Managing complex ischial pressure injury in a patient with congenital amelia: a multistage freestyle flap reconstructive strategy.

BACKGROUND: Management of complex stage 4 ischial pressure injuries (PIs) is challenging, particularly in patients with congenital anomalies, severe comorbidities, and limited reconstructive options. Ethical and functional considerations may further constrain surgical decision-making. CASE REPORT: The present report discusses a paraplegic patient with congenital amelia who developed a chronic, recurrent stage 4 ischial-perineal PI complicated by osteomyelitis and prior reconstructive failure. A multidisciplinary, staged approach was used, including serial debridement, infection control, nutritional optimization, negative pressure wound therapy, and delayed freestyle flap reconstruction. Intraoperative perfusion was assessed via intraoperative laser angiography using indocyanine green. Definitive reconstruction was achieved using a pelvic torso V-Y advancement flap with adjunctive groin advancement scrotoplasty to address testicular exposure. Ethical considerations, including preservation of the patient's only viable site for noninvasive blood pressure monitoring, directly influenced reconstructive planning. Durable wound closure was achieved without major complications, and satisfactory healing was noted at 3-month follow-up. CONCLUSION: This case highlights the importance of individualized, patient-centered, and ethically informed decision-making in the management of complex PIs. Multidisciplinary collaboration and tailored reconstructive strategies can achieve successful outcomes in patients with rare congenital conditions and limited surgical options.