Surgical methods for managing ischial pressure wounds

Dual-Plane Gluteal Myocutaneous Flap for Reconstruction of Ischial Tuberosity Pressure Wounds

PURPOSE

Ischial tuberosity pressure wounds are the most common type of pressure wound and contribute to a large percentage of the total cost of surgical and nonsurgical management of pressure wounds. Gluteal myocutaneous and fascocutaneous flaps are well-documented methods of coverage for ischial pressure wounds. This study aimed to describe results using a novel dual-plane gluteal myocutaneous flap technique for reconstruction of ischial tuberosity pressure wounds.

METHODS

A retrospective chart review was performed of all patients who underwent dual-plane gluteus maximus myocutaneous flap reconstruction for ischial tuberosity pressure wounds performed by a single surgeon from 2012 to 2018. Patient demographic, clinical, and operative characteristics were reviewed. Outcomes were assessed by analyzing complication rates including recurrence, need for revision surgery, dehiscence, necrosis, wound infection, seroma, and hematoma.

RESULTS

Eight dual-plane gluteus maximus myocutaneous flaps were performed for reconstruction of ischial tuberosity pressure wounds in 7 male patients with a mean age of 49.1 ± 14.9 years (mean ± SD) and mean body mass index of 26.7 ± 6.4 kg/m. All patients were nonambulatory secondary to spinal cord injury or congenital neurological disease. Two patients (28.6%) were diabetic, and 1 patient (14.3%) was an active smoker. The mean defect size after debridement of ischial pressure wounds was 60.7 ± 29.4 cm. After a mean follow-up of 16.4 months, partial wound dehiscence occurred in 1 patient (14.3%) and was managed with local wound care only. Infection and recurrence occurred in another patient (14.3%) and required revision surgery.

CONCLUSIONS

The dual-plane gluteal myocutaneous flap is an effective method for reconstruction of ischial tuberosity pressure wounds. Partially elevating the cutaneous layer off the gluteus maximus muscle allows for greater mobility and rotation of the muscle flap into the ischial pressure wound defect and closure of the flap and donor site with the cutaneous layer.

Reducing the period of immobilization following pressure sore surgery: a prospective, randomized trial

The cost to care for a patient with pressure sores can be exorbitant. One part of this expense results from the prolonged postoperative immobilization. Published protocols report 3 to 8 weeks of immobilization; however, there are no studies that establish longer periods to be superior. To justify our 3-week protocol, we conducted a prospective, randomized trial of 2 versus 3 weeks of postoperative immobilization. Each patient was randomized preoperatively to either 2 or 3 weeks of postoperative immobilization. A total of 42 patients with a diagnosis of paraplegia, tetraplegia, or multiple sclerosis and a solitary pressure sore were enrolled over 5 years. The complication rates in the two groups (9 of 23, or 39 percent, for the 2-week group and 9 of 19, or 47 percent, for the 3-week group) were not statistically different (p < 0.493). However, the time to mobilization was significantly reduced in the 2-week group (16.1 +/- 6.1 versus 22.9 +/- 4.9 days, p < 0.0003), as was the time to achieve sitting (21.2 versus 28.9 days, p < 0.0026). In summary, 2 weeks of postoperative immobilization following surgery is adequate for uncomplicated solitary pressure sores.

Closure of an ischial pressure sore using a free gastrocnemius musculocutaneous flap with a long venous pedicle

The recurrent pressure sore in an active paraplegic can become a frustrating challenge as available simple flap options become depleted. The medial gastrocnemius musculocutaneous free flap is an alternative that offers the benefits of muscle from an expendable donor site and still preserves the remainder of the donor limb for future use. Inclusion of an intact greater saphenous vein could augment venous drainage and potentially might be the sole means of outflow if veins at the recipient site were inadequate. This case report describes the closure of a recurrent ischial pressure sore with a free medial gastrocnemius flap, including a greater saphenous vein pedicle.

Use of the biceps femoris following failed inferior gluteal flap transfer. Case report

Considering the high recurrence rate of pressure ulceration in paraplegic patients, flap procedures to reconstruct a defect should not be at the expense of another possible future flap. The posterior thigh fasciocutaneous flap is useful for the coverage of ischial and trochanteric pressure sores; the biceps femoris musculocutaneous flap is a useful choice for deep ischial defects. However, the cutaneous portions of these two flaps is nearly identical. The previous transfer of the biceps flap excludes the further use of the posterior thigh flap. In contrast, use of the posterior thigh flap still permits the employment of a biceps V-Y advancement flap. Even if the donor site of the previous posterior thigh flap must be skin-grafted, the graft will remain viable on its muscular bed and function as the cutaneous portion of the flap; thus stable coverage is provided, despite previous use of 'first line' flaps. We demonstrate how careful planning of the stages of flap procedures can allow the most economic use of donor areas in this difficult patient group.

The contributions of plastic surgery to care of the spinal cord injured patient

Plastic surgeons have contributed to the understanding of pressure sore pathophysiology and prophylaxis. Increasingly sophisticated surgical techniques such as myocutaneous or innervated flaps add to the reliability and durability of repairs. The majority of quadriplegics may benefit from surgical restoration of active elbow extension, lateral pinch and grasp. Prolonged postoperative care in bed or immobilisation of the upper limb demands that patients should understand fully all that the reconstructive procedure involves. The nature and importance of subsequent rehabilitation must be appreciated by the patient so that he will be motivated to achieve the best possible result. Functional electrical stimulation may find an increasing role in the years to come.

The one-stage surgical treatment of multilocated pressure sores using various myocutaneous island flaps

Report on 32 patients suffering from chronical pressure sores (n = 18 solitary, n = 14 multilocated), Campbell stages IV-VI, overlaying sacral bone, ischial tuberosity and tuber femoris, which were treated by using various combinations of myocutaneous island flaps (uni- or bilaterally glutaeus maximus and/or biceps femoris flaps). Indications, operative procedures, perioperative management and follow-up results are presented. Superficial skin lesions (n = 2) and wound dehiscence (n = 1) appeared as temporary wound complications in the 14 patients with multilocated pressure sores. In all cases stable and durable coverage was achieved without any recurrence. The value of adequate rehabilitation in avoiding relapses is pointed out.

Bilateral hip resection for closure of trochanteric pressure sores: case report

Bilateral resection of the proximal femur, an orthopaedic procedure advocated in selected cases of infected hip joints, can be useful in the treatment of extensive pressure sores in paraplegics. It is especially indicated in those cases where a total thigh flap is considered with the advantage of saving the limb, and by shortening the leg providing more skin and soft tissue for closure of the pressure sores.