Gluteal necrosis following pelvic fracture and bilateral internal iliac embolization: Reconstruction using a transposition flap based on the lumbar artery perforators.

INTRODUCTION: The use of bilateral internal iliac artery embolization to control hemorrhage associated with pelvic fractures is a life saving intervention. Gluteal necrosis is a rare but potentially fatal complication of this procedure. Following debridement, reconstruction can present a considerable challenge due to the compromised vascularity of local tissue. PRESENTATION OF CASE: A 17 year old girl suffered an open book pelvic fracture following a road traffic accident. In order to stop profuse bleeding, bilateral internal iliac artery embolization was performed. This procedure was complicated by the development of right sided gluteal necrosis. Following extensive debridement, a transposition flap based on the lumbar artery perforators was performed to cover the soft tissue defect. DISCUSSION: Gluteal necrosis occurs in approximately 3% of cases following internal iliac artery embolization. Following complete excision of the devitalised tissue reconstructive surgery is necessary. Local flaps are suboptimal options when the integument supplied by branches of the internal iliac arteries has been compromised following embolization. Furthermore, the use of a free flap is restricted by the lack of a readily accessible undamaged recipient vessel. In the present case a transposition flap based on the lumbar artery perforators facilitated robust reconstruction of the buttock region.
CONCLUSION: To avoid sepsis, it is imperative that gluteal necrosis following internal iliac artery embolization is recognized and promptly debrided. A transposition flap based on the lumbar artery perforators is a good option for subsequent soft tissue coverage, which avoids use of tissue supplied by the branches of the internal iliac arteries.