Recurrence rates of ischial sores in para- and tetraplegics treated with hamstring flaps: an 8-year study

K. Tavakoli, S. Rutkowski*, C. Cope, M. Hassall, R. Barnett, M. Richards and J. Vandervord

Department of Plastic and Reconstructive Surgery and, *The Spinal Injuries Unit, Royal North Shore Hospital,Sydney, New South Wales, Australia

SUMMARY. We have collected data on the second follow-up of 27 patients who underwent musculocutaneousflap closure of their ischial pressure sores. Thirty-seven ulcers were operated on between 1988 and 1993 using theV–Y advancement hamstring musculocutaneous island flap. At the initial follow-up (mean = 20 months) in 1993,despite 33% of patients having had recurrent ulcers and 14.8% having undergone re-advancements, only 14% ofpatients had non-healing ulcers.

In 1997, follow-up period ranged from 18 to 90 months, with a mean of 62 months. Four patients were lost tofollow-up resulting in 23 patients (n = 23) for the current study. Nine patients were tetraplegic and the remaining14 were paraplegic. Four of the 23 patients had died at follow-up therefore making the number of living patients19 (n = 19). The total number of ulcers operated on in the current study was 29 (U = 29). Overall, ulcer andpatient recurrence rates were 41.4% and 47.8% respectively. Despite this, 89.5% of patients had intact flaps at thetime of follow-up.

We recommend the use of the hamstring V–Y musculocutaneous flap as a reliable and safe reconstructivemodality in the management of ischial pressure sores and by identifying the group of patients susceptible to ulcerrecurrence we have proposed a protocol for their long-term follow-up.

Keywords: pressure sores, ischial sore, recurrence, musculocutaneous flap, hamstring flap.

British Journal of Plastic Surgery (1999), 52, 476–479© 1999 The British Association of Plastic Surgeons

Pressure sores have been a problem since ancienttimes. In 1961, Thomson Rowling described pressureulcers seen during autopsy on Egyptian mummies.1

They have perplexed as well as vexed surgeons andphysicians alike. It is well established, as early as the19th Century by Brown-Sequard and Paget, that theprincipal, if not the sole, cause of the pressure ulcera-tion is excess pressure on bony prominences in suscep-tible individuals.2 In the management of recurrentpressure sores the latter fact must be properly assessed.

As we approach the next millennium, the gradualdecline in mortality rates from spinal cord injuriescoupled with an ageing population have led to anincrease in the group of patients prone to developingpressure sores. The mortality rate for patients withspinal cord injury has substantially reduced from astaggering 80% in the pre-antibiotic era to a current7%. The life expectancy of patients with spinal cordinjury in New South Wales is now 75% and 90% of theyears that would normally remain for tetraplegics andparaplegics respectively.3,4

In a literature review in 1996, Byrne and Salzbergstudied the major risk factors for pressure sores in thespinal cord disabled. It was concluded that cost esti-mates for treatment of pressure ulcers in the UnitedStates as a quarter of the total cost of caring for spinalcord injury patients, and it was proposed that changesin the health care system should include cost efficientand timely prevention programs to contain thesemedical costs in the future.5

In 1964, Dansereau and Conway published the

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largest series of pressure ulcers per various anatomicalsites.6 They evaluated 1604 pressure sores in 649patients from the Bronx Veterans AdministrationHospital and concluded that the ischial tuberosity isthe commonest site for pressure sores, accounting for28% of all ulcers. There have been many papers writ-ten about the closure of pressure ulcers in the past20 years. John Staige Davis first described the use of askin flap in the management of pressure sores in1938.2 In 1949, Blocksma et al rotated the bicepsfemoris muscle stump to cover ischium exposed as aresult of radical isciectomy.7 A revolution occurred inthe closure of pressure ulcers with the development ofmusculocutaneous flaps in reconstructive surgery inthe late 1970s. This enabled the greatly improvedblood supply, mobility and cavity filling abilities ofthese flaps to be used resulting in superior flap reliabil-ity and reduced recurrence rate. From its initialdescription by McCraw et al in 1977, the bicepsfemoris musculocutaneous flap, in its modified form,has become an invaluable tool in the armoury of thereconstructive surgeon.8 Tobin et al introduced thenotion of using the biceps femoris musculocutaneousflap as an advancement flap.9 In 1981, Hurteau et alsuggested the addition of semimembranous and semi-tendinous muscles together with a triangular overlyingskin paddle and advancing the musculocutaneous flapin a V–Y manner.10 Quaba and colleagues describedthe extended role of the biceps femoris musculo-cutaneous flap in resurfacing defects on the antero-lateral aspect of the thigh.11 Recently, the outcome of

