumatic LE reconstruction.

Materials and Methods: A retrospective review was conducted at a level 1 trauma center on patients who underwent LE reconstruction between 2007-2022. Patient demographics, comorbidities, perioperative blood transfusions, flap characteristics, complications, and ambulatory status were recorded. Chi-squared and independent t-tests were used for statistical analysis. Logistic regression was performed to examine the impact of patient factors and comorbidities on amputation status.

Results: Among 350 flaps placed, 147 (42.0%) received at least one packed red blood cell transfusion (Tf+), and 203 (58.0%) received no blood transfusions (Tf-). The Tf+ cohort had significantly higher amputation rates compared to the Tf- group (5.4% vs. 1.9%, p=0.014). Both transfusion status (odds ratio [OR]: 6.0, 95% confidence interval [CI]: 1.34-25.7; p=0.019) and age (OR: 1.1; 95% CI: 1.02-1.14; p=0.006) were identified as independent contributors for amputation rates. Age, gender, hypertension, diabetes mellitus, cocaine use, congestive heart failure, renal disease, and peripheral vascular disease did not significantly vary between cohorts. Overall flap survival across both cohorts was 95.1% with higher rates among the Tf- cohort (97.0% vs. 92.5%; p=0.052).

Conclusion: The Tf+ trauma patient cohort suffered significantly higher rates of postoperative LE amputation. Surgeons should consider a conservative transfusion protocol to mitigate transfusion-correlated limb loss/morbidity.