Abstract
Recurrence of pressure ulcers following reconstructive surgery occurs frequently, causing a significant burden on the patient and the public health care system. We assessed risk factors for the recurrence of pressure ulcers based on the experience of a single surgeon at our medical centre. We retrospectively analysed patients admitted to our medical centre with stage III and IV pressure ulcers who underwent reconstructive surgery. The hospital database was searched for patients diagnosed with pressure ulcers who underwent reconstructive surgery. Patient characteristics analysed included age, sex, cause and location of defect, comorbidities, lesion size, wound reconstruction methods, operation time, debridement times, duration of hospital stay, and wound complications. Recurrence and mortality rates were retrospectively examined. One hundred and eighty‐nine patients were enrolled, and 166 patients with 176 pressure ulcers met our inclusion criteria. All 14 recurrences (7.95%) were followed for at least 1 year. Logistic regression analysis indicated that recurrence was associated with albumin levels (P = 0.001) and wound size (P = 0.043); however, no association was found for body mass index, bacterial profile, comorbidities, localisation, previous surgery, operation time, or time to admission for reconstruction. In conclusion, higher albumin levels were associated with lower recurrence rates in patients who underwent reconstructive surgery.
Keywords: pressure ulcer, reconstructive surgical procedures, recurrence, risk factors, serum albumin
1. INTRODUCTION
Pressure ulcers are commonly associated with specific positions that place prolonged pressure on the skin, leading to hypoperfusion of local tissue (eg, sacral ulcers in the supine position and ischial ulcers in the sitting position). They frequently occur in patients with spinal cord injury, dementia, or other conditions involving long‐term immobilisation. In long‐term care, the incidence of pressure ulcers has been described in up to 24% of the healthy US population. 1 Conservative management is ineffective for stage III or IV pressure sores; therefore, surgical reconstruction with flap coverage is inevitable. However, despite surgical treatment, some patients still suffered from recurrence of pressure ulcer. Thus, the risk factors that led to recurrence after surgical reconstruction with flap coverage at pressure ulcer patients is crucial, which can increase the chance of pressure ulcer healing possibility.
This study aimed to retrospectively analyse risk factors such as age, sex, cause, location of defect, comorbidities, lesion size, wound reconstruction methods, operation time, debridement times, duration of hospital stay, and wound complications associated with the recurrence of pressure ulcers after the treatment of defect reconstruction performed by a single surgeon at our medical centre.
2. METHODS
We retrospectively analysed all patients diagnosed with stage III or IV pressure ulcers admitted to our medical centre who underwent reconstructive surgery between 2010 and 2021. In all patients, surgery was performed by a single plastic surgeon who specialised in pressure ulcer reconstruction. The patients and their families were all well informed of the operative risks, and they all agreed for the surgical treatment. Patients with inadequate home facilities or lack of family involvement or those who were not fit for anaesthesia were excluded from the surgery. We identified 166 patients with 176 pressure ulcers who were admitted with pressure ulcers and underwent surgery for defect reconstruction. These patients were closely followed up, and all pressure ulcer recurrences were analysed.
Patient characteristics including age, sex, cause of the defect, location of any comorbidities, wound culture results, lesion size, flap size, hospital stay, albumin level, and body mass index were recorded (Table 2). We used Fisher exact test to analyse the primary data and accurate data with logistic regression analysis for precise results. Recurrence was defined as after surgical flap closure, a new ulceration that occurs over the same surgical site requiring a secondary surgical reconstructive procedure for the same pressure ulcer, resulting in readmission to the hospital.
TABLE 2.
Risk factors for recurrence assessed by logistic regression analysis.
