Cross-leg Flap Research Articles

The use of cross-leg free muscle flaps in the reconstruction of lower extremity injuries

The cover of soft tissue and bone defects of the distal one-third of the leg resulting from crush injuries is a challenging problem. In such injuries healthy recipient vessels for free tissue transfer are frequently unavailable. Three cases of gunshot wounds and a mine explosion were managed successfully with cross-leg free muscle flaps, two latissimus dorsi and one rectus abdominis. The disadvantages of this technique are patient discomfort due to immobilization between the main and the flap division procedures together with the long hospital stay.

Early division of pedicled flaps using a simple device: a new technique

A simple occlusion clamp with screws used to achieve early division of two-staged, distant pedicled flaps is presented. The device is applied to the bridge of a distant flap on the 5th postoperative day and is gradually tightened. It was used on 20 consecutive pedicled flaps in 20 patients: 5 abdominal flaps, 4 superficial external pudendal artery (SEPA) flaps, 9 cross leg flaps, 1 groin flap and 1 medial arm flap. In 17 patients, the flaps were divided successfully between the 9th to the 14th day (Mean: 10 days). The device was removed in 3 patients when ischaemic changes became apparent; their flaps however survived completely and were divided after a longer interval. The principles on which the device works, the technique, feasibility, and advantages of using the device for early flap division are discussed.

The injured foot: cutaneous coverage with a distally based posterior tibial cross leg flap

Treatment of extensive soft tissue defects of the foot has long been a challenging problem for the reconstructive surgeon. We report a series of 5 injured feet with major soft tissue loss and significant bony injury, treated with distally based cross leg flaps based on the posterior tibial artery, with satisfactory cosmetic and functional results. The survival of the flap was complete in 4 of the 5 patients; in one case, the flap suffered about 2–3 cm distal partial necrosis. The mean hospital stay was 30 days, and walking without ambulatory support was possible about 60 days postoperatively. We consider this procedure a potential alternative to microvascular techniques for the treatment of severe foot injuries, in an area where microsurgery reconstruction is fraught with difficulties.

Analyse de la série S.O.T.EST

126 records were studied retrospectively. The average age was 31.8 years (15-80 years) with 81% men which corresponds to other reports in the literature. Nearly half of the cases involved an accident of a two wheeled vehicle. The fractures were in the middle third in 50.1% of cases, the lower third in 33.6% and the upper third in 11.4%. 4.9% of fractures were bifocal. 46% had additional injuries (34% multiple injuries, 8% head injury). 4% were true polytrauma cases. The fracture was treated by external fixation in 103 cases and by intermedullary nailing in 23. Skin cover was by pedicle flap in 53, muscle flap 41 and fasciocutaneous flap in 12. 25 free flaps were done. Nineteen of these were muscular or musculocutaneous, 3 osteocutaneous and cutaneous alone in 3 cases. There was only one cross leg flap. Eventual skin cover occurred by secondary intention in 45 cases. Immediate bone grafting was done in 13.3% of cases between the 4th and 21st days, in 10% of cases and later in 15% of cases.Primary union occurred most often if skin cover had been achieved immediately at the same time as bony stabilisation. None of the free flaps done as an emergency failed. If skin cover was delayed superinfection was more frequent although the risk of non-union was the same whether the skin cover was done immediately or during the first 3 weeks. Intramedullary nailing did not increase the risk of infection. Bone grafts after the 21st day were frequent in this series. The number of operations and general anaesthetics increased significantly as a function of the delay in skin cover. The duration of hospitalisation was also shorter if the flap was done sooner. The average time to union was 10.2 months. It fell to 7.6 months if skin cover had been obtained immediately and to 6.5 months with intramedullary nailing as opposed to 10.3 months for external fixation which in general was associated with later skin cover. With external fixation and healing by secondary intention the delay in healing was greater than 12.9 months. These figures are statistically significant. Of the 46 patients reviewed ankle mobility was more than 50% normal in 61% of cases. Running was possible for 39% of cases. Prolonged immobilisation in an external fixator gave twice as many fair results as nailing.1- The debridement was an important step. It should be completed straight away in one stage on admission. It is started under tourniquet and completed after release of the tourniquet to assess tissue vitality. 2- The fracture is best treated by locked nailing whenever possible. Skin cover manoeuvres are facilitated. The levels of the fractures limit the indications for nailing. Another limitation is delayed admission or severe contamination of the fracture site. 3- Coverage of the fracture site is best obtained a muscle flap which fills the dead space and whose trophic qualities offer the best barrier to infection. If the conditions are favourable a pedicle flap may be used. Any doubt about the integrity of a local flap is an indication for free muscle flap. Emergency cover os the most beneficial for the patient. It allows an osteocutaneous flap if necessary and protects the patient from superinfection with resistant hospital organisms. 4- When there is loss of bone substance or a butterfly fragment of doubtful viability the addition of cancellous or cortico-cancellous grafts may be done during cover of the fracture site as long as it is not infected. 5- Managing these serious open fractures is demanding but that is the price to pay to reduce the number of operations, the length of hospitalisation and the severity of the sequellae on which the return to work depends. Particular attention should be made to conserve the mobility of the ankle which in part has a bearing on the outcome.

