Recurrence rates of ischial sores in para- and tetraplegics treated with hamstring flaps: an 8-year study

Descriptive Analysis of Surgical Outcomes and Stoma Formation for Treating Sacral and Anal Pressure Injuries in Spinal Cord Injury: A Retrospective Study of Selected Cases

Introduction

Pressure injuries (PIs) arise from sustained pressure on tissue, leading to reduced blood flow to the affected area. In patients with spinal cord injuries (SCIs), these PIs can significantly diminish their independence and overall quality of life. This research sought to assess the frequency of surgical complications in treatment regimens for large sacral PIs involving the anus. Specifically, the study focused on the incorporation of stoma formation in patients with SCIs.

Methods

A retrospective review identified 25 SCI patients who had extensive sacral PIs. These patients underwent intestinal stoma formation as a preparatory step before plastic reconstructive surgery to address the wounds between 2015 and 2020.

Results

Successful wound closure was achieved in all instances. Notably, each patient had experienced a minimum of three unsuccessful reconstructive surgeries elsewhere before this intervention. The observed rate of surgical complications aligned with findings from previous analogous studies.

Conclusion

While often viewed as a treatment of last resort, an intestinal stoma might serve as a valuable strategy, particularly for SCI patients with extensive PIs near the anal region, to promote the healing of such injuries. Tailored decision-making is essential to ensure the best possible patient outcomes.

Reconstructive Surgery of Pressure Injuries in Spinal Cord Injury/Disorder Patients: Retrospective Observational Study and Proposal of an Algorithm for the Flap Choice

Pressure injuries (PIs) are a common complication in patients with spinal cord injury/disorder (SCI/D), and deep PIs require surgical treatment consisting of wide debridement and adequate reconstruction. We conducted a retrospective observational study at a tertiary rehabilitation hospital for SCI/D in Italy with the aim of describing the incidence and associated risk factors of postoperative complications in individuals with SCI/D presenting with chronic deep PIs, treated with a specific flap selection algorithm based on the site of the defect, the presence of scars from previous surgeries, and the need to spare reconstructive options for possible future recurrences. Medical records of surgical procedures performed on SCI/D patients with fourth-degree PIs, according to NPUAP classification (National Pressure Ulcer Advisory Panel), between July 2011 and January 2018 were reviewed. A total of 434 surgical procedures for fourth-degree PIs in 375 SCI/D patients were analyzed. After a mean follow-up of 21 months (range 12-36), 59 PIs (13.6%) had minor complications, and 17 (3.9%) had major complications requiring reoperation. The sacral site and muscular and musculocutaneous flaps were significant risk factors for postoperative complications. Six patients (1.4%) had a recurrence. The choice of flap correlates with the outcome of decubitus reconstruction. Therefore, reconstructive planning should be based on established principles.

Risk factors for pressure ulcer recurrence following surgical reconstruction: A cross-sectional retrospective analysis

Many studies on the recurrence of pressure ulcers after surgical reconstruction have focused on surgical techniques and socioeconomic factors. Herein, we aimed to identify the risk factors of the associated comorbidities for pressure ulcer recurrence. We enrolled 147 patients who underwent pressure ulcer reconstruction and were followed up for more than three years. The recurrence of pressure ulcers was defined as recurrent pressure ulcers with stage 3/4 pressure ulcers. We reviewed and analyzed systematic records of medical histories, including sex, age, associated comorbidities such as spinal cord injury (SCI), diabetes mellitus (DM), coronary artery disease, cerebral vascular accident, end-stage renal disease, scoliosis, dementia, Parkinson's disease, psychosis, autoimmune diseases, hip surgery, and locations of the primary pressure ulcer. Patients with recurrent pressure ulcers were younger than those without. Patients with SCI and scoliosis had higher odds, while those with Parkinson's disease had lower odds of recurrence of pressure ulcers than those without these comorbidities. Moreover, the decision tree algorithm identified that SCI, DM, and age < 34 years could be risk factor classifiers for predicting recurrent pressure ulcers. This study demonstrated that age and SCI are the two most important risk factors associated with recurrent pressure ulcers following surgical reconstruction.

The role of the perioperative prone position in the low recurrence of pressure injuries in the pelvic region

OBJECTIVE

A pressure injury (PI) is a localised area of damage to the skin and/or underlying soft tissue as a result of a sustained mechanical loading. There are three key aetiological mechanisms to PI formation-direct cell deformation, inflammatory oedema and ischaemic damage-which are typically activated sequentially to drive a spiral of injury. This article discusses the role of the perioperative prone position as a rational approach to reducing the recurrence of pelvic PI after reconstructive surgery.

METHOD

Patients with deep PI in the pelvic region, who were operated on from 2011 to 2019, were retrospectively evaluated. The protocol of care included training in the prone position, followed by maintenance of the prone position for 4-6 weeks postoperatively. The reconstruction was performed with fasciocutaneous and myocutaneous local or regional flaps.

