1331 - Walking Through Restrictions: Post-Flap Rehabilitation in a Non-Spinal Cord–Injured Patient

Thursday, February 19, 2026

5:00 PM - 6:30 PM AST

Presenting Author(s)

JK

John A. Kaster, MD

Resident Physician
Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin
Durham, North Carolina, United States

Co-Author(s)

AH

Andrew Hua, MD, PhD

Resident Physician
Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin
Milwaukee, Wisconsin, United States
CW

Christopher White, MD

Associate Professor and Chair
Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin
Milwaukee, Wisconsin, United States

Submitter(s)

JK

John A. Kaster, MD

Medical College of Wisconsin
Durham, North Carolina, United States

Case Diagnosis: Stage IV coccygeal pressure injury requiring debridement, coccygectomy, and reconstruction with a fasciocutaneous left gluteal rotation flap.

Case Description: An 84-year-old woman developed a coccygeal pressure injury after prolonged downtime during hospitalization for rhabdomyolysis. Despite multiple debridements, the wound failed to heal and ultimately required flap reconstruction. The postoperative course was complicated by partial flap dehiscence, infection treated with antibiotics, and initiation of negative pressure wound therapy. On admission to inpatient rehabilitation one year later, the wound measured 11 × 3 × 2.8 cm with 8 cm undermining. She was limited to 30 minutes of sitting three times daily with otherwise flat bedrest, but unlike spinal cord injury (SCI) patients undergoing similar flap protocols, she was permitted unrestricted ambulation. At admission, she required minimal assistance for bed mobility and ambulated 200 feet with a walker. Over three weeks, she improved to >300 feet with modified independence, completed 16 stairs with supervision, and advanced toileting hygiene and lower body dressing from maximal assistance to supervision or independence.

Discussions: Rehabilitation after sacral flap reconstruction traditionally emphasizes prolonged bed rest and strict activity limitation due to the risk of wound breakdown. This case is unique in that the patient did not have neurogenic impairment and was able to participate in standing, walking, and progressive functional training despite sitting restrictions. The ability to ambulate provided a broader therapy window and facilitated measurable improvements in mobility and ADLs without compromising flap integrity. This highlights the need to individualize protocols based on underlying pathology rather than uniformly applying SCI-based restrictions.

Conclusions: This case demonstrates that ambulation can be safely incorporated into rehabilitation for select non-spinal cord–injured patients following sacral flap reconstruction with sitting restrictions. Structured, interdisciplinary therapy tailored to wound precautions supported both functional recovery and flap preservation, underscoring the importance of tailored protocols.