Lower Extremity Reconstruction: Comprehensive Considerations in Preoperative Planning and Technique Selection

Lower extremity defects are common, complex, and often debilitating injuries that significantly impair mobility and function. Trauma remains the most common indication for reconstruction, particularly in the setting of open fractures and extensive soft tissue loss. Nontraumatic causes such as infection, wound dehiscence, vascular insufficiency, malignancies, and diabetes also require similar reconstructive strategies. Despite their prevalence, management of these defects remains challenging for many surgeons.

This comprehensive review provides a current literature review of lower extremity reconstruction, with emphasis on the timing of coverage, antibiotic management, limb-salvage decision-making, fracture management, and region-specific soft-tissue reconstruction. In this review, we examine and highlight the reconstructive strategies used for the thigh, leg, ankle, and foot.

Management of lower extremity defects depends on careful assessment of wound severity, vascular status, bony involvement, and patient-specific goals. Early debridement followed by timely soft-tissue coverage is often associated with improved outcomes, though delayed reconstruction can also be successful when guided by clinical readiness and supported by negative-pressure wound therapy. Reconstructive options range from local muscle and perforator flaps to free muscle and free fasciocutaneous flaps, with selection guided by defect location, zone of injury, and functional demands. In severe trauma, treatment may also require individualized decisions regarding limb salvage, skeletal stabilization, bone grafting, or amputation.

Lower-extremity limb salvage requires an individualized and multidisciplinary approach. As reconstructive techniques continue to advance, the field can move beyond standard hierarchies when necessary and adapt strategies that are tailored to the defect. Continued research is needed to refine reconstructive timing, optimize flap and graft selection, and further define long-term outcomes.