Salah Rubayi

Comprehensive Preoperative Management of Patients with Pressure Ulcer

When a pressure ulcer is diagnosed as stage IV or III and there is an indication for surgery in clinical practice, the ulcer(s) should be given an opportunity to respond to local wound treatment. The average time is 4 weeks before a surgical decision for closure, providing that all other requirements for wound healing are met. Initially, the clinical appearance of the ulcer should be evaluated and then a plan set for local wound care to prepare the wound for surgical closure. Clinically, the wound should be as clean as possible before surgical closure, with a low level of bacterial colonization (less than 105) and no necrotic tissue, sign of infection, or purulent discharge present at the time of surgery.

Reconstructive Surgery for Trochanteric Ulcer

Trochanteric ulcer is an ulcer which is located at the lateral part of the hip joint over the prominent bony part of the femur which is the greater trochanter. This ulcer is rarely seen in post-acute spinal cord injury or in other acute illnesses, because the patient is always in the supine position; however, this type of ulcer is commonly seen in chronic insensate patients which results from lying down on his/her side of the body. The harder the surface the patient is lying on, the deeper the damage to the skin and deep tissue. Anatomically, the greater trochanter is covered with anatomical bursa and skin; therefore, if ulceration occurs, it will involve the skin and the underlying bursa exposing the tendinous part of the vastus lateralis muscle origin. Healing in a stage IV ulcer may not occur because of the nature of the tissue and the formation of granulation tissue in the bursal cavity which is colonized by bacteria; consequently, surgical closure is indicated in this condition. Another condition is seen in spinal cord injury patients when the greater trochanter is rotated posteriorly secondary to subluxation of the hip joint which results from the paralysis and spasticity of the muscle. This abnormal position of the greater trochanter will create a new pressure point when patient is in the sitting or supine position which can cause skin ulceration. In repairing the trochanteric ulcer, it is important to excise the entire bursa and the surrounding tissue to help the healing process of the area. In addition to the important step of shaving the prominent trochanteric bone, the common flap available in the area to be utilized for repair of this ulcer is the tensor fascia lata flap which was described long time ago by Nahai in 1978 [1–4], as musculocutaneous flap or with modifications followed by Lewis in 1981 [5, 6] as V-Y advancement flap. The tensor fascia lata flap can be described as a myofasciocutaneous flap. In many instances, the muscle itself will not cover the defect because of the small size of the muscle, but the fasciocutaneous component of the flap will cover the defect. Taking into consideration that the blood supply of the fascia will be derived from the muscle and the skin island which covers that fascia will derive its blood supply from the fascia and muscle. The tensor fascia lata flap can be used as an island flap, V-Y advancement flap, or a rotation flap. All these modifications and their utilization depend on the size and location of the defect.

