Management of recurrent ischial pressure sore with gracilis muscle flap and V-Y profunda femoris artery perforator-based flap

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  • Management ogracilis muscleperforator-bas

    a,b,d, , Shb,d,

    , Depacultyaohsiun ROC

    Taiwan Nurses Association

    Gracilis flap; pressure-sore site to treat.

    muscle flap and readvancement of the VeY profunda femoris artery perforator-based flap were

    dn-adhe.2

    edetached and transposed muscle. However, for the recurrent ischial ulcer patients, readvance-ment of the perforator-based fasciocutaneous flap alone cannot provide adequate bulk to

    * Corresponding author. Address: Division of Plastic Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical University, 19 Fl, No. 100,Tz-You 1st Road, Kaohsiung 807, Taiwan. Tel.: 886 7 3208176; fax: 886 7 3111482.

    E-mail address: sushin@kmu.edu.tw (S.-S. Lee).

    1748-6815/$-seefrontmatter2008BritishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.doi:10.1016/j.bjps.2007.12.092

    Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1339e1346used to fill the dead space as well as cover the defect.Results: Among these 10 recurrent ischial pressure-sore patients, six of them had sufferebilateral ischial ulcers. Eight of them had previous sacral pressure sores. In all, 32 flap recostruction procedures were performed on these 10 patients. Unfortunately, one patient hrecurrent grade II bilateral ischial pressure sores after 11 months of ulcer-free period. Tother nine patients had no recurrence noted, and enjoyed their lives with an average 27months ulcer-free period (range 9e53 months).Conclusions: The fasciocutaneous flap provides a higher mechanical resistance than thNegative-pressuredressing

    Methods: From June 1998 to July 2006, there were 253 pressure-sore patients operated uponat Kaohsiung Medical University Hospital. Ten patients (eight men and two women) sufferedfrom recurrent ischial pressure sores, and all of them received more than one flap reconstruc-tion for the ischial defect. For the treatment of the recurrent ischial pressure sore, gracilisReceived 4 July 2007; accepted 24 December 2007

    KEYWORDSIschial pressure sore;Recurrence;Perforator flap;

    Summary Background: Inappropriate seating has been implicated as a major contributingfactor in ischial pressure-sore recurrence. During their lifetime, paraplegic patients may re-quire several flaps for closure of the same or some other adjacent pressure sore. Despite a widevariety of flap reconstruction options being described, the ischium remains the most difficultSu-Shin Lee *Kao-Ping Chang a,

    a Division of Plastic Surgeryb Department of Surgery, Fac Department of Nursing, Kd Plastic Surgical Associatioef recurrent ischial pressure sore withflap and V-Y profunda femoris arteryed flap

    u-Hung Huang a,d, Meng-Chum Chen c,e,Chung-Sheng Lai a,b,d, Sin-Daw Lin a,b,d

    rtment of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwanof Medicine, Collage of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwanng Medical University Hospital, Kaohsiung, Taiwan, Taiwan

  • aeadaci

    oftd rreh

    ofrve

    reconstruction.

    negative-pressure dressings werebase, depending on the surgeonsservative management for these uespecially for grade III or gradevancement of the myocutaneous flous flap was used to close the designificant changes in the tensioarea with different positioning oreadvanced flap lacks volume to fi

    e flap

    stomach for the first postoperation week.

    1340 S.-S. Lee et al.atively high tension across thnd wound care. Topicalused to treat the wound preference.8 Since con-lcers is often ineffective,IV ulcers,9 further read-ap or other fasciocutane-fect. However, there aren exerted across ischialf legs.7 Sometimes, thell the dead space and rel-edge causes a breakdown

    gracilis muscle flap and readvancement of the V-Y profundafemoris artery perforator-based flap were used to fill thedead space as well as to cover the defect. For theprocedure, each patient was put in the supine position.Then the ipsilateral gracilis muscle flap was elevated by thestandard method. The muscle could be felt when the legwas extended straight and externally rotated with abduc-tion of the hip. The full length of gracilis muscle washarvested (Figure 1). The dominant proximal pedicle of thismuscle was preserved. Then the patient was moved intothe prone position. The bursa of the recurrent ischialThe treatment of recurrent ischial pressure sores usuallystarts with ulcer debridement a

    For the treatment of the recurrent ischial pressure sore,obliterate the dead spacetissue. By combining the rfasciocutaneous flap and grcomplication.