RESULTS

The study evaluated a total of 26 patients. The rate of recurrence of PIs was 15.4% (4/26) in the mean follow-up of 54 months. Regarding postoperative complications, four cases of partial dehiscence of the suture occurred.

CONCLUSION

This perioperative protocol of maintaining a prone position seems to be safe for the patient, and it can be used to prevent or reduce the recurrence of deep PIs on the pelvic region after reconstructive surgery.

Hemicorporectomy - the ultimate solution of terminal pelvic sepsis

Hemicorporectomy is the amputation of the lower body - pelvis and lower limbs. It requires transection of the spine and dural sac at the level of aortic bifurcation and inferior lower vein, and permanent urinary and stool derivation. Performance indications are tumour trauma and terminal pelvic osteomyelitis. So far about 60 cases have been published; only 11 operations were performed for terminal osteomyelitis. We have successfully performed hemicorporectomy in a patient with chronic sepsis from terminal pelvic osteomyelitis after exhausting all other treatment options. The experience gained and the important moments of the procedure are given in the case report.

Volumetric Evaluation of Dead Space in Ischial Pressure Injuries Using Magnetic Resonance Imaging: A Case Series

OBJECTIVE

To establish a preoperative evaluation procedure by measuring the volume of dead space using MRI in patients with ischial pressure injuries.

METHODS

Patients with spinal cord injury and ischial pressure injuries who underwent treatment between August 2016 and November 2019 were included in the study. Preoperative MRI scan was conducted on all patients. The volume estimation and three-dimensional (3D) reconstruction were performed based on MRI data using a 3D Slicer. Based on the resulting volume, a muscle flap that could fit the dead space was selected. Surgery was performed with the selected muscle flap, and a fasciocutaneous flap was added, if necessary.

RESULTS

A total of eight patients with ischial pressure injuries were included in the study. The mean patient age was 59.0 ± 11.0 years. The mean body mass index was 26.62 ± 3.89 kg/m2. The mean volume of dead space was 104.75 ± 81.05 cm3. The gracilis muscle was the most selected muscle flap and was used in four patients. In five of eight cases, a fasciocutaneous flap was used as well. The mean follow-up period was 16 months, and by that point, none of the patients evinced complications that required surgery.

CONCLUSIONS

To the authors' knowledge, this is the first report on volumetric evaluation of dead space in ischial pressure injuries. The authors believe that the 3D reconstruction process would enable adequate dead space obliteration in ischial pressure injuries. The authors propose that preoperative MRI scans in patients with ischial pressure injury should become an essential part of the process.

Free Tissue Transfer in Pressure Ulcer Reconstruction: A Systematic Review

Background Pressure ulcers (PUs) affect 2.5 million people in the United States annually and incur health-care costs of 11 billion dollars annually. Stage III/IV PU often require local flap reconstruction. Unfortunately, PU recurrence is common following reconstruction; recurrence rates as high as 82% have been reported. When local flap options are inadequate, free tissue transfer may be indicated but the indications have yet to be delineated. To develop evidence-based guidelines for the use of free flaps in PU reconstruction, we performed a systematic review.

Methods A systematic review of the available English-language, peer-reviewed literature was conducted using PubMed/MEDLINE, Google Scholar, Scopus, EMBASE, and the Cochrane Database of Systematic Reviews. Articles were manually reviewed for relevance.

Results Out of 272 articles identified, 10 articles were included in the final analysis. Overall, this systematic review suggests that free-flap PU reconstruction yields fewer recurrences compared with local flaps (0–20 vs. 13–82%). Further, several types of free flaps for PU reconstruction were identified in this review, along with their indications.

Conclusion Free tissue transfer should be considered for recurrent PU. We offer specific recommendations for their use in PU reconstruction.

A Systematic review and meta-analysis of sensate versus non-sensate flaps for the prevention of pressure ulcer recurrence among individuals with spinal cord disease

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

To identify, critically appraise, and synthesize research findings on non-sensate versus sensate flaps among individuals with spinal cord disease and pelvic pressure ulcers, with pressure ulcer recurrence as primary outcome.

METHODS

PubMed, EMBASE, and Cochrane CENTRAL were screened for relevant studies. Data on surgical characteristics, ulcer recurrence, and sensory outcomes were retrieved and tabulated. Risk of bias was assessed with MINORS. The level of evidence was evaluated with GRADE. Meta-analysis was performed when possible.

RESULTS

Meta-analysis of 1794 non-sensate locoregional reconstructions indicated a recurrence rate of 34% within several years (95% CI, 27-42). Twenty-one articles provided data on 75 sensate reconstructions, performed in 74 individuals. Meta-analysis of the sensate reconstructions indicated a recurrence rate of 1% (95% CI, 0-8). Sensate reconstructions were not associated with an increase of wound complications (19%; 95% CI, 7-40) compared with non-sensate ones (34%; 95% CI, 27-42). A very low level of evidence was determined with use of GRADE.

