In this article, we present our experience in the treatment of traumatic lower extremity wounds by using crossleg flaps. Transplantation treatment of extensive softtissue defects. Because the crossleg flap, which is located in a lower rung of the reconstructive ladder fig. We describe our experience with crossleg flap in 18 patients for the reconstruction of difficult leg defects in which no suitable recipient vessels were available for microvascular. Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. Even in tertiary care centers cross leg flaps is a viable procedure in failed free flap surgeries. When a free flap is contraindicated or after a free flap failure, the crossleg flap is still nowadays a possible option. Original article distal perforator based cross leg flaps.
Reconstruction of large defects can only be achieved with microsurgical procedures. Cross leg free muscle flaps of large volume such as the. Crossleg flaps for lower limb wound coverage have been replaced by free tissue transfer in the last two decades. Crossleg flap is still a useful tool for leg wound coverage even in microsurgical unit in situations precluding free flap coverage. Evolution of local perforator flaps in lower extremity. The versatility of perforatorbased propeller flap for. Noordhoff ms, tang y 1997 crossleg free flaps for difficult cases of legs defects. We report the case of a patient with full thickness burns on both legs, leading to the exposure of joints of the right ankle and the right foot and left patellar. Twelve cases of such ulcers were covered with medial plantar vascular pedicled flaps and the results had been excellent. All three defects were covered with a medially based narrow pedicled triangular cross leg flap based on 23 adjacent posterior tibial perforators about 12 cm from the medial border of the tibia in its middle. However, there are certain difficult situations where the free flap cannot be employed and alternative methods. Crossleg free flap for limb salvage in the setting of. Cinpolat, md2 gamze bektas, md2 arzu akcal, md1 harun simsek, md1 polat bicici, md1 seckin ayd.
Microsurgery information for surgeons, health care professionals and patients, with detailed procedure descritpions. Background crossleg free flaps have been described for reconstruction of leg defects in cases of trauma with no suitable recipient vessels in the vicinity of the defect. We present the first documented case of a crossleg free flap for limb salvage in a radiated bed after infection and. Compared with a crossleg or crossbridge free flap, a distally based posterior tibial artery crossbridge flap is reliable and versatile, leading to shorter operation duration and a lower risk of. A crossleg free rectus abdominis flap, anastomosing to utilized carrier vessels of the contralateral noninjured leg, was used for reconstruction in six cases of. The operative technique used was the standard approach so elegantly.
In crosssection, the interosseous membrane is seen in green, spanning from the tibia to the fibula. The design and harvest of combined flap consisted of anterolateral thigh perforator flap and thoracic umbilical flap a. Crossleg flaps are a good choice for reconstructing traumatized lower extremities, especially when free flaps cannot be used. The crossleg flap became widely popular during world war ii as a limb salvage technique to treat injuries sustained in battle. The technique of transfer and the length of time required before pedicle division depend on the nature of the flap and the contact surface. Crossleg free flaps for difficult cases of leg defects. Reconstruction of the lower extremity with cross leg free flaps ozlenen ozkan, md1 an. Distal perforator based cross leg flaps for leg and foot defects. Versatility of a cross leg free rectus abdominis flap for leg reconstruction under difficult and unfavorable conditions.
In wellselected cases, flaps can play a pivotal role in optimizing outcomes in the acute phase of burns. Cross leg flaps for lower limb wound coverage have been replaced by free tissue transfer in the last two decades. We report a case of a male with a severe posttraumatic wound of the lower leg with. It is suggested as an alternative method to a difficult cross. When a free flap is contraindicated or after a free flap failure, the crossleg flap is still nowadays a possible. Four days following free flap reconstruction of his right leg, the patient was discharged to the plastic surgery ward where he continued to improve with no complications regarding his free flap reconstruction and 95% take of the skin graft covering the flap. Extension from the skin to the subcutaneous tissues occurs at times, and, although the infection usually is confined to the lower extremities, it may involve the hands and arms. The crossleg free flap procedure was first described by taylor et al.
However, with the advent of microvascular surgery and the introduction of the free flap in 1970, use of the crossleg flap and other distant flaps declined. Reconstruction of the lower extremity with crossleg free. The use of external fixator for immobilization circumvents many of these problems and facilitates the use of cross leg flaps in patients in whom free tissue transfer may not be optimal. The cross leg fasciocutaneous flaps are less frequently indicated for distal leg and foot. An alternative method to free flap for distal leg and foot. Standard cross leg flap, still a work horse for compound. In order to reconstruct very extensive defects, the free cross leg flap and the free cable bridge flap have been described.
Repair of bilateral lower limb injuries using a free latissimus dorsi crossleg flap. The details of each case are summarized in table 1. With the introduction of perforator flap, management of small and mediumsize defects of distal leg and ankle region is convenient. We report a case of a male with a severe posttraumatic wound of the lower leg with exposed tibia fracture firstly treated with two consecutive latissimus dorsi muscular free flaps, failed for vascular thrombosis. Surgical technique the posterior tibial vessels of the contralateral leg were prepared as recipient vessels for all patients. Retrograde cross leg perforator flaps are reliable option in cases of failed free flaps, unavailable ipsilateral proximal tissue, damaged distal perforators and distal most defects of foot. However, the crossleg flap remains an effective alternative in situations that require an alternative to free tissue transfer. Crossleg as salvage procedure after free flaps transfer failure. The cross leg flap is a safer, less complicated technique that allows for better matching of skin color, texture, and thickness, reduced operative time, and less donor site morbidity than distal free flaps. The technique of muscle transposition in the operative treatment of traumatic and ulcerative lesions of the leg. Hence, medially based standard cross leg flap was planned for covering the exposed tibia. An alternative method to free flap for distal leg and foot defects due to electrical burn injury. Table 1 demographics of three distinct cases describing the modified cross leg flap for large triangular defects of the foot and ankle.
