Proximal femoral resection and myocutaneous flap for treatment of pressure ulcers in spinal injury patients

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.

Hip resection arthroplasty for acute femoral neck fractures in the non-ambulator

Objectives:

Hemiarthroplasty (HA) is the current standard of care for displaced femoral neck fractures (FNFs) in non-ambulators. Despite excellent outcomes, arthroplasty-specific risks remain, including dislocation, implant failure, periprosthetic fracture and infection, and fat embolization syndrome. To eliminate the possibility of these complications, should non-ambulatory patients with acute, native hip FNFs be treated with simple hip resection arthroplasty (HRA) instead of HA?

Design:

Retrospective case series.

Setting:

Large, urban level-1 trauma center.

Patients/Participants:

Five non-ambulatory patients (6 hips) with acute, native hip FNF underwent femoral head and neck resection. Also, the most recent 10 FNFs treated with HA were also identified for comparison purposes.

Intervention:

HRA was performed via a Smith-Peterson approach with an oscillating saw or osteotome to complete the fracture or perform a fresh neck cut.

Main Outcome Measurements:

Outcomes included postoperative vs preoperative VAS pain scores and narcotics usage, and return to baseline functional status (sit up in bed or a chair postoperatively). Procedure time for HRA was compared with the 10 most recent patients with FNF treated with HA.

Results:

HRA resulted in decreased postoperative vs preoperative VAS pain scores (7.7 vs 3.3, P = .002), and decreased operative times (59.2 minutes for HRA, 111.8 minutes for HA, P < .001). All HRA patients had immediate return of baseline function.

Conclusion:

HRA offers shorter operative times when compared with HA, decreased postoperative VAS pain scores, and immediate return to functional baseline status without possibility of arthroplasty-specific complications. HRA may be an acceptable treatment option for FNFs in the non-ambulator.

Level of evidence: IV

Proximal femoral resection and Tensor Fascia Lata flap for recalcitrant trochanteric pressure ulcers

Introduction

Trochanteric pressure ulcers (PrUs) are difficult to treat and are often complicated by infection spreading to the hip joint. We review three cases from India where proximal femoral resection and pedicled Tensor Fascia Lata (TFL) flapping was used in the management of infected deep trochanteric ulcers communicating to the hip joint.

Case presentation

Three patients had a total of four trochanteric PrUs communicating to the hip joint. Proximal femoral resection along with radical debridement of the pressure ulcer (PrU) was the first step in our surgical protocol. Serial debridements were performed to make the resulting cavity healthier and ready for the subsequent flap surgery. TFL flapping was done to cover the raw area of the PrU and the donor site was closed either primarily or with a split skin graft. All patients were males with AIS A spinal cord injury (SCI) and stage 4 PrUs in the trochanteric region. One patient had bilateral trochanteric ulcers. There was complete healing of all PrUs with improvement in wheelchair mobility, and general health.

Discussion

PrUs are a common complication of patients with SCI and are often considered one of the most neglected issues of health care delivery in India. Proximal femoral resection with pedicled TFL muscle flap is a versatile and reliable procedure for the coverage of recalcitrant trochanteric PrU with hip joint involvement. Minimal donor site morbidity occurs.

The Modified Girdlestone Procedure With Muscle Flap for Management of Pressure Ulcers and Heterotopic Ossification of the Hip Region in Spinal Injury Patients: A 15-Year Review With Long-term Follow-up

BACKGROUND

Pressure ulceration, pyogenic arthritis, and hip heterotopic ossification are complications encountered in spinal cord injury patients. The Girdlestone procedure has been established as an effective treatment modality for hip pathology in this population and is particularly efficacious when a muscle flap is used to fill the femoral resection defect. We previously reported its use as a 3-stage procedure. Through time, experience was gained, and consequently, our technique has evolved to a 1-stage procedure.

METHODS

A retrospective analysis of all spinal cord injury patients who had undergone Girdlestone arthroplasty or excision of heterotopic ossification by the pressure ulcer management team at Rancho Los Amigos National Rehabilitation Center between 1991 and 2005 was performed. A description of our management, operative protocol, outcome, and complication is given.