CONCLUSION

Although of a very low-level, the present evidence suggests that restoration of sensory innervation may be an effective intervention for the prevention of pressure ulcer recurrence among individuals with spinal cord disease. A prospective RCT is needed to confirm or refute the results of this systematic review.

A 9-year retrospective evaluation of 102 pressure ulcer reconstructions

• Objective:

Several pressure ulcer (PU) risk factors including paralysis and age greater than 70 have been identified, while others such as nutrition are debated. The object of this study is to identify perioperative risk factors that may predict improved outcomes and reduced complications in primary and recurrent PU reconstructions.

• Method:

A retrospective chart review of patients treated surgically for PUs from 2004 to 2013 at the University of Toledo Medical Center, Toledo, Ohio, US, was completed. Data collected included ulcer and medical history, as well as risk factors, complications and postoperative outcome. Data were statistically analysed for perioperative variances between primary and recurrent ulcers and closure status.

• Results:

A total of 49 patients with 102 reconstructions were reviewed. Spinal cord injured patients accounted for 90% receiving flap coverage of ulcers. Numerous differences between primary and recurrent ulcers were identified, including ulcer location, patient nutritional status, wound infection, postoperative course and recurrence. Multivariate analysis revealed a flap reconstruction prediction model using creatinine, haematocrit, haemoglobin, and prealbumin that is able to successfully predict closure outcome in 83.6% of cases.

• Conclusion:

Many factors play a role in the development, course and treatment of PUs. It is vital to understand the role of patient risk factors in the development of PUs, to direct subsequent management and reconstruction, and to prevent future recurrences.

A Systematic Review and Meta-Analysis of the Pressure-Induced Vasodilation Phenomenon and Its Role in the Pathophysiology of Ulcers

BACKGROUND

Physiologic studies show that tissue perfusion increases during moderate amounts of tissue compression. This is attributed to sensory nerves initiating a vasodilatory cascade referred to as pressure-induced vasodilation.

METHODS

PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched for studies investigating perfusion during pressure exposure longer than 10 minutes. Retrieved studies were assessed using the Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal Studies. Results were pooled with random effects models. The body of evidence was rated using the Office of Health Assessment and Translation approach.

RESULTS

Twenty-nine articles were included, of which 19 articles were included in meta-analyses. The evidence indicates that moderate amounts of tissue compression have the capacity to increase perfusion in healthy humans by 46 percent (95 percent CI, 30 to 62 percent). Using the Office of Health Assessment and Translation approach, the authors found a high level of confidence in the body of evidence. Pressure-induced vasodilation blockade was associated with increased pressure ulcer formation. Pressure-induced vasodilation was impaired by neuropathy and by the drugs diclofenac and amiloride.

CONCLUSIONS

This systematic review and meta-analysis indicates that healthy humans have the capacity to increase local perfusion in response to mechanical stress resulting from tissue compression. Because pressure-induced vasodilation is mediated by sensory nerves, pressure-induced vasodilation emphasizes the importance of sensory innervation for durable tissue integrity. Pressure-induced vasodilation impairment seems to provide a complementary explanation for the susceptibility of neuropathic tissues to pressure-induced lesions.

Recurrence rate after pressure ulcer reconstruction in patients with spinal cord injury in patients under control by a plastic surgery and physical medicine and rehabilitation team

Objectives

This study aims to evaluate the recurrence rate after reconstruction of the pressure ulcer (PU) in patients with spinal cord injury (SCI) treated by a team consisted of plastic surgery and physical medicine and rehabilitation specialists.

Patients and methods

Between February 2002 and December 2008, a total of 39 patients with SCI (32 males, 7 females; mean age 38.1±6.7 years; range, 19 to 71 years) aged ≥18 years who were admitted to our rehabilitation unit and operated for PU were retrospectively analyzed. Demographic data and physical examination findings and potential risk factors for recurrence of PU were recorded. All patients were followed for the PU recurrence after reconstruction.

Results

The recurrence of PU was observed in nine patients (23.1%) with SCI. The most common recurrent PU was sacral ulcer (82.1%), followed by ischial ulcers (20.5%), trochanteric ulcers (15.4%), and others (2.6%). No risk factor was found to be statistically significant between the two groups in terms of both demographic risk factors and clinical risk factors. No statistically significant effect of clinical and demographic risk factors was found on the risk of recurrence of PU.

Conclusion

Our study results suggest that collaboration between plastic surgery and physical medicine and rehabilitation department with a strict follow-up protocol may help to prevent recurrences of PU after surgery in SCI patients.

[Surgical treatment of recurrent pressure ulcers in spinal cord injured patients]

Not to burn one's bridges. This is the basic principle that comes immediately to the mind of the plastic surgeon when one brings up the secondary surgery of pressure ulcers, which is a common pathology in the spinal cord injured patients. Which ones are good candidates for surgical treatment? When? What preoperative, infectious, rehabilitative management is most likely to minimize the number of failures and recurrences? Which operative technique to prefer in first intention? And in case of secondary surgery, how to choose the best strategy? We will see that some cases can be treated by primarily closing or flap remobilization but, in case of greater loss of substance the realization of a flap from another anatomical region will be essential.

