Evaluation of results and treatment variables for pressure ulcers in 48 veteran spinal cord-injured patients

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.

Incidence of Osteomyelitis in Sacral Decubitus Ulcers and Recommendations for Management

Stage-4 pressure ulcers are defined as ulcerations that violate the fascia and expose underlying bone, muscle, and tendon. Exposed bone is always colonized by bacteria, but this does not necessarily lead to osteomyelitis. The rates of osteomyelitis in exposed bone in stage-4 pressure ulcers range from 14% to 86%.There has been no evidence that the presence of osteomyelitis leads to higher complication rates following flap coverage. There has been no evidence that bone biopsy and preoperative treatment of osteomyelitis have any benefit before flap coverage.

Comparing 4- and 6-week post-flap protocols in patients with spinal cord injury

Objective: For patients with spinal cord injury (SCI) who undergo flap surgery to treat pressure injuries (PIs), the optimal duration of post-operative bedrest to promote healing and successful remobilization to sitting is unknown. At the study center, the minimum duration of post-operative bedrest was changed from 4 to 6 weeks. The purpose of this study is to compare outcomes of patients who underwent flap surgery using bedrest protocols of different duration.Design: This was a retrospective review of all flap procedures completed at VA Puget Sound Health Care System from 1997 to 2016 to treat PIs in patients with SCI. Surgeries were excluded if they were not a flap (i.e. primary skin closure or graft), involved a non-pelvic region, or were a same-hospitalization revision of a prior surgery. The primary outcome of this investigation was the number of days between surgery and the first time the patient mobilized to sitting out of bed for 2 h with an intact surgical incision.Methods: 190 patients received a total of 286 flap surgeries from 1994 to 2016. A chart review of each case was completed to determine the planned duration of bedrest (4- vs 6-weeks), first date of successful mobilization out of bed for 2 h, length of stay post-surgery, and occurrence of complications such as dehiscence or need for operative revisions.Results: Among 286 primary surgeries, 171 surgeries used the 4-week protocol and 115 used the 6-week protocol. When compared to the 4-week protocol, patients treated with the 6-week protocol were slightly older, more likely to have a diagnosis of diabetes, and less likely to be current smokers. Healing was never achieved after 4 surgeries in the 4-week group and 2 surgeries in the 6-week group. With the analysis restricted to a single surgery per subject who achieved healing (109 treated with 4-week protocol and 75 with 6-week protocol), there was a significant difference in days until 2-h sitting: median 54 days for the 4-week protocol compared to 60 days for the 6-week protocol (p = 0.041). Up to about 60 days post-operatively, the 4-week protocol produced a greater proportion remobilized to sitting, and thereafter the proportion of patients successfully remobilized did not differ between protocols.Conclusions: The 6-week protocol was not associated with improved remobilization outcomes (reduced rates of dehiscence or surgical revisions), and the 4-week protocol resulted in a significantly shorter time to remobilization to sitting for 2 h as well as a shorter length of stay. We did not identify any subgroup of patients that benefited from the longer protocol.

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.

Osteomyelitis Complicating Sacral Pressure Ulcers: Whether or Not to Treat With Antibiotic Therapy

The treatment of osteomyelitis in patients with stage IV sacral pressure ulcers is controversial. We conducted a systematic literature review and did not find evidence of benefit of antibacterial therapy in this setting without concomitant surgical debridement and wound coverage. Furthermore, many patients with chronically exposed bone do not have evidence of osteomyelitis when biopsied, and magnetic resonance imaging may not accurately distinguish osteomyelitis from bone remodeling. The goal of therapy should be local wound care and assessment for the potential of wound closure. If the wound can be closed and osteomyelitis is present on bone biopsy, appropriate antibiotic therapy is reasonable. We find no data to support antibiotic durations of >6 weeks in this setting, and some authors recommend 2 weeks of therapy if the osteomyelitis is limited to cortical bone. If the wound will not be closed, we find no clear evidence supporting a role for antibiotic therapy.

