16
Management of Pressure Sores PHILIP G. ANTYPAS, M.D. PRESSURE SORES constitute a common and serious complica- tion of spinal cord injury. It is the most common source of sepsis in paraplegics. As a cause of death, it is second only to urinary tract complications. It is estimated 2 that each pressure sore costs $5,000 in care and delays the overall rehabilitation program. In spite of significant improvements in their management, these complications remain troublesome and are often a source of frus- tration and despair to the patient and a real challenge to the med- ical care team. PATHOPHYSIOLOGY AND CAUSES OF PRESSURE SORES A pressure sore results from excessively long compression of the soft tissues between a bony prominence and the bed or chair on which the patient is resting. The earliest sign is erythema and increased skin temperature due to vasodilation. Since there is no sensation in the area of pressure, there is no discomfort to warn the patient that he/she has been in one position for too long. Con- tinued pressure renders the tissues bloodless and the resulting anoxia leads to necrosis and ulceration. 9 Such a "milieu" of devi- talized tissue is notoriously susceptible to infection, resulting in increased tissue damage, a-larger wound and loss of protein-rich fluid. A vicious cycle is established (Fig 17), leading to deteriora- tion of the patient's condition. Infection and necrosis spread to deeper structures and involve fascia, muscle, bone and joints. If not reversed in time, this vicious cycle will result in generalized sepsis and death. The most common sites for the occurrence of pressure sores are the bony prominences. More than 90% of pressure ulcers occur in the lower trunk, two thirds of these around the hips, namely, the sacral, ischial and trochanteric areas. 2, 19 Over these bony prom- inences, pressure twice as high as the normal capillary pressure was measured in the patient lying in bed.l° When skin necrosis occurs, the chances are good that deep tissue necrosis has already occurred, and has involved an area more extensive than the sore on the skin surface. Other factors contributing to the pathogenesis of pressure sores are the poor nutritional status of the patient, skin maceration, moisture, heat, soilage with urine and feces, friction and the shearing effect ofturningor sliding the patient in bed. ~, 15 229

Management of pressure sores

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Page 1: Management of pressure sores

Management of Pressure Sores

PHILIP G. ANTYPAS, M.D.

PRESSURE SORES const i tute a common and serious complica- tion of spinal cord injury. It is the most common source of sepsis in paraplegics. As a cause of death, it is second only to u r ina ry t ract complications. It is es t imated 2 tha t each pressure sore costs $5,000 in care and delays the overall rehabi l i ta t ion program. In spite of significant improvements in thei r management , these complications remain troublesome and are often a source of frus- t ra t ion and despair to the pat ient and a real challenge to the med- ical care team.

PATHOPHYSIOLOGY AND CAUSES OF PRESSURE SORES

A pressure sore results from excessively long compression of the soft t issues between a bony prominence and the bed or chair on which the pat ient is resting. The ear l iest sign is e ry thema and increased skin t empera tu re due to vasodilation. Since there is no sensat ion in the area of pressure, there is no discomfort to warn the pat ient t ha t he/she has been in one position for too long. Con- t inued pressure renders the tissues bloodless and the resul t ing anoxia leads to necrosis and ulceration. 9 Such a "milieu" of devi- talized t issue is notoriously susceptible to infection, resul t ing in increased t issue damage, a-larger wound and loss of protein-rich fluid. A vicious cycle is establ ished (Fig 17), leading to deteriora- tion of the pat ient ' s condition. Infection and necrosis spread to deeper s t ruc tures and involve fascia, muscle, bone and joints. If not reversed in t ime, this vicious cycle will resul t in generalized sepsis and death.

The most common sites for the occurrence of pressure sores are the bony prominences. More than 90% of pressure ulcers occur in the lower t runk , two thirds of these around the hips, namely, the sacral, ischial and t rochanter ic areas. 2, 19 Over these bony prom- inences, pressure twice as high as the normal capil lary pressure was measured in the pa t ien t lying in bed.l° When skin necrosis occurs, the chances are good tha t deep t issue necrosis has a l ready occurred, and has involved an area more extensive than the sore on the skin surface.

