Cross-Leg Sural Flap for Limb Salvage After Ballistic Femoral Trauma

Complex lower-limb reconstruction after ballistic trauma remains challenging when infection, repeated debridement and vascular compromise limit conventional options. We report the case of a 39-year-old active-duty soldier who sustained polytrauma after an improvised explosive device blast, including a comminuted open femoral fracture. Following staged bone reconstruction, recurrent multidrug-resistant infections and repeated revisions resulted in distal lateral thigh soft-tissue loss with exposed osteosynthesis material. Free flap reconstruction was considered unsafe because the recipient vascular territory was judged unreliable after blast injury and multiple operations. A contralateral distally based cross-leg sural flap was therefore performed and the limbs were stabilised with a Hoffmann III external fixator. Flap autonomisation was confirmed at 3 weeks and pedicle division was completed successfully. The flap survived completely, providing stable coverage; a minor proximal dehiscence healed with negative-pressure wound therapy. This case illustrates that cross-leg pedicled flaps remain relevant in modern limb salvage, particularly when microsurgical reconstruction would expose the patient to an excessive risk of failure.