Evidence-Based Gardening: Using Palliative Approaches to Cure Complex Wounds

Complex wounds are commonly thought to require aggressive surgical intervention to achieve healing. However, optimal healing results can often be achieved when greater emphasis is placed on optimizing patient factors prior to any surgical intervention. A retrospective review was performed of pressure ulcers and complex wound cases treated over 5 years at the Yale New Haven Wound Center. Optimal healing including clinical resolution of osteomyelitis and improved scarring was achieved when patient factors, such as glucose control and nutrition, were optimized. Surgical intervention can be more effective and even avoided entirely with the appropriate focus on optimizing patient factors.

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 Ulcers: Risk Stratification and Prognostic Factors That Promote Recurrence After Reconstructive Surgery

The aim of this study was to identify overall recurrence rates after reconstructive surgery in patients with pressure ulcers and to identify risk factors that associated with recurrence after reconstructive surgery. This study was done in Faculty of Medicine Chiang Mai University, including recurrence at the same site as well as on new sites, between January 1998 and December 2015. 165 patients with 272 pressure ulcers were retrospectively collected and analyzed. The overall pressure ulcer recurrence rate was 16.54% (45 from 272 ulcers) from an overall patient recurrence of 19.39% (32 from 165 patients). From multivariable analysis, we found 9 prognostic factors that were statistically significant for recurrence after surgery, divided into 2 groups: uncontrollable and controllable factors. Uncontrollable factors consisted of being female (hazard ratio [HR]=1.90;95%CI=1.54-2.34), being older than 45 years (HR=1.67;95%CI=1.40-2.0), and location of pressure ulcers on ischium (HR=1.65; 95% CI=1.51-1.80) and sacrum (HR=1.17;95%CI=1.10-1.23). Controllable factors included spasticity (HR=1.11;95%CI=1.04-1.20), incomplete healing before discharge (HR=5.42;95% CI=3.95-7.44), serum albumin level ≤3 g/dL (HR=1.27;95%CI=1.13-1.43), pressure ulcer stage 4 (HR=1.90;95%CI=1.41-2.54), non -muscle-based procedure (HR=3.82;95%CI=2.54-5.76), and length of hospitalization >21 days (HR=2.94;95%CI=1.60-5.40). Patients with these factors were strongly advised to address and improve all these factors for decreasing the recurrence rate after reconstructive surgery.

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.

A Formidable Foe Is Sabotaging Your Results: What You Should Know about Biofilms and Wound Healing

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Describe biofilm pathogenesis as it relates to problem wounds. 2. Understand the preclinical and clinical evidence implicating biofilm in problem wounds. 3. Explain the diagnostic and treatment challenges that biofilms create for problem wounds. 4. Demonstrate a basic understanding of emerging strategies aimed at counteracting these processes.

SUMMARY

Biofilm represents a protected mode of growth for bacteria, allowing them to evade standard diagnostic techniques and avoid eradication by standard therapies. Although only recently discovered, biofilm has existed for millennia and complicates nearly every aspect of medicine. Biofilm impacts wound healing by allowing bacteria to evade immune responses, prolonging inflammation and disabling skin barrier function. It is important to understand why problem wounds persist despite state-of-the-art treatment, why they are difficult to accurately diagnose, and why they recur. The aim of this article is to focus on current gaps in knowledge related to problem wounds, specifically, biofilm infection.

Two-stage treatment of ischial pressure ulcers in spinal cord injury patients: Technique and outcomes over 8 years

BACKGROUND

Despite newly introduced techniques, reconstruction of ischial pressure ulcers remains a difficult problem with high-reported failure rates.

METHODS

A retrospective chart review was performed on all spinal cord injury patients who underwent ischial pressure ulcer reconstruction by the senior author (V.L.) between 2004 and 2012. The two-stage procedure consisted of debridement and bone biopsy, followed by bursectomy, partial ischiectomy, fascial release, and gluteus maximus and hamstring advancement flaps. Postoperative care included 2-week supine bed rest on an air-fluidized bed, sitting tolerance rehabilitation, and thorough behavioral training.

