Original paper
Selection of surgical technique in treatment of pressure sores

Introduction

A pressure sore is a lesion of the skin and deeper tissues, due to ischaemia because of long-lasting pressure, shearing forces and friction. Most commonly it develops above bone eminences where pressure is the greatest [1].

Pressure sores are a serious medical problem. Most frequently they occur in bedridden patients – with para- and tetraplegia, cerebral palsy, SM and those who spend most time in a wheelchair. Bedsores have been found in Egyptian mummies. Today, despite huge medical progress, they cannot be prevented. In the literature pressure sores are found in papers dating from the first half of the 18th century. In 1938 Davis proposed surgical treatment by using flaps.

In hospitalized patients bedsores are observed in 3-10%; in cancerous patients up to 20%. Patients at high risk are those with paralysis (39%) [2]. The size of bedsores is proportional to their duration [3]. Most palsy is related to spinal cord injuries. According to the literature over 60% of spinal cord injuries occur in the lower cervical spinal cord (C5-Th1); they are caused by falls from height (60%) and crashes (30%) [4]. Since the 19th century it has been known that the main aggravating factor is persistent pressure, leading to circulatory dysfunction, ischaemia, hypoxia and tissue necrosis.

It was thought that pressure over 35 mmHg causes the changes. Now all pressure no matter the value or duration is significant in the development of pressure ulcers. Other external factors such as friction, shearing forces and patient’s skin condition (for example lesions from urine and faeces) also play a role. Internal factors contributing to higher risk of developing pressure sores are diseases aggravating healing, for example diabetes mellitus, blood vessel diseases, malnutrition, general weakness, and urinary and faecal incontinence. Examinations by Kaneko et al. demonstrated that patients with pressure sores have lower levels of albumins, lymphocytes, zinc and blood platelets [5]. Marjolin’s ulcer may develop on pressure ulcers. It is squamous cell carcinoma, commonly with a bad clinical course, and a tendency to local recurrence and metastases [6].

The NORTON point scale is used to define the probability of developing pressure ulcers (Tab. 1).

Decubitus ulcers most frequently occur on: ischial (about 30%), trochanteric (about 20%), lumbosacral (about 17%) and heel (9%) regions (Fig. 1-4). Sometimes they are also observed in the kneecap, elbow and popliteal fossa region (Fig. 5).

The aim of this paper is to present methods of operating on bedsores in patients treated in the Clinic of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Lodz.

Material and methods

During 2003-2009 in our clinic 36 patients (25 males and 11 females) were treated for bedsores. Most patients had palsy after spinal cord injuries. Trochanteric bedsores were most common (Tab. 2). Seven patients had multiple pressure ulcers.

Surgical treatment was planned individually, depending on the size and site of the pressure ulcer as well as the general condition of the patient. At first deficits in protein and haemoglobin ratio were eliminated. The wound was prepared in a conservative fashion by frequently changing dressings and removing necrotic tissue. The patients were given an antibiotic starting on the day of the surgery and for the next 4 days; the antibiotic was chosen based on a smear from the pressure ulcers. Preventive treatment for pressure ulcers was performed peri-operatively in all patients.

Surgical treatment involved excision of necrotic tissues with recesses and scars and resection of bone eminences causing pressure on soft tissues.

Loss of tissue after excision was treated with adipocutaneous, musculocutaneous or fasciocutaneous flaps well supplied with blood.

Tables 3-5 show the number of different flaps used in surgical treatment of sacral, ischial and trochanteric bedsores.

Results

Surgical techniques used in treating bed sore wounds in patients hospitalized during 2003-2009 are presented. 60 patients were operated on. All used flaps survived. Healing was uneventful by 30 (83%) out of 36 patients. In 6 (17%) patients there were complications due to partial wound dehiscence because of infection. By 3 (8%) patients bedsore recurrence was observed within 4-12 months after the surgery.

