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The medial femoral condyle free flap serves as an attractive reconstructive option for small- to intermediate-sized bony defects. It is commonly applied in the extremities with limited reports in the head and neck. Methods: A systematic review of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Seventeen articles met inclusion criteria, yielding 166 cases for analysis, with a majority of the cohort from a single study (n = 107; 64.4%). However, all included studies represented novel reconstructive sites and surgical indications. Flap components were described in 157 cases; periosteum was used only in four cases (2.5%), whereas all others are composed of cortical bone combined with periosteum, cancellous bone, and/or cartilage (97.5%). Additionally, a skin island was used in 43 cases (25.9%). Flap measurements were reported in 51 cases, averaging 4.5 ± 2.7 cm in length. Seven cases listed skin island dimensions, averaging 20.2 ± 12.8 cm2. The descending genicular artery was the primary pedicle employed (n = 162; 97.6%), while the superior medial genicular was used in the descending genicular artery's absence (n = 4; 2.4%). Descending genicular artery pedicle length from 15 reporting cases averaged 6.4 ± 1.2 cm. Successful reconstructions totaled 160 cases (96.4%). Recipient complications were seen in 16 cases (9.6%) with six constituting flap failures (3.6%). Donor site complications were minimal (n = 6; 3.6%); however, this included one major complication of femoral shaft fracture. Conclusion: The medial femoral condyle free flap is an effective reconstructive option for the head and neck due to its versatile nature, low complication profile at both recipient and donor site, ease of harvest, and two-team approach.
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The senior author first coined the "orthoplastic" approach to traumatic lower extremity reconstruction, by which multidisciplinary surgeons and specialists work together for optimal patient success. The goals of lower extremity salvage are to optimize limb appearance, restore unrestricted pain-free ambulation, and improve quality of life. Composite traumatic defects require an organized approach, and the reconstructive ladder is used for strategies of varying complexity for repair of soft-tissue wounds. The lower rungs of the ladder include simpler reconstructive options such as the use of skin grafts and local flaps, and the higher rungs represent complex techniques such as free tissue transfer. Although there is no notable difference between muscle and fasciocutaneous/perforator flaps in reconstructive outcomes, there has been a trend toward perforator flaps to minimize donor site morbidity.
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Traumatismos da Perna , Procedimentos de Cirurgia Plástica , Lesões dos Tecidos Moles , Humanos , Traumatismos da Perna/cirurgia , Extremidade Inferior/cirurgia , Qualidade de Vida , Procedimentos de Cirurgia Plástica/métodos , Estudos Retrospectivos , Lesões dos Tecidos Moles/cirurgia , Retalhos CirúrgicosRESUMO
BACKGROUND: Management of traumatic lower extremity injuries requires a skill set of orthopedic surgery and plastic surgery to optimize the return of form and function. A systematic review and meta-analysis was performed comparing demographics, injuries, and surgical outcomes of patients sustaining lower extremity traumatic injuries receiving either orthoplastic management or nonorthoplastic management. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analysis, Cochrane, and GRADE certainty evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, Scopus, and CINAHL databases were systematically and independently searched. Nine studies published from 2013 through 2019 compared 1663 orthoplastic managed patients to 692 nonorthoplastic managed patients with traumatic lower extremity injuries. RESULTS: Orthoplastic management, compared to nonorthoplastic management likely decreases time to bone fixation [standard mean differences: -0.35, 95% confidence interval (CI): -0.46 to -0.25, P < 0.0001; participants = 1777; studies = 3; I2 = 0%; moderate certainty evidence], use of negative pressure wound therapy [risk ratios (RR): 0.03, 95% CI: 0.00-0.24, P = 0.0007; participants = 189; studies = 2; I2 = 0%; moderate certainty evidence] with reliance on healing by secondary intention (RR: 0.02, 95% CI: 0.00-0.10, P < 0.0001; participants = 189; studies = 2; I2 = 0%; moderate certainty evidence), and risk of wound/osteomyelitis infections (RR: 0.37, 95% CI: 0.23-0.61, P < 0.0001; participants = 224; studies = 3; I2 = 0%; moderate certainty evidence). Orthoplastic management likely results in more free flaps compared to nonorthoplastic management (RR: 3.46, 95% CI: 1.28-9.33, P = 0.01; participants = 592; studies = 5; I2 = 75%; moderate certainty evidence). CONCLUSION: Orthoplastic management of traumatic lower extremity injuries provides a synergistic model to optimize and expedite definitive skeletal fixation and free flap-based soft-tissue coverage for return of extremity form and function.
