Ischial Pressure Ulcer Reconstruction: A Critical Review of the Paradigm Shift From Wound Coverage to Functional Restoration

Ischial pressure ulcers (IPUs), severe complications in patients with prolonged immobility, are challenging due to high recurrence. Moving beyond anatomical closure, the field now prioritises functional-integrated reconstruction. This paradigm emphasises radical debridement and the transfer of well-vascularized perforator flaps to obliterate dead space, cover wounds, and restore protective sensation, aiming to break the recurrence cycle and restore patient autonomy. This review critically synthesises contemporary advances driving this shift. It details the development of precision and minimally invasive perforator flap techniques, including sensory nerve coaptation and chimeric designs. The integration of multimodal perioperative strategies, such as antibiotic-loaded bone cement and fluorescence angiography, is discussed. The adjunctive role of traditional Chinese medicine and the exploratory potential of regenerative approaches (stem cells, 3D-bioprinting) are considered. Finally, practical recommendations for implementing this holistic approach are provided, along with a clinical flowchart to guide staged management. By consolidating these advances, this review provides a framework to transition IPU management from simple wound healing towards comprehensive functional and social rehabilitation.