Free Flap Reconstruction for Post-Earthquake Extremity Injuries: Outcomes and Experiences from the 2023 Kahramanmaraş Earthquakes

Free Flap Reconstruction for Post-Earthquake Extremity Injuries: Outcomes and Experiences from the 2023 Kahramanmaraş Earthquakes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Free Flap Reconstruction for Post-Earthquake Extremity Injuries: Outcomes and Experiences from the 2023 Kahramanmaraş Earthquakes erkan sabri ertaş, ali özdemir, mehmet ali acar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9210090/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background The 2023 Kahramanmaraş earthquakes resulted in a mass casualty scenario with more than 100,000 injured individuals, creating major challenges in the management of complex extremity trauma. While most earthquake-related reports focus on acute care, few studies have investigated delayed microsurgical reconstruction and its outcomes in such settings. Methods This retrospective study included 22 patients who underwent free flap reconstruction for earthquake-related extremity injuries at a tertiary microsurgical center. Demographic features, flap characteristics, anastomosis type, timing of fixation, postoperative complications, and final outcomes were analyzed. Additionally, specific operative and organizational experiences based on the authors’ direct involvement in the disaster response were examined. Results Flap survival was achieved in 21 of 22 patients (95.4%), with infection being the most frequent complication (50%). Latissimus dorsi (LD) flaps were used for large-volume defects, while anterolateral thigh (ALT) and superficial circumflex iliac perforator (SCIP) flaps were preferred for moderate or smaller defects. Only one patient underwent early-phase reconstruction; in the remaining cases, reconstruction was delayed due to logistical and infrastructure constraints inherent to the disaster environment. End-to-side anastomosis (ESA) was preferred in the majority of patients, reflecting anticipated vessel fragility in the trauma zone. Staged internal fixation following full flap integration resulted in favorable outcomes without chronic infection or flap compromise. Conclusion Free flap reconstruction can successfully salvage limbs in post-disaster environments when supported by experienced microsurgical teams, structured triage, and interfacility referral systems. Based on our experience, integrating reconstructive surgeons into disaster-zone triage, establishing predefined referral networks, and ensuring logistic preparedness at designated microsurgical centers are essential components of an effective disaster response strategy. Earthquakes Disaster medicine Mass casualty incident Free tissue flap Microsurgery Limb salvage Orthoplastic approach Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction On February 6, 2023, two catastrophic earthquakes measuring 7.7 Mw and 7.6 Mw struck southeastern Türkiye, occurring nine hours apart, with epicenters in the Pazarcık and Elbistan districts of Kahramanmaraş. The earthquakes affected 11 provinces—Adana, Adıyaman, Diyarbakır, Elazığ, Hatay, Gaziantep, Kahramanmaraş, Kilis, Malatya, Osmaniye, and Şanlıurfa—encompassing a population of approximately 13.5 million. Official reports documented 53,537 fatalities and 107,213 injuries, making this disaster one of the most devastating in the country’s modern history [ 1 ]. The extensive destruction caused widespread displacement and severely disrupted the regional healthcare and emergency response infrastructure. Several hospitals within the affected region were either destroyed or rendered non-functional, while numerous healthcare professionals working in the disaster area were personally impacted. In response, medical teams from across Türkiye were deployed to provide urgent surgical care under highly challenging conditions. Due to the overwhelming number of casualties that far exceeded local hospital capacities, many patients who received initial emergency management in the disaster zone were subsequently transferred to tertiary trauma centers for further evaluation and definitive reconstructive procedures. Although amputation may yield acceptable functional outcomes with appropriate rehabilitation [ 2 ], the preservation of extremities offers significant long-term advantages in terms of functional independence, social reintegration, and economic sustainability. Moreover, the high lifetime costs associated with prosthetic rehabilitation and device replacement impose a substantial financial burden on both patients and healthcare systems [ 3 ]. To date, most studies addressing earthquake-related injuries have primarily focused on the acute phase of disaster response, with limited attention given to delayed reconstructive strategies and outcomes [ 4 , 5 ]. In contrast, robust evidence has demonstrated that early soft-tissue coverage in trauma patients significantly reduces infection rates and improves reconstructive success [ 6 , 7 ]. Within this context, the current study aims to characterize the clinical features of earthquake-related extremity injuries requiring free flap reconstruction and to evaluate their surgical outcomes. Furthermore, it seeks to present practical insights and recommendations based on the authors’ experience in managing complex limb salvage procedures following the 2023 Kahramanmaraş earthquakes. Patients and Methods Earthquake-related extremity injuries, similar to other high-energy limb traumas, require a coordinated ortho-plastic surgical approach. Selçuk University Hospital, a Level I trauma center, has a dedicated orthopedic microsurgery team composed of three orthopedic surgeons, each with fellowship training in hand and microsurgery. The team has extensive experience in the management of complex limb trauma and in performing free tissue transfers for extremity reconstruction. Following the 2023 Kahramanmaraş earthquakes, two members of this team were deployed to the disaster zone on February 6, 2023, where they provided emergency surgical care for nine consecutive days before returning to the institution. The third surgeon remained at the hospital to coordinate the management of referred trauma patients. Beginning on the second day after the disaster, patients—either self-referred or transferred through the national referral network—began presenting to our center, located approximately 550 kilometers from the earthquake epicenter. Over the following weeks, additional patients from multiple affected provinces were referred for definitive reconstructive management. This retrospective observational study included all patients who underwent free flap reconstruction for earthquake-related extremity injuries at Selçuk University Hospital. Patients treated with pedicled or local rotational flaps were excluded. Clinical data were collected from hospital records, operative notes, and intraoperative photographs over a 60-day period beginning February 6, 2023. Information regarding the initial injury mechanism and early interventions was unavailable for most patients; however, documentation for three individuals confirmed that they had undergone primary surgical treatment by the same team at hospitals within the disaster region prior to transfer. The study was conducted in accordance with the ethical standards of the Declaration of Helsinki, and institutional ethics approval was obtained (approval date: April 11, 2023; reference number: 2023/178). Informed consent for inclusion was obtained from all participants or their legal guardians prior to data collection. The collected variables included demographic data, hospitalization details, injury characteristics and localization, flap type and dimensions, recipient vessels and anastomosis configuration, systemic comorbidities, postoperative complications, and additional surgical procedures performed. All surgeries and follow-up assessments were performed at Selçuk University Hospital, where all authors were affiliated during the study period. Statistical Analysis All statistical analyses were performed using IBM SPSS Statistics for Windows, version 27.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) and range (minimum–maximum), whereas categorical variables were presented as absolute frequencies and percentages. The normality of distribution for continuous variables was assessed using the Shapiro–Wilk test. Comparisons between groups were performed using the Independent Samples t -test for normally distributed data and the Mann–Whitney U test for non-normally distributed variables. Categorical variables were analyzed using the Chi-square test or Fisher’s exact test, as appropriate. One-way analysis of variance (ANOVA) followed by Tukey’s post-hoc test was used to compare flap surface areas among the different flap types (ALT, LD, and SCIP). Logistic regression analysis was applied to identify independent predictors of postoperative complications. Variables with a p -value < 0.10 in univariate analyses were entered into the multivariate logistic regression model. Statistical significance was set at p < 0.05. Results Demographics and Injury Characteristics A total of 22 patients underwent free flap reconstruction following earthquake-related extremity injuries. The mean age of the cohort was 40.2 ± 14.6 years (range, 10–62 years). Twelve patients were female and ten were male. Injuries were located on the left side in 12 cases and on the right in 10. When injury sites were analyzed, lower extremity involvement (16 cases) was more frequent than upper extremity involvement (6 cases) ( χ² = 4.55, p = 0.033). (Table 1 ) Table 1 Clinical characteristics of patients who underwent free flap surgery, including demographic data, additional injuries, and complications. (DoA: Day of Admission, FSD: Flap Surgery Date, Hosp: Duration of Hospitalization, ALT: Anterolateral Thigh Flap, ATA: Anterior Tibial Artery, BA: Brachial Artery, EEA: End-to-End Anastomosis, ESA: End-to-Side Anastomosis, FA: Femoral Artery, FCR: Flexor Carpi Radialis, FDS: Flexor Digitorum Superficialis, LD: Latissimus Dorsi Flap, MCP: Metacarpophalangeal Joint, ORIF: Open Reduction and Internal Fixation, PA: Popliteal Artery, PTA: Posterior Tibial Artery, PT: Pronator Teres, RA: Radial Artery, SA: Serratus Anterior Flap, SCIP: Superficial Circumflex Iliac Perforator Flap, UA: Ulnar Artery, VAC: Vacuum-Assisted Closure) Patient ID Age Gender DoA(d) FSD (d) Hosp(d) Injury Site Injury Details and Prior Interventions Flap Type & Harvested Flap Size (cm) Recipient artery and type of anastomosis Systemic Issues Complications Additional Surgical Procedures #01 10 M 18 20 11 Left lower extremity Knee region Knee disarticulation, posterior femoral condyles exposed. ALT, 14*9 PA, ESA None None None #02 13 M 3 4 35 Left upper extremity Forearm Previous forearm fasciotomies, necrosis of FDS, PT and FCR, radius fracture exposure. ALT, 25*9 BA, ESA None Infection ORIF of radius, 4x Debridement + VAC, skin grafting #03 19 F 23 24 10 Right lower extremity Ankle region Medial malleolus fracture, soft tissue defect around the anterior and medial regions of the ankle. SCIP, 12*8 PTA, ESA None Venous congestion The medial malleolus fracture was fixed with a cannulated screw in the same session as free flap surgery. Venous anastomoses were revised on the second postoperative day. #04 23 F 17 21 14 Left lower extremity Medial thigh region Late presentation of thigh compartment syndrome (fasciotomy not performed) and exposure of femoral artery, vein, and nerve in the medial thigh, with soft tissue necrosis overlying the neurovascular structures. SCIP, 14*8 FA, ESA None None None #05 26 M 13 16 44 Left upper extremity Forearm