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J Reconstr Microsurg 2018; 34(07): 522-529
DOI: 10.1055/s-0038-1641712
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Lower Extremity Limb Salvage with Cross Leg Pedicle Flap, Cross Leg Free Flap, and Cross Leg Vascular Cable Bridge Flap

Oscar J. Manrique
1   Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
,
Sarah N. Bishop
1   Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
,
Pedro Ciudad
2   Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan, ROC
3   Department of Biological Science and Technology, China Medical University, Taichung, Taiwan, ROC
,
Kian Adabi
1   Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
,
Jorys Martinez-Jorge
1   Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
,
Steven L. Moran
1   Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
,
Tony Huang
1   Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
,
Aparna Vijayasekaran
1   Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
,
Shih-heng Chen
4   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
,
Hung-chi Chen
2   Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan, ROC
› Author Affiliations Funding None.
Further Information

Publication History

08 December 2017

22 February 2018

Publication Date:
16 May 2018 (online)

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Abstract

Background Lower extremity salvage following significant soft tissue loss can be complicated by lack of recipient vessel for free tissue transfer. We describe our experience in lower limb salvage for patients with no recipient vessels with the use of pedicle, free and cable bridge flaps.

Methods A retrospective review from 1985 to 2017 of patients undergoing lower limb salvage using a contralateral pedicle cross leg (PCL) flaps, free cross leg (FCL) flaps, or free cable bridge (FCB) flaps was conducted. Demographics, etiology of the reconstruction, type of flap used, donor-site vessels, defect size, operating time, time of pedicle division, length of hospital stay, time to ambulation, and complications were analyzed.

Results A total of 53 patients (48 males and 5 females) with an average age of 35 years (range, 29–38 years) were identified. The etiology for the reconstruction was trauma in 52 patients and oncological resection in 1 patient. There were 18 PCL, 25 FCL, and 10 FCB completed. The recipient vessels for all flaps were the posterior tibial artery and vein. The average operating room times for PCL, FCL, and FCB flaps were 4, 9, and 10 hours, respectively. The average length of hospital stay was 5 weeks and average time to ambulation was 4 weeks. The average follow-up time was 7.5 years (range, 3–12 years). Complications encountered were hematoma (six), prolonged pain (six), total flap loss (two), reoperation (five), and infection (four). Limb salvage rates were 96.2%.

Conclusion When ipsilateral limb vessels are not available, and other reconstructive options have been exhausted, cross leg flaps can be a viable option for limb salvage in the setting of extensive defects.

Keywords

lower limb salvage - cross leg flap - cross leg free flap - cable bridge flap

Note

This study was presented at the World Society of Reconstructive Microsurgery, Seoul, Korea, 2017.


 

