The success rate for wound closure of grade III open tibia-fibula fractures with free muscle flaps is approximately 90%. Complications and loss of free flaps are due mainly to anastomotic problems, local anatomical considerations, or recipient vessel injuries, which prolong the ischemic time of the transferred free muscle tissue. We present the techniques used at the Shock Trauma Center of The Maryland Institute for Emergency Medical Services Systems (MIEMSS), which has allowed us a 100% success rate for the last 80 free muscle transfers performed. This surgical technique involves the use of locally applied hypothermia to decrease muscle metabolism and no-reflow phenomena. Representative cases are illustrated, which could have been failures because of increased ischemic time.
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