Flap Reconstruction for Pressure Ulcers: An Outcomes Analysis

Improving the Care and Cost of Treating Community-Acquired Stage 3 and 4 Decubitus Ulcers

INTRODUCTION

The healthcare costs for treatment of community-acquired decubitus ulcers accounts for $11.6 billion in the United States annually. Patients with stage 3 and 4 decubitus ulcers are often treated inefficiently prior to reconstructive surgery while physicians attempt to optimize their condition (debridement, fecal/urinary diversion, physical therapy, nutrition, and obtaining durable medical goods). We hypothesized that hospital costs for inpatient optimization of decubitus ulcers would significantly differ from outpatient optimization costs, resulting in significant financial losses to the hospital and that transitioning optimization to an outpatient setting could reduce both total and hospital expenditures. In this study, we analyzed and compared the financial expenditures of optimizing patients with decubitus ulcers in an inpatient setting versus maximizing outpatient utilization of resources prior to reconstruction.

METHODS

Encounters of patients with stage 3 or 4 decubitus ulcers over a 5-year period were investigated. These encounters were divided into two groups: Group 1 included patients who were optimized totally inpatient prior to reconstructive surgery; group 2 included patients who were mostly optimized in an outpatient setting and this encounter was a planned admission for their reconstructive surgery. Demographics, comorbidities, paralysis status, and insurance carriers were collected for all patients. Financial charges and reimbursements were compared among the groups.

RESULTS

Forty-five encounters met criteria for inclusion. Group 1's average hospital charges were $500,917, while group 2's charges were $134,419. The cost of outpatient therapeutic items for patient optimization prior to wound closure was estimated to be $10,202 monthly. When including an additional debridement admission for group 2 patients (average of $108,031), the maximal charges for total care was $252,652, and hospital reimbursements were similar between group 1 and group 2 ($65,401 vs $50,860 respectively).

CONCLUSIONS

The data derived from this investigation strongly suggests that optimizing patients in an outpatient setting prior to decubitus wound closure versus managing the patients totally on an inpatient basis will significantly reduce hospital charges, and hence costs, while minimally affecting reimbursements to the hospital.

Rotational V-Y Fasciocutaneous Advancement Island Flap to Cover Deep Sacrococcygeal Defects due to Pilonidal Disease, Pressure Ulcers, and Other Inflammatory Conditions

The sacrococcygeal area supports the lower body and endures mechanical forces during movement. However, current treatment methods for deep caudal sacrococcygeal defects have limitations, resulting in insufficient tissue for deep pocket obliteration and considering only the two-dimensional advancement plane in a three-dimensional defect topology. Our study proposes using a rotational V-Y fasciocutaneous advancement island flap to reconstruct deep caudal sacrococcygeal defects. By considering the three-dimensional nature of the defect, we distinguish a coccygeal plane of the V-Y flap from a sacral plane and set different directions and depths of movement for each plane. From March 2016 to July 2022, 12 patients underwent successful treatment with this surgery, and no complications or recurrences were observed in the study group. Our research found that patients in our study exhibited a smaller intercoccygeal angle than the average angle of the general Korean population, as previously reported. This implies a more pronounced curvature between the sacral and coccygeal planes. Therefore, our methods, which consider the three-dimensional structures of sacrococcygeal pathology, are significant. This technique provides a mechanically robust reconstruction after resecting deep sacrococcygeal pathology, with well-padded tissue to prevent dead space and wound disruption.

Reconstructive Surgery of Pressure Injuries in Spinal Cord Injury/Disorder Patients: Retrospective Observational Study and Proposal of an Algorithm for the Flap Choice

Pressure injuries (PIs) are a common complication in patients with spinal cord injury/disorder (SCI/D), and deep PIs require surgical treatment consisting of wide debridement and adequate reconstruction. We conducted a retrospective observational study at a tertiary rehabilitation hospital for SCI/D in Italy with the aim of describing the incidence and associated risk factors of postoperative complications in individuals with SCI/D presenting with chronic deep PIs, treated with a specific flap selection algorithm based on the site of the defect, the presence of scars from previous surgeries, and the need to spare reconstructive options for possible future recurrences. Medical records of surgical procedures performed on SCI/D patients with fourth-degree PIs, according to NPUAP classification (National Pressure Ulcer Advisory Panel), between July 2011 and January 2018 were reviewed. A total of 434 surgical procedures for fourth-degree PIs in 375 SCI/D patients were analyzed. After a mean follow-up of 21 months (range 12-36), 59 PIs (13.6%) had minor complications, and 17 (3.9%) had major complications requiring reoperation. The sacral site and muscular and musculocutaneous flaps were significant risk factors for postoperative complications. Six patients (1.4%) had a recurrence. The choice of flap correlates with the outcome of decubitus reconstruction. Therefore, reconstructive planning should be based on established principles.

The niche of dermal graft to reconstruct a complex pressure injury wound in sacral region: A case report

RATIONALE

Pressure ulcers are a common health issue, particularly among elderly and bedridden patients who are vulnerable to pressure injuries in the sacral region. Currently, free flap and local flap surgeries are the gold standard procedures for the reconstruction of such injuries. However, the recurrence rate of flap surgery appears to be high. In this context, we presented a case involving a sacral pressure ulcer reconstructed with dermal grafting.

PATIENT CONCERNS

A 59-year-old male with a medical history of hepatitis C, brain hemorrhage, hydrocephalus, and multiple fractures presented with a sacral ulcer. Owing to the patient's history of recurrent pressure injuries and the challenges associated with postoperative wound care, the patient and his family were hesitant to proceed with flap surgery.

DIAGNOSES

The patient was diagnosed with a stage IV pressure ulcer measuring 4 cm × 4 cm in size in the sacral region, according to the National Pressure Ulcer Advisory Panel staging system.

INTERVENTIONS

Before surgery, the patient received standard wound care with dressing for 4 months, along with short-term oral antibiotics due to a positive wound culture for Pseudomonas aeruginosa. During the surgery, a dermal graft with a size of 35 cm2 and a thickness of 0.014 inches was harvested from the patient's left thigh. The graft was then secured to the wound bed.

