Treatment of ischial pressure sores. Our experience of 99 patientswith 108 sores
Charalambos A. Georgiou & Pierre S. Nguyen &Zdravska Batchvarova & Ccile Philandrianos &Jacques Bardot & Dominique Casanova
Received: 24 May 2014 /Accepted: 18 August 2014 /Published online: 19 September 2014# Springer-Verlag Berlin Heidelberg 2014
AbstractBackground Ischial pressure sores concern patients in the sittingposition and particularly the rehabilitated patients. Spontaneoushealing may be very difficult without surgery, and ischial pres-sure sores have the highest recurrence rate among otherdecubitus. Furthermore, there is no consensus concerning theideal surgical technique in order to definitely treat the patients.This is a retrospective analysis of the surgical treatment of ischialpressure sores aiming to identify the ulcer recurrence rate persurgical technique and describe the early complications.Methods This was a retrospective study that was conducted inMarseille, France, between 1988 and 2007. The medical re-cords concerning patients with ischial pressure sores werecollected and analyzed. The main objective was to identifythe ulcer recurrence rate after ischial pressure sore surgicaltreatment. The secondary objective was the identification anddescription of early complications.Results Ninety-nine patients were finally selected and analyzedfor 108 ischial pressure sore treatments. Primary endpoint anal-ysis identified 25 recurrences for 108 sores (23.14 %). Ham-string V-Y advancement flap had 71 % recurrence rate. Wounddehiscence was the primary complication. Six out of sevenhamstring V-Yadvancement flaps had early complications.
Conclusions Pressure sore treatment can be difficult and chal-lenging. In this retrospective study, we have found that thehamstring V-Y advancement flaps have a much higher recur-rence rate and a higher rate of complications. Our results maybe limited by the retrospective nature of this study but theyimply that the V-Yadvancement flaps should not be used as afirst choice for ischial pressure sore treatment.Level of Evidence: Level IV, therapeutic study.
Keywords Ischial pressure sores . Decubitus . Pressureulcers . Hamstring flaps . Gluteus maximusmyocutaneousflaps . V-Yadvancement flaps
Pressure sores consist a frequent pathology that the plasticsurgeon is solicited to deal with in the everyday practice.Ischial pressure sores concern usually patients in the sittingposition and particularly the rehabilitated patients that needthis position in their professional and social life. Very oftenthis kind of sore is deep, and the bone prominence of theischion is exposed. Its dimensions can be easilyunderestimated, as the skin defect may be very small makingthe sore sinusoid, and very often, spontaneous healing forthese chronic ulcers may be very difficult without surgery.
Care workers consider this kind of decubitus as the mostdifficult to cure because of the high recurrence rate . Al-though Conway and Griffith  initially estimated this rate atapproximately 75 %, it has been more recently decreased to20 %  as a result of multidisciplinary patient care, preven-tive equipment, and better treatment protocol. Nevertheless,ischial pressure sores have the highest recurrence rate amongother pressure sores.
Furthermore, there is no consensus concerning the idealsurgical technique in order to definitely treat the patients.
C. A. Georgiou : P. S. Nguyen : Z. Batchvarova : J. Bardot :D. CasanovaPlastic, Reconstructive and Aesthetic Surgery Department,La Conception University Hospital, 147 Boulevard Baille,13005 Marseille, France
C. A. Georgiou (*)Plastic Reconstructive and Aesthetic Surgery Department, St RochUniversity Hospital of Nice, 5 Pierre Devoluy, 0600 Nice, Francee-mail: email@example.com
C. PhilandrianosPlastic, Reconstructive and Aesthetic Surgery Department, HpitalNord, University Hospital, Chemin des Bourrely, 13915 Marseille,France
Eur J Plast Surg (2014) 37:667672DOI 10.1007/s00238-014-1014-9
Many authors propose myocutaneous or muscular flaps so asto fill adequately the wound cavity and cover the surface of thesore at the same time . For some authors, the flap that ismost suitable is the gluteous maximus myocutaneous flap [5,6]. For others posterior thigh-based flaps such as hamstringmyocutaneous advancement in a V-Y manner are preferred. Even gracilis myocutaneous flap as well as tensorfasciae latae flap were proposed as possible solutions for thetreatment of this kind of sores . More recently, perforatorfasciocutaneous flaps were proposed [11, 12]. However, thechoice between fasciocutaneous and myocutaneous or mus-cular flaps remains debatable [13, 14] even though evidenceexists that flaps containing muscle may implement local cel-lular differentiation and healing . In every case thoughwound dimensions, previous surgeries, and scars must influ-ence the choice having as a principle the golden rule of tissueeconomy in order to address future recurrences.
