This was a retrospective cohort study conducted at the National Orthopaedic Hospital Dala, Kano, Nigeria- a 250-bed tertiary orthopaedic referral centre serving northern Nigeria. The study covered the period from 1 January 2019 to 30 June 2025. Ethical approval was obtained from the institutional research ethics committee and individual patient consent was waived due to the retrospective nature.

All consecutive patients with spinal cord injury who underwent bilateral V-Y advancement flap reconstruction for gluteal or sacral pressure injuries during the study period were assessed for eligibility. Patient selection flow: A total of 89 patients with spinal cord injury and pressure injuries were screened. Of these, 16 were excluded: 9 had incomplete medical records, 5 were lost to follow-up before 6 months, and 2 had undergone alternative flap procedures. The final analytic sample comprised 63 patients: 51 male (81.0%) and 12 female (19.0%).

This study included pressure injuries located in the gluteal and sacral regions. All patients had stage III or IV pressure injuries (NPUAP classification) involving the gluteal musculature or sacral prominence. The term “gluteal pressure injury” is used throughout to describe injuries in the gluteal region, which may also extend to the sacral area.

All patients underwent bilateral V-Y advancement flap reconstruction under general or spinal anaesthesia. The procedure involved radical debridement of the pressure injury, including excision of all necrotic tissue, bursa, and any underlying osteomyelitic bone; wound bed preparation with irrigation and haemostasis; design of bilateral V-Y fasciocutaneous flaps based on the gluteal region; advancement of the flaps into the defect and closure in a Y-shaped configuration; and placement of suction drains and layered closure. Interdigitation of the flaps was used to break the midline vertical scar and reduce tension, as described by Ay et al. [6]. Figure 1Figure 1 and Figure 2Figure 2 showed the Pre and Post-op image of the technique.

Figure 1. Pre-operative.

Figure 2. Post operative.

Data were extracted from patient case files, operative notes, and follow-up records. Variables collected included: age, sex, duration of SCI, level of injury, ASIA Impairment Scale grade, comorbidities (diabetes mellitus, hypertension), nutritional status (albumin), ulcer characteristics (size, stage, duration, presence of infection/osteomyelitis), and flap dimensions.

Definition of Adequate Postoperative Pressure Off-Loading

Adequate postoperative pressure off-loading was defined as adherence to a structured off-loading protocol comprising: 1) use of an air-fluidized or low-air-loss therapy bed for a minimum of 14 days postoperatively; 2) strict prohibition of sitting or lying directly on the surgical site for 6 weeks; 3) repositioning every 2 hours using a turning schedule; and 4) use of a specialized cushion (gel cushion) when sitting was resumed. Adherence was assessed by the ward nursing team and documented in the patient’s daily nursing records. The off-loading protocol was initiated immediately postoperatively and continued for 6 weeks. Data on off-loading were obtained from nursing chart documentation and physiotherapy records.

Patient Satisfaction and Quality of Life Assessment

Patient satisfaction was assessed using a structured questionnaire administered at final follow-up (mean 18.4 ± 6.8 months). The questionnaire comprised 5 items rated on a 5-point Likert scale (1 = very dissatisfied to 5 = very satisfied). Overall satisfaction was defined as a mean score ≥ 4 (satisfied or very satisfied). The questionnaire was administered to 57 patients (90.5%) who were available for follow-up; 6 patients could not be contacted.

Quality of life was evaluated using the Short Form-36 (SF-36) questionnaire [9], administered preoperatively and at 12-month follow-up. Of the 63 patients, 57 (90.5%) completed both preoperative and postoperative SF-36 assessments; 6 patients were lost to follow-up or had incomplete questionnaires. Paired analysis included only patients with both preoperative and postoperative scores (n = 57). The SF-36 measures eight domains: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. Higher scores indicate better quality of life.

Outcome Measures

Flap survival: Complete survival, partial necrosis, or total necrosis.Primary healing: Wound healing without complications.Complications: Dehiscence, seroma, infection, haematoma.Recurrence: Development of a new pressure injury at the same site.Good outcome: Defined as complete flap survival with primary healing and no recurrence.Patient satisfaction: Self-reported satisfaction with surgical outcomes.Quality of life: SF-36 scores preoperatively and at follow-up.

