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Page 2 of 11 Yu et al. Plast Aesthet Res 2022;9:37 https://dx.doi.org/10.20517/2347-9264.2021.124

[1]
by the reconstructive surgeon . Several factors must be noted when planning free tissue transfer for large
open fractures, many of which relate to the injured limb itself: the mechanism of injury and corresponding
zone of injury (i.e., low vs. high energy trauma), which tissues are missing, degree of contamination,
presence of hardware, and need for additional fixation. A number of patient-related factors must also be
evaluated prior to surgery: medical comorbidities, social support, participation in rehabilitation and
postoperative care, and patient goals of care. The decision of amputation vs. limb salvage must be tailored to
each individual case and should be a multidisciplinary discussion with the patient. Risk factors for
amputation, such as compartment syndrome resulting in myonecrosis, prolonged warm ischemia time, and
severe open injury to the hindfoot, should be identified and discussed . An amputation may represent the
[2]
most functional treatment plan and should be considered by the patient and treatment team during the
discussion of limb salvage . There have been numerous attempts at developing injury scoring systems to
[3]
aid in predicting the need for amputation, such as the Mangled Extremity Severity Score, the Predictive
Salvage Index, and the Limb Salvage Index, but there is no scoring system that has been validated in large
prospective studies . If amputation is to be avoided, limb salvage comprises both durable osseous support
[2]
and a stable soft tissue envelope for return to weight-bearing and ambulation.

Traumatized lower extremities with a single perfusing vessel across the ankle mortise (i.e., Gustilo IIIB in
patients with peripheral vascular disease and Gustilo IIIC injuries) present an even more challenging
reconstructive dilemma. Although these extremities are not necessarily dysvascular, microsurgical treatment
requires a greater degree of planning. A collaborative “orthoplastic” approach is even more important in
[4]
these cases ; while soft tissue reconstruction is often the final step of treatment addressed for patients with
significant extremity trauma, early collaboration with the plastic surgery team for debridement, timing for
surgery, and surgical planning have been shown to improve outcomes .
[5-7]

Historically, large open fractures devoid of soft tissue and periosteum were previously not amenable to
salvage; however, advances in microsurgical technique, flap selection and design, and improved
understanding of lower extremity anatomy and perfusion in recent decades have resulted in the successful
reconstruction of these mangled limbs. Contemporary rates of successful lower extremity free flap coverage
are reported as 91% to 97%. This rate falls to as low as 80% in extremities in the presence of arterial injury
and thus is the focus of this discussion [8-14] . With careful planning and a methodical approach to
reconstruction, salvage of complex lower extremity wounds with single vessel perfusion can be achieved.

PREOPERATIVE EVALUATION
Open fractures can be distracting features of the trauma patient’s presentation. It is critical to remember
that these injuries usually represent a high-energy mechanism associated with a number of concomitant
injuries [15,16] . A comprehensive trauma evaluation, including the primary, secondary, and tertiary surveys
with appropriate diagnostic imaging, should be completed in addition to addressing the injured limb. When
appropriate, early transfer to a higher level of care should be considered . On initial presentation, the
[17]
appearance and hemostasis of the wound should be noted. Photographs of the wound should be taken for
documentation in the medical record and for communication with the reconstructive team if they are not
present at the initial evaluation.

A careful and thorough neurovascular exam is critical as concerns about limb perfusion should prompt a
vascular surgery consult for emergent revascularization. Dorsalis pedis and posterior tibial pulses should be
evaluated by palpation, and if not palpable, a handheld Doppler probe should be used to verify distal
perfusion. A baseline motor and sensory nerve exam should be documented. An ankle-brachial index (ABI)
should be performed for all open fractures of the lower extremity. Abnormal pulses, pulsatile bleeding, or an