Abstract
Pressure sores remain a common health problem, particularly among the physically limited or bedridden elderly, and can cause significant morbidity and mortality. This study aimed to present our surgical treatment and strategy for patients with multiple pressure sores. Between January 2010 and December 2016, 18 patients were enrolled. After adequate debridement, pressure sores were managed based on our treatment protocol. Patients' age, aetiology, defect size and location, flap reconstruction, outcome, and follow‐up period were reviewed. A total of 10 men and 8 women (average age, 82.3 years) with a mean follow‐up period of 28.3 months (6‐72 months) were included. The mean defect area was 63.7 cm2. The most common aetiology of the bedridden state was cerebrovascular accident (38.89%), and the most frequent sores were trochanteric pressure sores (53.57%). The average operative time and blood loss were 105.5 minutes and 100.8 mL, respectively. No haemodynamic variation or blood transfusion was noted during the surgery. The complication rate for each sore was 10.7%, including late recurrence. In conclusion, treating pressure ulcers requires careful patient education, intensive multidisciplinary optimisation, and meticulous wound care, and our treatment protocol ensures a shorter surgery time, less bleeding, and low complication rate.
Keywords: flaps, multiple pressure sores, strategy
1. INTRODUCTION
Pressure sores are encountered frequently in acutely hospitalised patients or in those requiring long‐term institutional care. Although their incidence can be reduced by preventive measures, pressure sores remain a frequent complication among hospitalised patients, the geriatric population, and paraplegics.1 Gusenoff et al.2 reported that 50% of patients with pressure sores are aged 70 years or older; in an acute care hospital setting, the prevalence of pressure sores reaches 3% to 4%, and the incidence ranges between 1% and 8%.
Pressure sores represent a major health problem for both patients and the health care system because of delays in patient rehabilitation, time‐consuming management, labour‐intensive challenge to the health care system, adverse health outcomes, significant increases in hospital length of stay, and high treatment costs.3, 4, 5 Moreover, pressure sores are associated with an increased rate of mortality. Infection in severe pressure sores can lead to sepsis, with a 6‐month mortality as high as 68%.6, 7
Factors associated with pressure sores in adults in acute care hospitals are pressure, shear, friction, moisture, infection, ischaemia, anaemia, male gender, sensory perception, hypoalbuminemia, diabetes mellitus, incontinence, and frailty with aging.2, 8 The most common sites of pressure sore formation include the ischium, femoral trochanter, sacrum, and heel.2
Conservative management is ineffective for stage III or IV pressure sores, and surgery to create flap coverage becomes inevitable.1, 2 The optimal approach to high‐grade pressure sores involves collaboration among physiatrists, specialist nurses and social workers, and the plastic surgeon. Surgical reconstruction combined with patient rehabilitation and education effectively reduces the postoperative recurrence rate of pressure sores.2
However, few reports exist with regard to surgical treatment and strategy for patients with multiple pressure sores. Here, we aimed to report our treatment protocols and outcomes for multiple pressure sores.
2. MATERIALS AND METHODS
Between January 2010 and December 2016, 18 patients with at least 3 grade III or IV pressure sores were enrolled. All patients were admitted or consulted our plastic surgeon because of wound sepsis. Patients and their families were well informed of the operative risk, and they agreed with our treatment protocol. Patients with inadequate home facilities or lack of family involvement or those who were not fit for anaesthesia were excluded. Patient characteristics, including age, gender, aetiology of bedridden state, lesion size, and location, were recorded (Table 1).
Table 1.
Patients' data
| Total patients (n) | 18 |
|---|---|
| Age (y) | 82.3 (61‐97) |
| Male:Female | 10:8 |
| Aetiology of bedridden state (n) | |
| Cerebrovascular accident | 7 |
| General weakness | 6 |
| Parkinson's disease | 3 |
| Spinal cord injury | 2 |
| Total pressure sores (n) | 56 |
| Average of pressure defect (cm2) | 63.7 (4‐360) |
n, number.
2.1. Pre‐surgical planning
Nutrition and comorbidities of the patients were optimised during hospitalisation. In addition, patients and carers were comprehensively educated on skin care, pressure relief methods, and the need for close monitoring. Tube feeding via a gastrostomy or jejunostomy tube could be considered if patients did not meet their dietary goals via oral feeding. Ladwig et al.9 demonstrated that a serum albumin level greater than 2.0 g/dL allows normal wound healing. Rubayi et al.10 reported that a serum albumin value less than 3.5 g/dL is a risk factor for pressure sore development.
