**PURPOSE:** Gustilo type IIIC open tibia fractures are characterized by an ischemic limb requiring immediate arterial repair. Despite recent advances in microvascular reconstruction, these patients are at high risk of complications and the decision between primary amputation and limb salvage can be challenging for plastic surgeons. The purpose of this study is to evaluate our experience with Gustilo type IIIC patients who have underwent reconstruction with a free tissue transfer.

**METHODS:** We retrospectively reviewed an institutional database of all patients who underwent free tissue transfers. Patients with Gustilo type III open tibia fractures that underwent reconstruction with free flap coverage were included in this study. The following information was collected: patient demographics and comorbidities, operative details including flap type and anastomosis details, extent of arterial injury as determined by preoperative angiography and/or intraoperative findings, perioperative complications, and flap outcome (e.g., partial or total failure, take-backs, and salvage rates). To elucidate the difference in outcomes based on the extent arterial injury, we specifically compared the outcomes of Gustilo type IIIC patients and Gustilo type IIIB patients with 1 patent vessel.

**RESULTS:** Thirty-two patients with Gustilo type IIIC injuries underwent reconstruction with free tissue transfers. The average patient age was 32.6 ± 18 years old, with the majority being male (28, 87.5%). The mechanism of injury was traumatic in all patients. More than one-third of patients received flap coverage within one week of injury. The majority of cases were reconstructed with myocutaneous flaps (24, 75%). The two most commonly used muscle flaps were latissimus dorsi (13, 40.6%) and rectus abdominis (9,28.1%). The remaining two patients were reconstructed with tensor fascia lata and gracilis muscle flaps. Twenty-five percent of patients were reconstructed with fasciocutaneous flaps with the most common being the parascapular flap (4, 12.5%).

The rate of major perioperative complications in the Gustilo type IIIC patients and Gustilo type IIIB patients with one patent vessel was 31.3% and, 38.5%, respectively (*p*= 0.527). Three patients (9.4%) and 5 (15.6%) patients suffered partial and total flap loss, respectively in the Gustilo type IIIC cohort. This was not significantly different than the rates of partial and total flap loss (*p=*0.209 and *p=*0.596) in the Gustilo IIIB patients with one patent vessel, which were 12.8% and 20.5%, respectively. In the Gustilo type IIIC group, seven (21.9%) patients were taken back to the operating room and the salvage rate was 28.6% (2/7). The take-back rate in the Gustilo type IIIB group with one patent vessel was 25.6% and salvage rate was 20%. The take-back (*p=* 0.711) and salvage rates (*p*= 0.682) between these two groups were not statistically significant.

**CONCLUSION:** The perioperative complications and flap outcome rates for patients with ischemic limb injuries who underwent free tissue transfer is comparable to those of patients with continuous flow via one patent vessel. Patients who have suffered Gustilo type IIIC open tibia fractures should be considered candidates for limb salvage.