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The purpose of this study was to evaluate participants from the in-person Penn Flap Course (PFC) and virtual PFC to determine if the virtual PFC increased diversity in culture, sex, education, and surgical specialties internationally and within the United States. Our hypothesis is that the virtual PFC increases diversity internationally and within the United States. METHODS: A retrospective descriptive comparison was performed between participants from the in-person PFC from the years 2017 to 2019 and virtual PFC in 2020. Frequency maps were generated to determine differences in participation of cultures, sexes, education, and specialties internationally and within the United States. Net Promoter Scores (NPSs) were used to assess participant satisfaction with the virtual course. RESULTS: The in-person PFC included 124 participants from the years 2017 to 2019, whereas the virtual PFC included 770 participants in the year 2020. Compared to the in-person course, the virtual course included more cultures (countries: 60 versus 11; states: 35 versus 22), women (countries: 38 versus 7; states: 23 versus 9), students/researchers (countries: 24 versus 0; states: 9 versus 0), residents (countries: 44 versus 5; states: 26 versus 15), fellows (countries: 21 versus 2; states: 21 versus 9), attendings (countries: 34 versus 8; states: 16 versus 11), plastic surgery (countries: 54 versus 9; states: 31 versus 18), orthopedic surgery (countries: 12 versus 5; states: 11 versus 9), and other specialties (countries: 19 versus 1; states: 8 versus 2). Our overall NPS for the virtual PFC totaled 75%, categorized as "world class" based on global NPS. CONCLUSION: A virtual interface for a flap course increased participation and diversity of culture, sex, education, and specialties internationally and within the United States with "world class" participant satisfaction.
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Corantes , Trametes , Polyporaceae , Lacase/metabolismo , Trametes/metabolismo , FermentaçãoRESUMO
A novel bioreactor system (low cost and easily scaled-up) is presented for dye decolorization applying filamentous fungi. In this two-phase bioreactor, dyes were decolorized at 28°C in a first phase by immobilized fungi in spherical cartridges prepared with a high-density plastic polyethylene mesh and filled with wheat bran as substrate for growth. In a second phase the capacity of the ligninolytic enzymes (laccase and Mn-peroxidase) present in the extracellular extracts from the solid residues was exploited for decolorization at 50°C. Each sphere behaved as a small-scale bioreactor for cell-culture. This system allowed the decoupling of growth (sterile condition) and decolorization (non-sterile condition) stages. The ability to decolorize the azo dye xylidine and the triphenylmethane Malachite Green by two Argentinean strains of Trametes versicolor was evaluated. The highest decolorization rates were displayed by T. versicolor BAFC 2234. When both dyes were applied together in the bioreactor, after a first phase (100min) 73.5% of Malachite Green and 40% of xylidine decolorization was attained, while at the end of the second phase (240min) a 97% and 52% decolorization was observed. Laccase activity was detected in the decolorized solution, but no Mn-peroxidase activity. The easy change of the cartridges allows the continuous use of the bioreactor in the non-sterile decolorization of dye-containing effluents.