OUTCOMES

Although the dermal graft failed with sloughing after 1 week, the wound bed showed improvement with granulation. After 1.5 months, the wound area had decreased to half of its original size, and the wound eventually healed after 3.5 months.

LESSONS

Dermal grafts have a niche in reconstructing pressure injury wounds in the sacral region, because of the relative ease of wound care and additional benefits even in cases where the graft fails.

Flap Survival after Reconstructive Surgery for Pressure Ulcers: A Cohort Study

Background

Pressure ulcers are troublesome for patients and require considerable resources to resolve. Previous studies have focused on recurrence, whereas there are few studies on flap survival. The aim was to describe the group and to analyze possible factors for flap survival.

Method

A descriptive retrospective analysis of all operations between 2008 and 2020 was carried out. Flap survival at 40 days was assessed. A flap was classified as a failure if a reoperation with removal or replacement was planned before, or in connection with, the first return visit. Variables of patient demographics, details of the pressure ulcers, and surgical treatment and care were analyzed with multivariable logistic regression for their effect on flap survival.

Results

A total of 111 flaps were included [78 (70%) with random blood supply and 33 (30%) with axial or perforator-based blood supply]; 54 (49%) of the flaps were fasciocutaneous. Body mass index was 25 (IQR 22-28). Flap survival rate was 90%. Variables associated with flap failure were higher body mass index, congenital spinal cord injury, type of blood supply to the flap, and the use of methylene blue to guide debridement of the wound.

Conclusions

The findings show factors that can be modified to improve future results, including a normalized body mass index and use of methylene blue in surgery to outline wound edges and depth, as this has been shown to protect against flap failure. Our data suggest that random flaps, such as V-Y, are preferable to axial flaps in the studied group.

Measurement of combined flap thickness for reconstruction of decubitus ulcer using computed tomography

BACKGROUND

Various reconstruction options have been introduced to treat decubitus ulcers. A combined flap that takes advantage of the fasciocutaneous and muscle flaps has been proven to be effective in reconstructing decubitus ulcers in previous studies. However, no studies have measured combined flap thickness. This is the first study to demonstrate the superiority of the combined flap by measuring its thickness using enhanced abdominopelvic computed tomography (APCT).

AIM

To evaluate combined flap modality as a useful reconstruction option for decubitus ulcers using measurements obtained through APCT.

METHODS

Fifteen patients with paraplegia who underwent combined flap surgery for reconstruction of decubitus ulcers between March 2020 and December 2021 were included. The defects in the skin and muscle components were reconstructed separately. The inner gluteus muscle flap was split and manipulated to obliterate dead space. The outer fasciocutaneous flap was transposed to cover the muscle flap and opening of the decubitus ulcer. Subsequently, we performed enhanced APCT at 3 wk and 6 mo postoperatively to measure the flap thickness.

RESULTS

The mean flap thickness was 32.85 ± 8.89 mm at 3 wk postoperatively and 29.27 ± 8.22 mm at 6 mo postoperatively. The flap thickness was maintained without any major complications such as contour deformities or recurrence.

CONCLUSION

Although there was a significant decrease in flap thickness as measured by APCT, the combined flap provided sufficient padding and maintained its thickness even at 6 mo after reconstruction, suggesting that the combined flap modality may be a useful reconstruction option for patients with paraplegic decubitus ulcers.

Determinants of the success in flap reconstruction-Outcome analysis of 120 flaps in 484 procedures for pressure injury

Pressure injury (PI) mainly occurs in bedridden older adults or those with physical limitations. Here, we aimed to determine the appropriate timing to conduct flap reconstruction in patients with PIs and identify factors affecting surgical outcomes. We retrospectively reviewed the data of all patients who received debridement or flap reconstruction surgery for PIs in our hospital from January 2016 to December 2021. The extracted data included patient demographics, surgical records, blood test results, vital signs, and flap outcomes. In total, 484 surgical procedures (364 debridements and 120 flaps) were performed on 216 patients. Serum albumin level of ≥2.5 g/dL remarkably increased the likelihood of complete wound healing (odds ratio [OR] = 4.12, P = .032) and reduced the risk of postoperative complications (OR = 0.26, P = .040). In contrast, advanced age (OR = 1.04, P = .045) and serum creatinine level ≥2 mg/dL (OR = 5.07, P = .016) increased the risk of postoperative complications. Thus, patients with a favourable nutrition status have a higher likelihood of achieving complete wound healing. By contrast, patients who are older and have serum creatinine ≥2 mg/dL and serum albumin <2.5 g/dL tend to develop more postoperative complications. Overall, thorough correction for patient inflammation, infection, anaemia, and malnutrition status can provide optimal flap surgery outcomes.

Risk factors associated with pressure ulcer recurrence after reconstruction: Analysis of a national database

In this study, we sought to clarify the patient traits and comorbidities that are associated with pressure injury recurrence following pressure injury reconstruction. An insurance claims database, PearlDiver, was used to conduct a retrospective cohort study. The two cohorts included patients who underwent pressure injury reconstruction without recurrence and patients who experienced recurrence with subsequent reconstruction. Multiple logistic regression analysis was used to identify risk factors for recurrence after reconstruction. Recurrence was associated with hypoalbuminemia (p < 0.05), paraplegia (p < 0.05), and osteomyelitis (p < 0.05). In patients with osteomyelitis, primary closure was associated with recurrence (p < 0.05) while flap reconstruction was not (p > 0.05). Osteomyelitis was not associated with recurrence after flap reconstruction. Prior to reconstruction, patients with osteomyelitis and hypoalbuminemia should have their nutrition and infection optimised.

Surgical Reconstruction of Stage 3 and 4 Pressure Injuries: A Literature Review and Proposed Algorithm from an Interprofessional Working Group

OBJECTIVE

Stage 3 and 4 pressure injuries (PIs) present an enormous societal burden with no clearly defined interventions for surgical reconstruction. The authors sought to assess, via literature review and a reflection/evaluation of their own clinical practice experience (where applicable), the current limitations to the surgical intervention of stage 3 or 4 PIs and propose an algorithm for surgical reconstruction.

