Reconstruction Of Pressure Sores Research Articles

Surgical reconstruction of pediatric pressure sores: long-term outcome.

The long-term outcome after the surgical repair of pressure sores in the adult population has been well studied. Recurrence rates from 25 to 80 percent have been reported, despite improvements in surgical repair and mechanical support devices. Such high recurrence rates have led many investigators to question the rationale for the surgical closure of pressure sores. There are no published long-term data that document pressure sore recurrence after surgical treatment in the pediatric population. A retrospective analysis of all patients who underwent surgical reconstruction of grade III and IV pressure sores at the Children's Hospital of Philadelphia from 1987 to 1999 was performed. During this 12-year period, 19 consecutive patients with a mean age of 16.2 years were operated on for 25 pressure sores. Follow-up was obtained for 15 patients (79 percent), who underwent repair for 20 pressure sores. Mean postoperative follow-up was 5.3 years (range, 11 months to 11 years). Mean age at the time of surgery was 16.5 years. The overall pressure sore recurrence rate was 5 percent (1 of 20 sores). Overall patient recurrence (previous patient who developed a new sore) was 20 percent (3 of 15 patients). In contrast to the recurrence rates reported for the surgical repair of pressure sores in the adult population, the recurrence rate of 5 percent in the pediatric population is significantly lower. This demonstrates that the surgical reconstruction of pressure sores in the pediatric patient can be successful and provide long-term skin integrity.

Ischial pressure sore reconstruction using an inferior gluteal artery perforator (IGAP) flap

Perforator-flap technique has revolutionised the practice of free tissue transfer with the goal of muscle sparing for function and strength. These concepts are being widely explored for breast reconstruction. The field of pressure-sore reconstruction presents a new application for this technique, preserving muscle for function in ambulatory patients and for future reconstruction in paraplegic patients. Just as the superior gluteal artery perforator flap holds promise for sacral and trochanteric reconstruction, the inferior gluteal artery perforator flap may provide a muscle-sparing alternative for ischial reconstruction. A case report of the successful use of an inferior gluteal artery perforator flap for ischial pressure-sore reconstruction is described, including the surgical technique employed for flap harvest, and 2 year's follow-up.

Ischial pressure sores treated with a sensate gracilis myocutaneous flap

There are problems in finding a definitive treatment of ischial pressure sores because recurrence is frequently observed. The aim of surgical procedures is to cover the ischial region with stable and durable tissue, which has a good neurovascular supply. If the patient with ischial pressure sores has sensation above L3 level, the sensate gracilis musculocutaneous flap can be used to treat the defect after resection of the decubitis. This treatment was performed in 12 paraplegic patients in whom sensation was absent below the L3 level. The median age of the patients was 32.5 years, with ten males and two females. Four patients had recurrent pressure sores. The average time of follow-up was 8 months. Sensation was assessed with moving finger tip pressure, warm and cold cylinders, two point discrimination and dermal cortical somatosensory-evoked potential tests. Sensation was present in the transferred flap. Although the gracilis myocutaneous flap can also be used as a nonsensory flap for the reconstruction of ischial pressure sores in paraplegic patients under L3 level, the sensate gracilis myocutaneous flap should be chosen primarily when there is sensation over the gracilis region.

Hip Joint Exposure During Ischial Pressure Sore Reconstruction

(2000). Hip Joint Exposure During Ischial Pressure Sore Reconstruction. The Journal of Spinal Cord Medicine: Vol. 23, No. 2, pp. 86-89.

Tangentially Split Gluteus Maximus Myocutaneous Island Flap Based on Perforator Arteries for the Reconstruction of Pressure Sores

Tangentially Split Gluteus Maximus Myocutaneous Island Flap Based on Perforator Arteries for the Reconstruction of Pressure Sores

Tangentially split gluteus maximus myocutaneous island flap based on perforator arteries for the reconstruction of pressure sores.

From 1995 to 1997, the authors used tangentially split gluteus maximus myocutaneous island flaps based on the musculocutaneous perforator arteries for the reconstruction of pressure sores located in the trochanteric, sacral, and ischial regions of 30 ambulatory and paraplegic patients. The postoperative follow-up period was 18 months. Postoperative electromyograms were performed on the ambulatory patients to compare the function of the gluteus maximus muscles on each side. There were one major and two minor postoperative complications. There was no total flap loss. The major advantage of this technique is the preservation of most of the gluteus maximus for stair climbing and single-limb support in the ambulatory patient. The tangentially split gluteus maximus myocutaneous island flap is recommended as the procedure of choice for closure of sacral, ischial, and trochanteric ulcers in both the ambulatory and nonambulatory patient.

Limb-salvage in reconstruction of recalcitrant pressure sores using the inferiorly based rectus abdominis myocutaneous flap.

