Successful management of extensive stage four sacral pressure ulcer in a paraplegic patient: A case report

Abstract

Introduction and importance

Pressure ulcers (known as pressure injuries) occur when a bony prominence, such as the sacrum, is subjected to prolonged pressure and can result in soft tissue injury. Continuous and attentive repositioning is necessary to prevent and cure pressure-induced wounds.

Case presentation

A 49-year-old patient who presented to the hospital with a case of paraplegia post spinal injury due to Road Traffic Accident, with a huge infected sacral bed sore and complaints of generalized weakness and fever. His ulcer was 15 cm ∗ 15 cm ∗ 8 cm, grade 4. He underwent flap reconstruction, was post-operatively transferred into the ward, and started on IV antibiotics and analgesia. The flap is well vascularized with no signs of infection or dehiscence.

Clinical discussion

Wound management begins with the identification and aggressive management of the modifiable factors, such as positioning, incontinence, spasticity, diet, devices, and medical comorbidity, which contribute to pressure injury formation. Initial interventions include washing, cleaning, and maintaining the surfaces of the wound. In certain cases, it may be sufficient to debride the non-viable or contaminated tissue. However, operational care in more severe cases or to encourage patient satisfaction may be necessary.

Conclusion

The bilobed flap is the best technique for healing sacral pressure ulcers. It has a plentiful supply of blood. The layout is uncomplicated and straightforward. The fact that it has a low risk of complications is crucial. It ought to be taken into account as a component of the local flap arsenal for sacral pressure ulcers.

Highlights

• •Pressure ulcer is defined as any lesion caused by unrelieved pressure, resulting in damage to underlying tissue.
• •It is acknowledged to be a clinical challenge for both the clinician and the patient.
• •The bilobed flap is an ideal method for the reconstruction of sacral pressure ulcers.
• •Complication and recurrence rates are high following the surgical management.

1. Introduction

The term “fulminant pressure wound” is understood as the destruction of skin and deep tissues due to defective blood circulation caused by pressure, the skin around the wound showing signs of undermining and the wound visibly increasing in size in a short time, that, within days. Frequent symptoms negatively affecting the prognosis include coexisting infections accompanied by purulent exudate [1]. A pressure ulcer is defined as any lesion caused by unrelieved pressure, resulting in damage to underlying tissue, and is acknowledged to be a clinical challenge for both the clinician and the patient [2]. Comorbidities, reduced self-care abilities, and systemic infections contribute to high morbidity rates in this group of patients [3]. Suffering pain, bad odor, a co-existing risk of systemic infection, long-lasting therapy, and significant costs of dressings, pressure management mattresses, and rehabilitation, all adversely affect the quality of life in health and sickness [4]. This case report has been reported in line with the SCARE Criteria [5]. Although these patients are typically ignored and their therapy is limited to bedside debridement, without experience in flap reconstruction operations that might significantly enhance patients' lives, we explain the local situation in Palestine here. We think that more knowledge of such methods is necessary.

2. Presentation of case

A 49-year-old male patient presented to the hospital complaining of generalized weakness and fever with a huge infected sacral bed sore. He is a paraplegic post-spinal injury due to RTA (Road Traffic Accident). The patient reported no personal and/or family history of cancer, any acute, repeat, or discontinued medications, any allergies, or any genetic or psychosocial issues. He was admitted to the Intensive care unit (ICU) and general surgery ward, and during those days he developed a pressure ulcer in the sacral region. The ulcer increased with time, and on the day of presentation, the ulcer was evaluated by the general surgery team, which showed 15 cm ∗ 15 cm ∗ 8 cm, grade 4 (Fig. 1A & B). Two weeks following admission, the debridement was done by a general surgery specialist and the dressing was changed. The patient was conscious, alert, and with stable vital signs. Investigations still showed high inflammatory markers. A vacuum was applied and the patient is currently under observation for his vital signs, with vacuum changing every 3 days, daily labs, and Intravenous (IV) antibiotics covering proteus moribalis according to wound culture, Amikacin 1 g daily for 7 days was also prescribed as recommended by the infectious disease team. The patient clinically improved, stable vital signs, investigation showed improvement in inflammatory markers, IV antibiotics continued, and vacuum dressing was changed. The patient underwent flap reconstruction under general anesthesia and in a prone position after scraping of the necrotic and infected tissues. The gluteal artery was identified using doppler ultrasound. Dissection made down to the presacral fascia and Hemostasis secured. Skin and subcutaneous flap rotated and closed the defect. Jackson-Pratt drain size 10 Fr was placed. The subcutaneous tissues were approximated by a rapid vicryl 3/0. The Skin closed by Monocryl 3/0 with clips (Fig. 2), transferred into the ward post-operatively, and started on IV antibiotics and analgesia. The procedure was performed by a specialist in the general surgery department at a private hospital. After a month of admission, the patient is well, afebrile, and stable vitally. The wound is clean and exposed, healthy with no signs of infection or necrosis (Fig. 3). The drain was removed and he was discharged to go home. The patient was followed up for 6 months and he adhered to and tolerated the provided pieces of advice; avoiding vigorous exercise and heavy lifting, without any reported complications or adverse events.