The traditional crossleg reconstruction used a random patterned flap with a wide base, making the flap. In this technique, the vascular pedicle of the free flap is temporarily anastomosed to the recipient vessels of the contralateral leg and then detached after obtaining sufficient revascularization of the flap. Use of the medial plantar flap in soft tissue replacement. Because the crossleg flap, which is located in a lower rung of the reconstructive ladder, is less technically demanding, demonstrates greater safety, and could provide different types of tissue for repairing complex defects, we prefer to use the crossleg flap first instead of a free flap for reconstruction of traumatic lower extremities when local flaps are not available. Pedicled crossleg flaps pedicled crossleg flaps halls, michael j. Surgeons have long sought an alternative to the crossleg flap. The crossleg flap technique is a wellestablished method to cover soft. Pdf repair of a wide lower extremity defect with cross. A new and safer anastomosis technique in crossleg free flap procedure using the dorsalis pedis arterial system. Large ulcers around the heel region are common but difficult problems because the usual methods of resurfacing are unsatisfactory. Revisiting the fasciocutaneous perforator crossleg flap ncbi. Posttraumatic wounds of the lower leg with soft tissue defects and exposed fractures are a reconstructive challenge due to the scarce availability of local tissues and recipient vessels. The gracilis muscle is located in the inner aspect of the thigh. Pedicled crossextremity flaps for lower limb wound coverage have been replaced by free tissue transfer in the last two decades.
Composite tissue loss in extremities involving neurovascular structures has been a major challenge for reconstructive surgeons. This is quite relevant because the highest percentage of failure of free flaps is encountered in cases of resurfacing the traumatic defects of the distal leg and foot. Buchan ac 1978 the place of the crossleg flap in reconstructive surgery of the lower leg and foot. Eight cross leg free flap reconstructions were performed. We describe our experience with crossleg flap in 5 patients for the reconstruction of difficult leg defects in which no possible other. Standard cross leg flap, still a work horse for compound fracture leg bones with extensive soft tissue damage. However, this may lead to considerable donor site morbidity, is time consuming, and needs facility of microsurgery.
The primary goal in limb salvage is definite wound closure by using appropriate flaps. A small portion of this a small portion of this muscle with its blood supply artery and vein and nerve can be transplanted in the face to replace the facial muscles. The cross leg free flap procedure was first described by taylor et al. In order to reconstruct very extensive defects, the free crossleg flap and the free cable bridge flap have been described. Free flap reconstruction following lower leg trauma in the.
When harvesting the osteocutaneous flap, the septum is harvested in continuity with the paddle of skin and fascia of the lateral leg. Use of a crossleg free muscle flap to reconstruct an extensive burn wound involving a lower extremity. The purpose of this report is to introduce the cross. Pedicled crossleg flaps, journal of the american college. A previous redundant flap could be reused or recycled as a donor site from which a new flap could be raised. The pitfalls, however, have not been well documented in the literature. Crossleg as salvage procedure after free flaps transfer. The records of all patients who had cross leg flap for trauma in the last 2. A new and safer anastomosis technique in crossleg free. The traditional cross leg reconstruction used a random patterned flap with a wide base, making the flap vulnerable to ischemia and venous insufficiency. Moreover, a cross leg flap does not require microsurgical capabilities and can be performed with basic equipment.
Crossleg repair of large softtissue defects in distal. The lateral intermuscular septum separates the lateral compartment muscles from the soleus. Pdf repair of bilateral lower limb injuries using a free. Twentyseven crossleg free flap transfers were performed. Reconstruction of the lower extremity with crossleg free flaps. However, there are certain difficult situations where the free flap cannot be employed and alternative methods are needed. When there is no suitable vessel in the injured leg for microsurgical transfer, crossleg free flaps can be considered for lower extremity reconstruction. Crossleg free muscle flaps of large volume such as the. Crossleg free flaps have been used to reconstruct defects that would otherwise lead to amputation in patients with no ipsilateral recipient vessels. Stark1950 standardized the procedure and summarized its usefulness for lower extremities trauma.
Limb salvage in an irradiated patient with limited recipient vessels leaves few options for reconstruction. Preserving the blood flow of the recipient artery in cross. A cross leg flap was performed stabilizing both lower limbs with an external fixator. Even when a free tissue transfer can be performed the risk of failure remains considerable. Repair of a wide lower extremity defect with crossleg. When compared with the conventional cross leg flaps the discomfort, cross legging, joint stiffness and sore development are minimal. A new and safer anastomosis technique in crossleg free flap procedure using the dorsalis pedis arterial system topalan, murat m. Good local tissue coverage was not available and free tissue transfer. Both patients showed a satisfactory recovery returning to walk without additional help.