Improvisations in classic and modified techniques of flap surgery to improve the success rate for pressure ulcer healing in patients with spinal cord injury

Abstract

The recurrence of pressure ulcers (PrUs) and dehiscence of reconstructive flap have always been a problem. The present study aimed to evaluate the results of reconstructive flap surgeries in patients with spinal cord injury (SCI) having PrUs, using classic and modified flaps with improvisations to decrease wound dehiscence, flap necrosis and tension in flap. This is a prospective clinical study. The setting was a tertiary care centre in northern India. Thirty‐five patients with SCI having 37 stage III and IV PrUs. PrUs were treated using classic and modified flaps with improvisations. The outcome was evaluated using criteria of wound dehiscence, flap necrosis and recurrence. The results of flap surgery were excellent in 32 (86·48%) patients, good in 4 (10·81%) patients and poor in 1 (2·7%) patient. Partial flap necrosis (2·7%), low incidence of PrU recurrence rate at flap site (5·4%) and overall PrU recurrence (11·4%) were the complications observed. Improvisation of classic and modified techniques of flap surgeries along with reinforcement of general care principles of paraplegia can be effective in minimising complications often associated with PrU reconstructive surgery thus improving the ultimate outcome.

Introduction

As life expectancy is steadily improving through provision of modern spinal health care, increased survival in spinal cord injury (SCI) patients is associated with secondary complications, which continues to pose management challenges and impair the quality of life of such patients 1, 2. The secondary complications prolong the length of hospital stay, make patients' rehabilitation more difficult and the treatment of such complications is very expensive (2). Pressure ulcers (PrUs) were reported as the most frequent secondary medical complication in all years in an analysis of long‐term medical complications after traumatic SCI (3). The primary factors leading to PrUs include pressure, shear, moisture secondary to perspiration or incontinence, anaemia and nutritional deficiencies, and aged skin (4). PrUs can be complicated by sepsis, myonecrosis, osteomyelitis, necrotising fasciitis, septic arthritis, cellulitis, dysreflexia, amyloidosis, urethral fistula and malignant transformation of tissues. Despite rapid advances in medicine and health sciences, prevention and cure of PrUs remain a significant problem as it was in the past (5). In general, superficial PrUs (stages I and II) are likely to benefit from conservative treatment, whereas deep PrUs (stages III and IV) often require surgical intervention (6). The conservative mode of treatment is associated with prolonged immobilisation and is accompanied by a higher incidence of recurrence. Various operative procedures have been described to repair PrUs and include direct closure, skin grafting, skin flaps, musculocutaneous flaps, fasciocutaneous flaps and free flaps (6).

The recurrence of PrUs and dehiscence of reconstructive flap have always been a problem (7). An analysis of failure in repair of PrU reveals that the breakdown or early recurrence is usually the result of (i) inadequate excision of ulcer, leaving behind fibrotic, oedematous or infected tissues, (ii) inadequate excision of bursae and bony prominences, (iii) excessive tension of suture lines, (iv) poorly planned and constructed flaps, (v) local wound complications such as haematoma and infection and (vi) exacerbation of the patient's underlying disease or systemic infection (8). The present study aimed to evaluate the results of reconstructive flap surgeries in patients with SCI having PrUs, using classic and modified flaps with improvisations to decrease the wound dehiscence, flap necrosis and tension in flap.

Materials and methods

Thirty‐five patients with SCI having 37 PrUs (stages III and IV) presented to a tertiary level referral centre, between April 2005 and November 2010 and were included in the present prospective study. All patients who met the following eligibility criteria were included in the study: (1) occurrence of a traumatic event resulting in SCI with PrU; (2) failure of conservative treatment to heal the PrU; (2) a minimum regular follow‐up of 6 months; (3) signed informed consent; (4) age older than 18 years (5) and injury below C4. Patients with chronic medical illness particularly evident prior to injury which could affect rehabilitational outcome appreciably, for example head injury, neuropsychological disorder and brain tumours etc., were excluded. The patients were given detailed information about the purpose of study and written consent was obtained from all the participants. The complete history of patients was taken to rule out any other occult medical or neuropsychological problems and complete general physical examination and neurological examination were done. A demographic profile of the patients is given in Table 1. Roentgenography of the injury site as well as the site of PrU, routine blood and urine investigations were undertaken. The eschar was adequately removed and PrUs were staged according to the European Pressure Ulcer Advisory Panel (EPUAP) (9). Systemic antibiotics were used when there was sepsis, advancing cellulitis or osteomyelitis and were chosen based on blood culture and wound biopsy culture results. Associated co‐morbidities were also treated. The exposed bony prominences were removed with an osteotome. All necrotic tissues were removed from the PrU and surgery was done in stage III and IV PrUs when all necrotic materials were cleaned and healthy granulation tissues developed (usually took 3–6 weeks). The following general measures were taken in all patients with PrUs:

Table 1.

