INTRODUCTION — Pressure-induced skin and soft tissue injuries are the result of sustained force on soft tissue typically overlying bony prominences, which leads to hypoxia, ischemia, and eventual necrosis. These injuries are common, estimated by the United States Joint Commission on Patient Safety to occur in 2.5 million patients in US acute care facilities annually and result in 60,000 deaths each year [1,2]. The total annual cost of pressure injuries in the US was estimated to be USD $11 billion in 2006 and $26.8 billion in 2016, with a median treatment cost of $27,000 per single pressure-induced injury (range of $10,000 to $86,000) [1-3]. In Canada, a prevalence as high as 26 percent across all health care settings has been reported, with an estimated monthly cost of CAD $4750 per person with a spinal cord injury receiving care for a pressure-induced injury [4,5].
Increased awareness, improved preventive measures, and earlier diagnosis resulted in a decline in pressure injuries between 2012 and 2016 according to an international pressure ulcer prevalence survey; however, the prevalence of severe pressure injuries, and therefore those who usually require surgical management, has remained the same .
The surgical management of pressure-induced skin and soft tissue injury is reviewed. Risk factors for, and prevention and management of these injuries are reviewed separately. (See "Epidemiology, pathogenesis, and risk assessment of pressure-induced skin and soft tissue injury" and "Prevention of pressure-induced skin and soft tissue injury" and "Clinical staging and general management of pressure-induced skin and soft tissue injury".)
INDICATIONS FOR SURGERY — The management of pressure-induced skin and soft tissue injury depends on the clinical stage (table 1 and figure 1). The management of stage I and II pressure-induced skin and soft tissue injuries is generally conservative with appropriate wound care and elimination of causative factors that led to the initial injury. (See "Clinical staging and general management of pressure-induced skin and soft tissue injury".)
Stage III and IV injuries involve a level of injury that will almost always require surgical management to obtain wound closure . Surgical closure of stage III or IV pressure-induced wounds significantly improved mean quality-of-life scores in a review of patients with traumatic spinal cord injury .
Apart from higher injury stage, other indications for surgical management include significant necrosis in the wound, osteomyelitis, wounds causing systemic infection as well as deterioration in the patient's functional status, and persistent nonhealing wounds [8,9].
PREOPERATIVE CONSIDERATIONS — A multidisciplinary approach is important in all phases of care for the patient with pressure-induced injury; the team managing these patients consists of nurses, nutritionists, wound care specialists, internists, infectious disease consultants, plastic and reconstructive surgeons, orthopedic surgeons, anesthetists, rehabilitation specialists (physiatrists, occupational and physical therapists), and social workers [10-12]. Prior to surgery for pressure-induced skin and soft tissue injury, issues to consider are discussed below.
General considerations — Perioperative planning is of equal, if not greater, importance than the surgery itself in the context of pressure-induced injury care . Patients with severe pressure-induced injuries rarely present without serious comorbidities, and special attention must be applied to optimizing the condition of the patient preoperatively to reduce surgical risk and maximize the likelihood of satisfactory postoperative wound healing and recovery. The operative plan may entail multiple individual procedures and be associated with a long recuperation period and significant complications including bleeding, infection, wound recurrence, dehiscence, and flap loss. With the use of muscle flaps to reconstruct defects, especially in ambulatory patients, weakness or functional loss must be considered. All potential intraoperative and postoperative complications need to be explained to the patient to obtain informed consent; this is more likely to ensure compliance to the strategy of care that is chosen.
In addition to the surgical plan, the disposition and rehabilitation plans should be discussed well in advance, and preferably reflect a streamlined systematic approach, adapted to the factors unique to each patient. This reduces prolonged acute hospital length of stays and complications and optimizes wound healing and functional rehabilitation. The long recovery and special postoperative rehabilitation requirements after surgical reconstruction of pressure-induced injury may result in the need for modification of lifestyle and interruptions in livelihood. These considerations are of tremendous importance to patients and must, if possible, be anticipated and addressed adequately prior to embarking on the reconstructive course.
Anesthesia — Cardiorespiratory function must be carefully assessed and optimized to minimize perioperative complications. Most patients with pressure-induced injuries are classified as American Society of Anesthesiologists (ASA) class III to IV, requiring special anesthesia care, and are more likely to have intraoperative and postoperative complications. As an example, patients with high spinal cord injuries can manifest features of autonomic dysreflexia, an abnormal hemodynamic response to certain stimuli, which may result in life-threatening blood pressure disturbances, cardiac dysrhythmias, and excess bleeding [14,15].