Other factors contr ibut ing to the pathogenesis of pressure sores are the poor nut r i t iona l s ta tus of the pat ient , skin macerat ion, moisture, heat , so i lage wi th ur ine and feces, friction and the shear ing effect o f t u r n i n g o r sliding the pa t ien t in bed. ~, 15

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Fig 17.-Schematic representation of the pathophysiology of pressure

ulcers.

EArHOPHYSJOLOGY OF PRESSURE-. SORES

ABSENCE OF PROTECTIVE SENSATION .. AND MOTOR FUNCTION _

+ Pressure

T ,-. Erythema

........... t,t

Superhcdat Ulc~ralton ! NECROSIS

IFL;~ I. THtC~.N[ -¢;S t/'~f)lJP,~f~

LOSS OF # " ~ IN_FECTION NUTRIENTS [ [ I1 So-ft Tissue

y Jo~nl HYPOVOLEMIA Sepl,cemia WEAKNESS

LOSS OF APPETITE DEPRESSION

PREVENTION OF PRESSURE SORES

Measures to prevent decubitus ulcers in paralyzed pat ients include rel ief of pressure, proper skin care and adequate nutr i- tion.

Relief of Pressure In t e rmi t t en t rel ief of pressure remains the most effective single

measure for the prevent ioa of pressure sores. Relieving the pres- sure for as shor t a period as 5 minutes every 2 hours will prevent pressure ulceration. 's With every change of position of the pa- tient, the skin over the pressure points should be inspected for redness and checked for t empera tu re elevation; these 2 findings are the ear l ies t warn ing signals. 2, 15 The pa t ien t is t augh t to in- spect his own skin, with the aid ofa milTor if necessary. I fe ry the- ma is noted, pressure is kept off t ha t area, The amount of contin- uous pressure tha t one site can s tand varies greatly.15 It depends pr imar i ly on the amount of subcutaneous padding over bony prominences, the presence or absence of scar t issue, the age of the pat ient , previous acclimation to pressure and the surfaces on which the pat ient lies.

MECHANICAL D E V I C E S . - - T h e r e are several devices designed to relieve pressure. ! They fall into one of 3 categories, depending on whether they (1) support specific pressure areas of the body, such as heels, hips, back and elbows; (2) aid in tu rn ing or moving a patient; and (3) support the ent i re body surface in such a way tha t pressure is e i ther reduced to a m in imum or dis t r ibuted over a larger area.

The Foster or Stryker Frames are man ipu la ted by hand and are useful for tu rn ing pat ients . The pat ient is s t rapped between 2

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canvas layers, which can be made comfortable by the judicious use of several pillows. The Circolectric bed is automatic and re- quires constant supervision. These devices are expensive, time- cori'suming, and need much nursing care personnel to manipu- late and watch. They are reserved for multiple injuries or frac- tures and for head injuries. The "alternating pressure mat- tress" (Ripple Cell Mattress) shifts the pressure to different points and provides gentle skin massage to the area. "Water beds,""mud beds" and "air-fiuidized beds" distribute pressure over the surface area of the body in contact with the bed (Pascal's Law). The Gel Pad is soft, has the consistency of subcutaneous fat, can be wrapped around pressure points (heel, elbow) or it can be put over an ordinary mattress. "Sheepskin" is applied directly to the skin, is widely used, has a wooly feeling and allows a degree of air cir- culation between the skin and the mattress. It is durable, easy to clean and relatively inexpensive. Air-filled rubber cushions with interconnected compartments, two-thirds inflated, help distrib- ute the patient 's weight evenly. For wheelchair patients, care must be taken to prevent pressure sores over the posterior edge of the greater trochanter as a result of rubbing against the sloping sides of the chair seat, even though a cushion haw been used. To prevent this, a board is used under the cushion. It could be incor- porated within the cover of the foam cushion.