Recurrent ischial sores after hamstring flap repair 477

Table 1 Pressure sore recurrence rates per diagnosis andaetiology

Recurrence rate

Paraplegics 57.1%Tetraplegics 33.3%Traumatic 41.2%Non-traumatic 66.7%

27 patients with ischial pressure ulcers operated onbetween 1988 and 1993, at the Royal North ShoreHospital, was reviewed and published.12

Despite the overwhelming literature on the surgicalanatomy and operative techniques relating to the ham-string V–Y musculocutaneous flap,8–11 there is little onthe recurrence rates of ischial pressure sores in thespinal injury patients. The aim of this paper is toexamine the long-term data pertaining to hamstringV–Y musculocutaneous flaps with a view to analysingour management strategies in the follow-up of thesepatients.

Materials and method

We have previously reported on the means of patientselection, operative results and complications, at amean follow-up of 20 months.12 A retrospective analy-sis of long-term recurrence rate of pressure ulcers inthese patients was undertaken in 1997, with a view toanalysing the efficacy of our treatment protocol inrelation to both the surgery and postoperative preven-tative measures.

Methods of data collection included examinationof patients, medical record reviews including the out-patient notes, telephone contact with the patient or aclose family member or discussion with the patient’sfamily practitioner.

The information pertained to the overall health ofthe patient, evidence of any recurrence of ischialpressure sores and the current state of the flaps.Recurrence was defined as new ulceration on theoperated side. The time of recurrence was the timefrom the operation to the occurrence of flap break-down. Recurrence rate was calculated for bothpatient and ulcer. The state of flaps in those patientswho had died was noted and incorporated in the finalanalysis.

Results

There were four patients in the original study (n = 27)who were lost to follow-up in the current study(n = 23). Of this number, four patients had died, butthe state of their flaps had been known prior to theirdeaths. Six patients had bilateral ischial pressure ulcersand had undergone operations on both sides.

Of the four deaths recorded, two had intact skin atthe time of death and one died as a result of chronicosteomyelitis brought about by the infected recurrentpressure ulcer. The last patient died due to malignancyin the sacrum, which was the initial cause of paraplegia.

The age of the 23 patients ranged from 18 to 77years with a mean of 43.7 years. There were 13 malesto 10 females. Nine patients were tetraplegic (39.1%)and the remaining 14 were paraplegic (60.9%). Theaetiology of spinal cord injury (SCI) was secondary totrauma in 16 (73.9%) and non-traumatic (e.g. trans-verse myelitis) in 7 patients (26.1%).

Follow-up ranged from 18 to 90 months with amean of 62 months. Seven flaps (24.1%) had toundergo at least one re-advancement because of

pressure sore recurrence with only one patient requir-ing a second re-advancement. The period of recur-rence ranged from 0.5 to 70 months with a mean of 22months. The figures revealed that 53.8% of males inthe study developed recurrence of their ulcers com-pared to 40% of females. The mean age of patientswith recurrence was 37.8 years.

Recurrence rates of pressure sores were recorded bypatient and by ulcer. The overall ulcer and patientrecurrences were 41.4% and 47.8% respectively.Therefore, it was noted that 58.6% of all flaps hadnever broken down. Furthermore, in 1997, 17 out of19 patients (89.5%) still living were found not to showany evidence of ulceration in the region of their flaps.

Analysis of the data in the patients with pressuresore recurrences identified a number of problemgroups. In the six patients with non-traumatic SCI, therecurrence rate was 66.7%. This figure compared to arecurrence rate of 41.2% seen in the traumatic group.Furthermore, the recurrence rates seen in thetetraplegic versus paraplegic patients were 33.3% and57.1% respectively (Table 1).

Recurrence rate was particularly significant (80.0%)in the males with traumatic paraplegia where the dis-ability had been present for a relatively short time.Further analysis of male patients with traumatic SCIrevealed a mean age of 44 years in the intact group asopposed to 28 years in those with recurrent pressuresores.

It was also noted that two out of three patients whowere of Aboriginal background suffered recurrenceand in one of these patients pelvic osteomyelitis wasthe cause of death. In three patients living in the ruralareas delayed detection and referral led to majorbreakdown of intact flaps.

Statistical analysis was applied using the chi-squareand Fisher’s exact tests. Due to small sample size,statistical analyses were found to be insignificant.

