Reply: Identifying Factors Most Important to Lower Extremity Trauma Patients: Key Concepts from the Development of a Patient-Reported Outcome Instrument for Lower Extremity Trauma, The LIMB-Q

We would like to thank Dr. Aytaç et al. for their comments on our recent article.1 It is evident that this is a group of clinically experienced lower extremity trauma surgeons, and we appreciate their shared interest in a patient-reported outcome instrument developed specifically for lower extremity trauma patients. The authors requested additional information on the clinical history of our qualitative interview sample, which is outlined in Table 1. The overall median time to the flap procedure was 18 days (range, 3 days to 5.5 years). Among the 22 patients with initial attempted reconstruction, 13 patients presented at the time of injury to our institution and underwent planned soft-tissue reconstruction for soft-tissue defects that were recognized at the time of injury or during early débridement. Within this group of acute reconstruction, the median time to the flap procedure was 14 days (range, 3 to 29 days). The remaining patients were transferred from an outside institution or underwent soft-tissue reconstruction for a delayed presentation of a soft-tissue defect (e.g., osteomyelitis). Free tissue transfer was performed for the majority of the soft-tissue reconstructions, with anterolateral thigh, radial forearm, and latissimus muscle flaps performed most frequently. Table 1. - Clinical Treatment Characteristics of LIMB-Q Qualitative Interview Patients* Time to Treatment/Flap Types Reconstruction (n = 15) Early Amputation(n = 11) Delayed Amputation (n = 7) Time to flap, days Mean 155.8 — 17 Median 19 — 18 Range 3–2025 — 5–27 Time to amputation, days Mean — 3 252 Median — 0 200 Range — 0–11 19–610 Free flaps, no. Anterolateral thigh 4 — 1 Radial forearm 3 — — Latissimus 4 — 1 Rectus abdominus 1 — — Local/regional flaps, no. Gastrocnemius/ soleus 2 1 — Reverse sural 1 — 2 Propeller (fasciocutaneous) — — 1 Unknown flap type 2 — 2 *Some patients had multiple flaps; some patients had bilateral injuries requiring amputation/reconstruction. Time to flap and amputation is time to first flap/amputation in patients with multiple flaps/amputations. Clinical data were not available for all patients (some were managed at an outside institution). Timing of reconstruction and flap choice can certainly have an impact on reconstructive outcomes in lower extremity trauma patients. However, the goal of our qualitative interviews was not to identify methods to optimize patient success. Rather, these interviews were conducted with the purpose of identifying all relevant concepts of interest to patients after limb-threatening lower extremity traumatic injuries. To maximize variability in the patient experience, purposeful sampling was used to ensure we were capturing a variety of experiences from patients with varying backgrounds and treatment outcomes. Interviews were conducted until we reached a point of content saturation, where no new ideas or concepts were being discussed by patients. The majority of patients received definitive treatment at a tertiary academic hospital by a select number of orthopedic trauma and reconstructive plastic surgeons. The practice patterns of these individual surgeons are likely reflected in the care of these patients. However, some patients were managed either initially or in full at outside institutions. Overall, patients in the interview sample were recruited for variability in demographic and socioeconomic backgrounds, injury etiology, and treatment outcome. The LIMB-Q is a patient-reported outcome instrument that captures the breadth of the experience for lower extremity trauma patients, which is relevant for patients who have successful outcomes and those who experience complications. We are hopeful that the qualitative patient sample reflects that variability in the patient experience to ensure that the LIMB-Q is relevant for all. We thank the authors for bringing up these points for discussion and for their interest in our shared objectives of improving the care of lower extremity trauma patients. We are confident that the LIMB-Q will help us answer many of the unanswered questions in lower extremity trauma research, while providing a stronger voice to the patient perspective. DISCLOSURE None of the authors has a financial interest to declare in relation to the content of this communication. Lily R. Mundy, M.D.Division of Plastic and Reconstructive SurgeryDepartment of SurgeryDuke UniversityDurham, N.C. Anne Klassen, D.Phil.Department of PediatricsMcMaster UniversityHamilton, Ontario, Canada Andrea L. Pusic, M.D., M.H.S.Patient Reported Outcomes, Value, and Experience Center and Division of Plastic SurgeryDepartment of SurgeryBrigham & Women’s HospitalBoston, Mass. Scott T. Hollenbeck, M.D.Division of Plastic and Reconstructive SurgeryDepartment of SurgeryDuke UniversityDurham, N.C. Mark J. Gage, M.D.Section of Orthopaedic TraumaDepartment of Orthopaedic SurgeryDuke UniversityDurham, N.C.

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