Recurrent Ischial Pressure Sore Research Articles

Successful reconstruction of ischial pressure sores with inferior gluteal artery descending branch perforator flap.

Ischial pressure sores often recur, the surgical choice often troubled the surgeon, because surgery repair should consider future reconstructive procedures. The purpose of this article is to present a new surgical option for the reconstruction of primary or recurrent ischial pressure sores by using an inferior gluteal artery of the descending branch perforator flap. A study involving patients suffering from ischial pressure sores was performed from March 2016 to August 2020. Patients with large defects, for which direct closure was not possible, underwent reconstructive surgery using an inferior gluteal artery descending branch perforator flap. Collected data included age, diabetes, wound culture, size of the wound, whether or not negative pressure therapy was received, operative time, intraoperative blood loss, and postoperative complications. Patients were followed up through outpatient visits or by telephone. Five patients with ischial pressure sores (four primary and one recurrent) underwent reconstructive surgery with inferior gluteal artery descending branch perforator flap. One patient received colostomy and wound negative pressure therapy before lesion reconstruction. All patients successfully recovered without postoperative complications. The follow-up period ranged from 4 to 31 months. No wound disruption or recurrence was recorded. Inferior gluteal artery descending branch perforator flap treatment of ischial pressure sores is a simple and feasible method for preserving the inferior gluteal artery's main vascular perforators and could be used as a future surgical option.

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

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. 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. 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. 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.

Infragluteal fasciocutaneous flap for management of recurrent ischial pressure sore.

Objective:The objective of the study was to determine the feasibility of infragluteal fasciocutaneous flap in recurrent ischial pressure sore.Materials and Methods:In our study, from 2015 to 2017, nine patients suffering from recurrent ischial sore with scars of previous surgery were managed with infragluteal fasciocutaneous flap. Wound bed was prepared by surgical debridement and negative pressure wound therapy in each case. In two cases, gracilis muscle flap was used as adjuvant to fill up the residual cavity. Donor area of flap was primarily closed.Results:Infragluteal fasciocutaneous flap was used in all nine cases. Superficial distal congestion was present in two cases. Haematoma (1) and infection (1) at flap donor site occurred. Recurrence of ulcer was observed in two cases which were managed by bursectomy and advancement of the bridge segment of the original infragluteal fasciocutaneous flap. All flaps survived without any major complication.Discussion:Ischial pressure sores have a tendency of recurrence after conservative or flap surgery. Scars due to previous surgeries adjacent to the pressure sore preclude the use of local skin or muscle flap. Infragluteal fasciocutaneous flap is a thick reliable fasciocutaneous flap that can be used for resurfacing recurrent ischial pressure sore. This flap has an axial pattern blood supply along with rich subfascial and fascial plexus supplied by various perforators.Conclusion:Infragluteal fasciocutaneous flap is reliable option for managing recurrent ischial sore as it transposes well-vascularised thick fasciocutaneous flap from adjacent posterior thigh and its bridge segment can be further used in case of recurrence.

Management of recurrent ischial pressure sore with gracilis muscle flap and V-Y profunda femoris artery perforator-based flap

Inappropriate seating has been implicated as a major contributing factor in ischial pressure-sore recurrence. During their lifetime, paraplegic patients may require several flaps for closure of the same or some other adjacent pressure sore. Despite a wide variety of flap reconstruction options being described, the ischium remains the most difficult pressure-sore site to treat. From June 1998 to July 2006, there were 253 pressure-sore patients operated upon at Kaohsiung Medical University Hospital. Ten patients (eight men and two women) suffered from recurrent ischial pressure sores, and all of them received more than one flap reconstruction for the ischial defect. For the treatment of the recurrent ischial pressure sore, gracilis muscle flap and readvancement of the V-Y profunda femoris artery perforator-based flap were used to fill the dead space as well as cover the defect. Among these 10 recurrent ischial pressure-sore patients, six of them had suffered bilateral ischial ulcers. Eight of them had previous sacral pressure sores. In all, 32 flap reconstruction procedures were performed on these 10 patients. Unfortunately, one patient had recurrent grade II bilateral ischial pressure sores after 11 months of ulcer-free period. The other nine patients had no recurrence noted, and enjoyed their lives with an average 27.2 months ulcer-free period (range 9-53 months). The fasciocutaneous flap provides a higher mechanical resistance than the detached and transposed muscle. However, for the recurrent ischial ulcer patients, readvancement of the perforator-based fasciocutaneous flap alone cannot provide adequate bulk to obliterate the 'dead space' after debridement of the bursa and the surrounding necrotic tissue. By combining the readvancement of V-Y profunda femoris artery perforator-based fasciocutaneous flap and gracilis muscle flap, these recurrent ischial ulcers will heal without complication. Recurrence of ulceration often develops despite successful flap closure. Patients and their relatives have to be educated regarding pressure relief, personal skin, and self-care. Surgeons must collaborate with the rehabilitation department, nursing staffs, and social workers to improve long-term results.

