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7 Surgical Management of Pressure Ulcers
https://t.me/med1917
Fig. 7.7 Same patient 6 weeks postoperatively
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Fig. 7.8 One year post fl ap surgery
advancement fl ap. The left buttock demonstrates a gluteal myofasciocutaneous fl ap
(Figs. 7.7 and 7.8 ).
Outcome in sacral decubitus ulcer patient 1-year post reconstruction demonstration complete healing without recurrence. This kind of outcome requires four
elements: proper patient selection, an experienced surgeon, excellent post-op care,
and a patient who can adhere to an ongoing regimen of pressure offl oading.
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D.P. Kane
Trochanteric Pressure Ulcer: Case Study #2
Trochanteric pressure sores are less common and are typically associated from
prolonged side-lying position with less skin loss. Excisional debridement of
trochanteric ulcers in preparation for fl ap repair involves resection of the entire
bursa and greater trochanter of the femur. The tensor fascia lata myofasciocutaneous fl ap is the fi rst option for reconstruction of trochanteric pressure ulcers [ 35 ].
The fl ap has good blood supply and the muscle is expendable. The donor site can
often be closed primarily.
A patient with a right trochanteric pressure ulcer following multiple debridements
and bone removal for infection is shown in Fig. 7.9 . Notice the articular surface
of the hip joint which is considered infected by exposure. Distally (to the right) on the
leg are two healed skin graft donor sites which demonstrate failure of a partialthickness dermal cover as reconstruction of a pressure prone area. Skin lines mark
the undermined wound extent (Figs. 7.10 , 7.11 , 7.12 , and 7.13 ).
The right hip wound defect reconstruction is shown in Fig. 7.14 . Staples will
further support the incision against tension during the healing process. The entire
well-perfused, “pre-fabricated” tissue is rotated into the defect, covering the bony
prominence and apposed in layers over suction drains. Closure of the TFL donor
site with underlying suction drains. The donor site is also easily apposed in layers
for a tensionless closure.
The above right trochanteric pressure ulcer patient failed a prior split-thickness
skin graft as evidenced by the healed hypopigmented squares on the lower posterior
thigh. These photos illustrate the wide excision of the ulcer and ostectomy of the
underlying greater trochanter. The tensor fascia lata fasciocutaneous fl ap itself
is lifted on a vascular pedicle with the composite skin, fat, and fascia visible.
Fig. 7.9 A preoperative view of patient with a right trochanteric pressure ulcer following multiple
debridements who had bone excised due to osteomyelitis
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Fig. 7.10 The surgical specimen from the surgical excision of the trochanter pressure ulcer
Fig. 7.11 Is an illustration of the right trochanteric wound and underlying femur. The tensor fascia
lata (TFL) fasciocutaneous fl ap is outlined
Fig. 7.12 The right hip pressure ulcer excision with ostectomy defect and incised adjacent TFL fl ap
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Fig. 7.13 The TFL fl ap is shown being rotated into the right hip wound defect
D.P. Kane
Fig. 7.14 The right hip wound defect reconstruction completed
The entire well-perfused “prefabricated” tissue is rotated into the defect, covering the
bony prominence and apposed in layers over suction drains. The donor site is also
easily apposed in layers for a tensionless closure.
Ischial Pressure Ulcer: Case Study #3
The ischial location is the most common location in paraplegics and others with
unrelieved pressure while sitting. In preparation for fl ap repair of ischial wounds,
aggressive resection of the ischial tuberosity may risk a contralateral ischial
7 Surgical Management of Pressure Ulcers
https://t.me/med1917
Fig. 7.15 Shows a patient
with a chronic left ischial
tuberosity pressure ulcer that
has failed to progress
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Fig. 7.16 On Left : ischial excisional wound with ostectomy and biceps femoris myofasciocutane-
ous fl ap on the left . On right : the fl ap rotation and donor site closure
pressure ulcer from increased contralateral pressure, injure the perineum creating a
urethral or vaginal fi stula [ 36 ], and may preclude the use of the gluteal fl aps for
sacral ulcer reconstruction. A rotated biceps femoris myofasciocutaneous (one of
the hamstring s muscles) fl ap is a common fi rst choice to fi ll and close an ischial
pressure sore [ 37 ] (Figs. 7.15 and 7.16 ).
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Fig. 7.17 Left ischial wound
defect and elevated biceps
femoris fl ap and donor site
showing the axial blood
vessels perfusing the fl a p
D.P. Kane
The ischial ulcer in the above case appears quite small on the outside due to
contracture of the wound edges, but the undermining is wide and dangerously
close to adjacent vital structures. Careful excision and ostectomy are mandatory.
The biceps femoris myofasciocutaneous fl ap is elevated illustrating the vascular
pedicle and inset without tension (Figs. 7.17 and 7.18 ). A well-healed reconstruction
is shown in Fig. 7.19 .
Femoral Disarticulation for Hip Osteomyelitis or Joint
Infection: Case Study #4
Pyarthrosis of the hip joint can occur with communication of ischial or trochanteric
ulcers. Often, the femoral head contains osteomyelitis, which mandates its removal.