RESULTS

Sixty-five patients (74 flaps) were identified. A 45.9% had a previous attempt at reconstruction. The median follow-up period was 622 days. Overall, 67.6% of flaps were intact at the last follow-up. Superficial and deep dehiscence rates were 16.2 and 28.4%, respectively. Seven out of 35 flaps suffered late recurrence after being well healed for more than 1 year. History of previous reconstruction was found to be associated with increased odds of superficial (OR 6.02, 95% CI 1.55-23.3) and deep dehiscence (OR 12.3, 95% CI 1.99-76.9).

CONCLUSIONS

The evolution of the senior author's decades of practice has led to the development of a simpler repair, which relies on plane-by-plane release of scarred tissues to improve the mobility of muscle and skin flaps without large tissue movements, even in the setting of apparent extensive tissue loss. This technique is a reliable option, particularly for the primary ischial pressure ulcer.

Flap Reconstruction for Pressure Ulcers: An Outcomes Analysis

Background:

Historically, complication rates after pressure ulcer reconstruction utilizing flap coverage have been high. Patients undergoing operations for pressure ulcer coverage typically have multiple risk factors for postoperative complications. The purpose of this study was to examine a large patient series in the pressure ulcer population to uncover objective evidence of the linkage between risk factors and outcomes after flap coverage.

Methods:

This study was a retrospective chart review of patients who underwent flap reconstruction for a pressure ulcer between 1997 and 2015. The characteristics of patients were analyzed to determine those who had complications such as pressure ulcer recurrence, wound dehiscence, and wound infection.

Results:

All patients (N = 276) underwent flap coverage of their pressure ulcers. The overall complication rate was 58.7% (162 patients). Wound dehiscence was the most common complication (31.2%), and the pressure ulcer recurrence rate was 28.6%. Multivariate regression for pressure ulcer recurrence revealed that body mass index <18.5 [relative risk (RR) 3.13], active smoking (RR 2.33), and ischial pressure ulcers (RR 3.46) were independent risk factors for pressure ulcer recurrence. Ischial pressure ulcers (RR 2.27) and preoperative osteomyelitis (RR 2.78) were independent risk factors for wound dehiscence. Diabetes was an independent risk factor for wound infection (RR 4.34).

Conclusions:

Our retrospective analysis revealed numerous factors that are associated with high rates of major postoperative complications. Risk factors must be taken into account when offering flap coverage, and risk-reducing strategies must be implemented in patients before pressure ulcer reconstruction.

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.

Documentation of preventive care for pressure ulcers initiated during annual evaluations in SCI

OBJECTIVE

Community-acquired pressure ulcers (PrUs) are a frequent cause of hospitalization of Veterans with spinal cord injury (SCI). The Veterans Health Administration (VHA) recommends that SCI annual evaluations include assessment of PrU risk factors, a thorough skin inspection and sharing of recommendations for PrU prevention strategies. We characterized consistency of preventive skin care during annual evaluations for Veterans with SCI as a first step in identifying strategies to more actively promote PrU prevention care in other healthcare encounters.

DESIGN/SETTING/PARTICIPANTS

Retrospective cross-sectional observational design, including review of electronic medical records for 206 Veterans with SCI admitted to 2 VA SCI centers from January-December, 2011.

OUTCOME MEASURES

Proportion of applicable skin health elements documented (number of applicable elements/skin health elements documented).

RESULTS

Our sample was primarily white (78%) male (96.1%), and mean age = 61 years. 40% of participants' were hospitalized for PrU treatment, with a mean of 294 days (median = 345 days) from annual evaluation to the index admission. On average, Veterans received an average of 75.5% (IQR 68-86%) of applicable skin health elements. Documentation of applicable skin health elements was significantly higher during inpatient vs. outpatient annual evaluations (mean elements received = 80.3% and 64.3%, respectively, P > 0.001). No significant differences were observed in documentation of skin health elements by Veterans at high vs. low PrU risk.