    Recurrence of ulcerationrelatives have to be educatemust collaborate with theimprove long-term results. 2008 British AssociationElsevier Ltd. All rights rese

    Pressure ulcers are source of numerous complications,which result in long-term, frequent, and/or multiplehospital admissions. They constitute an important problemnot only in paraplegic but also in geriatric patients.Reconstructive surgery for pressure-sore defects presentsa difficult challenge because of the high rate of woundcomplications and recurrence.1 The incidence of pressureulceration among those with spinal cord injuries was re-ported up to 39%.2 Recurrence of ulceration often developsdespite successful flap closure, especially in paraplegic pa-tients who are able to move around in wheelchairs. Disaet al.,3 in their review of 66 cases of flap closure for pres-sure sores performed over 5.5 years, reported a 69% ulcerrecurrence in all patients. Tavakoli et al.4 reported thatthe male traumatic paraplegics had a recurrence rate of80%. During their lifetime, paraplegic patients may requireseveral flaps for closure of the same or some other adjacentpressure sore. Because of the high recurrence rate of pres-sure ulcers in these spinal cord injury patients, the possibil-ity of future reconstructive procedure should be consideredduring flap selection.

    Surgical treatment of pressure sores includes excision ofthe ulcer, underlying bony prominence and bursa if any,and closure of the defect with a flap.2,5,6 Various flap stud-ies have been performed to review the long-term result ofischial pressure sores. Foster et al.7 reviewed 139 ischialpressure sores and advised that proper flap selection andthe appropriate sequence of flap use significantly improvedsuccess rates for ischial pressure-sore coverage in both theshort and long term. He preferred the inferior gluteusmaximus island flap and gluteal thigh flap for ischial defectreconstruction with success rates of 94% and 93%, respec-tively. However, in clinical practice, a number of frequentlyrecurrent ischial pressure-sore patients caused our opera-tion team much concern as to the next step/flap forfter debridement of the bursa and the surrounding necroticvancement of V-Y profunda femoris artery perforator-basedlis muscle flap, these recurrent ischial ulcers will heal without

    en develops despite successful flap closure. Patients and theiregarding pressure relief, personal skin, and self-care. Surgeonsabilitation department, nursing staffs, and social workers to

    Plastic, Reconstructive and Aesthetic Surgeons. Published byd.

    of the wound. Accordingly, we believe that the recurrent is-chial ulcer is the most difficult pressure ulcer to treat.10 Inthis study, patients with recurrent ischial pressure soresthat were treated at Kaohsiung Medical University Hospitalover the last nine years (1998e2006) were reviewed.

    Patients and methods

    From June 1998 to July 2006, there were 253 pressure-sorepatients operated upon at Kaohsiung Medical UniversityHospital. A retrospective survey was performed and 20ischial pressure-sore patients were identified. Further de-tailed chart reviews were developed to determine thepredisposing factors causing the pressure ulcer (like levelof spinal cord injury, cerebral vascular accident, major limbamputation), incidence of rehospitalisation, ischial pres-sure-sore condition at admission, wound pus culture re-ports, types and numbers of flap reconstruction associatedwith these lesions, and the final follow-up date and result.Ten patients (eight men and 2 women) had recurrent ischialpressure sores and all of them received more than one flapreconstruction for the ischial defect. The mean age ofthese patients at first treatment was 46.3 years (range 20e70 years).

    All the pressure-sore patients were requested to prac-tice and get used to the prone position before the final flapsurgery. Before the definitive flap operation, routine socialwork and rehabilitation consultations were performed. Asfor the recurrent-pressure ulcer patients, we requestedextra help from social workers to make sure that thesepatients had at least some basic support from theirrelatives or the proper nursing care unit. Because theprone position maintained hip-joint extension and mini-mised skin tension at the ischial area, these recurrentischial pressure-sore patients were instructed to lie on their

  • pressure ulcer was stained with methyl blue, which washelpful for complete excision of the bursa. Bony promi-nence was rasped, if any. One subcutaneous tunnel wascreated to pull the gracilis muscle into the ischial cavity(Figure 2). This V-Y flap was based on the perforators com-ing from the first branch (artery perforans prima) of theprofunda femoris artery. Ultrasound Doppler AudioScopewas helpful in detecting the location of these perforators(Figure 3). Then the readvancement of the V-Y profundafemoris artery perforator-based flap was done to seal thedefect.

    In the recovery room, the patient was put in the supineposition until fully recovered from the anaesthesia and thenencouraged to keep the prone position to minimise thetension at the ischial area. Alternating air-therapy mattresswas used to reduce risks of further pressure sores. Patientswere allowed to sit but to keep off the operative site(s) for3e4 weeks after surgery.

    Results

    Among these 10 recurrent ischial pressure-sore patients, six

    tient clinical follow-up.Unfortunately, one patient (no.1) had recurrent grade II

    bilateral ischial pressure-sores again after an 11-monthulcer-free period (Figure 4). The other nine patients had norecurrence noted, and enjoyed their ulcer-free periodranging from 9 to 53 months (average 27.2 months)(Figure 5).

    Figure 3 Location identified by Ultrasound DopplerAudioScope.

    Management of recurrent ischial pressure sore 1341of them were bilateral ischial-ulcer patients. Eight of themhad suffered previous sacral pressure sores. These patientsreceived at least two flap reconstructions (range from 2 to 8times flap surgery). During the follow-up period (mean 74.2months, range from 25 to 113 months), they were hospi-talised 6.9 times on an average (range from 1 to15 times)owing to different health problems. Four of these patientshad bacteria isolated from the wound pus culture.

