Lower extremity free flap reconstructions in a tertiary trauma centre within a resource-limited health system: a case series

Traumatic lower extremity reconstruction remains a significant challenge for reconstructive surgeons, representing a true test of microsurgical expertise and requiring complex decision-making, particularly in delayed management scenarios. We present a case series of complex lower extremity free flap reconstructions performed at two tertiary trauma centers within a resource-limited health system, aiming to inspire the next generation of East African reconstructive surgeons and promote future research collaborations. We report a case series of 14 patients (10 males, 4 females) aged ≥ 18 years who underwent lower extremity free flap reconstruction at two tertiary trauma centers between 2022 and 2025. Eleven patients presented with Gustilo-Anderson type 2-3b open fractures, two with degloving injuries, and one required reconstruction following tumor extirpation of the hallux. A consultant microsurgeon performed all procedures at a Level 1 trauma facility with access to computed tomography angiography and Doppler ultrasonography—resources rarely available in similar settings. Recipient vessel selection was based on wound configuration, anatomy, and injury mechanism. Vascular pedicle integrity was assessed intraoperatively; when poor antegrade flow indicated proximal injury, anastomosis sites were relocated proximally. One end-to-side anastomosis was performed on the posterior tibial artery, while thirteen cases involved end-to-end anastomoses on the anterior tibial artery, dorsalis pedis artery, or superior genicular artery. Postoperative management included aspirin 75 mg and enoxaparin 40 mg subcutaneously once daily for 3–5 days with intensive flap monitoring by consultant and senior registrar teams. Fasciocutaneous free flaps were used in 9 patients (64%), while muscle flaps were employed in 5 patients (36%). Two flaps experienced complications—one suspected peripheral arterial disease and one multifactorial—necessitating debridement and skin graft reconstruction. The definitive management period ranged from 10 to 56 days, with an average hospital stay of 2–3 weeks. All patients completed at least 1 month of follow-up. Lower extremity free flap reconstruction is feasible in resource-limited settings when performed at well-equipped tertiary trauma centers, achieving successful limb salvage in selected patients. More microsurgical experts are needed in our setting in this field. Additionally, structured retrospective and prospective observational studies are necessary to gain further insights and advance clinical practice in lower extremity reconstruction.