METHODS

An interprofessional working group convened to review and assess the scientific literature and propose an algorithm for clinical practice. Data compiled from the literature and a comparison of institutional management were used to develop an algorithm for the surgical reconstruction of stage 3 and 4 PIs with adjunctive use of negative-pressure wound therapy and bioscaffolds.

RESULTS

Surgical reconstruction of PI has relatively high complication rates. The use of negative-pressure wound therapy as adjunctive therapy is beneficial and widespread, leading to reduced dressing change frequency. The evidence for the use of bioscaffolds both in standard wound care and as an adjunct to surgical reconstruction of PI is limited. The proposed algorithm aims to reduce complications typically seen with this patient cohort and improve patient outcomes from surgical intervention.

CONCLUSIONS

The working group has proposed a surgical algorithm for stage 3 and 4 PI reconstruction. The algorithm will be validated and refined through additional clinical research.

Surgical management of pressure ulcers in spinal cord injury patients

BACKGROUND

Pressure ulcers (PU) are a common yet debilitating injury within the spinal cord injury (SCI) population. This retrospective data analysis is intended to identify the contributing factors, review the current management protocol, and risk of recurrence of PU in SCI patients at Victoria's state referral centre for traumatic spinal cord injuries.

METHODS

A retrospective audit of the medical records of SCI patients with pressure ulcers was conducted for the period of January 2016 to August 2021. Patients aged 18 years and older who presented for surgical management of their PU were included in the study.

RESULTS

Among the 93 patients who met the inclusion criteria, there were a total of 195 surgeries for 129 PU. Ninety-seven percent were classified as grade of 3 or 4 and 53% had osteomyelitis on presentation. 58% were either current smokers or ex-smokers, and 19% were diabetic. Debridement alone was the most common type of surgical management (58%), followed by flap reconstruction (25%). Those who underwent flap reconstruction were admitted for 71 days longer, on average. 41% of the surgeries were associated with a post-operative complication, with the most prominent being an infection at 26%. Of the 129 PU, 11% recurred at least 4 months post initial presentation.

CONCLUSION

There are a multitude of a factors that impact prevalence, surgical complications, and recurrence of PU. This study provides insight into these factors to review our current practices and optimize surgical outcomes in the management of PU in the SCI population.

Pressure sore incidence and treatment in left ventricular assist device (LVAD)-equipped patients: Insights from a prospective series

INTRODUCTION

A left ventricular assistance device (LVAD) is indicated in patients with end-stage heart failure. Due to the non-physiologic blood flow, a LVAD may favor pressure sores with a devastating risk of infection. This work shows the prevalence and treatment of pressure sores in LVAD patients, to optimize their management.

MATERIAL AND METHODS

We retrospectively investigated all LVAD implantations at the Lausanne University Hospital (CHUV) from 2015 to 2019. We detected patients who developed a pressure sore and evaluated the timeline, management, and outcomes.

RESULTS

Forty-two patients benefited from LVAD, among whom 5 (12%) developed a stage III/IV pressure sore, within a mean time of 25 days. Due to their poor overall condition, 4/5 patients were treated surgically and 1/5 conservatively. Half of the patients treated with surgery had major complications requiring reoperation. After flap coverage, the mean time to healing for patients was 6 weeks.

DISCUSSION

The rapid development of deep pressure sores seen in 12% of patients may be a manifestation of the maladaptive blood flow induced by LVADs, combined with their bedridden condition. Initial signs of pressure sores should be considered seriously, as they are rapidly evolving and needing an aggressive surgical treatment whenever possible (80%). Complication rate was similar compared to standard pressure sore flap treatment. All patients benefiting from flap surgery achieved effective coverage after a mean follow-up of 24 months. No patient developed a LVAD infection.

CONCLUSION

Surgery must be considered early in this population to prevent potential device infection.

Effect of a computerized decision support system on the treatment approach of stage III or IV pressure injury in patients with spinal cord injury: a feasibility study

BACKGROUND

Stage III and IV pressure injuries (PIs) in patients with spinal cord injury (SCI) require complex interdisciplinary and interprofessional treatment approaches that are difficult to implement. Practical aspects, such as information exchange and coordination, remain challenging. We investigated whether a computerized decision support system (CDSS) could increase treatment adherence and improve clinical outcomes and interprofessional collaboration.

METHOD

In this feasibility study, a core team developed the initial treatment process and adapted it based on several discussions with clinical experts and information technologists. The CDSS followed the Basel Decubitus Approach and was used in a clinic specializing in SCI. Thirty patients with SCI admitted for stage III/IV PI between July 2016 and May 2017 were randomly allocated to standard or CDSS-supported care. Between-group differences in treatment adherence, complication rates, length of stay, and costs were analyzed using descriptive statistics. The use of the CDSS and potential barriers and facilitators were evaluated through interprofessional focus groups, transcribed verbatim, and thematically analyzed (30 participants).

RESULTS

No differences in SCI characteristics, comorbidities, or PI characteristics (localization: ischium [number (n) = 19 PI, 63%], sacrum [n = 10 PI, 33%], recurrent PI [n = 21, 70%]) were found between the two groups. Furthermore, no statistically significant differences were observed in treatment adherence, frequency of major (20% vs. 13% between CDSS and control group) and minor (33% vs 27%) complications, and length of stay (98 [±28] vs 81 [±23] days). Healthcare professionals found the CDSS to be helpful for visualizing the treatment process. However, the high workload and difficulties in the information technology processes, such as missing reminders, slow computer performance and data processing, and poor accessibility, hindered the effective implementation of the CDSS.

CONCLUSION

The implementation of the CDSS to support the treatment of stage III/IV PI in patients with SCI was feasible and included definitions of milestones, interventions, and outcomes. However, to assess the impact of the CDSS, a longer observation period is required. Further, the technical difficulties must be addressed, and solid integration of the CDSS into the clinical information system is necessary.

TRIAL REGISTRATION

This quality improvement project received a declaration of no objection from the Ethics Committee of Northwest and Central Switzerland (EKNZ UBE-16/003), and ethical approval was received for the focus groups (EKNZ Req-2017-00860).