Despite this recognition, there is a dearth of specific recommendations for anesthetic management of patients undergoing surgery for pressure-induced injuries . Options for anesthesia include general and regional modalities, with or without sedation. The ultimate anesthetic choice is based on the patient's general condition and preference, surgical positioning that is required, anticipated duration of the procedure, and anticipated airway management. Intraoperative positioning during surgery must be carefully considered to avoid the development of new pressure-induced injuries or exacerbation of pre-existing wounds. (See "Patient positioning for surgery and anesthesia in adults" and 'Surgical management by site' below.)
To the extent that is possible, debridement of wounds and flap coverage should be undertaken on an elective operating schedule at an academic center as part of a protocolized system of care. The only exception to this rule would be the emergency debridement of an infected wound in the context of sepsis. The need for postoperative intensive care monitoring and appropriate nursing should be considered in either context.
Nutritional status — All surgical patients should undergo preoperative nutrition assessment . (See "Overview of perioperative nutrition support", section on 'Preoperative nutrition support' and "Clinical assessment and monitoring of nutrition support in adult surgical patients".)
Patients with chronic wounds such as pressure-induced skin and soft tissue injuries are frequently malnourished. Wound healing in this context is severely impaired, necessitating prompt intervention by a nutritional specialist, and may require that definitive surgery be delayed if circumstances allow. Guidelines have been published jointly by the National Pressure Injury Advisory Panel and European Pressure Ulcer Advisory Panel for nutritional assessment and optimization of patients with pressure injuries [1,17].
One study found that while serum prealbumin and albumin levels were low in all enrolled older patients, they were lowest in patients with pressure-induced injuries, likely as a result of malnutrition and catabolism . In a study comparing 100 patients with pressure injuries with 213 healthy controls, patients with pressure-induced injuries have also been shown to have elevated markers of oxidative stress .
There may be some circumstances in which a staged approach may be favored, whereby the wound is debrided first, nutrition is then optimized, and subsequently surgical reconstruction is undertaken electively. No controlled studies have formally compared these two approaches. However, the approach supported by evidence is that debridement, which converts a chronic wound into an acute wound, and later reconstruction improves anemia, serum proteins, and inflammatory marker levels by removing the stimulus for chronic inflammation associated with long-standing wounds [1,13,18].
Antimicrobial therapy — Prior to surgical management of pressure-induced injuries, antimicrobial therapy should be initiated preoperatively and continued postoperatively, directed by clinical assessment and wound culture results. Pressure injuries are inevitably contaminated at the time of closure in spite of topical wound care strategies . While swabs are commonly taken, the ideal samples (soft tissue, bone) to be cultured are deep tissues taken during surgical debridement [19,20]. (See 'Debridement' below.)
Osteomyelitis is not an uncommon occurrence with deep pressure injuries and is often suspected on imaging studies (eg, computed tomography scan, magnetic resonance imaging) during preoperative workup but requires bone biopsy and culture to confirm the diagnosis. Osteomyelitis requires debridement of devitalized tissue and prolonged antibiotic coverage of several weeks (in the authors' practice, the protocol is six weeks of intravenous antibiotics) prior to definitive reconstruction. The presence of osteomyelitis may entail considerations such as insertion of central venous access for long-term antibiotics, long-term inpatient stays, or well-organized home or community support for appropriate treatment. Failure to adequately diagnose or treat acute osteomyelitis is associated with increased recurrence rates after surgical reconstruction [1,13,21,22].
Most wound cultures from pressure-induced injuries yield polymicrobial growth. Common organisms obtained from infected pressure injuries include Proteus mirabilis, group D Streptococcus, Escherichia coli, Staphylococcus species, Pseudomonas species, Enterococcus faecalis, and Corynebacterium organisms [1,19]. Osteomyelitis underlying pressure-induced injuries is also frequently polymicrobial; Staphylococcus aureus is the most commonly isolated organism . Infectious disease specialists can help to provide guidance on specific antimicrobial agents and durations of treatment and should be involved throughout the patient's treatment course. (See "Infectious complications of pressure-induced skin and soft tissue injury".)
WOUND BED PREPARATION
Debridement — All necrotic tissue should be aggressively debrided as a first step in the wound healing process . Deep tissue samples from surgically cleaned and debrided wounds can be obtained and are the standard for wound cultures to help guide antimicrobial therapy. For those with deep pressure-induced injury involving the bone, bone biopsies are necessary for the definitive diagnosis of osteomyelitis to determine the responsible pathogens and guide antimicrobial therapy [1,20]. (See 'Antimicrobial therapy' above.)
