Composite Soft Tissue Defects Research Articles

Reconstruction of the extensor tendon on the dorsal pedis with a chimeric skin-aponeurosis flap from the groin region

BackgroundComplex defects involving the extensor tendon on the dorsal pedis have been reconstructed using multiple procedures. Skin coverage and tendon transfers have also been performed. This study aimed to present our experience using a chimeric skin-aponeurosis flap for one-stage reconstruction of composite soft-tissue defects on the dorsal pedis. MethodsBetween May 2017 and September 2020, 12 patients with these defects received total treatment using a chimeric groin flap. Based on the superficial circumflex iliac vessels, the skin paddle resurfaced the cutaneous defect, and the vascularised external oblique aponeurosis was rolled to form a tendon-like structure to simultaneously replace the absent segment of the extensor tendons. A suitable “Y” bifurcation was dissected to enlarge the vessel diameter. Single-stage reconstruction was performed using a set of vascular anastomoses at the recipient site. ResultsFlap survival was achieved without significant complications. The hammertoe deformity was completely removed. The average dimension of the skin paddle was 8.0 × 13.0 cm (range, 6.5 × 11.0–10.0 × 14.0 cm), and the mean size of the aponeurosis was 8.0 × 4.0 cm (range, 6.0 × 3.0–10.0 × 5.0 cm). At the last follow-up visit, no morbidity was observed at the donor site. Natural shapes and walking functions were successfully achieved with a protective sensation. ConclusionThe chimeric groin flap with sheets of external oblique aponeurosis is a great candidate for one-stage reconstruction of composite soft tissue loss on the dorsal pedis. This approach provides cosmetic coverage, allowing faster wound healing and reduced tendon adhesions.

A preliminary analysis of patient reported outcomes following posterolateral mandible reconstruction: The role of flap type.

The choice of tissue type for free flap reconstruction of posterolateral mandible resections is dependent on patient and defect characteristics. We compared clinical and patient-reported outcomes following reconstruction of these defects with a soft tissue or bony free flap. A retrospective review was performed on patients who underwent posterolateral segmental mandibulectomy with immediate free flap reconstruction at MSKCC from 2006 to 2021. Outcomes of interest were patient-reported outcome measures (PROMs) assessed by FACE-Q surveys and complications at the flap recipient site. Ninety patients received a bony flap and 24 patients received a soft tissue flap. Patients reconstructed with soft tissue flaps had greater rates of composite soft tissue defects (p < 0.0001), condyle resection (p = 0.001), and peripheral vascular disease (p = 0.035). Complication rates were similar between the cohorts (p > 0.05). Bony flaps scored higher on multiple FACE-Q scales: Facial Appearance (p = 0.023) Eating/Drinking (p = 0.029), Smiling (p = 0.012), Speaking (p < 0.001), Swallowing (p = 0.012), Smiling Distress (p = 0.037), and Speaking Distress (p = 0.001). Reconstruction of posterolateral mandibular defects has a similar complication profile when utilizing a bony or soft tissue free flap. Bony flaps may perform better with respect to PROMs. Reconstructive surgeons should consider using bony flap reconstruction to achieve higher patient satisfaction and quality of life.

Reconstruction of Composite Soft Tissue Defect in the Distal Finger Using Partial Toenail Flap Transfer.