SPINE: An Initiative to Reduce Pressure Sore Recurrence

The recurrence rate after pressure sore reconstruction remains high. Primary inciting factors can be organized into efforts aimed at wound prevention: spasticity relief, pressure off-loading, infection and contamination prevention, nutrition optimization, and maximizing extremity function. This article presents our detailed protocol, SPINE, to address each inciting factor with a summary of cases at our facility and review best practices from evidence-based medicine in the literature.

Effectiveness of a fluid immersion simulation system in the acute postoperative management of pressure ulcers: A prospective, randomized controlled trial

The Fluid Immersion Simulation system (FIS) has demonstrated good clinical applicability. This is the first study to compare surgical flap closure outcomes of FIS with an Air-Fluidized Bed (AFB), considered as standard of care. The success of closure after 14 days post-op was the primary endpoint. Secondary endpoints were incidences of complications in the first two weeks after surgery and the rate of acceptability of the device. 38 subjects were in the FIS group while 42 subjects were placed in the AFB group. Flap failure rate was similar between groups (14% vs 12%; P= 0.84). Complications, notably dehiscence and maceration, were significantly higher in the FIS group (40% vs 17%; P=0.0296). The addition of a microclimate regulation device (ClimateCare®) to FIS for the last 43 patients showed a significant decrease in the rate of flap failure (71% vs 16%; P=0.001) and incidence of complications (33% vs 0%; P= 0.011). There was no statistically significant difference between the FIS and AFB in the rate of acceptability (nurse acceptance: 1.49 vs 1.72; P = 0.8; patient acceptance: 2.08 vs 2.06; P = 0.17), which further illustrates the potential implementation of this tool in a patient-care setting. Our results show that the use of ClimateCare® in combination with FIS can be a better alternative to the AFB in surgical closure of pressure ulcers.

The role of the perioperative prone position in the low recurrence of pressure injuries in the pelvic region

OBJECTIVE

A pressure injury (PI) is a localised area of damage to the skin and/or underlying soft tissue as a result of a sustained mechanical loading. There are three key aetiological mechanisms to PI formation-direct cell deformation, inflammatory oedema and ischaemic damage-which are typically activated sequentially to drive a spiral of injury. This article discusses the role of the perioperative prone position as a rational approach to reducing the recurrence of pelvic PI after reconstructive surgery.

METHOD

Patients with deep PI in the pelvic region, who were operated on from 2011 to 2019, were retrospectively evaluated. The protocol of care included training in the prone position, followed by maintenance of the prone position for 4-6 weeks postoperatively. The reconstruction was performed with fasciocutaneous and myocutaneous local or regional flaps.

RESULTS

The study evaluated a total of 26 patients. The rate of recurrence of PIs was 15.4% (4/26) in the mean follow-up of 54 months. Regarding postoperative complications, four cases of partial dehiscence of the suture occurred.

CONCLUSION

This perioperative protocol of maintaining a prone position seems to be safe for the patient, and it can be used to prevent or reduce the recurrence of deep PIs on the pelvic region after reconstructive surgery.

Prognostic Evaluation of Pressure Sore Surgery Index: Risk Assessment and Outcomes of a Retrospective Cohort Study

BACKGROUND

Complication rates of up to 46 percent are reported following pressure sore surgery. Pressure sore patients often exhibit ineffective postoperative wound healing despite tension-free flap coverage, necessitating surgical revision and prolonged hospitalization. Rather than pressure sore recurrence, such impaired healing reflects a failed progress through the physiologic stages of the normal wound-healing cascade. The principal objective of the study reported here was to elucidate potentially modifiable inherent variables that predict predisposition to impaired healing and to provide a tool for identifying cases at risk for complicated early postoperative recovery following pressure sore reconstruction.

METHODS

A retrospective chart review of late-stage (stage 3 or higher) sacral and ischial pressure sore patients who underwent flap reconstruction from 2014 to 2019 was performed. A multivariable logistic regression model was used to identify key patient and operative factors predictive of impaired healing. Furthermore, the Prognostic Evaluation of Pressure Sore Surgery Index (PEPSI) was established based on the identified risk factors.

RESULTS

In a cohort of 121 patients, 36 percent exhibited impaired healing. Of these, 34 patients suffered from dehiscences, necessitating surgical revision. Statistically significant risk factors comprising late recurrence (OR, 3.8), immobility (OR, 12.4), greater surface (>5 cm diameter; OR, 7.3), and inhibited thrombocytes (aspirin monotherapy; OR, 5.7) were combined to formulate a prognostic scoring system (PEPSI-LIGhT).

CONCLUSIONS

The PEPSI-LIGhT system serves as a prognostic instrument for assessing individual risk for impaired healing in pressure sore patients. Preoperative risk stratification supports rational decision-making regarding operative candidacy, allows evidence-based patient counseling, and supports the implementation of individualized treatment protocols.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Hemicorporectomy - the ultimate solution of terminal pelvic sepsis

Hemicorporectomy is the amputation of the lower body - pelvis and lower limbs. It requires transection of the spine and dural sac at the level of aortic bifurcation and inferior lower vein, and permanent urinary and stool derivation. Performance indications are tumour trauma and terminal pelvic osteomyelitis. So far about 60 cases have been published; only 11 operations were performed for terminal osteomyelitis. We have successfully performed hemicorporectomy in a patient with chronic sepsis from terminal pelvic osteomyelitis after exhausting all other treatment options. The experience gained and the important moments of the procedure are given in the case report.

Best Solutions for Perineal and Pressure Sore Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand variations of the myocutaneous rectus abdominis muscle flap as it is used for perineal reconstruction and discuss common and alternative options for perineal defect reconstruction. 2. Review primary options and alternatives to pressure sore reconstruction if the primary option is not available and recognize when pressure sore reconstruction is not feasible. 3. Highlight pertinent anatomy and techniques for the flaps described.