Previous forearm fasciotomies, necrosis of all forearm volar compartment muscles LD (functional), 23*10 BA, ESA None Infection 3x Debridement, skin grafting #06 32 M 22 26 15 Right lower extremity Cruris Cruris previously underwent fasciotomies, with necrosis of the anterior compartment muscles and the skin remaining between the fasciotomies, followed by debridement of necrotic areas before free flap surgery. ALT, 18*12 PTA, ESA None None None #07 35 M 18 28 44 Left lower extremity Cruris Previously applied fasciotomies, with necrosis of the total posterior compartment muscles and extensive necrosis of the skin remaining between the fasciotomy lines. LD + SA, 26*14 PA, ESA Preopratively acute renal failure, dialysis Infection 3x Debridement, skin grafting #08 38 F 20 25 47 Right upper extremity Forearm Previous forearm fasciotomies, necrosis of all forearm volar compartment muscles, amputation of 4th and 5th rays of ipsilateral hand due to ulnar artery long segment thrombosis. LD (functional), 21*11 BA, ESA None Infection 4x Debridement, skin grafting #09 39 F 24 34 43 Left upper extremity- Forearm Previous forearm fasciotomies, necrosis of all forearm volar compartment muscles, bilateral below knee amputations. LD (functional), 22*12 BA, ESA Preopratively acute renal failure, dialysis Infection 5x Debridement, skin grafting #10 40 F 24 26 11 Left upper extremity- Forearm Necrosis of extensor muscles and skin in the dorsal forearm fasciotomy area, with exposure of the dorsal aspect of the ulna. ALT, 16*12 RA, EEA None None None #11 40 M 33 46 26 Right lower extremity Cruris Previously underwent fasciotomy due to cruris compartment syndrome and external fixation for tibial segmental fracture, with a soft tissue defect and necrosis at the distal part of the anteromedial tibia fasciotomy incision, resulting in exposure of the tibia. SCIP, 14*7 PTA, ESA Preopratively acute renal failure, dialysis Infection 2x Debridement #12 43 F 17 33 52 Right lower extremity Pelvic region Previously underwent hip disarticulation, with an extensive soft tissue defect over the acetabulum and gluteal region. ALT, 22*16 Contralateral FA (Using vein graft), ESA Preopratively acute renal failure, dialysis, sepsis Flap loss and patient exitus due to sepsis in the postoperative period Removal of necrotic flap tissue, 2x debridement #13 46 F 12 15 34 Left lower extremity Cruris Cruris previously underwent fasciotomies, with necrosis of the anterior compartment muscles and the skin remaining between the fasciotomies. ALT, 17*12 PTA,ESA None Infection 2x debridement #14 48 F 26 29 17 Right lower extremity Knee region Soft tissue injury on the medial side of the knee involving the medial collateral ligament, with damage to the joint capsule and partial exposure of the femoral medial condyle. ALT, 15*11 PA, ESA None Infection Simultaneous knee medial collateral ligament reconstruction,with free flap procedure, 2x Debridement #15 48 M 18 21 25 Left lower extremity Ankle region Soft tissue defect in the anterior and lateral regions of the ankle, with prior external fixation due to tibio-talar dislocation and bimalleolar fracture. ALT, 13*9 PTA, ESA None Venous congestion Venous anastomoses were revised on the second postoperative day. Surgical fixation of the lateral malleolus with an anatomical plate and the medial malleolus with cancellous screws on the 16th day post-free flap surgery. #16 50 F 14 17 17 Right lower extremity Foot Underwent fasciotomy surgery due to foot and cruris compartment syndrome, with an extensive soft tissue defect on the dorsum of the foot. SCIP, 14*11 ATA, EEA None None During the same session as the free flap surgery, cruris fasciotomy incisions were approximated, and skin grafting was performed in a second stage. #17 52 M 16 25 33 Left lower extremity Cruris Cruris previously underwent fasciotomies, with necrosis of the anterior, lateral, and deep posterior compartment muscles, while only the gastrocnemius muscle was affected in the superficial posterior compartment. Anterior skin between fasciotomy sites was also necrotic. Debridement was done in a separate session before the free flap procedure. LD, 25*16 PA (Using vein graft), ESA None Infection 3x Debridement, skin grafting #18 53 F 38 41 11 Right lower extremity – Heel region Contralateral below-knee amputation with a soft tissue defect in the heel region, exposing the calcaneus. SCIP, 16*12 PTA, ESA None None None #19 55 M 12 22 32 Right lower extremity Cruris Tibial shaft fracture with a distal and mid-anterior cruris soft tissue defect, exposing the necrotic tibialis anterior muscle and tendon. The patient had prior external fixation. Before the free flap, debridement, excision of the necrotic tibialis anterior muscle and tendon and fixation revision were performed, revealing ATA thrombosis. ALT, 16*10 PTA, ESA None None Intramedullary nailing of the tibia on postoperative day 15 following free flap surgery. #20 55 F 42 43 9 Right lower extremity Dorsum of the foot 1st and 2nd metatarsal fractures fixed with K-wires, amputation of the 3rd, 4th, and 5th toes, soft tissue defect on the dorsum of the foot SCIP, 15*8 ATA, EEA None None K-wires in the metatarsals were revised during the same session as the free flap surgery. #21 58 M 15 17 20 Left upper extremity Hand 4th and 5th fingers amputated at the MCP joint level, extensive soft tissue defect on the dorsum of the hand and wrist with exposed extensor tendons, proximal phalanx fracture of the 1st finger, and defective fractures of the 2nd and 3rd metacarpals. SCIP (chimeric with bone), 15*7 UA, ESA None Infection 2x Debridement #22 62 F 33 37 29 Left lower extremity Ankle – Distal cruris Before admission, the patient underwent external fixation for a bimalleolar fracture and tibiotalar dislocation. There was a medial and posterior ankle soft tissue defect with Achilles tendon rupture and necrosis. Pre-flap debridement revealed an epineural tibial nerve injury with preserved continuity and a thrombosed PTA. ALT, 16*8 PTA, EEA None Infection 2x Debridement Ankle arthrodesis with a hindfoot nail was performed on postoperative day 18 following free flap surgery. The predominant mechanism of injury was prolonged entrapment under debris, observed in 20 patients, while 2 patients sustained injuries from jumping or falling from a height while escaping. Four patients presented with acute kidney injury (AKI) requiring dialysis, and one of them also had sepsis on admission. The mean interval from the earthquake to hospital admission was 20.8 ± 9.2 days (range, 3–42 days), and the mean time to flap surgery was 25.9 ± 10.1 days (range, 4–46 days). The average delay between admission and flap surgery was 5.1 ± 4.2 days (range, 1–16 days). The mean duration of hospitalization was 26.3 ± 13.8 days (range, 9–52 days). Flap Types and Distribution Among the reconstructions, anterolateral thigh (ALT) flaps were used in 10 patients, superficial circumflex iliac perforator (SCIP) flaps in 7, and latissimus dorsi (LD) flaps in 5. The LD flap was primarily employed for large soft-tissue defects: in three upper-extremity cases (Patients #05, #08, #9) for volar forearm coverage and finger flexor restoration as a free functional muscle transfer, and in two lower-extremity cases (Patients #07, #17) for extensive soft-tissue coverage. A SCIP flap incorporating a segment of bone as a chimeric flap was used in one patient (Patient #21). ALT or SCIP flaps were generally selected for small- to medium-sized defects depending on the defect location and surgeon preference. (Fig. 1 ) Flap surface area analysis demonstrated notable differences among the three flap types. The ALT group ranged from 117 cm² to 352 cm² (mean 188.5 cm²), the LD group from 230 cm² to 400 cm² (mean 297.8 cm²), and the SCIP group from 96 cm² to 192 cm² (mean 125.3 cm²). One-way ANOVA revealed a significant difference among the groups (F = 10.95, p = 0.0007). Tukey’s post-hoc test confirmed significant differences between ALT vs. LD ( p = 0.0135) and LD vs. SCIP ( p = 0.0005), while ALT vs. SCIP was not significant ( p = 0.13). (Fig. 2 ) Representative clinical photographs of patients reconstructed with ALT, SCIP, and LD free flaps are provided in Figs. 3 , 4 , and 5 , respectively. Skeletal Injuries and Fixation Timing Bone fractures were present in eight patients (Patients #02, #03, #11, #15, #19, #20, #21 and #22), with variability in both timing and method of skeletal stabilization. Only one patient (Patient #02) underwent early-phase reconstruction, in which internal fixation of an exposed radius fracture was performed concurrently with ALT flap transfer. Three patients received limited fixation procedures during delayed flap reconstruction: Patient #03 underwent screw fixation for a medial malleolus fracture, Patient #20 underwent K-wire revision for metatarsal fractures, and Patient #21 required reconstruction of multiple metacarpal and phalangeal fractures with a chimeric SCIP flap incorporating a vascularized bone segment. Three patients (Patients #15, #19, and #22) were treated in a staged manner, with initial soft-tissue coverage using ALT flaps, followed by delayed internal fixation after an average of 15 days after flap integration. Fixation techniques included intramedullary nailing (Patient #19), bimalleolar plating (Patient #15), and ankle arthrodesis using a hindfoot nail (Patient #22). No chronic infections were observed in any of these cases, regardless of fixation timing. Flap Outcomes and Complications Flap survival was achieved in 21 of 22 patients. One patient (Patient #12) experienced total flap loss due to postoperative sepsis and septic shock and subsequently died. This patient had preoperative sepsis and had previously undergone hip disarticulation at another hospital prior to transfer. (Fig. 6 ) Postoperative complications were observed in several patients, with infection being the most frequent. Eleven patients developed infectious complications, all successfully managed with serial debridements and intravenous antibiotic therapy. Venous congestion occurred in two patients (Patients #03 and #15), both of whom were successfully salvaged following revision of venous anastomoses. Figure 1 . Distribution of flap types (ALT, LD, SCIP) used in post-earthquake extremity reconstruction. Bar chart illustrating the number of cases reconstructed with each flap type. Figure 2 . Comparison of flap surface areas by flap type. Boxplot showing the range, median, and interquartile distribution of flap surface areas among ALT, LD, and SCIP flaps. Discussion Mass casualty incidents (MCIs) such as earthquakes create substantial challenges in managing traumatic extremity injuries. The 2023 Kahramanmaraş earthquakes resulted in more than 100,000 injuries [ 1 ], rapidly overwhelming the damaged healthcare infrastructure. Large-scale disasters create a sudden influx of severely injured patients, leading to resource exhaustion and delays in definitive reconstructive care [ 8 ]. In these circumstances, emergency life-saving interventions predominate, while complex microsurgical procedures are postponed because of limited operating capacity, insufficient microsurgical teams, and disrupted referral coordination. Extremity trauma constitutes a major proportion of earthquake-related injuries [ 9 , 10 ], and optimal management requires coordinated orthoplastic principles integrating bone stabilization and soft-tissue reconstruction. However, because only a limited number of centers are capable of advanced microsurgery, timely interfacility referral becomes crucial. Early identification of patients requiring limb salvage, strategic triage in the disaster zone, and rapid transfer to