Disarticulation and Total Thigh Flap

This flap is considered a lifesaving procedure especially in the spinal cord–injured patient. This flap is performed as an end-stage procedure for patients with recurrent extensive pressure ulcers when the patient has had a history of many previous flaps to repair the ulcers; as a result, the reserves of muscles and skin become exhausted. Clinically, the patients at this stage have a bowel diversion (colostomy), urinary diversion, and previous bilateral Girdlestone procedure with radiological evidence of destruction of the pelvic bone architect. When the patient is in a sitting position at this stage, the actual location is over the flat thin pelvic floor instead of his/her bilateral ischial bone. These patients unquestionably had many flaps in the past with some being reused twice or three times. The reconstructive surgeon faces a dilemma at this stage when there is no available muscle or skin in the patient’s body to use for repair of this multiple complex ulceration. When the ulcers involve the entire perineum and pelvis, the clinical picture is more complicated; as a result, the patient psychologically feels disturbed and disappointed to lose a leg. Even if the leg has no function for ambulation, it serves for a different purpose which is the psychological and emotional effect on the patient besides stability for sitting in a wheelchair and transferring. In addition to these factors, the patient feels threatened that if he/she loses a leg, this will indicate the end of options available to close future pressure ulcers should they occur, which is a common occurrence in spinal cord injury patients. The author’s clinical practice is to explain to the patient prior to approaching the stage of disarticulation and total thigh flap that if the patient develops future pressure ulcers, the next stage will be losing his/her leg. This will mentally prepare the patient for this extensive surgery. The terminology of disarticulation does not apply literally on the procedure because these patients already lost their hip in a previous Girdlestone procedure. The disarticulation and total thigh flap is not a common procedure like a simple flap which is done on a routine basis. The total thigh procedure was described first by Georgiade in 1956 [1]; at that time, muscle flap was not described and utilized as today. Initially, therefore, this procedure was utilized as a first line to repair multiple ulcers and hip infection, but at present with the utilization of the Girdlestone procedure and various muscle flaps, this has postponed the use of the total thigh procedure for a future time and reserved it as an end-stage procedure. The total thigh flap was reported by Berkas in 1961 [2] to close multiple ulcers; Spira in 1963 [3] described his experience with amputation in spinal cord–injured patients. Steiger in 1968 [4] described the use of total thigh flap procedure to treat chronic infection, and then Royer in 1969 [5] described his 16-year experience in closing extensive pressure ulcers with total thigh flap. The author’s experience in total thigh flap is to reconstruct extensive perineopelvic ulcers when the patient already has lost both ischia secondary to chronic ulceration and infection. The total thigh flap will create a soft tissue padding over whatever bony structure is left in the pelvis. The author’s early experience with total thigh flap is to perform the procedure in two stages because of concerns of infection. The first stage is to debride and remove the entire femur and amputate the thigh within the level of the knee area followed by local wound care to the open total thigh flap. A few weeks later, the second stage is to inset the flap in the large defect; unfortunately, it was found that the insetting of a flap was technically difficult because of the development of immature heterotopic ossification in the muscle group which was very difficult to dissect all the immature heterotopic ossification from the muscles. This procedure is associated with prolonged surgical time and large volume of blood loss. This experience was reported in 1992 [6]. The author’s practice since then has changed into a single-stage total thigh procedure. In addition, the author, in 1994 [7], successfully attempted splitting the total thigh flap into two parts based on the vascularity of the total thigh flap. This procedure is not always easy to perform and poses a risk of flap necrosis. The purpose of the flap division was to cover multiple separate defects. This procedure needs meticulous dissection and accurate identification of the vascular pedicles with a vascular Doppler intraoperatively to identify the superficial femoral artery and the deep femoral artery prior to division of the flap. The author currently utilizes an extended total thigh flap which includes the skin and muscle of the calf. This additional part is used to cover the distal sacrococcygeal area. Boyd in 1947 [8] described the anterior approach to hip disarticulation, and Slocum in 1949 [9] described the posterior approach to disarticulation of the hip joint. Their surgical indications were different from our indications to close multiple recurrent ulcerations, taking into consideration our patients’ condition with previous multiple flaps. As a result of this clinical history, the appearance of the entire thigh flap will show scarring all around the muscle groups and occasional heterotopic ossification formation which will make it very difficult, technically, to identify and utilize anterior or posterior thigh flap. Another important point to mention is that the step of insetting the total thigh flap is more difficult than the dissection of the femoral bone from the muscles because of extensive scarring from previous surgeries. Therefore, folding the flap to accommodate the defect is technically difficult. Release of the scars over the inner surface of the T.T. flap may carry risk of division to a vital blood supply. Minimum amount of scar release should be performed to facilitate the inset of the flap. Another point the surgeon will face when insetting the total thigh flap to cover the sacrococcygeal area is that the anus will be in the pathway of the T.T. flap. For this reason, the patient should be informed regarding the procedure which is to excise the anus and close the rectum in layers, providing the patient has a double-loop colostomy. If not, prior to this procedure, a mucous fistula is performed by bringing the defunctioning bowel loop to the skin surface. In summary, the total thigh flap procedure is a challenge to the reconstructive surgeon and not a rewarding procedure like the flap surgery. On the other hand, it is a procedure to prolong the life of the patient and improve the quality of life of the patient by permitting sitting in a wheelchair and moving around.

Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

These ulcers can develop in insensate patients over bony, prominent areas of the body and are different from ulcers developed from pressure on sitting areas. They occur at different stages of a patient’s life, whether during an acute accident or illness or later on. The etiologies result from some factors that predispose for pressure application on a particular part of the body. These ulcers are outside the pelvic girdle, which means they are not the result of weight-bearing activities like sitting. The majority of these ulcers heal if treated locally and the causative agent is eliminated. These ulcers are not seen clinically on a frequent basis, but they do occur from time to time, secondary to special etiologies. They are seen in insensate patients (patients with spinal cord injury) and in patients with diabetes, peripheral vascular diseases, or neuropathies.

Reconstructive Surgery for Sacral Ulcer

The sacral ulcer is a common occurrence in certain groups of patients. It can develop at different stages of a patient’s life, whether after acute injury or acute illness. The ulcer occurs when a patient is kept in a supine position without turning or using a special bed or mattress. It can also occur after the rehabilitation stage when an insensate patient is sent home to integrate back into normal life and begins sitting in a wheelchair, as seen in spinal cord injured patients (see Chap. 2). In a review of the literature on reconstructive options for sacral ulcer, some authors advise using the fasciocutaneous flap from the lumbar area to close a sacral defect [1–3]. The author’s experience in dealing with patients with spinal cord injury or spina bifida is that this flap is not suitable for these groups of patients because of the multiple surgeries they have had over their back and lumbar area. It is technically difficult to raise the fasciocutaneous lumbar flap because of the scarring and limited number of spinal perforators, which eventually subjects these flap to vascular compromise, ending in necrosis. The main muscle used for the repair of the sacrococcygeal ulcer is the gluteus maximus muscle in different design of flaps – musculocutaneous, muscular, and fasciocutaneous. The muscle can be used in rotation, advancement, and splitting. The gluteus muscle is the most durable muscle for closing a sacral defect and provides a soft tissue padding for the bony area that is anatomically not covered by muscle. The sacrum and coccygeal bone are covered by skin and subcutaneous tissue [4, 5, 7–9]. The method in which the gluteus maximus muscle is used depends on the primary diagnosis of the patient and whether the goal is to preserve muscle function after recovery [10, 11]. For ambulatory and sensory patients, the gluteus maximus island advancement flap is recommended more than the fasciocutaneous flaps, which are based on the gluteal muscle perforator [12–16]. The author’s experience is that these flaps cannot be revised or reused in cases of ulceration recurrence, as in patients with spinal cord injury.

Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma

The hip is a powerful joint in the human body. In ambulatory patients, the hip joint is necessary for standing, walking, and sitting. In paralyzed individuals (those with paraplegia or tetraplegia), the hip joint has an important function, depending on the extent of the paralysis, when sitting in a wheelchair. The hip joint acts to stabilize the sitting position, in transferring from the wheelchair to another surface and vice versa, and when turning from side to side. The hip joint acts to stabilize the lower extremities. It has a powerful muscle attachment and strong capsule. Unfortunately, in paralyzed individuals, the hip joint can be affected directly or indirectly by pathological conditions close to the hip joint or by traumatic conditions, for example, the direct extension of infection or necrosis from pressure ulcers such as the trochanteric ulcer or ischial ulcer. These are common examples of conditions that can affect the hip by causing septic hip and eventually osteomyelitis of the femoral bone or pelvic bone or abscess of the iliopsoas muscles.

Comprehensive Clinical Wound Evaluation

Pressure ulcers are skin lesions caused by unrelieved pressure or other forces resulting in damage to the underlying tissue. Usually, pressure ulcers are located over a boney prominence of the body. Pressure ulcers can be staged according to the extent of tissue damage. The staging was proposed by Shea in 1975 [1] and the Wound Ostomy Society (International Association of Enterostomal Therapy) in 1988, and was finally agreed upon in 1989 by the National Pressure Ulcer Advisory Panel, United States.

Pressure Ulcers: An Important Condition in Medicine and Surgery

Pressure ulcers are a condition of the skin and deep tissue that has been recognized for at least 5,000 years [1–6]. They can affect the human body at different sites, and many simple remedies have been prescribed and used to treat these ulcers. In the eighteenth and nineteenth [7–15] centuries, an accurate diagnosis of pressure ulcer was established. In the twentieth century, the etiology, management, and prevention were established, and physicians, nurses, and allied health professionals were expected to have knowledge of this condition and to manage and prevent pressure ulcers. The standard treatment was set in the United States in 1994 by the Agency for Health Care Policy and Research [16], and, in 2000, the Consortium for Spinal Cord Medicine [17] published the standard management of pressure ulcers. In 1999, the standard was published in Europe by the European Pressure Ulcer Advisory Panel [18].

Etiology and Pathology of Pressure Ulcers

It has been observed that the application of constant pressure of 70 mmHg for more than 2 h produced irreversible tissue damage [1]. Minimal tissue damage was observed when the pressure exceeded 240 mmHg, providing there was intermittent pressure relief [2]. Histopathological changes secondary to pressure on the tissues include occluding of the blood flow to the tissues. If occluding occurs for short periods of time, the result is anoxia of the cells. If the pressure continues for longer periods of time, complete occlusion of the blood flow results in ischemia of the cells and then necrosis and, consequently, irreversible tissue damage. Muscle fibers are more sensitive to the ischemia effect of prolonged pressure than the skin [3, 4]. Shear forces are an etiologic factor in development of pressure, and ulcers [5, 6] are caused by movement of boney prominence against the subcutaneous tissues. This occurs when the position of the patient, for example, in bed, is shifted in a way that the skin remains stationary in relation to the support of the body and, as a result of the movement, the subepidermal vessels are bent at a right angle. Shear alone does not cause tissue necrosis; however, it is a predisposing factor in causing pressure ulcers. Shear forces are seen more frequently in clinical practice when a patient loses weight and tissue sliding can occur over the boney prominences. Friction forces relate to rubbing of the skin against linen or clothing, or even when lifting a patient on a sling. Most abrasion injuries are caused by friction, although friction does not lead to all pressure ulcers; it can damage the epidermis and make the skin susceptible to pressure ulcers [1].

Reconstructive Surgery for Ischial Ulcer

Ischial ulcer is common among spinal cord injury patients as a result of sitting for prolonged periods of time without pressure relief or without a proper wheelchair cushion, which is an important tool to relieve pressure on insensate skin in that area. This ulcer accounts for about 23 % of all pressure ulcers. This type of ulcer is seen in the active stage of a patient’s life after injury, when the patient is discharged to home after rehabilitation to start a new life and adapt to sitting in a wheelchair.