We have conducted a retrospective analysis of the surgicaltreatment of ischial pressure sores aiming to identify the ulcerrecurrence rate per surgical technique and describe the earlycomplications.
Material and methods
This was a retrospective and descriptive study that was con-ducted in two centers (Hpital Nord and Hpital La Concep-tion) in Marseille, France, between 1988 and 2007. We col-lected and analyzed all of the medical records concerningpatients with pressure sores. Among them, we selected themedical records of patients with ischial pressure sores. Wethen proceeded to a descriptive analysis of patient character-istics, ulcer characteristics, treatment, and evolution. The mainobjective was to identify the ulcer recurrence rate after ischialpressure sore surgical treatment. Recurrence was defined asthe pressure sore (Stage >II) located at the initial sores loca-tion after complete healing and after permitting the sitedposition. The secondary objective of this study was the iden-tification and description of early complications. Complica-tions included wound dehiscence, hematoma, partial or totalflap loss, and postoperative skin fistulas. Early was defined asthe complications that occurred within the first postoperatorymonth.
All of the patients were treated with the same care protocolthat was identical for the two centers. It included:
1. An initial preoperative phase. In this phase, the candidatesfor surgery were hospitalized and prepared for operation.Preparation included nutrition, fluid resuscitation, anemia,and other deficiency correction. At the same time, localcare was intensified in order to acquire a clean wound. Forneglected cases, surgical debridement took place so as toacquire a suitable wound for coverage.
2. Second phase concerned the main surgery for coverage orwound closure. For all patients, a superficial excision ofwound walls and bursal sac as well as bone contouringtook place before closing or covering the wound. Thenwound closure or coverage followed according to classicsurgical techniques:
(a) Small wounds. Skin excision and tissue debridementare limited when the initial wound is small, and thisallows direct wound closure in multiple planes(Figs. 1 and 2). Delbets corrugated drains are usedfor drainage. This allows passive liquid drainage,and it can also be used for irrigation in case ofinfection.
(b) Larger wounds. When the wound is more important,then flaps are necessary for coverage. Nearby tissuesare harvested having always as a principle tissueeconomy. The initial treatment must allow othercoverage possibilities in case of recurrence. Ourpreference is the maximus gluteus myocutaneousrotation flap (Figs. 3, 4, and 5). It is easy to rotatewith adequate volume for filling the wounds cavity.In case of recurrence, it can be raised and advancedonce more without adding scars or sacrificing otherflaps. As a second choice, we use the flaps from theposterior site of the thigh. Biceps femoralis flap canbe also an interesting solution (Figs. 6 and 7)
Fig. 1 Small ischial pressure sore
Fig. 2 Direct closure treatment after multiple plane sutures
668 Eur J Plast Surg (2014) 37:667672
because it uses a distant cutaneous palette, and themuscle fills the wound. Also the V-Y myocutaneousadvancement flap of the hamstring muscles is aninteresting solution (Fig. 8). Gracilis is our lastchoice, and our team does not use the tensor fasciaelatae muscle flap because of inadequate volume onits distal portion.
Ninety-nine patients were finally selected and analyzed for108 ischial pressure sore treatments. Fifty-six patients had asingle ischial sore, 34 patients had a single ischial sore asso-ciated with sores other than ischial, and 9 patients had bilateralischial sores. Seventy-eight patients were male and 21 female.
Mean age was 42, 1 (1583 years)years. Data concerningetiology are illustrated in Table 1. The surgical techniquesutilized were excision and direct suture, local skin flaps,gluteus maximus-based myocutaneous flaps, hamstringmyocutaneous V-Y advancement flaps, biceps muscular-based flaps, combination of gluteus maximus flaps and ham-string flaps, gracilis flaps, and simple split thickness skingrafts. Their distribution is illustrated in Fig. 9.
Primary endpoint analysis identified 25 recurrences for 108sores. Hence, in this study, we found that ischial pressurewounds have a recurrence rate of 23.14 %. These were recur-rences that occurred long after initial healing, and they are notpostoperative wound dehiscence. Data for recurrence delaycould not be established because most of the patients did notconsult soon after the appearance of new skin lesion but rather
Fig. 3 Large ischial pressure sore
Fig. 4 Gluteus maxi