specialized centers outside the affected region have significant impact on functional outcomes. In our cohort, limb-salvage surgery utilizing free flap reconstruction was successful in 21 out of 22 patients, underscoring the effectiveness of an experienced surgical team and appropriate microsurgical techniques in achieving extremity reconstruction, even under challenging circumstances. However, complications were frequent, with infections being the most common. These required repeated debridements and extended antibiotic therapy for effective management. Despite these hurdles, free flap-based limb salvage played a crucial role in wound closure and restoring limb integrity, demonstrating its essential contribution to successful extremity preservation in disaster-related trauma. Three types of free flaps were utilized in our cohort: latissimus dorsi (LD), anterolateral thigh (ALT), and superficial circumflex iliac perforator (SCIP) flaps. The LD flap was particularly beneficial for large defects due to its extensive soft tissue coverage, reliable vascularization, and adaptability. Its use extended beyond coverage, as it provided functional restoration when transferred as a muscle flap, particularly in cases involving upper extremity injuries, such as restoring finger flexion following severe forearm trauma [ 11 ]. In contrast, the ALT and SCIP flaps were more suitable for moderate to smaller defects, offering effective coverage with minimal donor-site morbidity. Among the 22 patients, one case resulted in flap failure and subsequent mortality. This patient was a 43-year-old woman who was transferred to our center on post-disaster day 17, presenting with a right hip disarticulation but without associated pelvic fractures. (Fig. 6 ) Although not definitively documented, she had reportedly remained trapped under the rubble for approximately 80 hours before being rescued. Upon admission, she exhibited sepsis, acute kidney injury (AKI) secondary to crush syndrome, and required dialysis. Once her general condition allowed, on post-injury day 33, a free anterolateral thigh (ALT) flap was planned to cover the exposed acetabulum. However, during intraoperative dissection, widespread thrombosis and necrosis were observed in all vascular structures within the exposed right hemipelvis, including the external iliac artery. Consequently, a 20 cm great saphenous vein graft was used to perform an end-to-side anastomosis to the contralateral femoral artery. Despite this, on postoperative day 2, arterial insufficiency of the flap was detected. Due to the patient's worsening systemic condition, including respiratory failure and increasing dialysis dependence, flap removal was performed. The patient later developed septic shock and died on postoperative day 19. Notably, despite the absence of external compressive signs in the pelvic region, extensive intrapelvic necrosis was observed, raising the possibility of pelvic compartment syndrome. In cases of prolonged entrapment with severe lower extremity crush injuries, pelvic compartment syndrome should be considered as a potential cause of progressive tissue necrosis and systemic complications. The concurrent AKI observed in this patient may have been exacerbated not only by crush syndrome but also by undiagnosed pelvic compartment syndrome. Although gluteal muscle atrophy, gait abnormalities, paresthesia, and femoral neuropathy have been described as late-stage manifestations [ 12 , 13 ], they were not observed in this patient due to early amputation and critical illness. While rare, pelvic compartment syndrome can lead to severe ischemic consequences, particularly in the delayed phases of trauma management, and should be carefully evaluated in patients with hip disarticulations following prolonged entrapment. Although early reconstruction is widely supported as the gold standard for Gustilo IIIB/C injuries and is associated with lower infection and flap failure rates [ 14 – 17 ], only one patient (Patient #02) in our cohort underwent true early-phase reconstruction. In mass casualty or resource-limited settings, early intervention is often not feasible. In such circumstances, our staged approach—performing internal fixation only after the open wound had been converted into a closed, well-vascularized soft-tissue environment through complete flap integration—served as a practical alternative. In three patients (Patients #15, #19, and #22), fixation was performed approximately 15 days after flap healing, and none developed osteomyelitis or flap-related complications. Although limited by small numbers, these findings suggest that delayed fixation following establishment of a stable, closed soft-tissue envelope may be a safe and useful strategy when early reconstruction cannot be achieved, and warrant further investigation in larger studies. The choice between end-to-end (ETE) and end-to-side (ETS) microvascular anastomosis in lower-extremity free flap reconstruction continues to be discussed, particularly in trauma-related cases where recipient vessel continuity and quality may be compromised. ETS offers the theoretical benefit of preserving distal arterial flow and is considered advantageous in settings of crush injury, vessel spasm, fibrosis, or uncertain distal perfusion [ 18 ]. Traditionally, many surgeons have preferred selecting recipient vessels outside the zone of injury to avoid inflamed or fibrotic tissue; however, recent clinical series have demonstrated that ETE anastomosis can be safely performed even within the trauma zone, including near fracture sites, without increasing the risk of flap loss [ 19 ]. Moreover, a meta-analysis encompassing 1,153 traumatic lower-extremity reconstructions found no statistically significant difference in flap failure between ETE and ETS techniques, although there was a nonsignificant trend in favor of ETE (OR 0.72; 95% CI, 0.45–1.15) [ 20 ]. In our cohort, ESA was selected in the majority of patients (18 out of 22 cases) due to anticipated fibrosis and fragility in the traumatized vessels, as well as the delayed timing of reconstruction after high-energy injuries sustained during the earthquake. Despite these challenging circumstances, flap success rates were favorable, suggesting that ESA to proximal, reliable arteries is a safe and practical strategy in delayed post-traumatic reconstruction. Based on our experience, ESA to recipient vessels beyond the trauma zone may offer technical and physiological advantages in complex reconstructions, providing consistent inflow through non-compromised arteries. While our sample size limits definitive conclusions, these findings reinforce the view that both techniques remain viable, and that optimal anastomotic strategy should be individualized based on vessel quality, flow reliability, and anatomical feasibility. Based on the authors’ experience during the 2023 Kahramanmaraş earthquakes, several strategic recommendations can be made to improve the management of trauma care in mass casualty scenarios. In large-scale disasters, hospitals located near the epicenter are quickly overwhelmed by the surge of patients requiring urgent surgical interventions, while also dealing with infrastructure damage and personnel shortages. In such settings, complex limb-salvage procedures like free flap reconstructions are frequently deprioritized in favor of life-saving interventions such as fasciotomies and amputations. This reflects the inherent prioritization of survival over function during the acute phase. Therefore, patients with reconstructive needs must be identified early and systematically triaged for transfer to specialized centers outside the disaster zone. These centers—typically unaffected by the disaster—are better equipped with experienced multidisciplinary teams and stable conditions suitable for high-complexity surgeries. Integrating a member of the reconstructive team into the disaster area’s triage process facilitates proper patient selection, enables real-time coordination with referral centers, and ensures timely transfers, minimizing delays that could compromise limb salvage potential. Despite these needs, various systemic challenges emerged in the immediate aftermath of the earthquake. Healthcare workers in the disaster region were often personally affected—many suffering emotional trauma or the loss of family members—making it difficult to keep up with the overwhelming surgical load. In this context, deploying healthcare personnel from unaffected regions proved essential to support exhausted local teams. However, in the absence of predefined referral systems, some patients requiring reconstructive surgery had to travel between multiple cities and hospitals, causing significant delays in care. Moreover, surgeons unfamiliar with microsurgical reconstruction often hesitated to initiate transfers or surgical planning, resulting in missed or late interventions. To address this, governments should implement structured policies that define which reconstructive centers are designated for activation in disaster scenarios and ensure that all stakeholders—including non-specialist surgeons—are aware of these resources in advance. In addition to these organizational strategies, logistical preparedness at designated reconstructive centers is equally critical. The cumulative surgical burden, including fasciotomies, amputations, and repeated debridements, severely strained the available surgical infrastructure. In our cohort, approximately half of the patients who underwent free flap reconstruction developed infections and required additional surgeries. Meanwhile, emergency operations for trauma patients unrelated to the earthquake had to be conducted concurrently, and in many centers, multiple free flap procedures were performed on the same day. To manage this demand, elective surgeries should be promptly suspended following a disaster, and designated hospitals must be prepared to accept disaster victims. This includes immediate review and reinforcement of inventory—not only microsurgical tools and consumables, but also trauma-related equipment such as external fixator sets, orthopedic implants, and vacuum-assisted closure (VAC) devices. These materials should be pre-stocked in high-risk areas. While life-saving operations are the immediate priority, timely reconstruction significantly reduces long-term psychological distress and helps lower the future financial burden associated with amputation and prosthetic rehabilitation [ 21 – 23 ]. Conclusion The 2023 Kahramanmaraş earthquakes underscored the critical role of free flap reconstruction in limb salvage following large-scale disasters. Despite significant delays and resource limitations, high flap survival can be achieved with experienced microsurgical teams, appropriate triage, and coordinated referral systems. Delayed internal fixation following flap integration may offer a viable alternative when early reconstruction is not feasible, although further studies are required to clarify its indications. Establishing structured disaster preparedness plans—including triage integration, predefined referral pathways, and logistic readiness of designated microsurgical centers—is essential for optimizing limb-salvage outcomes in future mass casualty events. Abbreviations ALT Anterolateral thigh LD Latissimus dorsi SCIP Superficial circumflex iliac perforator ESA End-to-side anastomosis ETE End-to-end anastomosis AKI Acute kidney injury MCI Mass casualty incident Declarations Ethics approval and consent to participate This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Selçuk University Institutional Ethics Committee (approval date: April 11, 2023; reference number: 2023/178). Written informed consent for participation was obtained from all patients or their legal guardians prior to inclusion in the study. Consent for publication Written informed consent was obtained from all patients (or their legal guardians) for the publication of their clinical data and any accompanying images. All identifying information has been removed to ensure patient confidentiality. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Authors’ contributions ESE: Study conception and design, surgical procedures, data collection, manuscript writing AO: Data analysis, interpretation, manuscript revision MAA: Surgical procedures, data collection, critical revision All authors read and approved the final manuscript. Acknowledgements Not applicable. References https://en.wikipedia.org/wiki/2023_Turkey%E2%80%93Syria_earthquakes . 01.15,2025]. Hettiaratchy SP, Stiles PJ. Rehabilitation of lower limb traumatic amputees: the Sandy Gall Afghanistan Appeal's experience. Injury. 1996;27(7):499–501. Walsh NE, Walsh WS. Rehabilitation of landmine victims–the ultimate challenge. 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Functional free muscle transfer for upper extremity reconstruction. Plast Reconstr Surg. 2014;134(2):e257–74. Bosch U, Tscherne H. The pelvic compartment syndrome. Arch Orthop Trauma Surg. 1992;111(6):314–7. Ojike NI, Roberts CS, Giannoudis PV. Pelvic compartment syndrome: a systematic review. Acta Orthop Belg. 2012;78(1):6–10. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78(3):285–92. Qiu E, Kurlander DE, Ghaznavi AM. Godina revisited: a systematic review of traumatic lower extremity wound reconstruction timing. J Plast Surg Hand Surg. 2018;52(5):259–64. Haykal S, Roy M, Patel A. Meta-analysis of Timing for Microsurgical Free-Flap Reconstruction for Lower Limb Injury: Evaluation of the Godina Principles. J Reconstr Microsurg. 2018;34(4):277–92. Lee ZH, et al. Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm. Plast Reconstr Surg. 2019;144(3):759–67. Broer PN, et al. Comparison of Outcomes of End-to-End versus End-to-Side Anastomoses in Lower Extremity Free Flap Reconstructions. J Reconstr Microsurg. 2020;36(6):432–7. Bendon CL, Giele HP. Success of free flap anastomoses performed within the zone of trauma in acute lower limb reconstruction. J Plast Reconstr Aesthet Surg. 2016;69(7):888–93. Kadhum M, et al. End to end versus end to side microvascular anastomosis for traumatic lower limb free flap reconstructions: A systematic review and meta-analysis. J Hand Microsurg. 2024;16(4):100065. McKechnie PS, John A. Anxiety and depression following traumatic limb amputation: a systematic review. Injury. 2014;45(12):1859–66. Singh S, et al. The prevalence of depression in people following limb amputation: A systematic review and meta-analysis. J Psychosom Res. 2024;181:111677. Donnelley CA, et al. Cost Analyses of Prosthetic Devices: A Systematic Review. Arch Phys Med Rehabil. 2021;102(7):1404–15. e2. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 14 May, 2026 Reviewers agreed at journal 10 May, 2026 Reviews received at journal 06 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviewers agreed at journal 05 May, 2026 Reviewers invited by journal 05 May, 2026 Editor assigned by journal 04 May, 2026 Editor invited by journal 15 Apr, 2026 Submission checks completed at journal 14 Apr, 2026 First submitted to journal 14 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9210090","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":639237983,"identity":"e3915fa2-05b0-4faf-ae86-811fe54c6e18","order_by":0,"name":"erkan sabri ertaş","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYFACNjCZwMDMfICBsYE0LWwJpGph4DEgTgu/9LHEzwV/7PLM23m+SfzcYSPHwH746AZ8WiT70g5Lz2xLLpY5zLtNsvdMmjEDT1raDXxaDM6wN0jzNjAnzmDm3SbB23Y4sUGCxwyvFvsz7M2/ef7UA7XwPJP8S4wWAx62Y9I8bIdBWtikibJF4gxbmjVv2/FiCWY2Y2vZtjRjNkJ+4e9hM77N86c6T4L/8MObb9ts5PjZDx/DqwUZsEiASDZilYMA8wdSVI+CUTAKRsHIAQAghELBEa1DawAAAABJRU5ErkJggg==","orcid":"","institution":"Gülhane Eğitim ve Araştırma Hastanesi","correspondingAuthor":true,"prefix":"","firstName":"erkan","middleName":"sabri","lastName":"ertaş","suffix":""},{"id":639237984,"identity":"56ef98d9-e35d-4042-b04e-854c2f125c69","order_by":1,"name":"ali özdemir","email":"","orcid":"","institution":"Selçuk Üniversitesi Tıp Fakültesi Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"ali","middleName":"","lastName":"özdemir","suffix":""},{"id":639237985,"identity":"3e7b06cb-4187-4c2d-aceb-3b9ca4ef301f","order_by":2,"name":"mehmet ali acar","email":"","orcid":"","institution":"Private Meram Akademi Hospital","correspondingAuthor":false,"prefix":"","firstName":"mehmet","middleName":"ali","lastName":"acar","suffix":""}],"badges":[],"createdAt":"2026-03-24 09:53:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9210090/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9210090/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109176482,"identity":"968874b0-7656-4096-86c3-5ff98ac7a403","added_by":"auto","created_at":"2026-05-13 09:31:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":67321,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of flap types (ALT, LD, SCIP) used in post-earthquake extremity reconstruction.\u003cbr\u003e\nBar chart illustrating the number of cases reconstructed with each flap type.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9210090/v1/848ddbea9955f7dedd5388b6.png"},{"id":109176497,"identity":"529952aa-6618-4596-8741-0e9ec2dafbb4","added_by":"auto","created_at":"2026-05-13 09:32:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":50324,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of flap surface areas by flap type.\u003cbr\u003e\nBoxplot showing the range, median, and interquartile distribution of flap surface areas among ALT, LD, and SCIP flaps.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9210090/v1/1d98f79aa3f77b2c06bf659f.png"},{"id":109176540,"identity":"5ebd0f2a-c70d-4eac-8ca3-8472f430b323","added_by":"auto","created_at":"2026-05-13 09:32:17","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2469924,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Preoperative view of the left forearm with exposed radius fracture in a 13-year-old male (Patient #2). (B) \u0026nbsp;Inset of the anterolateral thigh (ALT) flap during the initial surgery. (C) Late postoperative view showing the healed flap after debridements and skin grafting.\u003c/p\u003e","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9210090/v1/76764306a9561a224a1a9f91.png"},{"id":109176591,"identity":"2ae10903-b22b-4fa1-84b7-c5efc1c022d0","added_by":"auto","created_at":"2026-05-13 09:32:44","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1145816,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Intraoperative view of the heel defect with exposed calcaneus in a 53-year-old female (Patient #18). (B) Postoperative view showing the successfully healed superficial circumflex iliac perforator (SCIP) flap.\u003c/p\u003e","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-9210090/v1/fcc52e68566efbdd5157dbba.png"},{"id":109176539,"identity":"4c70f4e9-f4c7-404f-ab0b-4b3d410e9803","added_by":"auto","created_at":"2026-05-13 09:32:17","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2230791,"visible":true,"origin":"","legend":"\u003cp\u003eA 39-year-old female (Patient #09) with a severe forearm crush injury and muscle necrosis. (A) Preoperative view of the volar forearm defect. (B) Intraoperative view of the harvested latissimus dorsi (LD) free flap. (C) Postoperative view after reconstruction with the functional LD free flap for soft tissue coverage and restoration of finger flexion.\u003c/p\u003e","description":"","filename":"figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-9210090/v1/1b638a3b7084e79fa804f632.png"},{"id":109176499,"identity":"48c86db2-cea2-40ea-ae23-b9e448edf2b8","added_by":"auto","created_at":"2026-05-13 09:32:12","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":94633,"visible":true,"origin":"","legend":"\u003cp\u003eA 43-year-old female (Patient #12) with a hip disarticulation and sepsis. Attempted acetabular coverage with a free ALT flap failed due to extensive pelvic vascular necrosis, suggestive of pelvic compartment syndrome. The patient later died from septic shock.\u003c/p\u003e","description":"","filename":"figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9210090/v1/454e2e89803f00f559d0c09e.jpg"},{"id":109176704,"identity":"7c78e499-7cab-4ff7-9846-47a701ed39d0","added_by":"auto","created_at":"2026-05-13 09:33:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5544806,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9210090/v1/d00fd13f-0c66-4f7d-9592-240154280517.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Free Flap Reconstruction for Post-Earthquake Extremity Injuries: Outcomes and Experiences from the 2023 Kahramanmaraş Earthquakes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOn February 6, 2023, two catastrophic earthquakes measuring 7.7 Mw and 7.6 Mw struck southeastern T\u0026uuml;rkiye, occurring nine hours apart, with epicenters in the Pazarcık and Elbistan districts of Kahramanmaraş. The earthquakes affected 11 provinces\u0026mdash;Adana, Adıyaman, Diyarbakır, Elazığ, Hatay, Gaziantep, Kahramanmaraş, Kilis, Malatya, Osmaniye, and Şanlıurfa\u0026mdash;encompassing a population of approximately 13.5\u0026nbsp;million. Official reports documented 53,537 fatalities and 107,213 injuries, making this disaster one of the most devastating in the country\u0026rsquo;s modern history [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The extensive destruction caused widespread displacement and severely disrupted the regional healthcare and emergency response infrastructure.\u003c/p\u003e \u003cp\u003eSeveral hospitals within the affected region were either destroyed or rendered non-functional, while numerous healthcare professionals working in the disaster area were personally impacted. In response, medical teams from across T\u0026uuml;rkiye were deployed to provide urgent surgical care under highly challenging conditions. Due to the overwhelming number of casualties that far exceeded local hospital capacities, many patients who received initial emergency management in the disaster zone were subsequently transferred to tertiary trauma centers for further evaluation and definitive reconstructive procedures.\u003c/p\u003e \u003cp\u003eAlthough amputation may yield acceptable functional outcomes with appropriate rehabilitation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], the preservation of extremities offers significant long-term advantages in terms of functional independence, social reintegration, and economic sustainability. Moreover, the high lifetime costs associated with prosthetic rehabilitation and device replacement impose a substantial financial burden on both patients and healthcare systems [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo date, most studies addressing earthquake-related injuries have primarily focused on the acute phase of disaster response, with limited attention given to delayed reconstructive strategies and outcomes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In contrast, robust evidence has demonstrated that early soft-tissue coverage in trauma patients significantly reduces infection rates and improves reconstructive success [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Within this context, the current study aims to characterize the clinical features of earthquake-related extremity injuries requiring free flap reconstruction and to evaluate their surgical outcomes. Furthermore, it seeks to present practical insights and recommendations based on the authors\u0026rsquo; experience in managing complex limb salvage procedures following the 2023 Kahramanmaraş earthquakes.