Fractures ouvertes de jambe — La série du C.H.U. Hautepierre

Nineteen cases were studied retrospectively between 1982 and 1993. All had been stabilised immediately by external fixators. Free or pedicle flap and early bone graft was carried out as required.Bone stability was obtained by Hoffmann or Orthofix fixators which allowed later manoeuvres for skin covers. The stabilisation by the fibula was attempted by intertibio-fibula grafting (ITF). Skin cover was obtained in 13 cases by pedicle flaps, in 4 by a free flap and 2 cases healed by secondary intention. The local flaps were 5 medial gastrocnemius or soleus flaps, 4 fasciocutaneous flaps, 3 medial gastrocnemius muscular cutaneous flaps and one cross-leg flap. These flaps were done on average at the 17th day (between 4th and 45th day). Four free flaps were done: 2 pure cutaneous flaps and 2 osteo-cutaneous flaps. A second flap was required in 3 cases because of infection or loss of soft tissue. A medial gastrocnemius flap and 2 free fibula flaps were done at the 105th and 210th day.Bony union was obtained primarily in 6 cases. Thirteen bone grafts were necessary of which 7 were done electively before three months (4 decortication grafts, 3 ITF). Additional bone graft was needed in 4 cases. Six non-unions were seen, 2 sterile which were treated by one decortication/graft and one ITF and 4 infected (21%) which were treated successfully by 2 ITF grafts and 2 free fibula flaps. Overall consolidation occurred by 9.9. months with good alignment in 15 cases. The complications were 2 varus and one 15° external rotation malunions and one shortening of 2 cm. Ankle movements were normal in 5 cases, reduced by 25% in 5 cases and by half in one case. There was one fixed equinus of 15° and one arhtrodesis. Five patients were able to run. The average number of general anaesthetics required was 5.7 and the average length of hospitalisation 120 days.In conclusion, the authors emphasise the beneficial role of early skin cover in the outcome of these fractures which is otherwise characterised by secondary contamination. They were extremely satisfied with the results of composite free grafts in cases of loss of substance of bone and soft tissue. At present, they tend towards locked nailing for these fractures preferably without reaming whenever possible. Skin cover can than be planned during the first 5 days after injury.

Tissue Expansion for Closure of the Donor Site of a Distant Pedicle Flap

RM Zuker, C Fielding, S Beatty. Tissue expansion for closure of the donor site of a distant pedicle flap. Can J Plast Surg 1994; 2(4):155-158. Tissue expansion continues to provide new and exciting applications in reconstructive surgery. Tissue expansion has allowed for an increase in size of specialized tissue, particularly about the head and neck. It has also been demonstrated that the blood supply of pedicle flaps can be augmented, thus extending the surviving length of expanded flaps. Recently tissue expansion has been used with free flap transfer to expand the amount of tissue to be transferred and to facilitate donor site closure. In certain situations free tissue transfer may not be recommended and pedicle flap and particularly cross leg and cross thigh flaps are required. In addition to the prolonged unnatural positioning of the patient, the donor defect of these flaps has been harshly criticized. In this report tissue expansion is used to provide adequate tissue for direct closure of the donor defect thus minimizing the deformity.

Principles of soft tissues repair at the foot and ankle

Soft tissue defects at the foot and ankle are a common and difficult problem because of the different features of juxtaposed tissues. One should distinguish several areas which require specific indications of coverage. These are the dorsum of the foot, the perimalleolar zone, the weight bearing area, the posterior aspect of the heel and the distal part of the achilleus tendon. The armamentarium of procedures comprises fascio-cutaneous and muscle flaps. As far as possible, we use island predicled flaps which are quicker, easier and more reliable than free revascularized flaps. Numerous loco regional island flaps are available as the dorsalis pedis, the latero supramalleolar, the medial plantar, the medialis pedis, the extensor digitorum brevis, the abductor hallucis and the peroneus brevis flaps. The coverage of the heel remains an unsolved problem. It seems preferable to employ fascio-cutaneous flaps to restore weight bearing areas. The cross leg flap is a good alternative to a loco regional flap or a free flap to repair the heel entirely. Complications and sequelae are usually due to shear stresses and require a permanent care. The restored sensibility does not seem to prevent the recurrent ulcerations which are provoked by mechanical factors.

