Management of a massive stage iv sacral decubitus ulcer with anterior flap hip disarticulation and myocutaneous gastrocnemius fillet flap in-continuity

Severe sacral decubitus ulcers represent a common and often recalcitrant clinical problem in paralyzed or bedridden patients and require treatment strategies ranging from specialty beds and local wound care to aggressive debridement and local or free tissue flap coverage. This article presents the case of a young soldier who sustained severe injuries as a result of an improvised explosive device blast, including bilateral sciatic nerve injuries, sacrogluteal degloving, and severe left acetabular and femoral head fractures. The patient subsequently developed a recalcitrant stage IV sacral decubitus ulcer, left acetabular protrusio with minimal left lower extremity function, and ankylosis of the posterior right hip due to heterotopic ossification. A novel left anterior (quadriceps-based) hip disarticulation was performed with a double gastrocnemius myocutaneous fillet flap incontinuity. The procedure was successful in providing robust, partially sensate soft tissue coverage for the decubitus ulcer, permitting removal of the bridging posterior heterotopic ossification of the right hip, and removing the left hip for which reconstructive options were limited due to the absence of superior and inferior gluteal nerve function. The patient healed uneventfully and was subsequently able to resume unrestricted positioning for sitting and wheelchair mobilization and became a limited ambulator with a hip disarticulation prosthesis and contralateral ankle-foot orthosis.