CONCLUSION

Additional PrU preventive care in the VHA outpatient setting may increase identification and detection of PrU risk factors and early PrU damage for Veterans with SCI in the community, allowing for earlier intervention.

Development and psychometric characteristics of the SCI-QOL Pressure Ulcers scale and short form

OBJECTIVE

To develop a self-reported measure of the subjective impact of pressure ulcers on health-related quality of life (HRQOL) in individuals with spinal cord injury (SCI) as part of the SCI quality of life (SCI-QOL) measurement system.

DESIGN

Grounded-theory based qualitative item development methods, large-scale item calibration testing, confirmatory factor analysis (CFA), and item response theory-based psychometric analysis.

SETTING

Five SCI Model System centers and one Department of Veterans Affairs medical center in the United States.

PARTICIPANTS

Adults with traumatic SCI.

MAIN OUTCOME MEASURES

SCI-QOL Pressure Ulcers scale.

RESULTS

189 individuals with traumatic SCI who experienced a pressure ulcer within the past 7 days completed 30 items related to pressure ulcers. CFA confirmed a unidimensional pool of items. IRT analyses were conducted. A constrained Graded Response Model with a constant slope parameter was used to estimate item thresholds for the 12 retained items.

CONCLUSIONS

The 12-item SCI-QOL Pressure Ulcers scale is unique in that it is specifically targeted to individuals with spinal cord injury and at every stage of development has included input from individuals with SCI. Furthermore, use of CFA and IRT methods provide flexibility and precision of measurement. The scale may be administered in its entirety or as a 7-item "short form" and is available for both research and clinical practice.

An evidence-based approach to pressure sores

The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.

Characteristics of recurrent pressure ulcers in veterans with spinal cord injury

BACKGROUND/OBJECTIVE

To describe characteristics of recurrent pressure ulcers (PrUs) in veterans with spinal cord injury (SCI).

DESIGN

Descriptive, cohort study.

SETTINGS AND PARTICIPANTS

Twenty-four veterans with SCI from 6 SCI centers in the Department of Veterans Affairs.

METHODS

Data from a prospective study evaluating PrUs were analyzed for 24 veterans with 29 recurrent PrUs during 9 months. Additional retrospective medical record data were analyzed for 15 veterans who received inpatient treatment.

RESULTS

Participants were male, 50% non-Hispanic white, with paraplegia (63%), complete SCI (83%), a mean age of 56 years, and mean time since SCI of 21 years. Most PrUs recurred (63%, n = 15 patients) in the same location as the most recent ulcer and at the ischial tuberosities (63%). Mean time to recurrence was 16.6 weeks. PrUs were stage III (28%, n = 8) or IV (45%, n = 13) with undermining (48%), necrotic slough (50%), and minimal exudate. One third were (n = 9) larger than 16 cm2. Mean Bates-Jensen Wound Assessment Tool Score was 33.63. Inpatient medical record data (n = 15) showed 73% with documentation indicating infection treated with antibiotics (53%, n = 8 patients), osteomyelitis (47%, n = 7), and/or cellulitis (13%, n = 2) noted. Plastic surgery consultation was obtained for 67% with surgery as an option for 73% (1 without consultation). Scheduled repositioning was documented for 21%.

CONCLUSIONS

Most PrUs were severe, located at the same anatomic site, and recurred within 4 months, suggesting that the recurrent ulcers were more likely incomplete healing of the initial PrUs. This sample of veterans with SCI provides early data on recurrent PrU characteristics.

Predictors of pressure ulcer recurrence in veterans with spinal cord injury

BACKGROUND/OBJECTIVE

To predict recurrence of pressure ulcers (PrUs) in a high-risk population of veterans with spinal cord injury (SCI).

DESIGN

Cross-sectional observational design.