The Cross-Leg Flap Revisited

Although free flaps are currently the gold standard for distal lower extremity reconstruction, situations occasionally arise when alternative methods are needed. We present three cases of cross-leg flaps, which have been modernized with current external fixation technology and current understanding of vascular anatomy. All cross-leg flaps were based on the axial blood supply of the posterior descending subfascial cutaneous branch of the popliteal artery. This axial flap afforded considerable length and well-vascularized tissue. All patients were placed in external fixation devices. Adjacent lower extremity joints were exercised during the period of attachment. There were no major complications or flap failures. All patients were ambulatory postoperatively. We conclude that the cross-leg flap, using external fixation techniques and axially based flaps, can be successfully and expeditiously used to cover defects of the lower extremities.

しょう部悪性腫よう広範囲切除後の再建法の検討

Reconstruction of a heel has been difficult in terms of producing favorable results due to the unique characteristics of the heel's function and structure. Because of this, to date a large number of procedures have been devised. Under the circumstances, we have succeeded in obtaining good results by means of medial plantar flaps for the reconstruction of heels in five patients after extensive resection of malignant heel tumor.We used to reconstruct the heels either with cross leg flaps or with the combination of muscle flaps and skin grafts. However, these methods would often involve disadvantages such as the development of ulcer and difficulties in accomplishing stable reconstruction of the heels. As a result, the patients would often complain of difficulties in walking after surgery.Therefore, in order to reconstruct heels, it is desirable to use flaps which have similar structure and sensation to those of the heels. Medial planter flaps satisfy such requirements.Postoperative disorders often lead to the limitation of patients' life. Needless to say, priority should be given to the radical treatment of malignant tumors, but is essential that due consideration should be given to the functional prognosis from the standpoint of “Quality of life.” Based on all this, we have reconfirmed the superiority of medial planter flaps

Cross-Leg Flap Imobilized with External Fixator Brace

Cross-Leg Flap Imobilized with External Fixator Brace

The cross-leg flap: still a useful flap in children

Reconstruction of the distal lower limb and foot is a difficult problem, especially where large areas of skin loss have occurred. The cross-leg flap is a safe and reliable alternative to free tissue transfer in paediatric lower limb trauma. By incorporating fascia or muscle the versatility of the flap can be enhanced. Our experience with the cross-leg flap in children during the last 5 years is discussed.

Use of a cross-leg free muscle flap to reconstruct an extensive burn wound involving a lower extremity

A young patient sustained a high-voltage burn with extensive destruction of the soft tissue in his left lower extremity. Occlusion of the anterior and posterior tibial arteries, loss of toe extensors and the superficial and deep peroneal nerves were noted, besides the exposure of the lower end of the tibia and metatarsal bones. In the absence of proper recipient vessels, a cross-leg free latissimus dorsi muscle flap with overlying skin and depending on the vessels of the contralateral foot was used successfully for reconstruction of the defect. The pedicle was divided 3 weeks after microvascular anastomosis and the flap survived completely. This technique permits transfer of free flaps to compromised wounds without available recipient vessels, and the latissimus dorsi muscle flap, with its characteristics of large size and copious vascularity, could be split to cover exposed bones in different areas simultaneously.

下肢外傷後の軟部組織再建法の検討

In extensive injuries of the lower limbs, skin closure is very difficult. At Fukuoka University Hospital, we examined 32 cases which had undergone reconstructive surgery involving skin and soft tissue defect of the lower extremity between June 1988 and August 1990. Patients include 24 males and 8 females whose mean age was 38.3 years. Causes: 12 cases involved in open fractures, 9 cases of softtissue injuries, 5 cases with chronic osteomyelitis, 3 in burn-ulcer victims, 2 ulcered from I. V. drip infusion, and 1 involved in a skin flap donor site. Reconstruction methods varied from fascio-cutaneous flaps in 15 cases, including cutaneous arterial flaps and septo-cutaneous. 12 cases had split thickness skin grafts. 6 cases were treated with conventional local skin flaps. 3 cases had micro-vascular free flap surgery. One case had cross leg flap. Postsurgical complications included partial skin necrosis in half of the conventional local skin flap method cases, necessitating another operation. One of the three free flap method cases slough totally due to thrombosis of the anastomosis side of the vein. Only one of the 15 fascio-cutaneous flaps suffered from partial necrosis. We concluded that the most convenient, most successful, fastest healing, and safest method is the fasciocutaneous flap method.