Demographic profile

Parameter	No. of patients	%
Sex
Male	23	65·7%
Female	12	34·3%
Marital status
Married	32	91·4%
Unmarried	3	8·6%
Mean age	34·12 years (range: 17–57 years)
Grades of neurologic deficit (Asia)
A	24	68·5%
B	8	22·8%
C	2	5·8%
C	1	2·9%
E	0	0

• 1Change of posture every 2 hours.
• 2Use of water or air beds.
• 3Avoid creases in bed sheets.
• 4Patients were encouraged for clean intermittent self‐catheterisation (CIC) to avoid wetting of the bed and body as soon as possible.
• 5Good nutritious diet.
• 6Daily antiseptic dressing, or dressing and debridement of the wound preoperatively.
• 7Patients were taught to lie down prone for more time, so that they could adopt this posture in postoperative period.

Operative procedures

Area surrounding the operative field and both lower limbs were shaved and cleaned with soap and water. On the preoperative night, skin was cleaned with soap and water and the whole area was wrapped in sterile dressing. Foley's catheter was put to avoid soakage of dressing. The skin was examined for mobility, laxity and line of minimum tension for transposition of flap. In most of the patients, no anaesthesia was given. They were either paraplegics or quadriplegics with complete sensory loss. In three patients with sensations intact general anaesthesia was given.

A total of 37 PrUs were operated: 27 sacral, 8 trochanteric, 1 ischial tuberosity, 1 thorax. Out of the operated PrUs, 16 were stage III and 21 were stage IV. Average size of the PrU was 12·6 × 9·6 cm. Type of flap was decided depending upon the site, size and availability of the local tissues.

In the present study, we improvised the classic and modified techniques of flap surgery by making multiple dermal incisions at flap surface, bilateral longitudinal incisions along the vertical suture line in the midline, and packing the cavity with muscle and flap depending upon the situation.

Postoperative care and follow‐up

In addition to all the general principles followed, the following measures were taken preoperatively:

• 1Daily inspection of flap by surgeon till the patient was admitted and later on by patient and/or caretaker after discharge from hospital.
• 2Proper positioning to avoid any pressure on the flap and change of posture/turning allowed earliest by 2 weeks of the surgery or later as per flap healing situation.
• 3Indwelling catheter during surgery and for at least 2 weeks postoperatively or till patient was allowed to turn.
• 4Sitting allowed after 6 weeks.
• 5Proper wheel chair/cushions/orthosis for mobilisation of the patient and to avoid any pressure on flap and avoid recurrence.
• 6Monthly follow‐up till 3 months and then after 6 months of flap surgery.
• 7Reinforcement of general care principles to patients and/or caretakers at each follow‐up to avoid any recurrence.

Results were evaluated using criteria reported by Aggarwal et al.(10) based on extent of wound dehiscence, flap necrosis and recurrence.

Results

Out of 37 flaps used, 19 were gluteus maximus V‐Y advancement flaps (unilateral in 5, bilateral in 14), 6 were tensor fascia lata flaps, 2 were tensor fascia lata vastus lateralis flap, 3 were gluteus maximus island flaps and 7 were fasciocutaneous rotation flaps. Modified slide‐in flap was done in six patients (Figure 1), interdigitating gluteus maximus V‐Y advancement flap was done in five patients and multiple dermal incision were provided in all flap surgeries (1, 2). Vertical incision along the suture line in the midline was made in two patients (Figure 2). Two patients with trochanteric ulcers had pathological subluxation of femoral head which necessitated excision of femoral heads leaving large cavities. Cavity packing in these patients was done with muscle and flap (Figure 3). Mean operative time was 99 minutes (range: 80–150). Mean blood loss during operation was 756·51 ml (range: 500–1200). The drains were removed at a mean of 13·16 days (range: 7–24) after surgery. Mean duration of hospital stay was 92·1 days (range: 23–209). Average duration of follow‐up was 14·34 months (9 months to 5 years). The results of the flap surgery were excellent in 32 patients (86·48%), good in 4 patients (10·81%) and poor in 1 (2·7%) patient. Table 2 shows the complications observed and their management in the present series.