National perioperative outcomes of flap coverage for pressure ulcers from 2005 to 2015 using American College of Surgeons National Surgical Quality Improvement Program

Background

Complication rates after flap coverage for pressure ulcers have been high historically. These patients have multiple risk factors associated with poor wound healing and complications including marginal nutritional status, prolonged immobilization, and a high comorbidities index. This study utilizes the National Surgical Quality Improvement Program (NSQIP) to examine perioperative outcomes of flap coverage for pressure ulcers.

Methods

Data from the NSQIP database (2005–2015) for patient undergoing flap coverage for pressure ulcers was identified. Demographic, perioperative information, and complications were reviewed. One-way analysis of variance and Pearson chi-square were used to assess differences for continuous variables and nominal variables, respectively. Multivariate logistic regression was performed to identify independent risk factors for complications.

Results

There were 755 cases identified: 365 (48.3%) sacral ulcers, 321 (42.5%) ischial ulcers, and 69 (9.1%) trochanteric ulcers. Most patients were older male, with some degree of dependency, neurosensory impairment, high functional comorbidities score, and American Society of Anesthesiologists class 3 or above. The sacral ulcer group had the highest incidence of septic shock and bleeding, while the trochanteric ulcer group had the highest incidence of superficial surgical site infection. There was an overall complication rate of 25% at 30-day follow-up. There was no statistical difference in overall complication among groups. Total operating time, diabetes, and non-elective case were independent risk factors for overall complications.

Conclusions

Despite patients with poor baseline functional status, flap coverage for pressure ulcer patients is safe with acceptable postoperative complications. This type of treatment should be considered for properly selected patients.

Pressure ulcer-related pelvic osteomyelitis: evaluation of a two-stage surgical strategy (debridement, negative pressure therapy and flap coverage) with prolonged antimicrobial therapy

Background

A two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated.

Methods

Adult patients with pressure ulcer-related pelvic osteomyelitis treated by a two-stage surgical strategy were included in a retrospective cohort study. Determinants of superinfection (i.e., additional microbiological findings at reconstruction) and treatment failure were assessed using binary logistic regression and Kaplan-Meier curve analysis.

Results

Sixty-four pressure ulcer-related pelvic osteomyelitis in 61 patients (age, 47 (IQR, 36–63)) were included. Osteomyelitis was mostly polymicrobial (73%), with a predominance of S. aureus (47%), Enterobacteriaceae spp. (44%) and anaerobes (44%). Flap coverage was performed after 7 (IQR, 5–10) weeks of NPT, with 43 (68%) positive bone samples among which 39 (91%) were superinfections, associated with a high ASA score (OR, 5.8; p = 0.022). An increased prevalence of coagulase negative staphylococci (p = 0.017) and Candida spp. (p = 0.003) was observed at time of flap coverage. An ESBL Enterobacteriaceae spp. was found in 5 (12%) patients, associated with fluoroquinolone consumption (OR, 32.4; p = 0.005). Treatment duration was as 20 (IQR, 14–27) weeks, including 11 (IQR, 8–15) after reconstruction. After a follow-up of 54 (IQR, 27–102) weeks, 15 (23%) failures were observed, associated with previous pressure ulcer (OR, 5.7; p = 0.025) and Actinomyces spp. infection (OR, 9.5; p = 0.027).

Conclusions

Pressure ulcer-related pelvic osteomyelitis is a difficult-to-treat clinical condition, generating an important consumption of broad-spectrum antibiotics. The lack of correlation between outcome and the debridement-to-reconstruction interval argue for a short sequence to limit the total duration of treatment.

The pedicled internal pudendal artery perforator (PIPAP) flap for ischial pressure sore reconstruction: Technique and long-term outcome of a cohort study

BACKGROUND

The ischial region is the site most affected by pressure sores and has the highest recurrence and complication rates compared to other affected sites. We developed a practical and safe pedicled flap for reconstruction of ischial pressure sores based on the rich available perforators from the internal pudendal artery and the surplus of skin at the infragluteal fold.

METHODS

A retrospective cohort study was conducted in all patients who underwent ischial pressure ulcer reconstruction using the PIPAP flap between March 2010 and March 2017. The skin flap was designed along the gluteal fold. The skin perforators of the pudendal artery were marked with a Doppler probe in the medial region of the gluteal fold. Surgery was performed in the jackknife position, and flaps were elevated in the suprafascial plane. Patients were assessed for minor (requiring no additional surgery) and major complications (requiring additional surgery).