PARTICIPANTS

A convenience sample of 64 subjects from 6 Department of Veterans Affairs (VA) SCI Centers who had been admitted to the hospital for the treatment of stage III-IV pelvic PrUs and were healed at the time of discharge back to the community.

MAIN OUTCOME MEASURES

Primary outcome measures were pelvic PrU recurrence, defined as self-reported new skin breakdown (stage II or greater) in the pelvic area (not necessarily in the same location as previous ulcer) and time to recurrence.

RESULTS

There were no differences between those with/without recurrences with regard to age, age at/level of injury, number of previous ulcers or surgery, rate of or time, to recurrence. Mean age was 56 years; most were white and men, lived at home, and had some college education. Mean time since SCI was 22 years; 28% had tetraplegia; mean number of prior pressure ulcers was 3; and almost one half had a previous ulcer in the same location. The strongest predictor of recurrence in a multivariate logistic regression was African American race (odds ratio = 9.3). Additional predictors included higher scores on the Charlson Co-Morbidity Index (indicating a higher burden of illness), the Salzburg PrU Risk Assessment Scales, and longer sitting time at discharge.

CONCLUSION

Identifying individuals at highest risk for recurrence and developing effective prevention programs are essential rehabilitation goals. We recommend that the unique findings of this exploratory study be considered preliminary until replication of these results is published.

The Use of Suture Anchors in Reconstruction of Sacral Pressure Ulcers With Gluteal Fasciocutaneous Advancement Flaps

Suture anchors have already been successfully used for soft-tissue fixation to bone. In this study, suture anchors were used in sacral pressure ulcer reconstruction, aiming at secure midline attachment of gluteal fasciocutaneous flaps, obliteration of any dead space, and recreation of the natal cleft. Thirteen patients with sacral pressure ulcers were treated with bilateral gluteal fasciocutaneous V-Y advancement flaps. Suture anchors were used to invert and attach the flaps to the midline crest of the sacrum. All flaps healed well, no postoperative anchor failure or wound dehiscence was noticed, and the esthetic result was very pleasing. In conclusion, the use of suture anchors offers an easy, practical, and secure attachment of V-Y advancement gluteal fasciocutaneous flaps in sacral pressure ulcer reconstruction. Main advantages of the method suggested are reduction of suture-line tension, obliteration of any cavity at the midline, and recreation of the natal cleft.

Pressure sores with associated spasticity: a clinical challenge

Paraplegic and quadriplegic patients particularly those suffering from spinal cord injuries are at a high risk of developing pressure ulcerations. Unlike pressure ulcers in geriatric patients, which usually can be controlled with pressure relieving devices and local wound care, pressure ulceration complicating spinal cord injuries should be viewed from another perspective. Clinical management is also more complex because of the associated spasticity. Although it is now recognised that spasticity control is critical for management of patients with cerebral or spinal cord diseases or injuries, published risk assessment studies and risk assessment pressure sore scales fail to recognise spasticity as a major risk factor. Identification of spasticity should heighten the awareness of medical and paramedical personnel and have a positive impact on prevention as well as on treatment of pressure sores in this particularly difficult group of patients. We present our experience with a young quadriplegic patient with severe spasticity presenting with a large infected ischial pressure sore. All surgical as well as conservative attempts to achieve healing failed because of our failure to recognise the importance of spasticity control in the overall treatment scheme. Spasticity control should be included as a prerequisite for any treatment protocol of such patients.

Prevention and Treatment of Pressure Ulcers

Pressure ulcers are complex chronic wounds for which no gold standard for prevention or treatment has yet been established. Several attempts at developing guidelines has been undertaken by different organizations. Pressure ulcers are devastating comorbidities for patients and difficult to prevent or manage. Whether or not pressure ulcers are preventable remains controversial. The strategy for prevention includes recognizing the risk, decreasing the effects of pressure, assessing nutritional status, avoiding excessive bed rest and prolonged sitting, and preserving the integrity of the skin. The principles of treatment of pressure ulcers include assessing severity, reducing pressure, friction and shear forces, optimizing local wound care, removing necrotic debris, managing bacterial contamination, and correcting nutritional deficits.