SUMMARY

Perineal reconstruction following tumor resection is often complicated by irradiated tissue and multiple comorbidities, making reconstruction challenging. Management of these conditions can have complication rates as high as 66 percent, which further compounds the costs and implications of managing these wounds. These complication rates can be significantly decreased using flap closure rather than primary closure. Pressure ulcers also occur in patients with poor overall health, multiple comorbidities, and often numerous prior failed reconstruction attempts. Comprehensive management of pressure sores is a significant burden to the health care system, at a cost of $9.1 to $11.6 billion per year. There exists an extensive body of literature describing the pathophysiology and management strategies for these problems. The focus of this article is to discuss best solutions for perineal and pressure ulcer reconstruction, and to explore alternative options for reconstruction.

Volumetric Evaluation of Dead Space in Ischial Pressure Injuries Using Magnetic Resonance Imaging: A Case Series

OBJECTIVE

To establish a preoperative evaluation procedure by measuring the volume of dead space using MRI in patients with ischial pressure injuries.

METHODS

Patients with spinal cord injury and ischial pressure injuries who underwent treatment between August 2016 and November 2019 were included in the study. Preoperative MRI scan was conducted on all patients. The volume estimation and three-dimensional (3D) reconstruction were performed based on MRI data using a 3D Slicer. Based on the resulting volume, a muscle flap that could fit the dead space was selected. Surgery was performed with the selected muscle flap, and a fasciocutaneous flap was added, if necessary.

RESULTS

A total of eight patients with ischial pressure injuries were included in the study. The mean patient age was 59.0 ± 11.0 years. The mean body mass index was 26.62 ± 3.89 kg/m2. The mean volume of dead space was 104.75 ± 81.05 cm3. The gracilis muscle was the most selected muscle flap and was used in four patients. In five of eight cases, a fasciocutaneous flap was used as well. The mean follow-up period was 16 months, and by that point, none of the patients evinced complications that required surgery.

CONCLUSIONS

To the authors' knowledge, this is the first report on volumetric evaluation of dead space in ischial pressure injuries. The authors believe that the 3D reconstruction process would enable adequate dead space obliteration in ischial pressure injuries. The authors propose that preoperative MRI scans in patients with ischial pressure injury should become an essential part of the process.

Reconstruction of Chronic Wounds Secondary to Injectable Drug Use with a Biodegradable Temporizing Matrix

Injectable drug use in the upper extremity often leads to chronic wounds complicated by osteomyelitis. Conventional reconstructive options are often not feasible and/or are contraindicated in this patient population. We have started using a synthetic, biodegradable temporizing matrix (BTM) for the treatment of these patients. We hypothesize that BTM is a safe, low-risk, and low-morbidity alternative reconstructive option. We report outcomes after staged debridement and BTM application followed by split-thickness skin grafting for two patients with large, chronic bilateral forearm wounds with concomitant osteomyelitis confirmed by MRI and biopsy. No acute surgical complications were encountered and at a mean follow-up of 13 months, both patients had maintained stable soft-tissue coverage. Reconstruction using BTM is a novel treatment option that can simplify the reconstruction, reduce donor-site morbidity, and optimize success for patients with chronic wounds resulting from injectable drug use. Initial outcomes are promising; however, further comparative studies are needed to better evaluate long-term outcomes of this technique.

Incidence of Osteomyelitis in Sacral Decubitus Ulcers and Recommendations for Management

Stage-4 pressure ulcers are defined as ulcerations that violate the fascia and expose underlying bone, muscle, and tendon. Exposed bone is always colonized by bacteria, but this does not necessarily lead to osteomyelitis. The rates of osteomyelitis in exposed bone in stage-4 pressure ulcers range from 14% to 86%.There has been no evidence that the presence of osteomyelitis leads to higher complication rates following flap coverage. There has been no evidence that bone biopsy and preoperative treatment of osteomyelitis have any benefit before flap coverage.

Challenges and Management in Wound Care

SUMMARY

Wounds have been one of the most prominent pathologies since the beginning of humanity. For the last 5 decades, a drastic improvement of healing has been observed, thanks to new medical devices based on fluid aspiration capacities and the development of negative pressure wound therapy. Negative-pressure wound therapy was initially designed for a double action, fluid aspiration and mechanical stimulation of wound edges by a foam. Successive technical evolutions of negative pressure wound therapy were declined since 1997 when Argenta and Morykwas first presented their solution. The adjunct of instillation in 2009 was considered as the first interactive dressing, allowing topical wound solutions to sequentially reach the wound, in alternance with negative pressure. Other devices based on the same principle were designed to prevent postoperative infections when placed over a suture after surgery. This long evolution could enhance the armamentarium of possible solutions, considerably reducing the wound healing time.

The 5-Factor Modified Frailty Index as a Predictor of 30-day Complications in Pressure Ulcer Repair

BACKGROUND

The 5-item modified frailty index (mFI-5) is a validated tool to assess postoperative risks in older surgical candidates. We sought to compare the predictive ability of mFI-5 to its individual components and other established risk factors for complications in flap reconstruction of late-stage pressure ulcer repair.

METHODS

The 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was queried for pressure ulcer diagnosis and reconstructive flap repair procedures. Univariate and multivariate regression analysis models were used to assess how mFI-5, the components of the mFI-5 (functional status before surgery, diabetes, history of chronic obstructive pulmonary disease, history of congestive heart failure, and history of hypertension requiring medicine), and other factors commonly used to risk-stratify (age, obesity, ASA classification, and history of smoking) were associated with complications.

RESULTS

35.1% of the total 1254 flap reconstructive procedures for pressure ulcer repair experienced complications. Most cases had at least one of the five mFI-5 factors in both the complication (42.7%) and no complication (45.7%) cohorts. Compared with the factors making up the mFI-5 score and other common variables used to risk-stratify, mFI-5 was significantly associated with complications in the univariate (OR 1.17, CI 1.03 - 1.33; P = 0.02) and multivariate analysis (OR 1.16, CI 1.02 - 1.34; P = 0.043).

CONCLUSIONS

The mFI-5 is a useful predictor of postoperative outcomes in patients undergoing reconstructive flap surgery for pressure ulcer injuries compared to other historically considered risk factors for surgical complications.