Distal Lower Leg Local Random Fasciocutaneous Flaps

Significant open wounds of the distal third of the lower leg that require some form of vascularized flap have historically been covered with distant cross-leg flaps or more appropriately with microsurgical tissue transfers. The rediscovery of the "random" fasciocutaneous flap as a reliable single-stage option for proximal lower leg defects has been extended distally to allow an expedient alternative in lieu of these more complicated procedures. Over the past 7 years, 17 selected patients had closure of distal leg and ankle wounds with 19 local antegrade-oriented fasciocutaneous flaps. All eventually healed without serious sequelae, although 5 (26 percent) had minor complications, except for one case that could only be salvaged with a free-tissue transfer in order to prevent limb amputation. For small- or moderate-sized, uncontaminated injuries, this approach warrants consideration under appropriate circumstances as a simpler option that may permit satisfactory healing and avoids the known risks of microsurgical tissue transfers.

Cost-effectiveness of free tissue transfer.

In a review of 61 patients with compound injuries to the upper and lower extremities. Operating Theatre costs were added to the costs of inpatient hospitalization after commencement of reconstruction with either a pedicled flap or free tissue transfer. The cost of pedicled groin flap to the upper limb and cross leg flap groups was double that of comparable free tissue transfer groups. The cost of abdominal tube pedicle to the lower limb was three times greater than for the free flap technique. The conclusion is drawn that apart from general advantages to the patient, the cost to the community is significantly reduced.

Fasciocutaneous flaps for burn reconstruction: a report of 57 flaps

We have used 57 fasciocutaneous flaps in 24 patients to correct burn contractures. There were six complications, four of which healed with dressings alone. The flaps were used either locally (22 patients) or as a cross-leg flap (2 patients). The local flaps have clearly shown that grafted areas can be raised as flaps provided that the fascia is included in the flap, and that the flap can also be based distally. Fasciocutaneous flaps have several advantages over the technique of cross-cutting the contracture, followed by split skin grafting. Firstly, there is no skin graft, which may result in further contracture. Secondly, if a patient does not have a skin graft on the secondary defect (83% in this series), the patient has the advantage of a shorter hospital stay. The techniques of the design and raising of fasciocutaneous flaps for burn reconstruction are discussed.

Perez Macias, J. M. Reconstruction of the foot and lower leg by a fasciocutaneous cross-leg flap after traumatic amputation and circumferential soft tissue loss

Perez Macias, J. M. Reconstruction of the foot and lower leg by a fasciocutaneous cross-leg flap after traumatic amputation and circumferential soft tissue loss

Free vascularized flaps for lower extremity reconstruction.

Large wounds of the lower extremity, particularly distal to the knee, have been difficult to cover by traditional means such as skin grafts, local flaps, cross-leg flaps and jump flaps. These wounds, particularly when associated with fractures and osteomyelitis, have frequently resulted in amputation of the lower extremity. Microvascular surgical techniques have allowed the transfer of large flaps of skin and/or muscle from a remote site of the body to the defect in the leg for soft tissue coverage and additional blood supply to the defect. Although these techniques are more tedious and require longer operating times, they usually shorten the patient's hospital stay, heal the wounds faster and shorten disability time. With wider experience, improved techniques and greater microsurgical skill, lower limbs with large defects due to trauma or tumor resection can be salvaged and reconstructed with acceptable risks and minimal donor site morbidity.

Soft tissue coverage of bone ?a historical perspective and review

Coverage of bony nonunions and osteomyelitis with either cross-leg flaps or muscle flaps dates back to before the turn of the century. Although today many surgeons prefer muscle flaps there are reports of successful treatment with cutaneous cross-leg flaps. Because of its rich blood supply muscle may have a greater ability to tolerate infection and promote revascularization of bone. A history of these techniques and reports of clinical results are presented.

Reconstruction of the foot and lower leg by a fasciocutaneous cross-leg flap after traumatic amputation and circumferential soft-tissue loss

The use of a fasciocutaneous cross-leg flap in two cases to cover severe soft-tissue injuries with circumferential degloving of the lower leg and foot is presented. This was preceded by local treatment with topical agents and debridement, followed by application of a mesh skin graft. The functional and aesthetic defect of the donor site is minimal.