V-Y advancement hamstring myocutaneous island flap repair of ischial pressure ulcers

Preference for Fasciocutaneous Flap Over Musculocutaneous Flap as a First-Line Option for Ischial Pressure Wound Reconstruction: A Review of 64 Cases

The ischial pressure wound usually comprises a large, extensive defect and involves the repair of more than a small opening. Most surgeons have used a musculocutaneous flap to fill the large dead space of an ischial pressure wound. However, sacrificing muscle tissue has a potential risk of postoperative bleeding. The transferred muscle ultimately loses function as a cushion to absorb pressure. Conservation of muscle structures may be beneficial for use in future recurrence, which is common with ischial pressure wound. We compared the difference in outcome between musculocutaneous and fasciocutaneous flaps and analyzed factors affecting complications with the flaps in ischial pressure wound reconstruction. This study reviewed the results of 64 flaps in 44 patients with ischial wounds. The wounds were reconstructed with 34 musculocutaneous flaps (53%) and 30 fasciocutaneous flaps (47%). Twenty-three cases (36%) had complete healing, and 41 (64%) had complications. There was no significant difference in outcomes between fasciocutaneous and musculocutaneous flap groups. Crude logistic regression analysis showed no significant risk factors for occurrence of major complications. When fasciocutaneous flaps were used, the neighboring perforators and muscle tissues could be conserved. With a perforator-based fasciocutaneous flap, a de-epithelized distal portion of the flap could be used to fill the dead space. Therefore, the fasciocutaneous flap may have priority over the musculocutaneous flap as a first-line option for ischial pressure wound reconstruction.

Pedicled Chimeric Perforator Flap Based on Inferior Gluteal Vessel Axis for the Reconstruction of Stage-Four Primary Ischial Pressure Sores-A New Design

Background  “Subfascial void reconstruction” in ischial pressure sores (IPSs) goes a long way in the amelioration of the common complications like persistent drainage, infection, wound dehiscence, and late recurrence. No locoregional flaps suffice this requirement. So we have designed a chimeric pedicled flap based on the inferior gluteal vessel axis (IGVA) perforators with two tissue components: (1) Pacman-style fasciocutaneous flap on a perforator and (2) gluteus maximus muscle (inferior portion) on another independent perforator.

Aim and Methods  After confirming the feasibility of novel design of chimeric pedicled IGVA perforator flap with cadaver study, we embarked on the clinical study with this chimeric flap. In this prospective cohort study, the study and the control existed in the same patient so that the biological factors affecting the wound healing would be the same.

Results  Twenty-one patients were included whose mean age was 39 years. Late recurrence occurred in one patient (4.8%) of chimeric flap while the control group (who had undergone conventional reconstruction) had recurrence in 11 patients (52.4%). On assessment with overall institutional score, grade A was observed in 18 patients of the chimeric IGVA flap group ( p < 0.045), and in only 3 patients of the control group.

Conclusions  This anatomically construed flap, a new addendum in the armamentarium of reconstruction of IPSs, with its potential to congruently fill the ischiogluteal subfascial void may provide a lasting solution for preventing recurrences.

A New Option for the Reconstruction of Primary or Recurrent Ischial Pressure Sores: Hamstring-Adductor Magnus Muscle Advancement Flap and Direct Closure

BACKGROUND

Owing to the high recurrence rates of ischial pressure sores, surgeons should consider the possibility of future secondary flap surgery during flap selection. The purpose of this article is to present a new surgical option for the reconstruction of primary or recurrent ischial pressure sores using a simple hamstring-adductor magnus advancement flap and direct closure.

METHODS

After horizontal fusiform skin excision, complete bursa excision and ischiectomy were performed. The tenomuscular origin of the adductor magnus and the conjoined tenomuscular origin of the biceps femoris long head and semitendinosus were isolated and completely detached from the inferior border of the ischial tuberosity. They were then advanced in a cephalad direction without detachment of the distal tendon or muscle and securely affixed to the sacrotuberous ligament. The wound was directly closed without further incision or dissection.