Figure 1.

Photograph of the pressure ulcer treated with bilateral V‐Y gluteal advancement flaps with slide‐in edges. (A) Preoperative photograph; (B) bilateral flaps prior to stitching; (C) slide‐in edges technique in suturing the flaps with multiple epidermal incisions; (D) photographs after 2 years of flap surgery.

Figure 2.

Photograph of the pressure ulcer treated with bilateral V‐Y gluteal advancement flaps modified with bilateral longitudinal epidermal incisions to decrease tension in the midline suture. (A) Preoperative photograph showing bilateral longitudinal epidermal incisions and (B) photographs at 9 months follow‐up.

Figure 3.

Photograph of the trochanteric pressure ulcer (stage IV) communicating with the hip joint. Proximal femoral resection was done and 3 months later the tensor fascia lata and vastus lateralis flap was done. Cavity left after proximal femoral resection was filled with part of the flap. (A) Photographs of the pressure ulcer at admission. (B) Proximal femoral resection with joint debridement. (C) Preoperative photograph showing markings of the flap. (D) Markings for deepithelialisation of the distal margin of the flap. (E) Deepithelialised distal margin of the flap used for packing the cavity. (F) Photographs after 6 months of flap surgery.

Table 2.

Postoperative complications and their management in the present study

Complications	No. of patients	Percentage (%)	Management
Skin graft site‐related problem	3	8·1%	No treatment was required
Haematoma/seroma under the flap	4	10·8%	Managed with stitch removal
Superficial infection	1	2·7%	Conservative management
Partial flap necrosis	1	2·7%	Serial debridement
Recurrence over flap	2	5·4%	Conservative management
Recurrence over new site	4	11·4%	Conservative management

Discussion

The development of PrUs in the course of management of a paraplegic represents a major setback, which not only delays rehabilitation but also prolongs hospital stay (11). The surgical approach and management techniques for PrUs have changed over the years resulting in reduction in the length of in‐hospital stay and preoperative and postoperative immobilisation period. The management of PrU can be complicated by its recurrence or dehiscence of reconstructive flap. This may occur due to inadequate excision of ulcer, bursae or bony prominence, excessive tension of suture lines, and local wound complications such as haematoma and infection (8). The present study aimed to evaluate the results of reconstructive flap surgeries for PrUs in patients with SCI, using classic and modified flaps with few improvisations to decrease the wound dehiscence, flap necrosis and tension in flap.

In the study by Hill et al.(12) on 17 paraplegic and 3 non‐paraplegic patients treated by a transverse back flap, major flap necrosis occurred in two cases (10%) and minor flap necrosis in two cases (10%). Aggarwal et al.(10) operated on 34 patients who had sacral pressure sores with gluteus maximus island flap and described 10 (29%) flap‐related complications such as haematoma formation, wound dehiscence, flap necrosis, seroma formation, flap donor site grafting infection and abscess formation at flap recipient site.Wong and Ip (13) compared gluteal fasciocutaneous flaps and myocutaneous flaps for the treatment of sacral sores and mentioned three (10%) wound complications in the fasciocutaneous group and three (15%) wound complications in their myocutaneous group. In the present study, there were three complications (15·7%) in the myocutaneous group (haematoma formation and partial flap necrosis) and one complication (14·2%) in the fasciocutaneous group (haematoma formation). In our study, one partial flap necrosis was due to non‐compliance of the patient about the posture postoperatively. Aggarwal et al.(10) also reported poor results in 5·8% of patients due to poor quality of postoperative care and the general poor health of patients.

Kierney et al.(14) reported 19% overall pressure sore recurrence rate (recurrence at same site) and 25% patient recurrence rate. In a series of 158 patients with 268 PrUs Srivastva et al.(15) reported a patient recurrence rate of 17·3%. In the present study, we had a comparatively low incidence of PrU recurrence rate at the flap site (5·4%) and an overall PrU recurrence rate of 11·4%. We are of the opinion that low recurrence rate in the present study might be due to improvisation and active rehabilitation of these patients. Kierney et al.(14) have reported that active participation of the rehabilitation team in perioperative care is important. The whole patient, not just the ulcer must be considered, because many physical and psychosocial factors need to be evaluated and treated to optimise healing and prevention of recurrence. Srivastva et al.(15) emphasised that reconstruction procedures are effective and should be an integral part of the rehabilitation program.

