Reconstructive Surgery for Sacral Ulcer

Abstract

The sacral ulcer is a common occurrence in certain groups of patients. It can develop at different stages of a patient’s life, whether after acute injury or acute illness. The ulcer occurs when a patient is kept in a supine position without turning or using a special bed or mattress. It can also occur after the rehabilitation stage when an insensate patient is sent home to integrate back into normal life and begins sitting in a wheelchair, as seen in spinal cord injured patients (see Chap. 2). In a review of the literature on reconstructive options for sacral ulcer, some authors advise using the fasciocutaneous flap from the lumbar area to close a sacral defect [1–3]. The author’s experience in dealing with patients with spinal cord injury or spina bifida is that this flap is not suitable for these groups of patients because of the multiple surgeries they have had over their back and lumbar area. It is technically difficult to raise the fasciocutaneous lumbar flap because of the scarring and limited number of spinal perforators, which eventually subjects these flap to vascular compromise, ending in necrosis. The main muscle used for the repair of the sacrococcygeal ulcer is the gluteus maximus muscle in different design of flaps – musculocutaneous, muscular, and fasciocutaneous. The muscle can be used in rotation, advancement, and splitting. The gluteus muscle is the most durable muscle for closing a sacral defect and provides a soft tissue padding for the bony area that is anatomically not covered by muscle. The sacrum and coccygeal bone are covered by skin and subcutaneous tissue [4, 5, 7–9]. The method in which the gluteus maximus muscle is used depends on the primary diagnosis of the patient and whether the goal is to preserve muscle function after recovery [10, 11]. For ambulatory and sensory patients, the gluteus maximus island advancement flap is recommended more than the fasciocutaneous flaps, which are based on the gluteal muscle perforator [12–16]. The author’s experience is that these flaps cannot be revised or reused in cases of ulceration recurrence, as in patients with spinal cord injury.