RESULTS

Twelve ischial pressure sores (6 primary and 6 recurrent; 12 patients) were surgically corrected. The follow-up period was 12 to 65 months. All patients healed successfully without early postoperative complications, such as hematoma, seroma, infection, wound dehiscence, or partial necrosis. Late complications included wound disruption 5 weeks after surgery that spontaneously healed in 1 case and recurrence 3 years later in another case.

CONCLUSIONS

The new surgical option presented herein, which involves hamstring-adductor magnus advancement flap and direct closure, is a simple and reliable method for providing sufficient muscle bulk to fill the dead space and proper padding to the bone stump while preserving the main vascular perforators and pedicles as well as future surgical options.

Outcome analyses of a multimodal treatment approach for deep pressure ulcers in spinal cord injuries: a retrospective cohort study

STUDY DESIGN

Retrospective observational cohort study.

OBJECTIVES

To describe outcomes, risk factors for complications, and relapse rates associated with the multimodal treatment approach for deep pressure ulcers (PUs) grade IV for the ischium, trochanter major, and sacral regions of patients with traumatic and non-traumatic spinal cord injury (SCI).

SETTING

The settings comprised two spinal cord units within a maximum care hospital. The treatment of all patients followed the modified interdisciplinary "Basler treatment concept".

METHODS

We included all individuals with SCI with a first occurrence of PU grade IV in the buttocks area between August 2008 and December 2012 inclusive, with a maximum follow-up of 3 years. Descriptive, univariate, and bivariate analyses were undertaken, as were group comparisons.

RESULTS

In 47 patients aged 18-87 years (mean age: 51 years) a total of 63 fasciocutaneous and myocutaneous flaps were performed. Wound healing was complete after a mean of 34 days (SD = 21). Postoperative mobilisation in a wheelchair was performed after a mean of 46 days (SD = 24). Delayed healing was reported in 18 patients (38%), and revision surgery was necessary in five patients (11%). ASIA impairment scale (AIS) A (p = .001), and male gender (p = .001) were identified as risk factors for delayed wound healing and prolonged inpatient stay. Treatment-associated pneumonia occurred in four cases (11% of all patients, 25% of patients with tetraplegia). Patients were discharged when the time spent sitting in a wheelchair was 2 × 2 h per day; this occurred after a mean of 100 days (SD = 36). PU recurrence was observed in six cases (18%).

CONCLUSIONS

Our multimodal treatment concept was found to have complication rates comparable to those in the literature; additionally, this approach might be associated with lower recurrence rates with respect to the literature. To reduce high rates of pneumonia occurrence among patients with tetraplegia, preventive measures need to be established. Further evidence of the efficiency of this complex treatment approach for PU in individuals with SCI is needed.

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

We have collected data on the second follow-up of 27 patients who underwent musculocutaneous flap closure of their ischial pressure sores. Thirty-seven ulcers were operated on between 1988 and 1993 using the V-Y advancement hamstring musculocutaneous island flap. At the initial follow-up (mean = 20 months) in 1993, despite 33% of patients having had recurrent ulcers and 14.8% having undergone re-advancements, only 14% of patients had non-healing ulcers. In 1997, follow-up period ranged from 18 to 90 months, with a mean of 62 months. Four patients were lost to follow-up resulting in 23 patients (n = 23) for the current study. Nine patients were tetraplegic and the remaining 14 were paraplegic. Four of the 23 patients had died at follow-up therefore making the number of living patients 19 (n = 19). The total number of ulcers operated on in the current study was 29 (U = 29). Overall, ulcer and patient recurrence rates were 41.4% and 47.8% respectively. Despite this, 89.5% of patients had intact flaps at the time of follow-up. We recommend the use of the hamstring V-Y musculocutaneous flap as a reliable and safe reconstructive modality in the management of ischial pressure sores and by identifying the group of patients susceptible to ulcer recurrence we have proposed a protocol for their long-term follow-up.