The prevailing treatment for distal third lower extremity defects is with autologous free tissue transfers. In the trauma patient, these reconstructions are wrought with challenges, including the selection of appropriate recipient vessels, avoiding the zone of injury, and choosing the appropriate flap for transfer, all while maintaining perfusion to the foot. With distal defects and a large zone of injury, the free flap pedicle may need additional length to cover the defect and reach the recipient vessels without excess tension. The creation of an arteriovenous loop from an autologous vein graft is the usual solution. We present a case where additional pedicle length was needed to have a free flap completely cover a distal leg defect and connect to the anterior tibial vessels proximally. The saphenous vein was not available as an interposition graft; therefore, the descending branch of the lateral femoral circumflex artery and venae comitantes were used as a composite arteriovenous interposition graft.
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