Limb salvage using reverse sural cross-leg flap in complex lower limb injury: A case series.

[BACKGROUND] Complex lower limb injuries involving soft tissue defects, fractures, and vascular compromise present significant reconstructive challenges. Free tissue transfer is often the gold standard for reconstruction; however, reverse sural cross-leg flaps provide a reliable alternative in resource-limited settings or when the recipient's vessels are compromised. This case series highlights the utility of this technique in challenging scenarios, including comminuted fractures, vascular injuries, and extensive soft tissue defects.

[METHODS] Six male patients with complex lower limb injuries treated from January 2021 to September 2023 underwent reverse sural cross-leg flap reconstruction. Demographic data, injury mechanisms, fracture types, and surgical outcomes were recorded. The flap was based on the sural artery, and external fixators were used to immobilize the legs during the healing process. Flap separation was performed after 3-4 weeks, depending on flap viability and neovascularization.

[RESULTS] All patients achieved limb salvage, with union times ranging from 8 to 14 months. Flap congestion was observed in two cases, but no flap failures occurred. The tibialis posterior artery remained intact in most cases, providing a reliable blood supply for limb survival.

[DISCUSSION] The reverse sural artery cross-leg flap is a versatile and reliable option for limb salvage in complex lower limb injuries and significant vascular injuries such as single-vessel runoff, especially in resource-limited settings or when free tissue transfer is contraindicated. Its advantages include simplicity, reliability, and good-quality coverage. However, disadvantages such as flap congestion, prolonged immobilization, and donor site morbidity must be considered.

[CONCLUSION] Careful patient selection, surgical technique, and postoperative management are critical to successful outcomes with the reverse sural artery cross-leg flap.