Crush injuries of the lower extremity with extensive osseous and soft tissue damage impose a big challenge even for an interdisciplinary reconstructive approach. Multistep reconstruction with negative wound pressure therapy for soft tissue management and external fixation for osseous stability preceding free flap transfer leads to optimized outcome. We report the successful multistep reconstruction of a third-degree open right tibial fracture with extensive soft tissue defect with an arteriovenous loop preceding latissimus dorsi flap coverage with a perforator skin island after loss of an anterior lateral thigh (ALT) flap due to intima damage of the recipient vessels. The described method is a safe reconstructive concept after primary flap loss with persistent extensive tissue damage.