Introduction:
Chronic sacral pressure sores in paraplegic are often quite extensive and difficult to reconstruct. Lack of post-operative beds in spinal units keep them in the community for months and years without definitive care. We decided to reconstruct neurologic sacral pressure sores with perforator propeller flaps with a modified post-operative nursing protocol.
Case report:
A 43 year old patient with spina bifida presented with an extensive grade III sacral wound of 20 cm by 20cm in size. Multiple failed local transposition flaps and surgically fused hip joints compounded the problem. With sufficient clinical experience with internal pudendal artery perforator flaps for perineal reconstruction and given the fixed flexion at bilateral hip joints, we decided to reconstruct this large defect with 2 perforator propeller flaps in a 2 staged procedure both with a 180 arc of rotation. The residual raw area was VACed for 4 weeks. Donor sites for both flaps were primarily closed.
The nursing care involved rule of 2 - no pressure bearing on the flap side for 2 weeks and intermittent 2 hourly flap offloading for a further 2 weeks. Seating protocol started after 2 months again with 2 hour offloading. Complete flap healing was achieved and patient care was transferred to nursing home on discharge.
Discussion:
Perforator flaps are quite reliable and robust to reconstruct extensive sacral wounds. Unlike regional pedicled flaps, the perforator vessel in a propeller design still remains mostly perpendicular to skin after the final inset. The direction, quantity and blood flow dynamics remain minimally altered. The redraping of the skin apron makes them more resistant to pressure dehiscence.
Conclusion:
A model of carefully planned perforator flaps combined with tailored nursing care can be tried while waiting for multi-million dollar spinal care units to rehabilitate such patients.