While bedside debridement may be performed in the context of selected small pressure-induced injuries with a clearly delineated eschar, it is not recommended for larger or deeper wounds due to patient discomfort and pain, less effective hemostasis, and a suboptimal view of the extent of the wound and the adequacy of debridement. Formal operative debridement of larger and deeper skin pressure-induced injuries is a safer and more thorough approach that also allows for planning of surgical closure options available. The amount of necrotic tissue is frequently underestimated on initial bedside examination, and debridement usually results in a larger defect than originally anticipated .
The goal of debridement is to achieve a viable wound bed devoid of necrotic, ischemic, and infected tissue that will impede wound healing and increase the risk of wound recurrence. The importance of adequate hemostasis cannot be overstated, as these wounds have a propensity to bleed, leading to significant blood loss in a short period of time. A graduated out-to-in approach usually works best, facilitating exposure and thorough debridement, starting with the skin edge circumferentially and potentially ending with debridement of bone. Each circumference should be completed before moving inward, while achieving adequate hemostasis along the way. Methylene blue may be applied to stain the defect, with debridement then carried out on any blue-stained tissues to adequately excise any exposed tissue and potential sinus tracts.
There is no consensus on the efficacy of the specific topical antimicrobial solutions in the literature, and their use is principally based on surgeon preference and availability . Solutions used in our operating room for antisepsis include: 0.025% sodium hypochlorite (1:20 Dakin solution), 2% acetic acid, and bacitracin (50,000 international unit/L); for blood clot removal and antisepsis: 3% hydrogen peroxide; and to initially aid with hemostasis prior to monopolar coagulation: epinephrine solution (1:1000). The authors use these solutions intraoperatively either by soaking in a nonadherent dressing (eg, Telfa pads) or by irrigating using a 50 mL syringe. Supporting their use is a reduction of bioburden and possible benefits for wound healing [25,26], while the opposing concern is that antiseptic solutions are all inherently cytotoxic [27,28]. However, it is relevant to point out that after application of any of these agents, the wounds are irrigated with copious amounts of saline, likely negating any ongoing sequelae.
Sodium hypochlorite (Dakin solution) is effective against multiple species of bacteria including S. aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, E. coli, P. mirabilis, Serratia marcescens, Enterobacter cloacae, and Bacteroides fragilis, among others, and is fungicidal against Candida albicans [29,30]. The solution may show bactericidal activity at dilutions at which it loses its cytotoxicity . One study showed that at 0.0125%, Dakin solution was bactericidal but showed minimal effects on fibroblast migration , whereas another demonstrated that all concentrations from 0.0025 to 0.025% show neutrophil, fibroblast, and epithelial toxicity . However, 86 percent of Dakin solution is degraded 15 minutes after its topical application, reducing both its sustained cytotoxic and microbiocidal effect . Despite the common intraoperative use of bacitracin-containing solutions to irrigate prostheses and infected wounds, polymyxin-bacitracin solution is not effective at eradicating S. aureus or E. coli . A quantitative analysis showed that hydrogen peroxide was bactericidal at a 3% concentration but this is ten-fold its cytotoxic concentration, and thus the study advocated against its use . S. aureus and P. aeruginosa were also reported to be resistant to hydrogen peroxide due to the presence of the enzyme catalase in these bacteria, thus rendering it ineffective for wound infections [36,37]. On the other hand, hydrogen peroxide has been advocated as a hemostatic agent . Epinephrine solution at a 1:1000 concentration used topically can also help with hemostasis and decreases electrocautery use . Epinephrine also has been shown to not to negatively affect wound healing .
Following debridement, definitive reconstruction of the skin and soft tissue defect may be performed in the same surgery or in a subsequent procedure, depending on amounts of necrotic tissue, ability to achieve an adequate debridement, patient nutritional status and general condition, and surgeon's discretion. There is a paucity of evidence to favor a single-stage over multiple-stage approach to pressure-induced injury debridement and reconstruction; no randomized trials have been conducted comparing the two approaches for complications and recurrence rates . There are advocates for each approach. Proponents of a single-stage approach cite fewer anesthetic and surgical procedures and potentially shorter hospital stays, with quicker initiation of rehabilitation as advantages [39,40], while the latter advocate that the multiple-stage approach allows for more meticulous ultimate debridement, shorter individual procedure times, and more appropriate antibiotic coverage due to availability of culture results in time for the reconstructive stage of the procedure . In addition, for staged reconstruction, urinary/fecal diversion procedures may be performed immediately after debridement, prior to definitive reconstruction, in order to obtain the maximum benefit . In well-organized multidisciplinary systems of care, there is more likely to be a single surgery rather than multi-stage approach, as the patient is generally better prepared from a general health and nutritional perspective in these settings.