Critical rehabilitation of the patient with spinal cord injury

Most healthcare practitioners have worked with patients with spinal cord injury at some point in their career, for some it is a specialty. The critical care area usually only has patient with spinal cord injury for a brief time before they are transferred. More recently, there are longer intensive care unit stays due to multiple trauma and lack of insurance. Nurses must be cognizant of indications, contraindications, and best practice interventions to contribute positively to patient's long-term outcomes. As part of the multispecialty team, nurses can be pivotal in preventing secondary complications, especially pressure ulcers. Rehabilitation team members can be consulted early to provide expertise in managing this complex diagnostic group.

Patterns of recurrent pressure ulcers after spinal cord injury: Identification of risk and protective factors 5 or more years after onset11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To identify risk and protective factors associated with a history of recurrent pressure ulcers among participants with spinal cord injury (SCI).

DESIGN

A mail survey was used to identify factors associated with the presence or absence of recurrent pressure ulcers.

SETTING

A large specialty hospital in the southeastern United States.

PARTICIPANTS

All participants had traumatic SCI, were nonambulatory, 18 years or older, and had been injured at least 5 years. A total of 826 subjects participated, 633 of whom reported a pressure ulcer history that could be classified as to whether they did or did not have a history of recurrent pressure ulcers.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

History of pressure ulcers was measured by a single item that required participants to classify their history into 1 of 5 options, ranging from never having any pressure ulcers to having almost continuous pressure ulcers, often requiring hospitalization. Those who either never had a pressure ulcer or had them mostly for a short period after SCI onset were classified as nonrecurrent, whereas those who reported at least 1 per year were classified as recurrent.

RESULTS

Seventy percent of the participants failed to report recurrent pressure ulcers (never had any or had them only immediately after SCI onset), whereas 13% reported a clear pattern of recurring pressure ulcers of 1 or more per year. Logistic regression analyses suggested several general behaviors were protective for recurrent pressure ulcers, including lifestyle, exercise, and diet. Yet none of the behaviors generally recommended during inpatient rehabilitation specifically to prevent pressure ulcers (eg, skin checks weight shifts) were associated with pressure ulcer history. Only 2 risk behaviors were identified (number of cigarettes smoked, use of medication for sleep), although several proxy variables were related to pressure ulcer history.

CONCLUSIONS

Pressure ulcer history is a more viable measure of pressure ulcer outcomes than measures taken at a single point in time (current), over a brief period (eg, 1y), or those relying on critical events occurring at any time since SCI onset (ie, surgeries to repair pressure ulcers). A healthy lifestyle appears to be strongly associated with avoiding pressure ulcers, whereas the efficacy of specific prevention behaviors was not demonstrated. Problem solving and coping strategies should be targets for further research.

Gluteal Perforator Flaps for Coverage of Pressure Sores at Various Locations

Flap coverage is essential for successful treatment of pressure sores, and musculocutaneous flaps have been preferred universally. Development of perforator flaps supplied by musculocutaneous perforators has allowed reconstructive surgeons to harvest flaps without including muscles. Perforator flaps have enhanced the possibility of donor sites because a flap can be supplied by any musculocutaneous perforator, and donor-site morbidity is also reduced. Between November of 1998 and June of 2002, the authors used 35 gluteal perforator flaps in 32 consecutive patients for coverage of pressure sores located at sacral (n = 22), ischial (n = 7), and trochanteric (n = 6) regions. The mean age of the patients was 53.1 years (range, 5 to 87 years), and there were 16 male and 16 female patients. All flaps in this series were supplied by musculocutaneous arteries arising from gluteal muscles. Patients were followed up for a mean period of 13.6 months. Wound dehiscence was observed in two patients and treated by secondary closure. Three patients died during the follow-up period. All flaps survived except one that had undergone total necrosis, and only one recurrence was noted during the follow-up period. Gluteal perforator flaps are safe and reliable options for coverage of pressure sores located at different locations. Freedom in flap design and low donor-site morbidity make gluteal perforator flaps an excellent choice for pressure sore coverage.

