Pedicled lower extremity fillet flap for reconstruction of extensive pressure injuries

Pressure injuries in paraplegic patients with multiple comorbidities are challenging to manage, particularly when ulcers are extensive, recurrent, and associated with osteomyelitis and sepsis. Conventional regional flaps may prove insufficient after previous reconstructions or when multiple pressure areas coexist. We report the case of a 52-yearold man with paraplegia secondary to myelomeningocele, multiple grade IV pressure injuries, bilateral septic arthritis of the hips, and sacral osteomyelitis. Following clinical optimisation and bilateral Girdlestone procedures with sacral and ischial ostectomy, a pedicled lower extremity fillet flap from the right leg, harvested at the supramalleolar level and including the entire limb, was used to reconstruct sacral and bilateral ischial-gluteal defects. Postoperative evolution was favourable, with resolution of sepsis, stable coverage of all reconstructed areas, and improved comfort and ease of care. A brief review of the literature identified 105 reported lower limb fillet flaps, of which only a small subset originated at the ankle level. The pedicled lower extremity fillet flap represents a salvage option when local reconstructive alternatives are exhausted, with the potential to improve quality of life in carefully selected non-ambulatory patients.