Case Report: Surgical Closure of Chronic Soft Tissue Defects Using Extracellular Matrix Graft Augmented Tissue Flaps

Chronic soft tissue defects are notoriously difficult to heal. Surgical reconstruction of chronic defects using tissue flaps is a routine approach for closure of challenging chronic defects. Due to the poor tissue quality of chronic defects and associated inflammation, infection and impaired blood supply the success of flap closure is marred by reported complication rates of 25-58%. Extracellular matrix (ECM)-based graft materials are commonly used for resolving chronic wounds and in plastic and reconstructive procedures to create a scaffold for tissue regeneration. We hypothesized combination use of ECM grafts with tissue flaps in a single-stage surgical procedure would reduce complications and improve outcomes in the closure of chronic soft tissue defects. We report a case series (n = 9) of chronic soft tissue defect reconstruction using this modified procedure of ECM graft augmented flap closure. Defects included pressure injuries and surgical dehiscence and ranged in wound age from 5 months to 7 years. Successful uncomplicated healing was achieved in six defects. Post-operative complications (dehiscence) occurred in two defects, however, these healed via secondary intention without additional surgical intervention. All healed defects exhibited acceptable cosmesis and "normal" function, with 100% patient satisfaction. Augmentation of tissue flaps with ECM graft materials in this modified single-stage procedure may improve outcomes and minimize typical complications encountered in flap closure of chronic defects attributed to inflammation, infection, hypoperfusion, and dead space.

Surgical reconstruction of pressure ulcers in spinal cord injury individuals: A single- or two-stage approach?

INTRODUCTION

There are two surgical approaches to reconstruct a pressure ulcer (PU): one-stage reconstruction or two-stage reconstruction. One stage reconstruction consists of surgical debridement and flap reconstruction during one operation. Two-stage surgery consist of a surgical debridement and a final reconstruction in two different sessions, with approximately six weeks between both sessions.

OBJECTIVE

The aim of this study was to compare the results of single stage surgery and two-stage surgery on the PU recurrence rate and other important post operative complications.

METHOD

A retrospective, comparative study in Spinal Cord Injured (SCI) individuals with a single- or two stage surgical reconstruction between 2005 and 2016 was designed. A total of 81 records were included for analysis.

RESULTS

The primary outcome, the difference in occurrence of a recurrent PU in the reconstructed area (33.3% versus 31.6%), is not statistically significant between one-and two-stages reconstruction. Also, the mean duration to develop a recurrent PU between both surgical reconstructions is not statistically significant. Other surgical complications in the reconstructed area like wound hematoma, hemorrhage, seroma or (partial) flap failure did not differ significantly between both groups, apart and in total. We calculated the additional costs in case of a two-stage approach compared with a single-stage reconstruction at EUR 16,362.

CONCLUSIONS

There are no statistical significant differences in PU recurrence rate or other post operative complications between SCI patients who have undergone one- or two stage PU reconstructive surgery. The most obvious choice for a one-stage approach in case of PU reconstructive surgery has great positive implications for the patient, family, health care providers and the health care system.

The gluteus maximus V-Y advancement flap for reconstruction of extensive soft tissue loss following an advanced sacral pressure ulcer. A case report and mini review

BACKGROUND

The occurrence of pressure injuries (PIs) in an inpatient is a serious medical condition that requires a rigorous clinical evaluation. Management of these lesions should be comprehensive, including general measures and local care. Wound care occupies a large part of the treatment. For large skin loss, the treatment requires plastic surgery techniques for reconstruction. Myocutaneous advancement flaps are a good therapeutic option due to the provision of vascularized tissue within the skin defect. To ensure the success of the surgery, a good surgical technique preceeded by careful preparation of the patient in conjunction with the anesthesia team is imperative.

CASE PRESENTATION

We report the case of a 60-year-old bed ridden man for more than two months following an ischemic stroke with left spastic hemiplegia and loss of sensitivity. He was transferred to our surgical unit for the management of a chronic stage 4 PIs in the sacral area complicated with cellulitis, subcutaneous abscess and severe sepsis. Initial management consisted of resuscitation measures combining fluid therapy, antibiotic therapy, analgesics, blood transfusion, nutritional support, physioteherapy, wound care as well as preventive measures and psychological support. Once the granulation tissues were fully developed, the patient underwent reconstruction surgery with a V-Y myocutaneous advancement flap. The graft was successful with complete wound healing thereafter.

CONCLUSION

PIs are a multifactorial, complex and disabling pathology that requires multidisciplinary care. Surgeons, anesthetists, nutritionists, physiotherapists, nurses must act in agreement in order to provide optimal treatment. Prevention is the rule.

Biofabrication of thick vascularized neo-pedicle flaps for reconstructive surgery

Wound chronicity due to intrinsic and extrinsic factors perturbs adequate lesion closure and reestablishment of the protective skin barrier. Immediate and proper care of chronic wounds is necessary for a swift recovery and a reduction of patient vulnerability to infection. Advanced therapies supplemented with standard wound care procedures have been clinically implemented to restore aberrant tissue; however, these treatments are ineffective if local vasculature is too compromised to support minimally-invasive strategies. Autologous "flaps", which are tissues equipped with their own hierarchical vascular supply, can be harvested from one region of the patient and transplanted to the wound where it is reperfused upon microsurgical anastomosis to appropriate recipient vessels. Despite the success of autologous flap transfer, these procedures are extremely invasive, incur obligatory donor-site morbidity, and require sufficient donor-tissue availability, microsurgical expertise, and specialized equipment. 3D-bioprinting modalities, such as extrusion-based bioprinting, can be used to address the clinical constraints of autologous flap transfer, primarily addressing donor-site morbidity and tissue availability. This advancement in regenerative medicine allows the biofabrication of heterogeneous tissue structures with high shape fidelity and spatial resolution to generate biomimetic constructs with the anatomically-precise geometries of native tissue to ensure tissue-specific function. Yet, meaningful progress toward this clinical application has been limited by the lack of vascularization required to meet the nutrient and oxygen demands of clinically relevant tissue volumes. Thus, various criteria for the fabrication of functional tissues with hierarchical, patent vasculature must be considered when implementing 3D-bioprinting technologies for deep, chronic wounds.

