This document summarizes a study on the outcomes of occlusion treatment for amblyopia in children under 12 years old with strabismus. The study reviewed medical records of 38 Qatari children treated with occlusion therapy for strabismic amblyopia from 1992-2002. Good outcomes, defined as final visual acuity of 6/9 or better, were found in 73% of patients. Poor outcomes with visual acuity less than 6/9 occurred in 26% of patients. Factors like age at presentation, type of strabismus, presence of anisometropia and compliance did not significantly affect treatment outcomes.

1. r-
Role of methylprednisolone in unrosolving cases of ARDS
4. Ihle BU. Adrenocortical response and cortisone replacement in 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 Jr, RC Burch JM, et al. Are corticosteroids salvage therapy for
refractory a9_ute respiratory distress syndro*"r Am i sorg
1995; 170: 591-595.
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Gross-l€g fasciocutaneous flaps. stiil a valid option for reconstruhtion of traumatic 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 of rthe leg and foot represents a great challenge for
plastic surgeons, especially when itre defect is iarge.
The reduced vascularify and subsequent poor healiig
encountered in these regions, as well aJ the timitel
availability of local tissue for reconstruction,
demands a careful evaluation of the wound, lod
detailed knowledge of the local anatomy to select
the best surgical procedure for each patient.l Cross-
Ieg flaps described by Hamilton ir lgs4, were
used widely to save limbs, but nowadsys, they are
considered by many as obsolete and '.awkward"
procedures.2 However, the lasf decades have
witnessed many surgeons using different types and
modifications of cross-leg flaps as a prim erry, or as
a salvage procedure, following failurb of previous
attempts at lower limb reconstruction.2 The oUiective of this retrospective review, is to evaluaie our
experience at the Jordan University Hospital, in using
cross-leg fasciocutaneous flaps for reconstruction o1
large defects of the lower UrirA of the leg and foot
regarding the outcome and complications.
A chart review, was conducted on lz patients
who undenvent cross-leg fasciocutaneous flaps for
reconstruction of large lower leg and foot difects
between 1998 and 2005 at the Jordan University
Hospital, Amman, Jordan. The medical records of
these patients were reviewed for demographics,
wound size, etiology, locatior, procedures perronneo,
complications, healing time, and furttrer revision
surgery related to the repair. Nine of the patients had
Figure I . The flap sutured to the recipient site.
a post traumatic defect induced by motor vehicle
accidents, 2 patients had defects resulted from
grushing by heavy objects, and one patient had a large
full thickness burn. The flaps were proximally UasJO
on the axial blood supply of the posterior desCending
subfascial cutaneous branch of the popliteal utt"ri
and raised frorn the posterior aspeci of ttre contri-lateral
leg. The donor site was cloied either primarity
or with skin graft (Figure l). The limbs wlre fixei 'by plaster of Paris cast. A window was created in
the cast opposite of flap for future inspection. The
average time between flap coverage and division was
approximately 20.8 days (range 18-23 days).
Twelve patients (8 males and 4 females) were
included in the study with a mean age of 10.3
years (range 0.3-30 years). The time between injury
Td repair_range approximately 5 days to 4 y.*r.
The site of defect was the lower third of the ieg in
5 patients (4l.6vo), dorsum of foot in 4 (33.3vo),f,eel
in 2 (l6.6vo), and the big toe in one patient (g .3vo).
