title: Application of the orthoplastic reconstructive ladder to preserve lower extremity amputation length.
abstract: 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.
authors.affiliation: 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.
authors.forename: Mark E
authors.initials: ME
authors.lastname: Fleming
authors.forename: Anthony
authors.initials: A
authors.lastname: O'Daniel
authors.forename: Husain
authors.initials: H
authors.lastname: Bharmal
authors.forename: Ian
authors.initials: I
authors.lastname: Valerio
mesh_terms: D000328:Adult; D000672:Amputation Stumps / Q000601:surgery*; D000673:Amputation, Traumatic / Q000601:surgery*; D006801:Humans; D007869:Leg Injuries / Q000601:surgery*; D008297:Male; D054843:Negative-Pressure Wound Therapy; D019651:Plastic Surgery Procedures / Q000379:methods*; D016038:Skin Transplantation; D013524:Surgical Flaps; D015626:Tissue Expansion