In the classic V‐Y procedures of sacral PrUs, the closure is a vertical line, and this is where the greatest tension occurs that may cause a dehiscence over the sacrum. Several modifications in the V‐Y procedures have been described to achieve effective advancement of the available tissue and to decrease tension along the closure line 16, 17, 18, 19, 20, 21, 22. Campus et al.(16) used unilateral modified V‐Y advancement flap to close rhomboidal defect. The disadvantage of this modification was the requirement of the excision of extra healthy tissue to convert a circular defect in to a rhomboidal one.Vaubel (18) combined two Limberg flaps with a V‐Y advancement flap; however, the excision of extra healthy tissue was also associated with this technique. Chen (23) refined the V‐Y advancement flaps by having a sharper angle (60° or less) at the donor site of the flap, cutting the edge of the gluteal muscle of 3 cm beyond the skin flap, and cutting most part of the gluteus muscle at a depth of only 2·5 cm (at the level of upper third portion). These improvements resulted in less tension closure of the donor site, easier closure of the advanced flaps in two planes without tension and better preservation of most part of gluteus muscular insertion to the femur and their functions. Blair et al.(23) used the V‐Y advancement flaps to close lower extremity defects, making an elliptical incision as if direct closure had been attempted, and then advanced the flaps bilaterally to close the defect in the V‐Y fashion. Because the extremities of the V‐Y flap were not used, larger defects could not be closed and midline tension was not decreased, even though larger flaps were designed. Ulusoy et al.(24) reported a modification of V‐Y advancement flap to decrease the tension in the closure and to break the midline vertical scar. The authors used bilateral extended V‐Y advancement flaps with additional limbs extending to the advancing edge of the standard flaps and hinged upper and lower extensions downward as transposition flaps to close the middle portion of the circular defect, where the maximum tension occurs. The main concern using this modified technique was ensuring the viability of the transposed extremities of the V‐Y advancement flaps although authors did not report any such problems. Akan et al.(20) transposed upper and lower extensions of the V flap of one side in to the defect and sutured it to the concave base of the opposing V flap at its midpoint. These extensions were then sutured it to each other. The extensions of the opposing V flap were then transposed in to the defect; the upper being superior and lower being inferior to the extensions of the first flap. The efficient redistribution of available tissue by the combined use of transposition and advancement principles resulted in the repair of relatively large skin defects with reduced tension along the closure.In the present study, modified slide‐in flap was done in six patients who had excellent results. Even in modified slide‐in flaps, multiple dermal incisions on the flap surface were made to decrease flap oedema, venous stasis and tension in the flap (Figure 1). In two cases of trochanteric PrUs, where large cavity was left behind after resection of femoral head, we deepitheliazed the distal portion of TFL flap and used it along with vastus lateralis muscle to fill the cavity (Figure 3). In the present study, we further improvised the technique of bilateral V‐Y advancement gluteal flap in two patients having tension along midline suture closure by giving bilateral longitudinal incision along the vertical closure line. Contrary to impairing the blood circulation at the suture line, this improvisation resulted in decreased tension at suture line which otherwise might have resulted in necrosis or flap and wound dehiscence (Figure 3). A similar procedure was done by Aggarwal et al.(10), where abscess under the flap was drained by incision along the suture. Ohjimi et al.(25) modified the musculocutaneous gluteal V‐Y advancement method and used it as a fasciocutaneous flap. This helped to close a circular defect by advancing subcutaneous pedicle triangular flaps. Ay et al.(26) used the arms of the flaps in the form of interdigitating fasciocutaneous gluteal V‐Y flaps so that more healthy tissues were included in the midline, further advancement was possible, final closure was broken and the zigzag closure decreased the tension on the midline suture over the sacrum without injury to gluteus maximus muscle. All flaps survived without major problem except in one patient in whom superficial necrosis occurred in the distal end of one arm of the flap; the wound healed without necessitating a secondary operation (26). In the present study, we performed interdigitating gluteus maximus V‐Y advancement flap in five patients with multiple dermal incisions on flap surface and achieved excellent results. Multiple dermal incisions were made in all flap surgeries in the present study. Authors are of the opinion that multiple dermal incisions decrease flap oedema, venous stasis and tension in the flap. But we have to be careful about the depth of incisions as deeper incisions can cause injury to underlying arterioles and venules resulting in flap necrosis or wound dehiscence.

In the present study, we have made certain improvisation to the classic and modified techniques of flap surgeries. These improvisations along with reinforcement of general care principles of paraplegia can be effective in minimising suture line dehiscence, graft failure and recurrence complications often associated with PrU reconstructive surgery; thus, improving the ultimate outcome of reconstructive surgery in PrUs.