Pressure sore grade 4 . noticing the great trochanter is visible. this patient is paraplegic and the choice of treatment is full  thickness flap to cover the exposed area

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Ahmed 

Pressure sores

''These can be defined as tissue necrosis with ulceration due to prolonged pressure. Less preferable terms are bed sores, pressure ulcers and decubitus ulcers.
They should be regarded as preventable but occur in approximately 5% of all hospitalised patients (range 3–12% in published literature). 
There is a higher incidence in paraplegic patients (the case in the photo) , in the elderly and in the severely ill patient

is obviously the best treatment, with good skin care, special pressure dispersion cushions or foams, the use of low air loss and air-fluidised beds and urinary or faecal diversion in selected cases. 

Pressure sore awareness is vital, and the bed-bound patient should be turned at least every 2 hours, with the wheelchair-bound patient being taught to lift themselves off their seat for 10 seconds every 10 minutes.

 It should be stressed that the most important treatment is to treat the cause of the pressure sore and that surgical treatment is a last resort often doomed to failure if the cause persists.

Surgical management of pressure sores follows the same principles involved in acute wound treatment. 
The patient must be well motivated, clinically stable with good nutrition and adhere to the preventative measures advised postoperatively.

 Preoperative management of the pressure sore involves adequate debridement, and the use of vacuum-assisted closure (VAC) may help to provide a suitable wound for surgical closure (see below).

 The aim is to fill the dead space and to provide durable sensate skin. 

Large skin flaps that include muscle are best (which was the choice of treatment in our case) 
and, occasionally, an intact sensory innervated area can be included (e.g. extensor fascia lata flap with lateral cutaneous nerve of the thigh). If possible, use a flap that can be advanced further if there is recurrence and that does not interfere with the planning of neighbouring flaps that may be used in the future.''

Bailey & Love’s SHORT PRACTICE of SURGERY

Pressure sores

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