Optimal timing of lower extremity reconstruction is debatable. Initial outcome studies by Gustilo, Byrd, and Godina in the late 1970s and early 1980s proposed that microsurgical reconstruction of traumatized lower extremities is best performed in the first week after injury [6–8]. Godina reviewed a series of 532 patients requiring free-flap transfer in extremity reconstruction and noted a 0.75% flap failure rate for flaps performed in the immediate phase (less than 72 h after injury), 12% failure rate of flaps performed within the delayed phase (3 days–3 months after injury), and 9.5% rate of failure in the group receiving flap coverage in the late phase (more than 3 months after injury) [8]. In our experience, we could not find any difference in outcome between the three phases.

Intimal damage from the blast wave contributes to the pathogenicity of vascular complications in the acute period following injury [8, 9]. This principle underscores the importance of careful microvascular anastomosis outside the zone of injury, particularly within the acute phase of injury [10].

In war injuries, immediate reconstruction is often not applicable due to associated injuries, resuscitative needs, patient stabilization, and logistical delays starting from patient transportation to surgical scheduling [11].

Our primary goal is wound closure as soon as possible preferably within 7–10 days after injury to decrease the risk of infection, osteomyelitis, nonunion, and further tissue loss [12]. Byrd et al. reported an overall complication rate of 18% for wounds closed within the first week of injury as compared to a 50% complication rate for wounds closed in the subacute phase (1–6 weeks after injury) [12, 13].

Parrett et al. highlighted that optimal synchronization between orthopedic surgeons and plastic surgeons results in better treatment in their retrospective review of 290 soft-tissue reconstructions over open tibial fractures [14].

First described by Fleischmann, NPWT was introduced as a semiocclusive dressing and a suction device over an open fracture [15].

The principles governing NPWT are the following:

Rezzadeh et al. demonstrated lower overall complication rates with NPWT compared to conventional wound care in the management of mangled lower extremities with Gustilo grade IIIB or IIIC open tibial fractures [17].

We strongly agree with Liu et al. that NPWT is considered a bridging tool either to buy time until complex reconstruction with a free flap is achieved or to provide granulation tissue in small wounds that can be covered with a skin graft [18].

Management of bone defects strongly depends on the length of the existing gap. Three modalities for bone reconstruction are:

Composite defect (bone, muscle, skin, and tendon with or without nerve loss) reconstruction is considered more complex. It is important to analyze the defect in a three-dimensional fashion in order to distribute skin paddles according to the perforating vessels to cover the defect as shown in Fig. 9.3. The skin paddle is also important to monitor the viability of the flap ; however, when the perforators are damaged or not available, an internal Doppler might be used to monitor the patency of the anastomosed vessels. A muscle component can be included within the flap to cover any infected bone or for additional soft-tissue coverage whenever the skin paddles are not enough.

Composite defect reconstruction is either performed in a single stage using a single chimeric flap (bone, skin, and/or muscle) or a double free flap or in two stages by providing soft-tissue coverage and bone spacer as first step followed by bone reconstruction at a later stage [20, 21].

We prefer a one-stage reconstruction using a vascularized free fibula osteocutaneous or osteomyocutaneous flap in which variable muscles can be included such as flexor hallucis longus muscle or the soleus muscle . We believe that a one-stage reconstruction hastens recovery, lowers costs, prevents adjacent soft tissue and recipient vessel scarring, avoids repeated microvascular tissue transfer, achieves early structural stability of the bone, promotes bone union, improves success rates of infection resolution, and reduces overall healing time of severe complex injuries of the lower extremities [21].