Data were analysed using SPSS version 26. Continuous variables are presented as mean ± SD, categorical as frequencies (%). Paired t-tests compared pre- and postoperative SF-36 scores. Univariate and multivariate logistic regression identified independent predictors of good outcome. Variables with p < 0.10 in univariate analysis were entered into the multivariate model. Given 48 patients with good outcome (complete flap survival, primary healing, no recurrence), the final model retained 3 predictors (age < 50 years, absence of diabetes mellitus, adequate postoperative pressure off-loading) to maintain a stable events-per-variable ratio (>10 events per predictor) [10]. Adjusted odds ratios (OR) with 95% confidence intervals (CI) were calculated. Statistical significance was set at p < 0.05.

A total of 63 patients were included. The mean age was 42.6 ± 14.8 years (range 18 - 72). Males constituted 81.0% (51/63). The mean duration of spinal cord injury was 4.2 ± 2.8 years. The most common level of injury was thoracic (54.0%), followed by lumbar (28.6%) and cervical (17.5%). Comorbidities included diabetes mellitus (22.2%) and hypertension (28.6%). Table 1 presents the baseline characteristics.

Table 1. Baseline characteristics of 63 patients characteristic, category value.

Table 2 presents the outcomes. Complete flap survival was achieved in 61 patients (96.8%). Partial necrosis occurred in 2 patients (3.2%), and total necrosis in 0 patients. Primary healing occurred in 48 patients (76.2%). Complications occurred in 15 patients (23.8%): dehiscence (9.5%), seroma (6.3%), infection (4.8%), and partial necrosis (3.2%). Recurrence occurred in 7 patients (11.1%) during a mean follow-up of 18.4 ± 6.8 months. Good outcome (complete flap survival, primary healing, no recurrence) was achieved in 48 patients (76.2%).

Table 2. Outcomes.

Table 3 presents the SF-36 quality of life scores. Significant improvements were observed across all domains, with the greatest improvements in physical functioning (38.4 ± 12.6 to 62.8 ± 14.2, p < 0.001), role-physical (22.6 ± 10.8 to 48.4 ± 14.6, p < 0.001), and bodily pain (31.2 ± 11.4 to 58.6 ± 13.8, p < 0.001). Paired analysis included 57 patients with both preoperative and postoperative scores.

Table 3. SF‑36 quality of life scores (Paired analysis, n = 57).

Univariate analysis (Table 4) identified age < 50 years (OR 2.8, 95% CI: 1.3 - 6.2), absence of diabetes mellitus (OR 2.5, 95% CI: 1.1 - 5.8), adequate postoperative pressure off-loading (OR 3.8, 95% CI: 1.5 - 9.6), and hypertension (OR 1.8, 95% CI: 0.8 - 4.1) as factors associated with good outcome (p < 0.10). Multivariate logistic regression (Table 5) retained three independent predictors:

Table 4. Univariable estimates for predictors of good outcome.

Table 5. Multivariate logistic regression-predictors of good outcome.

Age < 50 years: adjusted OR 3.2 (95% CI: 1.4 - 7.3), p = 0.006Absence of diabetes mellitus: adjusted OR 2.8 (95% CI: 1.2 - 6.5), p = 0.02Adequate postoperative pressure off-loading: adjusted OR 4.1 (95% CI: 1.6 - 10.5), p = 0.003

The final model was based on 48 outcome events (good outcome) and 63 complete records, with 3 predictors retained to maintain a stable events-per-variable ratio (>10 events per predictor).

The patient satisfaction survey is shown in Table 6. Patient satisfaction was assessed in 57 patients (90.5%) available for follow-up. Overall, 47 patients (82.5% of those assessed, 74.6% of total cohort) reported satisfaction with their surgical outcomes. The most commonly cited reasons for satisfaction were improved sitting tolerance (78.7%), reduced wound care burden (72.3%), and regained independence in daily activities (61.7%). Among those dissatisfied (n = 10, 17.5%), reasons included persistent pain (60.0%) and recurrence (30.0%).

Table 6. Patient satisfaction survey results.