Implantable Baclofen Pump as an Adjuvant in Treatment of Pressure Sores

Currently, the success of ulcer treatment is limited by the high recurrence and complication rates. Spasticity is an important contributing factor to ulcer recurrence, and intrathecal baclofen is an effective method to reduce spasticity. Spasticity creates friction, shear, and mobility impairment resulting in wound dehiscence, flap loss, infection, and hematoma. Spasticity can be managed pharmacologically and surgically; baclofen is the drug of choice. Baclofen inhibits spasticity by blocking excitatory neurotransmitters in the spinal dorsal horn. Intrathecal baclofen maximizes the dose delivered to spinal receptors and minimizes the side effects associated with oral baclofen. Case reports of intrathecal baclofen used in patients with pressure sores demonstrate the use of intrathecal baclofen to improve reconstructive outcomes in spastic patients.

A prospective study of tobacco smoking as a predictor of complications in general surgery

OBJECTIVE

To analyze whether tobacco smoking is related to nosocomial infection, admission to the intensive care unit, in-hospital death, and length of stay.

DESIGN

A prospective cohort study.

SETTING

The Service of General Surgery of a tertiary-care hospital.

PATIENTS

A consecutive series of patients admitted for more than 1 day (N = 2,989).

RESULTS

Sixty-two (2.1%) patients died and 503 (16.8%) acquired a nosocomial infection, of which 378 (12.6%) were surgical site and 44 (1.5%) were lower respiratory tract. Smoking (mainly past smoking) was associated with a worse health status (eg, longer preoperative stay and higher American Society of Anesthesiologists score). A long history of smoking (> or = 51 pack-years) increased postoperative admission to the intensive care unit (adjusted odds ratio [OR] = 2.86; 95% confidence interval [CI95], 1.21 to 6.77) and in-hospital mortality (adjusted OR = 2.56; CI95, 1.10 to 5.97). There was no relationship between current smoking and surgical-site infection (adjusted OR = 0.99; CI95, 0.72 to 1.35), whereas a relationship was observed between past smoking and surgical-site infection (adjusted OR = 1.46; CI95, 1.02 to 2.09). Current smoking and, to a lesser degree, past smoking augmented the risk of lower respiratory tract infection (adjusted OR = 3.21; CI95, 1.21 to 8.51). Smokers did not undergo additional surgical procedures more frequently during hospitalization. In the multivariate analysis, length of stay was similar for smokers and nonsmokers.

CONCLUSION

Smoking increases in-hospital mortality, admission to the intensive care unit, and lower respiratory tract infection, but not surgical-site infection. Deleterious effects of smoking are also observed in past smokers and they cannot be counteracted by hospital cessation programs.

Hemipelvectomy for severe decubitus ulcers in patients with previous spinal cord injury

BACKGROUND

Patients with spinal cord injury (SCI) frequently have pressure ulcers. Surgery is sometimes needed to close them. In rare cases, hemipelvectomy is warranted for extremely severe complications.

METHODS

We conducted a retrospective study using national Department of Veterans Affairs (DVA) computer data sets to identify clinical features of SCI patients who underwent hemipelvectomy for life-threatening septic complications of decubitus ulcers.

RESULTS

Among the approximately 4 million patients receiving care in the DVA system, more than 40,000 patients were treated on an inpatient basis for SCI during the search period (fiscal years 1989 to 1998). They represent approximately 20% of the total national patient pool. There were 56 patients who supposedly had undergone hemipelvectomy. Chart review eliminated cases that did not meet our inclusion criteria, resulting in 8 evaluable cases. All had complete SCI due to trauma and later developed severe pressure sores with pelvic osteomyelitis or life-threatening soft tissue infection.

