Emergency Free Flap Reconstruction in Traumatic Extremity Injuries: Clinical Indications and Framework

Emergency free flap reconstruction (EFFR) involves flap coverage performed during initial operative intervention or within 24 h after traumatic injury. Although EFFR offers notable advantages, standardized criteria for its application are not well established. This manuscript proposes a treatment framework outlining three primary indications for EFFR, including the use of viable tissue from spare parts.

We retrospectively analyzed 14 patients (15 flaps) with traumatic limb-threatening injuries treated with EFFR across two academic centers from 2016 to 2024. Data collected included patient demographics, injury patterns, operative details, and clinical outcomes, with results compared to existing literature. Functional recovery was defined as independent ambulation for lower extremity injuries and restoration of range of motion for upper extremity or digital injuries.

The cohort (mean age 35 years; 79% male) presented three key indications for 15 EFFR flaps: spare part utilization (47%, n = 7), immediate coverage of exposed critical structures (20%, n = 3), and distal revascularization using flow-through flaps (33%, n = 5). Flap success rate was 87%, with an overall complication rate of 47%. In multiple cases, spare part flaps preserved functional levels of amputation, such as the below-elbow or below-knee level. Functional recovery averaged 5 months (range, 2-11), and mean hospital stay was 15 days (range, 8-39).

EFFR is effective for traumatic limb salvage when tailored to specific indications. Our experience-based framework offers structured guidance based on spare part use, timely soft-tissue coverage, and distal revascularization, supporting this acute orthoplastic approach for care of traumatic injuries.