None of the devices available at present provides the answer to all problems. Each has some limitation of cost, difficulty of manip- ulation or interference with daily patient care. Of all of these devices, the ones commonly used are the Gel Pad, sheepskin, al- ternat ing pressure mattress and the water bed.

Proper S k i n Care Simple washing of the skin with soap and water, "pat" drying

and the application of talcum powder is effective in keeping pro- per skin cleanliness. 1, i~ Gentle massage is helpful, but vigorous rubbing should be avoided. The skin! is kept free of urine or feces soilage. The application of "bland" Creams or lotions, lanolin or silicone-protective creams, is helpful in preventing maceration. Minor irri tation around pressure sites responds to zinc oxide ap- plication.

Adequate Nutrition Older patients and paraplegics=~who were previously in good

general health often suffer weight loss during a long illness. They lose padding of subcutaneous tissue over bony prominences. Pres- sure that caused no skin problems before the illness can no longer be tolerated. On the other hand, obesity in itself affords no protec- tion. Excessive weight discourages proper turning to avoid ulcers. Occasionally, skin burns with subsequent breakdowns are pro- duced by dragging the obese patient across a bed sheet, ra ther than elevating and turning him.

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,.~ ll t t l tncl r~ Intermittent relief of pressure is essential for the prevention of

pressure sores. A patient should not remain in one position for longer than 2 hours. Unless this is observed strictly, other mea- sures will not prevent pressure ulceration.

PREOPERATIVE PREPARATION OF PATIENTS

Control of Infection in Pressure Sores Reducing bacterial contamination and ridding the wound of

dead and devitalized tissue in preparation for operation is best accomplished by repeated cha~zge of dressings, using several lay- ers of gauze soaked with normal saline, with or without antibac- terial.agents and packed lightly into undermined edges and cavi- ties. Drainage of infected pockets and abscesses and repeated small excisions of slough can be carried out as a bedside proce- dure. Et~zylncttic debridement is too slow and costly to be effective and has not proved superior to simple saline-gauze dressings. The use of topical agents is a controversial issue. The list of topical agents used is a long one, but none is known to enhance wound healing.r,, ~s A few of the more commonly used ones are the silver sulfadiazine (used in burn wounds) and local antibiotics, namely, bacitracin, polymyxin, and neomycin. Administration of oxygen- releasing agents (hydrogen peroxide, zinc oxide) are useful in anaerobic infections. They also eliminate foul odors and loosen slough. Hyperbaric oxygen therapy to the entire body or locally to the ulcer has been tried with promising results. 1 However, the apparatus is too cumbersome and expensive to be of practical value on a large scale. The value of systemic antibiotics is debat- able. There is no general agreement as to whether the prophylac- tic use of antibiotics is justified. 7' ~ Antibiotics are generally giv- en to pat ients with invasive local infection, generalized sepsis with fever, tachycardia, prostration or toxicity, and for coverage 24 hours before and 3 - 5 days after operation.

In practice, most of the patients with pressure sores eventually receive antibiotics for the treatment of one or more of several problems, e.g., urinary tract infection, pulmonary or other com- plications. The choice of" the antibiotic agent is determined by cul- ture and sensitivity studies from the wound and blood. In a series of 21 patients with decubitus ulcers, Golpin et al. found bactere- mia in 76%. Bacteremia involved obligate anaerobes in 50% and was polymicrobial in 50%. If there is massive infection, antibiot- ics are started before the results of culture are available. The choice would include a broad-spectrum antibiotic or a combina- tion that is effective against anaerobes and aerobes. The combi- nation of antibiotics most commonly advocated for sepsis in pres- sure sores is an aminoglycoside (gentamycin or kanamycin) for gram-negative bacteria, clindamycin or chloramphenicol for an- aerobes, and one or more of the following: ampicillin, methicillin,

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penicillin or cephalosporin. A thorough knowledge of the toxic effects of these agents is essential. Most paraplegics develop renal complications. Insult is added to injury by the injudicious admin- istration of antibiotics that are nephrotoxic.