Without a femoral head prosthesis or fusion, the entire leg becomes fl accid and
unstable and must be removed. A hip disarticulation is indicated with muscle coverage
of the articular surface and soft tissue with a thigh fi let fl ap over the hip defect.
In Fig. 7.20 , left illustration shows a left hip pressure sore and hip pyarthrosis
with (anterior) rectus femoris muscle for fl ap lining of the articular surface. Right
illustration shows rectus muscle inset into the hip following disarticulation, curettage
of the femoral articular surface, inset of the rectus femoris muscle fl ap, removal of
the femur and distal leg, and thigh fi llet fl ap reconstruction.
7 Surgical Management of Pressure Ulcers
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Fig. 7.18 The left biceps
femoris fl ap inset and donor
site closure
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Fig. 7.19 Staples removed
from left ischial pressure
ulcer reconstruction at 12
weeks
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D.P. Kane
Fig. 7.20 Left iIllustration : a left hip pressure sore and hip pyarthrosis with rectus femoris muscle
for fl ap lining of the articular surface. Right Illustration : rectus muscle inset into the hip following
disarticulation
Figure 7.21 shows the postoperative state of the hip disarticulation for femoral
head osteomyelitis and pyarthrosis of the hip joint. The femur and distal leg are
removed. A rectus femoris or vastus lateralis muscle fl ap lines the excised joint
space and a thigh fi llet fl ap covers the wound. This type of surgery is aggressive but
can result in a better quality of life for selected patients who otherwise have to live
with a chronic infected wound.
Other Considerations
Multiple pressure sores occurred in this same patient. Excision of each ulcer,
ostectomy, and reconstruction of multiple ulcers may require the use of a total
thigh fl ap. It should be reserved as a salvage procedure when other attempts have
been unsuccessful.
Some surgeons will recommend colonic or urinary diversion prior to reconstruction
in patients with heavily colonized wounds from stool or urine. This is a controversial topic and recommendations are case specifi c [ 38 ].
7 Surgical Management of Pressure Ulcers
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Fig. 7.21 Shows the
post-operative state of the hip
disarticulation for femoral
head osteomyelitis
Fixed contractures and muscular spasm in spinal cord injury patients need to be
addressed preoperatively. Serial casting and even surgical release of fl exion contractures are at times indicated prior to surgery. Any type of traction on the suture line
can result in surgical wound dehiscence. Contractures make postoperative repositioning diffi cult as well.
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Complications
Complications following pressure sore reconstruction can be high because of patient
noncompliance, seromas, hematomas, wound infections, and dehiscence. Sutures
dissolve by 3–6 weeks leaving minimal wound strength across the reconstructed
incision. Follow-up evaluation and monitoring for a minimum of 3 months following wound closure are essential to maintain incision integrity. Staple reinforcement
across the incision line should not be removed for 3 months. Thereafter, the patient
is deemed surgically stable.
Flap Failure
The complication rate of pressure ulcer reconstruction is high; poor candidates for
surgery should not undergo pressure ulcer reconstruction. Patients without a good
support system at home are not good candidates for pressure sore reconstruction.
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Box 7.3 Signs of Impending Flap Failure
• Swelling (hyperpermeability)
• Erythema (hyperemia)
• Cyanosis (venous congestion)
• Epidermolysis (partial-thickness necrosis)
Patients who are noncompliant with pressure offl oading and local care are also poor
candidates for reconstruction.
The postoperative regimen for the transition from bed rest to sitting and return to
wheelchair seating must be strict and careful. Patients may need to be reevaluated
by the rehabilitation team so to have all the needed adaptive equipment and training
when the surgeon gives clearance.
Even with valiant attempts for wound closure, offl oading, and rehabilitation,
underlying problems may cause fl ap or skin graft failure. Flap or graft failure
proceeds through a series of events that, if caught early enough, may be reversed.
The cardinal signs of impending fl ap failure are included in Box 7.3 .
Flap failure can occur due to secondary infection or compromise in blood supply.
Diminished blood supply to the fl ap can occur due to unavoidable intrinsic vascular
compromise or to unrelieved pressure to the vulnerable fl ap.
Rescue of failing fl aps is possible but dependent on diligent observation of the
wound by the attending physician and referral for immediate reevaluation by the
reconstructive surgeon.
D.P. Kane
Adjunctive Therapies to Surgical Management
Moist wound healing is the best method to promote healing to occur in chronic
wounds [ 39 ]. A moist, clean wound promotes epithelialization from the edges
across an adequate granular base to sustain and protect the budding peripheral cells
during the mid-proliferative phase of healing. A chronic wound may need serial
sharp debridement to remove necrotic tissue not eliminated by autolysis or enzymatic debridement.
Negative pressure wound closure therapy can be considered for deep wounds
that are clean and in bacteriologic balance. Negative pressure therapy has been
found to enhance wound healing by increasing blood fl ow, decreasing edema, and
increasing the formation of granulation tissue [ 40 – 42 ]. It will also decrease healing
time and bacterial contamination [ 43 ]. Relative contraindications to the use of nega-
tive pressure wound therapy include infection or vascular structures adjacent to the
wound base.
Hyperbaric Oxygen (HBO) Therapy may be useful for rapidly progressive
cellulitis or fasciitis. The principal treatment for severe soft tissue infections such as
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