Composite tissue loss involving the distal finger pulp and the nail is a common but challenging finger injury to restore. This study introduces a reconstruction procedure for a distal finger pulp and nail defect using a partial toenail flap transfer. Twenty digits, including 16 thumbs, two index fingers, and two middle fingers, with composite soft tissue defects were treated with a partial toenail flap transfer from October 2015 to January 2020. Shortening revision of the great toe phalanx, a V-Y advancement flap of the toe pulp, and a local pedicle flap from a second toe transfer were used to cover the donor sites, and no skin grafts were required. Functionality was evaluated using the validated Spanish version of the Quick-DASH scale. The aesthetics of both the reconstructed and donor sites were evaluated using the Vancouver Scar Scale (VSS). The static two-point discrimination (2-PD) of the finger pulp was used as a measure of tactile agnosia. All donor site wounds healed well. The average follow-up time was 23.6 months (6-39 months). The mean Quick-DASH functional score was 7.1. The VSS scores were 4.02 ± 0.29 and 4.00 ± 0.38 for the reconstructed and donor sites, respectively. The static 2-PD of finger pulp was 4.5 ± 0.76 mm. The patients were satisfied with finger motion, sensory function, and aesthetic contour. Partial toenail flap transfer is the recommended treatment to regain motion, sensation, function, and a satisfactory aesthetic appearance when considering repairing a composite soft tissue distal finger defect with accompanying loss of the perionychium, particularly in the thumb, index finger, or middle finger.

Orthoplastics in Periprosthetic Joint Infection of the Knee: Treatment Concept for Composite Soft-tissue Defect with Extensor Apparatus Deficiency.

Introduction: Reconstruction of composite soft-tissue defects with extensor apparatus deficiency in patients with periprosthetic joint infection (PJI) of the knee is challenging. We present a single-centre multidisciplinary orthoplastic treatment concept based on a retrospective outcome analysis over 20 years.Methods and Results: One-hundred sixty patients had PJI after total knee arthroplasty. Plastic surgical reconstruction of a concomitant perigenicular soft-tissue defect was indicated in 47 patients. Of these, six presented with extensor apparatus deficiency. One patient underwent primary arthrodesis and five patients underwent reconstruction of the extensor apparatus. The principle to reconstruct missing tissue 'like with like' was thereby favoured: Two patients with a wide soft-tissue defect received a free anterolateral thigh flap with fascia lata; one patient with a smaller soft-tissue defect received a free sensate, extended lateral arm flap with triceps tendon; and two patients who did not qualify for free flap surgery received a pedicled medial sural artery perforator gastrocnemius flap. Despite good functional results 1 year later, long-term follow-up revealed that two patients had to undergo arthrodesis because of recurrent infection and one patient was lost to follow-up.Conclusion: These results show that PJI of the knee and extensor apparatus deficiency is a dreaded combination with a poor long-term outcome. Standardization of surgical techniques for a defined PJI problem and consensus on study variables may facilitate interinstitutional comparisons of outcome data, and hence, improvement of treatment concepts.

Application of free lateral tarsometatarsal composite tissue flap in repair of finger composite soft tissue defects

目的 探讨游离足跗外侧复合组织瓣修复手指复合软组织缺损的临床疗效。 方法 自2014年6月至2017年6月，我们对12例手指掌侧复合软组织缺损患者，采用趾长伸肌腱桥接指深屈肌腱、足背外侧皮神经内侧支桥接神经以及跗外侧穿支皮瓣覆盖软组织缺损创面。皮瓣切取面积为1.5 cm×2.0 cm~2.5 cm×4.0 cm。 结果 术后皮瓣及手指远端全部存活，随访时间为6~18个月，平均10个月，皮瓣皮下脂肪少不臃肿，色泽与指体皮肤相似，感觉恢复良好，两点分辨觉为6~11 mm，手指屈伸功能满意。根据手指总主动活动度（TAM）评分法评定手功能：优8例，良3例，可1例。术后皮瓣供区恢复满意。 结论 足跗外侧皮瓣质地薄，血管神经解剖恒定，血管管径与近端指动脉口径相差无几，是手指掌侧复合软组织缺损修复较好的选择。

The combined use of flaps transfer and ilizarov technique reconstruct the large soft tissue defects and bone lose in the lower leg