Broad‐spectrum antibiotics were initially given and could then be tailored based on the microbiology. Local wound care with bedside wound drainage was performed to eliminate further infection. Bladder and bowel diversions were considered to prevent wound contamination. Moreover, the patient, family, social support, and care team must be prepared and in agreement with the postoperative care plan and all support services put in place before surgery.
2.2. Surgical planning
Adequate debridement is a key initial step prior to reconstruction. A wound including any infected or involved bone and bursa was excised to leave a cavity lined with healthy tissue. Tissue culture and biopsy samples were sent for histological tests and were essential to identify the target organisms for antibiotic therapy.
Flap reconstruction for dead space filling was often required if delayed primary closure was not suitable. Staged surgery was performed according to our surgical plan to treat patients with multiple pressure sores (Figure 1). Vacuum‐assisted closure (VAC) has an important role in pressure sore management as a bridge to future surgery. In the case of sacrum pressure sores, we preferred a superior gluteal artery perforator (SGAP) flap11, 12 for a larger defect and V‐Y fasciocutaneous flap for a smaller defect. For a trochanteric defect, we preferred a pedicled anterolateral thigh (pALT) myocutaneous flap13 for a larger defect and a hatchet‐shaped tensor fascia lata (TFL) flap for a smaller defect. All surgical procedures were performed by 1 experienced surgical team in the Tri‐Service General Hospital, Taipei, Taiwan.
Figure 1.
Algorithm for reconstructive surgery
Flap reconstruction details, such as location of sores and decision of flaps, were recorded. Outcomes including average number of pressure sores in each patient, operative time and blood loss, mortality, and follow up were also recorded. Complications including wound disruption, haematoma, infection, partial loss of the flap, late recurrence (more than 3 months), and treatment of complications were reviewed. The study was approved by the Tri‐Service Hospital Institutional Review Board Committee before the initiation of the data analysis.
2.3. Post‐surgical planning
All patients were treated in our wound care centre by a multidisciplinary team comprising well‐trained nursing staff, aides, a physician, a dietician, physical therapists, and a social worker. A postoperative non‐weight‐bearing period was required. Changes in patient positions, that is, supine and lateral decubitus, were usually required every 2 hours, and low‐air‐loss beds were helpful to prevent the development of new pressure sores. Suction drainage was applied under the flaps and in the donor area to avoid haematoma or seroma and was removed once <20 cm3 was collected in 24 hours.
Chest rehabilitation could be initiated earlier to prevent pneumonia. Active and passive range‐of‐motion exercises of the uninvolved extremity could be started as soon as possible after each surgery, and the affected extremity could be ranged once the wound healed (about 2 weeks).
The patients were discharged from the hospital or referred to the nursing home after removal of drains. Minor wound management including dressings could be performed by the caregivers.
3. RESULTS
A total of 18 patients (10 men and 8 women) were enrolled. The average age of the patients was 82.3 years (range 61‐97 years), and the mean defect area was 63.7 cm2 (range 4‐360 cm2). The common aetiologies of bedridden state were cerebrovascular accident (7 patients; 38.89%), general weakness (6 patients; 33.33%), Parkinson's disease (3 patients; 16.67%), and spinal cord injury (2 patients; 11.11%). A total of 56 pressure sores, including 30 trochanteric pressure sores (53.57%), 16 sacrum pressure sores (28.57%), 4 ischium pressure sores (7.14%), 4 upper back pressure sores (7.14%), 1 shoulder pressure sore (1.79%), and 1 waist pressure sore (1.79%), were recorded (Table 1).
For the 30 trochanteric pressure sores, the most frequently utilised flap for reconstruction was the TFL flap (15 patients, 50%), followed by the pALT flap (8 patients, 26.67%), delay primary closure (6 patients, 20%), and gluteus maximus myocutaneous flap (1 patient, 3.33%). For the 16 sacrum pressure sores, the most frequently utilised flap for reconstruction was the V‐Y flap (7 patients, 43.75%), followed by the SGAP flap (4 patients, 25%), delay primary closure (3 patients, 18.75%), and gluteus maximus myocutaneous flap (2 patients, 12.5%). For the 4 ischium pressure sores, the most frequently utilised flaps for reconstruction were the gluteus maximus myocutaneous flap (3 patients) and pALT flap (1 patient). For the 4 upper back pressure sores, the most frequently utilised flaps for reconstruction were delay primary closure (3 patients) and V‐Y flap (1 patient). For shoulder and waist pressure sores, delayed primary closure was performed in 1 patient each (Table 2).
Table 2.