    A total of 32 flap reconstruction procedures wereperformed for these 10 patients (Table 1). The types offlap used included gluteus maximus myocutaneous flap(8 times), readvancement of gluteus maximus myocutane-ous flap (7 times), gluteus fasciocutaneous flap (2 times),profunda femoris artery perforator-based V-Y advancementflap (11 times), redone V-Y advancement flap (12 times),gracilis muscle flap (7 times), tensor fascia lata flap(1 time), and anterior thigh fillet flap (1 time) (Table 2).

    Figure 1 Full length of the gracilis muscle was harvested.All of the ischial defects healed successfully within 3 weeksafter the final flap surgery. They received regular outpa-

    Figure 2 One subcutaneous tunnel was created to pull thegracilis muscle into the ischial cavity.

  • Discussion

    Many factors may affect the occurrence of pressure sores.They include immobility, incontinence, and poor nutritional

    status and consciousness level changes.6 Recurrence ratesas high as 33e100% have been described, depending onthe different aetiology and age of patients.3 The overalllong-term follow-up recurrence rate of the pressure ulcer

    Table 1 Ischial pressure-sore patient data

    No. Sex Age at 1sttreatment(years)

    Predisposing factor Ischial lesion Hospitalisationduring follow-upperiod

    Follow-up(months)

    Ulcer-freefollow-up (months)

    1 Male 20 L1 burst fracture Bilateral 15 times 113 11/BilateralGrade IIulcer recurrent

    2 Male 31 L2 compression fracture Right side 14 times 107 193 Male 56 Old cerebral vascular accident Left side 2 times 99 244 Female 25 L1 and L3 compression

    fracture soreBilateral 2 times 94 52

    5 Male 59 T 12 spinal injury Bilateral 6 times 78 536 Female 56 Spinal cord injury, Left

    below-knee amputationRight side 13 times 69 19

    7 Male 37 T12 compression fracture Bilateral 2 times 54 388 Male 58 Apical bifida occulta post

    laminectomyBilateral 7 times 52 22

    9 Male 70 T4e5 spondylolisthesis Bilateral 7 times 51 910 Male 51 C-spine injury Right side 1 time 25 9

    Table 2 Flap history of patients

    No Other Pressure-sore history Flap reconstruction history

    1 Sacral ulcer 1. Bilateral gluteal maximus myocutaneous flap2. Readvancement of gluteal maximus myocutaneous flap3. Bilateral gluteal fasciocutaneous flap4. Readvancement of bilateral gluteal fasciocutaneous flap5. V-Y profunda femoralis artery perforator-based fasciocutaneous flap

    -Yflaarte-Ytan

    1342 S.-S. Lee et al.6. Readvancement of the V7. Bilateral gracilis muscle

    2 No 1. V-Y profunda femoralis2. Readvancement of the V3. Gluteal maximus myocu

    4. Readvancement of gluteal

    3 Sacral ulcer 1. V-Y profunda femoralis arte2. Gracilis muscle flap read

    4 Sacral ulcer 1. Bilateral V-Y profunda fem2. Gracilis muscle flap read

    5 No 1. Right: gluteal maximus my2. Bilateral gluteal maximus m

    6 Sacral ulcer 1. V-Y profunda femoralis arte2. Right gluteal fasciocutaneo3. Readvancement of gluteal4. Right gluteal maximus myo5. Gracilis muscle flap read

    7 Sacral ulcer 1. Anterior thigh fillet flap2. Split thickness skin graft

    8 Sacral ulcer 1. Right V-Y profunda femoral2. Left Gracilis muscle flap

    9 Sacral ulcer 1. Bilateral V-Y profunda fem2. Right readvancement of V-

    10 Sacral ulcer 1. Right V-Y profunda femoral2. Right Gracilis muscle flap flapp readvancement of V-Y flapsry perforator-based fasciocutaneous flapflapeous flap

    maximus myocutaneous flapry perforator-based fasciocutaneous flapvancement of V-Y flapsoralis artery perforator-based fasciocutaneous flapvancement of V-Y flapsocutaneous flap, Left: tensor fascia lata fasciocutaneous flapyocutaneous flapry perforator-based fasciocutaneous flapus flapfasciocutaneous flapcutaneous flapvancement of V-Y flaps

    is artery perforator-based fasciocutaneous flapV-Y profunda femoralis artery perforator-based flapsoralis artery perforator-based fasciocutaneous flapY flaps; left gluteal maximus myocutaneous flapis artery perforator-based fasciocutaneous flapreadvancement of V-Y flaps

  • Management of recurrent ischial pressure sore 1343can exceed 50%.7 Disa et al.3 studied 40 patients with 68pressure sores over an 8-year period. He concluded thatthe operative therapy for pressure sores in traumatic para-plegics and elderly, debilitated patients is not always indi-cated. However, when considerin...

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