Efficacy of one‐stage surgical treatment and clinical features in patients with multiple pressure ulcers

Abstract

Treating patients with multiple pressure ulcers is a very challenging task for physicians. However, there are very few reports on treatment protocols for multiple pressure ulcers and treatment outcomes. The authors have consistently treated multiple pressure ulcers in a one‐stage operation rather than a staged operation. We evaluated multiple pressure ulcers patients who underwent a one‐stage operation from 2007 to 2014. A comparison was made between 20 patients who underwent a one‐stage operation on 44 foci and 68 patients with a single focus. Though the results, we could conclude that one‐stage operation of multiple pressure ulcers was found to have a shorter recovery period and shorter hospitalization without a significant increase in complications.

Introduction

Treating patients with pressure ulcers is a very challenging task for medical personnel as these are associated with delayed healing, recurrence, and difficulties in surgical procedures 1, 2, 3. Without appropriate management, severe side effects including sepsis, chronic infection, metabolic abnormalities, and heterotopic ossification can occur, and these can lead to death 4.

In Korea, approximately 17 000 patients are diagnosed with pressure ulcers every year, and this number is on the rise 5. Pressure ulcers are known to occur commonly in the sacral, ischial, and trochanteric areas. Dansereau and Conway 6, in 1964, reported the ischium to be the most common site (28%), whereas Meehan 7, in 1990, and VanGilder et al. 8, in 2010, reported the sacrum to be the most common site (36% and 28·3%, respectively).

Despite these differences, pressure ulcers are known to commonly occur in the sacral and ischial areas. However, without appropriate management, the patient's condition deteriorates leading to development of pressure ulcers at multiple sites including the sacrum, ischium, trochanteric region, heel, and lateral malleolus. In such cases, it is difficult to simultaneously improve the patient's general condition and carry out pre‐operative planning.

A common belief is that performing a one‐stage operation in patients with multiple pressure ulcers limits changing of positions, thereby increasing the likelihood of pressure ulcers recurrence. Conway and Griffith 9 have stated that although staged operation requires prolonged hospitalization, it is necessary in these patients. Conventionally, physicians have performed staged operations to treat patients with multiple pressure ulcers, with the first operation performed at the primary site and the following operations at 1‐month intervals after complete healing 4.

The authors have performed one‐stage surgeries since 2007. This study aims to compare the results of one‐stage operation with the conventional staged surgery. In addition, we have evaluated the pressure ulcers development pattern in this institution for the last 6 years.

Materials and methods

A retrospective chart review of patients who underwent pressure ulcers surgery between January 2007 and June 2014 was conducted. A total of 88 patients (54 men, 34 women) with pressure ulcers at 114 sites were included in this study. In order to minimize the differences in the location and extent of pressure ulcers, the sites were narrowed down to sacral, ischial, and trochanteric pressure ulcers. With respect to the wound condition, only stage IV pressure ulcers that showed resolution of infection and growth of healthy granulation tissue were selected. Twenty patients underwent an operation for covering more than 2 pressure ulcers sites each, which was a total of 46 pressure ulcer wounds.

Flap selection

The most commonly used surgical method was performed at each site (Figures 1 and 2). It included gluteus maximus muscle‐based musculocutaneous V‐Y advancement flap and gluteal artery perforator‐based fasciocutaneous V‐Y advancement or rotation flap for the sacral area, gracilis muscle‐based musculocutaneous rotational flap, posterior thigh V‐Y advancement flap, and gluteal artery perforator‐based fasciocutaneous V‐Y advancement or rotation flap for the ischium, and tensor fascia latae muscle‐based musculocutaneous V‐Y advancement or rotation flap and gluteal artery perforator‐based fasciocutaneous V‐Y advancement or rotation flap for the trochanteric region. A two‐team surgical approach was used if necessary.

Figure 1.

(A) A patient diagnosed with a stage IV pressure sore in the sacral and bilateral trochanteric areas after general weakness. (B) This clinical photograph was taken after bilateral tensor fascia lata muscle‐based musculocutaneous V‐Y advancement flap coverage was performed in the trochanteric areas, and superior gluteal artery perforator‐based fasciocutaneous V‐Y advancement flap coverage was performed in the sacral area.

Figure 2.

(A) A 30‐year‐old man with quadriplegia following a vehicular accident presenting with bilateral pressure sores in the trochanteric area. (B) This clinical photograph was taken after bilateral gluteus maximus muscle‐based musculocutaneous V‐Y advancement flap coverage was performed in the trochanteric area.