Summary Surgical debridement remains the most effective way to control

infection resulting from pressure sores. The use of topical agents and systemic antibiotics is adjuvant to therapy, but should not delay definitive surgical intervention unduly. In septic patients, the mortality rate following conservative therapy is higher than with surgical debridementJ

SUPPORTIVE THERAPY

Chronic protein depletion is common in bedridden paraplegic patients with pressure sores. This delays wound healing, retards maturat ion of connective tissue and delays tensile s trength of the wound. A diet high in protein, calories and vitamins (especially vitamin C, for its role in wound healing) is given by mouth. Hy- peral imentat ion is used if the patient is unable to take food in adequate quantities by mouth. Hormones (androgens) are given as anabolic agents. They have reportedly been effective in rever- sing tissue breakdown in severely injured, bedridden, immobi- lized patients. ~.~ Blood transfusions are given to restore red cell mass to a hematocrit of 36%. Iron is given to correct anemia. Hemoglobin level should be at least 12 gin/100 ml.

Other preoperative preparations include bowel cleansing be- fore surgery. Paregoric is given to control bowels for a few days to avoid a bowel movement and the danger of soilage of the wound postoperatively. Preoperative x-ray studies of bones and joints and sinograms are made in order to determine the extent of the disease. ~'

CONTROL OF MUSCLE SPASMS

Surgery on ulcers in the ischial or trochanteric sites are doomed in the presence of severe spasms. ~2 Muscle spasms, post- operatively, can cause hematomas, infection and wound disrup- tion. They will also make it difficult to keep the patient in the prone position and avoid pressure on flaps. Therefore, spasms must be reduced or e l imina ted during the preoperative period. (Control of spasm is discussed at length elsewhere in this mono- graph:)

SURGERY FOR PRESSURE ULCERS

The objectives of surgery for pressure sores include debride- ment of dead and nonviable tissue and early closure by the method most appropriate for tha t patient.

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Deb ridemen t To be adequate, debridement should include all dead and non-

viable or devitalized tissue and infected granulation tissue. If any diseased tissue is left behind, the chances of rec.urrence or persis- tence of ulcers are increased. Sinus tracts are followed and if found to be involved, are excised in their entirety, including bursae, joints and bones. Sinography performed preoperatively is helpful in determining the extent of the disease, l' A small sinus opening in the skin often leads to extensive, deep and wide pockets of infection. The injection of methylene blue and hydrogen peroxide (in equal parts) into the sinus opening at the time of operation, is helpful in identifying the extent of infected tissue that should be included in the debridement. The adequacy of excision is deter- mined by the presence of diffuse, brisk capillary bleeding (not an occasional spurter) from the excised skin margins and by the skin color and capillary refill after pressure. Bony prominences and pressure points over the sacrum, ischium and greater trochanter are leveled off. All diseased bone and joints are included in the de- bridement. If not involved in the disease process, these bony pro- tuberances are excised conservatively but adequately, in order to prevent recurrence. Adequate padding with muscle and myo- cutaneous flaps has precluded the need to perform radical exci- sion of the sacrum or ischium. Such excisions are fl-aught with the danger of troublesome bleeding from the sacrum and fistula for- mation from injury to the rectum or urethra following total ischiectomy. The greater troehanter is resected flush with the femoral shaft. If sharp edges and prominences are eliminated, the risks of recurrence of pressure ulcers are greatly reduced.

Wound Closure Wound closure is performed immediately after debridement.

Flaps can be rotated or transposed in one stage without a delay procedure. Closure of wounds is intended to provide soft tissue padding over the pressure areas and to introduce well-vascular- ized tissue for healing. By closing the open ulcer, the toss of pro- tein-rich exudate is prevented, infection is controlled, and posi- tive nitrogen balance is established and the downhill course of the patient is reversed.

