L. Scott Levin Recognized for Extremity Reconstruction Tech

L. Scott Levin, M.D., FACS, FAOA, FAAOS, is this year’s recipient of the Kappa Delta Elizabeth Winston Lanier Award.

Levin has spent his 44-year career studying and popularizing the use of microsurgery in orthopedics and integrating both orthopaedic surgery and plastic surgery to significantly improve extremity salvage, reconstruction, and restoration. “In conjunction with my mentors and colleagues, I’ve spent four decades researching and developing techniques to advance patient care and educate residents and fellows on the full spectrum of reconstructive microsurgery that includes revascularization, replantation, composite free tissue transfers and, most recently, vascularized composite allotransplantation, all of which are vitally important to optimize limb salvage and functional outcomes for a variety of upper and lower extremity conditions,” said Levin, vice president and associate dean for Resource Development, the Paul B. Magnuson professor and chairman of the Department of Orthopaedic Surgery, and professor of surgery (plastic surgery) at the University of Pennsylvania School of Medicine (Penn Medicine). “By integrating concepts of orthopaedics and plastic surgery, we were able to solve clinical problems that seemed intractable resulting in the need for limb amputation. By applying microsurgical techniques, limb salvage became possible, helping patients avoid amputation.”

Levin is a double-board certified surgeon in orthopedic and plastic surgery, and has a certificate of qualification in hand surgery. Leveraging his background in clinical, anatomic, and basic science research in reconstructive microsurgery, Levin introduced the orthoplastic discipline, which simultaneously applies the principles and practices of both specialties to clinical problems. Levin described the microsurgical reconstructive ladder in 1993, defining the orthoplastic principles, to establish a paradigm for which microsurgical techniques (from replantation to transplantation) should be used for a given orthopedic condition.
 
For more than six decades, the use of the operating microscope for extremity surgery has led to significant advances in managing orthopedic trauma, tumors, infections, and congenital differences. It has also facilitated considerable advances in extremity reconstruction, such as digital artery or nerve repair and autologous tissue transplantation (free tissue transfer). This is due to the microscope’s ability to magnify the operative field to perform vascular anastomosis, a surgical procedure used to connect very small blood vessels (typically 1 millimeter in diameter or less), using tiny needles and ultrafine sutures to salvage and reconstruct limbs.

“Reconstructive microsurgery should be and is an essential component of orthopedic surgery,” said Levin. “Microsurgery has no specialty home, and the orthopaedic community must realize the inordinate power of the operating microscope to solve problems by applying orthoplastic principles to treat these injuries.”
 
Patients with orthopedic injuries such as open fractures, bone, and soft tissue tumors, dysvascular and diabetic feet, absence of upper limbs, and brachial plexus injuries, can benefit from microvascular surgery, as outlined in the microsurgical reconstructive ladder. Proper handling of soft tissue is paramount to successful outcomes and compromise of the soft tissue envelope can result in morbidity, increased costs of care, readmission and the need for complex salvage procedures or amputation.
 
As microvascular tools and techniques for limb salvage and reconstruction have evolved to treat reconstructive procedures on the microsurgical ladder, Levin has taken this a step further to include restorative surgery using vascularized composite allotransplantation (VCA) to completely restore all missing structures. In 2015, Levin led the team that performed the world’s first bilateral hand transplant in a child using VCA and a year later he led a team to perform the first transcontinental hand transplant.
 
Levin’s first peer reviewed publication in 1978 titled, “Digital Sensibility Following Replantation” has led to more than 400 papers, 93 book chapters and 11 books dedicated to extremity reconstruction. Highlights of his work include:

• Identifying a “fascial cleft” in the upper and lower limb based on anatomic dissections. This discovery provided a constant potential anatomic space that can be accessed endoscopically and expanded with balloon dissectors to create an “optical cavity.” As a result, he and his team developed a series of techniques that were designed to create a minimally invasive approach to extremity reconstruction and microsurgery (i.e., tissue harvest, tissue expansion placement). 
• Bringing more attention to the aesthetic aspects of limb salvage utilizing plastic surgery. By introducing these principles to the trauma community, the reconstructive effort of a limb not only includes restoring limb function, but also values the aesthetics of limb appearance.   
• Conducting animal studies that have resulted in the creation of an innervated vascularized elbow allotransplantation model that holds promise for young patients afflicted by elbow trauma or a tumor. The team’s anatomic work on elbow transplantation has established the surgical procedure for VCA of the elbow. Furthermore, a patient is currently being evaluated to undergo this procedure in the near future. 
• Increasing education and awareness in this field through the development of an orthoplastic fellowship, and a journal titled, “Orthoplastic Surgery.” He also established a human tissue cadaver laboratory, first at Duke University, and then at University of Pennsylvania School of Medicine. These cadaver labs are dedicated to training residents and fellows in microvascular tissue transfer and are also used for surgical team rehearsal for hand transplantation. 

“It is incredibly rewarding to receive the Kappa Delta Award that recognizes our efforts to advance the field of extremity reconstruction, particularly our work in VCA,” said Levin. “None of this would have been possible without my colleagues and the contributions of my mentors, icons in their own right, for which I was gifted the opportunity to train with early in my career. I want to recognize the countless residents, fellows, and research scholars who I’ve worked with throughout my career. Their questions sparked research work that contributed to the development of orthoplastic surgery and advanced techniques for limb salvage. I’ll spend the rest of my career working to solve some of the immunologic barriers in allotransplantation, as advancing and evolving this field will hold great promise for the future of orthoplastic extremity reconstruction.”
 
The Kappa Delta Sorority established the Kappa Delta Research Fellowship in Orthopaedics in 1947. The first annual award, a single stipend of $1,000, was made available to the Academy in 1949 and presented at the American Academy of Orthopaedic Srugeons meeting in 1950. The Kappa Delta Awards have been presented by the Academy to persons who have performed research in orthopaedic surgery that is of high significance and impact. The sorority has since added two more awards and increased the award amounts to $20,000 each. Two awards are named for the sorority national past presidents who were instrumental in the creation of the awards: Elizabeth Winston Lanier, and Ann Doner Vaughn. The third is known as the Young Investigator Award. 
 
With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS provides education to help orthopedic surgeons and allied health professionals at every career level best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments, and related musculoskeletal health care issues and it leads the healthcare discussion on advancing quality.