Postoperative care

Pressure on the surgical sites was avoided in patients who underwent operation on more than 2 pressure ulcers; however, if the pressure was inevitable, a strict regimen of changing positions every hour was implemented. An air‐fluidized bed was used for a minimum of 4 weeks. The drain was removed when the drainage amount reached 30 cc, and stitch out was performed within 2–3 weeks postoperatively. A graduated sitting program was initiated 6 weeks after the operation, starting with a daily 30‐minute session, which was extended by 30 minutes if tolerated by the patient. The patients were discharged from the hospital after removal of drain, and minor wound management including dressings and stitch outs were performed through home nursing care, which was provided 2–3 times a week.

Statistical analysis

A comparison was made between 20 patients with multiple pressure ulcers and 68 patients with single pressure sores regarding the average defect size, operating time, blood loss, complication rate, and hospital stay. The independent t‐test was used for analysis of every criteria except the complication rate, for which the Mann–Whitney test was used. A value of P < 0·05 was considered statistically significant. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 13.0 (SPSS, Inc., Chicago, IL).

Results

Patient information is listed in Table 1. Among the 88 patients, 114 pressure ulcers were treated surgically. Patient age ranged from 22 to 87 years (average, 55·6 years), and the follow‐up period ranged from 4 months to 5 years (average, 1 year and 2 months). Twenty patients with multiple pressure ulcers comprising 23% (20/88) underwent surgical treatment for 46 pressure ulcers, which was an average of 2·4 pressure ulcers per patient. The causes for patients' bed‐ridden state are listed in Table 2. Spinal cord injury resulting from motor vehicular accidents and falls (56%) was the most common cause followed by general weakness due to aging (26%) and cerebrovascular accidents (15%).

Table 1.

Patient data

Total no. of patients	88
Total no. of pressure ulcers	114
Age	55·6 years (22–7 years)
Mean follow‐up period	1 year and 3 months (4 months to 5 years)
No. of multiple ulcers (20 patients)	46
Average no. of multiple ulcers (per patient)	2·4

Table 2.

Etiology of Bedridden State

Mechanism	No. of patients (%)
Spinal cord injury (motor vehicle accident)	38
General weakness	26
Spinal cord injury (falls)	18
Cerebrovascular accident	15
Knee amputation	1
Brain tumor	1

A comparison between multiple and single pressure ulcer is shown in Table 3. No significant difference was found in the defect size. The two groups had statistically significant differences in the operating time (110·53 minutes in the multiple ulcer group versus 93·82 minutes in the single ulcer group) and amount of blood loss (160·53 cc in the multiple ulcer group versus 112·35 cc in the single ulcer group). However, the differences in the complication rate (15% in the multiple ulcer group versus 10·3% in the single ulcer group) and hospital stay (25·47 in the multiple ulcer group versus 26 days in the single ulcer group) were not statistically significant.

Table 3.

Differences in data between multiple and single pressure ulcers

	Multiple pressure ulcers	Single pressure ulcer	P‐value
No. of patients	20	68
Defect size (cm2)	72·237 (each defect)	72·456	0·99
Operating time (hours)	110·53	93·82	0·005
Blood loss (cc)	160·53	112·35	0·004
Complication rate (%)	15·00%	10·30%	0·507
Hospital stay (days)	25·47	26	0·942

Data of defect size, operation time, blood loss and hospital stay are average values.

Complications included flap necrosis, wound disruption, hematoma, seroma, and infection. A major complication is defined as a condition that requires a re‐operation, whereas a minor complication is defined as a condition that can be treated conservatively (Figure 3). The three complications that developed in the multiple ulcer group included one case of flap necrosis, which required a re‐operation within 2 weeks postoperatively, and two cases of wound disruption, in which complete healing was achieved conservatively.

Figure 3.

A patient with multiple pressure sores, who developed major complications. (A) Preoperative photograph. (B) Immediate postoperative state. (C) Partial necrosis of the flap led to a revision operation.

In the single ulcer group, there were 46 cases of pressures ulcers in the sacral area, 16 involving the ischial area, and 6 involving the trochanteric area, with sacrum being the most common site. However, in the multiple ulcers group, the occurrence had an even distribution with 16 cases involving the sacral area, 14 involving the ischial area, and 16 involving the trochanteric area (Figure 4).

Figure 4.

(A) Distribution of pressure sore occurrence in patients with multiple sores. (B) Distribution of pressure sore occurrence in patients with a single sore. These indicate that the pressure sore initially develops in the sacral area and eventually progresses to the sacral, ischial, and trochanteric areas with an even distribution.

Discussion

For the past half a century, surgery has been the mainstay of treatment for pressure ulcers 9. Furthermore, recent progress in the development of diverse surgical methods, anesthesiology, and intensive care units has enabled more physicians to operate on patients with extensive pressure ulcers 10, 11, 12.