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Corantes , Trametes , Fermentação , Lacase/metabolismo , Polyporaceae , Trametes/metabolismoRESUMO
PURPOSE: Currently, numerous assessment tools are available to measure functional outcomes after bilateral hand transplantation. The purpose of this article is to present our experience utilizing quantitative assessment tools for functional evaluation and to describe our results after bilateral hand transplantation. METHODS: A single surgeon's experience with bilateral hand transplantation from 2011 to 2016 was retrospectively reviewed. Three bilateral hand transplantations were performed in 2 adults and 1 child. A minimum 2-year follow-up evaluation was available. For the adult patients, postoperative outcome measures included patient-reported pain and disability scores, return of sensation, muscle strength, range of motion, and return to work/activities of daily living, the Hand Transplant Scoring System (HTSS), the Sollerman hand function test, and complications. For our pediatric patient, postoperative outcome measures included the Functional Independence Measure for children (WeeFIM) scale, a functional independence measure for children, the 9-Hole Peg Test, the Box and Block test, and complications. RESULTS: Our 2 adult patients were age 28 and our pediatric patient was age 8 at transplantation. Follow-up ranged from 2 to 7 years. The functional assessments were performed over a period from 11 to 48 months after transplantation. Both adult patients achieved functional independence and the HTSS, Short Form-36 Health Score (SF-36), DASH, and Sollerman tests demonstrated sequential improvement compared with pretransplantation scores assessed with the use of prostheses. Our pediatric patient demonstrated improvement in his Box and Block test score for each hand at sequential visits after transplantation. His 9-Hole Peg Test demonstrated improvement, and his WeeFIM assessment at 20 months indicated a greater level of independence. CONCLUSIONS: Patient-reported outcomes and the Sollerman test when used in addition to the HTSS appear to reflect functional improvement in adult patients after bilateral hand transplantation. Although children pose a unique challenge with functional assessment, we found the WeeFIM assessment, 9-Hole Peg Test, and the Box and Block test helpful in evaluating functional outcomes in our pediatric patient. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.
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Transplante de Mão , Alotransplante de Tecidos Compostos Vascularizados , Atividades Cotidianas , Adulto , Criança , Mãos/cirurgia , Humanos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
The American Society for Surgery of the Hand (ASSH) was established in 1946. Since then, important advances have been made in the diagnosis and treatment of conditions affecting the upper extremity. However, there has been little documentation regarding how the largest and oldest society dedicated to hand surgery has evolved over time. Furthermore, an understanding of the history of the ASSH and the specialty of hand surgery should be emphasized in resident and fellow education. The authors aim to provide a historical overview of the ASSH through the speeches of ASSH past presidents that sheds light on future directions and long-term goals. Presidential addresses from 1961 to 2018 (courtesy of ASSH Chase Library historical archives) were reviewed. The overall percentage of ASSH presidents by specialty was 67% orthopedic, 25% plastic surgery, and 8% general surgery. The most common speech theme overall was how to be a good hand surgeon (31%). The most common speech themes were, by decade: the 1960s, history and the current state of ASSH; the 1970s and 1980s, assessments of how to be a good surgeon and goals for ASSH; the 1990s, health care and governmental regulation; the 2000s, how to be a better hand surgeon; and the 2010s goals for ASSH. In earlier years, there was more of a focus on education and technical skill development in the ASSH. Work-life balance, introduced in the 1990s, has become more of a focus in the past 20 years. Revisiting the history of the ASSH and its goals allows us to reflect on progress made while recognizing what is important as we look into the future. Furthermore, as we strive to make progress in the field of hand surgery during the current pandemic, valuable tools surface that will allow the specialty to strengthen its education, research, and patient care delivery in the future.