Objective To determine the outcome of the combined use of flaps transfer and ilizarov technique re-construct the large soft tissue defects and bone lose in the lower leg. Methods Sixteen patients were identified from a retrospective review from July, 2008 to July, 2013, who suffered the large soft tissue defects and bone lose in the lower leg and underwent single-stage soft tissue and osseous reconstruction using the flap technique and Ilizarov method. There were 12 males and 4 females aged from 22 to 62 years old (average 42.6 years old). The size of soft tissue defect ranged from 8 cm×9 cm to 30 cm×20 cm. The length of the bone discrepancy ranged from 2 to 14 cm. According to the local con-dition of the lower leg and the size of the composite tissue defects, 10 patients received the free flap covering, 6 patients repaired by the saphenous neurocutaneous perforator flap (3 cases) and sural nerve neurocutaneous flap (3 cases). Daily monitoring the skin temperature postoperative. Distraction was commenced on postoperative day 10 to 14 at the rate of 1 mm/day and continued in 4 equal increments. Results The follow-up time ranged from 18 to 36 months. Sixteen flaps survived completed, only 1 flap was observed the venous congestion in postoperative day 2. The duration of ilizarov appli-cation ranged from 3.5 to 18.0 months. All patients achieved final union. All patients were satisfied with the outcome of the surgery. Conclusion The combined use of neurocutaneous flap and Ilizarov technique for reconstruction of large composite soft tissue defect in the lower leg. Significantly reduce patient treatment time, improving traction osteogenesis of long bones and the ability of resistance to infection. Key words: Surgical flap; Ilizarov technique; Lower leg; Composite tissue defects; Reconstruction

Osteocutaneous Radial Forearm Flaps for Mandibular Reconstruction

Purpose of Review The radial forearm free flap has been the mainstay of soft tissue reconstruction for composite defects after tumor ablation in the head and neck. On an anatomic basis, the flap also has the potential to be harvested with a boney component. Up to half of the radial forearm bone can be harvested and included in the flap. This allows the flap to be used not only for composite soft tissue defects but for composite boney defects.

Reconstruction of a Functional Gliding Surface With Extensor Retinaculum in Extensor Tendon Reconstruction in the Digits

Tendon gliding is key to optimal recovery of hand function after complex tendon injuries. Gliding is facilitated by a low-friction gliding surface that is normally provided by the periosteum of the underlying bone. However, significant injuries may damage the periosteum, which must be reconstructed to allow uninterrupted tendon excursion. The absence of the periosteum may compromise a tendon's ability to glide freely, thereby limiting the range of motion. Six digits in 4 patients with complex, composite soft tissue defects involving tendon, periosteum, and skin of the hand underwent surgical repair. Each digit had disruption of the bony cortex underlying the tendon injury including periosteal loss. Through an incision on the dorsum of the ipsilateral wrist, an extensor retinaculum graft corresponding to the size of the periosteal defect was harvested. It was then sutured into place over the bare cortex to replace the lost periosteum. All the 6 digits in the 4 patients had complete return to function. Additionally, all patients had near normal strength in the repaired hand along with excellent tendon excursion in both flexion and extension. The average time of follow-up of this series of patients was 1.5 years. Extensor retinaculum grafting to replace lost periosteum is a technique that is easily used, uses locally available autogenous tissues, and produces excellent tendon function. Additionally, the histologic similarities between extensor retinaculum and periosteum add scientific merit to this novel approach. On the basis of our experience, we recommend the use of extensor retinaculum for periosteal reconstruction to provide an adequate gliding surface for a reconstructed tendon.

Fixation and reconstruction of severe tibial shaft fractures with vascularized fibular grafting

