Strategy for Reconstructing Multiple Pressure Sores in a Single Patient: A Case of Three Pressure Sores on One Pelvis
Article information
Abstract
Pressure sores are frequently observed in chronically bedridden patients. When body position is not changed regularly, a single ulcer may develop in the area subjected to constant pressure, such as the sacral or trochanteric region; one habitual position usually results in one sore. The simultaneous presence of pressure sores on the sacrum and both trochanteric regions in a single patient is uncommon, and their reconstruction is challenging. A 48-year-old male paraplegic patient with three pressure sores on the pelvis was referred. The sores involved the sacral and bilateral trochanteric regions and were complicated by infection, including osteomyelitis. Serial flap coverage was staged according to wound readiness and the resolution of infection. First, the right trochanteric sore was reconstructed using a perforator-based island flap (PBIF). After 9 days, the sacral sore was reconstructed with another PBIF. After an additional 20 days, the left trochanteric sore was covered using a pedicled anterolateral thigh musculocutaneous flap. All flaps were selected based on lesion size and condition and survived without major complications. When reconstructing multiple sores in one patient, establishing a clear strategy is essential. The order of reconstruction, appropriate intervals between procedures, and optimal flap selection are key considerations.
Introduction
Pressure sores commonly occur in chronically bedridden patients, particularly older adults and individuals with paraplegia [1]. Because these patients are unable to reposition themselves, ulcers may form in areas subjected to prolonged pressure, such as the sacral or trochanteric region. When external pressure exceeds the capillary closing pressure (approximately 30–32 mmHg) for extended periods (approximately 2 hours or more), ischemic tissue damage develops at the compressed site [2]. Typically, one habitual position produces a single sore at the corresponding pressure point. A persistent supine position results in a sacral sore, whereas sustained lateral positioning leads to trochanteric sores. Therefore, although sacral and trochanteric regions are common pressure-injury sites, simultaneous involvement of the sacrum and both trochanteric areas in one patient is relatively rare [3]. Reconstruction of such multiple complex wounds is challenging and requires a strategic approach for optimal outcomes. Here, we present a case involving multiple pelvic pressure sores that were successfully reconstructed using an appropriate strategy.
Case
This study was conducted in accordance 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. 2025-12-009). The patient provided written informed consent for publication.
A 48-year-old paraplegic man with multiple pressure sores on the pelvis was referred to the Department of Plastic Surgery. The sores involved the sacral and bilateral trochanteric regions and were classified as stage 4, with associated infection and osteomyelitis (Fig. 1). The lesions first appeared in the sacral region 2 years earlier, prompting the patient to avoid a supine position and remain mostly on his lateral sides. This resulted in subsequent pressure sores in the trochanteric regions, ultimately leading to three distinct sores.
A 48-year-old man with three pressure sores on the pelvis. (A) A 12×9×4 cm sacral sore. (B) An 11×8×3 cm right trochanteric sore. (C) A 13×7×6 cm left trochanteric sore.
The bacterial culture from sores showed infection with Proteus mirabilis, Pseudomonas aeruginosa, Enterococcus faecalis, Escherichia coli, and methicillin-resistant Staphylococcus aureus. Pelvis magnetic resonance imaging revealed osteomyelitis on all sores. Infection control consisted of intravenous antibiotics and topical antibacterial dressings (Betadine-soaked gauze changed three times daily). Antibiotic therapy—including ampicillin, cefepime, ertapenem, ciprofloxacin, vancomycin, and tigecycline—was administered either as monotherapy or in combination over a total of 10 weeks spanning the perioperative period.
To perform reconstruction during a single hospitalization, serial flap coverage was staged according to the clinical readiness of each wound bed. Because covering a single lesion would allow the patient to lie only on the other side, sequential reconstruction was the most practical approach. Serial debridement, including partial ostectomy and thorough infection control, was performed until each wound was ready for flap coverage.
The first lesion to achieve infection clearance was the 11×8×3 cm right-side trochanteric sore, which was reconstructed with a perforator-based fasciocutaneous island flap (Fig. 2). The patient was allowed only the left lateral and supine positions until the flap stabilized. After 9 days, the flap remained stable even with positional pressure applied. The second procedure involved reconstruction of the 12×9×4 cm sacral sore using another perforator-based fasciocutaneous island flap (Fig. 3). To ensure flap stability, the patient was maintained in alternating lateral positions during the initial healing phase. Although the flap itself was stable, the patient experienced mild perianal wound disruption, which delayed full stabilization of the second reconstruction. After 20 additional days, the second flap demonstrated sufficient stability to tolerate positional changes. The third reconstruction addressed the 13×7×6 cm left trochanteric sore, which was the deepest of the three wounds and involved joint exposure. A pedicled anterolateral thigh musculocutaneous flap was selected to provide adequate muscle bulk to fill the dead space and protect the exposed joint (Fig. 4). Until the flap stabilized, the patient was permitted only the supine or right lateral positions to avoid compromising the surgical site. Once the flap remained stable for an additional 10 days, we transitioned the patient to a 2-hourly turning schedule across three positions: supine, left lateral, and right lateral. The prone position was avoided as it could disturb the patient’s breathing, especially after the operations under general anesthesia.
