(CS-126) Vastus Lateralis and Vastus Intermedius Myocutaneous Flap Reconstruction for Complicated Trochanteric and Ischial Pressure Sores with Extended Girdlestone Resection: A Case Series

Introduction: After performing Girdlestone arthroplasty for a trochanteric pressure sore involving the hip joint, reconstruction with the vastus lateralis is the flap of choice. With more extensive defects or combined ischial pressure ulcers, a modified flap is necessary to obliterate the large dead space. This study aims to present a case series of vastus lateralis (VL) and vastus intermedius (VI) myocutaneous flap reconstruction after extended proximal femoral osteotomy in a paraplegic patient and to discuss the background anatomy.

Methods: Between March 2017 and December 2021, a total of 8 patients having trochanteric and ischial sore patient with exposed proximal femur with chronic hip joint arthritis who needed the Girdlestone operation were selected for the surgery. The anterolateral thigh (ALT) perforators were located, and a skin paddle was designed around them. The VL and VI muscles were dissected and raised together as a unit from the femur. The descending branch of the lateral circumflex femoral artery was not exposed during the procedure. (Figure 1)

Figure 1. An illustration showing the surgical path and surgical plane in a cross-section of the mid-thigh. The green dotted line represents the dimension of the flap. (F, femur; RF, rectus femoris; VM, vastus medialis; VI, vastus intermedius; VL, vastus lateralis; BF, biceps femoris; ST, semitendinosus)

Results: A total of 9 flaps was elevated and the defect was successfully reconstructed without dead space. After surgery, all patients healed within 1 month; 3 patients experienced minor complications. The average follow-up period was 14.5 months, during which time only one patient with ischial pressure ulcer developed wound disruption and recurrence. The average thickness of the rotated muscle was 51.95mm at 2 to 4 weeks postoperatively and 53.07mm at 6 months postoperatively (𝑝=0.071).

Discussion:

For paraplegic patients with muscle atrophy in the legs, vastus lateralis and vastus intermedius myocutaneous flap obtain a sufficient volume to eliminate the dead space of the hip joint socket. This technique offers several advantages: a) it is an anatomically ideal composition which has skin and muscle of the same vascular origin; b) it provides adequate volume; and c) by preserving the rectus femoris, it protects the bare femur with superior structural stability, resulting in reduced donor site morbidity. However, in the ischial area, an increased range of motion of the hip joint may be a drawback in the application of this method.

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