Tag Archives: skin graft

Tips and Techniques: A Modified Cross Leg Flap for Large Triangular Defects of the Foot and Ankle

by B. Jagannath Kamath, M.S. (Ortho) 1 , Thangam Varghese, Mch (Plastic Surgery) 2,
Praveen Bhardwaj, M.S., (Ortho) 3

The Foot & Ankle Journal 1 (8): 5

An important technical modification in the conventional medial based cross leg flaps is described by the authors. The technique involves resurfacing large triangular defects in the medial lower leg, ankle and foot. This modification, by virtue of narrowing the pedicle, will help the surgeon to maximize the inset avoiding delaying of the flap or flap loss. Secondary defects created by raising the triangular flaps are amenable to considerable narrowing and leaving behind smaller defects that can easily be covered with a split thickness skin graft. Another advantage of the triangular flap is the primary inset portion of the flap provides more than 75-80 % coverage to the injury site. This not only promotes early division of the flap without delay, but also enables the surgeon to maximize the secondary inset during the division of the flap and to cover the recipient area completely with the flap obviating the need for the split skin graft at the crucial triangular area of the original defect.

Key Words: Modified cross leg flap, medial based, triangular defect, foot and ankle, skin graft

Accepted: July 2008
Published: August 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0108.0005

Cross leg flaps have stood the test of time ever since its first description by Hamilton in 1854. It has always found an important place in the surgeon’s armamentarium in reconstructive surgeries of the lower limb even in the era of micro and super-microsurgery. It is still a safe and viable option in primary and secondary care centers for the reconstructive surgery of the lower limb in situations such as larger distal defects in the leg and foot where distally based flaps from the ipsilateral leg calf are not feasible.

Even in tertiary care centers cross leg flaps is a viable procedure in failed free flap surgeries. This is quite relevant because the highest percentage of failure of free flaps is encountered in cases of resurfacing the traumatic defects of the distal leg and foot.

Like most of the proven procedures, cross leg flaps have also undergone refinement and modifications. With the advent of fasciocutaneous flaps described by Ponten in 1983 [1], the cross leg flaps have been raised safely and easily with 1:3 to 1:3.5 width to length ratio. Several authors have advocated routine use of external fixators in maintaining the position of cross leg and ease of nursing care and post operative wound management.

This modification has been used both in children and adults with good results. Cross leg flaps have been used with their bases proximal, distal, medial and lateral depending on the size and shape of the recipient site and ease of planning in reverse. Some surgeons have used myocutaneous cross leg flaps to provide bulk, safety and to obliterate dead space in the recipient area. Conventional posterior tibial artery flap, sural artery flaps have been used as ‘cross leg flaps’. Recently Pandey, et al., [2] has used virtually the whole leg medially based fasciocutaneous cross leg flap with or without fibula for reconstructing large defects. Also, Bhattacharya, et al., [3] have used distal perforator based cross leg flaps successfully for leg and foot defects with narrow pedicles and larger inset with greater patient comfort.

To the best of our knowledge, large triangular medially based cross leg flaps nourished by two or three posterior tibial perforators have not been described. These flaps are most suited in large triangular defects on the medial side of the foot and ankle, which are quite commonly encountered in children and adults following trauma. By virtue of creating a very narrow pedicle large triangular fasciocutaneous flaps involving different angiogomes can be raised to improve the perimeter or the circumference of the inset of the flap. This obviates the need for delaying of the flap before division. This is important because traumatic distal leg and foot defects leave behind a very poorly vascularised bed contributing very little to the neovascularisation of the cross leg flap. These defects demand a larger and more reliable inset preferably more than 70 % of the original injury site or defect.

If the shape of the defect is triangular it will be difficult to meet the requirement dimensions of the conventional broad based cross leg flaps. Medial fasciocutaneous cross leg flaps based on perforators can be used without altering the original shape of the wound. Unlike the conventional broad based rectangular cross leg flaps, the narrow based triangular or oval flaps permit considerable narrowing of the secondary wound and can be covered with split thickness skin graft. This also adds to the cosmetic benefits of the flap both at the donor and the recipient sites.

The authors recently had an opportunity to use cross leg flaps with a technical modification to suit the need of resurfacing triangular defects of the lower leg after the trauma. Three patients with large triangular medial defects over the lower leg, ankle and foot were treated in our surgery department between December 2004 and January 2006. (Table 1)

Table 1  Demographics of three distinct cases describing the modified cross leg flap for large triangular defects of the foot and ankle.

