Background: Limb salvage in resource-constrained environments poses a major surgical challenge. While technological advances and microsurgical techniques have revolutionized reconstructive surgery in high-income countries, surgeons in low- and middle-income countries (LMICs) often rely on limited tools, basic flaps, and improvisation to achieve functional outcomes.
Objective: This review explores current reconstructive strategies used for limb salvage in LMICs, analyzes key barriers, and highlights recent innovations adapted for low-resource contexts.
Methods: A narrative review was conducted using PubMed, Scopus, and regional databases to synthesize literature on limb salvage techniques, particularly in trauma, burns, and infections. Articles focused on tropical or LMIC settings were prioritized.
Results: Local and regional flaps remain the mainstay of limb reconstruction in LMICs. The use of free flaps is limited by infrastructure gaps, lack of microsurgical expertise, and intensive care unit (ICU) resources. Cost-effective innovations, such as modified vacuum-assisted closure (VAC) systems and xenograft dressings, offer promise. Common challenges include delayed presentation, high infection rates, and limited access to postoperative rehabilitation.
Conclusion: Achieving limb salvage in low-resource settings requires not just surgical skill, but systemic problem-solving and context-adapted innovations. With increased investment in training, infrastructure, and locally driven research, the future of reconstructive surgery in LMICs can shift from compromise to confidence.

Limb salvage, Low-resource settings, Wound care, Reconstructive surgery, Global surgery, Trauma.

Burden of limb-threatening injuries in LMICs: Limb-threatening injuries, results of road traffic accidents, burns, falls, and occupational hazards constitute a major public health challenge in LMICs. Although injuries account for approximately 8% of all global deaths (~4.4 million annually), they contribute to over 220 million disability-adjusted life years (DALYs), a burden eclipsing the combined DALYs from tuberculosis, human immunodeficiency viruses (HIV), and malaria. Crucially, 90% of these injury-related deaths and 83% of disability occur in LMICs.[1]

Musculoskeletal injuries, such as fractures, crush injuries, and burns, lead to about 78% of all injury-related disabilities worldwide. In Africa alone, incidence rates of extreme injuries range from 779 to 1,574 per 100,000 person-years, underscoring a massive yet underreported burden. According to the Global Burden of Disease (GBD) 2017, over 57.7 million people globally live with traumatic amputations, with LMICs bearing the brunt, driven predominantly by road traffic collisions, falls, and trauma.[1]

Despite the immense prevalence, timely limb salvage remains rare in these environments. Factors such as delayed presentation, limited microsurgical expertise, absence of vascular reconstruction resources, and inadequate critical care and rehab facilities frequently result in avoidable amputations. This narrative review aims to:

• Map of practical reconstructive strategies used in LMICs.
• Analyze systemic and resource-driven challenges.
• Profile emerging, low-cost innovations.
• Recommend priority areas for training, policy, and research.

A critical examination of how reconstructive techniques intersect with context may guide more sustainable, locally led approaches to limb preservation in low-resource settings.

Definition and scope of limb salvage: Limb salvage refers to the use of medical and surgical interventions aimed at preserving a limb that would otherwise be amputated due to severe trauma, infection, vascular compromise, or malignancy. It encompasses a multidisciplinary approach involving timely debridement, skeletal stabilization, vascular repair, soft tissue reconstruction, infection control, and rehabilitation. The goal is not only anatomical preservation but also functional restoration, enabling the patient to regain mobility, independence, and quality of life.

In high-resource settings, limb salvage often involves advanced modalities such as free tissue transfer, revascularization techniques, nerve grafting, and microsurgical reconstruction—procedures that are guided by comprehensive imaging, reliable postoperative monitoring, and access to intensive care units. However, in LMICs, the concept of limb salvage must be reframed to align with local limitations and capabilities. In these contexts, the emphasis is frequently on more pragmatic solutions such as cross-leg flaps, fasciocutaneous flaps, local muscle transpositions, or even skin grafting, which can preserve limb integrity without requiring microsurgical expertise.

