Eur J Plast Surg (1989) 12:231-233 European ] [ ' ~1 __e Joumal of I .IaSIIC bur i ry © Springer-Verlag 1989

Total Thigh and Leg Myocutaneous Flap for Repair of Multiple Pressure Ulcers

H . M . A . E1 F a k i Ministry of Health, Mafraq Hospital, P.O. Box 2951, Abu Dhabi, United Arab Emirates

Summary. A la rge m y o c u t a n e o u s f l ap o b t a i n e d b y f i l le t ing the l o w e r l i m b was u s e d to c o v e r t he de fec t r e s u l t i n g f r o m exc i s ion o f t h r e e ex tens ive p r e s s u r e so res in a s ingle o p e r a t i v e p r o c e d u r e . T h e p r o c e - d u r e w a s ea sy a n d t i m e sav ing . I t ha s lef t the p a - t i en t w i t h sof t t i s sue re se rves in the e v e n t t h e r e s h o u l d be r e c u r r e n c e o f d e c u b i t i s in the fu tu re .

Key words: M u l t i p l e p r e s s u r e sores - M y o c u t a n - eous f l ap - T o t a l leg - F i l l e t t e c h n i q u e

P r e s s u r e u lce r s a re a c o m m o n p r o b l e m in p a t i e n t s w i th s p i n a l c o r d in ju ry . T r e a t m e n t f r e q u e n t l y in- volves l o n g - t e r m h o s p i t a l i z a t i o n , m u l t i p l e su rg i ca l p r o c e d u r e s , a n d f r e q u e n t r ecu r r ences .

M u l t i p l e p r e s s u r e sores a r e a c h a l l e n g e to the p l a s t i c s u r g e o n . M a n y loca l a n d m y o c u t a n e o u s f laps a r e a v a i l a b l e , b u t t hey a r e o c c a s i o n a l l y im- p o s s i b l e to use b e c a u s e t he p r o x i m i t y o f p r e s s u r e u lce r s to e a c h o t h e r r e su l t in de f i c i ency o f the ava i l - ab l e a d j a c e n t so f t t i ssue fo r c o v e r a g e o f de fec t s f o l l o w i n g d e b r i d e m e n t .

Th i s is a case o f a y o u n g p a r a p l e g i c m a l e w h o h a d t h r e e l a rge p r e s s u r e so res : one l a rge sac ra l so re w i t h e x t e n s i o n to the l o w e r b a c k a n d two l a rge t r o c h a n t e r i c sores . T h e one o n the r i g h t e x t e n d e d i n t o the h i p j o i n t w i t h c o m p l e t e d e s t r u c t i o n o f the a r t i c u l a r h e a d o f the f e m u r ; in a d d i t i o n , the u p p e r t h i r d o f the f e m u r s h o w e d o s t e o m y e l i t i c changes . T h e r i g h t t h i g h was swo l l en a n d the o v e r l y i n g sk in was s h i n y a n d e d e m a t o u s . T h e lef t t r o c h a n t e r i c so re was deep a n d ex tens ive . A l a rge m y o c u t a n - eous f l ap was c r e a t e d a f t e r f i l l e t ing the r e m a i n i n g p a r t o f the f emur , t ib ia , a n d f ibu la . T h e f l ap was t r a n s f e r r e d en m a s s to c o v e r the de fec t in a one s t age p r o c e d u r e .

Case Report

A 26-year-old man was involved in a car crash which resulted in a spinal cord injury. Six months after the injury, he was transferred to our hospital. On admission, he was weak, toxic, pale, and febrile with a foul smelling and soiled dressing. He had paraplegia below D6. He had three large pressure sores (Fig. 1). The central one involved almost the entire sacral region with undermining of the skin of the lower back. The right tro- chanteric sore was moderate in size on the surface, but extended deeply into the hip joint. On manipulating the right thigh, the upper part of the femur extruded from the ulcer. The left tro- chanteric sore was also deep and extensive. His blood investiga- tions showed Hb of 8 gm and negative blood culture. A swab from the ulcers grew a wide spectrum of aerobic and anaerobic organisms. X-ray of the pelvis showed complete destruction of the head of the right femur and osteomyelitis of the upper part of the femur (Fig. 2). The gravity of his condition was explained to his family, and various treatment modalities were discussed. He received blood transfusion and antibiotics. The ulcers were irrigated daily with Eusol and packed with Eusol paraffin gauze. Three weeks later, his general condition im- proved. The patient and family agreed to sacrifice the right lower limb to reconstruct the multiple decubitis ulcers.

Operative Procedure

Under general anesthesia with the patient in the prone position, the three pressure ulcers were debrided, including excision of the upper part of the right femur. The two small musculocutan- eous bridges between the sacral sore and trochanteric sores were transposed inferiorly creating one continuous defect (Fig. 3). Through a lateral incision on the right thigh extending onto the anterolateral aspect of the leg, the remaining part of the femur was removed by subperiosteal dissection through the usual lateral muscle splitting approach. The patella was dissected off its ligamentous and tendinous attachments by sharp dissection. The tibia was removed by subperiosteal dissec- tion without disturbing the extensor muscle compartment. The upper third of the fibula was difficult to fillet, and we had to follow the attachment of the interosseous membrane to avoid injuring the peroneal branch of the anterior tibial artery. A huge musculocutaneous flap was harvested extending to 10 cm above the ankle joint (Fig. 5).

The postoperative course was uneventful. The patient was ,discharged in good health and has remained in satisfactory condition (Fig. 6).

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Fig. 1 a, b. Multiple decubiti in a young paraplegic. a Sacral and right troehanteric sore; b Sacral and left trochanteric sore

Fig. 2. Destruction of right hip joint

Fig. 3. Debridement of pressure sores

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Fig. 4. Fillet of right leg

Fig. 5. Large thigh and leg myocutaneous flap used to close defects

Fig. 6. Patient after six months. Note excess of soft tissue

Discussion

The neglected pressure ulcers in this patient with associated joint and bone involvement were endan- gering his life. The infected joint and the osteomye- litic changes in the bone did not play a role in our decision to sacrifice the whole limb. The inci- dence of flap failure is due to hematoma [2]. The soft tissue defects were too extensive to cover by conventional flaps. Other methods of treatment such as bilateral hip resection [1] and use of avail- able soft tissue to cover the defects in bilateral tro- chanteric sores, would not have supplied enough soft tissue and skin to cover the extensive sacral sores in this patient.

This patient is now left with good skin cover which provides a cushion. He has enough reserve of soft tissue to repair any future ulcers which may develop. This method of repair is only suggested for neglected paraplegic patients with extensive pressure ulcers complicated by bone and joint sep- sis.

References

1. Saqi A, Meller Y, Kon M, Rosenberg L, Ben-Yakar Y (1987) Bilateral hip resection for closure of trochanteric pressure sores - case report. Paraplegia 25:39-43

2. Thornhill-Joynes M, Gonzales, Stewart CA, Kanel GC, Ca- pen DA, Sapico FL, Canwati HW, Montgomerie JZ (1986) Osteomyelitis associated with pressure ulcers. Arch Physiol Med Rehabil 67: 314-318