All three defects were covered with a medially based narrow pedicled triangular cross leg flap based on 2-3 adjacent posterior tibial perforators about 1-2 cm from the medial border of the tibia in its middle third. The perforators are identified preoperatively by a hand held Doppler. No attempt is made to isolate or skeletonize the perforator and hence by definition these flaps could be termed as perforator plus flaps as described by Sharma, et al. [4] Flaps are raised as fasciocutaneous flaps involving not only posterolateral but also anterior compartmental tissue.

The secondary wound created is considerably reduced as the triangular edges are primarily sutured using the visco-elastic property of the calf skin. The rest of the donor site is covered with a split thickness skin graft and the larger, triangular flap is used to cover the injured site. The inset region provides more than 75 –80% coverage to the perimeter of the injury site in all three cases. The cross-legged position is maintained be external fixators and the flap is divided at the end of 2 ½ weeks. All three defects healed primarily providing stable skin cover.

An illustrative example using this triangular technique is described in the following figures.

Photo Description of Technique

Figure 1  Preoperative photograph showing the traumatic defect over the medial aspect of the foot with exposed bone.

Figure 2  Picture showing the ‘planning in reverse’.

Figure 3 Flap with primary inset providing more than 75 –80% coverage to the perimeter of the injury site.

Figure 4 Follow up result, showing stable skin cover.


1. Ponten B. The fasciocutaneous flap. Its use in soft tissue defects of lower leg. Br. J Plast Surg. 34: 215, 1981.
2. Pande S, Kohli JS, Arora S, Bajaj SP. The osseofasciocutaneous flap: a new method to transfer fibula along with a sufficient amount of skin. Br. J Plast Surg. 55: 312-319, 2002.
3. Bhattacharya V, Reddy GR. Distal perforator based cross leg flaps for leg and foot defects. Indian J Plast Surg. 38(1): 18-21, 2005.
4. Sharma RK, Mehrotra S, Nanda V. The perforator “plus” flap: a simple nomenclature for locoregional perforator-based flaps. Plast Reconstr Surg. 116(6): 1838-9, 2005.

Address correspondence to: Dr. B. Jagannath Kamath. Jyothi Mansion, Opposite Prabhat Theatre, K. S. Rao Road, Mangalore, India. Pin- 575001. Phone: 91-0824-2440233; Mobile: 91-9845235747
E-mail: bjkamath@satyam.net.in

Professor of Orthopaedics, Kasturba Medical College, Mangalore, Karnataka, India.
Professor of Plastic Surgery, Kasturba Medical College, Mangalore Karnataka, India.
Fellow in Hand and Reconstructive Microsurgery, Ganga Hospital, Coimbatore, India.

© The Foot & Ankle Journal, 2008

Use of External Ring Fixation in a Full-Thickness Achilles Wound: A Case Report

by Lee C. Rogers, DPM 1, Nicholas J. Bevilacqua, DPM 2, Kenneth Francis, MD 3, Michael C. Piccarelli, DPM 4

The Foot & Ankle Journal 1 (3): 4

An 84 year-old male with a full-thickness Achilles ulcer for 4 months was successfully healed with split-thickness skin grafting after application of an external ring fixator as an offloading and immobilizing tool. This method allowed for weight-bearing during treatment. The use of external fixation devices for soft tissue reconstruction of the lower extremity can be a useful adjunct.

Key words: External ring fixator, Achilles ulcer, skin graft

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org 

Published online: March 1, 2008

ISSN: 1941-6806/08/0103-0004
doi: 10.3827/faoj.2008.0103.0004

Management of posterior ankle wounds involving the Achilles tendon pose a reconstructive challenge due to of the paucity of soft tissue surrounding the ankle. [1,2] It is often anecdotally thought that the perfusion in the region overlying the Achilles tendon is poor, resulting in healing delays. However, the source of blood supply to the skin has been well delineated by Ian Taylor, a plastic surgeon in Michigan, who has published much work on angiosomes and musculocutaneous/fasciocutaneous perforators, which supply the subdermal plexus and capillary network.