The scope of limb salvage has expanded beyond military or oncologic cases to now include road traffic injuries, electrical burns, gas explosions, chronic osteomyelitis, and diabetic foot gangrene, particularly in regions where prosthetic access and rehabilitation services are limited or unaffordable. In such environments, even partial preservation of limb structure can confer psychological, economic, and functional benefits far beyond what prostheses can currently offer. As such, the scope of limb salvage in LMICs is as much a surgical challenge as it reflects health systems capacity, socioeconomic context, and community-level rehabilitation resources.

Importance in public health and disability prevention: Limb salvage plays a critical role in the broader public health landscape, particularly in LMICs, where traumatic injuries are a leading cause of long-term disability and economic hardship. The loss of a limb, especially among working-age adults, often translates into loss of income, increased caregiver dependence, social exclusion, and mental health decline. In many resource-constrained societies, where access to prosthetics, rehabilitation, or vocational retraining is limited or unaffordable, amputation becomes a source of lifelong vulnerability.

Preserving a limb, even if functionally suboptimal, often allows patients to resume basic mobility, self-care, and employment, reducing the burden on families and public health systems. This makes limb salvage not merely a surgical decision but a public health intervention, with long-term implications for poverty reduction, social reintegration, and national productivity.

Furthermore, many limb-threatening injuries occur in economically productive age groups (15–49 years), exacerbating the economic toll at both individual and societal levels. In Sub-Saharan Africa, for instance, post-traumatic amputees face higher unemployment rates and lower life satisfaction compared to limb-salvaged patients, even when prosthetic services are available. From a policy standpoint, preventing disability through salvage is often more cost-effective than sustaining long-term social support and healthcare for amputees. As global health efforts increasingly prioritize non-communicable diseases, trauma systems, and surgical equity, the ability to perform timely and effective limb salvage must be recognized as a core component of disability prevention strategies in LMICs.

Surgical strategies in resource-limited settings: In high-income countries, limb salvage typically relies on advanced imaging, microsurgical reconstruction, and post-operative intensive care. In contrast, surgeons in low-resource settings often lack these tools and must depend on fundamental principles and adaptable techniques to achieve functional limb preservation. This has given rise to a unique and evolving spectrum of reconstructive strategies tailored to resource availability and patient presentation.

1. Primary closure and skin grafting: In cases where tissue loss is minimal and contamination is controlled, primary closure may be possible. However, such scenarios are rare in delayed or contaminated presentations, which are common in LMICs. More frequently, split-thick skin grafts are used to cover granulating wounds. While they are low-cost and easy to perform, they offer limited protection over mobile areas or exposed bone and tendon.[2]
2. Local and regional flaps: Local flaps, including rotational and advancement flaps, remain the cornerstone of soft tissue reconstruction in many LMIC settings. For larger or deeper defects, regional muscle flaps such as the gastrocnemius, soleus, or gracilis provide bulk, vascularity, and infection control. These flaps do not require microsurgical anastomosis and can be performed without sophisticated tools, making them especially valuable in rural or peripheral centers.[2]
3. Cross-leg flaps: The cross-leg flaps, considered obsolete in high-income countries, remain a vital technique in resource-constrained environments. Though it requires prolonged immobilization, it enables salvage in cases where local options are exhausted or when microsurgery is unavailable. Studies in India and Africa report successful outcomes when protocols are strictly followed.[3]
4. Free flap surgery: Microsurgical free flaps, considered the gold standard for large or complex defects in high-resource settings, are rarely feasible in LMICs due to the need for microscopes, micro-instruments, trained personnel, and ICU monitoring. However, some urban teaching hospitals in countries like India, Nigeria, and South Africa have developed dedicated microsurgery teams and shown promising results with lower-cost adaptations.[4]
5. VAC therapy: VAC therapy has gained popularity for managing contaminated wounds and optimizing granulation before grafting or flapping coverage. Commercial devices are expensive, but improvised VAC systems using syringes, feeding tubes, and wall suction have been successfully employed in hospitals across Uganda, Nepal, and Nigeria.[5,6] When performed correctly, these systems offer similar benefits in wound contraction and exudate control.
6. Use of natural and low-cost adjuncts: In addition to conventional treatments, healthcare providers in resource-limited settings have long employed natural adjuncts—such as honey, sugar, and plant extracts—to manage wounds. These substances offer antimicrobial, anti-inflammatory, and osmotic properties that support healing, especially when modern dressings are unavailable.

