The authors review the principles of reconstructive surgery for lower limb salvage after severe lower limb trauma to determine factors that have been used as decision-making criteria for limb salvage or amputation in severe lower extremity injuries and the methods of reconstruction and their outcome. The use of scoring systems and their value in acute decision making (primary amputation or limb salvage) are described. Soft-tissue reconstructive techniques, with emphasis on the use of flaps and the importance of selecting the best technique and time for the reconstruction are reviewed. Skeletal reconstructive techniques are described, including available options and currently held views on indications and use of the best contemporary methods. It is essential for the physician to make a good initial decision on the need for primary amputation or limb salvage. A multidisciplinary approach is fundamental to successful salvage.