Achilles Tendon Reconstruction After Electrical Injury With a Neurotized Cross-Leg Fillet Flap

Abstract

The authors present a case where a cross-leg fillet flap from an amputated limb allowed reconstruction of the contralateral disrupted Achilles tendon and provided neurotized soft tissue. Achilles tendon reconstruction of the left leg was achieved by utilizing vascularized extensor tendons from the dorsum of the right foot based on the dorsalis pedis circulation. Neurotization was accomplished end to side between a cutaneous nerve from the dorsum of the foot and the recipient sural nerve. Healing was complete and without complication. Cross-leg flaps including tendon and nerve may be used to reconstruct complex lower-extremity injuries, even when free flaps are not feasible.

Cross-Leg Flaps for Lower Extremity Salvage: A Scoping Review

“…14,21,32,37,[39][40][41][42][43][44][45][46] The third most common reason why free tissue transfer was not used was anatomic limitation (28 of 51 publications, n ¼ 170 of 322, 52.8% of patients) described in a variety of ways: no recipient vessels, inadequate vasculature, poor vascular supply, severe arterial injury, vascular damage, extensive zone of injury, lack of vasculature, one vessel run-off, or slight variations on the same language. 6,12,15,19,20,36,37,39,41,42,45,[47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] Prior free flap failure was cited as the indication for cross-leg flap in six publications (n ¼ 27 of 250, 10.8% of patients). 12,39,49,56,63,64 Comorbidities prohibiting free tissue transfer (n ¼ 19 of 250, 7.6% of patients), 12,…”

“…Other flap types were not described according to common nomenclature, and it was impossible to tell if they were fasciocutaneous or musculocutaneous (n ¼ 83). The majority of publications named the axial blood supply to the flaps described, though in 18 studies, 6,15,17,23,24,[27][28][29][33][34][35]37,45,46,50,52,55,60,63 the blood supply was unknown since it was not named, was described as random (used to describe as many as 136 patients) or was not easily inferred. Of those publications that did name an axial blood supply and made the number of patients with a given axial supply clear, the most common were the posterior tibial artery 25,36,38,42,43,48,53,[56][57][58]66 (11 of 37 publications, n ¼ 50 of 182, 27.5%) and peroneal artery 18,21,31,40,41,51,61,65 (8 of 37 publications, n ¼ 49 of 182, 26.9%) (►Fig.…”

“…19 publications). 6,11,19,24,31,32,36,38,40-42,51,53,54,57 59,61-63 External fixators were the immobilization method used in 57.7% of cases (26 publications, n ¼ 184 of 319) of the cases, 6,12,15,20,22,[26][27][28]30,31,37,39,40,43,[46][47][48][49]52,54,55,57,60,61,63,64 with plaster cast 11,14,18,32,36,38,42,44,50,53,65 (33.2%, 11 publications, n ¼ 106 of 319), or other immobilization method being much less frequent. Pedicles were typically divided at 3 weeks (mean 20.9 days, range: 11-42 days).…”

“…The next most common complications were infection (n ¼ 10 of 350, 2.9%), osteomyelitis (n ¼ 7 of 350, 2.0%), skin graft loss at either the flap or donor site (n ¼ 4 of 350, 1.1%), venous congestion (n ¼ 2 of 350, 0.6%) and ulceration, shearing, deep vein thrombosis (DVT), and hypertrophic scar mentioned in one case each. 6,12,14,17,18,20,25,[30][31][32]34,[37][38][39][40][41][42][43]52,[58][59][60]64 Two-third of publications commented on mobility or ambulatory status, with ability to ambulate (n ¼ 240 patients, 29 publications) 6,12,16,18,19,22,23,26,29,31,36,37,39,[41][42][43][44]46,52,[55][56][57][58][59][60]…”

“…Very little documentation was made with regard to donor site morbidity (13 publications) but the most common problems were partial skin graft loss (five publications, unable to assess number of patients), followed by heal ulcers from prolonged immobilization, loss of nerve sensation, hypertrophic scars, below knee amputation, planned amputation of donor site, and minor erosion in one publication per condition. 6,12,13,15,17,18,30,37,38,40,42,43,47,49,55,62,64,65 Subsequent procedures were also incompletely documented, with approximately one-third of publications making any mention of procedures ranging from dog ear revision to bone grafting. 6,13,19,20,22,25,29,34,37,42,43,47,52,55,56,58,60,63-65 Follow-up time ranged from 10 weeks to 9.5 years, with an average of 2.2 years (n ¼ 238).…”