Objective: Salvage of the respective extremity. Standardized approach to adequate soft-tissue coverage (isolated severe soft-tissue trauma) and preconditioning for fracture healing (in complex trauma) as a basis for functional restoration. Limitation of secondary soft-tissue loss. Prevention of infection.
Indications: Isolated extended severe soft-tissue trauma (crush trauma, degloving injury) in the region of the shoulder and the upper extremity. Complex trauma with soft-tissue involvement Gustilo IIIB/C or Tscherne GIII/IV. Segmental soft-tissue/bone loss. Subtotal or partial amputations.
Contraindications: Unstable polytraumatized patient with vital hazards and the priority for lifesaving measures. Irretrievable devascularization or unreconstructable neural destruction, extended severe loss of multiple muscular units.
Surgical technique: Systematic, eventually serial debridement, temporary joint transfixation, reconstruction of macrocirculation, dermatofasciotomy in compartment syndrome, preferably primary shortening in segmental soft-tissue/bone loss, temporary soft-tissue coverage, systematic conditioning of soft tissues, postprimary or secondary soft-tissue reconstruction, secondary change to preferably internal fixation techniques.
Postoperative management: Individualized earliest possible passive or assisted mobilization of nontransfixed joints, early removal of transfixation and change to internal fixation modes, eventually secondary reconstructive measures (e.g., augmentation of bone defects, flap correction, secondary nerve reconstruction, functional muscle transposition procedures, arthrolyses).
Results: Patency rate after vascular reconstruction > 90%, flap survival > 95%, need for amputation is a rare entity; main determinants of prognosis: severity of soft-tissue trauma, neural damage, and potential for reconstruction.