r-4. Ihle BU. Adrenocortical response and cortisone replacementin systemic inflammatory response syndrome. Anaesth

Intensive Care 2001 29: 155- 16A.5. Meduri GU, Headley s, Tolley E, Shelby M, stentz F,

Postlethwaite A, et al. Plasma and BAL .yiotin";;rp*;to corticosteroid rescue treatment in late ARDS. ChestiggS;108:1315-l3ZS.

6. Biffl wL, Moore FA, Moore EE, Haenel JB, Mclntyre RCJr, Burch JM, et al. Are corticosteroids salvage therapy forrefractory a9_ute respiratory distress syndro*"r Am i sorg1995; 170: 591-595.

1

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Gross-l€g fasciocutaneous flaps. stiila valid option for reconstruhtion oftraumatic lower extremity defecfs

samir Jabaiti, MD, FRCS(Ed), Bareqa salah, MD, FRCS(Eil),M ahmo ud abab ne lg uo_, s haher E l-H odiiy,-M;, F RC s ( E d ),Freih Abu-Hassan, MD, rncslortnl,

NidalA. Younes, MSc, MD.

p econstruction of defects of the lower third ofr\the leg and foot represents a great challenge forplastic surgeons, especially when itre defect is iarge.The reduced vascularify and subsequent poor healiigencountered in these regions, as well aJ the timitelavailability of local tissue for reconstruction,demands a careful evaluation of the wound, loddetailed knowledge of the local anatomy to selectthe best surgical procedure for each patient.l Cross-Ieg flaps described by Hamilton ir lgs4, wereused widely to save limbs, but nowadsys, they areconsidered by many as obsolete and '.awkward"procedures.2 However, the lasf decades havewitnessed many surgeons using different types andmodifications of cross-leg flaps as a prim erry, or asa salvage procedure, following failurb of previousattempts at lower limb reconstruction.2 The oUiectiveof this retrospective review, is to evaluaie ourexperience at the Jordan University Hospital, in usingcross-leg fasciocutaneous flaps for reconstruction o1large defects of the lower UrirA of the leg and footregarding the outcome and complications.

A chart review, was conducted on lz patientswho undenvent cross-leg fasciocutaneous flaps forreconstruction of large lower leg and foot difectsbetween 1998 and 2005 at the Jordan UniversityHospital, Amman, Jordan. The medical records ofthese patients were reviewed for demographics,wound size, etiology, locatior, procedures perronneo,complications, healing time, and furttrer revisionsurgery related to the repair. Nine of the patients had

Role of methylprednisolone in unrosolving cases of ARDS

Figure I . The flap sutured to the recipient site.

a post traumatic defect induced by motor vehicleaccidents, 2 patients had defects resulted fromgrushing by heavy objects, and one patient had a largefull thickness burn. The flaps were proximally UasJOon the axial blood supply of the posterior desCendingsubfascial cutaneous branch of the popliteal utt"riand raised frorn the posterior aspeci of ttre contri-lateral leg. The donor site was cloied either primarityor with skin graft (Figure l). The limbs wlre fixei'by plaster of Paris cast. A window was created inthe cast opposite of flap for future inspection. Theaverage time between flap coverage and division wasapproximately 20.8 days (range 18-23 days).

Twelve patients (8 males and 4 females) wereincluded in the study with a mean age of 10.3years (range 0.3-30 years). The time between injuryTd repair_range approximately 5 days to 4 y.*r.The site of defect was the lower third of the ieg in5 patients (4l.6vo), dorsum of foot in 4 (33.3vo),f,eelin 2 (l6.6vo), and the big toe in one patient (g .3vo).seven patients (58 .3vo) had compound fractureswith bony exposure, 3 patients (25vo) had bonyexposure without fractures, and Z patients ( 16.6q;)had exposure of dorsal extensoi tendons. Twopatients (l6.6vo) received non-vasculari zed bonegrafts to replace the bone loss; one graft washarvested from the opposite fibula; andlhe otherone from the iliac crest. The mean size of thedefect was 59.3 cm2 (range 27-r20).The mean timebetween repair and flap division was 20.g days(range 18-23). AII the patients were dischargedfrom the hospital with viable flaps after iH"procedure. The mean follow-up period was 37.6months (ran ge 2-71). one patient (g.3 vo) hadpartialflap loss that healed later by dressings in the outpatient clinic. Two patients ( l6.6Vo) with heel defects(in the weight bearing area) developed recurrentulceration and hyperkeratosis that required furtherreconstruction. Four patients (33 .3vo) required

www.smj.org.sa Saudi Med I 2ffi6;yot.27 (10) 1609

YCross-leg fasciocutaneous fl aPs

Table t ' Operative data and complications.

