Cross-leg flaps: Case series, review, and proposed classification.

Background: Cross-leg (CL) flap procedures have a long history in reconstructive surgery, having been described for the first time in 1854. The application of these flaps can potentially solve many reconstructive issues with satisfactory outcomes. Patients and methods: During our research into the history and development of CL flaps, we identified a variety of flaps for which a classification system can be proposed based on blood supply and flap modifications. In this study, 10 patients with different complaints were managed using posterior tibial artery (PTA) perforator CL flap and superiorly based sural CL flap with satisfactory outcomes. Results: All flaps survived and healed smoothly; consequently, the flaps provided stable coverage, and the donor sites were reconstructed using skin grafts, which provided satisfactory results to the patients and/or their guardians. Conclusion: To our knowledge, this is the first study to propose a simple classification and group different types of flaps mentioned in the literature under one category. CL flaps are a common reconstructive option for patients with injuries that limit their mobility.

Successful treatment of Gustilo type 3C open tibial fracture with a massive muscles and soft tissues wasting: A case report.

Introduction and importance: Gustilo-Anderson type 3 open tibial fractures are commonly accompanied by extensive damage and serious complications, especially in types 3B and 3C. Case presentation: A 25-year-old male was transferred after motor vehicle accident and the emergent choice was an above-knee amputation in other two hospital. A left open distal tibial fracture (Gustilo type 3C) with a wide and contaminated soft tissues defect, that extended from the knee to the midfoot, is accompanied by wasting of the anterior compartment muscles and ruptured of the anterior tibial artery. We did irrigation and debridement and then we placed an anteriomedial external fixation system type AO with pins. A cross-leg flap and free skin grafts from the opposite limb was performed three weeks after a daily irrigation and debridement, povidon and ozone cream bandages, and antibiotics. After twelve months of follow-up, the fracture was healed and the external fixator was removed. Discussion/conclusion: Gustilo-Anderson type 3 open fractures remain a veritable orthopedic challenge, even for surgeons with greater experience, because of neurovascular damages, high amputation rate, and vast soft tissue injuries. The collaboration of the multidisciplinary surgical team led to preserve the limb with good result after one year. It is reasonable to judge and attempt a limb preservation even with wide open tibial fractures.

Parallel Cross-Leg Free Flap with Posterior Tibial Artery Perforator Pedicle Propeller Cable Bridge Flap for the Treatment of Lower Extremity Wounds: A Case Series Report.

BACKGROUND: A cross-leg flap can be used to treat severely injured lower limbs but associated with complications. Herein, we describe a technique of a parallel cross-leg free flap combined with posterior tibial artery perforator pedicle propeller cable bridge flap for the treatment of lower extremity wounds. METHODS: The artery and veins of the free flap are anastomosed to the contralateral posterior tibial artery and vein, respectively. The vascular pedicle is wrapped with a posterior tibial artery perforator pedicle propeller flap. The legs are allowed to remain in a straight, relaxed position which is maintained with a bandage or Kirschner wire placed at the distal limbs. Pedicle division is performed around 21 days after flap creation, and the posterior artery is re-anastomosed and pedicled flap returned to its original position. RESULTS: From June 2017 to March 2020, 7 patients with lower extremity wounds and tissue loss received reconstruction with this method. The recipient vessels for all flaps were the posterior tibial artery and vein. The average operation time was 5 hours. The average time to ambulation was 4 weeks, and the average follow-up time was 13.7 months. All flaps survived, and limb salvage was successful in all patients. Patients were not uncomfortable with the limbs held in position until pedicle division, and there were no complications. At the final follow-up, the function of all limbs was normal, and the esthetic appearance was acceptable to all patients. CONCLUSIONS: The method described overcomes the disadvantages of traditional cross-leg flaps for the treatment.

A historical analysis of surgery performed between 1941 and 1942 at the Bangour Maxillofacial and Plastic Surgery Unit, Scotland.

