In reconstruction, the question is not whether a limb can be saved. It is whether the life attached to it can be lived.
L. Scott Levin, MD, chair emeritus of orthopedic surgery and professor of plastic surgery at Philadelphia-based Penn Medicine, has spent decades working at the edge of that distinction. He has treated devastating extremity injuries caused by trauma, infection and tumors, and he has supported limb salvage efforts in conflict zones including Ukraine and Israel.
Across those settings, the calculus is rarely sentimental. It is functional, personal and increasingly shaped by how far prosthetics and restorative reconstruction have advanced.
“Limb salvage is about integrating a patient back into society,” Dr. Levin said. “A pain-free extremity with function that’s as good as, if not better than, a prosthesis.”
If it is not, he added, “then we have to question efforts in limb salvage.”
The new definition of success
Dr. Levin said the modern goal of limb salvage is not simply preserving a limb. It is restoring one that feels usable and comfortable enough that the patient can stop organizing life around it.
A successful outcome, he said, is “having good sensibility, a pain-free extremity that allows the patient to work or even do sports or social activities. That’s a criterion.”
That standard has become sharper as prosthetics have improved. “Prosthetics have undergone a pretty remarkable technological advance,” he said. But even the most advanced devices still require a daily ritual of attachment.
“The patient still has to put on and take off the prosthetic, to be mobile,” he said.
That difference matters, he added, especially in lower-extremity injuries where the comparison between salvage and amputation is no longer simple. The question is increasingly about what will let the patient move through the world with the least friction.
“We have seen in our wounded warriors that sometimes we do attempt to salvage a limb,” he said. “And we can do that, but is the limb as functional as the patient wants to be?”
If it is not, he said, some patients eventually choose amputation. In the right circumstances, that choice is not a defeat.
“Ultimately, that patient may elect for an amputation,” Dr. Levin said, “which is a liberating operation.”
Orthoplastics changed the bedside by changing the priorities
Dr. Levin traces the rise of orthoplastic surgery to a shift in how surgeons approached recovery. It was not bone first and soft tissue later, but both at once, with vascularity and tissue health treated as essential to the outcome.
Using open fractures as a reference point, he described an injury where the risk is not only the broken bone. It is the entire damaged environment around it.
“An open fracture is a break in the skin with soft tissue loss and soft tissue injury,” he said. “We define an open fracture as a soft tissue injury with a broken bone in it.”
Orthoplastics, he said, emerged from paying closer attention to the tissue envelope and how much it governs infection risk, fixation success and healing.
“The evolution at the time was to pay attention to the role of vascularity around fractures, the role of the soft tissue envelope as it relates to fracture healing and recovery,” Dr. Levin said. It pushed surgeons toward “less-invasive approaches” that “respected or protected soft tissue.”
For Dr. Levin, that evolution became personal and professional. He trained in orthopedics, then completed plastic surgery training, focusing on reconstructive microsurgery, a skill set he describes as foundational to modern limb salvage.
“The power of reconstructive microsurgery and orthopedics cannot be underestimated,” he said.
Over time, he said, orthoplastic care has moved from a niche concept to an expected standard in complex cases.
“I think people are starting to accept it as the gold standard, for trauma care, for tumor patients who need limb salvage and for infections,” he said. “That includes dysvascular diabetic foot, infected knee prostheses and osteomyelitis.”
At the far end of what is now possible, he pointed to restorative reconstruction that was not on the table in earlier eras.
“Even now, we can do restorative surgery,” he said, describing “vascularized composite allotransplantation.”
War accelerates learning and exposes uneven access to expertise
Dr. Levin quoted Hippocrates as a blunt summary of how trauma knowledge advances.
“Hippocrates said, ‘If you want to learn surgery, go to war,’” he said.
Modern conflicts, he added, have produced a new reality: better survival, worse extremity injuries. Body armor and rapid evacuation save lives, but they often preserve patients through injuries that would have been unsurvivable decades ago.
“The rate of survival has improved because of Kevlar and rapid evacuation from the battlefield,” he said. “Lives are protected, but patients arrive with some of the worst extremity injuries we’ve ever seen.”
That shift creates a pressure point surgeons cannot avoid: deciding whether salvage will lead to function or prolong suffering.
“The question then becomes, do we salvage this extremity or do we amputate?” he said.
The difference now, Dr. Levin explained, is that surgeons have more tools, and that expanded toolkit can make borderline cases salvageable when they previously were not.
“That allows us to really throw in the kitchen sink sometimes, and create a functional extremity that will be better than a prosthetic at the end of the day,” he said.
But modern warfare has also exposed a global gap. The ability to do advanced reconstruction is not evenly distributed. In some regions, the right expertise exists only in a handful of places, and patients can lose years, or limbs, waiting to reach it.
Dr. Levin described a Ukrainian soldier who arrived after a prolonged attempt to heal a severe injury. The patient had spent 22 months in an external fixator and underwent an extraordinary number of procedures. “He had 54 operations,” Dr. Levin said.
The attempts failed. When the patient finally reached Dr. Levin’s team, he said the outcome changed. “Using the orthoplastic approach, we’re able to get him to walk again,” he said.
For Dr. Levin, the case is a measure of both progress and system failure. The techniques existed. The access did not.
“That shows you the need for sophisticated determination of salvage versus [amputation],” he said. “We still don’t have, around the world, the capability to do that to the benefit of the patient.”
How decisions get made
Dr. Levin said the most important limb decision is not made in isolation. It is made in partnership, sometimes with a strong recommendation, but always with the patient owning the final choice.
“It’s a discussion with the patient,” he said. “You have what’s called shared decision making.”
His approach, he explained, is to lay out both pathways clearly: the likely outcome of reconstruction, the likely outcome of amputation and what each road demands from the patient over time.
“If you came to me with a mutilated leg and I felt you’d be better off with amputation and a prosthesis, I would tell you that,” he said. “If I think I can save your leg and you’ll have pretty good function, I’ll tell you that too, and I’ll lay out what’s involved.”
Sometimes, he said, the recommendation becomes more direct, especially when salvage would leave a patient trapped in pain and limited activity.
“Holding on to this limb,” he said, “it’s like a ball and chain around your neck, literally keeping you from engaging in a normal life. You’ll be living around pain for the rest of your life.”
Then comes the question he believes surgeons owe patients, even when it is uncomfortable.
“Is that what you want?” he said.
The patient, he emphasized, still has agency. Some choose salvage even with limitations. Others choose amputation as the most functional way forward. Either can be the right decision if it is made with full clarity.
“That’s their decision,” he said. “But that’s how we make the decision. It’s called informed consent.”
The lesson he wants to export
After years working with war injuries and complex reconstruction, Dr. Levin said the most urgent need is not a new technique. It is widening access to the expertise that already exists, so patients are not forced into amputation simply because no one nearby can offer another path.
“I wish the orthoplastic ability and the orthoplastic techniques were more readily available,” he said.
He has been involved in training Ukrainian surgeons since the war began, he said, and described a similar model of education in Israel, where fellows come to learn advanced techniques and bring them back home.
“That’s something that I hope, as time goes on, we can promote more so that there’s expertise to be able to give patients options,” he said, “as opposed to, ‘Nobody has the skills to do this. So you’re going to have to have your leg amputated.’”
In his view, progress in limb salvage means little if only a select number of hospitals can provide it.
At the end of the day, he said, the field’s direction should be guided by a simple principle: expand what is possible, then let patients choose what is right.
“It’s about putting the patient first and offering the best possible options given their individual circumstances and the limitations of medical science,” Dr. Levin said.
