“Further Reading”), found that wound com­plications were associated with African American race, ASA class >4, smoking his­tory, obesity, and chronic obstructive pulmo­nary disease (COPD). Other comorbid conditions that have been associated with poor wound healing include diabetes, inam­matory bowel disease (IBD), immunode­ciency and vasculopathy. While these comorbidities are not generally reversible, they should be aggressively controlled with medical treatment and specialty consultation.

pressure sores will signicantly impede heal­ing, and may ultimately lead to ulceration and necrosis. Radiation injury in the form of radionecrosis is unique in that the injury may be both delayed (6weeks after exposure) and then progressive over time. Pressure ulcer­ation in the perineum occurs in bedridden or paraplegic patients, and may rst compro­mise the tissue immediately overlying the ischium or sacrum. In many cases of cellular injury, tissue is scarred or malperfused in the areas surrounding the wound itself. This may limit the success of local rotational aps and skin grafts. Non-viable tissue should be widely debrided and reconstructed with tis­sue from outside the zone of injury, i.e. a regional or free ap.

Other infectious causes for NHPW include pilonidal disease and hidradenitis suppura­tiva, and management for both of these problems can be found in other chapters of this book.

H. Imaging is not always critical, but it may

often be helpful to exclude underlying pro­cesses such as abscess, stulae, or bony involvement. Studies may include pelvic computed tomography (CT), magnetic reso­nance imaging (MRI), or stulagram. Bone scans can be used to assist with evaluation of osteomyelitis. However, bone biopsy is often required to conrm the diagnosis.

are two options for cleaning wounds in preparation for further healing and eventual closure. Macrodebridement involves surgi­cal excision of nonviable or infected tissue back to healthy-appearing bleeding edges, and removal of any brinous debris. Depending on the degree of involvement, this can be accomplished at the bedside or in the operating room under anesthesia. Microdebridement refers to the use of regu­lar wet-to-dry dressing changes, which help remove brin and stimulate growth of fresh granulation tissue.

and social factors a course of healing by sec­ondary intention may prove the best options in some cases, for example, if the patient is a poor surgical candidate. Healing by secondary inten­sion may also be the appropriate choice for wounds that are too large for primary closure, or that contain persistent contamination requir­ing serial macrodebridement. It should be noted, however, that healing by secondary intention can be a very lengthy and labor inten­sive/resource fueled endeavor. Thus, a variety of adjuncts have been developed to expedite the process. Moist wound dressings include algi­nate, silicone or polyurethane foam or beads, or hydrocolloid dressings. There are mixed data regarding superior healing for any of these techniques over gauze dressings, though foam dressings have been shown to improve patient comfort. Antimicrobial applications such as Betadine, Medihoney, petroleum or silver sul­fasalazine are used to theoretically help reduce contamination. Negative- pressure wound dressings (NPWD) have been credited by many as helpful in promoting granulation and even­tual re- epithelialization. The data on hyperbaric oxygen therapy is mixed but leans towards hav­ing an overall benecial effect on wound healing in certain cases. Bioelectric treatments and stem cell-based therapies remain experimental.