Outcomes of Cross-Leg Flap Use in Lower Limb Salvage in Resource-Limited Settings: A Systematic Review of Indications, Limitations, and Success Rates

Abstract

Cross-leg flaps remain a vital reconstructive option in the management of complex lower limb injuries, particularly in settings where microsurgical techniques are unavailable or unaffordable. This systematic review evaluates the outcomes, indications, limitations, and success rates of cross-leg flap use in lower limb salvage within resource-limited settings. A comprehensive search of PubMed, Google Scholar, Scopus, ScienceDirect, and the Cochrane Library was conducted to identify studies published up to July 2025, following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Seven studies encompassing a total of 726 patients were included, comprising case reports, case series, retrospective cohorts, and systematic reviews. Trauma was the most common indication for reconstruction, and fasciocutaneous flaps were the predominant type used. External fixators were frequently employed for limb immobilization, with the average time to pedicle division ranging from 20 to 62 days, depending on flap type. Flap survival rates were consistently high across all studies, ranging from 96% to 100%, with minimal reported complications. The review highlights that cross-leg flaps offer a simple, effective, and context-appropriate solution for limb salvage in low-resource environments. Despite limitations in study design and outcome reporting, the consistency of clinical success supports the continued use and teaching of cross-leg flap techniques in global reconstructive surgery. Further prospective studies are needed to standardize outcomes and refine protocols for broader application in underserved surgical systems.