Discussion

It is generally accepted that in the management ofpressure sores, the best surgical outcome can easily bejeopardised by the ill informed or the non-compliantpatient.13 Despite this simple fact, the bulk of the liter-ature to date has dealt with mainly technical aspects ofpressure sore management.7–11

Long-term follow-up of musculocutaneous flapclosure of pressure sores has demonstrated wide vari-ability in recurrence rates.14–17 In 1979, Hentz reviewedthe result of 15 muscle flaps performed on 50 unilat-eral ischial ulcers. He reported one ulcer recurrence

478 British Journal of Plastic Surgery

in this group of patients.15 A 33% recurrence rate ofpressure sores repaired using musculocutaneous flapswas reported by Relander and Palmer, in a studyspanning 12 years.16

Disa et al, in their review of 66 cases of flap closureof pressure sores performed over 5.5 years, reported a69% ulcer recurrence in all the patients. This studyincluded both cutaneous and musculocutaneous flapsin which the V–Y hamstring flap only constituted fourof the total number of flaps used for reconstruction.The mean period for ulcer recurrence was 9.3 months.They identified two groups of patients in which thesurgical reconstruction of pressure sores may not bebeneficial. Analysis of data pertaining to the youngpost-traumatic paraplegics and the cerebrally compro-mised elderly revealed recurrence rates in the order of 79% and 69% respectively. They argued that poorpatient compliance governed by their personalities,social situation and family network were responsiblefor the high recurrence rate.17

Although different studies in essence, there havebeen certain parallels between our results and thoseobtained by Disa et al.17 In this study, we were able todemonstrate that 47.8% of all patients had recurrentulceration with a mean of 22 months. Initial analysisidentified two groups of patients with high recurrencerates: the paraplegics (57.1%) and the patients inwhich the cause of their SCI was non-traumatic(66.7%). Further examination of the former grouprevealed that the male traumatic paraplegics had arecurrence rate of 80% compared to the rest of thestudy. In a similar study conducted by our unit alltypes of pressure sores surgically treated over a 5-yearperiod were examined. Long-term follow-up revealeda similar overall recurrence rate (50%) to the currentstudy (Barnett, 1994: presentation).

The group of patients requiring major interventionfor pressure sores represents a small but significantnumber of the total prevalent population of approxi-mately 3000 patients with spinal cord injury managedby Royal North Shore Hospital Spinal Injuries Unit.3

The cost to the community is enormous in thesepatients who require valuable resources includinglengthy hospital stays.4 Closure of pressure sores byoperative measures such as the V–Y hamstring flapreduces the length of stay in hospital for healing,5,17

however significant recurrence as demonstrated in thisstudy and others indicates that more tertiary preventa-tive measures in the follow-up period are required. Itappears from our study that the first 2 postoperativeyears are particularly significant and stringent follow-up at least during this period may help reduce therecurrence rate. Others have argued for the duration offollow-up not to be related to the recurrence of pres-sure sores in their study.17

In this study it was noted that flap re-advancementcould easily be performed. Technically the re-advance-ment involved mobilising the proximal musculocuta-neous border without the need for detailed dissectionof the perforating vasculature, already performed inthe initial operation. Furthermore, the complicationrate was no different in the group of patients undergo-ing flap revisions.

Our results have indicated existence of certainvariables that suggest a greater potential risk of ulcerrecurrence. These psychological and behavioural fac-tors must be taken into account when preparing pre-vention strategies and education of patients and theircarers.18 The younger age of male patients with trau-matic lesions suffering from recurrence of ulcers sug-gests risk factors may be related to lifestyle activities(sporting and leisure) which led to neglect of skin careor which reduce awareness of vigilance.17 In thesepatients ischial sore recurrence was attributed to pro-longed pressure on bony prominences directly as aresult of activities such as abseiling, motor racing androwing.

Drug and alcohol were other causative factors inpressure ulcer recurrence in the younger group ofpatients. Episodes of binge drinking were responsiblefor recurrences in at least two patients. Cultural differ-ences need to be addressed in the discharge process,with more network planning to be done in thosebelonging to the minority groups, such as theAborigines. Follow-up process in these groups ofpatients needs to be more rigorous and frequent, withpooling of resources in establishment of a regularmobile spinal team for those living in the metropolitanarea. Furthermore, better education and more effec-tive communication between the spinal team and ruralmedical practitioners may lead to an earlier detectionof pressure sore problems and appropriate referral ofthose patients living out in the country areas.

