Reconstructive Surgery for Trochanteric Ulcer

Abstract

Trochanteric ulcer is an ulcer which is located at the lateral part of the hip joint over the prominent bony part of the femur which is the greater trochanter. This ulcer is rarely seen in post-acute spinal cord injury or in other acute illnesses, because the patient is always in the supine position; however, this type of ulcer is commonly seen in chronic insensate patients which results from lying down on his/her side of the body. The harder the surface the patient is lying on, the deeper the damage to the skin and deep tissue. Anatomically, the greater trochanter is covered with anatomical bursa and skin; therefore, if ulceration occurs, it will involve the skin and the underlying bursa exposing the tendinous part of the vastus lateralis muscle origin. Healing in a stage IV ulcer may not occur because of the nature of the tissue and the formation of granulation tissue in the bursal cavity which is colonized by bacteria; consequently, surgical closure is indicated in this condition. Another condition is seen in spinal cord injury patients when the greater trochanter is rotated posteriorly secondary to subluxation of the hip joint which results from the paralysis and spasticity of the muscle. This abnormal position of the greater trochanter will create a new pressure point when patient is in the sitting or supine position which can cause skin ulceration. In repairing the trochanteric ulcer, it is important to excise the entire bursa and the surrounding tissue to help the healing process of the area. In addition to the important step of shaving the prominent trochanteric bone, the common flap available in the area to be utilized for repair of this ulcer is the tensor fascia lata flap which was described long time ago by Nahai in 1978 [1–4], as musculocutaneous flap or with modifications followed by Lewis in 1981 [5, 6] as V-Y advancement flap. The tensor fascia lata flap can be described as a myofasciocutaneous flap. In many instances, the muscle itself will not cover the defect because of the small size of the muscle, but the fasciocutaneous component of the flap will cover the defect. Taking into consideration that the blood supply of the fascia will be derived from the muscle and the skin island which covers that fascia will derive its blood supply from the fascia and muscle. The tensor fascia lata flap can be used as an island flap, V-Y advancement flap, or a rotation flap. All these modifications and their utilization depend on the size and location of the defect.