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eEarthquake-related extremity injuries, similar to other high-energy limb traumas, require a coordinated ortho-plastic surgical approach. Sel\u0026ccedil;uk University Hospital, a Level I trauma center, has a dedicated orthopedic microsurgery team composed of three orthopedic surgeons, each with fellowship training in hand and microsurgery. The team has extensive experience in the management of complex limb trauma and in performing free tissue transfers for extremity reconstruction.\u003c/p\u003e \u003cp\u003eFollowing the 2023 Kahramanmaraş earthquakes, two members of this team were deployed to the disaster zone on February 6, 2023, where they provided emergency surgical care for nine consecutive days before returning to the institution. The third surgeon remained at the hospital to coordinate the management of referred trauma patients. Beginning on the second day after the disaster, patients\u0026mdash;either self-referred or transferred through the national referral network\u0026mdash;began presenting to our center, located approximately 550 kilometers from the earthquake epicenter. Over the following weeks, additional patients from multiple affected provinces were referred for definitive reconstructive management.\u003c/p\u003e \u003cp\u003eThis retrospective observational study included all patients who underwent free flap reconstruction for earthquake-related extremity injuries at Sel\u0026ccedil;uk University Hospital. Patients treated with pedicled or local rotational flaps were excluded. Clinical data were collected from hospital records, operative notes, and intraoperative photographs over a 60-day period beginning February 6, 2023. Information regarding the initial injury mechanism and early interventions was unavailable for most patients; however, documentation for three individuals confirmed that they had undergone primary surgical treatment by the same team at hospitals within the disaster region prior to transfer.\u003c/p\u003e \u003cp\u003e The study was conducted in accordance with the ethical standards of the Declaration of Helsinki, and institutional ethics approval was obtained (approval date: April 11, 2023; reference number: 2023/178). Informed consent for inclusion was obtained from all participants or their legal guardians prior to data collection.\u003c/p\u003e \u003cp\u003eThe collected variables included demographic data, hospitalization details, injury characteristics and localization, flap type and dimensions, recipient vessels and anastomosis configuration, systemic comorbidities, postoperative complications, and additional surgical procedures performed. All surgeries and follow-up assessments were performed at Sel\u0026ccedil;uk University Hospital, where all authors were affiliated during the study period.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using IBM SPSS Statistics for Windows, version 27.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and range (minimum\u0026ndash;maximum), whereas categorical variables were presented as absolute frequencies and percentages. The normality of distribution for continuous variables was assessed using the Shapiro\u0026ndash;Wilk test.\u003c/p\u003e \u003cp\u003eComparisons between groups were performed using the Independent Samples \u003cem\u003et\u003c/em\u003e-test for normally distributed data and the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test for non-normally distributed variables. Categorical variables were analyzed using the Chi-square test or Fisher\u0026rsquo;s exact test, as appropriate. One-way analysis of variance (ANOVA) followed by Tukey\u0026rsquo;s post-hoc test was used to compare flap surface areas among the different flap types (ALT, LD, and SCIP).\u003c/p\u003e \u003cp\u003eLogistic regression analysis was applied to identify independent predictors of postoperative complications. Variables with a \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.10 in univariate analyses were entered into the multivariate logistic regression model. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDemographics and Injury Characteristics\u003c/p\u003e \u003cp\u003eA total of 22 patients underwent free flap reconstruction following earthquake-related extremity injuries. The mean age of the cohort was 40.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6 years (range, 10\u0026ndash;62 years). Twelve patients were female and ten were male. Injuries were located on the left side in 12 cases and on the right in 10. When injury sites were analyzed, lower extremity involvement (16 cases) was more frequent than upper extremity involvement (6 cases) (\u003cem\u003eχ\u0026sup2;\u003c/em\u003e = 4.55, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.033). (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristics of patients who underwent free flap surgery, including demographic data, additional injuries, and complications. (DoA: Day of Admission, FSD: Flap Surgery Date, Hosp: Duration of Hospitalization, ALT: Anterolateral Thigh Flap, ATA: Anterior Tibial Artery, BA: Brachial Artery, EEA: End-to-End Anastomosis, ESA: End-to-Side Anastomosis, FA: Femoral Artery, FCR: Flexor Carpi Radialis, FDS: Flexor Digitorum Superficialis, LD: Latissimus Dorsi Flap, MCP: Metacarpophalangeal Joint, ORIF: Open Reduction and Internal Fixation, PA: Popliteal Artery, PTA: Posterior Tibial Artery, PT: Pronator Teres, RA: Radial Artery, SA: Serratus Anterior Flap, SCIP: Superficial Circumflex Iliac Perforator Flap, UA: Ulnar Artery, VAC: Vacuum-Assisted Closure)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge Gender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDoA(d)\u003c/p\u003e \u003cp\u003eFSD (d)\u003c/p\u003e \u003cp\u003eHosp(d)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInjury Site\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInjury Details and Prior Interventions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFlap Type \u0026amp; Harvested Flap Size (cm)\u003c/p\u003e \u003cp\u003eRecipient artery and type of anastomosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSystemic Issues\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdditional Surgical Procedures\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft lower extremity Knee region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKnee disarticulation, posterior femoral condyles exposed.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eALT, 14*9\u003c/p\u003e \u003cp\u003ePA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft upper extremity Forearm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrevious forearm fasciotomies, necrosis of FDS, PT and FCR,\u003c/p\u003e \u003cp\u003eradius fracture exposure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eALT, 25*9\u003c/p\u003e \u003cp\u003eBA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eORIF of radius,\u003c/p\u003e \u003cp\u003e4x Debridement\u0026thinsp;+\u0026thinsp;VAC, skin grafting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003cp\u003e24\u003c/p\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight lower extremity Ankle region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedial malleolus fracture, soft tissue defect around the anterior and medial regions of the ankle.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSCIP, 12*8\u003c/p\u003e \u003cp\u003ePTA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVenous congestion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eThe medial malleolus fracture was fixed with a cannulated screw in the same session as free flap surgery.\u003c/p\u003e \u003cp\u003eVenous anastomoses were revised on the second postoperative day.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003cp\u003e21\u003c/p\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft lower extremity Medial thigh region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLate presentation of thigh compartment syndrome (fasciotomy not performed) and exposure of femoral artery, vein, and nerve in the medial thigh, with soft tissue necrosis overlying the neurovascular structures.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSCIP, 14*8\u003c/p\u003e \u003cp\u003eFA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft upper extremity Forearm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrevious forearm fasciotomies, necrosis of all forearm volar compartment muscles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLD (functional), 23*10\u003c/p\u003e \u003cp\u003eBA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3x Debridement, skin grafting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight lower extremity Cruris\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCruris previously underwent fasciotomies, with necrosis of the anterior compartment muscles and the skin remaining between the fasciotomies, followed by debridement of necrotic areas before free flap surgery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eALT, 18*12\u003c/p\u003e \u003cp\u003ePTA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003cp\u003e28\u003c/p\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft lower extremity Cruris\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePreviously applied fasciotomies, with necrosis of the total posterior compartment muscles and extensive necrosis of the skin remaining between the fasciotomy lines.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLD\u0026thinsp;+\u0026thinsp;SA, 26*14\u003c/p\u003e \u003cp\u003ePA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePreopratively acute renal failure, dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3x Debridement, skin grafting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight upper extremity Forearm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrevious forearm fasciotomies, necrosis of all forearm volar compartment muscles, amputation of 4th and 5th rays of ipsilateral hand due to ulnar artery long segment thrombosis.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLD (functional), 21*11\u003c/p\u003e \u003cp\u003eBA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4x Debridement, skin grafting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003cp\u003e34\u003c/p\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft upper extremity- Forearm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrevious forearm fasciotomies, necrosis of all forearm volar compartment muscles, bilateral below knee amputations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLD (functional), 22*12\u003c/p\u003e \u003cp\u003eBA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePreopratively acute renal failure, dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5x Debridement, skin grafting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft upper extremity- Forearm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNecrosis of extensor muscles and skin in the dorsal forearm fasciotomy area, with exposure of the dorsal aspect of the ulna.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eALT, 16*12\u003c/p\u003e \u003cp\u003eRA, EEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003cp\u003e46\u003c/p\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight lower extremity Cruris\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePreviously underwent fasciotomy due to cruris compartment syndrome and external fixation for tibial segmental fracture, with a soft tissue defect and necrosis at the distal part of the anteromedial tibia fasciotomy incision, resulting in exposure of the tibia.