RESULTS

Twenty-seven patients (34 flaps) were identified. The median follow-up period was 38 months (IQR 37). Primary closure of the donor-site was achieved in all procedures, only one flap required muscle flap transposition in order to fill the dead space. The mean operating time was 60 ± 21 minutes. In six flaps (9%) wound healing problems were noted that did not require an additional operative procedure. Among the nine flaps (27%) that required a second procedure, 3 (9%) were necessary due to recurrent ulcers.

CONCLUSIONS

The PIPAP flap is a safe and reliable alternative for ischial pressure sore reconstruction, certainly when compared to available techniques. Moreover, it has significant advantages over other techniques including minimal donor-site morbidity, preservation of posterior thigh skin, buttock-line integrity and reliable vascularity.

Reconstruction of acquired ischiatic and perineal defects: an anatomical and clinical comparison between gluteal thigh and inferior gluteal perforator flaps

BACKGROUND

Flap coverage is the gold standard in treating pressure sores, and due to the high recurrence rate, the possibility of multiple surgical procedures should be considered during flap selection. The gluteal thigh (GT) flap has become a workhorse for ischiatic pressure sore treatment at our hospital. Follow-up revealed a group of patients presenting recurrence of the pressure sore that needed a second flap. The inferior gluteal artery perforator (IGAP) flap was chosen in this series. The positive experience with both flaps raised the question of which flap should be the first option for the treatment of ischiatic and perineal pressure sores.

METHODS

IGAP and GT flaps were dissected in 21 fresh human cadavers to allow comparison of anatomical features. In a series of 60 patients, the authors used both the gluteal thigh and the IGAP flap to cover 76 ischiatic and perineal ulcers.

RESULTS

The IGAP flap was found to be wider and thicker than the gluteal thigh, but presented a shorter pedicle. All flaps healed uneventfully. Recurrent ulcers were treated successfully with both flaps.

CONCLUSIONS

Both flaps are suitable for coverage ischiatic and perineal sores. Due to its anatomical features, the IGAP flap should be considered the first choice of treatment for ischiatic ulcers. The gluteal thigh flap should be used in the recurrent sores.Level of Evidence: Level IV, therapeutic study.

Bacterial load of conditioned pressure ulcers is not a predictor for early flap failure in spinal cord injury

OBJECTIVES

Pressure ulcers impose a major lifetime medical problem to patients with high-grade spinal cord injury (SCI). For patients with stages 3-4 pressure ulcers, plastic surgery is often the only remaining treatment option. Despite considerable flap failure rates of around 30%, only sparse knowledge exists on predictors for flap failure. Hence, identification of predictors for flap failures is needed.

METHODS

We prospectively enrolled 38 SCI patients with stages 3-4 pressure ulcers scheduled for plastic surgery. Preoperative wound swabs, intraoperative tissue samples and postoperative drainage liquids were microbiologically analyzed. In multivariable logistic regression analyses, bacterial loads of deep tissue cultures of intraoperative samples as well as other clinical variables were analyzed with respect to the prediction of flap failures.

RESULTS

The flap failure rate was 27.5%. Bacterial loads of deep tissue cultures were not predictive for flap failure, neither was the colonization with a specific bacterial strain. We observed a considerable fluctuation of microbiological environment from initial swab cultures, intraoperative samples and postoperative drainage fluids. Antibioprophylaxis was sufficient in only 75% of deep tissue cultures and 69% of drainage fluids. Insufficient antibioprophylaxis was associated with a higher flap failure rates (odds ratio 6.3, confidence interval 1.2-41.0).

CONCLUSION

After inpatient wound conditioning, bacterial load analysis of intraoperative wound tissue cultures is ineffective in order to predict flap failure rates in SCI patients with stages 3-4 pressure ulcers after flap surgery. Instead, insufficient antibioprophylaxis might be a factor contributing to flap failure.

The operative treatment of pressure sores in the pelvic region: A 10-year period overview

CONTEXT

Pelvic region pressure sores often develop following spinal cord injury. Surgery is often necessary for long standing, large-sized pressure sores not responding to conservative treatment. Authors analyze their results of a 10-year period, and identify factors contributing to the reduction of the recurrence rate.

METHODS

A total of 119 pressure sores were operated on 98 patients in two institutions during a 10-year period (1 January 2003 to 31 December 2012). The encountered perioperative complications are summarized, and the recurrence rate is analyzed with a patient follow-up questionnaire.

RESULTS

We experienced 15 perioperative complications (12.6%). All complications were fully resolved by conservative treatment. Fifty-eight returned patient replies were processed. The average follow-up time after surgery was 5.2 years. The recurrence rate was 5.47%.

CONCLUSION

The strict adherence to surgical indications, full patient compliance, specialized pre- and post-operative patient care, our routinely used preferred surgical method, all contribute to a low post-operative complication rate, long-term flap survival, and an extended recurrence free period.