RESULTS

Over 15 years (between 1991 and 2005), 295 patients underwent 330 procedures. Hips were operated for infection, heterotopic ossification, pressure ulceration, dislocation, femoral head necrosis, or fracture or a combination of the above. Twenty-five cases (7.6%) required surgical revision for wound breakdown in the immediate postoperative period. Average follow-up was 40.3 months; 43.6% of patients developed recurrence of ulceration requiring surgery. The average time until recurrence was 27.3 months.

CONCLUSIONS

The Girdlestone arthroplasty is an effective modality to treat hip infection, ankylosis, heterotopic ossification, dislocation, or other pathology associated with the spinal cord injury patient. Long-term follow-up of a large patient population reveals the efficacy of the procedure in preventing recurrence and improving patient quality of life.

Pressure ulcer reconstruction in patients with heterotopic ossification after spinal cord injury: A case series and review of literature

Heterotopic ossification (HO) is widely recognized as a common occurrence among patients suffering from traumatic spinal cord injuries (SCI). The exact etiology of HO formation remains unknown. Published medical and surgical management strategies are often plagued with questionable effectiveness and frequent complications. There are minimal publications regarding the management strategies of HO in SCI patients as it pertains to plastic surgery. We present a case series of patients treated at our institution who underwent treatment for pressure ulcers with underlying HO to highlight the vast spectrum of clinical phenotypes present in this population. The pathophysiology, diagnostic tools, methods of prevention, and surgical management of HO are discussed here. We believe that there are two clinically relevant patterns of HO in SCI patients. A neurogenic process that occurs early after injury is usually bilateral and involves uninjured hip joints. Pressure sores that occur are related to poor joint mobility and subsequent development of pressure points. An infection-driven process in which HO development is associated with either pressure sores or septic hip joints is generally unilateral and not always associated with hip contractures. They present different challenges and reconstructive options to plastic surgeons. Although complications such as infection and HO recurrence are common, the functional and psychological benefits of restoring hip flexion are usually worthwhile.

Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends

Pressure ulcers in spinal cord injury represent a challenging problem for patients, their caregivers, and their physicians. They often lead to recurrent hospitalizations, multiple surgeries, and potentially devastating complications. They present a significant cost to the healthcare system, they require a multidisciplinary team approach to manage well, and outcomes directly depend on patients' education, prevention, and compliance with conservative and surgical protocols. With so many factors involved in the successful treatment of pressure ulcers, an update on their comprehensive management in spinal cord injury is warranted. Current concepts of local wound care, surgical options, as well as future trends from the latest wound healing research are reviewed to aid medical professionals in treating patients with this difficult problem.

Modified total thigh musculocutaneous flap: 'operation of last resort' for massive pressure ulcers

Massive bilateral pressure ulcers of dependent areas may complicate spinal cord injuries. These may be life threatening to patients and challenging for reconstructive surgeons. In massive recurrent ulcers, local tissue is either inadequate or previously exhausted. The total thigh musculocutaneous flap is an operation of last resort; we present a new variation of this procedure and a case of life threatening pressure ulcers with underlying osteomyelitis. A paraplegic patient had recurrent, extensive, bilateral pressure areas with some preserved tissue bridges. The nature of the pressure areas and lack of local options in this patient required modification of previously described total thigh flaps. An extended total thigh flap was partially de-epithelialised to fill the extensive sacral defect and a tunnelled extension was fashioned to cover the contralateral trochanteric defect. The timing of surgery was determined by balancing pre-operative nutritional optimisation against life-threatening drug resistance of infective organisms. The total thigh flap can close massive bilateral pressure ulcers. Modifications are presented which preserve viable local tissue and demonstrate the versatility of this technique. It remains a 'last-resort' salvage procedure.

Vastus lateralis flap reconstruction after girdlestone arthroplasty: thirteen consecutive cases and outcomes

BACKGROUND

Pressure ulcers are found in approximately 4.7% of hospitalized populations. Up to 12.3% of hospitalized populations are at risk for developing these wounds. Decubitus ulcers are more common among the inpatient spinal cord injury group, with prevalence rates up to 30%. Surgical intervention is required when bone or the hip joint becomes involved. Girdlestone arthroplasty is a procedure that excises affected proximal femur and acetabular tissues; however, this resection typically results in a sizeable defect. The vastus lateralis flap has been extensively reviewed as a soft tissue filler option for this deficit.