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PURPOSE: Acute infections of the distal upper extremity (UE) can require one and possibly multiple debridements. We aimed to develop and validate a prognostic scoring system based on patient, infection, and microbiology risk factors to help with operative planning and patient counseling. METHODS: We studied all acute surgical UE infections distal to the elbow joint over a 5-year period. A split-sample design was created with 1:1 randomization into development and validation samples. The primary outcome was infection persistence, defined as the need for additional operative drainage according to usual indications. Multivariable logistic regression identified risk factors for persistent infections in the development sample, which was translated to a simple clinical scoring system derived from regression coefficients. The model was then tested separately against the validation sample. RESULTS: A total of 602 patients were included; 31% of all infections exhibited persistence. Independent risk factors from the development sample included diabetes (3 points), smoking (2 points), leukocytosis at presentation (2 points), animal bite mechanism (3 points), osteomyelitis (4 points), tenosynovitis (7 points), pyarthrosis (3 points), necrotizing fasciitis (11 points), and methicillin-resistant Staphylococcus aureus (3 points). These were all confirmed in the validation sample. Infections were categorized into 3 groups based on risk for persistent infection: low (less than 8 points), medium (8-11 points), and high (12 points or more). In the validation sample, the probability of persistent infection for these 3 groups was 23%, 57%, and 79%, respectively. The c statistic for the model in the validation sample was 0.79. CONCLUSIONS: Persistence of acute surgical distal UE infections is mediated by patient and microbiology factors, as well as infection mechanism and type. Surgeons can use this risk-adjusted prognostic scoring system to anticipate which infections may require additional therapeutic debridement and plan operative schedules and counsel patients accordingly. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.
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Staphylococcus aureus Resistente à Meticilina , Extremidade Superior , Animais , Humanos , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Extremidade Superior/cirurgiaRESUMO
BACKGROUND: The saline load test has previously been shown to be an effective tool to diagnose traumatic arthrotomies, but no studies have assessed the test's efficacy in the wrist. The purpose of this study was to investigate the amount of fluid required during a saline load test to detect intra-articular wrist involvement of traumatic wounds with high sensitivity. METHODS: A cadaveric study was conducted using 7 thawed, fresh-frozen forequarter amputations from 7 different donors (3 male, 4 female). Specimen age (mean: 67.7 y, range: 52 to 80 y), laterality (1 right, 6 left), body weight (mean: 164.3 lbs, range: 100 to 223 lbs), and wrist range of motion (ROM) was assessed before testing. The wrist capsule was punctured with an 11-blade scalpel through the 6R radiocarpal portal site under fluoroscopic guidance to ensure the injury was intra-articular. A 19-G needle was then placed through the 3,4 radiocarpal portal site and confirmed with fluoroscopy to ensure intra-articular placement. Normal saline was then injected at a steady rate into the 3,4 radiocarpal portal site until extravasation of the saline was observed from the 6R radiocarpal arthrotomy site. The volume of saline required for extravasation from the 6R radiocarpal arthrotomy was recorded as the volume required to detect the arthrotomy. A plot of saline volumes (by percentile) was created, and a logarithmic distribution was calculated. A Wilcoxon rank-sum test was used to compare injection volumes between male and female specimens, and Pearson Coefficients were used to determine any correlations between injection volume and ROM. RESULTS: The average amount of saline that resulted in extravasation was 4 mL (range: 2 to 7 mL). In order to identify 75%, 90%, 95%, and 99% of the simulated wrist arthrotomies, 5 (95% confidence interval: 3-7), 6 (4-9), 7 (4-10), and 9 (5-14) mL were required, respectively. Pretest ROM did not correlate with saline volume. CONCLUSIONS: This study demonstrates the efficacy of the saline load test in detecting traumatic arthrotomies of the wrist joint with 95% sensitivity after loading 7 mL of saline. Prompt and accurate diagnosis of traumatic arthrotomies is paramount to guide management and optimize postinjury outcomes.
