L. Scott Levin, MD, FAAOS, FACS, FAOA

AAOS Now

Published 3/25/2022

Kappa Delta Elizabeth Winston Lanier Award Presented to L. Scott Levin, MD, for Research in Evolution of Microsurgery

The 2022 Kappa Delta Elizabeth Winston Lanier Award, which recognizes research in musculoskeletal disease or injury with great potential to advance patient care, was awarded to L. Scott Levin, MD, FAAOS, FACS, FAOA. With more than 40 years of clinical, anatomic, and basic science research in reconstructive microsurgery, Dr. Levin has dedicated his career to studying and popularizing the use of microsurgery in orthopaedics and integrating the fields of orthopaedic surgery and plastic surgery to significantly improve extremity salvage, reconstruction, and restoration.

As a double-Board-certified surgeon in orthopaedic and plastic surgery, in addition to a certificate of added qualification in hand surgery, Dr. Levin introduced the orthoplastic discipline, which simultaneously applies the principles and practices of both specialties to clinical problems. In addition, Dr. Levin described the microsurgical reconstructive ladder in 1993, defining orthoplastic principles, to establish a paradigm for which microsurgical techniques (from replantation to transplantation) should be used for a given orthopaedic condition.

For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopaedic trauma, tumors, infections, and congenital differences. It also has facilitated remarkable advances in extremity reconstruction, such as digital artery or nerve repair and autologous tissue transplantation (or free tissue transfer), owing to the microscope’s ability to magnify the operative field for vascular anastomosis. Anastomosis is a surgical procedure that connects very small blood vessels (typically 1.0 mm in diameter or less) using tiny needles and ultrafine sutures to salvage and reconstruct limbs.

“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 (VCA),” said Dr. 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). “All of these techniques are vitally important to optimize limb salvage and functional outcomes for a variety of upper- and lower-extremity conditions.”

Dr. Levin continued: “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. Applying microsurgical techniques made limb salvage possible and helped patients avoid amputation.”

Patients with orthopaedic injuries—such as open fractures, bone and soft tissue tumors, dysvascular and diabetic feet, absence of upper limbs, and brachial plexus injuries—can all 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.

“Reconstructive microsurgery should be and is an essential component of orthopaedic surgery,” said Dr. 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.”

As microvascular tools and techniques for limb salvage and reconstruction have evolved, Dr. Levin has been able to take these developments a step further to include restorative surgery using VCA to restore completely all missing structures. In 2015, Dr. 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.

Dr. Levin’s first peer-reviewed publication, in 1978, titled “Digital Sensibility Following Replantation,” was the beginning of a publishing record that now includes 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 to create a minimally invasive approach to extremity reconstruction and microsurgery (i.e., tissue harvest and tissue expansion placement).

Dr. Levin’s work also brought more attention to the aesthetic aspects of limb salvage utilizing plastic surgery. By introducing these principles to the trauma community, he has shown that the reconstructive effort of a limb not only includes restoring limb function, but also values the aesthetics of limb appearance. He also conducted 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.

Dr. Levin has led efforts to increase education and awareness of orthoplastics as a 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 Penn 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 Dr. Levin. “None of these advances would have been possible without my colleagues and the contributions of my mentors—icons in their own rights—whom I was gifted the opportunity to train with early in my career. I want to recognize the countless residents, fellows, and research scholars whom 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.”