Data and complications N (Vo)

Period from injury to repair (range) (5 days - 4 years)

Operative time in minutes: mean (range) 92.L (55-165)

Donor site repairSptit-thickness skin graft 3 ' (25)

Full-thickness skin graft 8 (66.7)

Primary repair I (8.3)',

Time for repair to flap division in days:

mean (range)

ComplicationsPartial flap necrosisWound infectionJoint stiffness

Recurrent ulceration and hyperkeratosis 2 (16.6)

Minor flap revision or thinning 4 (33.3)

20.8 (18-23)

1 (8.3)0 (0)0 (0)

minor flap revision for better cosmesis. A11 the otherpatients maintained durable soft tissue cover withsatisfactory esthetic results. None of the patients had

wound infection or joint stiffness (Thble L).

Management of traumatic lower limb soft tissue

defects, remains a major challenge to plasticsurgeons. The beginning of microsurgery in the1970s, and the introduction of myocutaneous and

fasciocutaneous flaps by Ponten3 in 1981, have

revolutionized the reconstruction of lower extremitydefects. Free flaps using the microsurgicaltechniques, have been used successfully to coveracute and chronic large lower extremity defects.a

However, free flaps require special skills andrelatively expensive instrumentation not readilyavailable to all reconstructi'Le surgeons, particularlyin the developing countries. Moreover in serious

cases, free flaps are highly risky or even difficultto perform.z The other alternative is to use localfasciocutaneous and muscle flaps. This optionhowever, may not also be achievable due to the

absence of adequate healthy 'local tissues. In such

circumstances, the use of cross leg fasciocutaneousflaps offers a valid alternative to free flaps or localflaps. The major drawbacks of this procedure includean unreliable blood supply, limited arc of rotationcaused by a short and thick pedicle, and the need forinconvenient postoperative immobilization.z Some

surgeons used external fixation devices to achievebetter patient convenience and joint mobility, inaddition to facilitating flap monitoring and woundcare. The optimal time for flap division has not been

determined in the literature; Thatte et al5 divided 10

1610 Saudi Med J 2006; Yol.27 (10) www.smj.org.sa

cro s s - le g fas c iocutaneou s fl ap s on the tenth day s w ithoutcomplications. George et al6 used a simple occlusionclamp with screws to apply gradual tightening at the

pedicle, producing intermittent periods of ischemia,they could divide the flap safely after 9 to L4 days

(mean 10 days). However, in this series, all flaps weredivided aftgr 18 days. The facilities for free tissuetransfer in our center, like most of the centers in the

developing countries are still lacking. We depend

mainly on cross-leg posterior tibial fasciocutaneousflaps to repair defects of the lower leg and foot.Only 9Vo of our patients in this series had partial flapnecrosis, which compares well with the rate of partialor complete flap loss reported by other series (0-

26.9%o).'n Soft tissue defects in weight bearing areas,

such as the heel regions; have long been viewed as

troublesome due to the continuous pressure load, and

the special anatomical nature of these areas. Twopatients with heel defects (I6.6Vo) in this series had

recurrent ulcerations following cross-leg flaps.

Cross-leg flaps , are still safe and reliable methodfor soft tissue reconstruction of traumatic lowerextremity defects. They should be viewed as a viablealternative for wounds with extensive exposure ofbone and tendon. These flaps provide similar tissue tothat lost, they are easy to raise, require short operativetime, are associated with minimal blood loss, and

they preserve the major arteries in the traumatizedleg.

Acknowledgment. This work was supported by the Faculty ofMedicineAJniversity of Jordan. We would like to thank Saleh Massad

(Medical Photography) for his help in processing the picture.

Received 25th February 2006. Acceptedfor publication infinal form 28th

June 2006.

From the Section of Plastic & Reconstructive Surgery, Department ofSurgery Qabaiti, Salah), Section of Orthopedics, Deparnnent of SpecialSurgery (Ababneh, El-Hadidy, Hassan) and the Section of EndocrineSurgery, Departrnent of Surgery (Younes), Faculty of MedicinelUniversityof Jordan, Amman, Jordan. Address correspondence and reprint requests

to: Dr. Nidnl A. Younes, Section of Endocrine Surgery, Department ofSurgery, Faculty of MedicinelUniversity of Jordan, PO Box I3024,Amman11942, Jordan. Fax. +926 5353388. E-mail: niyounes@ju.eduio

References

1. De Almeida OM, Monteiro AA Jr, Neves R[, de Lemos RG,BrazJC, Brechtbuhl ER, et al. Distally based fasciocutaneous

' flap of the calf for cutaneous coverage of the lower leg and

dorsum of the foot. Ann Plast Surg 2000; 44: 367 -373.

2. Long CD, Granick MS, Solomon MP. The cross-leg flap

revisited. Ann Plast Surg 1993; 30: 560-563.3. Ponten B. The fasciocutaneous flap: its use in soft tissue

defects of the lower heg. Br J Plast Surg 1981 ;34: 215-220.4. Celikoz B, SengezerM, Isik S, Turegun M, Deveci M, Duman

H, et al. Subacute reconstruction of lower leg and foot defects

due to high velocity-high energy injuries caused by gunshots,

missiles, and land mines. Microsurgery 2005; 25:3-L4-

r--

5. Thatte RL, yeJikar AD, Chhajlani p, Thatte MR. successfuldetachment of cross-leg fasciocutaneous flaps on the tenth9?V_,

a report of 10 cas-es. Br J ptast Surgiqfi 39: 491_497.

