Reconstructive surgery for treating pressure ulcers

Stories About Living and Going Through Reconstructive Surgery for Pressure Injuries-A Narrative Study

We investigated the lived experience of adult patients with ischial, sacral and trochanteric pressure injuries going through reconstructive surgery. Five informants were recruited. The study was conducted using narrative methodology including in-depth interviews. The transcripts were analysed using structural and thematic methods as described by Riessman. Three main themes were derived: The wound-that changes life; Time-it's my life passing by; and Surgery-a fast track back to life. This study emphasises the importance of surgery as a way to reduce the time it takes for a pressure injury to heal. Involving patients in their own care and sharing information about their treatment is crucial to empower them and maintain a sense of hope.

Flap reconstruction of pressure ulcers in patients with spinal cord injury: a retrospective cohort study

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To describe our five-year experience of surgical excision and flap reconstruction of pressure ulcers in individuals with spinal cord injury (SCI).

SETTING

Tertiary spinal centre in Stoke Mandeville, United Kingdom.

METHODS

All spinal injury patients that underwent surgical reconstruction of pressure ulcers at the Stoke Mandeville Hospital National Spinal Injury Centre between 2018 and 2022 inclusive were included. Ulcers underwent 'pseudotumour' excision followed by either immediate or staged flap reconstruction. The primary outcome was complete healing at one year. Secondary outcomes included flap loss, complications, and return to theatre.

RESULTS

52 cases were included across 44 patients. 43 cases (82.7%) underwent immediate debridement and reconstruction. The mean number of procedures was 1.9 (range 1-6). Local flaps were used in 22 (41.5%) cases. There was one (1.9%) free flap (anterolateral thigh), eight (15.4%) pedicled flaps, and 21 (39.6%) flaps based on single perforators. 49 cases completed follow-up; 41 (83.7%) were healed at one year after their initial surgery. Immediate reconstructions were 36.7% more likely to achieve healing at this time point than staged cases (P = .028, Fisher's exact). There was partial or total flap loss in 15 (28.8%) cases. Thirty-nine complications were seen in 24 (46.2%) cases. Twenty-three cases (44.2%) required returns to theatre.

CONCLUSIONS

Surgical debridement with flap reconstruction is a safe and reliable treatment approach for pressure ulcers in those with SCI, with a complication rate comparable to existing literature. Immediate flap reconstruction and local flap designs may be associated with a lower risk of complications and higher healing rates.

Pressure Injury Recurrence After Flap Surgery in Home-Dwelling Patients With Spinal Cord Injury in Norway: A Retrospective Study

A retrospective single-centre study. To investigate the period prevalence of pressure injury recurrence (PIR) and characteristics associated with PIR in the population of persons with spinal cord injury (SCI) who were treated with flap surgery between 2008 and 2019. A spinal cord unit (SCU) in Norway. The study is based on analysis of patient data from the electronic medical record. Crosstabs and logistic regression were used to investigate the potential correlations between the odds of PIR and potential risk characteristics. We identified 54 patients who were treated with flap surgery in the period of interest, and 47 (87%) were men. The mean age for flap surgery was 51 years (SD = 12.7). The occurrence of PIR post-flap surgery was 46% (n = 25). Factors associated with increased risk of PIR were use of manual wheelchair (65% vs. 32%, odds ratio [OR] = 3.9, 95% confidence interval [CI] = 1.06-14.33, p = 0.04) when compared with powered wheelchair, and history of PI and flap surgery at the ischial tuberosity (sit bones) (68% vs. 24%, OR = 3.67, 95% CI = 1.01-13.40, p = 0.04) compared with all other body locations. Factors associated with decreased risk of PIR were independence in position changes (29% vs. 58%, OR = 0.29, 95% CI = 0.91-0.95, p = 0.04) compared with not needing assistance with position changes, tetraplegia (C5-C8) (21% vs. 60%, OR = 0.18, CI = 0.04-0.83, p = 0.02) compared with paraplegia, and postoperative follow-up by the SCU (15% vs. 55%, OR = 0.28, 95% CI 0.03-0.76, p = 0.04) compared with no follow-up from the SCU, as well assistance from personal assistant follow-up (PAF) (26% vs. 56%, OR = 0.15, 95% CI = 0.03-0.76, p = 0.01) compared with not receiving assistance from PAF. The period prevalence of PIR post-flap surgery in the Norwegian population of people with SCI is high and increased odds of PIR were related to flap surgery on the sit bones. Reduced odds of PIR were related to tetraplegia, powered wheelchair use, follow up by PAF and the SCU. The study is registered in the Open science framework.

Clinical Presentation and Integrated Management of Pressure Injuries in the Emergency Hospital Setting: A Plastic Surgeon's Perspective