Perhaps, it might be said that the cushion effect of the subcutaneous tissue being absent overlying the Achilles renders the perforators more susceptible to injury. This results in relatively poor regenerative capacity when injured. To avert these challenges, wounds with exposed Achilles tendon have been treated with autologous keratinocytes, [3] frozen epidermal allograft, [4] and free flaps. [5] Traditionally, there has been reluctance in using split-thickness skin grafts (STSG) on the Achilles tendon and past treatment involved the use local, pedicle, or free flaps. Recently, Attinger et al, demonstrated that with a properly prepared wound bed, skin grafting is as effective as local or free flaps in healing Achilles tendon wounds. [6] The requirement for offloading and immobilization is paramount in these wounds with exposed Achilles tendon and is achieved with casting or windowed total contact casting. [7] We present a method to achieve these goals utilizing external ring fixation allowing weight-bearing during treatment.

Case Report

An 84 year-old white male presented with a full-thickness Achilles tendon ulcer. The injury resulted from shearing trauma against a bed rail while at home. The patient’s past medical history was significant only for hypertension. The ulcer had been present for 4 months and treated with variety of topical antimicrobials and regular clinic debridement. The wound failed to progress in a timely manner and eventually cellulitis developed. The patient was referred to the emergency department at our facility. The Achilles tendon was visible and desiccated at the base of the wound. (Fig. 1)

Figure 1 Full-thickness necrotic ulcer with exposed Achilles tendon.

With ankle motion, the tendon could be seen sliding in and out of the intact paratenon. The periwound area was fibrotic with patches of necrotic tissue. Erythema extended for 2 cm around the wound but no purulence was present. Noninvasive vascular studies revealed an ABI of 0.94 on the ulcerated extremity. After a 5 day hospital admission for treatment of cellulitis with parenteral antibiotics, the patient underwent surgical debridement of the tendon and application of an external fixator.

A Wound V.A.C.® (Kinetic Concepts, Inc. or KCI, San Antonio, TX) was utilized over the exposed tendon. Pin care consisted of application of povidine-iodine solution soaked gauze around the pin sites. A standard post-operative shoe was drilled and mounted to an Ilizarov ring and connected plantar to the foot plate. (Fig. 2) This allowed the patient to ambulate in a method similar to that described by Roukis and Zgonis. [8]

Figure 2 External ring fixator in place with a post-operative shoe drill-mounted into the tibial ring for ambulation.

The patient was admitted to a short-term rehabilitation center. After 15 days, the patient was brought back to the operating room for a repeat debridement and Apligraf placement under the Wound V.A.C. ® Twenty days passed until the granulation tissue thoroughly formed over the tendon.

At this time, the patient returned to the OR for application of a STSG donated from his ipsilateral thigh. The STSG was secured with staples and the Wound V.A.C. ® was replaced for 4 days. After 28 days approximately 50% of the graft had incorporated. (Fig 3) The decision was made to harvest a second STSG and apply it to the remaining wound. Within the next 4 weeks the wound had completely epithelialized.

Figure 3   Twenty-eight days after application of a split-thickness skin graft showing 50 percent graft incorporation.

The patient remained active and was allowed to bear weight and ambulate throughout treatment. The external fixator was removed after 90 days of use. The patient remained in the rehabilitation center for 2 weeks after removal of the fixator, then discharged home.

At 10 months the patient remained fully healed and an active ambulatory community. (Fig 4) Eleven months after the post external fixation was removed, the patient developed a superficial blister to the posterior ankle. The area was examined closely and appeared to be free of infection. He was sent home with topical becaplermin gel and a walking Multipodos®. The wound healed uneventfully after 3 weeks and the patient successfully returned to his previous lifestyle.

Figure 4   The ulcer over the Achilles tendon is completely healed.  The graft site is shown here at 10 months after removal of external fixator.


External ring fixation has been described primarily for osseous fixation, but there are reports in the literature for soft tissue conditions. [9] There are descriptions of its use to gradually reduce soft tissue contractures such as ankle equinus deformity [10] and flexion contractures of the knee. [11]

Noack, et al, described the use of external fixation after a reverse flow sural artery flap to provide strict immobilization of the affected leg. [12] Roukis, et al, has used it for pressure relief after soft tissue reconstruction of heel defects. [13] Specifically in the Achilles tendon, external fixation has been used to offload the tendon repair and may lead to a lower re-rupture rate. [14,15,16] The external fixator in our case served several purposes: It elevated and offloaded the posterior ankle, allowed for daily inspection of the wound, immobilized the ankle and Achilles tendon, and more importantly, it allowed the patient to ambulate during treatment. In this example, negative pressure wound therapy (NPWT) was initiated to enhance granulation tissue and ease the transition to wound closure. The Wound V.A.C.® device was also used as a bolster dressing after applying the bilayer skin replacement and meshed STSG. Although difficult, the external fixation device allowed us to combine NPWT with our immobilization, which could not be accomplished in a cast. External ring fixation may prove a useful tool in difficult to heal wounds involving the Achilles region.