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSCIP, 14*7\u003c/p\u003e \u003cp\u003ePTA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePreopratively acute renal failure, dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2x Debridement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003cp\u003e33\u003c/p\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight lower extremity Pelvic region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePreviously underwent hip disarticulation, with an extensive soft tissue defect over the acetabulum and gluteal region.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eALT, 22*16\u003c/p\u003e \u003cp\u003eContralateral FA (Using vein graft), ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePreopratively acute renal failure, dialysis, sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFlap loss and patient exitus due to sepsis in the postoperative period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRemoval of necrotic flap tissue, 2x debridement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft lower extremity Cruris\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCruris previously underwent fasciotomies, with necrosis of the anterior compartment muscles and the skin remaining between the fasciotomies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eALT, 17*12\u003c/p\u003e \u003cp\u003ePTA,ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2x debridement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e29\u003c/p\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight lower extremity Knee region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSoft tissue injury on the medial side of the knee involving the medial collateral ligament, with damage to the joint capsule and partial exposure of the femoral medial condyle.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eALT, 15*11\u003c/p\u003e \u003cp\u003ePA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSimultaneous knee medial collateral ligament reconstruction,with free flap procedure, 2x Debridement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003cp\u003e21\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft lower extremity Ankle region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSoft tissue defect in the anterior and lateral regions of the ankle, with prior external fixation due to tibio-talar dislocation and bimalleolar fracture.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eALT, 13*9\u003c/p\u003e \u003cp\u003ePTA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVenous congestion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVenous anastomoses were revised on the second postoperative day.\u003c/p\u003e \u003cp\u003eSurgical fixation of the lateral malleolus with an anatomical plate and the medial malleolus with cancellous screws on the 16th day post-free flap surgery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003cp\u003e17\u003c/p\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight lower extremity\u003c/p\u003e \u003cp\u003eFoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnderwent fasciotomy surgery due to foot and cruris compartment syndrome, with an extensive soft tissue defect on the dorsum of the foot.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSCIP, 14*11\u003c/p\u003e \u003cp\u003eATA, EEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDuring the same session as the free flap surgery, cruris fasciotomy incisions were approximated, and skin grafting was performed in a second stage.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft lower extremity\u003c/p\u003e \u003cp\u003eCruris\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCruris previously underwent fasciotomies, with necrosis of the anterior, lateral, and deep posterior compartment muscles, while only the gastrocnemius muscle was affected in the superficial posterior compartment. Anterior skin between fasciotomy sites was also necrotic. Debridement was done in a separate session before the free flap procedure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLD, 25*16\u003c/p\u003e \u003cp\u003ePA (Using vein graft), ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3x Debridement, skin grafting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003cp\u003e41\u003c/p\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight lower extremity \u0026ndash; Heel region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eContralateral below-knee amputation with a soft tissue defect in the heel region, exposing the calcaneus.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSCIP, 16*12\u003c/p\u003e \u003cp\u003ePTA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e22\u003c/p\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight lower extremity Cruris\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTibial shaft fracture with a distal and mid-anterior cruris soft tissue defect, exposing the necrotic tibialis anterior muscle and tendon. The patient had prior external fixation. Before the free flap, debridement, excision of the necrotic tibialis anterior muscle and tendon and fixation revision were performed, revealing ATA thrombosis.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eALT, 16*10\u003c/p\u003e \u003cp\u003ePTA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIntramedullary nailing of the tibia on postoperative day 15 following free flap surgery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003cp\u003e43\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight lower extremity Dorsum of the foot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1st and 2nd metatarsal fractures fixed with K-wires, amputation of the 3rd, 4th, and 5th toes, soft tissue defect on the dorsum of the foot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSCIP, 15*8\u003c/p\u003e \u003cp\u003eATA, EEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eK-wires in the metatarsals were revised during the same session as the free flap surgery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e17\u003c/p\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft upper extremity\u003c/p\u003e \u003cp\u003eHand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4th and 5th fingers amputated at the MCP joint level, extensive soft tissue defect on the dorsum of the hand and wrist with exposed extensor tendons, proximal phalanx fracture of the 1st finger, and defective fractures of the 2nd and 3rd metacarpals.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSCIP (chimeric with bone), 15*7\u003c/p\u003e \u003cp\u003eUA, ESA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2x Debridement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003cp\u003e37\u003c/p\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft lower extremity\u003c/p\u003e \u003cp\u003eAnkle \u0026ndash; Distal cruris\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBefore admission, the patient underwent external fixation for a bimalleolar fracture and tibiotalar dislocation. There was a medial and posterior ankle soft tissue defect with Achilles tendon rupture and necrosis. Pre-flap debridement revealed an epineural tibial nerve injury with preserved continuity and a thrombosed PTA.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eALT, 16*8\u003c/p\u003e \u003cp\u003ePTA, EEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2x Debridement\u003c/p\u003e \u003cp\u003eAnkle arthrodesis with a hindfoot nail was performed on postoperative day 18 following free flap surgery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe predominant mechanism of injury was prolonged entrapment under debris, observed in 20 patients, while 2 patients sustained injuries from jumping or falling from a height while escaping. Four patients presented with acute kidney injury (AKI) requiring dialysis, and one of them also had sepsis on admission.\u003c/p\u003e \u003cp\u003eThe mean interval from the earthquake to hospital admission was 20.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2 days (range, 3\u0026ndash;42 days), and the mean time to flap surgery was 25.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1 days (range, 4\u0026ndash;46 days). The average delay between admission and flap surgery was 5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2 days (range, 1\u0026ndash;16 days). The mean duration of hospitalization was 26.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8 days (range, 9\u0026ndash;52 days).\u003c/p\u003e \u003cp\u003eFlap Types and Distribution\u003c/p\u003e \u003cp\u003eAmong the reconstructions, anterolateral thigh (ALT) flaps were used in 10 patients, superficial circumflex iliac perforator (SCIP) flaps in 7, and latissimus dorsi (LD) flaps in 5. The LD flap was primarily employed for large soft-tissue defects: in three upper-extremity cases (Patients #05, #08, #9) for volar forearm coverage and finger flexor restoration as a free functional muscle transfer, and in two lower-extremity cases (Patients #07, #17) for extensive soft-tissue coverage. A SCIP flap incorporating a segment of bone as a chimeric flap was used in one patient (Patient #21). ALT or SCIP flaps were generally selected for small- to medium-sized defects depending on the defect location and surgeon preference. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFlap surface area analysis demonstrated notable differences among the three flap types. The ALT group ranged from 117 cm\u0026sup2; to 352 cm\u0026sup2; (mean 188.5 cm\u0026sup2;), the LD group from 230 cm\u0026sup2; to 400 cm\u0026sup2; (mean 297.8 cm\u0026sup2;), and the SCIP group from 96 cm\u0026sup2; to 192 cm\u0026sup2; (mean 125.3 cm\u0026sup2;). One-way ANOVA revealed a significant difference among the groups (F\u0026thinsp;=\u0026thinsp;10.95, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0007). Tukey\u0026rsquo;s post-hoc test confirmed significant differences between ALT vs. LD (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0135) and LD vs. SCIP (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0005), while ALT vs. SCIP was not significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.13). (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) Representative clinical photographs of patients reconstructed with ALT, SCIP, and LD free flaps are provided in Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, respectively.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSkeletal Injuries and Fixation Timing\u003c/p\u003e \u003cp\u003eBone fractures were present in eight patients (Patients #02, #03, #11, #15, #19, #20, #21 and #22), with variability in both timing and method of skeletal stabilization.\u003c/p\u003e \u003cp\u003eOnly one patient (Patient #02) underwent early-phase reconstruction, in which internal fixation of an exposed radius fracture was performed concurrently with ALT flap transfer.\u003c/p\u003e \u003cp\u003eThree patients received limited fixation procedures during delayed flap reconstruction: Patient #03 underwent screw fixation for a medial malleolus fracture, Patient #20 underwent K-wire revision for metatarsal fractures, and Patient #21 required reconstruction of multiple metacarpal and phalangeal fractures with a chimeric SCIP flap incorporating a vascularized bone segment. Three patients (Patients #15, #19, and #22) were treated in a staged manner, with initial soft-tissue coverage using ALT flaps, followed by delayed internal fixation after an average of 15 days after flap integration. Fixation techniques included intramedullary nailing (Patient #19), bimalleolar plating (Patient #15), and ankle arthrodesis using a hindfoot nail (Patient #22).