Flap reconstruction of pressure sores
| Sore location | N. of sores | N. of flap for reconstruction |
|---|---|---|
| Trochanter | 30 | |
| TFL | 15 | |
| pALT | 8 | |
| Delayed PC | 6 | |
| GM | 1 | |
| Sacrum | 16 | |
| V‐Y | 7 | |
| SGAP | 4 | |
| Delayed PC | 3 | |
| GM | 2 | |
| Ischium | 4 | |
| GM | 3 | |
| pALT | 1 | |
| Back | 4 | |
| Delayed PC | 3 | |
| V‐Y | 1 | |
| Shoulder | 1 | |
| Delayed PC | 1 | |
| Waist | 1 | |
| Delayed PC | 1 |
GM, gluteus maximus; N., number; pALT, pedicled anterolateral thigh; PC, primary closure; SGAP, superior gluteal artery perforator; TFL, tensor fascia lata.
The average number of pressure sores in each patient was 3.1 (range 3‐5). Of the 18 patients, 2 patients died because of sepsis‐related multiple organ failure (11.11%). The average operative time was 105.5 minutes (range 25‐150 minutes), and the average operative blood loss was 100.8 mL (range 20‐150 mL). The mean follow‐up period was 28.3 months (6‐72 months). The surgical‐related complications included wound disruption (3 patients), followed by late recurrence (2 patients) and haematoma (1 patient); no flap loss or infection was noted. Flap revision was performed in 2 patients with late recurrence by re‐advancement of previous flaps, and other wound complications were treated conservatively. The overall surgical complication rate was 33.3% in each patient and 10.7% in each pressure sore (Tables 3 and 4).
Table 3.
Outcome of patients and flaps
| Average n. of multiple ulcers (per patient) | 3.1 (3‐5) |
|---|---|
| In‐hospital mortality (%) (n) | 11.1 (2) |
| Complication rate/patients (%) (patients) | 33.3 (6/18) |
| Complication rate/sores (%) (patients) | 10.7 (6/56) |
| Operating time (min) | 105.5 (25‐150) |
| Average blood loss (cc) | 100.8 (20‐150) |
| Mean follow‐up period (mo) | 28.3 (6‐72) |
n., number.
Table 4.
Complication of flaps and treatment
| Wound disruption | 3 |
|---|---|
| Conservative treatment | 3 |
| Haematoma | 1 |
| Conservative treatment | 1 |
| Infection/flap necrosis | 0 |
| Late recurrence | 2 |
| Revision of flaps | 2 |
4. CASE PRESENTATION
4.1. Case 1
An 83‐year‐old bedridden woman with a history of senile dementia, type 2 diabetes, and old cerebrovascular accident developed grade IV pressure sores on the sacrum and bilateral trochanter region. According to our treatment strategy, the left trochanteric defect was initially reconstructed by delayed primary suture owing to the cleanest defect. The right trochanteric defect was the most distant lesion from the previous reconstruction and was chosen for the second reconstruction by the TFL flap. The sacrum pressure sore was finally covered with a SGAP flap. The patient showed no recurrence at the 6‐month follow‐up examination (Figure 2).
Figure 2.
An 83‐year‐old woman with multiple pressure sores. A, B, C, 12 cm × 16 cm sacral pressure sore, 8 cm × 5 cm right trochanteric pressure sore, and 3 cm × 3 cm left trochanteric pressure sore, respectively; D, left trochanteric pressure sores treated with delayed primary closure; E, right trochanteric defect covered with hatchet‐shaped tensor fascia lata flap; F, planning of SGAP flap for sacrum defect; G, appearance of elevated f lap; and H, I, postoperative result 8 weeks after the surgery
4.2. Case 2
An 84‐year‐old bedridden man with a history of Parkinson's disease, sick sinus syndrome, and oesophagus stricture presented with sacrum and bilateral trochanteric pressure sores. According to our treatment strategy, the sacrum defect was the cleanest defect and was initially filled with a SGAP flap. Subsequently, the left trochanteric defect was treated with a pALT flap because of the least skin tension from the previous flap reconstruction. Finally, the right trochanteric defect was covered with a TFL flap. The flap remained healed at 4‐year follow up (Figure 3).
Figure 3.