• Honey: Honey, particularly medical-grade varieties like manuka and heather honey, has shown strong potential in wound healing.[3] A systematic review of randomized controlled trials found honey to be as effective as conventional treatments in accelerating the healing of burns and superficial wounds, with added benefits in infection control and pain reduction. Honey promotes healing via:
  • Antimicrobial action: A combination of hydrogen peroxide, low pH, phenolic compounds, and methylglyoxal in manuka honey effectively inhibits both gram-positive and gram-negative organisms, including MRSA and Pseudomonas aeruginosa.
  • Osmotic effect and debridement: Its high sugar content draws fluid from the wound, facilitating the removal of necrotic tissue and debris.
  • Anti-inflammatory and antioxidant properties: Honey reduces edema, suppresses inflammatory markers, and supports epithelial regeneration.
  • Evidence in LMIC wounds: A study from Nigeria reported improved healing in 59 patients with chronic ulcers treated with local honey.[9] Despite some heterogeneity in study designs, meta-analyses have shown honey to significantly shorten healing time in chronic wounds (~17 days faster) and reduce pain during therapy. Cochrane evidence specifically supports honey’s efficacy in partial thickness burns and postoperative wounds.

• Sugar: High-concentration sugar dressings provide similar osmotic and antimicrobial effects to honey, effectively drawing fluids and inhibiting microbial growth.[3] Though less extensively studied, they represent a pragmatic option when honey is unavailable.
• Plant extracts and other adjuncts: Low-cost traditional treatments such as papaya (papain enzyme), acetic acid, and aloe vera also play a role in autolytic debridement and tissue regeneration. Preliminary evidence supports their antimicrobial and anti-inflammatory properties, though further trials are required to determine standardized use.[7,8]

Integration into practice: These natural adjuncts are particularly valuable in LMIC settings lacking access to sterile dressings. Implemented according to basic protocols, they can:

• Reduce dependency on costly antimicrobials
• Aid in autolytic wound debridement
• Accelerate the formation of granulation tissue
• Diminish pain and inflammation during healing.

Barriers and challenges to limb salvage in LMICs
Despite the growing recognition of limb salvage as a critical strategy for disability prevention, several systemic and contextual barriers hinder its implementation across LMICs. These challenges are deeply intertwined with infrastructural, economic, and human resource limitations, and they significantly influence surgical decision-making, especially in the context of trauma, infection, and burns.