Right trochanteric sore reconstructed with a perforator-based island flap. (A) Flap design following debridement. (B) Immediate postoperative photograph showing flap coverage. (C) Appearance 1 year after flap coverage.
Sacral sore reconstructed with a perforator-based island flap. (A) Flap design following debridement. (B) Immediate postoperative photograph showing flap coverage. (C) Appearance 1 year after flap coverage.
Left trochanteric sore reconstructed with a pedicled anterolateral thigh flap. (A) Flap design following debridement. (B) Elevation of the pedicled musculocutaneous flap. (C) Immediate postoperative photograph showing flap coverage. (D) Appearance 1 year after flap coverage.
All lesions were successfully reconstructed with flap coverage, and no major complications occurred. The patient regained the ability to resume daily activities without recurring pressure sores, resulting in an improved quality of life. There has been no recurrence of sores for 27 postoperative months, as the patient adhered faithfully to the prescribed position-changing protocol.
Discussion
Paraplegic patients frequently develop pressure sores on the pelvis when they are unable to change position. Among the various bony prominences, the sacral region and greater trochanteric areas are consistently identified as common sites for pressure sore development [4]. In chronically bedridden individuals, the sacrum bears most of the pressure in the supine position, whereas the greater trochanter is the primary risk area in the lateral decubitus position [5]. Single sores are more common than multiple simultaneous sores, and their reconstruction is usually less complex. However, when multiple pressure sores occur across different regions, reconstructive surgery becomes significantly more challenging due to limited positioning options, compromised general condition, and high rates of complications and recurrence [6]. Patients are generally limited to three primary recumbent positions: supine, left lateral, and right lateral. If two regions are reconstructed simultaneously, the patient is deprived of two of these three options, as newly created flaps must remain uncompressed until stabilized. Such restricted mobility can lead to the exacerbation of any remaining untreated pressure injuries while the reconstructed regions are healing. For this reason, when managing multiple pressure sores in a single patient, staged reconstruction—treating one lesion at a time—is inevitable.
Reconstruction in such cases must be performed using durable flaps. Simple primary closure or skin grafting alone is generally inadequate for pressure sores because they lack sufficient soft-tissue bulk and are prone to recurrent breakdown from persistent pressure and shear forces [7]. When planning serial flap coverage for multiple pressure sores, three major factors are to be carefully considered: the order of reconstruction, the appropriate interval between surgeries, and optimal flap selection.
The order of reconstruction is determined by the readiness of each wound. Flap coverage should proceed when the wound demonstrates clean granulation tissue. Through serial debridement, ostectomy when necessary, and rigorous infection control, including intravenous antibiotics and antimicrobial dressings, the wound beds were optimized for definitive reconstruction. Complete eradication of bacterial infection serves as the most critical milestone for scheduling reconstruction. Once negative bacterial cultures are achieved following a targeted antimicrobial regimen, the wound bed is considered optimized for reconstruction; flap coverage is then prioritized according to the clinical readiness of each site. The interval between procedures depends on the time required for the previous flap to become sufficiently stable to withstand at least 2 hours of compression in a functional position. In the absence of complications, such as circulatory compromise or wound dehiscence, this stabilization generally occurs after about 1 week. Flap selection must be based on the characteristics of each sore, including its size, depth, and presence of structural exposure. In our case, the sacral and right trochanteric sores were reconstructed with fasciocutaneous flaps because their depth was appropriate for this flap type. However, the left trochanteric sore was deeper due to severe osteomyelitis and consequent joint exposure, rendering the fasciocutaneous flap unsuitable. This complex defect required a musculocutaneous flap to obliterate the dead space and cover the exposed joint, combined with skin resurfacing. A pedicled anterolateral thigh musculocutaneous flap from the ipsilateral side was deemed the optimal reconstructive option to provide both ample muscle tissue and healthy skin.
Even when the flap coverage is successful, problems such as wound dehiscence due to shear forces and friction often emerge. To prevent postoperative wound problems, secure suturing between the flap and wound should be performed during the operation. Meticulous layered closure of the fascia, subcutaneous tissue, and skin is essential to prevent wound dehiscence. This is the most labor-intensive step in sore reconstruction surgery. In addition, caution when making position changes is also imperative. To prevent damage from shear forces, nurses should be warned to lift, not roll the patient when changing their position.
Though reconstructive surgeons often find cases involving multiple pelvic pressure sores particularly difficult, approaching such cases with a well-structured and deliberate strategy enables successful reconstruction. When the patient’s condition allows for serial flap surgeries, surgeons should not be discouraged. Thoughtful, staged reconstruction ultimately improves the patient’s quality of life and helps prevent further deterioration.
Notes
Jungwoo Chang is an editorial board member of the journal but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflicts of interest relevant to this article were reported.