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Injeções Intra-Articulares , Solução Salina/administração & dosagem , Traumatismos do Punho/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Cadáver , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Vascularized composite allotransplantation (VCA) is an emerging and growing field. Little is known about the prevalence and distribution of the adult potential donor population in the United States now that it falls under the oversight of the United Network for Organ Sharing (UNOS). METHODS: We assessed the UNOS database from 2008 to 2015 to estimate the prevalence and distribution of adult potential vascularized composite allograft donors. Donor inclusion and exclusion criteria were developed in a way to minimize risk to recipients and were applied to the dataset. Donors were categorized by factors that influence vascularized composite allograft matching including ABO blood type, cytomegalovirus status, and ethnicity (correlate for skin color) and sorted by UNOS region. RESULTS: Just under half of all brain dead donors met the inclusion/exclusion criteria. Blood type O, cytomegalovirus+, White donors represented the most frequent donor profile while blood type AB, cytomegalovirus-, Asian donors were the least common. UNOS region 3 had the most and region 1 had the least potential VCA donors per year. Nearly all potential VCA donors were solid organ donors with the liver being the most commonly donated solid organ in this population. CONCLUSIONS: A large portion of the solid organ donor pool would qualify as adult vascularized composite allograft donors in the current UNOS system. These data will assist transplant teams in determining the prevalence and distribution of vascularized composite allograft donors for their individual patients awaiting composite allografts based on relevant matching characteristics in addition to standard transplant criteria.
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There is a devastating lack of access to surgical care, including orthopaedic surgery, in low- and middle-income countries. Similar to other low- and middle-income countries, Tanzania has a severe shortage of trained orthopaedic surgeons. The surgeons available are inundated with acute trauma care and musculoskeletal infections; elective procedures are infrequently performed and the burden of neglected care continues to rise annually. Over the past several years, our interdisciplinary team of both American and Tanzanian members has worked to understand the current local cultural and economic barriers to increasing surgical capacity, ensuring surgical safety, delivering affordable care, providing adequate patient follow-up, and improving surgical education. We propose a new paradigm for the delivery of musculoskeletal care and creation of sustained surgical capacity in this setting by building an Orthopaedic Center of Excellence in Moshi, Tanzania, augmented by international partner institutions year-round. This initiative is a public-private partnership led by the University of Pennsylvania in conjunction with Kilimanjaro Christian Medical Center. A growing number of contributors, including the Tanzanian Health Ministry, several universities, and industry partners, including general electric (GE) Health Care Africa, are currently helping to advance this concept into reality. Through our model, we aim to increase surgical capacity and quality, as well as enhance local surgical education, with the ultimate objective of training the next generation of African surgeons in the latest surgical techniques and equipment.
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Países em Desenvolvimento , Doenças Musculoesqueléticas/cirurgia , Sistema Musculoesquelético/lesões , Sistema Musculoesquelético/cirurgia , Procedimentos Ortopédicos/normas , Ortopedia/normas , Humanos , Cooperação Internacional , Avaliação de Programas e Projetos de Saúde , TanzâniaRESUMO
With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two infants who had developed refractory chylothoraces secondary to thoracic duct injury following cardiac surgery for congenital cardiac anomalies. In addition, this article reviews the relevant pathophysiology of chylothoraces, current treatment algorithm following failed conservative management, and potential role of the microsurgeon in the multidisciplinary management of this life-threatening problem. As part of the evolving microsurgery frontier, physiologic operations, such as lymphovenous anastomosis, may have a considerable role in the management of refractory pediatric chylothoraces. In our experience, lymphovenous anastomosis can restore normal lymphatic circulation within 1 to 2 weeks, liberate patients from mechanical ventilation, and enable expeditious return to enteral feeding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
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Quilotórax/cirurgia , Microcirurgia/métodos , Ducto Torácico/cirurgia , Veias/cirurgia , Anastomose Cirúrgica/métodos , Humanos , Lactente , Masculino , Cuidados Pós-Operatórios/métodos , Vênulas/cirurgiaRESUMO
As the field of vascularized composite allotransplantation continues to expand, new upper extremity transplant candidates are being considered. We recently evaluated a bilateral amputee who had a mid-forearm amputation and a contralateral metacarpal hand amputation. In the latter limb, a "partial" hand transplant that preserved the majority of the patient's existing hand, including a partially severed thumb with intact thenar muscle function, was proposed. The feasibility of this partial hand transplant was studied in fresh-frozen cadaver limbs. This report details the proposed approach, the cadaveric dissections, and the lessons learned from these dissections. Issues of osteosynthesis, microvascular planning, and intrinsic muscle recovery are discussed, all of which are critical considerations for partial hand transplant candidates. Ultimately, the partial hand approach was felt to be inferior to a more conventional distal forearm transplant in this particular candidate. Practical, functional, and ethical implications of such decision are presented.
