Cross-Leg Flaps for Lower Extremity Salvage: A Scoping Review

Abstract

Background Lower extremity trauma with soft tissue loss presents a challenge to the reconstructive surgeon. Cross-leg flaps, first described by Hamilton in 1854, are still used to salvage traumatized lower extremities in patients not suitable for free tissue transfer, or those who are receiving care in locations with limited resources. Methods A scoping review methodology was used to examine the evidence supporting the use of cross-leg flaps in modern healthcare. Results There have been 409 cases of cross-leg flaps reported in the modern literature, with the majority of flap cases occurring outside the United States in Turkey, India, and Japan. The most common indication was trauma, mentioned in 93.2% of patients (n = 353 of 379), and anatomic limitation, including inadequate vasculature, was the main reason for not performing free tissue transfer (52.8% of patients; n = 170 of 322). The majority are cross-leg fasciocutaneous flaps (85.8%, n = 273 of 318), based off the posterior tibial artery (27.5%, n = 50 of 182) and peroneal artery (26.9%, n = 49 of 182) and, covering defects of the distal third of the leg (55.5%, n = 151 of 272), or the foot (27.9%, n = 76 of 272). The pedicles are typically divided at 3 weeks (mean 20.9 days) after external fixation is used as the immobilization method (57.7%, n = 184 of 319). Flap survival was 100% across all publications except one (n = 349 of 350 patients), making cross-leg flaps a robust and reliable reconstructive option. Conclusion In resource-limited environments or in patients who are unsuitable for microvascular free tissue transfer, the cross-leg flap remains an impactful and reliable option for limb salvage.

Repair of severe peri-knee soft tissue defect using an anterolateral thigh flap with the descending genicular vessels as the recipient pedicle: a case series of 14 patients

“…To save the knee joint function after this kind of injury to the greatest extent, in addition to good fracture management, timely and appropriate flap repair is the best choice (2). Three main types of flaps are currently available: free flaps, partial flaps, and cross-leg flaps, each having its advantages and disadvantages (3)(4)(5)(6). Among them, the anterolateral thigh flap is recognized as a "universal flap" and is widely used to repair various soft tissue defects and wounds, and good clinical results have been achieved (4).…”

Importance of Vascularity and Selecting the Recipient Vessels of Lower Extremity Reconstruction

“…Nevertheless, cross-leg approach using the contralateral leg as recipient still remains as an ultimate plan B. 49,50…”

Modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure for complex lower extremity reconstruction

“…Cross-leg pedicled flaps are reliable choices to salvage traumatized lower limb with both complex soft tissue and vessels damages. Since Hamilton first introduced it in 1854, cross-leg pedicled flap method has been widely used in complex lower extremity reconstruction, and various cross-leg pedicled flap procedures have been reported for various degrees of lower limb injury [ 1 , 2 ]. The common feature of these procedures is that the pedicled flap is designed based on the major arteries in intact lower limb, mainly including the posterior tibial artery and the peroneal artery [ 3 – 9 ].…”

“…The common feature of these procedures is that the pedicled flap is designed based on the major arteries in intact lower limb, mainly including the posterior tibial artery and the peroneal artery [ 3 – 9 ]. Although cross-leg pedicled flaps have a favorable survival rate of nearly 100%, its disadvantages are also apparent; for example, limited coverage of the tissue defects, the sacrifice of tissues or vessels in healthy side, and aesthetic impairment of the healthy leg [ 2 ].…”