Review and discussion

Most patients suffering from bedsores in our clinic were paralysed, and despite prophylaxis and surgical treatment, relapses occurred. Therefore, when planning flap plasty a possibility of collecting another flap with good perfusion must be taken into consideration. The flap covering the loss of tissue should be appropriately wide, long and well supplied with blood. In patients with no permanent paralysis (palsy), flap collection should not cause dysfunctions.

The loss of the soft tissue above the sacral bone was filled with a musculocutaneous flap, taken from the great gluteal muscle, and used as a rotational flap (Fig. 6) or V-Y plasty. Perfusion of this flap is optimal because it comes from two arteries – gluteal lower and upper. The flap innervation is provided by gluteal branches of the ischiadic nerve. Another advantage of this flap is only slight loss of the muscle's function, especially if only the upper or lower part of it is used. The site from which the flap was collected was usually sutured or covered with a free skin graft. Other authors have also successfully used it [7-9]. Wong et al. [9] showed that this flap is more resistant than a fasciocutaneous flap from the gluteal area. Its modifications, for example a bilateral flap with V-Y plasty [10] (Fig. 7), are also successfully used. A good alternative in extensive loss of tissues is a pedunculated fasciocutaneous flap composed of a classic musculocutaneous flap with great gluteal muscle and eccentrically pedunculated by a perforator flap [11].

Loss in the trochanter area was usually completed with a flap from the tensor fascia lata (Fig. 8). It may be used as a rotational flap. Branches of the thigh surrounding the lateral artery supply it with blood. Innervation comes from upper gluteal nerve branches. Collection is not difficult in this area and the flap is long, which enables a wide range of implementation. This method, with modifications, is used most often by other authors [12-14]. The lower part of the great gluteal muscle, lateral vastus muscle of the thigh and musculocutaneous flap of straight muscle of the thigh have also been used. Ischiadic bedsores were usually closed with a musculocutaneous flap with biceps femoris (Fig. 9, 10) nourished by a few lancinating branches of thigh profound artery from the site of collection was covered using V-Y plasty. Innervation of this flap comes from branches of the tibial posterior nerve [15, 16]. A musculocutaneous flap from straight muscle of the thigh has been used as well. Its nerve supply comes from branches of the femoral nerve. Its disadvantage is a significant loss of muscle function due to dislocation of the biceps femoris muscle. It is not significant in patients with permanent limb paralysis.

In the literature, a double rotational fascio-adipose flap is considered to be safe and appropriate in small bedsores [17]. Other authors often use a fasciocutaneous femoral posterior flap or combined – the latter one with biceps of thigh in this area [18] (Fig. 11). Modifications of the classical flaps can also be used. Borgognone et al. suggest using a musculocutaneous "criss-cross" flap created from two flaps: muscular, from the great gluteal muscle, and a local rhomboid fasciocutaneous flap, as a safe alternative in recurrent ischiadic bedsores [19]. Kim et al. emphasise the numerous advantages of using an IGAP (interior gluteal artery perforator) flap in this area [20].

Postoperative complications in our patients were infection and partial wound dehiscence. They were observed in 6 patients (17%), most of whom had other medical problems, mainly diabetes. Relapses were seen in 3 patients (8%) within 4-12 months after the surgery. They were re-operated on using a different method of closing the wound. The recurrences may have been due to insufficient prophylaxis rather than the method used, which is also confirmed by other authors [21, 22]. Our observations confirm that local plasty with a flap from the neighbourhood is the best method in treating loss of tissues in patients with pressure sores. The literature on the subject also presents the use of adipocutaneous, fasciocutaneous and musculocutaneous flaps, but it seems that the best results are observed when using musculocutaneous flaps [23, 24], which not only improve the local blood supply in tetra- and paraplegics, but also increase tissue mass in sites at risk of pressure.

Conclusions

1. The best surgical method of treating bedsores in patients with palsy is with musculocutaneous flaps.

2. The kind and tissue content depends on the site and size of the tissue to be reconstructed and general state of the patient.

3. Fasciocutaneous flaps are most commonly used in the surgical treatment of recurrent pressure sores.

4. Preoperative treatment, both general and local, as well as bed sore prevention are vital in treating patients with pressure sores.

References

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