A 45-year-old diabetic woman with a 6 cm sacral pressure ulcer (Stage IV — full-thickness tissue loss exposing bone) has failed 3 months of conservative management. The wound bed is clean with healthy granulation tissue. The reconstructive ladder principle and best option is:

• A Split-thickness skin graft (STSG) directly over exposed bone
• B Negative pressure wound therapy (NPWT) indefinitely until healing
• C Gluteus maximus musculocutaneous flap reconstruction ✓
• D Full-thickness skin graft (FTSG) after debridement

Explanation

Stage IV pressure ulcers with exposed bone require durable soft tissue coverage for healing, as SSGs over exposed bone fail due to poor vascularity. The gluteus maximus musculocutaneous flap (or gluteal advancement flap) is the workhorse for sacral reconstruction, providing well-vascularized muscle (resistant to infection) and durable padding over the bony prominence. It also adds bulk to reduce recurrent pressure injury. STSG fails over avascular bone. FTSG is insufficient for depth and location. NPWT can prepare the wound bed but cannot definitively close a Stage IV sacral ulcer with bone exposure. The reconstructive ladder principle progresses from simple (primary closure, STSG) to complex (local flaps, regional flaps, free flaps) based on wound requirements.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.