An 84‐year‐old woman with multiple pressure sores. A, B, 12 cm × 8 cm sacral pressure sore, 10 cm × 14 cm left trochanteric pressure sore, and 8 cm × 8 cm right trochanteric pressure sore. C, SGAP flap was designed to cover the sacral defect. D, pALT flap was designed to cover the left trochanteric defect. E, Right trochanteric defect was covered with hatchet‐shaped TFL flap. F, G, H, Appearance of the flap 4 years after the surgery
4.3. Case 3
An 89‐year‐old long‐bedridden man with a history of old cerebral vascular accident, hypertension, and chronic obstructive pulmonary disease presented with sacrum and bilateral trochanteric pressure sores. According to our treatment strategy, the cleanest defect was the sacrum and was initially reconstructed with the V‐Y flap. The least skin tension defect from the previous defect was the left trochanter and was reconstructed with the pALT flap. The right trochanteric defect was then reconstructed with the pALT flap. The donor site of both lateral thighs was primarily closed. This demonstrated a fine flap contour with slight scarring (Figure 4).
Figure 4.
An 89‐year‐old man with multiple pressure sores. A, B, C, 4 cm × 5 cm sacral pressure sore, 6 cm × 5 cm left trochanteric pressure sore, and 10 cm × 8 cm right trochanteric pressure sore, respectively; D, sacrum pressure sores with closure by V‐Y fasciocutaneous flap; and E, left trochanteric defect covered with pALT flap. F, The pALT flap was tunnelled into the right trochanteric defect from the flap donor site. G, H, I, Postoperative result 8 weeks after the surgery
4.4. Case 4
A 61‐year‐old bedridden woman with a history of Parkinson's disease and type 2 diabetes was treated for sacrum and bilateral trochanteric grade IV pressure sores. According to our treatment strategy, the sacrum pressure sore was initially closed by delay primary closure. Because of the similar skin tension on both sides of the trochanter, the cleanest defect of the left trochanter was initially covered with the pALT flap. The right trochanteric lesion was finally closed with the pALT flap. The patient showed no recurrence at the 3‐year follow‐up examination (Figure 5).
Figure 5.
A 61‐year‐old woman with multiple pressure sores. A, B, 18 cm × 20 cm sacral pressure sore, 12 cm × 10 cm right trochanteric pressure sore, and 20 cm × 10 cm left trochanteric pressure sore. Sacral pressure sores treated with delayed primary closure. C, Planning of pALT flap for the right trochanteric defect. D, The pALT flap was tunnelled into the right trochanteric defect from the flap donor site. E, Preoperative appearance of the left trochanteric defect. F, Appearance of the elevated flap. G, Early postoperative appearance of the flaps. H, I, Appearance of the flap 3 years after the surgery
5. DISCUSSION
Treating patients with multiple pressure sores remains a challenge for plastic surgeons. Basic surgical principles for the treatment of pressure sores include complete excision of all devitalised tissue in the wound and filling of the defect with a durable and well‐perfused flap. Local flaps are the first choice for such coverage, and free flaps can be used in cases in which local tissues are inadequate.1 These may be musculocutaneous, fasciocutaneous, or perforator flaps. They can be applied as rotation, advancement, or island flaps.14
In our management strategy for multiple pressure sores in the elderly, we preferred treatments with a shorter operative time, lesser bleeding, and shorter anaesthesia time in 1 operation. Therefore, multiple‐staged operation for 1 patient is inevitable. The skin in the elderly was lax, and delayed primary closure layer by layer could possibly obliterate the cavity without tension and wound dehiscence. Therefore, we preferred to perform delayed primary closure in elderly if possible.
According to Wang et al. and our previous studies, the modified design of the pALT myocutaneous flap without skeletonisation of perforators is reliable and easily harvested for the reconstruction of trochanteric and ischium pressure sores with limited morbidity.13, 15, 16 Li et al.17 reported that pALT flaps have a lower recurrence rate but require a longer operative time and prolonged anaesthesia than hatchet‐shaped TFL flaps for the surgical management of trochanteric sores. Consequently, in treating trochanteric pressure sores, we preferred to utilise hatchet‐shaped TFL flaps for a smaller defect and pALT flaps for a larger defect. Our previous studies showed that a modified SGAP flap with less dissection of the perforator and assistance of intraoperative indocyanine green fluorescent angiography provides a shorter operative time and lesser bleeding, which make the SGAP flaps an excellent choice for sacral sore coverage.11, 12 As a result, in sacrum pressure sore management, we preferred to utilise V‐Y advancement flap for a smaller defect and SGAP for a larger defect. In ischium pressure sores, the defect is usually deep, and delayed primary closure often leads to high recurrence and complication rates. Thus, we preferred the GM flap or pALT flap in this case.