Negative pressure wound therapy — Negative pressure wound therapy (NPWT) merits special mention in the wound management of pressure-induced injuries. NPWT improves the local wound environment through both direct and indirect effects, accelerating healing and reducing time to wound closure. (See "Negative pressure wound therapy", section on 'Mechanism of action'.)
As a dressing, NPWT provides the advantages of less frequent changes and therefore reduced pain, while facilitating the removal of secretions, reducing contamination from urine and stool, some degree of splinting to control pain, and arguably, reduction of defect size. These beneficial effects culminate in reduced healing times, length of hospital stays, while minimizing personnel time . NPWT modalities also enable the delivery of antiseptics (ie, instillation) to the wound bed. Furthermore, foams of various densities give practitioners the ability to protect sections of the wound or augment debridement and the rapid generation of granulation in others. Foams with large pores have also been observed to clearly demarcate viable areas from areas requiring further sharp debridement, as viable areas will granulate more rapidly with this foam than others [8,41-45].
As destination therapy, NPWT may provide a feasible option to help in granulation and gradual healing of some smaller, less complex defects without exposure of vital structures, and may be considered in frail and older patients who are incapable of tolerating definitive surgical interventions, as well as patients who have a paucity of local reconstructive options in the context of multiple pressure injuries, or failure of previous reconstructions [1,40,44,46].
The caveat to implementing NPWT is that a secure dressing seal is imperative for the function of the dressing, particularly when instillation is desired, and to avoid exacerbation of infection; this may prove challenging to maintain due to the location of the wounds (eg, proximity to genitalia and anus), as well as skin maceration, moisture and shear.
Fecal/urinary diversion — Patients with long-standing and deep sacral and ischial pressure sores may benefit from fecal and sometimes urinary diversion to minimize or eliminate wound soiling. In discussions with the patient and during the consent process, it must be conveyed that surgical fecal/urinary diversion may become permanent. (See "Overview of surgical ostomy for fecal diversion" and "Placement and management of urinary bladder catheters in adults".)
Advantages to diversion have long been cited to offer more rapid healing times, shorter hospital stays, and fewer total surgeries in patients who are diverted as compared with those who are not diverted [47,48]. Given that many patients with severe pressure-induced injury suffer from incontinence, paraplegia, or are otherwise unable to perform adequate independent toileting, a permanent colostomy may facilitate care and potentially improve patient independence and quality of life [8,49,50]. It very important to consider the inherent complications of urinary or fecal diversion procedures when formulating a management plan, stratifying individual patient risks versus potential benefits .
Temporary nonsurgical fecal diversion devices are also available, including commercial soft tubing products designed for placement in the rectum with an inflatable 40 cc balloon that can be used for up to one month. For this strategy to support the surgical plan, the bowel contents are generally softened or liquefied by way of a bowel regime of laxatives. Alternatively, selected patients may benefit from a short constipating regimen rather than a liquefying one.
SURGICAL WOUND CLOSURE — Following thorough debridement and wound bed preparation, fundamental to successful reconstruction of pressure-induced injuries is padding of pressure points with full thickness, well-vascularized skin, and tension-free closure. The requisite bulk, padding, and wound coverage needed for closure of pressure-induced induced injuries are best provided by soft tissue flaps [13,51]. Locoregional flaps incorporating fascia and/or muscle with its overlying skin are the gold standard techniques for this purpose (table 2). Free flap reconstruction may be an option for a minority of patients. The various types of flaps that can be used for soft tissue reconstruction are reviewed separately. (See "Overview of flaps for soft tissue reconstruction".)
Primary closure of a pressure-induced injuries is seldom possible or successful in the long term [6,8]. Skin grafts also fail to provide sufficient bulk or padding to bony prominences and are a suboptimal reconstructive treatment for pressure injuries, inevitably leading to recurrence [9,13,52].