6. George A, cunha-Gomes D, Thatte RL. Earry division ofpedicled flaps using a simple device: a new teihniq ue. Br JPlast Surg 1996 49: tt9-i22.

outco[re of occrusion trlatment forstrabismic amblyopia in children belowl2 years old '

Huda S. Al-Mahdi, FCcs, ophth,Abdulbari B e ne r, MF p HM,FRs^s.

A mblyopia refers to a decrease of vision, eitherAunilaterally or bilaterally for which no cause canbe focused

_by physicat examination of the eye (noevidence of organic eye disease). Most vision lossfrom amblyopia is preventable or reversible with theright kind of intenrention. r Amblyopia has a high riskof becoming blind due to potentiailoss to the soundeye from other causes. Treatment of amblyopia byocclusion has been described for more than iOO y.*tand remains the accepted treatment. r,2 The incidenceof amblyopia caused by sffabismus in Qatar is notknown. rn this study, we aimed to determine theoutcome of occlusion treatment given for strabismicamblyopia, and analyze which factors afflect theoutcome in Qatari children.

This is a retrospective study based at HamadGeneral Hospital, Doha. This hospital providescomprehensive tertiary health care s.*i.r, forall the residents residing in the State of Qatar, andthis is the main tertiarl-care center in the country.All strabismic amblyopia cases are treated in thishospital. We collecirO data retrospectively fromthe medical records of Qatari chiliren beiow lzyears who were treated with occlusion therapy forstrabismic^ gglyopia at Hamad General Hospitalfrom 1992-2002. Amblyopia was defined ui atleast 2 Snellen lines difference in visual acuity.The inclusion criteria were strabismus amblyopiuwith and without anisometropia. Anisom.iropiuwas defined as a difference in refractive .,,o,between 2 eyes of one diopter or more. Exclusioncriteria were pure anisometropic amblyopia, organicamblyopia, deprivation amblyopia, and patients withnystagmus or mental delay affecting the accuracyof visual acuity testing. We analyzed the followi;;risk factors; refractive error and anisometropial

Cross-leg fasciocutaneous flaps

age at presentation, age at initiation of treatment.vision at initiation of treatment, type of occlusi;;and compliance. Compliance was determin.Jby orthoptist comment as having good or poo,compliance. As slrabismus is diagnosed early, noaccurate measurement of initial visual acuity ttSnellen charts can be obtained in some patientiand we need to determine the fixation paftern asalternate or poor. The oulcome of the treatment wasdetermined by final visual acuity, which was testedusing Snellen charts,. We classified the patients into2 groups: Good group with visual acuiiy of 6/9 ormore, and poor group with visual acuity of less than619. Student's t-test, Chi-square, and Fiiher exact testwere performed, and the level p<0.05 was consideredas the cut-off value for significance.

During the study period, we identified 3gpatients, 15 boys and 23 girls. of these, 29 patients(76.3vo) had strabismus, and 9 patienrs (zz.7vo)had mixed strabismus and anisornetropia. Theirage at presentation, ranged from less than one upt9 8 years. All patients received occlusion therapy,full time (18 .4vo) and part time (gl .6vo). Th;;;were 28 children in the good outcome group,-and 10 in the bad outcome group. Figure I showsthe final visual acuity in the- amblyopir eye afterthe treatment on discharge: 73vo achieved 619 orbetter, 26vo achieved less than 6/9. Figure 2 showsthe percentage of patients with different nn* visualacuity for strabismus, and strabismus associatedwith anisometropia. Stigmatism in the good outcomegroup was 57vo, and 60vo. in the poor outcome group(p=a.642). Hyperrnetropia was present, g5vo for th;good outcome group, compared with 90vo for thepoor outcome group (p4.9zg). The mean age atpresentation for the good outcome group was 3.46years (SD 1.5) and for the poor outcome group was

!.05 years (SD 2.01); (p=0.34). Some patients had aSnellen acuity measurement prior to the start of thetreatment, and it was found that poor initial visualacuity appears to be significantly rrigrrer among thepoor outcome (70Vo) compared to the good outComegroup (l7.9Vo) (p=0.005). In 15 patients, fixationpattern was recorded as alternate or poor, in whicha measurement of initial visual acuity could not beobtained in those patients, 9 patients were recordedas having alternate fixation and all of them had goodoutcome. Poor fixation was recorded in 6 patients, 2of them had good outcome and 4 patrents had pooroutcome. There was a significant association betweencompliance and final visual acuity (as recorded by theorthoptist). Patients in the good outcome group hada significantly better compliance than th6se i" thepoor outcome group (p<0.001). In the good outcome

www.smj.org.sa Saudi Med I 2006;vol. 27 (10) 1611r