\u003c/p\u003e \u003cp\u003eNo chronic infections were observed in any of these cases, regardless of fixation timing.\u003c/p\u003e \u003cp\u003eFlap Outcomes and Complications\u003c/p\u003e \u003cp\u003eFlap survival was achieved in 21 of 22 patients. One patient (Patient #12) experienced total flap loss due to postoperative sepsis and septic shock and subsequently died. This patient had preoperative sepsis and had previously undergone hip disarticulation at another hospital prior to transfer. (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePostoperative complications were observed in several patients, with infection being the most frequent. Eleven patients developed infectious complications, all successfully managed with serial debridements and intravenous antibiotic therapy. Venous congestion occurred in two patients (Patients #03 and #15), both of whom were successfully salvaged following revision of venous anastomoses.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eDistribution of flap types (ALT, LD, SCIP) used in post-earthquake extremity reconstruction.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eBar chart illustrating the number of cases reconstructed with each flap type.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eComparison of flap surface areas by flap type.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eBoxplot showing the range, median, and interquartile distribution of flap surface areas among ALT, LD, and SCIP flaps.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMass casualty incidents (MCIs) such as earthquakes create substantial challenges in managing traumatic extremity injuries. The 2023 Kahramanmaraş earthquakes resulted in more than 100,000 injuries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], rapidly overwhelming the damaged healthcare infrastructure. Large-scale disasters create a sudden influx of severely injured patients, leading to resource exhaustion and delays in definitive reconstructive care [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In these circumstances, emergency life-saving interventions predominate, while complex microsurgical procedures are postponed because of limited operating capacity, insufficient microsurgical teams, and disrupted referral coordination.\u003c/p\u003e \u003cp\u003eExtremity trauma constitutes a major proportion of earthquake-related injuries [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and optimal management requires coordinated orthoplastic principles integrating bone stabilization and soft-tissue reconstruction. However, because only a limited number of centers are capable of advanced microsurgery, timely interfacility referral becomes crucial. Early identification of patients requiring limb salvage, strategic triage in the disaster zone, and rapid transfer to specialized centers outside the affected region have significant impact on functional outcomes.\u003c/p\u003e \u003cp\u003eIn our cohort, limb-salvage surgery utilizing free flap reconstruction was successful in 21 out of 22 patients, underscoring the effectiveness of an experienced surgical team and appropriate microsurgical techniques in achieving extremity reconstruction, even under challenging circumstances. However, complications were frequent, with infections being the most common. These required repeated debridements and extended antibiotic therapy for effective management. Despite these hurdles, free flap-based limb salvage played a crucial role in wound closure and restoring limb integrity, demonstrating its essential contribution to successful extremity preservation in disaster-related trauma.\u003c/p\u003e \u003cp\u003eThree types of free flaps were utilized in our cohort: latissimus dorsi (LD), anterolateral thigh (ALT), and superficial circumflex iliac perforator (SCIP) flaps. The LD flap was particularly beneficial for large defects due to its extensive soft tissue coverage, reliable vascularization, and adaptability. Its use extended beyond coverage, as it provided functional restoration when transferred as a muscle flap, particularly in cases involving upper extremity injuries, such as restoring finger flexion following severe forearm trauma [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In contrast, the ALT and SCIP flaps were more suitable for moderate to smaller defects, offering effective coverage with minimal donor-site morbidity.\u003c/p\u003e \u003cp\u003eAmong the 22 patients, one case resulted in flap failure and subsequent mortality. This patient was a 43-year-old woman who was transferred to our center on post-disaster day 17, presenting with a right hip disarticulation but without associated pelvic fractures. (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) Although not definitively documented, she had reportedly remained trapped under the rubble for approximately 80 hours before being rescued. Upon admission, she exhibited sepsis, acute kidney injury (AKI) secondary to crush syndrome, and required dialysis. Once her general condition allowed, on post-injury day 33, a free anterolateral thigh (ALT) flap was planned to cover the exposed acetabulum. However, during intraoperative dissection, widespread thrombosis and necrosis were observed in all vascular structures within the exposed right hemipelvis, including the external iliac artery. Consequently, a 20 cm great saphenous vein graft was used to perform an end-to-side anastomosis to the contralateral femoral artery. Despite this, on postoperative day 2, arterial insufficiency of the flap was detected. Due to the patient's worsening systemic condition, including respiratory failure and increasing dialysis dependence, flap removal was performed. The patient later developed septic shock and died on postoperative day 19. Notably, despite the absence of external compressive signs in the pelvic region, extensive intrapelvic necrosis was observed, raising the possibility of pelvic compartment syndrome. In cases of prolonged entrapment with severe lower extremity crush injuries, pelvic compartment syndrome should be considered as a potential cause of progressive tissue necrosis and systemic complications. The concurrent AKI observed in this patient may have been exacerbated not only by crush syndrome but also by undiagnosed pelvic compartment syndrome. Although gluteal muscle atrophy, gait abnormalities, paresthesia, and femoral neuropathy have been described as late-stage manifestations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], they were not observed in this patient due to early amputation and critical illness. While rare, pelvic compartment syndrome can lead to severe ischemic consequences, particularly in the delayed phases of trauma management, and should be carefully evaluated in patients with hip disarticulations following prolonged entrapment.\u003c/p\u003e \u003cp\u003eAlthough early reconstruction is widely supported as the gold standard for Gustilo IIIB/C injuries and is associated with lower infection and flap failure rates [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], only one patient (Patient #02) in our cohort underwent true early-phase reconstruction. In mass casualty or resource-limited settings, early intervention is often not feasible. In such circumstances, our staged approach\u0026mdash;performing internal fixation only after the open wound had been converted into a closed, well-vascularized soft-tissue environment through complete flap integration\u0026mdash;served as a practical alternative. In three patients (Patients #15, #19, and #22), fixation was performed approximately 15 days after flap healing, and none developed osteomyelitis or flap-related complications. Although limited by small numbers, these findings suggest that delayed fixation following establishment of a stable, closed soft-tissue envelope may be a safe and useful strategy when early reconstruction cannot be achieved, and warrant further investigation in larger studies.\u003c/p\u003e \u003cp\u003eThe choice between end-to-end (ETE) and end-to-side (ETS) microvascular anastomosis in lower-extremity free flap reconstruction continues to be discussed, particularly in trauma-related cases where recipient vessel continuity and quality may be compromised. ETS offers the theoretical benefit of preserving distal arterial flow and is considered advantageous in settings of crush injury, vessel spasm, fibrosis, or uncertain distal perfusion [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Traditionally, many surgeons have preferred selecting recipient vessels outside the zone of injury to avoid inflamed or fibrotic tissue; however, recent clinical series have demonstrated that ETE anastomosis can be safely performed even within the trauma zone, including near fracture sites, without increasing the risk of flap loss [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Moreover, a meta-analysis encompassing 1,153 traumatic lower-extremity reconstructions found no statistically significant difference in flap failure between ETE and ETS techniques, although there was a nonsignificant trend in favor of ETE (OR 0.72; 95% CI, 0.45\u0026ndash;1.15) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In our cohort, ESA was selected in the majority of patients (18 out of 22 cases) due to anticipated fibrosis and fragility in the traumatized vessels, as well as the delayed timing of reconstruction after high-energy injuries sustained during the earthquake. Despite these challenging circumstances, flap success rates were favorable, suggesting that ESA to proximal, reliable arteries is a safe and practical strategy in delayed post-traumatic reconstruction. Based on our experience, ESA to recipient vessels beyond the trauma zone may offer technical and physiological advantages in complex reconstructions, providing consistent inflow through non-compromised arteries. While our sample size limits definitive conclusions, these findings reinforce the view that both techniques remain viable, and that optimal anastomotic strategy should be individualized based on vessel quality, flow reliability, and anatomical feasibility.\u003c/p\u003e \u003cp\u003eBased on the authors\u0026rsquo; experience during the 2023 Kahramanmaraş earthquakes, several strategic recommendations can be made to improve the management of trauma care in mass casualty scenarios. In large-scale disasters, hospitals located near the epicenter are quickly overwhelmed by the surge of patients requiring urgent surgical interventions, while also dealing with infrastructure damage and personnel shortages. In such settings, complex limb-salvage procedures like free flap reconstructions are frequently deprioritized in favor of life-saving interventions such as fasciotomies and amputations. This reflects the inherent prioritization of survival over function during the acute phase. Therefore, patients with reconstructive needs must be identified early and systematically triaged for transfer to specialized centers outside the disaster zone. These centers\u0026mdash;typically unaffected by the disaster\u0026mdash;are better equipped with experienced multidisciplinary teams and stable conditions suitable for high-complexity surgeries. Integrating a member of the reconstructive team into the disaster area\u0026rsquo;s triage process facilitates proper patient selection, enables real-time coordination with referral centers, and ensures timely transfers, minimizing delays that could compromise limb salvage potential.