CROSS-LEG TIBIAL POSTERIOR PERFORATOR FLAP
ALEXANDRU V. GEORGESCU, M.D., Ph.D.,* CAPOTA IRINA, M.D., and MATEI ILEANA, M.D.
Background: In the lower leg posttraumatic pathology, we are frequently confronted with tissue defects that are difcult to cover by local ordistance means, because of either the poor tissue quality or the precarious local vessels. One of the still available methods for solvingthese cases remains the cross-leg ap. The authors will try to demonstrate the advantages of this method, by using the cross-leg apbased on perforator vessels. Methods: We are presenting two cases for which we practiced a cross-leg perforator ap, based on perforatorvessels emerging from the posterior tibial artery. Results: The results were favorable, demonstrated by immobilization in a comfortableposition, perfect ap integration, pedicle aps division at 1421 days, early postsurgery ambulation. Conclusions: The cross-leg perforatorap diminishes many of the disadvantages created by the classic cross-leg ap and can be successfully used in cases in which other pro-cedures are prohibited. VVC 2007 Wiley-Liss, Inc. Microsurgery 27:379383, 2007.
The covering of soft tissue defects of the lower leg presentsa notable challenge for the reconstructive surgeon, rst of all
because of the poor availability of local tissues to be used,
especially in posttraumatic conditions.14 For these reasons,
a lot of various methods were used in the attempt to solve the
problem: cross-leg aps,26 proximally7 or distally24,810
based fascial or fasciocutaneous aps, distally based muscle
aps,1113 and free aps.1416 The new era of perforator aps
determined an improvement in the possibilities to use both
local/regional1720 or free2125 perforator aps in covering
these difcult defects.
Unfortunately, in the clinical practice, we are some-
times confronted with cases in which, because of the
local anatomical conditions, the local resources or the
free aps cannot be used. In such cases, one of the best
surgical alternatives remains the cross-leg procedure.
We will present two cases in which we used a cross-
leg perforator ap. We consider that this method offers
some advantages over the classical cross-leg ap and,
more, brings the advantages of a perforator ap.
A 32-year-old man sustained a severe crush trauma of
the right lower leg, with open fracture of both the tibia
and peroneum bones in the middle third and interruption
of the tibial posterior and peroneal arteries. He was oper-
ated ve times in an orthopedic surgery clinic (centrome-
dulary ostheosynthesis, numerous debridements). Finally,
the patient developed a septic pseudarthrosis of the tibia
and was referred to our service 8 months later presenting
a stulized septic pseudarthrosis (Fig. 1A). We decided
to perform a large debridement and to use a free latissi-
mus dorsi muscle ap to cover the defect. But, during
the surgery, we found an extensive brosis in the poste-
rior muscle compartment and both the posterior tibial and
peroneal arteries, with no pulse proximal to the level of
the previous rupture.
So, because of the local situation (multiple vicious post-
operative scars and very poor skin quality), we decided to
cover the 12/4 cm defect by using a bipedicled transposition
ap of 15/6 cm, harvested from the anteroextern aspect of
the lower leg in a subfascial plane.
Because of the poor local vascular conditions, 10
days later, a wound dehiscence occurred. In these condi-
tions, we decided to cover the defect by using a perfora-
tor cross-leg ap.
An 18/8-cm ap was designed in the distal half of the
anteromedial aspect of the left lower leg. We rst incised the
anterior border, and the distal and proximal ends of the ap.
We identied a very nice perforator coming through the tibi-
alis posterior muscle 20 cm above the tibial maleola (Fig.
1B). The dissection of the ap was started on the anterior
border and was done in a subfascial plane. The posterior bor-
der of the ap was then incised and the dissection of the per-
forator was completed, keeping a 2-cm adipofascial cuff
around it (Fig. 1C). The ap was rotated 908 and applied onthe exposed tibial bone of the right lower leg (Fig. 1D). The
remaining defects were covered with split-skin grafts. The
immobilization was obtained using plaster casts in a very
comfortable position. The pedicle was divided after 21 days
(Fig. 1E), and the ambulation was possible after 1 week. No
suffering of the ap, before or after the pedicle division, was
observed. The patient used elastic compression support for 4
months. Seven months after the surgery, the ap was com-
pletely integrated with no septic relapse (Fig. 1F).
A 58year-old man sustained a severe crush trauma
with subtotal amputation of his lower leg, 15 years ago.
Clinic of Plastic Surgery and Reconstructive Microsurgery, University of Med-icine Iuliu Hatieganu, Cluj-Napoca, Romania
*Correspondence to: Alexandru Georgescu, Spitalul Clinic de Recuperare,Str.Viilor Nr.46-50, 400347 Cluj-Napoca, Romania.E-mail: firstname.lastname@example.org
Received 28 February 2007; Accepted 5 March 2007
Published online 7 June 2007 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20375
VVC 2007 Wiley-Liss, Inc.
After revascularization and other complex surgical proce-
dures (local and free aps), he remained with a vicious
position of the foot, well tolerated until now. Because
some pain appeared a few months before, he decided to
accept a tallo-crural arthrodesis in functional position.
Because of a hematoma in the postoperative period, a
wound dehiscence appeared (Fig. 2A). The local and re-
gional poor quality of soft tissues and vessels made
impossible the coverage using local or free aps, and so we
decided to use a tibial posterior perforator cross-leg ap.