seven patients (58 .3vo) had compound fractures
with bony exposure, 3 patients (25vo) had bony
exposure without fractures, and Z patients ( 16.6q;)
had exposure of dorsal extensoi tendons. Two
patients (l6.6vo) received non-vasculari zed bone
grafts to replace the bone loss; one graft was
harvested from the opposite fibula; andlhe other
one from the iliac crest. The mean size of the
defect was 59.3 cm2 (range 27-r20).The mean time
between repair and flap division was 20.g days
(range 18-23). AII the patients were discharged
from the hospital with viable flaps after iH"
procedure. The mean follow-up period was 37.6
months (ran ge 2-71). one patient (g.3 vo) hadpartial
flap loss that healed later by dressings in the out
patient clinic. Two patients ( l6.6Vo) with heel defects (in the weight bearing area) developed recurrent
ulceration and hyperkeratosis that required further
reconstruction. Four patients (33 .3vo) required
www.smj.org.sa Saudi Med I 2ffi6;yot.27 (10) 1609

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Cross-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 repair
Sptit-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)
Complications
Partial flap necrosis
Wound infection
Joint stiffness
20.8 (18-23)
1 (8.3)
0 (0)
0 (0)
Recurrent ulceration and hyperkeratosis 2 (16.6)
Minor flap revision or thinning 4 (33.3)
minor flap revision for better cosmesis. A11 the other
patients maintained durable soft tissue cover with
satisfactory 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 plastic
surgeons. The beginning of microsurgery in the
1970s, and the introduction of myocutaneous and
fasciocutaneous flaps by Ponten3 in 1981, have
revolutionized the reconstruction of lower extremity
defects. Free flaps using the microsurgical
techniques, have been used successfully to cover
acute and chronic large lower extremity defects.a
However, free flaps require special skills and
relatively expensive instrumentation not readily
available to all reconstructi'Le surgeons, particularly
in the developing countries. Moreover in serious
cases, free flaps are highly risky or even difficult
to perform.z The other alternative is to use local
fasciocutaneous and muscle flaps. This option
however, may not also be achievable due to the
absence of adequate healthy 'local tissues. In such
circumstances, the use of cross leg fasciocutaneous
flaps offers a valid alternative to free flaps or local
flaps. The major drawbacks of this procedure include
an unreliable blood supply, limited arc of rotation
caused by a short and thick pedicle, and the need for
inconvenient postoperative immobilization.z Some
surgeons used external fixation devices to achieve
better patient convenience and joint mobility, in
addition to facilitating flap monitoring and wound
care. 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 ithout
complications. George et al6 used a simple occlusion
clamp 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 were
divided aftgr 18 days. The facilities for free tissue
transfer in our center, like most of the centers in the
developing countries are still lacking. We depend
mainly on cross-leg posterior tibial fasciocutaneous
flaps to repair defects of the lower leg and foot.
Only 9Vo of our patients in this series had partial flap
necrosis, which compares well with the rate of partial
or 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. Two
patients with heel defects (I6.6Vo) in this series had
recurrent ulcerations following cross-leg flaps.
Cross-leg flaps , are still safe and reliable method
for soft tissue reconstruction of traumatic lower
extremity defects. They should be viewed as a viable
alternative for wounds with extensive exposure of
bone and tendon. These flaps provide similar tissue to
that lost, they are easy to raise, require short operative
time, are associated with minimal blood loss, and
they preserve the major arteries in the traumatized
leg.
Acknowledgment. This work was supported by the Faculty of
MedicineAJniversity 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 of
Surgery Qabaiti, Salah), Section of Orthopedics, Deparnnent of Special
Surgery (Ababneh, El-Hadidy, Hassan) and the Section of Endocrine
Surgery, Departrnent of Surgery (Younes), Faculty of MedicinelUniversity
of Jordan, Amman, Jordan. Address correspondence and reprint requests
to: Dr. Nidnl A. Younes, Section of Endocrine Surgery, Department of
Surgery, Faculty of MedicinelUniversity of Jordan, PO Box I3024,Amman
11942, 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-

3. r--
Cross-leg fasciocutaneous flaps
5. Thatte RL, yeJikar AD, Chhajlani p, Thatte MR. successful
detachment of cross-leg fasciocutaneous flaps on the tenth
9?V_,
a report of 10 cas-es. Br J ptast Surgiqfi 39: 491_
497.