[Surgical treatment of recurrent pressure ulcers in spinal cord injured patients]

Not to burn one's bridges. This is the basic principle that comes immediately to the mind of the plastic surgeon when one brings up the secondary surgery of pressure ulcers, which is a common pathology in the spinal cord injured patients. Which ones are good candidates for surgical treatment? When? What preoperative, infectious, rehabilitative management is most likely to minimize the number of failures and recurrences? Which operative technique to prefer in first intention? And in case of secondary surgery, how to choose the best strategy? We will see that some cases can be treated by primarily closing or flap remobilization but, in case of greater loss of substance the realization of a flap from another anatomical region will be essential.

A prospective, randomised controlled trial evaluating the effectiveness of the fluid immersion simulation system vs an air-fluidised bed system in the acute postoperative management of pressure ulcers: A midpoint study analysis

The use of pressure-offloading support surfaces is considered the standard of care for pressure ulcers (PUs) by most surgeons. The fluid immersion simulation system (FIS) has shown significant results in previous studies. We compared it, for the first time, with a representative air-fluidised bed (AFB) for outcomes related to post-surgical flap closures. This trial was performed over 25 months, in which 40 subjects between 18 and 85 years of age with ≤2 PUs and history of <3 surgical closures underwent reconstruction by one surgeon. Subjects were randomly assigned to either treatment group for 2 weeks after closure. The primary endpoint was success of closure after the study period. Secondary endpoints included incidence of complications and nursing and patient acceptability of the device. The FIS group included 19 subjects, and the AFB group included 21. Flap failure rate was similar between groups (15% vs 17%; P = .99). The Minor complications rate, particularly dehiscence, was higher in the FIS group (66.7% vs 15%; P = .02). Nurse and patient self-reported acceptability had better mean numeric scores in the FIS compared with AFB (nurse: 1.5 vs 1.9; P = .12; patient: 1.9 vs 2.2; P = .14). Further analysis will be conducted to gain better insight on the FIS as an alternative treatment for PUs.

Incisional negative pressure therapy reduces complications and costs in pressure ulcer reconstruction

Complications after pressure ulcer reconstruction are common. A complication rate of 21% to 58% and a 27% wound recurrence has been reported. The aim of this study was to decrease postoperative wound-healing complications with incisional negative pressure wound therapy (iNPWT) postoperatively. This was a prospective non-randomised trial with a historic control. Surgically treated pressure ulcer patients receiving iNPWT were included in the prospective part of the study (Treatment group) and compared with the historic patient cohort of all consecutive surgically treated pressure ulcer patients during a 2-year period preceding the initiation of iNPWT (Control). There were 24 patients in the Control and 37 in the Treatment groups. The demographics between groups were similar. There was a 74% reduction in in-hospital complications in the Treatment group (10.8% vs 41.7%, P = 0.0051), 27% reduction in the length of stay (24.8 vs 33.8 days, P = 0.0103), and a 78% reduction in the number of open wounds at 3 months (5.4 vs 25%, P = -0.0481). Recurrent wounds and history of previous surgery were risk factors for complications. Incisional negative pressure wound therapy shortens hospital stay, number of postoperative complications, and the number of recurrent open wounds at 3 months after reconstructive pressure ulcer surgery, resulting in significant cost savings.

Management and Treatment of Pressure Ulcers: Clinical Experience

Objectives:

Pressure ulcers are a common healthcare problem, particularly among hospitalized patients who need long-term treatment; however, preventive medicine can reduce the prevalence. A multidisciplinary approach is fundamental to providing proper care, and the general health status and cooperation of the patient determine treatment modalities. Simple methods can prevent pressure ulcers and their recurrence. The aim of this study was to share clinical experience and evaluate the approach and treatment modalities used for pressure ulcers.

Methods:

Fifty-two patients hospitalized with the indication of pressure ulcers were evaluated retrospectively. Age, sex, localization of the decubitus ulcer, treatment method, comorbid diseases, and any postoperative complications were analyzed.

Results:

Thirty-five patients were male and 17 were female. The mean age was 50.3 years. The most common accompanying disease was diabetes mellitus and the most common etiology was paraplegia. Pressure ulcers were localized on the sacral area in 45 patients, the ischial area in 23, the trochanteric area in 11 patients, and other parts of the body (scapular, lumbar) in 3 patients. Fasciocutaneous rotation flaps, myocutaneous flaps, and perforator flaps were the most used reconstruction techniques. No major complication was observed.

Conclusion:

The most important point with regard to pressure ulcers is prevention. Healthcare system expenses can be significantly reduced by preventing the formation of decubitus ulcers. The progression of pressure ulcers can be easily controlled if the necessary care and treatment are provided in the early period. The role of the plastic surgeon in advanced stages is to perform reconstruction in appropriate cases and to educate patients and their caregivers with the aim of preventing recurrence.

National perioperative outcomes of flap coverage for pressure ulcers from 2005 to 2015 using American College of Surgeons National Surgical Quality Improvement Program

Background

Complication rates after flap coverage for pressure ulcers have been high historically. These patients have multiple risk factors associated with poor wound healing and complications including marginal nutritional status, prolonged immobilization, and a high comorbidities index. This study utilizes the National Surgical Quality Improvement Program (NSQIP) to examine perioperative outcomes of flap coverage for pressure ulcers.

Methods

Data from the NSQIP database (2005–2015) for patient undergoing flap coverage for pressure ulcers was identified. Demographic, perioperative information, and complications were reviewed. One-way analysis of variance and Pearson chi-square were used to assess differences for continuous variables and nominal variables, respectively. Multivariate logistic regression was performed to identify independent risk factors for complications.

