Double Cross-Leg Reverse Sural Flap for Coverage of an Extensive Single-Leg Soft-Tissue Defect: A Case Report

Extensive soft-tissue defects of the distal lower extremity following high-energy trauma represent a major reconstructive challenge, particularly when involving the heel and ankle. The reverse sural flap is a well-established option for distal leg and foot coverage; however, its dimensions are traditionally limited, and large defects often require free tissue transfer. We report the case of a 23-year-old male who sustained a high-speed motorcycle accident resulting in an extensive right heel and ankle soft-tissue defect with exposed calcaneus, associated with calcaneal fracture, subtalar dislocation, and talar dislocation. After fracture reduction and serial surgical debridements, a circular defect measuring approximately 18 cm in diameter persisted. Due to the absence of a microsurgical service, bilateral crossed reverse sural fasciocutaneous flaps were performed to achieve adequate coverage. Pedicles measuring approximately 14 cm were transposed in a cross-leg fashion, and both lower limbs were temporarily stabilized with transosseous tibial fixation for three weeks. Following pedicle division, both flaps demonstrated full vascular autonomy without partial or total necrosis. Donor sites were covered with split-thickness skin grafts harvested from the posterior thighs. At nearly one year of follow-up, the patient achieved partial ambulation with stable soft-tissue coverage, preserved protective sensitivity, and satisfactory scar maturation. Bilateral crossed reverse sural flaps may represent a viable limb-salvage strategy for massive unilateral heel and ankle defects when microsurgical reconstruction is not feasible, expanding the traditional indications of the reverse sural flap in complex post-traumatic injuries.