Cross-leg Flaps and Pressure Ulcers: An Experience from a Tertiary Care Centre in India

Abstract

Cross-leg flaps are done infrequently today due to advancements in micro- and super micro-surgeries. Problems like pressure ulcers, joint stiffness, etc., have been seen in cross-leg flaps. Pressure ulcers develop due to awkward positioning and prolonged immobilization of limbs. Sites for these ulcers include usual predisposed locations like the heel and the malleoli. Unusual sites like the dorsum of the recipient foot have also been found to develop pressure ulcers. Immobilization has been achieved by methods like external fixators, POP and dressings. Pressure ulcers prevention has been done by offloading with non-surgical strategies like air mattresses, gloves, pillows, etc. These are useful only for usual predisposed sites. For unusual predisposed sites other methods have not been described literature. External fixators, which have been used for immobilization in cross-leg flaps can be used with modifications to achieve surgical off-loading of these unusual sites. Patients operated with cross-leg flap from 2021 to 2023 at All India Institute of Medical Sciences (AIIMS), Patna in the Department of Burns and Plastic Surgery were identified from the departmental database. Their case record was retrieved from MRD, and relevant data regarding the method of immobilization, method of off-loading, development of pressure ulcer and other complications were obtained and analysed, retrospectively. Three patients with history of RTA were operated with cross-leg flaps for various indications. Immobilization of legs was done by external fixators in first and third patient and with POP in second patient. Non-surgical off-loading with either air-mattress, gloves, pillows etc., was used in all three patients. Surgical off-loading with modifications in external fixators was used in the third patient. Pressure ulcer developed in first and second patients. In both these patients, it developed at usual predisposed site of the heel of the recipient leg as well as unusual site of the dorsum of the foot of the recipient leg. The third patient was free of pressure ulcer. Non-surgical off loading alone is insufficient. External fixators used for immobilization can be used for surgical off-loading by modifications and adjustments in its design. Improvisation by adjusting pins and bars can be used for off-loading usual sites for pressure ulcers, like the heels, the calcaneal areas as well as unusual sites such as the dorsum of the foot.