Based on the considerable experience for management of combined bone and composite soft-tissue defects in the limbs by free vascularized fibula or osteocutaneous fibular flap grafting, the authors present the effective alternative for management of the severe comminuted tibial shaft fractures in one-stage reconstructive technique. Twenty-six patients were male and 12 were female, and their mean age was 32 years (range 15-57 years). Ten tibial shaft fractures were closed and 28 were open. Based on the AO classification, there were 12 group C1 fractures and 24 group C3 fractures according to the fracture pattern and degree of comminution. With the exception of eight cases that were delayed for 3-5 days for primary treatment in another hospital, 30 cases were treated on an emergency basis within an average of 12 h since the initial injury (range 6-22). Normal healing occurred in 31 fractures with a mean healing time of 21 weeks (range 18-24 weeks). Delayed union in 7 with a mean of 32 weeks (range 28-41 weeks), and there were no nonunion and infections. The vascularized fibula allows for fast bone fusion. In this context, the grafted fibula segment appeared to be a valuable reconstructive tool that offered good fracture stabilization and vascularised bone graft. The attached fibular flap can also provide a large piece of mobile skin to cover the soft-tissue defect in grade III open-tibial fractures. It demonstrates that this early free vascularized fibula graft is a useful and effective option for treating the severe comminuted tibial shaft fractures.

Versatility of the Anterolateral Thigh Flap with Vascularized Fascia Lata for Reconstruction of Complex Soft-Tissue Defects: Clinical Experience and Functional Assessment of the Donor Site

The anterolateral thigh flap is commonly used for reconstruction of various soft-tissue defects. This article presents the authors' approach to one-stage reconstruction of composite soft-tissue defects using an anterolateral thigh flap with a vascularized fascia lata. This retrospective review analyzed 973 patients who had undergone anterolateral thigh flap reconstruction for various soft-tissue defects over the past 10 years. Various types of complicated defects in 36 patients were reconstructed with a composite anterolateral thigh flap combined with vascularized fascia lata. The fascia lata component of the flap was used for abdominal wall and fascial defect reconstruction in 12 patients, for lip-cheek defect reconstruction in 15 patients, for reconstruction of composite defects in extremities in nine patients, and for reconstruction of the perineum in one patient. Functional outcomes of donor sites were investigated by using a dynamometer. All flaps except one survived. The overall flap survival rate was 97 percent. Patients achieved satisfactory results without major postoperative complications. The study revealed that vascularized fascia may mimic a fascial sheath but lacks the muscle-synchronized excursion properties. Apart from a mild deficiency in quadriceps femoris muscles contraction in the donor thighs, no difficulties in daily ambulation were reported by the patients. The anterolateral thigh flap with vascularized fascia lata provides a reliable fascial component for single-stage reconstruction of complex soft-tissue defects.

Anatomical study and clinical application of the vascularized composite fibula perforating osteoseptocutaneous flap

Objective To report the anatomical study and clinical application of the vascularized composite fibula perforating osteoseptocutaneous flap. Methods Latex injection studies were performed on 24 adult cadaveric lower limbs. The presence, prevalence, and location of the peronel artery and its perforators in the distal leg were documented. 16 vascularized fibul osteoseptocutaneous flaps were performed for reconstruction of composite soft-tissue defect of limbs. The flap areas ranged from 6 cm×4 cm to 16 cm× 8 cm. Results A mean of 5.3 perforating vessels of the peroneal artery was noted in the specimen. 40.6% of them were muscularcutanous perforators, and the other were septacutanous perforators. The perforating vessels were all located within 3.1 cm from the postlateral fibula. The average diameter was 1.1 mm at the deep fascial level, and the interval of them was 4-8 cm. There were two constant perforators which located about 15-25 cm and 4-7 cm from the lateral maleolar respectively. All of the 16 clinical cases survived uneventfully and the time to union of the graft-host junction site were 3 to 5 months. The appearance of flaps and the function of the limbs were satisfied during 10 to 36 months following up. Conclusion It is the anatomic basis that there are pedorating vessels of the peroneal constantly. The vnscularized compound fibula perforating osteoseptocutaneous flap has the advantage of flexible design. It is the safe and suitable choice in the cases when compound bone and soft tissue defects of the limbs are required for reconstruction. Key words: Surgical flaps; Fibula osteoseptocutaneeus flap; Transplantation; Microsurgery

