In-Service Exam
Pressure Sore - 2001





A 20-year-old man with paraplegia has a large grade IV pressure ulcer of the left ischium. He previously underwent ligation of the profunda femoris artery on the left. Which of the following flaps is most appropriate for reconstruction in this patient?

(A) Gluteal thigh flap
(B) Gracilis flap
(C) Rectus femoris flap
(D) Tensor fascia lata flap
(E) Vastus lateralis flap

The correct response is Option A.

The gluteal thigh flap is most appropriate for reconstruction of this paraplegic patient's ischial pressure ulcer because this is the only flap of those listed whose regional arterial vascularity is provided by a source other than the profunda femoris artery, namely the inferior gluteal artery and venae comitantes. As much as 10 cm * 35 cm can be harvested with this flap. It is frequently transferred as a fasciocutaneous flap with elevation of the inferior portion of the gluteus maximus muscle to the lateral edge of the sacrum.

The gracilis myocutaneous and rectus femoris flaps have a type II vascular pattern and can also be used for coverage of most ischial pressure ulcers. Circulation is provided by the profunda femoris artery via the ascending branch of the medial circumflex artery and venae comitantes for the gracilis flap and via the descending branch of the lateral circumflex artery and venae comitantes for the rectus femoris flap.

In contrast, the tensor fascia lata and vastus lateralis flaps both have a type I vascular pattern. The tensor fascia lata flap can be used for coverage of trochanteric, ischial, and sacral pressure ulcers and the vastus lateralis flap for coverage of trochanteric and ischial pressure ulcers. Like the rectus femoris flap, circulation of the vastus lateralis flap is provided by the profunda femoris artery via the descending branch of the lateral circumflex artery and venae comitantes. In contrast, vascularity of the tensor fascia lata flap is provided by the profunda femoris via the ascending branch of the lateral circumflex artery and venae comitantes.

References
1. Mathes SJ, Nahai F, eds. Reconstructive Surgery: Principles, Anatomy, and Technique. New York, NY: Churchill Livingstone, Inc; 1997;1:499-679, 1161-1307.
2. Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Grabb's Encyclopedia of Flaps. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1998;3:1429-1431, 1664-1666, 1681-1684, 1689-1697.

In paraplegic patients with chronic pressure ulcers, which of the following is the most common cause of death?

(A) Pulmonary sepsis
(B) Pulmonary thromboembolism
(C) Renal failure
(D) Sepsis secondary to pressure ulcers
(E) Urosepsis

The correct response is Option C.

In paraplegic patients with chronic pressure ulcers, renal failure secondary to chronic amyloidosis is the most common cause of death. Pulmonary sepsis, thromboembolism, and respiratory failure are frequent causes of death immediately following the traumatic onset of paraplegia but not in patients with long-standing paraplegia who subsequently develop pressure ulcers. Sepsis secondary to pressure ulcers is uncommon. Although urosepsis is a common problem for patients with long-standing paraplegia, antibiotics decrease the likelihood of death.

References
1. Colen SR. Pressure sores. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;6;3797-3798.
2. Hackler RH, Dalton JJ, Bunts RC. Changing concepts in the preservation of renal function in the paraplegic. Urology. 1965;94:107-111.