A Modified Total Thigh Flap in the Reconstruction of Decubitus Ulcer

A total thigh flap may be another treatment option that surgeons may consider when they cannot achieve a coverage of the defect using other treatment modalities in patients with extensive decubitus ulcer concurrently with complications. It has a sufficient vascular supply and is therefore advantageous in providing a sufficient thickness, thus possibly minimizing the recurrence of decubitus ulcer. We divided the thigh muscle into the anterior and posterior compartment depending on the vascular territory to the desirable shape and size without affecting the healthy tissue. Thus, we restored defect sites to the natural shape. A 56-year-old man recently sustained grade 4 decubitus ulcer of the sacral, right ischial and bilateral subscrotal regions, accompanied by femoral osteomyelitis. The patient had a spinal cord injury due to the compression fracture of the 11th and 12th thoracic vertebrae and the 1st and 2nd lumbar ones, thus presenting with paraplegia. The patient had a past history of taking surgery for decubitus ulcer of the sacral and ischial regions (Fig. 1). In the right ischium, the tunnel connected decubitus ulcer to the proximal femur. On X-ray findings, there were multiple bony lesions in the ischium. On magnetic resonance imaging (MRI) scans, there was osteomyelitis accompanied by pathologic fracture in the proximal femur. On bone scan scintigraphy, there were findings that are suggestive of increased uptake and multiple osteomyelitis of the sacrum and ischium at the sites of decubitus ulcer. A bacterial culture test identified such bacterial strains as Pseudomonas aeruginosa and Klebsiella pneumoniae. The patient refused to take lower extremity amputation, and underwent dissection of the subtrochanteric area involving the right ischium. We therefore elevated semitendinosus and biceps femoris flaps to restore the sites of decubitus ulcer. From postoperative day 3 on, the patient had wound disruption with yellowish discharge at suture margins, accompanied by gross findings of inflammatory responses in the adjacent tissue accompanied by the partial necrosis of the femur. Therefore, we performed the infection control using daily surgical dressing, AQUACEL hydrofiber Ag (Convatec, Princeton, NJ, USA) and vacuum assisted wound dressing for approximately 15 days. Before the flap procedure, we performed a 3-dimensional (3D) femoral artery computed tomography (CT) to confirm major branches of the deep femoral artery and thereby evaluated the shape and type of preoperative vessels of the descending branch and medial circumflex branch of the lateral circumflex artery [1]. In addition, we also performed colostomy Fig. 1. The patient …