fig3

Figure 3. A: The 25-year-old patient had a severe crush injury to his right lower limb in a car accident. The leg survived after thrombectomy of the right femoral artery. There was a 12 cm defect of the right tibia after debridement, and the fractured fibula was plated as shown; B: there was no available recipient artery in the thigh and leg. In the first stage operation, a radial forearm flap was used as a vascular bridge flap, it was connected to the posterior tibial artery of the left leg in end-to-side fashion; C: in the second stage operation, a free flap was harvested from the back, including myocutanous latissimus dorsi and the lower part of serratus muscle, carrying two ribs (6th and 8th); D: the flaps were connected to the free end of radial forearm flap. The two legs were temporarily bound together with an external skeletal fixator; E: four weeks later, the bridge was divided and part of the radial forearm flap was used for coverage of the residual defect of the right leg; F: bone union was achieved and, with proper physiotherapy, the right leg was gradually trained to resume weight-bearing. As shown, the ribs increased thickness, in a long term follow up