Closure can be effected in any one stage or by a combination of methods. Primary closure is possible in small, deep ulcers, provid- ed the adjacent skin is soft and not scarred. Most often this is not feasible and tension on the suture line precludes primary closure. Coverage is most often effected by skin [laps (skin and subcuta- neous tissue), muscle or myocutaneous flaps, and skin grafts to the donor defect, s, r_,, ,,~, ~:,

Skin Grafts Split-thickness skin grafts (STSG) are used primarily for clo-

sure of flap donor areas and for covering external surfaces of mus- cles turned over to cover defects or fill cavities. Reverse dermal

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skin grafts"-" have no place in the coverage of decubitus ulcers. They provide little protection and do not enhance blood supply to the healing wound, More versatile skin flaps and muscle flaps have eliminated the use of reverse dermal grafts. Meshed grafts, which allow for drainage, reduce the risk of hematoma collection and infection, They also contour better around convex surfaces, r~

Skin, (and Subcutaneous Tissue) Flaps These flaps are hinged on their pedicle for blood supply. Several

such flaps are available in the gluteal and thigh areas. They can be transposed or rotated without delay, provided the length-to- width ratio does not exceed 2 : 1. The donor defect is covered with a split-thickness skin graft. Either simple or meshed grafts are used.

Muscle Flaps These are axial flaps. They should have at least one major vas-

cular bundle that supplies the muscle belly bulk. It usually en- ters the proximal third of the muscle belly. Muscle flaps are used to cover large defects or dead spaces resulting from disarticula- tion of the hip joint, or after ischiectomy. They can be surfaced with a skin flap or, if this is not available, with a split-thickness skin graft.

Myoc u ta neo us Flaps Myocutaneous flaps provide good skin coverage and soft tissue

padding and enhance vascularization of the skin through perfo- rating vessels from the underlying muscle. This is particularly useful in recurrent or scarred areas with reduced vascularization, where a skin flap alone has little chance of survival (Figs 18- 29).

Fig 18.-A, sacral ulcer and gluteal skin flap. B, flap rotated, sutured, and donor area covered with split-thickness skin graft, No tie-over sutures are applied to the skin graft adjacent to the flap.

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\ 4 +

4 4

C :~ ""':"~:', ~~<~'~'i'!::::-~, ,.:,' , : " ' ~

I=1£ 19.--A, sacral ulcer and gluteus maximus myocutaneous flap. B, muscle-skin flap elevated. C, vascular bundle (retracted with hook). D, primary wound closure, no skin graft was needed. Note 2 suction drainage catheters on upper right. E, final result.

Principles of Flap Coverage The following general guidelines are essential for the success-

ful closure ofdecubitus wounds: 1. A good knowledge and familiarity with the anatomy and vas-

cular supply of skin and muscle flaps and the location of the vas- cular pedicles is essential.

2. Gentle handling of tissues, according to sound surgical prin- cip|es and techniques, is recommended.

3. Flaps are designed to be larger than the defects, to allow for rotation and closure without tension.

4. No tie-over sutures are anchored to the flap margin where a skin graft is applied adjacent to a flap.

5. Adequate suction drainage is insti tuted to prevent hemato- ma formation and infection. Suction tubes are checked frequently and their pa~ncy is assured at all times.

6. Adequacy of flap circulation is tested before the flap is su- tured in place. Return of color after compression a n d bleeding from the edges are helpful means to evaluate circulation. The- fluorescein test 1~ is an effective, simple and safe test o£ flap circu- lation adequacy. The patient is given 10 ml of 10% fluorescein

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:<.,

Fig 20.-A, recurrent ischial ulcer with a small skin sinus opening (X). B, extensive undermining seen by sinography. C, excision and primary closure performed without tension on the suture line. Injection of methylene blue at the time of surgery helps identify the extent of disease.

solution intravenously in one shot after the flap is raised. About 15 minutes later, the flap color is observed under a Woods lamp (ultraviolet light). The presence of fluorescence indicates ade- quate circulation. Sometimes, patch, absence of fluorescein may occur in viable flaps. The patient is ~ rarned that a yellow tinge of the skin may persist for several da ,s. Flap margins that do not fluoresce should be excised, leaving a flap with adequate circula- tion for healing.