In 1939, Bangour Emergency Medical Services Hospital was built as an annexe to Edinburgh War Hospital. The Maxillofacial and Plastic Surgery Unit opened in 1941, one of the several set-ups built with the support of Sir Harold Gillies, to ensure a service with specialist skills throughout Great Britain. The unit was led by Alexander Burns Wallace, who had to rapidly adapt the service to reflect the patterns of injury reflected by the more modern warfare practiced in the Second World War, while also incorporating techniques that were, at the time, revolutionary. Although much has been written about other units, Bangour's activity revealed through its case histories' highlights that plastic surgery was developing in parallel throughout Britain. The influence of Sir Harold Gillies was clear, and his input to support the fledgling service serves as an important aspect of the newly developing specialty of plastic surgery: collaboration and sharing of knowledge. This paper analyses the work of the Maxillofacial and Plastic Surgery Unit at Bangour General Hospital in Scotland between 1941 and 1942 and demonstrates its historical significance, as well as its relevance to current practice. Ninety-two case notes from the unit recently became accessible. These were analysed and four were selected for review in this study. These cases were selected as they were well-documented with photographs and good examples of the work performed at the unit in order to highlight the innovative, creative and complicated work carried out at the Unit.

Review of Cross-Leg Flaps in Reconstruction of Posttraumatic Lower Extremity Wounds in a Microsurgical Unit.

Since the advent of microsurgery, and expanding expertise in the field, extensive traumatic wounds of leg have been managed successfully with free tissue transfer. Various patient-related factors may preclude the use of free flaps even in units with available expertise and infrastructure. It is in such situations that the "cross-leg flap" comes into play. In these cases, instead of attempting complicated anastomotic techniques or anastomosis in the zone of trauma, it is better to perform the simpler and more reliable cross-leg flap. In this study, we try to show the utility of a cross-leg flap based on a retrospective study of 198 patients who underwent cross-leg flap in our institute over a period of 15 years extending from November 2003 to March 2018. MATERIALS AND METHODS: Case sheets of all patients who underwent cross-leg flap from November 2003 to March 2018 were reviewed. The location of defect in the leg, the indication for cross-leg flap, the pattern of cross-leg flap, and perioperative complications were noted. RESULTS: A total of 198 patients underwent cross-leg flap for traumatic soft tissue injury of leg during this period. The most common reason for performing cross-leg flap was poor pulsatility of the recipient artery as seen intraoperatively, followed by the economics of the procedure wherein the initial cost of free flap was found significantly higher compared with cross-leg flap. All flaps survived with partial necrosis occurring in 23 patients. All flaps settled well by 2 years' time. Bony union/fracture healing evaluation was not a part of this study. CONCLUSION: Cross-leg flap is still a useful tool for leg wound coverage even in microsurgical unit in situations precluding free flap coverage.

Transplantation Treatment of Extensive Soft-Tissue Defects in Lower Extremities with a Combination of Cross-Bridge Flap and Combined Free-Tissue Flap Covered by Vacuum Sealing Drainage: One Case Report.

This article reported the ultilization of cross-bridge flap transplantation and combined free-tissue flap transplantation to treat a 54-year-old male with Gustilo type III-C injuries. Thorough debridement, external fixation and vacuum sealing drainage were performed in the fist-stage treatment. After the removal of negative pressure on VSD devices, the joined free-tissue flaps and the cross-bridge flap were performed to repair the extensive soft-tissue defects. One month later the pedicle of cross-bridge flap was divided and the external fixator connecting both the lower legs was removed. In 3-month follow-up, the extensive defects was completely covered by a nearly normal skin and radiograph showed tibia and talus healing.

[Clinical application of changeable cross-leg style sural neurovascular flap in repairing contralateral fairly large soft tissue defect on dorsum of forefoot].

Objective: To explore the effectiveness of changeable cross-leg style sural neurovascular flap in repairing contralateral fairly large soft tissue defects on dorsum of forefoot. Methods: Between June 2006 and June 2015, 12 patients with fairly large soft tissue defect on dorsum of forefoot were treated. There were 8 males and 4 females, with an average age of 35.6 years (range, 18-57 years). Defects were caused by traffic accident injury in 4 cases, machine crush injury in 3 cases, and heavy object crush injury in 3 cases, with a median disease duration of 11 days (range, 5 hours to 28 days) in the 10 cases; the defect cause was atrophic scar in 2 cases, with disease duration of 2 years and 3 years respectively. The wound size of soft tissue ranged from 6.2 cm×4.1 cm to 11.5 cm×7.4 cm; combined injuries included tendon exposure in all cases and bone exposure in 6 cases. The changeable cross-leg style sural neurovascular flaps were used to repair defects. The width and length of flap pedicle were increased. The cross-leg position was maintained with the elastic net bandage. The size of flaps was 16 cm×7 cm to 21 cm×11 cm, with a pedicle of 8-16 cm in length and 5-6 cm in width. Results: After operation, 10 flaps survived, and wound healed by first intention. Extravasated blood occurred at the flap edge in 2 cases and was cured after symptomatic treatment. No pressure sore occurred. All patients were followed up 3-24 months (mean, 7 months). The appearance and function of the affected legs were good, and the flaps had soft texture and normal color. Conclusion: Changeable cross-leg style sural neurovascular flap can achieve good effectiveness in repairing fairly large soft tissue defect on dorsum of forefoot. Some drawbacks of single cross-leg style can be avoided.

