title: History of lower limb reconstruction after trauma.
abstract: BACKGROUND
  The principles guiding reconstruction of the lower limb after trauma have become established over 300 years through advances in technology and studies of epidemiology. This paper reviews how these principles came about and why they are important.
  
  
  METHODS
  This is a structured review of historical and recent literature pertinent to lower limb reconstruction. The outcomes assessed in the pre-modern era were wound mortality, amputation mortality and amputation rate. In the modern era, infection and non-union emerged as measures of outcome, which are morbidity- rather than mortality-based. Indications for amputation published during the eras are taken to reflect the reconstructive practices of the time.
  
  
  RESULTS
  Amputation and wound mortality fell throughout the pre-modern era, from 70% and 20% to 1.8% and 1.8%, respectively. Amputation rates peaked in the American Civil War (53%) but have remained less than 20% since then. Infection and non-union rates in the modern era have fluctuated between 5% and 45%.
  
  
  CONCLUSIONS
  Priority areas for research include refinement of soft tissue reconstruction, injury classification, standardization of outcome measures and primary prevention. The impact of débridement and antisepsis on outcomes should not be forgotten as progress is made.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia. michaelwagels@hotmail.com
authors.forename: Michael
authors.initials: M
authors.lastname: Wagels
authors.forename: Dan
authors.initials: D
authors.lastname: Rowe
authors.forename: Shireen
authors.initials: S
authors.lastname: Senewiratne
authors.forename: David R
authors.initials: DR
authors.lastname: Theile
mesh_terms: D000671:Amputation, Surgical / Q000266:history* / Q000379:methods; D016025:Bone Transplantation / Q000266:history / Q000379:methods; D003646:Debridement / Q000266:history / Q000379:methods; D005060:Europe; D005592:Fracture Fixation / Q000266:history* / Q000379:methods; D049670:History, 17th Century; D049671:History, 18th Century; D049672:History, 19th Century; D049673:History, 20th Century; D049690:History, Ancient; D006801:Humans; D007194:India; D007869:Leg Injuries / Q000266:history* / Q000601:surgery; D023821:Limb Salvage / Q000266:history* / Q000379:methods; D016067:Nerve Transfer / Q000266:history; D016038:Skin Transplantation / Q000266:history / Q000379:methods; D013524:Surgical Flaps / Q000266:history; D014481:United States; D014857:Warfare