6. George A, cunha-Gomes D, Thatte RL. Earry division of pedicled flaps using a simple device: a new teihniq ue. Br J Plast Surg 1996 49: tt9-i22.
outco[re of occrusion trlatment strabismic for amblyopia in children below l2 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, either Aunilaterally or bilaterally for which no cause can
be focused
_by physicat examination of the eye (no
evidence of organic eye disease). Most vision loss
from amblyopia is preventable or reversible with the
right kind of intenrention. r Amblyopia has a high risk
of becoming blind due to potentiailoss to the sound
eye from other causes. Treatment of amblyopia by
occlusion has been described for more than iOO y.*t
and remains the accepted treatment. r,2 The incidence
of amblyopia caused by sffabismus in Qatar is not
known. rn this study, we aimed to determine the
outcome of occlusion treatment given for strabismic
amblyopia, and analyze which factors afflect the
outcome in Qatari children.
This is a retrospective study based at Hamad
General Hospital, Doha. This hospital provides
comprehensive tertiary health care s.*i.r, for
all the residents residing in the State of Qatar, and
this is the main tertiarl-care center in the country. All strabismic amblyopia cases are treated in this
hospital. We collecirO data retrospectively from
the medical records of Qatari chiliren beiow lz
years who were treated with occlusion therapy for
strabismic^ gglyopia at Hamad General Hospital from 1992-2002. Amblyopia was defined ui at
least 2 Snellen lines difference in visual acuity.
The inclusion criteria were strabismus amblyopiu with and without anisometropia. Anisom.iropiu
was defined as a difference in refractive .,,o,
between 2 eyes of one diopter or more. Exclusion
criteria were pure anisometropic amblyopia, organic
amblyopia, deprivation amblyopia, and patients with
nystagmus or mental delay affecting the accuracy
of visual acuity testing. We analyzed the followi;;
risk factors; refractive error and anisometropial
age at presentation, age at initiation of treatment.
vision at initiation of treatment, type of occlusi;; and compliance. Compliance was determin.J
by orthoptist comment as having good or poo,
compliance. As slrabismus is diagnosed early, no
accurate measurement of initial visual acuity tt
Snellen charts can be obtained in some patienti
and we need to determine the fixation paftern as
alternate or poor. The oulcome of the treatment was
determined by final visual acuity, which was tested
using Snellen charts,. We classified the patients into
2 groups: Good group with visual acuiiy of 6/9 or
more, and poor group with visual acuity of less than
619. Student's t-test, Chi-square, and Fiiher exact test
were performed, and the level p<0.05 was considered
as the cut-off value for significance.
During the study period, we identified 3g
patients, 15 boys and 23 girls. of these, 29 patients
(76.3vo) had strabismus, and 9 patienrs (zz.7vo)
had mixed strabismus and anisornetropia. Their
age at presentation, ranged from less than one up
t9 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 shows
the final visual acuity in the- amblyopir eye after
the treatment on discharge: 73vo achieved 619 or
better, 26vo achieved less than 6/9. Figure 2 shows
the percentage of patients with different nn* visual
acuity for strabismus, and strabismus associated
with anisometropia. Stigmatism in the good outcome
group 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 the
poor outcome group (p4.9zg). The mean age at
presentation for the good outcome group was 3.46
years (SD 1.5) and for the poor outcome group was
!.05 years (SD 2.01); (p=0.34). Some patients had a
Snellen acuity measurement prior to the start of the
treatment, and it was found that poor initial visual
acuity appears to be significantly rrigrrer among the
poor outcome (70Vo) compared to the good outCome
group (l7.9Vo) (p=0.005). In 15 patients, fixation
pattern was recorded as alternate or poor, in which
a measurement of initial visual acuity could not be
obtained in those patients, 9 patients were recorded
as having alternate fixation and all of them had good
outcome. Poor fixation was recorded in 6 patients, 2
of them had good outcome and 4 patrents had poor
outcome. There was a significant association between
compliance and final visual acuity (as recorded by the
orthoptist). Patients in the good outcome group had
a significantly better compliance than th6se i" the
poor outcome group (p<0.001). In the good outcome
www.smj.org.sa Saudi Med I 2006;vol. 27 (10) 1611r