Inappropriate seating has been implicated as amajor contributing factor in pressure sore recurrence.Establishment of a multidisciplinary seating clinicwhere pressure over prominences can be measured andfitting of custom made cushions can take place is rec-ommended. Regular visits are mandatory in order tomonitor any ongoing changes with early detection ofpressure area problems.

We believe that the use of the V–Y hamstring flap is justified and the recurrence rates demonstrated inthis study are comparable to those published in theliterature.14–17 However, it has become apparent to us that although the hamstring flaps represent a reli-able alternative in the management of pressure ulcers,it is the meticulous education and prompt follow-upthat ensures surgical reconstruction will remain themainstay of treatment in this very select group ofpatients.

References1. Thomson Rowling J. Pathological changes in mummies. Proc R

Soc Med 1961; 54: 409–14.2. Davis JS. The operative treatment of scars following bedsores.

Surgery 1938; 3: 1–7.3. Walsh J. Costs of spinal cord injury in Australia. Paraplegia

1988; 26: 380–8.4. Yeo JD, Walsh J, Rutkowski S, Soden R, Craven M, Middleton

J. Mortality following spinal cord injury. Spinal Cord 1998;36: 329–36.

5. Byrne DW, Salzberg CA. Major risk factors for pressure ulcersin the spinal cord disabled: a literature review. Spinal Cord1996; 34: 255–63.

6. Dansereau JG, Conway H. Closure of decubiti in paraplegics.Report on 2000 cases. Plast Reconstr Surg 1964; 33: 474–80.

Recurrent ischial sores after hamstring flap repair 479

7. Blocksma R, Kostrubala JG, Greeley PW. The surgical repair ofdecubitus ulcers in paraplegics: further observations. PlastReconstr Surg 1949; 4: 123–32.

8. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent myocutaneous vascular territories. PlastReconstr Surg 1977; 60: 341–52.

9. Tobin GR, Sanders BP, Man D, Weiner LJ. The biceps femorismyocutaneous advancement flap: a useful modification forischial pressure ulcer reconstruction. Ann Plast Surg 1981; 6:396–401.

10. Hurteau JE, Bostwick J, Nahai F, Hester R, Jurkiewicz MJ.V–Y advancement of hamstring musculocutaneous flap forcoverage of ischial pressure sores. Plast Reconstr Surg 1981;68: 539–42.

11. Quaba AA, Chapman R, Hackett MEJ. Extended applicationof the biceps femoris musculocutaneous flap. Plast ReconstrSurg 1988; 81: 94–105.

12. Cope C, Barry P, Hassall M, Barnett R, Richards M,Vandervord J. V–Y advancement hamstring myocutaneousisland flap repair of ischial pressure ulcers. Aust NZ J Surg1995; 65: 412–16.

13. Morgan JE. Recurrence of pressure ulcers: a study of five cases.JAMA 1976; 236: 2430–1.

14. Ger R, Levine SA. The management of decubitus ulcers bymuscle transposition: an 8-year review. Plast Reconstr Surg1976; 58: 419–28.

15. Hentz VR. Management of pressure sores in a specialty center:a reappraisal. Plast Reconstr Surg 1979; 64: 683–91.

16. Relander M, Palmer B. Recurrence of surgically treated pressuresores. Scand J Plast Reconstr Hand Surg 1988; 22: 89–92.

17. Disa JJ, Carlton JM, Goldberg NH. Efficacy of operative cure inpressure sore patients. Plast Reconstr Surg 1992; 89: 272–8.

18. Krause JS. Skin sores after spinal cord injury: relationship tolife adjustment. Spinal Cord 1998; 36: 51–6.

The Authors

K. Tavakoli MB, BS, BSc(Med), MS, Senior Resident, Departmentof Plastic and Reconstructive Surgery,

S. Rutkowski FRACRM, Director of the Spinal Injuries Unit,C. Cope MB, BS, Registrar, Department of Plastic and

Reconstructive Surgery,M. Hassall FRACS, Consultant, Department of Plastic and

Reconstructive Surgery,R. Barnett FRACS, Consultant, Department of Plastic and

Reconstructive Surgery,M. Richards FRACS, Consultant, Department of Plastic and

Reconstructive Surgery,J. Vandervord FRACS, Head, Department of Plastic and

Reconstructive Surgery,

Royal North Shore Hospital, Sydney, New South Wales, Australia.

Correspondence to Dr K. Tavakoli, 12 Cumberland Avenue, LaneCove 2066, New South Wales, Australia.

Paper received 8 May 1998.Accepted 9 February 1999, after revision.