7. "Dog ears" are not excised a the time of operation. They provide added padding and will sh7 mk within a few months.

8. Suture lines are kept away from the center of the ulcer (pressure points).

9. The choice of anesthesia, i.e., general, local or sedation, is made on the basis of whether the skin graft donor area is anes- thetic or sensitive. The length of time, extent of surgery and the patient's tolerance to discomfort, patience and readiness to coop- erate during the procedure are also taken into account. An anes- thesiologist is in attendance to monitor the patient's condition throughout the procedure.

S u m m a r y o f F laps C o m m o n l y U s e d f o r P ressu re U l c e r C o v e r a g e

Location of Ulcer • Type of Flap

A. Sacral 1. Gluteal, rotation skin flap (based superiorly or inferiorly), primary

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closure or STSG to donor defect. 2. Gluteus maximus muscle turnover

flap. STSG over muscle. 3. Gluteus maximus myocutaneous flap.

Pr imary closure or STSG to donor defect.

4. Transverse flap (crosses midline). STSG to defect.

B. Ischia] 1, Posterior thigh skin flap (medially based). STSG to donor defect.

2. "Saddle flap," STSG to donor defect. 3. Biceps femoris or semitendenosus

muscle flap. STSG over muscle. 4. Gluteus maximus myocutaneous flap

based superiorly. STSG to donor defect. 5. Gracilis muscle or myocutaneous flap.

Pr imary closure or STSG to donor defect.

C. Trochanteric 1. Adjacent rotation flap (based anterior-

Fi9 21.-A, recurrent ischial ulcer, previously operated on (note skin graft donor area on thigh). B, excision of ulcer and ischium, posterior thigh skin flap outlined. C, flap raised and transferred. D, radiograph of ischial bone. E, closure of wound and split-thickness skin graft to secondary defect. F, final result.

" ~ . : ~ . ' . , ... ~ / , . • , , .. : . . , . • . , ~ : .

- _ - - - . - . : , ~ . ~ v ~ H ~ l n ~ . " , ~ - . , ~ U ~ D C ~ L . v ~ I " ~

~9.',;~ ~-~, ::'~

238

Page 11: Management of pressure sores

. , , , , ~ - . , ,~ ,~ :

Fig 22.-A, ischial ulcer and a myocutaneous flap (gluteus maximus). B, flap raised. C, closure of wound. Note: a larger flap could have eliminated the undesirable suture line over the previous ulcer site.

D. Heel

ly or posteriorly). STSG to donor defect. 2. Tensor fascia la ta myocutaneous flap

(island flap). Primary closure or STSG to donor defect.

3. Vastus lateralis muscle turnover flapl STSG over muscle.

4. Bipedicle skin flap. STSG to donor defect. Rarely used.

5. Groin skin flap. STSG to donor defect. Rarely used.

1. Flexor digitorum brevis or abductor digitorum brevis. STSG over muscle.

P O S T O P E R A T I V E C A R E

Close observation of vital signs and replacement of blood lost intraoperatively is essential during the first postoperative day. Patency of the suction tubes is established at all times. The pa- tient is kept constipated for 2 or 3 days. He is put in the prone po- sition to keep pressure off the operated areas. Flaps are inspected for cyanosis or hematoma. Drains are removed after 3 - 5 days, or when drainage is less than 50 ml per day. Patient's activity is started after the 3d week, with gradual and slow return to pre- operative level, and increasing periods of sitting, starting with 15 minutes 3 or 4 times daily: Physical therapy is started and joint motion is encouraged.

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Fig 23.-#., left trochanteric ulcer. Tensor fascia lata myocutaneous flap. B, ulcer excised, flap raised and fascia closed. C, myocutaneous flap sutured over ulcer defect and split-thickness skin graft applied to donor area. D, final result. Note excessive padding provided by myocutaneous flap.