• Delayed presentation and referral: Patients in LMICs often present late to tertiary centers due to poor emergency transport systems, lack of prehospital care, and limited community awareness of limb-threatening symptoms. Delays of 24–72 hours after injury are not uncommon, particularly in rural areas, leading to ischemia, necrosis, and advanced infection that reduce salvage potential. Studies in Nigeria and India report that over 40% of open fracture cases arrive after the optimal window for primary debridement or vascular repair.[1]
• Limited reconstructive expertise: Access to plastic and reconstructive surgeons remains severely limited. Sub-Saharan Africa, for instance, has an average of 1 reconstructive surgeon per 10 million people, compared to 1 per 60,000 in high-income countries.[1] General surgeons are often left to perform complex limb-saving procedures without formal microsurgical training or dedicated mentorship. This scarcity is compounded by the brain drain of trained specialists, the low availability of reconstructive fellowships in-country, and minimal exposure to flap surgery in medical education.
• Equipment and infrastructure deficits: Microsurgical procedures require essential infrastructure: surgical loupes or microscopes, micro-instruments, anesthesia support, ICU beds, and a reliable power supply. Many LMIC surgical centers lack one or more of these components, forcing reliance on simpler, but often less ideal, alternatives. Additionally, VAC machines, dermal substitutes, and biologic dressings are either unavailable or unaffordable in most public hospitals, with commercial VAC systems costing upwards of $5,000 USD per unit.[2]
• Infection control limitations: Tropical climates and poor sanitation expose wounds to rapid colonization by Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella, and anaerobes. Many facilities are lacking microbiology support, cultures, broad-spectrum antibiotics, and wound care for nurses or specialized dressings. Postoperative infections are a leading cause of flap failure and eventual amputation in LMIC settings.[5]
• Rehabilitation and follow-up gaps: Even when limb salvage is achieved, the absence of structured physical therapy, occupational therapy, and community reintegration programs results in poor long-term outcomes. Patients are often discharged without assistive devices, follow-up protocols, or mobility training. This significantly affects functional outcomes, often making salvaged limbs practically non-functional, which leads to psychological distress and social exclusion.[7]
• Financial and ethical dilemmas: Healthcare in LMICs is predominantly out-of-pocket [7]. Families must weigh the high cost of prolonged treatment and multiple surgeries against the economic burden of disability. Surgeons may feel ethically conflicted between offering ideal treatment and the patient’s ability to afford or adhere to it. Amputation, though functionally limiting, is often cheaper and quicker to perform, and may be chosen simply for logistical or financial reasons, not because it is clinically superior.

Innovations and workarounds in resource-limited limb salvage
Faced with significant infrastructural and economic barriers, surgeons and health systems in LMICs have developed creative, context-adapted innovations to facilitate limb salvage. These solutions emphasize functionality, affordability, and reproducibility using locally available materials and skills. While not substitutes for high-end technology, they offer practical and often lifesaving alternatives in low-resource settings.

• Improvised VAC systems: Commercial VAC systems are often unavailable due to cost. In response, many hospitals have adopted makeshift VAC systems using feeding tubes or infant suction catheters, gauze and transparent plastic, and wall suction or syringes to maintain negative pressure. Studies from Uganda, India, and Nigeria have demonstrated that these improvised systems can effectively reduce wound size, promote granulation, and prepare wounds for grafting at a fraction of the cost.[6] Though lacking precise pressure regulation, these adaptations have been shown to yield comparable outcomes in chronic wounds and post-debridement cases.
• Modular and mobile surgical skills training: To address the shortage of trained reconstructive surgeons, mobile surgical camps, task-sharing programs, and low-cost flap simulation models have emerged. Organizations such as Smile Train, ReSurge International, and the College of Surgeons of East, Central, and Southern Africa (COSECSA) run training programs that teach local surgeons practical flaps using simple instruments and stepwise protocols. Simulation-based training with banana peels, silicone sheets, or pigs’ feet has shown promise in teaching suture techniques, flap planning, and basic anastomosis.[7] These innovations are being integrated into plastic surgery boot camps across East Africa and Southeast Asia.
• Use of local biological alternatives: In the absence of dermal substitutes like Integra, surgeons in LMICs have explored low-cost alternatives such as xenografts (e.g., porcine skin for temporary coverage), amniotic membranes (used in chronic ulcers and burns), and autologous platelet-rich plasma (PRP), created using bedside centrifuges. Preliminary evidence shows that amniotic membranes can reduce inflammation and promote epithelialization in chronic diabetic wounds, though regulatory and preservation issues persist.[9]
• Community-based rehabilitation (CBR): Since formal rehab facilities are rare, some regions now utilize community volunteers, family training, and local production of assistive devices to continue rehabilitation post-discharge. These models, championed by WHO’s CBR framework, help ensure limb-salvaged patients are not lost to follow-up.[7]
• Context-specific guidelines and protocols: Locally developed wound management protocols—such as the Lagos Wound Care Pathway or Delhi Debridement Guide—standardize triage and treatment using locally available tools. These serve as alternatives to Western guidelines, which often assume ICU-level infrastructure. These innovations reflect a broader truth: resource constraints can fuel ingenuity, and surgical excellence does not always require high-tech equipment—only training, creativity, and commitment to patient-centered care.[10]

Case examples from the literature
Real-world cases from low-resource settings demonstrate the adaptability and ingenuity required to achieve limb salvage without advanced infrastructure. The following examples, drawn from peer-reviewed literature, illustrate how basic techniques, context-sensitive decision-making, and multidisciplinary care can produce meaningful outcomes.