Flap types and selection — Surgeons involved in the care of patients with pressure-induced injuries should ideally be comfortable with several flap options, tailored to each patient and their wound, and each option should also have a "back-up" or second-line option (table 2). Traditionally, musculocutaneous flaps were favored for reconstruction of pressure-induced injuries because of their bulk and ability to conform to large deep defects, in addition to their reliable blood supply from consistent dominant blood vessels. This philosophy has been challenged with an improved understanding of the angiosome theory of skin perfusion. (See "Overview of flaps for soft tissue reconstruction", section on 'Axial flap'.)
Reported outcomes of different flaps used for pressure-induced injury sites are variable with a wide range of follow-up times, which has made it difficult to draw conclusions about the efficacy and complications of individual approaches. The literature consists primarily of case series of the use of different flaps for pressure-induced injuries; there are no randomized data comparing various techniques [41,53]. A systematic review comparing complication rates between fasciocutaneous, musculocutaneous, and perforator flaps found no significant difference in complication rates or recurrences between the flaps . Nevertheless, fasciocutaneous flaps are favored as a first option for the following reasons [1,9,55,56]:
●Fasciocutaneous flaps may be more resistant to pressure and ischemia compared with muscle flaps.
●Fasciocutaneous flaps do not result in as much functional loss in mobile patients.
●Fasciocutaneous flaps often involve less extensive dissection and shorter surgeries with less blood loss.
●Fasciocutaneous flaps preserve muscle flaps for use where deep cavities are present, or for recurrences.
Free tissue transfer for reconstruction of pressure-induced injuries is usually reserved for the rare case of ambulatory patients who have had locoregional flap failure with few remaining local reconstructive options for large defects. Free flaps are not sensate. Even if the flap contains a sensory nerve, there is a prolonged duration before any sensation returns, if it returns at all. Free flaps described for this purpose include fasciocutaneous or musculocutaneous options, and include latissimus dorsi, serratus anterior, anterolateral thigh, and tensor fascia lata (TFL) flaps, among others . Recipient vessels are commonly the gluteal vessels dissected through a muscle-splitting technique. The deep femoral vessels and their perforators, posterior intercostals, or mobilized inferior epigastric vessels can also be used [57-59]. Some reports describe vein grafts as a solution for short pedicle lengths to reach the defect [57,59]; however, this strategy has higher associated complication rates and is best avoided.
It is generally accepted that latissimus dorsi free flaps should not be used as a free flap in patients who are paraplegic, as this patient population depends heavily on upper body strength for mobilization [57,59,60]. However, transferring a partial ("split") latissimus dorsi free flap may be a reasonable alternative to preserve function provided that the defect is not too large for the bulk provided by the partial muscle flap. One study of 11 patients reported no functional shoulder deficits nine months after partial latissimus dorsi free flap transfer .
Surgical management by site — The most commonly reported locations for pressure-induced injury are the ischium, followed by the sacrum, the trochanter, and the heel [1,27,61-63]. However, incidences vary considerably depending on facility (acute or long-term care), patient comorbidities and demographics, and the presence of spinal cord injury or other acute or chronic causes of immobility. Specific flap closures at these common sites are reviewed below.
Sacrum — Flaps for the reconstruction of sacral pressure-induced injuries can be unilateral or bilateral, depending on the size of the wound.
Fasciocutaneous flaps can have a random or axial blood supply [9,55,64-68]. Designs include V-to-Y advancement flaps (picture 1 and picture 2 and figure 2), Limberg flaps, gluteal fasciocutaneous rotation flaps (picture 3), hatchet flaps, transverse lumbar flaps, or combinations of flaps (picture 4). Perforator flaps based off the superior gluteal artery (ie, super gluteal artery perforator [SGAP] flap) or the inferior gluteal artery (ie, inferior gluteal artery perforator [IGAP] flap) can be designed with the aid of Doppler ultrasound and advanced or islanded into the defect [1,56,69,70]. The SGAP flap technique was first described in 1993 to reconstruct a sacral pressure-induced defect [11,71]. It is advisable, where possible, to overlap tissue layers by de-epithelializing the leading edge of at least one of the flaps to avoid a single weak suture line between skin and areas of bony debridement . These areas will require a longer healing time and possibly further surgery in the case of wound complications. Our preference is to make use of large fasciocutaneous V-to-Y advancements as a first-line option to reduce tension on closure, and also allows for readvancement in the case of recurrence or alternatively a smaller flap within the large flap can be used.