  • References

  • 1 Bradley L, Kirker SG. Secondary prevention of arteriosclerosis in lower limb vascular amputees: a missed opportunity. Eur J Vasc Endovasc Surg 2006; 32 (05) 491-493
    CrossrefPubMedGoogle Scholar
  • 2 Nance ML. National Trauma Data Bank 2015 Annual Report. American College of Surgeons; 2015:66
    PubMedGoogle Scholar
  • 3 Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 2008; 89 (03) 422-429
    CrossrefPubMedGoogle Scholar
  • 4 Howe Jr HR, Poole Jr GV, Hansen KJ. , et al. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. Am Surg 1987; 53 (04) 205-208
    PubMedGoogle Scholar
  • 5 Johansen K, Daines M, Howey T, Helfet D, Hansen Jr ST. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990; 30 (05) 568-572 , discussion 572–573
    PubMedGoogle Scholar
  • 6 McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: a retrospective evaluation of the Mangled Extremity Severity Score (MESS). J Orthop Trauma 1994; 8 (02) 81-87
    CrossrefPubMedGoogle Scholar
  • 7 Russell WL, Sailors DM, Whittle TB, Fisher Jr DF, Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg 1991; 213 (05) 473-480 , discussion 480–481
    CrossrefPubMedGoogle Scholar
  • 8 Bosse MJ, MacKenzie EJ, Kellam JF. , et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002; 347 (24) 1924-1931
    CrossrefPubMedGoogle Scholar
  • 9 MacKenzie EJ, Bosse MJ, Pollak AN. , et al. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am 2005; 87 (08) 1801-1809
    PubMedGoogle Scholar
  • 10 Bhuvaneswar CG, Epstein LA, Stern TA. Reactions to amputation: recognition and treatment. Prim Care Companion J Clin Psychiatry 2007; 9 (04) 303-308
    CrossrefPubMedGoogle Scholar
  • 11 Chien SH, Huang CC, Hsu H, Chiu CH, Lin CM, Tsai JP. Free tissue transfers for limb salvage in patients with end-stage renal disease on dialysis. Plast Reconstr Surg 2011; 127 (03) 1222-1228
    CrossrefPubMedGoogle Scholar
  • 12 MacKenzie EJ, Jones AS, Bosse MJ. , et al. Health-care costs associated with amputation or reconstruction of a limb-threatening injury. J Bone Joint Surg Am 2007; 89 (08) 1685-1692
    CrossrefPubMedGoogle Scholar
  • 13 Caudle RJ, Stern PJ. Severe open fractures of the tibia. J Bone Joint Surg Am 1987; 69 (06) 801-807
    CrossrefPubMedGoogle Scholar
  • 14 Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg 1992; 89 (03) 478-487 , discussion 488–489
    CrossrefPubMedGoogle Scholar
  • 15 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
    CrossrefPubMedGoogle Scholar
  • 16 Stark RB. The cross-leg flap procedure. Plast Reconstr Surg (1946) 1952; 9 (03) 173-204
    CrossrefPubMedGoogle Scholar
  • 17 Stark RB. Pre-operatively applied, mated, plaster of paris casts as an aid in the migration of open-pedicle cross leg flaps. Plast Reconstr Surg (1946) 1947; 2 (05) 433-438
    CrossrefPubMedGoogle Scholar
  • 18 Soutar DS, Scheker LR, Tanner NS, McGregor IA. The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 1983; 36 (01) 1-8
    CrossrefPubMedGoogle Scholar
  • 19 Ducic I, Rao SS, Attinger CE. Outcomes of microvascular reconstruction of single-vessel lower extremities: limb salvage versus amputation. J Reconstr Microsurg 2009; 25 (08) 475-478
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Morris AM, Buchan AC. The place of the cross-leg flap in reconstructive surgery of the lower leg and foot: a review of 165 cases. Br J Plast Surg 1978; 31 (02) 138-142
    CrossrefPubMedGoogle Scholar
  • 21 Jayes PH. Cross-leg flaps; a review of 60 cases. Br J Plast Surg 1950; 3 (01) 1-5
    CrossrefPubMedGoogle Scholar
  • 22 Gencel E, Eser C, Kesiktas E, Tabakan I, Yavuz M. A cross flow-through pedicle free latissimus dorsi flap for high voltage electrical burns. Burns 2016; 42 (04) e55-e60
    CrossrefPubMedGoogle Scholar
  • 23 Zhang GL, Chen KM, Zhang JH, Wang SY. Repair of a large soft tissue defect in the leg with cross-leg bridge free transfer of a latissimus dorsi myocutaneous flap: a case report. Chin J Traumatol 2012; 15 (06) 373-375
    PubMedGoogle Scholar
  • 24 Yu L, Tan J, Cai L. , et al. Repair of severe composite tissue defects in the lower leg using two different cross-leg free composite tissue flaps. Ann Plast Surg 2012; 68 (01) 83-87
    CrossrefPubMedGoogle Scholar
  • 25 Turgut G, Kayalı MU, Köse O, Baş L. Repair of a wide lower extremity defect with cross-leg free transfer of latissimus dorsi and serratus anterior combined flap: a case report. Strateg Trauma Limb Reconstr 2010; 5 (03) 155-158
    CrossrefPubMedGoogle Scholar