Treatment of ischial pressure sores with both profunda femoris artery perforator flaps and muscle flaps

Background

Reconstruction of ischial pressure sore defects is challenging due to extensive bursas and high recurrence rates. In this study, we simultaneously applied a muscle flap that covered the exposed ischium and large bursa with sufficient muscular volume and a profunda femoris artery perforator fasciocutaneous flap for the management of ischial pressure sores.

Methods

We retrospectively analyzed data from 14 patients (16 ischial sores) whose ischial defects had been reconstructed using both a profunda femoris artery perforator flap and a muscle flap between January 2006 and February 2014. We compared patient characteristics, operative procedure, and clinical course.

Results

All flaps survived the entire follow-up period. Seven patients (50%) had a history of surgery at the site of the ischial pressure sore. The mean age of the patients included was 52.8 years (range, 18-85 years). The mean follow-up period was 27.9 months (range, 3-57 months). In two patients, a biceps femoris muscle flap was used, while a gracilis muscle flap was used in the remaining patients. In four cases (25%), wound dehiscence occurred, but healed without further complication after resuturing. Additionally, congestion occurred in one case (6%), but resolved with conservative treatment. Among 16 cases, there was only one (6%) recurrence at 34 months.

Conclusions

The combination of a profunda femoris artery perforator fasciocutaneous flap and muscle flap for the treatment of ischial pressure sores provided pliability, adequate bulkiness and few long-term complications. Therefore, this may be used as an alternative treatment method for ischial pressure sores.

A retrospective study on flap complications after pressure ulcer surgery in spinal cord-injured patients

STUDY DESIGN

A retrospective study reporting specific complications of certain skin flaps for treating pressure ulcers.

OBJECTIVES

To describe the rate and type of complications after pressure ulcer surgery in patients with spinal cord injury.

SETTING

Germany, Rheinland Pfalz.

METHODS

We collected data from 352 patients treated with 421 skin flaps to determine the rate and type of complications of each skin flap used.

RESULTS

In this study, we analyzed the results of 421 skin flaps in 352 patients with a total of 657 pressure ulcers from January 2006 to December 2010. Our patients had ischial, pelvic, sacral, trochanteric and lower extremity ulcers. Ischial ulcers were most common, followed by sacral and trochanteric ulcers. There were 87 complications in 421 flaps, which was an overall rate of 21%. Suture line dehiscence was the most common complication with 27 cases (31%), followed by 22 cases of infection (25.2%), 17 cases of hematoma (19.5%), 12 cases of partial necrosis (13.7%) and 9 cases of total flap necrosis (10.3%).

CONCLUSION

Pressure ulcers in spinal cord-injured patients are very common and difficult and expensive to treat. The high rate of complications and the associated costs suggest the importance of evaluating the efficacy of treatment options. Conservative procedures have been standardized, but there still has been limited success in establishing guidelines on how to manage complications arising from flap surgery. Our extensive documentation of flap plastics will be useful managing complications after the surgical treatment of pressure ulcers in spinal cord-injured patients.

[Resurfacing of an ischial and trochanteric recurrent pressure sore by a pedicled fasciocutaneous anterolateral thigh flap]

Ischial pressure sores, common in paraplegic patient, are the most difficult to treat, and poor prognosis associated with a high rate of postoperative recurrence. Many surgical techniques by muscular or myocutaneous flap coverage have been described. We report an original use of a fasciocutaneous pedicled anterolateral thigh (ALTp) flap for coverage of an ischial pressure sore combined with a trochanteric pressure sore, exceeded beyond any conventional therapeutic solution. A 45-year-old paraplegic patient suffered from a trochanteric and ischial pressure sore, which had already received coverage by a muscular flap of biceps femoris and gluteus maximus. At 1 year, the result is satisfactory, with good coverage without recurrence. The fasciocutaneous ALTp flap can be a solution to cover recurrent ischial pressure sores beyond conventional methods.

Clinical evaluation of gauze-based negative pressure wound therapy in challenging wounds

The aim of this randomised clinical study was to evaluate the effectiveness and safety of gauze-based negative pressure wound therapy (NPWT) in patients with challenging wounds. A total of 50 consecutive patients who had wound drainage for more than 5 days, required open wound management and had existence of culture positive infection were included the study. In this study, gauze-based NPWT was compared with conventional dressing therapy in the treatment of patients with difficult-to-heal wounds. The patients were randomly divided into two groups. Group I (n = 25) was followed by conventional antiseptic (polyhexanide solution) dressings, and group II (n = 25) was treated with saline-soaked antibacterial gauze-based NPWT. The wounds' sizes, number of debridement, bacteriology and recurrence were compared between group I and group II. The mean age of the patients was 59·50 years (range 23-97). In group I, average wound sizes of pre- and post-treatment periods were 50·60 ± 55·35 and 42·50 ± 47·92 cm(2), respectively (P < 0·001). Average duration of treatment was 25·52 ± 16·99 days, and average wound size reduction following the treatment was 19·99% in this group. In group II, the wounds displayed considerable shrinkage, accelerated granulation tissue formation, decreased and cleared away exudate. The average wound sizes in the pre- and post-treatment periods were 98·44 ± 100·88 and 72·08 ± 75·78 cm(2) , respectively (P < 0·001). Average duration of treatment was 11·96 ± 2·48 days, and average wound size reduction following the treatment was 32·34%. The patients treated with antibacterial gauze-based NPWT had a significantly reduced recurrence (2 wounds versus 14 wounds, P = 0·001), and increased number of the culture-negative cases (22 wounds versus 16 wounds, P < 0·047) in a follow-up period of 12 months. There was a statistically significant difference between two groups in all measurements. As a result, we can say that the gauze-based NPWT is a safe and effective method in the treatment of challenging infective wounds when compared with conventional wound management.