Background: Pressure injuries are localized areas of tissue damage or necrosis that occur when pressure is applied to the skin for prolonged periods, often over bony prominences, often the sacrum, heels, ischial tuberosities, and greater trochanters. The pathophysiology is complex, involving a combination of mechanical forces, ischemia, and tissue hypoxia. Methods: We conducted a 2-year retrospective study aiming to assess the clinical characteristics, risk factors, and management of pressure injuries in patients admitted to an emergency hospital who underwent a plastic surgery examination. Results: This study included 176 patients with clinically diagnosed pressure ulcers, with findings showing 28.52% of cases as stage III and 35.57% as stage IV. Common sites included the sacrum (40.94%), ischium (15.1%), and heel (14.43%). The median patient age was 76 years, with 47.15% between 60 and 80 years and 36.93% ≥ 80 years, often presenting with comorbidities increasing the risk of pressure injuries, such as cardiovascular disease (71.59%), diabetes (18.18%) and obesity (9.66%). Important risk factors included neurological diseases (46.02%), spinal cord injuries (14.7%), and nutritional deficiencies, as indicated by anemia (10.43g/dL; 95% CI [10.04; 10.82]), low serum albumin (2.56 g/dL; 95% CI [2.43; 2.69]) and proteins (5.54 g/dL; 95% CI [5.34; 5.73]). Mortality was significant, at 36.93%, with 23.3% occurring within the first 7 days of hospitalization due to the patients' critical condition. Decision-making for surgical intervention considered the patient's general status, comorbidities, and ulcer severity. Surgical treatment consisted of seriate debridement, negative pressure vacuum therapy, and/or coverage using skin grafting, local advancement, or rotation flaps. Conclusions: The key question for a plastic surgeon to consider is how pressure ulcers should be managed. Various debridement and covering techniques should be tailored to the wound's characteristics, considering patient comorbidities and general health condition.

Repair of pressure ulcers in the elderly using autologous microskin implantation and negative pressure wound therapy: A retrospective study

BACKGROUND

Pressure ulcers remain a worldwide problem.

OBJECTIVE

To introduce an intermittent and feasible wound treatment method for the treatment of pressure ulcers in elderly patients.

METHODS

This surgical procedure was performed on eight elderly patients suffering from pressure ulcers. Microskin measuring 0.1 × 0.1 centimeters was cut from a small amount of thin skin and then grafted onto the wound surface in conjunction with closed negative pressure therapy.

RESULTS

Seven patients had their wounds closed after a single surgery, while one patient required two surgeries to close the wound.

CONCLUSION

Autologous microskin implantation for the treatment of pressure ulcers in the elderly is an effective method to close the wound, which can prevent the elderly from living with wounds in their later years and is a viable treatment option.

Bioanalytical and chemical characterization of organic micropollutant mixtures in long-term exposed passive samplers from the Joint Danube Survey 4: Setting a baseline for water quality monitoring

Monitoring methodologies reflecting the long-term quality and contamination of surface waters are needed to obtain a representative picture of pollution and identify risk drivers. This study sets a baseline for characterizing chemical pollution in the Danube River using an innovative approach, combining continuous three-months use of passive sampling technology with comprehensive chemical (747 chemicals) and bioanalytical (seven in vitro bioassays) assessment during the Joint Danube Survey (JDS4). This is one of the world's largest investigative surface-water monitoring efforts in the longest river in the European Union, which water after riverbank filtration is broadly used for drinking water production. Two types of passive samplers, silicone rubber (SR) sheets for hydrophobic compounds and AttractSPETM HLB disks for hydrophilic compounds, were deployed at nine sites for approximately 100 days. The Danube River pollution was dominated by industrial compounds in SR samplers and by industrial compounds together with pharmaceuticals and personal care products in HLB samplers. Comparison of the Estimated Environmental Concentrations with Predicted No-Effect Concentrations revealed that at the studied sites, at least one (SR) and 4-7 (HLB) compound(s) exceeded the risk quotient of 1. We also detected AhR-mediated activity, oxidative stress response, peroxisome proliferator-activated receptor gamma-mediated activity, estrogenic, androgenic, and anti-androgenic activities using in vitro bioassays. A significant portion of the AhR-mediated and estrogenic activities could be explained by detected analytes at several sites, while for the other bioassays and other sites, much of the activity remained unexplained. The effect-based trigger values for estrogenic and anti-androgenic activities were exceeded at some sites. The identified drivers of mixture in vitro effects deserve further attention in ecotoxicological and environmental pollution research. This novel approach using long-term passive sampling provides a representative benchmark of pollution and effect potentials of chemical mixtures for future water quality monitoring of the Danube River and other large water bodies.

Nuciferine improves random skin flap survival via TFEB-mediated activation of autophagy-lysosomal pathway

Due to their simplicity and reliability, random-pattern skin flaps are commonly utilized in surgical reconstruction to repair cutaneous wounds. However, the post-operative necrosis frequently happens because of the ischemia and high-level of oxidative stress of random skin flaps, which can severely affect the healing outcomes. Earlier evidence has shown promising effect of Nuciferine (NF) on preventing hydrogen peroxide (H₂O₂)-induced fibroblast senescence and ischemic injury, however, whether it can function on promoting ischemic flap survival remains unknown. In this work, using network pharmacology analysis, it was possible to anticipate the prospective targets of NF in the context of ischemia. The results revealed that NF treatment minimized H₂O₂-induced cellular dysfunction of human umbilical vein endothelial cells (HUVECs), and also improved flap survival through strengthening angiogenesis and alleviating oxidative stress, inflammation and apoptosis in vivo. These outcomes should be attributed to TFEB-mediated enhancement of autophagy-lysosomal degradation via the AMPK-mTOR signaling pathway, whilst the restriction of autophagy stimulation with 3MA effectively diminished the above advantages of NF treatment. The increased nuclear translocation of TFEB not only restored lysosome function, but also promoted autophagosome-lysosome fusion, eventually restoring the inhibited autophagic flux and filling the high energy levels. The outcomes of our research can provide potent proof for the application of NF in the therapy of vascular insufficiency associated disorders, including random flaps.