A new technique of transferring island pedicled anterolateral thigh and vastus lateralis myocutaneous flaps for reconstruction of recurrent ischial pressure sores

We describe island pedicled anterolateral thigh and vastus lateralis myocutaneous flaps for reconstruction of the difficult, recurrent ischial pressure sore. Rather than transfer through a subcutaneous tunnel, the flap is transferred directly through the upper thigh to the ischial defect. A total of 15 patients with 16 recurrent ischial pressure sores were treated between May 2003 and April 2005. Eleven sores were treated with pedicled island anterolateral thigh flaps and five sores with vastus lateralis myocutaneous flaps. There was no difficulty in transferring the flap to reach the ischial defect in any patient. The length of the pedicle ranged from 8.5 to 14 cm. All donor sites were closed primarily. Fifteen of the 16 flaps survived completely. Total necrosis occurred in one vastus lateralis myocutaneous flap, which was located at the distal third of the thigh. We conclude this flap can be added to the repertoire for the treatment of recurrent, difficult ischial pressure sores.

The lateral thigh V-Y flap for the repair of ischial defects

The lateral thigh fasciocutaneous flap described by Maruyama et al in 1984 is a useful method for the repair of ischial and trochanteric defects. We clinically re-evaluated the potential vascular territory of the nutrient artery for this flap, i.e., the first profunda perforator, and have newly designed the postero-lateral thigh V-Y flap in the area including the proximal two-thirds of the posterior thigh. This flap was applied to five difficult or recurrent ischial defects, and satisfactory results were obtained in all cases. For the reconstruction of ischial defects, the postero-lateral thigh V-Y flap has the following advantages; the proximal and well-vascularised portion of the flap is inserted into the area of the previously excised pressure sore, and this flap can potentially be readvanced if a recurrent pressure sore should develop. A Z-plasty can be performed to prevent excessive tension on the skin closure at the junction of the V-Y advancement flap. The postero-lateral thigh V-Y flap can be considered one of the first-line options for both primary and recurrent ischial pressure sores.

Closure of an ischial pressure sore using a free gastrocnemius musculocutaneous flap with a long venous pedicle

The recurrent pressure sore in an active paraplegic can become a frustrating challenge as available simple flap options become depleted. The medial gastrocnemius musculocutaneous free flap is an alternative that offers the benefits of muscle from an expendable donor site and still preserves the remainder of the donor limb for future use. Inclusion of an intact greater saphenous vein could augment venous drainage and potentially might be the sole means of outflow if veins at the recipient site were inadequate. This case report describes the closure of a recurrent ischial pressure sore with a free medial gastrocnemius flap, including a greater saphenous vein pedicle.

Reconstruction of ischial pressure sore using an inferior rectus abdominis myocutaneous flap

In this article, a reconstructive method for ischial pressure sores using an inferior rectus abdominis myocutaneous flap, is reported. Results obtained with two paraplegic patients with recurrent ischial pressure sores were excellent, and they were free from recurrence over two years after this operation. This technique is one of the methods of choice in cases of recurrent ischial pressure sore where conventional methods have been tried.

A combined biceps and semitendinosus muscle flap in the repair of ischial sores

In large or recurrent ischial pressure sores with extensive bony involvement, scarring and absence of surrounding soft tissue, radical excision of all involved bone and soft tissue leaves a large space which Conway and Griffith (1956) recommended should be filled by a biceps femoris muscle flap before being covered with a large medially based posterior thigh rotation flap. We have occasionally found the biceps so atrophied in paraplegics that it was inadequate to fill the hole. Additional bulk may be obtained by rotating the semitendinosus together with the biceps.