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

A patient with poorly controlled diabetes and severe peripheral arterial disease whose revascularization had failed underwent staged orthoplastic limb salvage.

• The patient was a 56-year-old man with a chronic foot ulcer complicated by toe gangrene after unsuccessful revascularization.
• Initial management was urgent radical débridement, ray amputation, culture-directed antibiotics, and negative-pressure wound therapy.
• This was a single case report, not a controlled study.

Transtibial transport (TTT) was used after the initial débridement to improve microcirculation in the 'no-option' limb.

• TTT was performed after urgent débridement, ray amputation, antibiotics and negative-pressure wound therapy.
• The stated purpose of TTT was to improve microcirculation when conventional revascularization was not feasible.

Definitive reconstruction used a large anterolateral thigh perforator free flap with a flow-through microsurgical technique.

• Reconstruction was done after infection control and wound stabilization.
• The flow-through technique was chosen to provide durable coverage while preserving distal perfusion.

At 12-month follow-up the limb was salvaged with good flap and functional outcomes.

• The flap remained viable with complete epithelialization.
• There was no ulcer recurrence and foot architecture was preserved.
• The patient walked independently with protective footwear, indicating meaningful functional recovery.

The authors propose that combining TTT with microsurgical reconstruction may expand limb-salvage options in 'no-option' CLTI.

• Early revascularization, endovascular or open, is the cornerstone of CLTI treatment, but some patients are 'no-option' because of diffuse infrapopliteal disease, poor distal runoff, or failed previous interventions.
• The authors suggest that enhancing microcirculation alongside robust soft-tissue coverage may expand limb-salvage possibilities when traditional revascularization is not feasible.
• The conclusion rests on one patient, so generalizability is not established.