Successful Pedicled Anterolateral Thigh Flap Reconstruction for a Recurrent Ischial Pressure Ulcer: A Case With Multiple Recurrences Over a 7-year Follow-up

Ischial pressure ulcers are difficult ulcers to treat and have a low treatment success rate compared to sacral and trochanteric ulcers; regional flap failure further complicates the treatment. Reported here is a case of a 65-year-old man who experienced a spinal injury with paraplegia due to trauma 20 years ago. The patient experienced a recurrent ischial ulcer since 2007, and underwent several types of flap reconstruction with poor outcomes over a 7-year period.   Therefore, the chosen intervention was a pedicled anterolateral thigh (pALT) fasciocutaneous flap reconstruction for the ischial ulcer via a subcutaneous route. Over the 10-month follow-up, the recurrent ischial ulcer healed without wound dehiscence. Island pALT reconstruction appears to be an alternative technique for treating recurrent ischial pressure ulcers. Though reconstruction of ischial ulcers via the pALT technique has been described previously, this may be the first case report to describe pALT flap in a patient with recurrent ischial ulcers after failed reconstructions using a gluteus maximus flap, V-Y advancement flap, and hatchet flap.

Ischial pressure ulcers are difficult to treat and have a low treatment success rate¹ compared to sacral and trochanteric ulcers. In addition, there are many different techniques that can be used to treat ischial pressure ulcers, including primary wound closure, gluteus maximus flaps, V-Y advancement flaps, or inferior gluteal artery perforator flaps. However, several experts have recently described using the pedicled anterolateral thigh (pALT) flap for reconstruction of recurrent ischial pressure ulcers.^1,2 In the presented case, the authors followed a single patient with paraplegia with a recurrent ischial ulcer who had undergone several types of wound treatment over a 7-year period. The indurated ulcer was ultimately resolved by pALT reconstruction.

A 65-year-old man had experienced a spinal injury with paraplegia due to trauma more than 20 years ago prior to presentation at Tri-Service General Hospital, Taipei, Taiwan. The patient was living alone and was performing his activities of daily life (eg, sleeping, eating, showering, and driving) without assistance. He had a history of type 2 diabetes mellitus with regular oral medication, and a personal history that included cigarette smoking and alcohol consumption. He subsequently experienced an ischial ulcer in 2007, which was unsuccessfully treated via numerous techniques, including a gluteus maximus flap, a V-Y advancement flap, and hatchet flap reconstruction (Table 1). Therefore, the authors chose to perform a pALT flap reconstruction in November 2013 in an attempt to treat the recurrent ulcer.

At the final surgery, the ischial ulcer was approximately 5 cm x 5 cm, and located deep within the muscular fascia (Figure 1A). Therefore, the authors performed pALT reconstruction via the subcutaneous route. The pALT flap was raised in the standard manner, and perforators were carefully preserved intraoperatively. The length of the pedicle was approximately 10 cm, and the donor site was closed primarily, without any morbidity (Figures 1B and 1C). During the 10-month postoperative follow-up for this surgery (carried out in the outpatient department), the ischial ulcer resolved without wound dehiscence (Figures 1D and 1E).

As chronic recurrent ischial pressure ulcers are a common cause of morbidity in paraplegics and geriatric patients, it is important to treat these ulcers effectively. In the described case, the 65-year-old male patient was a paraplegic following spinal injury who underwent 10 different surgeries for the recurrent ischial pressure ulcer over a 7-year period before being successfully treated with pALT flap reconstruction.

Unfortunately, ischial ulcers are difficult to treat and have a high recurrence rate. Foster et al³ reported a 42% recurrence rate in an earlier study and a recent German study reported a 30% recurrence rate.⁴ The first-line surgeries for ischial ulcers include reconstruction using the gluteus maximus myocutaneous flap, the inferior gluteal thigh flap, the V-Y hamstring flap, or the tensor fascia lata flap. However, if the ischial ulcer recurs after these surgeries, the choices for reconstruction are limited, and pALT flap reconstruction should be considered.

Since its introduction by Song and colleagues⁵ in 1984, the free anterolateral thigh flap has been used extensively in the reconstruction of head and neck defects.^6,7 The advantages of using the island pALT or vastus lateralis myocutaneous flaps include a constant blood supply, sufficient bulk, simple elevation, no need to sacrifice the muscle if a fasciocutaneous flap is raised, and primary closure of the donor site without morbidity.^1,2 In addition, the pALT flap provides sufficient bulk to compensate for the dead space caused by adequate debridement. In this case, a patient who had experienced numerous ulcer recurrences was successfully treated via pALT flat reconstruction, and no recurrence or wound dehiscence was observed during the 10-month outpatient follow-up. Therefore, island pALT fasciocutaneous flap reconstruction can be used as an alternative technique for treating recurrent ischial pressure ulcers after previous failed treatments.

Chi-Yu Wang, MD; Yu-Jen Shih, MD; Chang-Yi Chou, MD; Tim-Mo Chen, PhD; Shyi-Gen Chen, PhD; and Yuan-Sheng Tzeng, MD are from the Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. Dr. Wang is also affiliated with the Division of Plastic Surgery, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan

Address correspondence to:
Yuan-Sheng Tzeng, MD
Plastic and Reconstructive Surgery
Tri-Service General Hospital
National Defense Medical Center
No. 325, Cheng-Kung Rd, Sec 2 Neihu 114
Taipei, Taiwan
m6246kimo@yahoo.com.tw

Disclosure: The authors disclose no financial or other conflicts of interest.