Orthoplastic Limb Salvage Using Transtibial Transport and Free-Flap Reconstruction in Patients With Diabetes-Related Chronic Limb-Threatening Ischemia

Early revascularization—through endovascular or open surgery—is the cornerstone of treatment for chronic limb-threatening ischemia (CLTI). However, some patients are deemed “no-option” because of diffuse infrapopliteal disease, poor distal runoff, or failed previous interventions, leaving limited limb-salvage strategies. We report an orthoplastic limb-salvage case in a 56-year-old man with poorly controlled diabetes, severe peripheral arterial disease, and a chronic foot ulcer complicated by toe gangrene after unsuccessful revascularization. After urgent radical débridement, ray amputation, culture-directed antibiotics, and negative-pressure wound therapy, transtibial transport (TTT) was done to improve microcirculation. After infection control and wound stabilization, definitive reconstruction was achieved using a large anterolateral thigh perforator free flap with a flow-through microsurgical technique to provide durable coverage while preserving distal perfusion. At 12-month follow-up, the flap remained viable with complete epithelialization, no ulcer recurrence, preserved foot architecture, and independent ambulation with protective footwear, indicating meaningful functional recovery. This case highlights the potential role of combining TTT with microsurgical reconstruction in orthoplastic management of “no-option” CLTI. Enhancing microcirculation alongside robust soft-tissue coverage may expand limb-salvage possibilities when traditional revascularization is not feasible.