Outcomes and Challenges of Flap Reconstruction for Pressure Injuries in Clinically Complex Patients

Background: Pressure injuries (PIs) are common in patients with limited mobility and may require flap reconstruction for definitive management. However, postoperative complications and PI recurrence frequently occur. Certain flap types may be more prone to poor outcomes. This study evaluated outcomes after flap reconstruction for PIs in a medically complex population. Methods: We performed a retrospective review of patients who underwent flap reconstruction for sacral, ischial, trochanteric, or lateral malleolar PIs by a single surgeon at a tertiary care center between 2015 and 2023. Patient demographics, comorbidities, neurologic status, wound characteristics, flap type, and postoperative outcomes were collected. Outcomes were analyzed at the flap level. Results: Sixty-eight patients underwent 101 flap reconstructions. Most patients were male (68%), and spinal cord injury was present in 71%. Medical comorbidity burden was high, including anemia (61%), malnutrition (42%), preoperative osteomyelitis (44%), stool exposure near the wound (49%), and near-universal urinary incontinence. Postoperative complications were common across flap types, most commonly wound dehiscence and PI recurrence. New PIs developed at non-operative sites in about 14% of reconstructions during recovery. During the eight-year follow-up period, 19 (28%) patients expired and 21% of reconstructions were complicated by recurrence at the operative site. Conclusions: Flap reconstruction remains an important treatment for advanced PIs but is associated with high complication and recurrence rates in patients with substantial comorbidities and limited mobility. These findings support careful patient selection, preoperative optimization, and multidisciplinary postoperative care focused on preventing new PIs.