Open leg fractures are severe and common injuries. When a free flap and/or a local pedicled flap is not feasible or has failed, the cross-leg flap remains a last-resort option to avoid amputation. The aim of this study is to explain the technical aspects and clinical advantages of the distal bipedicled “supra cross-leg” flap, based on a series of four cases. Four patients underwent reconstruction using a distal bipedicled “supra cross-leg” flap between 2016 and 2026 at HIA Percy, a Level I trauma center and burn treatment center (Clamart, France). Demographic, trauma-related, and surgical data were collected. All patients were male, with a mean age of 35 years (± 7.9). The distal bipedicled “supra cross-leg” flap was performed at a mean of 59 days (± 15.9) after injury. The mean flap size was 408 cm2 (± 99.3). Three patients required early surgical revision due to infection. Flap division was performed at a mean of 34 days (± 4.1). No flap failure was observed. The reconstructed soft tissue coverage subsequently allowed secondary bone reconstruction through partial elevation of the flap. The distal bipedicled “supra cross-leg” flap is a reliable and reproducible technique that allows extensive cutaneous coverage. This flap, combining a distal sural flap and a distal great saphenous flap of the leg, enables coverage of large soft-tissue defects thanks to a wide usable flap surface and a rich, mixed vascular supply dependent on the posterior tibial and fibular vascular networks. The timing of flap division should be delayed when premature flap elevation is required for septic reasons. The length of the pedicle facilitates positioning of the flap on the recipient site. The use of external fixation to temporarily stabilize the two lower limbs provides a stable construct that facilitates nursing care and patient mobilization. IV.
Background Heart failure (HF) in older adults is frequently accompanied by frailty, multimorbidity, cognitive impairment, and functional vulnerability, making standard disease-centred pathways difficult to apply in routine practice. Although frailty-informed care and age-friendly principles are increasingly advocated, detailed real-world descriptions of operational cardiogeriatric service models remain scarce. We therefore describe the development and implementation of a hospital-based cardiogeriatric decision algorithm for older adults with HF, integrating frailty stratification and the 4Ms framework. Methods This study is a descriptive, single-centre service development report conducted in the Department of Cardiogeriatrics at Hôpital La Porte Verte, Versailles, France. Its aim was not to evaluate effectiveness, but to describe the rationale, structure, implementation process, and operationalization of a real-world decision algorithm for older adults with HF. The model was informed by heart failure guidelines, frailty-based clinical reasoning, and the Age-Friendly Health Systems 4Ms framework. It incorporated frailty stratification, comprehensive geriatric assessment, advanced practice nurse coordination, day-hospital management, telemonitoring, therapeutic education, and supportive or palliative care when appropriate. Results From 2023 onwards, the decision algorithm was progressively embedded into routine inpatient, outpatient, day-hospital, and telemonitoring practice. It provided a shared multidisciplinary framework for aligning therapeutic intensity with frailty status, functional reserve, cognitive status, and patient priorities. In practice, the algorithm supported profile-adapted therapeutic orientation across inpatient, ambulatory, and supportive care settings, while helping structure coordination between cardiology, geriatrics, nursing teams, and community care. This report does not present a formal comparative evaluation of clinical outcomes; its findings should therefore be interpreted as descriptive and hypothesis-generating. Conclusions This single-centre experience describes a pragmatic and age-friendly cardiogeriatric decision algorithm for older adults with HF and complex care needs. By integrating frailty assessment, the 4Ms framework, and coordinated multidisciplinary care into routine practice, the model offers a transferable organisational approach for clinicians managing older patients with HF. Formal evaluation is now needed to assess implementation outcomes, patient-centred outcomes, and scalability.