The 'reading man flap' for pressure sore reconstruction

Background:

The treatment of pressure sores represents a significant challenge to health care professionals. Although, pressure wound management demands a multidisciplinary approach, soft tissue defects requiring reconstruction are often considered for surgical management. Myocutaneous and fasciocutaneous flaps can provide stable coverage of pressure sores.

Purpose:

Here, we describe our experience using a recent fasciocutaneous flap, which is named ‘reading man’ flap, in sacral, ischial, and trochanteric pressure sores.

Materials and Methods:

During a period of 1 year the authors operated 16 patients, 11 men, and 5 women, using the reading man flap. The ages of the patients ranged from 24 to 78 years. The location of pressure sores was 8 sacral, 5 ischial, and 3 trochanteric pressure sores. The mean size of pressure sores was 8 cm × 9 cm.

Results:

All pressure sores covered bt the Reading Man flap healed asymptomatically. After follow-up of 2-8 months, no recurrences were encountered and no further surgical intervention was required.

Conclusion:

The reading man flap was found to be a useful technique for the closure of pressure sore in different anatomic locations. The advantage of tension-free closure and the minimal additional healthy skin excision made this flap a useful tool in pressure sore reconstructions.

Tip anchor flap in decubital surgery

Anchoring a flap remains a key procedure in decubital surgery because a flap needs to be stable against shearing forces. This allows an early mobilization and undisturbed primary wound healing. This study evaluated a uniform group of eight paraplegic patients with sacral decubital ulcers and covered the lesions using gluteal rotation flaps with a deepithelialized tip to anchor the flap subcutaneously on the contralateral ischial tuber. Initial wound healing and recurrence after one year were evaluated. All but one flap showed uneventful wound healing, and all the flaps presented without any signs of recurrence or instability. The authors suggest that sufficient anchoring using a deepithelialized part of the flap helps to integrate and stabilize sacral rotation flaps.

[Surgical issues and outcomes in ischial pressure sores treatment]

INTRODUCTION

Ischiatic pressure sores are frequent in spinal cord injury patients, associated with bad prognosis and high recurrence rate. Many surgical techniques were described, including surgical debridement followed by pedicled flap coverage. We aim to propose a practical decision tree for primary or secondary ischial pressure sore treatment.

PATIENTS AND METHOD

Our series of 48 operated ischial sores with an average follow up of 4 years (range 2 to 8years) is analyzed and compared to previously published reports. Surgical techniques are discussed according to their specific indications.

RESULTS

The optimal recurrence rate in published reports about pressure sore treatment is 20%; a rate inferior to 19% is found in our series, showing the equal importance of flap selection and postoperative care and education. Depending on each situation, various available flaps are described and compared: gluteus maximus flap, biceps femoris flap, gracilis flap, tensor fascia lata flap, fasciocutaneous thigh flaps, rectus femoris and vastus lateralis flap, rectus abdominis flap. Specific surgical indications for more extensive wounds are studied: resection arthroplasty of the hip, hip disarticulation, fillet flaps from the leg, microsurgery.

CONCLUSION

Based upon our experience, a decision tree summarizes our proposition of flap selection, depending on the wound size and the patient background.

The operative treatment of pressure wounds: a 10-year experience in flap selection

This study sought to both assist in the selection of flaps for ischial pressure wound re-construction and to evaluate the overall complication rates associated with re-construction. A retrospective medical record review was conducted for 78 patients following the surgical re-construction of an ischial pressure sore. Records were reviewed for demographics, location of sores, methods of re-construction and flap selection, as well as any complications and recurrences. Seventy-two wounds were re-constructed with an average of 1.4 flaps used per wound. An ischial flap complication rate of 16% was observed in flap follow up, with a recurrence rate of 7% recorded. The vast majority of complications went on to heal with 15% of patients requiring a second re-construction. Our relatively large sample of ischial flaps allowed for a close comparison with previously published work. Both flap selection and site of reconstruction significantly affected the success rates for pressure sore coverage. The overall complication rates by flap and re-constructive site in this review are lower than previously published reports. Our experience with ischial re-construction was extensive enough to suggest a posterior medial thigh fasciocutaneous flap combined with a biceps femoris muscle flap as a first choice in ischial pressure wound re-construction.

