Ischial sores commonly occur in relatively younger paraplegic patients who are active wheelchair users [1]. In the sitting position, pressure on the ischium can reach approximately 100 mmHg—about twice the pressure exerted on the sacrum in the supine position [2]. Consequently, recurrence of ischial sores after reconstruction is not uncommon [3,4]. Successful reconstruction requires sufficient volume to fill the dead space and durable resurfacing of the defect to prevent recurrence. Here, we describe a case of bilateral ischial sores in a single patient, reconstructed successfully using two different methods.

This study was conducted in conformity with the World Medical Association Declaration of Helsinki, and the protocol was approved by the Institutional Review Board of Hanyang University Guri Hospital (IRB No. 2025-11-018). Written informed consent for publication of the patient’s clinical information and accompanying images was obtained. A 62-year-old paraplegic man presented to the plastic surgery department with bilateral stage 4 ischial sores, both with bone exposure. The wounds were infected and complicated by osteomyelitis involving both ischial tuberosities (Fig. 1). Bacterial cultures demonstrated infection with methicillin-resistant Staphylococcus aureus (MRSA) on the left-side sore, and MRSA and multi-drug-resistant Acinetobacter baumannii on the right-side sore. Osteomyelitis of both ischial tuberosities was revealed by pelvis magnetic resonance imaging. The left-side sore was the primary lesion, appearing 1 month earlier, while the right-side sore was a recurrent lesion previously reconstructed several times at another hospital. Infection control of both wounds was accomplished with antibacterial dressings (Betadine-soaked gauze dressing three times a day) and intravenous antibiotics, which were administered for 6 weeks. Vancomycin and meropenem were administered for 15 days before the first flap coverage on the left side, followed by tigecycline for 40 more days. Serial surgical debridement, including partial ostectomy using an electrical burr to identify healthy bleeding bone, was performed as well to prepare the wounds for flap coverage.

The left ischial sore, measuring 6×4 cm, was reconstructed using dual-plane flaps (Fig. 2). Two separate flaps were elevated to achieve both volume filling and defect resurfacing. In the prone position, a biceps femoris muscle flap was first elevated to provide adequate padding over the ischial tuberosity. The distal two-thirds of the muscle were rotated 180° and anchored within the entire cavity without tension. Subsequently, a perforator-based fasciocutaneous island flap was raised for resurfacing the wound. Using handheld Doppler probe to locate a perforator adjacent to the defect, a lateral fasciocutaneous island flap was elevated and rotated into position over the muscle flap already turned over.

Two weeks later, the 7×4 cm right ischial sore was reconstructed using a single hamstring flap (Fig. 3). This combined flap consisted of a semitendinosus muscle flap and a distally linked skin flap. Again, a handheld Doppler probe was used to trace a perforator on the hamstring muscle, without preoperative vascular imaging such as computed tomographic angiography. After a perforator was identified at the distal portion of the hamstring muscle, a skin flap was designed over the distal semitendinosus. The hamstring flap was elevated with careful preservation of its perforating vessels, allowing for a 180° rotation centered at the proximal third of the muscle belly. The muscle flap was secured within the cavity to provide bulk without tension, while the connected skin flap was positioned over the defect for resurfacing.

Both flaps survived without complications, resulting in successful reconstruction of both lesions. None of the bilateral ischial sores displayed recurrence during a 16-month follow-up after reconstruction. The patient was able to resume daily activities with wheelchair ambulation, an important functional outcome for paraplegic individuals.

The high recurrence rate of ischial sores presents a difficult challenge for reconstruction [5]. These sores often develop in relatively young paraplegic patients who remain active in outdoor activities with wheelchairs or spend long periods sitting indoors for computer work. Most patients do not change their lifestyle or activity patterns even after undergoing reconstruction, which contributes to the frequent recurrence of these sores. Therefore, appropriate reconstruction with a durable flap that provides both adequate bulk and reliable resurfacing is essential. When reconstruction focuses solely on resurfacing and uses a thin fasciocutaneous flap, wound dehiscence or sore recurrence can easily occur, especially in cases involving ischial tuberosity osteomyelitis [6,7].

When selecting a muscle flap, advancement of the buttock muscles adjacent to the ischial sore is not an ideal approach. Advancing the muscle after wide undermining merely approximates tissue rather than filling the cavity, often resulting in wound breakdown when the patient resumes wheelchair use with full hip flexion. In our case, the right ischial sore was a recurrent lesion that had previously been reconstructed with an advancement musculocutaneous flap. In such cases, turnover of a hamstring muscle can be an excellent option to effectively obliterate the cavity [8]. The distal portion of the hamstring provides sufficient volume for padding over the ischial tuberosity without tension. Depending on the cavity size, one or more of the four hamstring muscles—the semitendinosus, semimembranosus, and the two heads of the biceps femoris—can be used. As these muscles receive their vascular supply from the perforating branches of the profunda femoris artery, the proximal third of the muscle must remain intact during flap elevation. Accordingly, the pivot point for the turnover flap must be positioned distal to the proximal third of the muscle to ensure the preservation of the primary vascular pedicle [8,9].

For resurfacing the external defect of the ischial sore, an additional fasciocutaneous flap is necessary. When the hamstring is used for the muscle component, two options exist for the accompanying fasciocutaneous flap, as demonstrated in our case. The first option is an independent island flap from an adjacent area, and the second is a skin flap linked directly to the muscle flap. The independent island flap—referred to here as the dual-plane flap—is a fasciocutaneous flap based on the rich perforators of the buttock. Although this technique requires a longer operation than the single hamstring flap because two flaps must be elevated, it is considered safer, owing to robust perforator supply. In contrast, the linked flap—referred to here as the single hamstring flap—combines the muscle and skin components into one continuous flap. Because only a single flap is elevated, the overall operative time is shortened by approximately 25 minutes. However, it is crucial to visually confirm the presence of a healthy perforator connecting the muscle and skin components, as perforating vessels in the posterior thigh are generally less reliable than those in the buttock region.

In this case, the patient presented with bilateral ischial sores of similar size and condition, which were reconstructed using the two different approaches. This allowed a direct comparison of the advantages and disadvantages of each technique. Both the dual-plane and single hamstring flaps proved effective in providing sufficient volume and reliable resurfacing. Given its capacity to reduce operative duration, the single hamstring flap may be considered the primary surgical modality for ischial reconstruction. However, if no reliable perforator is found between the hamstring muscle and overlying skin during flap dissection, conversion to dual-plane flaps should be considered as the secondary option. This approach may serve as a viable clinical algorithm for ischial sore reconstruction.