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Dedicated to the treatment of patients at high-risk for amputation, the Penn Orthoplastic Limb Salvage Center (POLSC) streamlines care of patients at risk of amputation due to complex trauma, bone loss, soft tissue compromise or infection. 

When to Transfer a Patient for Lower Extremity Limb Salvage

Evidence suggests that early intervention at a specialized trauma center, and early debridement/soft tissue coverage, is the best way to optimize outcomes for patients with severe lower extremity injuries and reduce the number of avoidable amputations. 

Penn limb salvage experts proposed the first formal guidelines to facilitate early transfer for lower extremity salvage. This protocol published in Orthoplastic Surgery, Lower Extremity Guidelines for Salvage (“L.E.G.S”), is outlined below.

 

Assessing Risk Factors for Amputation 

Many factors are considered when assessing a patient’s risk for amputation. Optimal treatment often requires a variety of limb salvage treatments and technologies, and dedicated support services.

Risk factors include:

  • Burns: Massive severe burns with open long bone fractures.
  • Ballistics: High velocity ballistic or projectile injury.
  • Open fractures: Open fracture with or without bone loss or comminution.
  • Psycho-social: Patients who will require special social, psychological, or rehabilitative intervention. Traumatic lower extremity injuries requiring microvascular reconstruction.
  • Vascular: Absent distal pulses, concern for vascular injury/known disease.
  • Comorbidities: Open fracture with significant comorbidities (e.g. Diabetes, immunocompromised state, hypertension, venous insufficiency).
  • Soft-tissue loss: Significant foot/ankle soft tissue loss (including plantar soft tissue loss).
  • Nerve injury: Absent plantar sensation, concern for nerve injury.
  • Crush/blast injury: Crush or blast mechanism injury involving multiple fascial compartments.
  • Uncloseable: Open fracture exposed bone/joint, or exposed instrumentation with soft tissue loss not amenable to primary closure.
  • Compartment syndrome: Fracture with associated compartment syndrome.
  • Polytrauma: Polytrauma with limb injury meeting above criteria following initial stabilization as necessary based on triaging physician's judgment.

 

Assessing Limb Salvage Resources 

If your facility does not have comprehensive limb salvage capabilities, after initial stabilization, immediately transfer the patient to a tertiary facility that specializes in limb salvage and reconstruction.

Transfer a Patient with Severe Lower Extremity Trauma

Penn offers the expertise, resources and facilities to expertly address amputation risk factors and patient support services for their post-surgical and rehabilitative care.

 

To have patients with severe lower extremity injury treated by our limb salvage experts, transfer your patient to Penn Presbyterian Medical Center’s Level 1 Trauma Center.

Transferring the Patient

  • Call Penn’s provider-only hotline: Initiate your patient’s transfer by calling Penn’s 24/7 provider-only line at 877-937-7366. 
  • Request transfer: Share that your patient has severe lower extremity injuries and is at risk for amputation, and request a transfer to Penn Presbyterian Medical Center’s Level 1 Trauma Center (51 N. 39th Street, Philadelphia, PA 19104). 
  • Consult with a limb salvage surgeon: You will be directly connected with a Penn limb salvage surgeon to discuss your patient’s case. 
  • Transport: Once the patient is accepted, expedited transport to Penn’s Level 1 Trauma Center at Penn Presbyterian Medical Center will begin.

Preparing Transfer Documentation 

  • Obtain transfer consent: Have the patient or authorized family member sign an EMTALA-compliant transfer form.
  • Prepare chart copy: Organize a copy of the patient’s chart including all pertinent diagnostic and radiologic studies for handoff.

A Chance for Better Outcomes at Penn Orthoplastic Limb Salvage Center

 

Approximately 160–180,000 adults suffer lower extremity amputations annually, often due to trauma. A significant number of these amputations occur at non-tertiary facilities.

Introduced by Said C. Azoury, MD, and colleagues at the Penn Orthoplastic Limb Salvage Center, our proposed Lower Extremity Guidelines for Salvage (“L.E.G.S”) guidelines are evidence-based and designed to optimize patient outcomes.

In addition to improving the chance for limb salvage, data from our institution shows that direct admission to a specialized center:

  • Decreases time to first definitive surgery, and the total number of surgeries is reduced
  • Risk of mortality is reduced by 73% 
  • Risk of venous thromboembolism and systemic infections is reduced by nearly 90%
  • Risk of total complications is reduced by more than half 
  • Risk of osteomyelitis is reduced by more than half

National data shows that African Americans are four times more likely to suffer an amputation than white Americans. Our data show that patients treated at Orthoplastic Limb Salvage center have similar outcomes, regardless of race/socioeconomic background. We believe this is the result of our specialized, coordinated care from our multidisciplinary team and close patient follow-up.

View full citation: Orthoplastic Surgery, Volume 3, 2021

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