The operative treatment of pressure wounds: a 10-year experience in flap selection

This study sought to both assist in the selection of flaps for ischial pressure wound reconstruction and evaluate the overall complication rates associated with reconstruction. A retrospective medical record review was conducted for 78 patients following the surgical reconstruction of an ischial pressure sore. Records were reviewed for demographics, location of sores, methods of reconstruction and flap selection, as well as any complications and recurrences. A total of 72 wounds were reconstructed with an average of 1.4 flaps used per wound. An ischial flap complication rate of 16% was observed in flap follow-up, with a recurrence rate of 7% recorded. The vast majority of complications went on to heal with 15% of patients requiring a second reconstruction. Our relatively large sample of ischial flaps allowed for a close comparison with previously published work. Both flap selection and site of reconstruction significantly affected the success rates for pressure sore coverage. The overall complication rates by flap and reconstructive site in this review are lower than previously published reports. Our experience with ischial reconstruction was extensive enough to suggest a posterior medial thigh fasciocutaneous flap combined with a biceps femoris muscle flap as a first choice in ischial pressure wound reconstruction.

A multi-channel stimulator and electrode array providing a rotating current whirlpool for electrical stimulation of wounds

When electrical stimulation is used on wounds, the electrical current has difficulty penetrating areas where there is necrotic tissue. Further, for an irregularly shaped wound, current distribution is poor in some areas of the wound since conventional two-electrode delivery systems provide the greatest current in a line directly between the electrodes. A new stimulator and electrode system is described which uses three electrodes spaced around a wound to disperse current more evenly. The stimulator senses tissue impedance and then redirects current by altering its Thevenin's output impedance for each electrode; each of the three electrodes becomes the active one in sequence while the remaining are the sink electrodes. Eight subjects were examined to test the stimulator. Electrical stimulation was applied to the skin above the quadriceps muscle at currents of 15 mA in six subjects without wounds and in two subjects with wounds. The relationship between electrode position and current dispersion on the skin was examined with a two-electrode vs. a three-electrode system to set stimulation parameters for the computer. The results showed that the three-electrode system could (1) detect areas of the skin with high impedance; (2) compensate by altering the Thevenin's output impedance at each of the three electrodes to shift current to high impedance areas; (3) provide uniform current across the skin as assessed by skin current and blood flow measurements with a laser Doppler flow imager.

Successful management of giant ischial decubitus ulcers complicated with urethral disorder

SUMMARY

We report a case of bilateral ischial pressure sores complicated with urethral fistula, caused by previous complete ischiectomy. Successful reconstruction was achieved after closure of the bladder neck. The large defect in the bilateral ischium and perineum was covered simultaneously with a free total plantar flap. The paucity of suitable recipient vessels for microvascular anastomoses was resolved by the creation of an arteriovenous loop, when the closure of bladder neck was performed in a supine position.

Management of recurrent ischial pressure sore with gracilis muscle flap and V-Y profunda femoris artery perforator-based flap

BACKGROUND

Inappropriate seating has been implicated as a major contributing factor in ischial pressure-sore recurrence. During their lifetime, paraplegic patients may require several flaps for closure of the same or some other adjacent pressure sore. Despite a wide variety of flap reconstruction options being described, the ischium remains the most difficult pressure-sore site to treat.

METHODS

From June 1998 to July 2006, there were 253 pressure-sore patients operated upon at Kaohsiung Medical University Hospital. Ten patients (eight men and two women) suffered from recurrent ischial pressure sores, and all of them received more than one flap reconstruction for the ischial defect. For the treatment of the recurrent ischial pressure sore, gracilis muscle flap and readvancement of the V-Y profunda femoris artery perforator-based flap were used to fill the dead space as well as cover the defect.

RESULTS

Among these 10 recurrent ischial pressure-sore patients, six of them had suffered bilateral ischial ulcers. Eight of them had previous sacral pressure sores. In all, 32 flap reconstruction procedures were performed on these 10 patients. Unfortunately, one patient had recurrent grade II bilateral ischial pressure sores after 11 months of ulcer-free period. The other nine patients had no recurrence noted, and enjoyed their lives with an average 27.2 months ulcer-free period (range 9-53 months).

CONCLUSIONS

The fasciocutaneous flap provides a higher mechanical resistance than the detached and transposed muscle. However, for the recurrent ischial ulcer patients, readvancement of the perforator-based fasciocutaneous flap alone cannot provide adequate bulk to obliterate the 'dead space' after debridement of the bursa and the surrounding necrotic tissue. By combining the readvancement of V-Y profunda femoris artery perforator-based fasciocutaneous flap and gracilis muscle flap, these recurrent ischial ulcers will heal without complication. Recurrence of ulceration often develops despite successful flap closure. Patients and their relatives have to be educated regarding pressure relief, personal skin, and self-care. Surgeons must collaborate with the rehabilitation department, nursing staffs, and social workers to improve long-term results.