Total thigh flaps as a salvage procedure in paraplegics with massive ulcers

Abstract

A small percentage of spinal cord injured (SCI) patients with frequent recurrent pressure sores will eventually develop massive ulcers of the buttocks that are no longer amenable to local tissue coverage. The amputation of one leg and the creation of a total thigh musculocutaneous flap (TTF) may then be appropriate. The purpose of this paper is to evaluate the indications for and the efficacy of this procedure in nine SCI patients who underwent 10 TTF between February 1989 and November 1994. These patients had numerous previous hospitalizations (mean 12.1 admissions) and operations (mean 13.1 operations) for pressure sores. Past psychiatric evaluation found seven of eight males to have a similar history of social, financial and behavioral problems. The typical presentation was a septic, malnourished patient with massive ulceration of his buttocks. Only after wound and patient stabilization was the TTF chosen as a salvage procedure. The operation was long and associated with excessive blood loss. The most common complications were wound dehiscence or partial necrosis (five of 10), sepsis (five of 10), hemodynamic instability (five of 10), and chronic drainage (four of 10). The reoperation rate for complications was six of 10 cases. Long term follow-up (mean 3.5 years) on seven of eight surviving patients showed that these patients had resumed independent living but they had all developed new pressure sores as early as three months post TTF. The underlying risk factors for pressure sores had not changed. The total thigh flap operation remains a last resort procedure in a very small percentage of spinal cord injured patients because of its high morbidity, high reoperative rate for complications, and inability to prevent recurrence of pressure sores.