The priority of first reconstruction lesion was based on the cleanest defect to achieve short operative time and less bleeding. The succeeding reconstruction lesion was based on the least skin tension from the previous reconstruction to avoid skin tension between the previous flap and the reconstructive defect and lessen complications. In our 18 patients with 56 pressure sores, all reconstruction procedures were performed by 1 plastic surgeon. The average operative time was 105.5 minutes without intraoperative blood transfusion or intraoperative haemodynamic variation. The overall complication rate was low (10.7%, 6 of 56 pressure sores) compared with previous studies (4.57%‐46.4%).18, 19
In our treatment protocol, we performed VAC therapy after wound debridement as a bridge to final reconstruction. VAC, also known as negative pressure wound therapy, is a well‐known wound care system for the treatment of complex wounds.20 The cyclical application of negative pressure can accelerate wound healing, where optimised blood flow increases local oxygenation and promotes angiogenesis, decreases local tissue oedema, and accelerates the removal of excessive fluid from the wound bed, which in turn reduces bacterial contamination.21, 22 Pre‐reconstruction can shrink the size of a large wound, facilitating a smaller surgical flap closure.23 Previous comparative studies showed that, with the use of VAC, patients have fewer dressing changes, less pain, fewer skipped meals, greater mobility, and reduced length of hospital stay.22, 24
Pressure sores are a common complication of long‐term institutional care. Surgical coverage of late‐stage ulcers in the elderly refractory to conservative therapy remains controversial.2 Conservative treatment, on the other hand, requires skilled nursing care, multiple daily dressing changes, and wound assessments, which account for a substantial portion of health care costs in the long term in hospitalised elderly patients.25 Aside from the pain and risk of infection associated with sores, the patient may experience humiliation and depression.2 Surgical reconstruction offers the patient prevention against infection, protein loss, and less daily skilled wound care, resulting in reduced morbidity, mortality, and economic burden.2, 19 Khor et al.26 found a 68% mortality rate within 12 weeks of hospital admission among elderly patients (80.8 ± 8.0 years) with a pressure ulcer. In Kwok et al.’s19 analysis of national data, including participants aged 65 years or older, a history of diabetes and total functional dependency were independently associated with increased risk of mortality following pressure ulcer surgery. Moreover, flap repair was associated with decreased complications. Therefore, in careful patient selection, we advocate wound debridement and flap coverage for the elderly population in conjunction with comprehensive postoperative rehabilitation.
Few studies are available on the treatment of multiple pressure sores in the elderly.10, 27, 28 Rubayi and Burnett10 reconstructed multiple pressure sores in patients with spinal cord injury with single‐stage surgical management. The mean age of the patients was 37.5 years. Two surgical teams were involved in their surgery. The average blood loss in 1‐stage surgery was 980 mL, with an average surgical time of 4.7 hours. Physical therapy was initiated at 4 weeks postoperatively. The reported complication rate was 43%, and late recurrence was 12%. The mean age of our patients was greater, and the surgery was performed by 1 plastic surgeon. The operation time was shorter with less bleeding and a lower complication rate. Moreover, physical therapy was initiated as early as possible after each surgery. Han et al.28 reported 1‐stage surgical treatment in patients with multiple pressure sores through a 2‐team surgical approach. The average number of pressure sores in each patient was 2.4. The mean age of the patient was 55.6 years, and the overall complication rate was 15%. Prolonged anaesthesia and intraoperative bleeding were noted. Postoperative care and rehabilitation were more challenging. Compared with our study, our treatment protocol with multiple‐staged operation was more reasonable. The limitations of our series include the small sample size and varying patterns of injury, which make it difficult to compare the outcomes of this study with those of other studies. Further prospective randomised controlled trials, including larger cohorts, are required to confirm these results.
In conclusion, multiple‐staged operation for elderly patients with multiple pressure sores in our treatment protocol can provide shorter operation time, less bleeding, and a low complication rate. Moreover, the patient's quality of life increases after sepsis control, and the burden of caregiver is alleviated. Patient selection is critical, and a multidisciplinary management team to ensure stringent care is required.
AUTHOR CONTRIBUTION
I.‐H. C. contributed to the literature search, data collection, data analysis, data interpretation, writing and figure collection, and formatting. C.‐H. W. contributed to the literature search, data collection, and critical revision. Y.‐S. T. contributed to the study design, data analysis, data interpretation, writing, and editing.
ACKNOWLEDGEMENT
Dr. Y.‐S. T. acknowledges the financial support for this work provided by National Defense Medical Center and Tri‐Service General Hospital, ROC (TSGH‐C107‐117).
Chiang, I.‐H , Wang, C.‐H , Tzeng, Y.‐S . Surgical treatment and strategy in patients with multiple pressure sores. Int Wound J. 2018;15:900–908. 10.1111/iwj.12942
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