Systematic Review and Operative Technique of Recalcitrant Pressure Ulcers Using a Fillet Flap Technique.

Pressure ulcers occur frequently in patients who are paraplegic or quadriplegic after spinal cord injuries. An estimated 1.3 to 3 million individuals developed some form of pressure ulcer in 2004.1 New pressure ulcers are associated with significantly longer hospitalizations and cost and have been categorized as “never events” by the Center for Medicare and Medicaid Services (CMS), and hospitals are penalized by decreased reimbursement. Accordingly, the treatment of pressure ulcers represents a clinically and financially important issue. Pressure ulcers progress through a continuum ranging from blanching erythema to exposure of bone, which may develop osteomyelitis. Patients who are either insensate or unable to move carry a significant risk of both primary and recurrent pressure ulcers. Some spinal cord injury patients over time develop recurrent and large pressure sores for which there are few reconstructive options. There remains a finite quantity of local tissue for conventional fasciocutaneous and myocutaneous flaps, and when all options have been exhausted, there remain a large surface area and volume of cavitation that will require reconstruction; ulcers at this stage are in essence end-stage pressure ulcers. There is little written about the reconstruction of end-stage pressure ulcers, specifically with respect to the long-term outcomes. There are 7 articles detailing the operative technique and postoperative outcomes of using a fillet technique for pressure ulcer reconstruction, with 1 article describing free tissue transfer of the filleted tissue. Excision of the femur and lower extremity bones with preservation of the soft tissue (ie, a fillet) for pressure ulcer reconstruction was initially described in 1956 by Georgiade et al1 for treatment of a sacral pressure ulcer and reported an overall good outcome in 1 patient, followed by an article 13 years later by the same group detailing their experience in 28 patients.2 Menzoian et al3 in 1972 published a case report on the use of a fillet technique in combination with bilateral hip disarticulation in 1 patient without complication. Chen et al4 performed a free tissue transfer of a fillet segment for a large sacral ulcer reconstruction in 1986. Berger et al5 subsequently described the division of a thigh flap into 2 segments, thereby creating independent flaps based off the profunda femoris and superficial femoral artery. In 2009, Jandali and Low6 published a case report entailing 4 patients who underwent an anteriorly based flap; unique to this article was use of the entire-leg soft-tissue envelope to the ankle. Most recently in 2014, Verveld et al7 published their experience with reconstructing 5 patients using a fillet technique; an interesting variation in their technique is starting the operation in the supine procedure, basing the flap on the posterior thigh soft tissue and tunneling the flap from anterior to posterior through a gluteal defect. Our plastic surgery division has provided comprehensive multidisciplinary care to patients with pressure ulcers and complex wounds for over 30 years. Perhaps unsurprisingly, we intermittently encounter recalcitrant end-stage pressure ulcers in whom the total surface area of the wound far exceeds all other local options (which have previously been utilized). In the past 2 years, we have performed 5 fillets of leg flaps for such ulcers. We sought to perform a systematic review of this technique to offer surgeons caring for similar populations insight into the outcomes, complications, and surgical approaches to the fillet flap for the purpose of pressure ulcer reconstruction.