| Independent variable | Crude‐OR (95% CI) | P‐value | Adj‐OR (95% CI)# | P‐value |
|---|---|---|---|---|
| Flap type | 0.228 | 0.885 | ||
| V‐Y flap | 1.00 (reference) | 1.00 (reference) | ||
| SGAP | 0.00 (0.00 ‐ Inf) | 0.991 | 0.00 (0.00 ‐ Inf) | 0.993 |
| Primary closure | 0.29 (0.06‐1.41) | 0.125 | 4.82 (0.24‐96.37) | 0.303 |
| Pedicle ALT | 3.94 (0.63‐24.68) | 0.142 | 0.44 (0.01‐20.85) | 0.676 |
| Other | 0.56 (0.07‐4.81) | 0.600 | 0.31 (0.01‐16.27) | 0.566 |
| Albumin (g/dL) | 0.11 (0.03‐0.39) | 0.001 | 0.02 (0.00‐0.36) | 0.007 |
| BMI | 1.07 (0.94‐1.21) | 0.333 | 1.07 (0.81‐1.43) | 0.632 |
| Wound size (cm2) | 1.00 (0.99‐1.01) | 0.602 | 0.97 (0.94‐1.00) | 0.043 |
| Operation time | 1.01 (1.00‐1.02) | 0.238 | 1.03 (0.99‐1.07) | 0.096 |
Abbreviations: BMI, body mass index; CI, confidence interval; pedicle ALT, pedicled anterolateral thigh flap; SGAP, superior gluteal artery perforator.
This study was approved by the Institutional Review Board of the Tri‐Service General Hospital (Taipei, Taiwan). All data were analysed anonymously and in accordance with the principles of the Declaration of Helsinki.
3. RESULTS
One hundred and eighty‐nine patients were enrolled in our study, and 166 patients with 176 pressure ulcers met our inclusion criteria. Of the 166 patients, 92 were females and 74 were males. Their ages ranged from 20 to 97 years (mean, 77 years). The mean defect size was 52.34 cm2. The most common cause of long‐term immobilisation was dementia (26.1%), followed by cerebrovascular accident (24.4%) (Figure 1). The most common comorbidities were hypertension (37.2%) and diabetes mellitus (27%) (Figure 2). The pressure ulcer locations were sacral (80.1%), trochanter (10.8%), back (1.1%), ischial (5.1%), and other (2.8%) (Figure 3). The flap choices were the V‐Y flap (46%), superior gluteal artery perforator (SGAP) flap (10.8%), pedicled anterolateral thigh (pALT) flap (3.4%), primary closure (31.8%), and other local flaps (5.7%) (Figure 4).
FIGURE 1.
Cause of long‐term immobilisation of 166 analysed patients.
FIGURE 2.
Comorbidities of 166 analysed patients.
FIGURE 3.
Pressure ulcer location of 166 analysed patients.
FIGURE 4.
Surgical reconstructive flap type of 166 analysed patients. pedicle ALT, pedicled anterolateral thigh flap; SGAP, superior gluteal artery perforator; V‐Y, V‐Y advanced flap.
The most common wound culture result was Enterococcus faecalis (19.8%), followed by no growth (18.7%), mixed flora (16.5%), and Pseudomonas aeruginosa (10.4%). The mean amount of debridement was 1.59 times the lesional area (range, 0‐13) with a mean hospital stay of 65.63 days (range, 8‐1365 days). The average albumin level was 2.91 mg/dL (range, 1.5‐4.4 mg/dL). The average body mean index was 21.5 kg/m2 (range, 14.9‐38.2 kg/m2).
Minor complications were defined as wound complications without surgical intervention that eventually healed. The minor complication rate was 19.89% (n = 35), including partial dehiscence and hematoma. Recurrence was defined as a wound complication requiring another reconstructive surgery. The recurrence rate was 7.95% (14 patients), including flap failure and poor wound healing requiring surgery. The mortality rate was 12.5% (n = 22). The causes of mortality included one case of urosepsis, 14 cases of respiratory failure, four cases of acute kidney injury, one case of upper gastrointestinal bleeding, one case of fungemia, and one case of sudden cardiac arrest.
The mean serum albumin level was lower in patients who experienced pressure ulcer recurrence (2.95 g/dL ±0.49) compared to that in those who did not (2.44 g/dL ±0.37; P < 0.001) using Fisher exact test analysis (Table 1). No other patient characteristics showed a statistically significant association. Therefore, we had collected some patient characteristics with lower P value in Table 1 and using logistic regression analysis for further precise result. Logistic regression analysis further indicated that recurrence was associated with the albumin level (P = 0.001) and wound size (P = 0.043); however, no association was found for body mass index, bacterial profile, comorbidities, localisation, previous surgery, operation time, or time to admission for reconstruction (Table 2).
TABLE 1.
