BACKGROUND: Patients with severe comorbidities and refractory lower leg and foot infections face high risks from prolonged anaesthesia and complex soft tissue reconstruction. Our institution collaborates with anaesthetists to perform limb salvage using free flaps, primarily under combined spinal-epidural anaesthesia (CSE) without general anaesthesia (GA). This study aimed to evaluate the treatment outcomes of our limb salvage algorithm in high-risk patients. MATERIALS AND METHODS: Between January 2020 and December 2023, we included patients with ASA class III or higher undergoing limb salvage for chronic osteomyelitis or diabetic gangrene, who desired limb preservation, had palpable main arteries and no urgent cardiovascular conditions. We investigated 12 patients with 13 limbs and 14 free flaps who underwent infection control and free flap reconstruction under CSE without GA. RESULTS: Among the 14 free flaps, 9 were ASA class III and 5 were class IV. The median anaesthesia time was 562 min and median surgical time was 479 min. All flap surgeries, except for one, required no vasopressor usage to control intraoperative hypotension. Partial necrosis occurred in 2 flaps, but all flaps survived. One limb with recurrent osteomyelitis required a vascularised fibula graft. No severe systemic complications were observed, and all limbs were preserved with weight-bearing function in 11 of 13 limbs (85%). CONCLUSIONS: Our treatment algorithm using CSE without GA for severe lower limb infections demonstrates that limb salvage can be safely achieved by preventing flap necrosis and systemic complications.