1. Leung PC, Hung LK, Leung KS. Use of the medial plantar flap in soft tissue replacement around the heel region. Foot Ankle 8(6):327-330, Jun 1988.
2. Yilmaz M, Karatas O, Barutcu A. The distally based superficial sural artery island flap: clinical experiences and modifications. Plast Reconstr Surg. 102(7):2358-2367, Dec 1998.
3. Dalla Paola L, Cogo A, Deanesi W, Stocchiero C, Colletta VC. Using hyaluronic acid derivatives and cultured autologous fibroblasts and keratinocytes in a lower limb wound in a patient with diabetes: a case report. Ostomy Wound Manage. 48(9):46-49, Sep 2002.
4. Bolivar-Flores YJ, Kuri-Harcuch W. Frozen allogeneic human epidermal cultured sheets for the cure of complicated leg ulcers. Dermatol Surg. 25(8):610-617, Aug 1999.
5. Hallock GG. Free-flap coverage of the exposed Achilles tendon. Plast Reconstr Surg. 83(4):710-716, Apr 1989.
6. Attinger CE, Ducic I, Hess CL, Basil A, Abbruzzesse M, Cooper P. Outcome of skin graft versus flap surgery in the salvage of the exposed achilles tendon in diabetics versus nondiabetics. Plast Reconstr Surg. 117(7):2460-2467, Jun 2006.
7. Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes [see comments]. N Engl J Med. 331(13):854-860, 1994.
8. Roukis TS, Zgonis T. Postoperative shoe modifications for weightbearing with the Ilizarov External Fixation System. J Foot Ankle Surg. 43(6):433-435, Nov-Dec 2004.
9. Gugenheim JJ, Jr. The Ilizarov method. Orthopedic and soft tissue applications. Clin Plast Surg. 25(4):567-578, Oct 1998.
10. Tsuchiya H, Sakurakichi K, Uehara K, Yamashiro T, Tomita K. Gradual closed correction of equinus contracture using the Ilizarov apparatus. J Orthop Sci. 8(6):802-806, 2003.
11. Bar-Meir E, Yaffe B, Winkler E, Sher N, Berenstein M, Schindler A. Combined Iliazarov and free flap for severe recurrent flexion-contracture release. J Burn Care Res. 27(4):529-534, Jul-Aug 2006.
12. Noack N, Hartmann B, Kuntscher MV. Measures to prevent complications of distally based neurovascular sural flaps. Ann Plast Surg. 57(1):37-40, Jul 2006.
13. Roukis TS, Landsman AS, Weinberg SA, Leone E. Use of a hybrid “kickstand” external fixator for pressure relief after soft-tissue reconstruction of heel defects. J Foot Ankle Surg. 42(4):240-243, Jul-Aug 2003.
14. Shea KG, Showalter L. Ilizarov method of repair of achilles tendon rupture in a patient with congenital insensitivity to pain. A case report. J Bone Joint Surg Am. 85-A(9):1816-1818, Sep 2003.
15. Casteleyn PP, Opdecam P, De Clercq D. Surgical treatment of Achilles tendon ruptures, combined with an external fixation system. Acta Orthop Belg. 46(3):310-313, May-Jun 1980.
16. Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of achilles tendon ruptures. Am J Sports Med. 30(4):565-575, Jul-Aug 2002.

Address correspondence to: Lee C. Rogers, DPM. Director, Amputation Prevention Center, Broadlawns Medical Center, 1801 Hickman Road, Des Moines, IA 50314. Email: Lee.C.Rogers@gmail.com

1,2Amputation Prevention Center, Broadlawns Medical Center, 1801 Hickman Road, Des Moines, IA 50314.

3Chief; Plastic Surgery Section. Caritas Health Care, Inc. (formerly; Saint Vincent Catholic Medical Centers) St. John’s Hospital, 90-02 Queens Boulevard, Elmhurst, NY 11372.

4Assistant Program Director; PM&S 24 and PM&S 36 Residency Programs. Caritas Health Care, Inc. (formerly; Saint Vincent Catholic Medical Centers) St. John’s Queens Hospital, 90-02 Queens Boulevard; Elmhurst, NY 11372.

© The Foot & Ankle Journal, 2008

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