Fig. 1.

The ulcer before flap surgery.

Fig. 2.

Flap reconstruction.

Fig. 3.

Clean and healthy wound with no signs of infection or necrosis.

3. Discussion

Normal healing is a linear multistep process that progresses from hemostasis through inflammation, granulation tissue formation, and re-epithelialization, to scar formation. Vacuum-assisted closure (VAC®; KCI USA Inc., San Antonio, TX) therapy creates a closed wound environment, reduces edema, promotes perfusion, and removes infectious materials and chronic inflammatory cells from the wound environment by applying topical negative pressure [6], [7]. It also stimulates blood flow to the wound bed [8], resulting in the delivery of fresh leukocytes and plasma that counteract the chronic wound environment. The uniform negative pressure creates tissue deformation and cell stretching, leading to metabolic activity, fibroblast migration, and cell proliferation [9].

Pressure ulcer treatment is known to be costly, although the exact costs have not been definitively demonstrated. What role can NPWT have in reducing those costs? A health economics audit of NPWT cited studies in diabetic foot ulcers, which demonstrated lower costs when compared with saline-moistened gauze. Baynham et al. [10] found that three-stage intravenous sacral and ischial wounds, which were refractory to surgical therapy for the past 10 months, healed in about 2 months with VAC. The device operated at a negative pressure of 125 mmHg with 5 min on and 2 min off cycle.

Marcus et al. [11] presented a prospective study of randomizing 22 patients. Two groups of 11 patients each with pressure sores in the pelvic region were included. The time difference to heal was almost the same in the groups treated with VAC (27 days) and the traditional group with Ringer's solution dressings thrice a day (28 days). However, no hospital stays, reduced costs and improved comfort were noted in the VAC group.

Late-stage pressure ulcers requiring surgical coverage with flaps are common. Various flap techniques have proven effective for defect coverage, but these continue to have high complication and recurrence rates [12], leading to additional patient discomfort, scheduling and management issues for surgical teams, and overall high costs of care and treatment [13]. Complication and recurrence rates are high, driving the costs and resource usage cited above. In a systematic review of the literature on flap surgeries for the treatment of pressure sores, Sameem et al. reported mean complication rates for myocutaneous flaps at 18.6 %, fasciocutaneous flaps at 11.7 %, and perforator-based flaps at 19.6 %, while recurrence rates for the same three groups were 8.9 %, 11.2 %, and 5.6 %, respectively [12]. Other studies have reported complications and recurrence rates of up to 54 % and 61 %, respectively [14].

The most commonly cited factor in complications and recurrence is wound dehiscence, generally associated with persistent dead space in the wound cavity, shear forces on the tissue planes, and accumulation of serous fluids [12]. Elimination (closure) of the dead space is critical to effective healing, but this is not always easy or possible to obtain with previously described techniques or technologies.

4. Conclusion

The bilobed flap is an ideal method for the reconstruction of sacral pressure ulcers. Its blood supply is abundant. The design is simple and easy to learn. Most importantly, it has a low complication profile. It should be considered as part of the local flap armamentarium for sacral pressure ulcers.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

This study is exempt from ethical approval in our institution.

Sources of funding

The authors declare that writing and publishing this manuscript was not funded by any organization.

Author contribution

Writing the manuscript: Oadi N. Shrateh, Afnan W.M. Jobran

Imaging description: Oadi N. Shrateh, Zeyad Al-Maslamani, Rabee Adwan

Reviewing & editing the manuscript: Zeyad Al-Maslamani, Ayman tarifi

Guarantor

Oadi N. Shrateh.

Research registration

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest

The authors declare that there is no conflict of interest regarding the publication of this article.