Fig 24. -A, right trochanteric ulcer (patient in prone lr~osition) and incision lines to expose vastus lateralis (VL) muscle. B, VL muscte raised. Note vessels entering muscle (arrow). C, muscle turned over to fill defect. D, healed skin graft covering muscle.

" " ' ; ,,.-~'~,~.'~:t,i'~,'. ' . ' : ' ~ . . . . . . . . , ~ c ~ , ~ : - , _ ,

~ . . . . . . . ~; :~i ~.,I,

240

Page 13: Management of pressure sores

POSTOPERATIVE COMPLICATIONS

Complications will occur in spite of careful preparation of the patient and adherence to basic principles of surgery. Most of these complications are directly or indirectly related to wound healing. Hematoma is a serious complication that may lead to infection and wound separation or necrosis. [remedY.ate evacua- tion of the hematoma is carried out, bleeders are controlled and suction drainage is reestablished. Paraplegic patients are prone to hemorrhage and, therefore, careful hemostasis during opera- tion is essential. The surgeon should not rely on pressure to con- trol bleeding,'and dressings should be light. Inadequate circuit1. tion to the flap during the first 24- 48 hours is managed by remov- al of sutures, evacuation of a hematoma, or adjusting the pa- tient's position to relieve any tension on the flap. If all measures fail to salvage the flap, early excision of the nonviable segment of the flap is carried out before infection sets in. Primary closure without tension or skin grafting is done. Infection is usually due to impaired vascularity or hematoma and resultant necrosis. The treatment consists of drainage, antibiotics, and immobilization. Two-way irrigation using normal saline solution with antibiotics (5,000 p,m Bacitracin, 50 mg polymyxin or 1 gm neomycin in 1,000 ral of normal saline solution) has given encouraging re- sults. !~' Skin graft loss is not uncommon, but it is:not a serious comp~,ication if loss is limited to a small portion of the graft. If the area of skin loss is large, it may require regrafting as soon as the wound is clean and healthy. Recurrence of ulcers is not un- common if the factors that initiated pressure sores continue to ex- is/t. Such factors as continuous unrelieved pressure, inadequate excision of bony pressure points, inadequate padding, uncon- trolled severe spasms, infection or other complications, will inter- fere with wound healing and result in wound disruption and ul- ceration. Continuity of care at home and education of the patient and his family in reporting early warning signs, as well as good follow-up are important in preventing recurrence.

SPECIAL PROBLEMS

Multiple recurrent ulcers in patients with fixed hip or knee joints can be managed by proximal femoral resection TM or filet amputation and the use of the entire skin and muscles of the thigh as a flap to cover the ulcers and provide a good sitting pad. The loss of dead weight of the extremity gives the patient added mobility. Bilateral amputation :as advocated by some authors 3 is reserved for very selected cases and only when the patient and surgeon understand the implications, advantages and disadvan- tages of such an undertaking. Pressure ulcers over the iliac spine or the elbow are usually managed by excising the underlying

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Fig 25.-A, right trochanteric ulcer, anterior thigh (spiral) rotation skin flap. B, defect covered with skin flap, donor area covered with split-thickness skin graft. Dog ear gives added padding,

bone and closing the overlying skin. Ulcers over the heels can be excised and covered with one of the foot muscles, e.g., flexor digi- to rum brevis or abductor digi torum brevis. Around the knee, lo- cal skin flaps are too risky. The gast rocnemius muscle is used as a flap to cover such defects. In nonparaplegic patients or in para- plegic ones who have a reversible lesion, conservat ism is advised and muscle flaps should not be used. In terminal, patients, conser- vative the rapy is preferred. These patients, usual ly debili tated, are poor surgical risks. In isolated cases, where fulminating sep- sis resul ts from ulcer infection, guil lotine thigh amputa t ion is performed as a life-saving measure.

