OBJECTIVES: To determine long-term outcomes and costs of Ilizarov bone transport and flap coverage for lower limb salvage. DESIGN: Case series with retrospective review of outcomes with at least 6-year follow-up. SETTING: Academic tertiary care medical center. PATIENTS: Thirty-four consecutive patients with traumatic lower extremity wounds and tibial defects who were recommended amputation but instead underwent complex limb salvage from 1993 to 2005. INTERVENTION: Flap reconstruction and Ilizarov bone transport. MAIN OUTCOME MEASUREMENTS: Outcomes assessed were flap complications, infection, union, malunion, need for chronic narcotics, ambulation status, employment status, and need for reoperations. A cost analysis was performed comparing this treatment modality to amputation. RESULTS: Thirty-four patients (mean age: 40 years) were included with 14 acute Gustilo IIIB/C defects and 20 chronic tibial defects (nonunion with osteomyelitis). Thirty-five muscle flaps were performed with 1 flap loss (2.9%). The mean tibial bone defect was 8.7 cm, mean duration of bone transport was 10.8 months, and mean follow-up was 11 years. Primary nonunion rate at the docking site was 8.8% and malunion rate was 5.9%. All patients achieved final union with no cases of recurrent osteomyelitis. No patients underwent future amputations, 29% required reoperations, 97% were ambulating without assistance, 85% were working full time, and only 5.9% required chronic narcotics. Mean lifetime cost per patient per year after limb salvage was significantly less than the published cost for amputation. CONCLUSIONS: The long-term results and costs of bone transport and flap coverage strongly support complex limb salvage in this patient population.