Risk factors for recurrence assessed by Fisher exact test analysis.
| Variable | No recurrence n (%) | Recurrence n (%) | P‐value |
|---|---|---|---|
| Sex | 0.106 | ||
| Female | 94 (58.0) | 5 (35.7) | |
| Male | 68 (42.0) | 9 (64.3) | |
| Age (years) | 75.17 ± 14.44 | 76.00 ± 12.27 | 0.959 |
| Flap type | 0.268 | ||
| V‐Y flap | 131 (80.9) | 10 (71.4) | |
| SGAP | 17 (10.5) | 2 (14.3) | |
| Primary closure | 7 (4.3) | 2 (14.3) | |
| Pedicle ALT | 7 (4.3) | 0 (0.0) | |
| Sacral | 0.483 | ||
| Trochanter | 0.651 | ||
| Ischial | 0.153 | ||
| Back | 1.000 | ||
| Other position | 1.000 | ||
| Dementia Alzheimer | 1.000 | ||
| CVA or ICH | 0.193 | ||
| Parkinson | 0.698 | ||
| Other CNS problem | 0.076 | ||
| Fracture of the femur | 0.071 | ||
| Other | 1.000 | ||
| Comorbidities | 0.752 | ||
| Comorbidities: 0 | 37 (22.8) | 2 (14.3) | |
| Comorbidities: 1 | 53 (32.7) | 4 (28.6) | |
| Comorbidities: 2 | 49 (30.2) | 5 (35.7) | |
| Comorbidities: 3 | 17 (10.5) | 3 (21.4) | |
| Comorbidities: 4 | 4 (2.5) | 0 (0.0) | |
| Comorbidities: 5 | 2 (1.2) | 0 (0.0) | |
| Hypertension | 0.722 | ||
| Congestive heart failure | 1.000 | ||
| Valvular heart disease | 0.396 | ||
| Cardiovascular disease | 1.000 | ||
| Arrythmia | 1.000 | ||
| Dyslipidaemia | 0.284 | ||
| Peripheral artery occlusion disease | 1.000 | ||
| Diabetes mellitus | 0.415 | ||
| Acute kidney injury | 0.284 | ||
| Chronic kidney disease | 0.245 | ||
| End stage renal disease | 1.000 | ||
| Cachexia | 1.000 | ||
| Other chronic disease | 0.180 | ||
| Nil | 0.738 | ||
| Wound culture | 0.555 | ||
| Wound culture: negative | 37 (22.8) | 1 (7.1) | |
| Wound culture organism: 1 | 80 (49.4) | 8 (57.1) | |
| Wound culture organism: 2 | 28 (17.3) | 4 (28.6) | |
| Wound culture organism: 3 | 14 (8.6) | 1 (7.1) | |
| Wound culture organism: 4 | 3 (1.9) | 0 (0.0) | |
| Debridement times | 0.290 | ||
| Debridement times: 0 | 33 (20.4) | 2 (14.3) | |
| Debridement times: 1 | 72 (44.4) | 5 (35.7) | |
| Debridement times: 2 | 28 (17.3) | 1 (7.1) | |
| Debridement times: 3 | 15 (9.3) | 4 (28.6) | |
| Debridement times: 4 | 6 (3.7) | 2 (14.3) | |
| Debridement times: 5 | 3 (1.9) | 0 (0.0) | |
| Debridement times: 6 | 2 (1.2) | 0 (0.0) | |
| Debridement times: 7 | 1 (0.6) | 0 (0.0) | |
| Debridement times: 9 | 1 (0.6) | 0 (0.0) | |
| Debridement times: 13 | 1 (0.6) | 0 (0.0) | |
| Flap type | 0.061 | ||
| V‐Y flap | 71 (43.8) | 9 (64.3) | |
| SGAP | 19 (11.7) | 0 (0.0) | |
| Primary closure | 54 (33.3) | 2 (14.3) | |
| Pedicle ALT | 4 (2.5) | 2 (14.3) | |
| Other | 14 (8.6) | 1 (7.1) | |
| VY | 0.153 | ||
| SGAP | 0.369 | ||
| Pedicle ALT | 0.073 | ||
| Primary closure | 0.231 | ||
| Other | 1.000 | ||
| Negative pressure wound therapy | 1.000 | ||
| Operation time | 72.54 ± 43.33 | 87.21 ± 53.77 | 0.254 |
| Wound size cm2 | 52.05 ± 53.39 | 59.64 ± 35.67 | 0.126 |
| Minor complication | 1.000 | ||
| Mortality | 0.221 | ||
| Albumin (g/dL) | 2.95 ± 0.49 | 2.44 ± 0.37 | <0.001 |
| BMI | 21.41 ± 3.79 | 22.46 ± 4.67 | 0.424 |
Abbreviations: BMI, body mass index; pedicle ALT, pedicled anterolateral thigh flap; SGAP, superior gluteal artery perforator.