FUTURE PROSPECTS

Daniel and Terzis ~ and Dibbell ~ have described skin flaps that contain sensory nerve supply. These flaps are outl ined to corre- spond to the intercostal vessels and nerves and have been trans- posed to the region of the sacrum to provide protective sensation.

Fig 26.-A, multiple ulcers (right trochanteric and ischial) in a paraplegic patient with fixed hip and knee joints. B, filet amputation performed and soft tissues used as a flap to cover both defects, In selected cases, amputation may be the quickest and most effective method to close the u~cers and rehabilitate the patient.

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',C:/~:',%:~.~'X.~*Y',~'.,~ ~ ' ~ ' ~ : " ~ ' " " ~ ; : ' ~ . . ! " : " . . . . , " '

Fig 27.--A, bilateral ischial ulcers and outline of gracilis myocutaneous flap (vascular bundle located 6 cm distal to pubic tubercle). B, ulcer and bone excised and flap rotated. C, final closure. Donor defects closed primarily.

Although the resul ts are encouraging, the type of sensation pro- vided is crude and the operation is a major under taking. Free f laps 5 consisting of skin or musculocutaneous flaps, have been t ransp lan ted by microneurovascular anastomosis to a different site to restore not only ar ter ia l and venous flow, but also nerve function, e i ther by direct anastomosis or by a bridging nerve graft. T e m p e r a t u r e a n d p r e s s u r e sensors have been developed by biomedical engineers. '", ,T These can give visual or audi tory stim- uli every 10 minu tes and will stop automat ica l ly after pressure has been relieved for 1 0 - 1 5 seconds. The appara tus is cumber- some and requires a conscious patient . Results will have to awai t fur ther clinical t r ia ls and ref inements in the apparatus .

B e d s or m a t t r e s s e s designed to tu rn the pa t ien t manua l ly or au toma t i ca l l y a t set intervals, could save t ime and labor, espe- cially when 24-hour nursiffg care is not available. Exist ing mod- els, e.g., pa t ien t tu rn ing air mat t ress , could serve as a basis for developing such a mat t ress . F u r t h e r improvements and refine- ments are needed to make it practical, economical, safe and easy to use at home as well as in the hospital.

REFERENCES

1. Berecek, K. H.: Treatment of decubitus ulcers, Nurs. Clin. North Am. 10:171, 1975.

2. Berecek, K. H.: Etiology of decubitus ulcers, Nurs. Clin. North Am. 10:157, 1975.

3. Chase, R., and White, W.: Bilateral amputation in rehabilitation of paraple- gics, Plastic and Reconstructive Surgery 24:445, 1959.

4. Daniel, R. K., and Terzis, J. K.: Sensory flaps for coverage of pressure sores in paraplegic patients, Plastic and Reconstructive Surgery 58:317, 1976.

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6. Dibbell, D. G.: Useofa long island flap to bring sensation to the sacral area in young paraplegics, Plast. Reconstruct. Surg. 54:220, 1974.

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9. Griflitb, B. H.: Modern Trends in Plastic Surgery (2d series) Washington: Butterworth, 1966), chap. 6, p. 150.

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12. Mathes) S., Vasconez, L., and Jurkiewicz, M.: Extensions and further applica- tions of muscle flap transposition, Plastic and Reconstructive Surgery 60:6, 1977.

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16. Stallings, J. O., Delgado, J. P., and Converse, J. M.: Turnover island flap of gluteus maximus muscle for the repair of sacral decubitus ulcers, Plastic and Reconstructive Surgery 56:52, 1974.

17. Trandel, R. S., and Lewis, D. W.: A small pliable humidity sensor with special reference to the prevention of decubitus ulcers, J. Am. Geriatr. Soc. 23:322, 1975.

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19. Vasconez, L. O., Schneider, W. J., and Jurkieweiz, M. H.: Pressure sores, Curr. Probl. Surg. XIV, no. 4, April, 1977.

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