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Transplante de Mão/métodos , Adulto , Aloenxertos , Anastomose Cirúrgica , Placas Ósseas , Cadáver , Desenho Assistido por Computador , Dissecação , Feminino , Mãos/irrigação sanguínea , Mãos/inervação , Humanos , OsteotomiaRESUMO
BACKGROUND: Total knee arthroplasty is a common orthopedic procedure in the United States and complications can be devastating. Soft-tissue compromise or joint infection may cause failure of prosthesis requiring knee fusion or amputation. The role of a plastic surgeon in total knee arthroplasty is critical for cases requiring optimization of the soft-tissue envelope. The purpose of this study was to elucidate factors associated with total knee arthroplasty salvage following complications and clarify principles of reconstruction to optimize outcomes. METHODS: A retrospective review of patients requiring soft-tissue reconstruction performed by the senior author after total knee arthroplasty over 8 years was completed. Logistic regression and Fisher's exact tests determined factors associated with the primary outcome, prosthesis salvage versus knee fusion or amputation. RESULTS: Seventy-three knees in 71 patients required soft-tissue reconstruction (mean follow-up, 1.8 years), with a salvage rate of 61.1 percent, mostly using medial gastrocnemius flaps. Patients referred to our institution with complicated periprosthetic wounds were significantly more likely to lose their knee prosthesis than patients treated only within our system. Patients with multiple prior knee operations before definitive soft-tissue reconstruction had significantly decreased rates of prosthesis salvage and an increased risk of amputation. Knee salvage significantly decreased with positive joint cultures (Gram-negative greater than Gram-positive organisms) and particularly at the time of definitive reconstruction, which also trended toward an increased risk of amputation. CONCLUSIONS: In revision total knee arthroplasty, prompt soft-tissue reconstruction improves the likelihood of success, and protracted surgical courses and contamination increase failure and amputations. The authors show a benefit to involving plastic surgeons early in the course of total knee arthroplasty complications to optimize genicular soft tissues. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Artroplastia do Joelho , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/cirurgia , Terapia de Salvação/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Clinical indications are expanding for the use of fasciocutaneous free flaps in lower extremity traumatic reconstruction. The authors assessed the impact of muscle versus fasciocutaneous free flap coverage on reconstructive and functional outcomes. METHODS: A multicenter retrospective review was conducted on all lower extremity traumatic free flaps performed at Duke University (1997 to 2013) and the University of Pennsylvania (2002 to 2013). Muscle and fasciocutaneous flaps were compared in two subgroups (acute trauma and chronic traumatic sequelae), according to limb salvage, ambulation time, and flap outcomes. RESULTS: A total of 518 lower extremity free flaps were performed for acute traumatic injuries (n = 238) or chronic traumatic sequelae (n = 280). Muscle (n = 307) and fasciocutaneous (n = 211) flaps achieved similar cumulative limb salvage rates in acute trauma (90 percent versus 94 percent; p = 0.56) and chronic trauma subgroups (90 percent versus 88 percent; p = 0.51). Additionally, flap choice did not impact functional recovery (p = 0.83 for acute trauma; p = 0.49 for chronic trauma). Flap groups did not differ in the rates of flap thrombosis, flap salvage, flap loss, or tibial nonunion requiring bone grafting. Fasciocutaneous flaps were more commonly reelevated for subsequent orthopedic procedures (p < 0.01) and required fewer secondary skin-grafting procedures (p = 0.01). Reconstructive and functional outcomes remained heavily influenced by injury severity. CONCLUSIONS: Muscle and fasciocutaneous free flaps achieved comparable rates of limb salvage and functional recovery. Flap selection should be guided by defect characteristics and reconstructive needs. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.