Pressure sore closure is frequently a reconstructive challenge. This challenge is particularly evident in cases of multiply recurrent sores. In such settings, there are often opportunities to manage the recurrent wounds either by repeated advancement of previous flaps or by design of alternative ones. However, these interventions are not always feasible, and limb amputation with total thigh flap closure must be considered. A review of operative experience with seven such complex pressure sores in seven patients is presented. Each patient had previously suffered a permanent thoracic-level spinal cord injury. Prior attempts at wound closure were unsuccessful. Despite consideration of all described locoregional flaps, no limb-sparing procedure could be designed satisfactorily. As an alternative to either hip disarticulation and total thigh flap coverage or distant free-tissue transfer, we reconstructed the debrided ulcer beds with inferiorly based rectus abdominis myocutaneous flaps. Six of the seven wounds healed primarily, whereas one required repeated debridement and the addition of a gracilis muscle flap to achieve complete closure. Postoperative follow-up has ranged from 6 to 45 months. Each patient has returned to his baseline preoperative activity level with no clinical compromise of abdominal wall function. All wounds have healed. Successful application of the inferiorly based vertical rectus abdominis myocutaneous flap for cases of both recalcitrant ischial and trochanteric pressure sores is demonstrated and its consideration is advocated if no reconstructive options short of extremity amputation and total thigh flap coverage exist for such challenging sores.

Surgical treatment for ischial pressure sores with gracilis myocutaneous flap

Surgical reconstruction of ischial pressure sores is technically complex and presents a significant problem. Although there is consensus about the use of muscle or myocutaneous flaps in the closure of these sores, there is still dispute about which muscle or myocutaneous flap to use. This evaluation describes the use of the gracilis myocutaneous flap for the treatment of wide and chronic ischial pressure sores. Details of 14 cases are presented and compared with those described in the literature.

V-Y Tensor Fascia Lata for Trochanteric Pressure Sore Treatment

There are several alternatives for pressure sore reconstruction, but it is of utmost importance that an appropriate surgical technique be adopted, because although treatment is successful, recurrence of these ulcers is frequent. The purpose of this study was to conduct a precise evaluation of the V-Y tensor fascia lata flap, pointing out its advantages compared with the classical flap and with other possibilities described in the literature. The author employed 20 V-Y tensor fascia lata flaps to correct 20 trochanteric ulcers. The use of the classical tensor fascia lata flap to cover trochanteric ulcers is unquestionable. However, primary closure for flaps wider than 10 cm is difficult, necessitating an eventual skin grafting of the donor site. The V-Y tensor fascia lata allows a covering similar to the classical flap, simplifies primary closure and essentially presents the possibility of numerous reutilizations.

Long-term outcome of pressure sores treated with flap coverage.

This article provides our experience with 45 ischial sores and 24 sacral sores in 53 paraplegic patients between 1990 and 1995. Data were evaluated as to the sites of sores and types of the transferred flaps. Types of the transferred flaps were categorized into the fasciocutaneous flap and the myocutaneous or muscle flap. In the treatment of 45 ischial sores, 18 were reconstructed with the fasciocutaneous flaps and 27 with the myocutaneous or muscle flaps. In the treatment of 24 sacral sores, 23 were reconstructed with the fasciocutaneous flaps and 1 with the myocutaneous flap. The recurrence rate was analyzed by percent pressure sore free survival (%PSFS) by the Kaplan-Meier method. Overall, the ischial sores provided a higher recurrence rate than sacral sores; however, there was no significant difference in the %PSFS between the sites of sores. The group of the sores reconstructed with the fasciocutaneous flap demonstrated significant or marginally significant better results in the %PSFS (total of ischial and sacral, p = 0.0155; ischial, p = 0.0555) compared with the group of the sores reconstructed with the myocutaneous or muscle flap. These findings indicated that the use of the fasciocutaneous flap is expected to provide a better long-term result in surgical reconstruction of pressure sores than the myocutaneous or muscle flap.

Flap selection as a determinant of success in pressure sore coverage.

To establish a treatment algorithm for the long-term surgical management of pressure sores. Retrospective case series. University-based teaching hospital. From March 1979 to July 1995, 280 unselected pressure sore reconstructions (113 ischial, 94 sacral, and 73 trochanteric sores) were performed in 201 patients (130 men and 71 women; age range, 16-90 years; mean, 50 years). Of the patients, 90% had severe spinal cord injuries (paraplegia or quadriplegia). Forty-one percent of the wounds were chronic (present longer than 3 months). Length of stay, postoperative morbidity and mortality, and flap success (defined as a completely healed wound). Overall, 89% of the flaps healed primarily (ischium, 83% [94/113]; sacrum, 91% [86/94]; trochanter, 93% [68/73]). Three fourths of cases were treated in a single stage (debridement and reconstruction). The inferior gluteus maximus island flap (ischium) (94% [32/ 34]), the V-Y gluteus maximus advancement flap (sacrum) (97% [36/37]), and the tensor fascia lata flap (trochanter) (95% [42/44]) had the highest success rates. Flap success was not significantly affected by the size of the pressure sore or the number of previous flaps used. Postoperative hospital stays averaged 20 days. The overall complication rate was 28%, most commonly from a slight wound edge dehiscence. Flap selection and the appropriate short- and long-term sequence of flap use significantly improve success rates for pressure sore coverage. Reconstruction can be reliably performed in a single stage with a relatively short hospitalization.