MATERIALS AND METHODS

Thirteen consecutive cases from a single institution using the vastus lateralis muscle flap reconstruction after Girdlestone arthroplasty were reviewed. A search of internal records identified 11 patients with 13 vastus lateralis flap reconstructions performed immediately after Girdlestone arthroplasty for stage 4 ulcers or chronic, infected wounds affecting the hip joint. All patients involved were subjected to a similar standardized post-procedure activity schedule. Complications were defined as minor (superficial wound breakdown) or major (requiring further operative procedures to close the wound).

RESULTS

The majority of patients were male (91%) with a mean age of 43 years at the time of the procedure. All wounds involved the hip joint proper. Ninety-one percent of the patients had a history of spinal cord deficits. Thirty-one percent of the flaps had minor, superficial wound breakdown. Another 31% of the reconstructions required an additional operative procedure for major wound complications. One patient's wound was from multiple prior failed hip replacements. He eventually became ambulatory using a walker after reconstruction. Ultimately, 69% of the flaps healed satisfactorily without the need for further operative intervention.

CONCLUSIONS

Surgical debridement is required for chronic wounds involving the proximal femur, acetabulum, and hip joint. This review demonstrates that the use of a single-stage procedure including Girdlestone arthroplasty with immediate vastus lateralis muscle flap reconstruction is a practical treatment option for chronic wounds involving the acetabular joint. The use of a postoperative protocol and subsequent sitting schedule contributed to the success of these reconstructions. Overall, this procedure is applicable to spinal cord injury/pathology patients and to failed total hip arthroplasty patients for future assisted ambulation.

Treatment of large ischial ulcers communicating with the hip joint with proximal femoral resection and reconstruction with a combined vastus lateralis, vastus intermedius and rectus femoris musculocutaneous flap

Pressure ulcers which communicate with the hip joint are very difficult to treat. Often, the hip joint is infected with osteomyelitis of the proximal femur resulting in bouts of sepsis and flap failure. These patients require proximal femoral resection and wide debridement in order to eradicate the infection, which in turn results in large and deep cavities. Reconstruction requires either a muscle flap or even a total thigh flap if the defect is very large and the pelvis is involved. In a series of six ischial or ischio-trochanteric pressure sores communicating with the hip joint, following multiple serial debridements, the vastus lateralis, vastus intermedius and rectus femoris muscles were raised as a single musculocutaneous flap ('three muscle flap'), based on the descending branch of the lateral femoral circumflex artery, and transposed into the defect. All patients were paraplegics and had signs of sepsis during admission. Two patients had prior failed reconstructions within 3 months of admission and the others had not been operated on before. The external skin defect of the ulcers ranged from 7 x 5 cm to 30 x 12 cm. After 12 months follow up there was no recurrence of pressure sores or sepsis. The 'three muscle flap' offers the advantage of providing large bulk to fill deep cavities, while preserving the rest of the thigh. The flap elevation is fast and safe and the vascular pedicle is reliable. This technique is not for simple pressure sores, but should be reserved for large pressure sores complicated with large cavities created after resection of the proximal femur.

Lessons learned while conducting research on prevention of pressure ulcers in veterans with spinal cord injury

OBJECTIVE

To describe the challenges of conducting a large randomized controlled trial (RCT) to assess the effectiveness of an intervention to prevent recurrent pressure ulcers among a high-risk population of subjects with spinal cord injury (SCI).

DESIGN

Prospective multisite, randomized design comparing outcomes of patients who received individualized education and structured telephone counseling follow-up with those of patients receiving customary care. This study was stopped early because of unanticipated recruitment problems.

SETTING

Six Veterans Affairs SCI specialty centers.

PARTICIPANTS

Veterans (N=150) treated for stage III or IV pelvic pressure ulcers.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Recurrence (defined as new skin breakdown in the pelvic area) and time to recurrence. The study was stopped early because of slow recruitment, so the focus of this study is lessons learned, not the main planned outcome measures.

RESULTS

Subject recruitment did not meet original expectations because almost 50% of those enrolled left the hospital with the study ulcer unhealed (having a healed ulcer was a requirement for participation). No significant differences were observed between groups on rate of or time to recurrence at the time the study was stopped. Among the 6 sites, variability in ulcer management (eg, length of stay, receipt of medical vs surgical treatment, sitting tolerance before discharge) and time to recurrence (median, 4mo) were observed.