The ideal treatment for a pressure ulcers is to cover the entire open wound and educate both the patients and guardians to prevent recurrence 13. However, many patients with pressure ulcers have a poor general condition caused by prolonged underlying disease and suffer from an unstable socio‐economic status due to limitation in social activity, which leads to delay in appropriate treatment. Such patients are more likely to be vulnerable to multiple pressure ulcers. The authors have found that nearly a quarter (23%, 20/88) of patients in this institution have multiple pressure ulcers.

In the last 5 years, more than 400 reports on pressure ulcers have been published in the English literature but very few have been on treatment protocol or data on multiple pressure ulcers 13. One study was published in Chinese in the year 2008 14. Additionally, Lari and Rajacic 15 in 1992 and Tizian et al. 16 in 1988 have reported several treated cases of pressure ulcers. The most recent study was published by Rubayi and Burnett 4 in 1999, which reported 120 cases but, had a small control group of ten cases. Rubayi and Burnett stated that the one‐stage operation may increase the operation time and blood loss, but given the fact that no significant difference was found in the results, it was concluded that the one‐stage operation may be more cost‐effective.

Our study lacks a direct comparison between one‐stage operations and staged operations in patients with multiple pressure sores. However, compared to a group of patients with only one pressure ulcer, in whom surgeries are simpler and a fast recovery can be found during the admission, no statistically significant differences were found in the complication rate and hospitalization period in the group with multiple pressure ulcers. Thus, the authors believe that this provides enough credible evidence.

Even though an increase in blood loss and operating time was noted, when the average blood loss and operating time per pressure ulcer is considered, it is clear that these were actually greater in single sore group. The data from this institution revealed no difference in the hospitalization period, and Rubayi and Burnett 4 also proved that the hospitalization period can be shortened by approximately 10 weeks with one‐stage surgery. This is beneficial for pressure ulcer patients because one‐stage operation, besides being cost‐effective, can also alleviate the psychological burden of multiple operations under general anesthesia.

Nutrition deficiency also plays an important role in one‐stage operation. It is well known that nutritional support, especially protein, is essential in the prevention and recovery from pressure ulcers 17, 18, 19, 20. At least 1·8 g/kg or 1·2 g/kg protein is required for patients with pressure sores receiving enteral feeding 21. However, it is not easy to meet this nutritional demand and maintain a balanced nutritional status since nutrition leaks through open wounds such as pressure ulcers. When undergoing a staged operation, such nutritional leakage is present and it is likely to cause delayed healing or development of a new pressure ulcer. We believe that the one‐stage operation causes minimum nutritional leakage leading to an outstanding recovery rate in patients with multiple pressure ulcers despite the extent of the operation.

However, these results are achieved only under specific conditions. First, a two‐team approach to surgery is required. Reduction in operation time and blood loss was possible with the two‐team surgical approach. Second, strict postoperative care is required. The patient's position after operation on multiple pressure ulcers is a primary concern. Generally, changing of position is recommended every 2 hours 13. However, when all dependent portions are covered after operation, pressures on the surgery sites are inevitable. In the authors' experience, changing patient position every hour is necessary. Longer exposure to pressure might lead to disruption but ≤1 hour of pressure provides compression for prevention of hematoma formation and improves flap adhesion.

In this study, the pressure ulcer sites were limited to the sacral, ischial, and trochanteric areas. The fact that sacral and ischial areas are the most common sites of pressure ulcer development has already been stated in the introduction 6, 7, 8. This is due to the patient's condition when lying supine, which leads to pressure ulcer development in the sacral area, and when sitting, which results in pressure ulcers in the ischial area. In this study, the sacrum was the most common site in the group of patients with a single pressure ulcer. On the other hand, for the group with multiple pressure ulcers, no difference was found in the sacral, ischial, and trochanteric areas. This can be explained by the pressure ulcer initially developing in the sacral area, but when untreated, it progresses to other sites. This emphasizes the importance of early intervention in patients with a single pressure ulcer.

The most common cause of the patients' bed‐ridden state in this study was spinal cord injury (56%), especially from motor vehicular accidents. However, the statistics reveal that the most common cause in the US is spinal cord injury due to a gunshot 4, 22. Thus, this explains the influence of regional differences, considering the fact that weapon bearing is prohibited in Korea.

In conclusion, one‐stage operation in patients with multiple pressure ulcers can provide a shorter recovery period, shorter hospitalization, and cost effectiveness without a significant increase in the complication rate. This can be achieved by a two‐team surgical approach in a facility that provides stringent postoperative care.