When salvage becomes suffering: re-evaluating the limits of limb preservation in modern orthoplastic surgery

Modern orthoplastic surgery has expanded the possibilities of limb preservation after severe extremity trauma through advances in microsurgical reconstruction, skeletal stabilization, vascular repair, and multidisciplinary trauma care. However, increasing reconstructive capability has also emphasized the distinction between anatomical limb preservation and meaningful long-term recovery. Despite technically successful salvage, some patients experience chronic pain, repeated procedures, prolonged rehabilitation, impaired mobility, psychological distress, and socioeconomic decline. This editorial re-examines conventional salvage paradigms and argues that reconstructive success should not be defined solely by flap survival, fracture union, infection control, vascular patency, or limb retention. Traditional scoring systems, including the Mangled Extremity Severity Score, Limb Salvage Index, and Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score, remain limited in predicting long-term functional and patient-centered outcomes. Evidence from the Lower Extremity Assessment Project and the Military Extremity Trauma Amputation/Limb Salvage Study highlights the complex relationship between limb preservation, functional recovery, quality of life, and return to meaningful participation after severe lower extremity trauma. This editorial proposes a broader patient-centered framework for salvage decision-making that incorporates biological viability, functional utility, rehabilitative feasibility, and contextual life circumstances. Ultimately, successful limb salvage should be defined not only by technical reconstruction but by whether recovery restores sustainable function, independence, and meaningful participation in life.