Federico Sacasa, Gustavo Herdocia Baus
Functional preservation after sacral reconstruction in ambulatory patients can be achieved across reconstructive modalities and may depend more on patient selection, physiological optimization, and biomechanical considerations than on flap type alone. Unilateral muscle-splitting gluteus maximus V-Y advancement offers a reliable option for selected stage IV sacral defects requiring durable coverage, functional preservation, and maintenance of future reconstructive options.
BACKGROUND: Sacral ulcer reconstruction is usually described in chronically immobilized or neurologically impaired patients. In ambulatory patients, reconstruction must provide durable coverage while preserving function and future reconstructive options. Ambulatory-specific functional outcomes remain poorly synthesized.
METHODS: We report the case of a previously ambulatory 69-year-old woman with a stage IV sacral pressure ulcer after transient immobilization due to an acute metabolic derangement. Reconstruction was performed using a unilateral muscle-splitting gluteus maximus myocutaneous V-Y advancement flap. A focused appraisal of published reports in ambulatory patients was performed to contextualize functional outcomes across reconstructive modalities.
RESULTS: After serial debridement, infection control, and metabolic optimization, a clean 14 × 8 cm defect was reconstructed. The flap enabled midline closure through convergent advancement vectors while preserving the femoral insertion, avoiding pedicle dissection, and maintaining a multipedicled vascular architecture for dead-space obliteration and central padding. At 12 months, durable closure without recurrence was achieved. Functional recovery improved from a Barthel index of 65 to 95, with return to independent ambulation. Available ambulatory-specific reports generally describe preserved ambulation across reconstructive modalities despite heterogeneity in technique, cohort composition, and follow-up.
CONCLUSIONS: Functional preservation after sacral reconstruction in ambulatory patients can be achieved across reconstructive modalities and may depend more on patient selection, physiological optimization, and biomechanical considerations than on flap type alone. Unilateral muscle-splitting gluteus maximus V-Y advancement offers a reliable option for selected stage IV sacral defects requiring durable coverage, functional preservation, and maintenance of future reconstructive options.