  • 26 Shiwei B, Mingyong Y, Senkai L. Cross-leg pedicled free scapular flap for the repair of extensive soft tissue defect with tibial bone exposure. Wounds 2007; 19 (02) 46-50
    PubMedGoogle Scholar
  • 27 Kesiktas E, Yavuz M, Gencel E, Dalay C, Acartürk S. Use of cross-leg latissimus dorsi free flap for repair of extensive lower leg electrical injury in a child. Burns 2006; 32 (04) 507-510
    CrossrefPubMedGoogle Scholar
  • 28 Yamada A, Harii K, Ueda K, Asato H, Tanaka H. Versatility of a cross-leg free rectus abdominis flap for leg reconstruction under difficult and unfavorable conditions. Plast Reconstr Surg 1995; 95 (07) 1253-1257
    CrossrefPubMedGoogle Scholar
  • 29 Hodgkinson PD, Andhoga M, Wilson GR, McLean NR. Cross-leg free muscle flaps for reconstruction of open fractures of the tibia. Injury 1994; 25 (10) 637-640
    CrossrefPubMedGoogle Scholar
  • 30 Lai CS, Lin SD, Chou CK, Cheng YM. Use of a cross-leg free muscle flap to reconstruct an extensive burn wound involving a lower extremity. Burns 1991; 17 (06) 510-513
    CrossrefPubMedGoogle Scholar
  • 31 Townsend PL. Indications and long-term assessment of 10 cases of cross-leg free DCIA flaps. Ann Plast Surg 1987; 19 (03) 225-233
    CrossrefPubMedGoogle Scholar
  • 32 Yu ZJ, Tang CH, He HG. Cross-bridge transplantation of free latissimus dorsi skin flap in one case. Chin Med J (Engl) 1983; 96 (10) 772-776
    PubMedGoogle Scholar
  • 33 Ambroggio G, Oberto E, Teich-Alasia S. Twenty years' experience using the cross-leg flap technique. Ann Plast Surg 1982; 9 (02) 152-163
    CrossrefPubMedGoogle Scholar
  • 34 Yu ZJ, Zeng BF, Huang YC. , et al. Application of the cross-bridge microvascular anastomosis when no recipient vessels are available for anastomosis: 85 cases. Plast Reconstr Surg 2004; 114 (05) 1099-1107
    PubMedGoogle Scholar
  • 35 Topalan M, Ermis I. Cross-leg free flap for emergency extremity salvage: case report. J Reconstr Microsurg 2001; 17 (03) 157-161
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Chen H, El-Gammal TA, Wei F, Chen H, Noordhoff MS, Tang Y. Cross-leg free flaps for difficult cases of leg defects: indications, pitfalls, and long-term results. J Trauma 1997; 43 (03) 486-491
    CrossrefPubMedGoogle Scholar
  • 37 Ozkan O, Ozkan O, Bektas G, Cinpolat A. Experiences with the flow-through radial forearm flap as a bridge in lower extremity reconstruction. Microsurgery 2016; 36 (02) 128-133
    CrossrefPubMedGoogle Scholar
  • 38 Moran SL, Salgado CJ, Serletti JM. Free tissue transfer in patients with renal disease. Plast Reconstr Surg 2004; 113 (07) 2006-2011
    CrossrefPubMedGoogle Scholar
  • 39 Haddock N, Garfein ES, Reformat D, Hecht E, Levine J, Saadeh P. Perforator vessel recipient options in the lower extremity: an anatomically based approach to safer limb salvage. J Reconstr Microsurg 2010; 26 (07) 461-469
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Lin CH, Mardini S, Lin YT, Yeh JT, Wei FC, Chen HC. Sixty-five clinical cases of free tissue transfer using long arteriovenous fistulas or vein grafts. J Trauma 2004; 56 (05) 1107-1117
    CrossrefPubMedGoogle Scholar
  • 41 Bullocks J, Naik B, Lee E, Hollier Jr L. Flow-through flaps: a review of current knowledge and a novel classification system. Microsurgery 2006; 26 (06) 439-449
    CrossrefPubMedGoogle Scholar
  • 42 Pan SC, Yu JC, Shieh SJ, Lee JW, Huang BM, Chiu HY. Distally based anterolateral thigh flap: an anatomic and clinical study. Plast Reconstr Surg 2004; 114 (07) 1768-1775
    CrossrefPubMedGoogle Scholar
  • 43 Komorowska-Timek E, Gurtner G, Lee GK. Supercharged reverse pedicle anterolateral thigh flap in reconstruction of a massive defect: a case report. Microsurgery 2010; 30 (05) 397-400
    CrossrefPubMedGoogle Scholar
  • 44 Swartz WM, Ramasastry SS, McGill JR, Noonan JD. Distally based vastus lateralis muscle flap for coverage of wounds about the knee. Plast Reconstr Surg 1987; 80 (02) 255-265
    CrossrefPubMedGoogle Scholar
  • 45 Yildirim S, Avci G, Akan M, Misirlioğlu A, Aköz T. Anterolateral thigh flap in the treatment of postburn flexion contractures of the knee. Plast Reconstr Surg 2003; 111 (05) 1630-1637
    CrossrefPubMedGoogle Scholar
  • 46 Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 1991; 44 (01) 53-54
    CrossrefPubMedGoogle Scholar
  • 47 Pestana IA, Coan B, Erdmann D, Marcus J, Levin LS, Zenn MR. Early experience with fluorescent angiography in free-tissue transfer reconstruction. Plast Reconstr Surg 2009; 123 (04) 1239-1244
    CrossrefPubMedGoogle Scholar