“The reality is that there are not a lot of hospitals and health systems that have this kind of surgical expertise,” says Dr. Levin, “the procedures are very demanding and require years of experience to properly treat these cases – and few have more experience than the professionals here at Penn.”
“Before you amputate, send them to Penn.”
— Dr. L. Scott Levin, MD, FACS
These severe cases of complex extremity trauma, bone and soft tissue tumors, and infection are treated with techniques focused on soft tissue microsurgical reconstruction – enabling Penn to help many patients avoid amputation.
Microvascular Surgery for Reconstruction: Turning the worst cases into best-case scenarios
The primary goal of limb salvage and reconstruction is to restore or improve function in the affected limb, facilitating the patient’s return to normal life. The strategic combination of microvascular surgery and skeletal stabilization – among other complex procedures – achieves this goal.
For limb salvage cases, Penn surgeons use an array of microsurgical tissue transfers to provide new living tissue for wound closure by taking living tissue from a donor site in the patient’s body and transferring it to fill the defect using microsurgical techniques. A highly specialized skill, microvascular reconstructive surgery relies on suturing very small blood vessels - typically one millimeter in diameter - using an operating microscope and sutures small enough to pass through a human hair.
There are several options for skeletal reconstruction considered including autogenous bone grafts, vascularized bone
transfer (pedicled or free), and the Ilizarov technique. Option selection is determined by the size and severity of the bone defect.
“We also concentrate on the aesthetic aspects of extremity reconstruction,” says Dr. Levin, “We use techniques such as endoscopic tissue expansion to not only release contractures but resurface the extremity for more aesthetically pleasing results, which will have positive psychological implications for the patient.”
CASE STUDY: The frostbitten patient who avoided amputation
Frost bitten feet before surgery
Frost bitten feet after surgery
Speeding through the snowy Colorado landscape, Patient A was enjoying his vacation and the thrill of his rented snowmobile. As the day turned to dusk however, he realized that he had become lost and was running out of gas. He had no cell phone reception to call for help and soon found himself trying to survive a cold night alone in the woods – developing severe frostbite. Fortunately, first responders found him and took him to a local healthcare facility where his doctors told him he was lucky to be alive – but he may lose his feet.
Wanting a second opinion and remaining hopeful that his feet could be saved, he was referred to Dr. Levin at Penn Medicine. “When he arrived here, his toes and the front of his feet were completely black,” says Dr. Levin, “he was told he’d have to get both his feet amputated. He was understandably upset and terrified that he might never be able to walk again,” says Dr. Levin.
Dr. Levin and the team of orthopaedic, plastic and reconstructive surgeons took him into surgery that very day. Donor tissue was taken from each upper arm to salvage both feet. While the microvascular reconstruction procedure took over five hours per foot, it was a complete success as the team was able to save both feet. Dr. Levin remembers the look on his face after he was told the good news, “He was so happy he wasn’t going to have to use prosthetics. He did great with his rehab and is glad to be – literally – back on his own two feet.”
CASE STUDY: The tree-trimmer who overcame his trauma
Foot after tree limb accident before surgery
Injured foot shortly after surgery
Injured foot fully recovered after surgery
Even the most seasoned tree trimming professionals understand the hazards involved in their job. Their day-to-day job duties routinely involve being suspended in an aerial harness over electrical wires while using a chainsaw to saw through tree branches. These risks impacted Patient B when a massive branch came crashing down and completely crushed his foot. Much like Patient A, he was devastated when his doctor told him he would need a below-the-knee amputation. Seeking a second opinion, he came to see Dr. Levin and the Penn Limb Salvage team.
Dr. Levin and the team wasted no time scheduling his microvascular reconstructive surgery using free flap tissue transfer from the patient’s thigh. Like the majority of their cases, this surgery was also a success. “He told me when that tree fell on his foot, he didn’t think he’d ever be able to walk again,” says Dr. Levin, “He was so happy and was able to walk on his reconstructed foot just a few months later.”
Better Outcomes from Experience, Expertise & Passion
Because microvascular procedures are so specialized and demanding, there are very few facilities anywhere in the world that have the clinical experience and expertise of Penn’s team. In fact, while the American Academy of Orthopaedic Surgeons boasts over 40,000 members, the American Society for Reconstructive Microsurgery – of which Dr. Levin is a former President - has only 800 members nationwide.
The multi-disciplinary approach taken for these cases combines the best, most experienced clinical talents in orthopaedics, plastic surgery, reconstructive surgery and other specialties to provide patients with integrated orthoplastic care. That’s why, despite handling more than 100 of these complex cases every year, 98-99% of patients who are treated at Penn end up avoiding an amputation.
“This is the highest form of reconstructive surgery and we have a real passion for it,” says Dr. Levin, “our team members are dedicated and skilled. It’s demanding but very rewarding work.”