Free flap reconstruction of a cast-related pressure ulcer in a pediatric patient with spinal muscular atrophy.

Spinal muscular atrophy (SMA) is a hereditary neuromuscular disorder characterized by progressive lower motor neuron loss, resulting in severe muscle atrophy, fatty degeneration, and impaired tissue perfusion. These changes increase susceptibility to pressure-related soft tissue injuries and delay wound healing. We report a rare case of free flap reconstruction in a pediatric patient with SMA type 2 who developed a cast-related pressure ulcer. A 9-year-old girl underwent bilateral hamstring release and distal femoral extension osteotomy followed by long leg circular casting. After cast removal, a progressive anterolateral crural pressure ulcer with exposed necrotic muscle developed despite conservative treatment. Reconstruction was performed using an anterolateral thigh (ALT) free flap. Due to extensive muscle atrophy, fibrosis, and loss of normal anatomical planes, a modified en bloc myocutaneous flap elevation based on antegrade pedicle dissection was used instead of standard perforator-based dissection. The flap was successfully anastomosed to the posterior tibial vessels without complications. At 6-month follow-up, complete and stable wound healing was achieved. This case emphasizes the reconstructive challenges in SMA patients and demonstrates that free flap reconstruction can be safely performed using adapted surgical techniques.