\u003c/p\u003e \u003cp\u003eDespite these needs, various systemic challenges emerged in the immediate aftermath of the earthquake. Healthcare workers in the disaster region were often personally affected\u0026mdash;many suffering emotional trauma or the loss of family members\u0026mdash;making it difficult to keep up with the overwhelming surgical load. In this context, deploying healthcare personnel from unaffected regions proved essential to support exhausted local teams. However, in the absence of predefined referral systems, some patients requiring reconstructive surgery had to travel between multiple cities and hospitals, causing significant delays in care. Moreover, surgeons unfamiliar with microsurgical reconstruction often hesitated to initiate transfers or surgical planning, resulting in missed or late interventions. To address this, governments should implement structured policies that define which reconstructive centers are designated for activation in disaster scenarios and ensure that all stakeholders\u0026mdash;including non-specialist surgeons\u0026mdash;are aware of these resources in advance.\u003c/p\u003e \u003cp\u003eIn addition to these organizational strategies, logistical preparedness at designated reconstructive centers is equally critical. The cumulative surgical burden, including fasciotomies, amputations, and repeated debridements, severely strained the available surgical infrastructure. In our cohort, approximately half of the patients who underwent free flap reconstruction developed infections and required additional surgeries. Meanwhile, emergency operations for trauma patients unrelated to the earthquake had to be conducted concurrently, and in many centers, multiple free flap procedures were performed on the same day. To manage this demand, elective surgeries should be promptly suspended following a disaster, and designated hospitals must be prepared to accept disaster victims. This includes immediate review and reinforcement of inventory\u0026mdash;not only microsurgical tools and consumables, but also trauma-related equipment such as external fixator sets, orthopedic implants, and vacuum-assisted closure (VAC) devices. These materials should be pre-stocked in high-risk areas. While life-saving operations are the immediate priority, timely reconstruction significantly reduces long-term psychological distress and helps lower the future financial burden associated with amputation and prosthetic rehabilitation [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe 2023 Kahramanmaraş earthquakes underscored the critical role of free flap reconstruction in limb salvage following large-scale disasters. Despite significant delays and resource limitations, high flap survival can be achieved with experienced microsurgical teams, appropriate triage, and coordinated referral systems. Delayed internal fixation following flap integration may offer a viable alternative when early reconstruction is not feasible, although further studies are required to clarify its indications. Establishing structured disaster preparedness plans\u0026mdash;including triage integration, predefined referral pathways, and logistic readiness of designated microsurgical centers\u0026mdash;is essential for optimizing limb-salvage outcomes in future mass casualty events.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnterolateral thigh\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLatissimus dorsi\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCIP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSuperficial circumflex iliac perforator\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnd-to-side anastomosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eETE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnd-to-end anastomosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAKI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcute kidney injury\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMass casualty incident\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Sel\u0026ccedil;uk University Institutional Ethics Committee (approval date: April 11, 2023; reference number: 2023/178). Written informed consent for participation was obtained from all patients or their legal guardians prior to inclusion in the study.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eWritten informed consent was obtained from all patients (or their legal guardians) for the publication of their clinical data and any accompanying images. All identifying information has been removed to ensure patient confidentiality.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eESE: Study conception and design, surgical procedures, data collection, manuscript writing\u003cbr\u003e\u0026nbsp;AO: Data analysis, interpretation, manuscript revision\u003cbr\u003e\u0026nbsp;MAA: Surgical procedures, data collection, critical revision\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://en.wikipedia.org/wiki/2023_Turkey%E2%80%93Syria_earthquakes\u003c/span\u003e\u003cspan address=\"https://en.wikipedia.org/wiki/2023_Turkey%E2%80%93Syria_earthquakes\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 01.15,2025].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHettiaratchy SP, Stiles PJ. 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J Plast Surg Hand Surg. 2018;52(5):259\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaykal S, Roy M, Patel A. Meta-analysis of Timing for Microsurgical Free-Flap Reconstruction for Lower Limb Injury: Evaluation of the Godina Principles. J Reconstr Microsurg. 2018;34(4):277\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee ZH, et al. Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm. Plast Reconstr Surg. 2019;144(3):759\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBroer PN, et al. Comparison of Outcomes of End-to-End versus End-to-Side Anastomoses in Lower Extremity Free Flap Reconstructions. J Reconstr Microsurg. 2020;36(6):432\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBendon CL, Giele HP. Success of free flap anastomoses performed within the zone of trauma in acute lower limb reconstruction. J Plast Reconstr Aesthet Surg. 2016;69(7):888\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKadhum M, et al. End to end versus end to side microvascular anastomosis for traumatic lower limb free flap reconstructions: A systematic review and meta-analysis. J Hand Microsurg. 2024;16(4):100065.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKechnie PS, John A. Anxiety and depression following traumatic limb amputation: a systematic review. Injury. 2014;45(12):1859\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh S, et al. The prevalence of depression in people following limb amputation: A systematic review and meta-analysis. J Psychosom Res. 2024;181:111677.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonnelley CA, et al. Cost Analyses of Prosthetic Devices: A Systematic Review. Arch Phys Med Rehabil. 2021;102(7):1404\u0026ndash;15. e2.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Earthquakes, Disaster medicine, Mass casualty incident, Free tissue flap, Microsurgery, Limb salvage, Orthoplastic approach","lastPublishedDoi":"10.21203/rs.3.rs-9210090/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9210090/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe 2023 Kahramanmaraş earthquakes resulted in a mass casualty scenario with more than 100,000 injured individuals, creating major challenges in the management of complex extremity trauma. While most earthquake-related reports focus on acute care, few studies have investigated delayed microsurgical reconstruction and its outcomes in such settings.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study included 22 patients who underwent free flap reconstruction for earthquake-related extremity injuries at a tertiary microsurgical center. Demographic features, flap characteristics, anastomosis type, timing of fixation, postoperative complications, and final outcomes were analyzed. Additionally, specific operative and organizational experiences based on the authors\u0026rsquo; direct involvement in the disaster response were examined.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFlap survival was achieved in 21 of 22 patients (95.4%), with infection being the most frequent complication (50%). Latissimus dorsi (LD) flaps were used for large-volume defects, while anterolateral thigh (ALT) and superficial circumflex iliac perforator (SCIP) flaps were preferred for moderate or smaller defects. Only one patient underwent early-phase reconstruction; in the remaining cases, reconstruction was delayed due to logistical and infrastructure constraints inherent to the disaster environment. End-to-side anastomosis (ESA) was preferred in the majority of patients, reflecting anticipated vessel fragility in the trauma zone. Staged internal fixation following full flap integration resulted in favorable outcomes without chronic infection or flap compromise.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFree flap reconstruction can successfully salvage limbs in post-disaster environments when supported by experienced microsurgical teams, structured triage, and interfacility referral systems. Based on our experience, integrating reconstructive surgeons into disaster-zone triage, establishing predefined referral networks, and ensuring logistic preparedness at designated microsurgical centers are essential components of an effective disaster response strategy.\u003c/p\u003e","manuscriptTitle":"Free Flap Reconstruction for Post-Earthquake Extremity Injuries: Outcomes and Experiences from the 2023 Kahramanmaraş Earthquakes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-13 09:30:18","doi":"10.21203/rs.3.rs-9210090/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-14T12:01:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181839498465880387141830712052817298733","date":"2026-05-11T03:42:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T13:50:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127033349171747109260819329672190311516","date":"2026-05-06T13:45:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15981117118783639548945756395157062352","date":"2026-05-06T01:51:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-05T21:07:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-04T13:29:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-15T11:27:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-14T19:54:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-04-14T19:49:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2fc405cf-e156-4918-bc98-6a6f49b3b964","owner":[],"postedDate":"May 13th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-14T12:01:59+00:00","index":65,"fulltext":""},{"type":"reviewerAgreed","content":"181839498465880387141830712052817298733","date":"2026-05-11T03:42:38+00:00","index":46,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T13:50:50+00:00","index":44,"fulltext":""},{"type":"reviewerAgreed","content":"127033349171747109260819329672190311516","date":"2026-05-06T13:45:14+00:00","index":43,"fulltext":""},{"type":"reviewerAgreed","content":"15981117118783639548945756395157062352","date":"2026-05-06T01:51:47+00:00","index":41,"fulltext":""},{"type":"reviewersInvited","content":"30","date":"2026-05-05T21:07:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-04T13:29:41+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T09:30:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-13 09:30:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9210090","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9210090","identity":"rs-9210090","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}