Case 1: Cross-leg flap for open tibial fracture in rural India
A 26-year-old male presented with a Grade IIIB open tibial fracture following a motorcycle accident. Due to the absence of microsurgical capacity and a delay of 48 hours before referral, a cross-leg flap was employed after serial debridements. Immobilization was maintained for 3 weeks using an external fixator. The flap survived, infection was controlled, and partial weight-bearing resumed within 8 weeks.

Outcome: Successful wound closure and limb preservation with acceptable function.[11]

Case 2: Honey-assisted healing of chronic diabetic ulcer in Nigeria
A 55-year-old diabetic woman developed a chronic non-healing foot ulcer following minor trauma. After limited success with antibiotic dressings, locally sourced honey was applied daily. The wound showed granulation by day 5, and complete epithelialization occurred within 4 weeks. No systemic antibiotics were required.

Outcome: Complete wound healing with no recurrence at 6 months.[12]

Case 3: Improvised VAC in severe burn wound management in Uganda
A 34-year-old man with 15% TBSA flame burns over both legs developed infected eschar requiring debridement. A low-cost VAC system was assembled using a feeding tube, gauze, and wall suction. Negative pressure was applied intermittently over 10 days. This facilitated granulation tissue formation and allowed timely split-thickness skin grafting.

Outcome: Graft take >95% with no need for amputation.[13]

Case 4: Pedicled latissimus dorsi flap for traumatic elbow defect in Kenya
In a tertiary center with basic surgical tools but no microsurgery suite, a young construction worker with a crushed elbow underwent a pedicled latissimus dorsi flap to cover exposed bone and neurovascular structures. This avoided the need for forequarter amputation and preserved some range of motion.

Outcome: Stable soft tissue coverage and retention of elbow flexion.[14]

These cases illustrate that while advanced technologies enhance outcomes, innovative adaptation of classic techniques, combined with local knowledge and patient-centered care, can lead to remarkable success stories in limb preservation.

Future directions and research gaps
The growing emphasis on global surgical equity calls for a deliberate shift in how limb salvage is conceptualized, taught, and delivered in low-resource environments. While ingenuity has led to remarkable outcomes in LMICs, sustainable improvements in limb preservation require investment in systems, evidence-based innovation, and context-relevant policy reform.

• Development of context-specific protocols: Much of the existing literature and surgical guidance is derived from high-income settings, where assumptions about infrastructure (ICU care, imaging, implants) limit applicability in LMICs. There is an urgent need to develop and validate limb salvage protocols that consider delayed presentations, intermittent resources, and basic flap options. National surgical societies and global health alliances can help facilitate this.
• Expansion of surgical training and mentorship: Addressing the deficit in reconstructive capacity requires scalable, low-cost training models, including simulation-based learning, short-term flap courses, and regional fellowships. International mentorship networks—such as the Global Surgery Foundation, ReSurge International, and COSECSA—have already begun to fill this gap. Investment in South-South collaboration (between LMICs) can foster locally led capacity building.
• Low-Cost technological innovation: There is increasing potential for 3D printing, bedside PRP kits, and biologic scaffolds adapted for tropical conditions. Collaborative research should focus on low-tech, high-impact innovations such as:

1. Modular VAC systems
2. Affordable prosthetic interfaces for salvaged limbs
3. Solar-powered sterilization or suction devices

These tools can significantly improve outcomes without the cost burden of high-end imports.

