Treatment of large ischial ulcers communicating with the hip joint with proximal femoral resection and reconstruction with a combined vastus lateralis, vastus intermedius and rectus femoris musculocutaneous flap.

Pressure ulcers which communicate with the hip joint are very difficult to treat. Often, the hip joint is infected with osteomyelitis of the proximal femur resulting in bouts of sepsis and flap failure. These patients require proximal femoral resection and wide debridement in order to eradicate the infection, which in turn results in large and deep cavities. Reconstruction requires either a muscle flap or even a total thigh flap if the defect is very large and the pelvis is involved. In a series of six ischial or ischio-trochanteric pressure sores communicating with the hip joint, following multiple serial debridements, the vastus lateralis, vastus intermedius and rectus femoris muscles were raised as a single musculocutaneous flap ('three muscle flap'), based on the descending branch of the lateral femoral circumflex artery, and transposed into the defect. All patients were paraplegics and had signs of sepsis during admission. Two patients had prior failed reconstructions within 3 months of admission and the others had not been operated on before. The external skin defect of the ulcers ranged from 7 x 5 cm to 30 x 12 cm. After 12 months follow up there was no recurrence of pressure sores or sepsis. The 'three muscle flap' offers the advantage of providing large bulk to fill deep cavities, while preserving the rest of the thigh. The flap elevation is fast and safe and the vascular pedicle is reliable. This technique is not for simple pressure sores, but should be reserved for large pressure sores complicated with large cavities created after resection of the proximal femur. (c) 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.