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Pressure sore surgery — preparation, flaps and recurrence
A non-healing stage 3 or 4 pressure sore is operated on only after the causes have been corrected — pressure, nutrition, continence, spasm and bone infection — and then the sore and the bony prominence are excised and covered with a muscle or fasciocutaneous flap designed so that it can be re-advanced if the sore recurs.
Why it matters in the exam
Common sites: sacrum (lying), ischium (sitting — the highest-pressure area when seated), trochanter and heel. By NPIAP: stage 1 — non-blanching erythema; 2 — partial skin loss; 3 — full skin loss down to fat; 4 — exposed muscle, tendon or bone; "unstageable" when slough or eschar covers the base; and deep tissue injury. Preparation for surgery: debridement, bone biopsy to diagnose osteomyelitis (the accurate test), correction of albumin and protein, faecal diversion or a catheter when the wound is repeatedly soiled, treatment of spasm and contractures, and smoking cessation. Surgery in an unprepared patient fails in most cases.
Flaps by site: sacrum — gluteus maximus rotation or V-Y advancement, or a perforator flap (SGAP); ischium — posterior thigh flap (inferior gluteal thigh), V-Y advancement of the hamstrings, or gracilis; trochanter — tensor fasciae latae flap. In ischial ostectomy only part of the bone is removed: complete removal shifts pressure to the other side and can create a urethral fistula or diverticulum in the perineum — especially with bilateral resection. After surgery: an air bed, no sitting for about 3 to 6 weeks and a gradual sitting programme. Recurrence is high, especially in young paralysed patients, so options for future flaps are preserved. A chronic wound that has not healed for years needs biopsy to exclude Marjolin ulcer.
Key points
- Stages 1 to 4, unstageable and deep tissue injury.
- Preparation: pressure, nutrition, continence, spasm, bone biopsy.
- Sacrum — gluteus; ischium — posterior thigh or hamstring; trochanter — TFL.
- Partial ostectomy; no complete ischiectomy.
- Recurrence is common — plan for repeat flaps.
Summary table
| Site | Pressure source | Accepted flap | Note |
|---|---|---|---|
| Sacrum | Lying | Gluteus maximus (rotation or V-Y), SGAP | Preserve the option of re-advancement |
| Ischium | Sitting | Posterior thigh, hamstring V-Y, gracilis | Partial ostectomy only |
| Trochanter | Lying on the side | Tensor fasciae latae | Hip contractures |
| Heel | Lying, vascular | Usually non-operative | Arterial work-up before surgery |
| Preparation | All sites | Bone biopsy, nutrition, faecal diversion | Without preparation — failure |
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Sources
- NPIAP/EPUAP/PPPIA International Guideline: Prevention and Treatment of Pressure Ulcers/Injuries, 2019 — Staging and surgical management
- Plastic Surgery (Neligan), 5th edition (2023) — Pressure sores
- Israeli Ministry of Health circular on pressure injury prevention and treatment, current — Assessment and reporting
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.
See also: Pressure injuries