• Community and rehabilitation integration: Future models of care must integrate CBR as a key component of limb salvage. Structured follow-up, mobility aids, and vocational support systems must be embedded into surgical plans from the outset. This ensures that anatomical success translates into real-world function and reintegration.
• Research in understudied populations: Many reconstructive outcomes in LMICs remain undocumented. More studies are needed to assess:

1. Long-term function after salvage
2. Quality of life and cost-benefit comparisons with amputation
3. Cultural perceptions of limb deformity vs prosthetic use
4. Surgical outcomes in women, children, and marginalized groups

Such research would inform locally appropriate guidelines and influence surgical decision-making with real-world evidence.

• Strengthening data and surgical registries: Reliable data on limb salvage procedures, outcomes, and complications are lacking in most LMICs. Investment in hospital-based surgical registries, even on simple platforms like REDCap or Excel, would improve quality control, benchmarking, and surgical audit culture. By centering local solutions, empowering surgical providers, and investing in cost-effective innovations, the future of limb salvage in LMICs can evolve from improvisation to standardization—and from isolated success stories to population-wide impact.

Limb-threatening injuries remain a significant and underrecognized public health issue in low- and middle-income countries, with devastating consequences for individuals, families, and economies. While limb salvage has advanced in high-income settings, its application in resource-constrained environments demands innovation, adaptability, and systems-level reform.

This review has highlighted that successful limb salvage in LMICs is not solely a function of surgical expertise but of coordinated, multidisciplinary care that addresses delayed presentation, infection control, infrastructure limitations, and post-operative rehabilitation. From cross-leg flaps to honey dressings and improvised VAC systems, practitioners in LMICs continue to demonstrate that creative adaptation can overcome systemic limitations when guided by sound principles.

However, ad hoc innovation must evolve into structured, evidence-informed practice. There is a pressing need for context-specific protocols, scalable surgical training, affordable technologies, and robust data systems. Equally important is the integration of community-based rehabilitation and patient-centered care models that ensure anatomical preservation translates into functional and social reintegration.

Ultimately, limb salvage in low-resource settings is both a clinical pursuit and a moral imperative, one that calls for global solidarity, local leadership, and sustained investment in surgical systems that serve the underserved.

We acknowledge the collaborative support of the surgical and academic teams involved in the development of this manuscript. We also want to thank Rivers State University Teaching Hospital staff for their support, especially the CMD, Prof Chizindu Alikor.

This study received no specific funding from any agency in the public, commercial, or not-for-profit sectors.

Corresponding Author:
Ernest Chukwuma
Department of Surgery
Rivers State University Teaching Hospital, Port Harcourt, Nigeria
Email: ernestjnr4@gmail.com

Co-Authors:
Obikoya Pelumi Jesse, James Godswill
Department of Medicine and Surgery
Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria

Ehondor Osayande Michael
Department of Surgery
National Hospital Abuja, Nigeria

Okezie Joshua Ikechukwu
Department of Family Medicine
Baptist Medical Centre, Igbajo, Osun State, Nigeria

Altraide Prince Boma
Department of Surgery
Rivers State University Teaching Hospital, Port Harcourt, Nigeria

Yusuf Mubarak
Department of Pediatrics
R-Jolad Hospital, Gbagada, Lagos, Nigeria

Chukwuma Ernest Nnanyereugo supervised and spearheaded the project. Obikoya Pelumi Jesse was responsible for data analysis. Ehondor Osayande Michael contributed by handling photography and drafting the manuscript. Okezie Joshua Ikechukwu, Altraide Prince Boma, and James Godswill were involved in drafting the manuscript. Dr. Yusuf Mubarak reviewed the manuscript.

Not applicable

The authors declare no conflicts of interest.

None

https://doi.org/10.63096/medtigo3062333

Chukwuma E, Jesse OP, Michael EO, et al. Limb Salvage in Low-Resource Settings: Strategies, Challenges, and Innovations. medtigo J Med. 2025;3(3):e3062333. doi:10.63096/medtigo3062333 Crossref