Design and application of slide support nursing bed / 医疗卫生装备

Objective To design a slide support nursing bed for the patient after cross leg flap transplant operation.Methods The bed was designed based on the principle of four-link-type mechanism slide,which was composed of a bed body,slide support,sliding rails,locking bolt,connector bar for sliding rails,extension arm,leg support and etc.Accurate localization of leg support was executed by zero setting,readjustment and etc.Results The bed could be adjusted up and down,back and forth or at different angles so as the compression on the cross leg flap was avoided to enhance the comfort of the patient after cross leg flap transplant operation.Conclusion The bed gains advantages in convenience,safety,effect and etc,and is worthy promoting clinically for the patient after cross leg flap transplant operation.

Repair of pretibial atonic wound with long cross-leg flap.

Soft-tissue defects of the pretibial region constitute a major reconstructive challenge because of the insufficiency of the local tissues. In such cases, a long cross-leg flap may be an alternative option. This study presents a case with an atonic wound in the pretibial region caused by a previous traffic accident, which had received cross-leg flap repair following the excision.

Cross-leg flap: Its role in limb salvage.

BACKGROUND: Pedicled cross-extremity flaps for lower limb wound coverage have been replaced by free tissue transfer in the last two decades. However, there are certain difficult situations where the free flap cannot be employed and alternative methods are needed. We describe our experience with cross-leg flap in 18 patients for the reconstruction of difficult leg defects in which no suitable recipient vessels were available for microvascular anastomosis in the vicinity of the defect. MATERIALS AND METHODS: 18 patients (17 men and 1 woman) with mean range 31.5 yrs(range 18-70 yrs) grade III B tibial fractures were included in the study. fasciocuteneous cross leg flap was employed and extremities were immobilized by external Fixator. RESULTS: Fifteen flaps were completely available with two had marginal necrosis and one supsficial epidermal necrosis. No complications were related to the donor site, flap, or by immobilization are noted. Each patient resumed essentially normal gait and activity without any stiffness of joints related with the flap or external fixator. CONCLUSION: The addition of external fixator stabilization aids greatly in wound care, as well as for general ease of the patient mobility and positioning. Cross-leg flap offers the possibility of salvaging limbs that are otherwise nonreconstructable.

Cross-Leg Achilles Tendon Reconstruction Using a Composite Flap of Dorsalis Pedis and Tendon Strips of the Extensor Digitorum Longus in a Vascular Compromised Wound

Reconstructions of soft tissue defect of the posterior ankle including Achilles the tendon should take into account not only coverage but functional outcome. Various methods of tendon transfer and tendon graft have been reported as a single-stage procedure. With advances and refinements in microsurgical techniques, several free composite flaps including tendon, fascia, or nerve have been used in single-stage reconstructions of large defects in this area minimizing further damage to the traumatized leg. However, when free flap is not feasible for some reasons, this cannot be accomplished successfully. Here we present a patient with Achilles tendon and circumferential large soft tissue defect. Because of circulatory compromise of the lower extremity, free flap reconstruction could not be applied. Instead, cross-leg composite flap of the dorsalis pedis flap including the extensor hallucis brevis musle and tendon, and tendon strips of the Second, third and fourth extensor digitorum logus were employed, Functional reconstruction of the tendon and resurfacing were obtained at the same time. The flap was detached 3 weeks postoperatively, and the transplanted flap has survived without any complications. By 3 months after surgery, full weight bearing, tip-toe standing and even walking without crutch assistance was possible. When functional reconstruction with the free flap is unattainable in the large defect of the posterior ankle including the Achilles tendon, cross-leg composite island flap of dorsalis pedis flap and tendon strips of the extensor digitorum longus tendon is a viable alternative.