CONCLUSIONS

RCTs in real-world settings are the most robust method of assessing the effectiveness of prevention strategies. However, in complex, rapidly changing health care organizations, blinding is infeasible, it may be impractical to control for every variable that influences a study's outcome, and any assumptions that usual care is static are probably mistaken. Investigators must be prepared to use innovative approaches to maintain the integrity of the study design, including flexibility in inclusion and exclusion criteria to support accrual, obtaining a better understanding of the important aspects of usual care that may need to be standardized, continuous improvement within the intervention arm, and anticipation and minimization of risks from organizational changes. With attention to these delivery system issues and the usual design features of randomized trials, we believe real-world care settings can serve as important laboratories to test pressure ulcer prevention strategies in this population.

Pressure ulcer risk in spinal cord injury: predictors of ulcer status over 3 years

OBJECTIVE

To identify predictors of pressure ulcers in men with spinal cord injury over a 3-year period.

DESIGN

Longitudinal, two-panel, cohort.

SETTING

Community.

PARTICIPANTS

One hundred eighteen men with spinal cord injury.

MEASURES

Interviews, questionnaires, and physical examinations were completed in two phases, 3 years apart. Information obtained included demographic and spinal cord injury characteristics; ulcer history; health beliefs and practices; measures of impairment, disability, and handicap; and skin integrity.

RESULTS

Thirty-one percent of the participants reported having a pressure ulcer in the 12 months before Phase 2. Some Phase 1 predictors of self-reported ulcers in the year before Phase 2 were a younger age at onset of spinal cord injury, previous pressure ulcer surgery, and the presence of a pressure ulcer in the year before Phase 1. On examination at Phase 2, 59% presented with an ulcer. Phase 1 predictors of ulcer presence at Phase 2 examination were similar to predictors for self-reported ulcers.

CONCLUSION

Individuals with the identified predictive characteristics are at greater risk for developing pressure ulcers. These individuals should receive additional interventions to reduce that risk. Potential interventions include more systematic and frequent follow-up, frequent review of pressure ulcer prevention and management strategies, and provision of needed personal assistance and relevant equipment.

Total thigh flaps as a salvage procedure in paraplegics with massive ulcers

A small percentage of spinal cord injured (SCI) patients with frequent recurrent pressure sores will eventually develop massive ulcers of the buttocks that are no longer amenable to local tissue coverage. The amputation of one leg and the creation of a total thigh musculocutaneous flap (TTF) may then be appropriate. The purpose of this paper is to evaluate the indications for and the efficacy of this procedure in nine SCI patients who underwent 10 TTF between February 1989 and November 1994. These patients had numerous previous hospitalizations (mean 12.1 admissions) and operations (mean 13.1 operations) for pressure sores. Past psychiatric evaluation found seven of eight males to have a similar history of social, financial and behavioral problems. The typical presentation was a septic, malnourished patient with massive ulceration of his buttocks. Only after wound and patient stabilization was the TTF chosen as a salvage procedure. The operation was long and associated with excessive blood loss. The most common complications were wound dehiscence or partial necrosis (five of 10), sepsis (five of 10), hemodynamic instability (five of 10), and chronic drainage (four of 10). The reoperation rate for complications was six of 10 cases. Long term follow-up (mean 3.5 years) on seven of eight surviving patients showed that these patients had resumed independent living but they had all developed new pressure sores as early as three months post TTF. The underlying risk factors for pressure sores had not changed. The total thigh flap operation remains a last resort procedure in a very small percentage of spinal cord injured patients because of its high morbidity, high reoperative rate for complications, and inability to prevent recurrence of pressure sores.

A complicated trochanteric pressure sore: what is the best surgical management? Case report

Pressure sores are a common complication after spinal cord injury. But great advances in their management (nursing care, prevention and surgery) have been made in the last four decades. Neglected pressure ulcers may affect the adjacent joint, leading to septic arthritis. We report a paraplegic patient with a large trochanteric sore with hip arthritis, in whom we performed an upper femoral resection and acetabular curettage (Girdlestone's technique) and coverage with the homolateral vastus lateralis muscle flap in one stage. Some questions pertaining to this operation are discussed and there is a comparison with other ways of management described in the literature. We conclude that a successful outcome with the management of such large sores depends on a radical, aggressive operation to remove all of the affected tissue, and ensure a safe coverage with a reliable, viable muscle flap. The collaboration and the positive attitude of the patient towards the procedure and the result obtained are decisive in preventing recurrences.