The Versatility of the Dorsalis Pedis Compound Free Flap in Hand Reconstruction

The dorsalis pedis flap has demonstrated considerable versatility in the reconstruction of composite soft-tissue defects of the hand. It has the potential benefit of being thin and pliable, having reliable vascularity, and being relatively easy to harvest. However, the flap has been plagued by questions of its reliability and concerns over the donor site. An institutional review of dorsalis pedis free flap (DPFF) reconstructions of the hand was performed for the interval 1996-2006. A modified Hallock classification scheme was used to stratify the flaps. A total of 20 DPFF reconstructions of the hand were identified. There were 14 male and 6 female patients aged 20 to 53 years. The ensuing defects included secondary web contracture as well as primary amputations and exposed bony and tendinous structures. The flaps ranged in size from 15 cm2 to 110 cm2. Flap survival was 100% except one partial flap necrosis treated with a secondary skin graft. Partial donor skin graft loss was noted in 5 patients and 3 of them required a secondary resurfacing of the donor site. Functional data on 6 of 7 patients with web space contracture reconstruction showed improvements. DPFF provides durable reconstruction for composite soft-tissue defects of the hand without unduly sacrificing function or form. Donor site complications in our series were minor.

Clinical study of reconstructing the medial malleolus with free grafting of fibular head composite tendon bone flap

Objective To explore new surgical procedure for repairing and reconstructing medial malleolus and soft tissue defect. Methods According to the size of medial malleolus and composite soft tissue defect, vascular fibular head composite tendon bone flap free grafting using anterior tibial recurrent vessel as the perforating branch was designed to reconstruct the medial malleolar saddle and triangular ligament, and composite back broadest muscle flap free grafting was designed to repair the medical malleolar wound surface. From January 2000 to December 2006, the technique was used in 5 male patients who were injured by machine or in traffic accidents, causing bone and soft tissue defect. The size of wound surface ranged from 19 cm × 12 cm to 24 cm × 12 cm. Results The wound surface was healed at the first stage in 4 cases, and the other case had infection and was cured in 6 months with anti infection therapy. Postoperative follow-ups from 6 months to 6 years showed that grafted bones and free cutaneous flaps were healed well, malleolar joints were stable, joint movement was normal, and the appearance was satisfactory. The overall outcome was good. Conclusion Fibular head composite tendon bone flap free grafting is effective for repairing medical malleolar defect.

Evolution of a paradigm for free tissue transfer reconstruction of lateral temporal bone defects

Tumors of the lateral skull base are best treated with surgery plus or minus radiation therapy. Surgical ablation may involve cutaneous structures, the auricle, the parotid, and the lateral temporal bone. These composite soft tissue defects are best reconstructed with composite tissue. Multiple pedicled flaps have been used to reconstruct these defects. Free flaps have been shown to provide the best tissue for these reconstructions. We review our experience and present an algorithm for their reconstruction. A case series of consecutive patients treated between 1999 and 2006 at 2 tertiary care institutions, Oregon Health and Science University and University of Alabama at Birmingham were reviewed. There were 73 patients who had periauricular defects requiring 74 free tissue transfers in this retrospective chart review. All defects had extensive cutaneous loss and underwent some form of parotidectomy. There were 57 lateral temporal bone defects and 16 periauricular defects where the external auditory canal was preserved. The majority of patients had nonmelanoma skin malignancies (65%). Eighty percent of patients had undergone previous treatment (radiation therapy, surgery, or a combination therof). Early on, reconstruction was performed using a radial forearm (RFFF, n=29), evolving to lateral arm (n=6), rectus (n=11), and finally an anterolateral thigh (ALT, n=28) free flap. The average hospital stay was 6 days, and the overall complication rate was 22%. The rectus flap needed debulking in 34% of patients, and the anterolateral thigh in 9%. Periauricular defects were classified based on preservation of the external auditory canal (class I), lateral temporal bone resection with preservation of the auricle (class II), or lateral temporal bone with total auriculectomy (class III). Class I defects were best managed by RFFF reconstruction, class II defects were managed well with the ALT flap, and class III defects required the ALT or rectus flap.

