[The medial saphenous hetero (cross leg) flap in coverage of soft tissue defects of the leg and foot].
OBJECTIVE
Reconstruction of large areas of soft tissue defects of the lower limb is a major challenge, particularly when the zone involves the lower part of the leg and the foot. The cross-leg flap can be a reliable alternative to free flaps, both in adults and children. We analyzed our experience in a retrospective series of 26 patients who underwent a standardize surgical procedure.


METHODS
Twenty-six cross-leg flap procedures were performed between 1984 and 2000 using the same technique. Mean patient age was 32 years (range 7-67 years). All patients were trauma victims. Mean delay from trauma to flap reconstruction was 2.5 years (range 18 days-16 years). A free flap or loco-regional flap for coverage had been unsuccessful in 19 patients. The zones involved were: leg (n=7), anterior ankle area (n=3), malleolar area (n=2), dorsal aspect of the foot (n=1), heal (n=11, including 4 in an exclusively non-weight-bearing area). Mean patient follow-up was 3 years (1-10 years). The same surgical technique with external fixation was used for all patients. The flap was harvested according to a standard technique with ratios ranging from 3: 1 to 4: 1. The donor site and the flap pedicle were covered with a thin skin flap, at least during the first operative time. During the first operative time, the recipient site was resected to the exact size of the flap, the remaining coverage was achieved during the weaning process using part of the flap pedicle. Weaning was achieved after a mean 27 days (21-38 days).


RESULTS
Complete flap necrosis occurred in one case and partial necrosis in six. Punctual necrosis was observed in five cases requiring revision surgery or local care. One abscess of the donor site occurred two years after flap reconstruction. Coverage was satisfactory for leg and ankle reconstructions, with no recurrent ulcerations or hyperkeratosis at last follow-up. A satisfactory esthetic aspect was achieved in all cases. For foot reconstructions, ulcerations or hyperkeratosis of the plantar skin-flap junction was observed in five cases. All of the patients were however able to wear normal shoes and felt there had been an improvement after surgery.


CONCLUSIONS
The cross-leg flap procedure should, in our opinion, be used in three situations. i) After failure of other techniques: results are very reliable for salvage procedures; 19 of our 26 patients had had failed free or loco-regional flap procedures prior to the cross-leg flap. ii) The reconstruction is large and blood supply contraindicates a free flap procedure (only one intact vascular axis). iii) The entire heal area to be reconstructed would be insufficiently covered by a free flap. Most of the long-term problems are related to heal coverage in weight-bearing areas.
Fitoussi
F
F
Service de Chirurgie Orthopédique et Traumatologique, Hôpital Avicenne, 125, route de Stalingrad, 93000 Bobigny.
Bajer
B
B
Bégué
T
T
Penneçot
G F
GF
Masquelet
A C
AC
D000038:Abscess / Q000209:etiology; D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D018409:Foot Injuries / Q000601:surgery*; D006801:Humans; D007869:Leg Injuries / Q000601:surgery*; D008875:Middle Aged; D009336:Necrosis; D012086:Reoperation; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000009:adverse effects / Q000379:methods; D017695:Soft Tissue Injuries / Q000601:surgery*; D013524:Surgical Flaps / Q000009:adverse effects; D013530:Surgical Wound Infection / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome; D016474:Weight-Bearing; D014945:Wound Healing