Results

There were 755 cases identified: 365 (48.3%) sacral ulcers, 321 (42.5%) ischial ulcers, and 69 (9.1%) trochanteric ulcers. Most patients were older male, with some degree of dependency, neurosensory impairment, high functional comorbidities score, and American Society of Anesthesiologists class 3 or above. The sacral ulcer group had the highest incidence of septic shock and bleeding, while the trochanteric ulcer group had the highest incidence of superficial surgical site infection. There was an overall complication rate of 25% at 30-day follow-up. There was no statistical difference in overall complication among groups. Total operating time, diabetes, and non-elective case were independent risk factors for overall complications.

Conclusions

Despite patients with poor baseline functional status, flap coverage for pressure ulcer patients is safe with acceptable postoperative complications. This type of treatment should be considered for properly selected patients.

Risk Factors for Postoperative Complications among the Elderly after Plastic Surgery Procedures Performed under General Anesthesia

Background

The frequency of surgery involving elderly patients has been increasing. The use of free tissue transfers in the elderly has been examined previously (Howard et al., 2005, Hwang et al., 2016, Grammatica et al., 2015, Serletti et al., 2000, and Sierakowski et al., 2017), whereas there have not been any such studies of plastic surgery procedures. We evaluated the risk factors for complications after plastic surgery procedures performed under general anesthesia in patients aged ≥75 years.

Methods

The cases of patients aged ≥75 years who underwent plastic surgery procedures under general anesthesia at the Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, between 2009 and 2016 were reviewed retrospectively. Multiple logistic regression analysis was used to identify the risk factors for postoperative complications.

Results

Two hundred and sixty-three cases were reviewed. Complications were seen in 137 patients. Age was not predictive of complications. The risk factors included a serum albumin level of <2.8 g/dl (odds ratio (OR): 2.96), an operative time of ≥120 min (OR: 6.22), and an American Society of Anesthesiologists performance status of ≥3 (OR: 2.39).

Conclusions

Age is not contraindication for surgery in the elderly. It is important to assess comorbidities and perform surgical procedures as soon as possible to shorten the surgical period.

Pressure ulcer-related pelvic osteomyelitis: evaluation of a two-stage surgical strategy (debridement, negative pressure therapy and flap coverage) with prolonged antimicrobial therapy

Background

A two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated.

Methods

Adult patients with pressure ulcer-related pelvic osteomyelitis treated by a two-stage surgical strategy were included in a retrospective cohort study. Determinants of superinfection (i.e., additional microbiological findings at reconstruction) and treatment failure were assessed using binary logistic regression and Kaplan-Meier curve analysis.

Results

Sixty-four pressure ulcer-related pelvic osteomyelitis in 61 patients (age, 47 (IQR, 36–63)) were included. Osteomyelitis was mostly polymicrobial (73%), with a predominance of S. aureus (47%), Enterobacteriaceae spp. (44%) and anaerobes (44%). Flap coverage was performed after 7 (IQR, 5–10) weeks of NPT, with 43 (68%) positive bone samples among which 39 (91%) were superinfections, associated with a high ASA score (OR, 5.8; p = 0.022). An increased prevalence of coagulase negative staphylococci (p = 0.017) and Candida spp. (p = 0.003) was observed at time of flap coverage. An ESBL Enterobacteriaceae spp. was found in 5 (12%) patients, associated with fluoroquinolone consumption (OR, 32.4; p = 0.005). Treatment duration was as 20 (IQR, 14–27) weeks, including 11 (IQR, 8–15) after reconstruction. After a follow-up of 54 (IQR, 27–102) weeks, 15 (23%) failures were observed, associated with previous pressure ulcer (OR, 5.7; p = 0.025) and Actinomyces spp. infection (OR, 9.5; p = 0.027).

Conclusions

Pressure ulcer-related pelvic osteomyelitis is a difficult-to-treat clinical condition, generating an important consumption of broad-spectrum antibiotics. The lack of correlation between outcome and the debridement-to-reconstruction interval argue for a short sequence to limit the total duration of treatment.

Exploring the association between initial serum alcohol concentration and polysubstance use: More than a simple "gateway drug" effect?

Introduction

Polysubstance abuse (PSA) is a significant problem affecting our society. In addition to negatively affecting the health and well-being of substance users, alcohol and/or drug abuse is also associated with heavy injury burden. The goal of this study was to determine if elevated serum alcohol (EtOH) levels on initial trauma evaluation correlate with the simultaneous presence of other substances of abuse (SOAs). We hypothesized that PSA would be more common among patients who present with EtOH levels in excess of the legal blood alcohol content (BAC) (≥0.10%).

Methods

An audit of trauma registry records from January 2009 to June 2015 was performed. Abstracted data included patient demographics, BAC measurements, all available formal determinations of urine/serum "drug screening," Glasgow Coma Scale (GCS) assessments, injury mechanism/severity, and 30-day mortality. Stratification of BAC was based on the 0.10% cutoff. Parametric and nonparametric statistical testing was performed, as appropriate, with significance set at α = 0.05.

Results

We analyzed 1550 patients (71% males, mean age: 38.7 years) who had both EtOH and SOA screening. Median GCS was 15 (interquartile range [IQR]: 14-15). Median ISS was 9 (IQR: 5-17). Overall 30-day mortality was 4.25%, with no difference between elevated (≥0.10) and normal (<0.10) EtOH groups. For the overall study sample, the median BAC was 0.10% (IQR: 0-0.13). There were 1265 (81.6%) patients with BAC <0.10% and 285 (18.4%) patients with BAC ≥0.10%. The two groups were similar in terms of mechanism of injury (both, ∼95% blunt). Patients with BAC ≥0.10% on initial trauma evaluation were significantly more likely to have the findings consistent with PSA (e.g., EtOH + additional substance) than patients with BAC <0.10% (377/1265 [29.8%] vs. 141/285 [49.5%], respectively, P < 0.001). Among polysubstance users, BAC ≥0.10% was significantly associated with cocaine, marijuana, and opioid use.

Conclusions

This study confirms that a significant proportion of trauma patients with admission BAC ≥0.10% present with the evidence of additional substance use. Cocaine and opioids were most strongly associated with acute alcohol intoxication. Our findings support the need for further research in this important area of public health concern. In addition, specific efforts should focus on primary identification, remediation of withdrawal symptoms, prevention of drug-drug interactions, and early PSA intervention.