A historical perspective on the changing methods of management for major trauma of the lower extremity

The quantity of severe injuries to the extremities challenging the modern, civilian surgeon cannot compare with that produced at Gettysburg or other battles of the Civil War. Nonetheless, the extent and severity of the trauma to the extremity generated on our "civilian battlefields" match and often surpass the wounds confronted by our predecessors. In the Civil War, as it had been for many preceeding years, amputation remained the dominant approach to managing a great variety of injuries to the extremities. However, constant surgical progress, as reflected by a gradual reduction in recourse to amputation, had enabled each succeeding generation of surgeons to surpass and distance themselves from their predecessors. Amputation of the traumatized extremity had always defined and continues to represent the prevalent abilities and limitations of conservative and reconstructive surgical efforts. Operative treatment, for much of its existence, represented a collection of dangerous ablative procedures which were used reluctantly when all other measures were exhausted. Its transformation into a successful reconstructive endeavor evolved primarily in this century. The understanding of bone healing and the functional importance of the knee joint led to a transformation in amputation and to changes in the management of fractures which are still evolving. The next revolution in operative treatment came with the ability to restore blood flow in injured extremities. Finally, the recent introduction of a variety of free flaps enables the reconstitution of extensive soft tissue and bony defects and further lowers the number of obligatory amputations. These innovations enabled the surgeon to reduce his or her recourse to amputation of severely injured extremities. Nonetheless, the significant number of amputations still performed constitute a reminder that there is still work to be done.