Desmopressin Decreases Operative Blood Loss in Spinal Cord Injury Patients Having Flap Reconstruction of Pelvic Pressure Sores

To test the effectiveness of desmopressin in decreasing operative blood loss in major flap reconstructions, 44 hemostatically normal patients with spinal cord injury and pelvic pressure sores participated in a randomized, prospective, double-blind clinical trial. Each patient received a single dose of desmopressin (0.3 micrograms/kg) or saline placebo intravenously at the initiation of a reconstructive surgical procedure. Preoperative and postoperative hemoglobin, hematocrit, von Willebrand factor, and factor VIII determinations and measurement of intraoperative blood loss and transfusions of packed red cells were recorded. Desmopressin-treated patients experienced a smaller decline in hemoglobin and hematocrit levels postoperatively. In those patients requiring major flap reconstructions, the use of desmopressin significantly decreased intraoperative blood loss and subsequent transfusion requirements. The levels of von Willebrand factor and factor VIII tended to be higher, although not significantly so, in subjects receiving desmopressin. No patient experienced an adverse reaction to the drug. We conclude that a single dose of desmopressin, given immediately preoperatively, is safe and effectively decreases blood loss and transfusion requirements in patients undergoing major flap reconstructive surgery.

Efficacy of Operative Cure in Pressure Sore Patients

The advent of air flotation-type beds and purified growth factors that may accelerate open wound contraction, coupled with very high recurrence rates and decreasing health resources, suggests that surgical reconstruction of pressure sores may not be indicated in all patients. In an effort to define which patients might benefit from operation, we reviewed the data from 40 consecutive patients with 68 pressure sores operated on under the direction of a single surgeon between 1981 and 1989. Patients were categorized on the basis of the presence or absence of paraplegia and its etiology. Sixty-six operations were performed, 55 muscle or fasciocutaneous flaps and 11 cutaneous flaps. There was a 36 percent operative complication rate, with no operative mortalities. Follow-up ranged from 1 to 71 months, with a mean of 21 months. Despite an 80% healed rate at the time of discharge, 61% of sores and 69% of patients had recurrent ulceration within a mean of 9.3 months. Analysis of these data indicates that surgical reconstruction of pressure sores does not appear to be efficacious in young posttraumatic paraplegics or cerebrally compromised elderly patients. Further review of the data failed to identify those patients likely to remain healed after operative repair of their pressure sores.

The Inferiorly Based Rectus Abdominis Myocutaneous Flap for Reconstruction of Recurrent Pressure Sores

Eight neurologically impaired patients underwent reconstruction of chronic perineal and ischial pressure sores utilizing an inferiorly based rectus abdominis myocutaneous flap. Other local and regional flap options had been previously used or were not feasible. In six patients, healing was uncomplicated. One patient required local debridement and flap readvancement. The second involved minor separation of a suture line and healed by secondary intention. All donor sites were closed directly and healed by primary intention. There was no evidence of hernia formation, and no functional deficit was detected from removal of the rectus muscle in any of the patients. In conclusion, it was felt that the inferiorly based rectus abdominis myocutaneous flap should be considered a reconstructive option in dealing with perineal and ischial pressure sores. Furthermore, for reasons discussed, we found distinct advantages to using this flap in spinal cord injury patients.

The Inferiorly Based Rectus Abdominis Myocutaneous Flap for Reconstruction of Recurrent Pressure Sores

The Inferiorly Based Rectus Abdominis Myocutaneous Flap for Reconstruction of Recurrent Pressure Sores

Buried Inferiorly Based Gluteus Maximus Musculocutaneous Flap for Reconstruction of Large, Recurrent Ischiopubic Pressure Sores

The ischium is the most common site for recurrence of pressure sores in the paraplegic population. Successful reconstruction of these wounds depends on the total excision of ulcer, soft tissue debris, bony prominence, and the durability of the soft tissue repair. The V-Y gluteus maximum musculocutaneous flap based on the inferior gluteal vessels can be advanced medially, deepithelialized, and buried to fill large, deep soft tissue ischial wounds. Local rotational flaps close the superficial wound. This buried flap, although not previously described, is useful for the reconstruction of large ischiopubic pressure sores initially or at the time of recurrence.