CONCLUSIONS

This series is the largest reported to date. The surgery involved significant blood loss (mean 2.6 L). Reoperations and complications were common. The mortality rate was 25%, but the survivors were all markedly improved by the surgery. Some of the complications appeared to be related more to the SCI than to the pelvic sepsis or surgery, suggesting that meticulous perioperative care may be valuable in reducing the complication rate in SCI patients undergoing this radical operation for very severe sequelae of pressure ulcers.

Outcomes for surgical coverage of pressure sores in nonambulatory, nonparaplegic, elderly patients

Pressure sores are a common complication of long-term institutional care. Surgical coverage of late-stage ulcers in the elderly refractory to conservative therapy remains controversial. The authors reviewed the outcome of 22 predominately nonambulatory, nonparaplegic, elderly patients with coverage of 27 pressure sores. The mean patient age was 59 years (range, 50-82 years). The average follow-up was 6 months (range, 3 months-2 years). There were 11 complications for the 22 patients (50%) and the 27 ulcers (41%). Postoperatively, a well-healed ulcer was present in 19 of 27 patients (70%) at 6 months. Of the 19 reconstructed sacral ulcers, there were 10 complications (53%) and one recurrence at 6 months. Seven trochanteric ulcers were covered with tensor fascia lata flaps without complications or recurrences at the 6-month follow-up. One ischial ulcer was managed using a V-Y hamstring advancement flap, resulting in dehiscence and a subsequent revision. The authors advocate surgical coverage to treat late-stage pressure sores in nonparalyzed elderly persons to reduce the morbidity, mortality, and economic burden of patients with late-stage pressure ulcers. With an increasing geriatric population, prevention and postoperative care are necessary to diminish the incidence, recurrence, and burden of pressure sores.

Long-term outcome study of growth factor-treated pressure ulcers

BACKGROUND

Exogenous application of growth factors have been reported in an attempt to accelerate healing of chronic wounds. Most of the trials were of brief duration with short to no follow-up periods. Long-term outcome studies are sparse for pressure ulcer therapies with success rates around 30% for both operative and nonoperative treatments.

METHODS

Follow-up evaluations were performed serially up to 12 months for patients completing a 35 day blinded, placebo-controlled cytokine clinical trial of pressure ulcers.

RESULTS

Fifty-four of 61 patients completed the follow-up period with 68.5% of the patients (37 of 54) being healed after 1 year. Of patients healing > or =85% during the active treatment phase, 84.6% were healed after 1 year compared with 61% of those that healed <85% during treatment (P <0.05).

CONCLUSION

Long-term outcome was better in this growth factor trial than with surgical or standard nonoperative treatment of pressure ulcers. Since only patients receiving exogenously applied cytokines achieved >85% closure during the treatment phase of the trial, the excellent long-term outcome appears attributable to the cytokine therapy.

A model of outcomes research: spinal cord injury

OBJECTIVE

To use spinal cord injury (SCI) care and research as a paradigm to illustrate how the principles and practices of outcomes research have been and can be applied to the sequelae of a specific disability.

DATA SOURCES

Review of data sources and literature pertaining to outcomes of SCI.

STUDY SELECTION

English language literature, health status and health services research agencies, academic and governmental research, and surveillance settings.

DATA EXTRACTION

A critical review of measures that have been and may be used to measure the outcomes of SCI. Special attention was paid to data sources; the need for methodologic accommodations: the research balance between generic and condition-specific methods; and the measurement outcomes that are highly relevant to people with SCIs.

DATA SYNTHESIS

There is a substantial research record related to the natural history, rehabilitation, survival, and long-term social reintegration of people with SCI, but relatively less addressing widely used generic health outcomes.

CONCLUSION

Contemporary outcomes research is relevant to people with SCI and those who provide treatment. One area of special attention is the occurrence of secondary conditions. To a large extent, SCI outcomes research can use conventional methods and generic instruments. There also is a need to modify research methods and to refine and apply some measures specific to people with SCI.