The same procedure as in case 1 was used, but the
blood supply was ensured through two septocutaneous
perforators identied 8 cm above the tibial maleola and
coming from the posterior tibial artery (Fig. 2B).
The dimensions of the ap were 27 cm in length, 9
cm width at the proximal part and 4 cm width at the dis-
Figure 1. A: Right lower leg. Large soft tissue defect and osteitis of the tibia after an open fracture in a 32-year-old man. B: Left lower
leg. A ap of 18/8 cm was designed and a musculocutaneous tibial posterior artery perforator was identied. C: The ap was harvested by
keeping a 2-cm adipofascial tissue cuff around the perforator. D: The ap was rotated 908 and applied to the defect. Free split skin graftone the donor site. E: 21 days later, after sectioning the pedicle. F: 7 months after surgery. [Color gure can be viewed in the online issue,
which is available at www.interscience.wiley.com.]
380 Georgescu et al.
Microsurgery DOI 10.1002/micr
Figure 2. A: Wound dehiscence after right ankle arthrodesis in a 58year-old man. B: A perforator ap is harvested from the left lower
leg. Two septocutaneous posterior tibial artery perforators were identied 8 cm above the tibial maleola. C: The harvesting of the ap (27
cm length, 9-cm width proximally and 4 cm distally) was completed. D: After the ap was rotated 908, about 90 cm2 of its proximal partwas de-epidermised and lled into the defect. E: 48 h after surgery. F: The immobilization was obtained by using two plaster casts secured
to each other. G: The very comfortable position and the possibility to move the knees can be observed. H: After sectioning the pedicle.
[Color gure can be viewed in the online issue, which is available at www.interscience.wiley.com.]
tal part (Fig. 2C). Its proximal 90 cm2 were de-epider-
mised in the attempt to ll the dead space (Fig. 2D). Theap was turned 908 and applied into and on the defect(Fig. 2E). The immobilization was done using two plastercasts secured to each other, involving only the lower legsand feet; the knees mobilization was possible and theposition in bed was very comfortable for the patient(Figs. 2F and 2G). The ap survival was complete. Thepedicle was divided in the 14th day (Fig. 2H), and theambulation was permitted 1 week later.
Sometimes, in both acute and sequelar conditions, the
local or regional soft tissues and vascular resources are
not available for reconstructive purposes. One of the few
available surgical solutions in such cases remains the
First described in 1854 by Hamilton,6 the cross-leg
procedure was considered in the 70th to be the solution
for covering the soft tissue defects in the distal third of
the leg and foot.26
The disadvantages of the traditional cross-leg proce-
dure, such as random blood supply, short pedicle, limited
rotation arch, and uncomfortable immobilization, that can
generate frequent complications made the cross-leg ap
to be used less and less.4
Since Ponten7 introduced the concept of fasciocutane-
ous aps and Masquelet et al.27 suggested that the new
achievements in the knowledge of the leg blood supply
could rehabilitate the cross-leg ap, the interest in using
again this procedure increased.
So, a lot of cross-leg aps were done as conventional
pedicled aps5,6,2830 or neurocutaneous aps,24,10 but
also as free cross-leg aps.3133
But all these procedures do not completely avoid the
well-known disadvantages (especially the immobilization
in uncomfortable positions) and, in the free aps case,
the risks of vascular anasthomosis.
Because of the local conditions, in both our patients,
the use of local or regional aps was not possible. So,
we decided to use a cross-leg ap, but in the attempt to
avoid part of the traditional procedures disadvantages
(especially the immobilization in uncomfortable positions
and the knee xation in some degree of exion or exten-
sion), we chose to base the ap on perforator vessels.
It is better to base the ap on perforators coming from
the posterior tibial artery. As Koshima et al. has shown in
1992,34 there are three types of perforators emerging from
the posterior tibial artery: septocutaneous, musculocutane-
ous, and periosteal. From these, the musculocutaneous per-
forators, located in the proximal half of the leg, and the sep-
tocutaneous perforators, located mainly in the distal third,
are of great interest in performing a cross-leg perforator ap.
Very important is the fact that the distribution of
these perforators is relatively constant and that they are
very well represented, and so they are able to blood sup-
ply very wide areas, as we proved in our cases.
The need to rotate the ap more than 908 is generallynot necessary so will be no chance to compromise the
perforator, especially if the ap is based on two such ves-
sels. Because sometimes deep defects are to be covered,
some surgeons harvest together with the distally based
pedicle ap a segment of the gastrocnemius muscle that
improves the blood supply of the ap and facilitates the
defect lling.3,35 But, as we have shown in case 2, it is
also possible to ll the defect by using a partially de-epi-
dermised ap. Our method also requires both extremities
immobilization but, by using plaster cast applied only on
the lower leg and foot in a comfortable position, we
avoided the need to maintain the knees in exion or
extension. So, it is very easy for the patient to care for
himself and to mobilize his legs and all the body.
Despite the fact that, to our knowledge, the use of a
pedicled cross-leg perforator ap has not been previously
reported, we think that this procedure could be consid-
ered in the armamentarium of lower leg and foot defects
coverage in very well-selected cases.
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