Spare-parts free flap reconstruction in polytrauma with limb amputation: Pearls, pitfalls, and an illustrative case report

Abstract

Spare-part free-flap reconstruction involves free tissue transfer from an unsalvageable extremity for reconstruction of a separate defect. In the setting of traumatic injury, spare-part surgery requires special attention to donor site zone of injury assessment and multidisciplinary coordination. Here we describe a case of upper extremity reconstruction using a free flap harvested from a lower extremity which was indicated for transfemoral amputation. Key pearls and pitfalls are reported in an effort to facilitate collaborative interdisciplinary reconstructive opportunities in cases where amputation is planned in the setting of multi-limb trauma. A 53-year-old male presented after a motorcycle collision with open fractures of the right elbow and tibia/fibula. After initial fracture stabilization and serial debridement, the upper extremity wound required flap coverage for the indication of exposed implants. Extensive bone and soft tissue loss of the lower limb indicated the patient for transfemoral amputation, and spare-part free flap reconstruction of the upper extremity defect was planned. Intra-operative venous pedicle thrombosis caused failure of an initial flap based on the posterior tibial artery. A second spare-part flap based on the anterior tibial artery was successfully transferred under the same anesthetic. When amputation is planned in the context of the multiply traumatized patient, coordinated orthopedic trauma and microsurgical care can facilitate spare-parts free-flap reconstruction. Though these cases require careful planning and intra-operative flexibility to accomplish flap harvest adjacent to a zone of injury, spare-part reconstruction worth pursuing as this strategy obviates the need for an additional donor site. • Spare-part free flaps are useful when amputation is planned in cases of polytrauma. • Collaboration and communication are critical to identify eligible patients. • Carefully assess the zone of injury adjacent to the donor site. • Harvest a large flap and assess with intraoperative fluorescence angiography. • Many unsalvageable limbs do not harbor an uninjured donor site.