4. DISCUSSION
In our study, analysis of 174 patients with pressure ulcers who underwent defect reconstruction surgery showed that recurrence was related to the serum albumin level. Albumin levels represent the nutritional status of a patient and may also be related to wound healing. However, there is no clear evidence in the literature that the albumin level has impact on the recurrence of ulcers. 2 , 3 A previous study only showed marginally significant differences in the albumin level of recurrence rate after reconstructive surgery. 4 In our study, serum albumin showed a significant decrease in patients with pressure ulcer recurrence. It is established that albumin levels are subject to change even during a single hospital stay, even more so between hospital stays; therefore, in our study, albumin levels were checked on the day before surgery to evaluate the preoperative nutritional status.
In addition, some studies suggest that there is a correlation between malnutrition and BMI, which may be related to an increased risk of recurrence of pressure ulcers. 2 , 4 In our study, we were not able to show this conclusion, in which the P‐value of BMI was not significantly different. Malnourished or overweight patients seem to be more susceptible to pressure ulcer recurrence; however, this aspect requires more research.
The size of the wound defect was associated with pressure ulcer recurrence (P = 0.043). In our study, the location of the defect did not correlate with the recurrence rate. However, a study by Keys et al. 5 has indicated that the location of the ulcer, especially ischial ulcers, was prone to recurrence. More studies are required for further analysis to clarify the correlation between wound size, location of pressure ulcers, and recurrence rate.
In patients with positive polymicrobial swab cultures, we did not observe any impact on the recurrence rate in our study, which is consistent with that in previous studies. 6 , 7
In our study, the recurrence rate of 7.95% was lower than that reported in other studies (11%‐39%) 5 , 7 , 8 , 9 , 10 , 11 (Table 3). This may be explained by the different hospitalisation rules in different countries and surgeons. Patients at our hospital experienced longer durations of hospitalisation (mean, 65.63 days) compared with those in other studies. Patients cannot be discharged until the wound heals and stitches are removed; it is convenient to observe the wound condition and care in the hospital under the direct supervision of a medical professional.
TABLE 3.
Overview of the recurrence rate in the recent literature.
| Source | N | No. of sores | Recurrence rate |
|---|---|---|---|
| Larson, Plastic and Reconstructive Surgery, 2012 7 | 101 | 179 | 17 |
| Keys, Plastic and Reconstructive Surgery, 2010 5 | 135 | 227 | 39 |
| Gusenoff, Annals of Plastic Surgery, 2002 8 | 22 | 27 | 30 |
| Wettstein, International Wound Journal, 2013 9 | 118 | 170 | 11 |
| Grassetti, Annals of Plastic Surgery, 2014 10 | 143 | 143 | 22 |
| Wound repair and regeneration, 2018 11 | 55 | 63 | 27 |
| Average | 95.76 | 134.83 | 24.33 |
| Current study | 166 | 176 | 7.95 |
Our study was limited by its retrospective design, single‐centre setting, and single‐surgeon design. Nevertheless, we identified risk factors for an increased recurrence rate, as in other studies.
In conclusion, serum albumin level and initial defect size were the main risk factors in patients developing recurrent pressure ulcers after defect reconstructive surgery in our study of 166 patients. Before patients with pressure ulcers undergo reconstructive surgery, improving the nutritional status is critical for preventing recurrence. However, whether laboratory values of serum albumin levels are adequate predictors for the recurrence of pressure ulcers warrants further investigation.
FUNDING INFORMATION
There was no funding source.
CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.
ACKNOWLEDGEMENTS
Not applicable. This study was conducted at Tri‐service General Hospital, Taiwan.
Lin‐Yin W, Chia‐Ming L, Lin H‐L, Chu‐Yu C, Tzeng Y‐S. Risk factors for recurrent pressure ulcers after reconstructive surgery: A retrospective study in a single medical centre. Int Wound J. 2023;20(7):2511‐2517. doi: 10.1111/iwj.14112
DATA AVAILABILITY STATEMENT
Data available on request due to privac restrictions
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Data Availability Statement
Data available on request due to privac restrictions