Free Functioning Muscle Transfer for Lower Extremity Posttraumatic Composite Structure and Functional Defect

Traumatized lower extremities may present not only composite soft-tissue defects but also flexor and/or extensor loss. Free functioning muscle transfer can provide composite structural and functional restoration. From 1996 to 2004, 19 patients with lower extremity injuries whose lesions exhibited composite soft-tissue damage, with or without bone defects, and certain accompanying functional disabilities were allocated to study groups on the basis of impression, as follows: group I, open fracture IIIB (n = 10); group II, neglected compartment syndromes [open IIIB (n = 4) and open IIIC (n = 1)]; and group III, crush injuries (n = 4). Free flap resurfacing was indicated for these lesions. Fifteen patients underwent free functioning muscle transfer; source muscles were the rectus femoris (n = 3), rectus femoris with anterolateral thigh flap (n = 5), and gracilis (for ankle dorsiflexion) (n = 7). Two patients underwent composite rectus femoris and vascular iliac crest for ankle dorsiflexion and segmental tibial defect reconstruction. Two received rectus femoris muscle and anterolateral thigh flaps for posterior compartment defect and quadriceps defect reconstruction, individually. Two patients required reexploration; salvage was successful in only one, with below-knee amputation necessary in the other. Skin grafts were needed for partial skin paddle necrosis (n = 3) or remaining skin defect (n = 2). Functioning muscle reinnervation failed in four cases, with one individual undergoing ankle fusion, two people electing ambulation with stiff ankles, and one person using an orthosis. In the sample population, range of motion varied and was related to the severity of injury and the extent of skin grafting on the distal musculotendinous portion. Less function was exhibited in the compartment syndrome group (group II). Functioning muscle transfer can be performed posttraumatically in lower limbs with composite soft-tissue and motor-unit defects, resulting in acceptable functional results and reliable limb salvage.

Microvascular Reconstruction of the Upper Extremity.

Upper extremity composite tissue defects may result from trauma, tumor resection, infection, or congenital malformations. When reconstructing these defects the ultimate objectives are to provide adequate soft tissue protection of vital structures, and to provide optimal functional and esthetic outcomes. The development of clinical microsurgery has added a large number of treatment options to the trauma surgeon's armamentarium - primarily replantation of amputated tissues and transplantation of vascularized tissues from distant donor sites. Since the early 1970s, considerable refinement in microsurgical tools and techniques together with a better understanding of the anatomy and physiology of microcirculatory tissue perfusion led to the introduction of a variety of thin, pliable and versatile-free flap designs. Sources for this manuscript include a comprehensive literature search using the PUBMED and EMBASE databases along with relevant text books, Selected Readings in Plastic Surgery(®), and personal experiences of upper extremity reconstruction and microsurgery. In this manuscript, we describe the primary microsurgical techniques used to reconstruct upper extremity tissue defects and discuss the basis for selecting one technique over another. Where possible, the best results may be achieved by reattaching the amputated original tissues (microsurgical replantation). In noninfected, uncontaminated traumatic injuries resulting in composite soft tissue defects, Early free flap reconstruction of the upper extremities has important advantages over delayed (72 h-3 months) or late wound closure (3 months-2 years). In recent years, thin, pliable, and versatile fasciocutaneous flaps such as the anterolateral thigh (ALT) and lateral arm (LA) free flaps have been increasingly used with great success to reconstruct the upper extremity. The use of "spare parts" and functional reconstructions using osteomyocutaneous free flaps or toe to thumb transfers complete the armamentarium of the upper limb reconstructive microsurgeon.

Free Functioning Muscle Transfer for Lower Extremity Post-Traumatic Composite Structure and Functional Defect

The traumatized lower extremity may present not only a composite soft tissue defect, but also a certain functional disability. A microsurgical free functioning muscle transfer (FFMT) may provide structural reconstruction and functional restoration for composite tissue defects.

One-Stage Reconstruction of Composite Bone and Soft-Tissue Defects in Traumatic Lower Extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.