Musculocutaneous or muscle flaps may be used for large and deep sacral defects for thin patients where fasciocutaneous flaps may be too thin to provide adequate wound coverage or padding or in the case of failure of fasciocutaneous flaps. Muscle flap options include gluteus maximus rotation, advancement, islanding, or transverse-splitting partial gluteal flaps. The latter is preferable in ambulatory patients, as some gluteal function is preserved. All gluteus maximus musculocutaneous/muscle flaps are based on one or both of its dominant vessels, the superior gluteal or inferior gluteal vessels .
Ischium — Flaps for coverage of ischial defects (figure 3) should be designed with the knowledge that the patient will require hip flexion to facilitate sitting. As such, bolsters should be placed under the anterior superior iliac spine to partially replicate this position while in the prone position intraoperatively, and therefore limit the tension applied during rehabilitation.
Fasciocutaneous options for ischial defect reconstruction include gluteal rotation, medial thigh flaps, posterior thigh V-to-Y or hatchet advancement flaps (picture 5), as well as IGAP flaps [11,40,51,64-66,72].
Musculocutaneous flaps used to reconstruct ischial defects include gluteus maximus rotation (based on IGAP), transversely split gluteus maximus advancement, hamstring V-to-Y or hatchet advancement (profunda femoris perforators), biceps femoris advancement/folding (profunda femoris perforators), gracilis muscle (medial femoral circumflex artery), and rectus abdominis (inferior epigastric artery) [1,11,64,67,68,73,74].
Trochanter — While fasciocutaneous flaps have been described and used for trochanteric pressure ulcer reconstruction, this is an area that benefits from the choice of a musculocutaneous flap initially (figure 4) due to the significant bony prominence of the trochanter as well the scarcity of fasciocutaneous tissue of adequate thickness to provide durable padding.
Musculocutaneous flap options described most commonly include the TFL flap (picture 6), which can be transposed, advanced through a V-to-Y pattern, or raised as an island on a perforator (from lateral femoral circumflex artery) . The TFL flap, if available and large enough to cover the defect, is an attractive option due to its predictable and reliable blood supply, minimal donor site morbidity, and limited impact on lower extremity motor strength . Other musculocutaneous flaps used for trochanteric defect coverage include the vastus lateralis, gluteus maximus, and rectus femoris muscle flaps [74,75].
Heel — The heel is particularly predisposed to pressure-induced injuries in bed-bound patients. The plantar surface of the heel is composed of thick skin, adipose tissue for padding, and layers of connective tissue imparting strength and resistance to pressure and friction. By contrast, the posterior surface of the heel has thinner skin, with little fat overlying the calcaneus to facilitate ankle mobility.
Pressure-induced heel injuries are commonly recognized at stage I or II and treated conservatively by pressure off-loading with specially designed boots and attentive wound care. Factors that contribute to formation of deeper heel pressure injuries that may necessitate surgical intervention are prolonged immobilization, diabetes mellitus, overall poor physiological condition, and reduced perfusion (ie, ischemia) of the lower extremity . In an observational study of 155 patients with pressure-induced heel injuries, 83 percent had evidence of peripheral artery disease on noninvasive vascular testing .
It is therefore imperative to consider the vascularity of the limb when considering reconstruction of heel ulcers. Wound healing is suboptimal in poorly vascularized limbs, which may lead to wound dehiscence and rapid recurrence of soft tissue defects despite the best efforts of the reconstructive team. Moreover, attempting a free flap reconstruction on an ischemic lower extremity may have serious consequences that include not only flap necrosis, but possibly limb ischemia distal to the site of anastomosis. Thus, we advocate noninvasive vascular mapping of all lower limbs considered for microsurgical reconstruction to evaluate the patency and quality of recipient vessels, and vascular surgery referral, as necessary. (See "Overview of lower extremity peripheral artery disease".)
The preoperative evaluation for significant pressure-induced heel injuries must also include radiographic imaging to exclude osteomyelitis. The first step in active surgical treatment is debridement (including calcaneal bone if required). In cases of extensive bony involvement, a partial or complete calcanectomy may be warranted .
Coverage options for heel wounds include locoregional flaps such as medial plantar artery flaps, reverse sural artery flaps, perforator propeller flaps, and occasionally transposition flaps from surrounding tissues [78-80]. Distal lower extremity flap defects may not be amenable to locoregional reconstruction, and like other traumatic injuries, microsurgical flap coverage is a more frequently indicated reconstructive option for this region compared with other anatomic regions. (See "Surgical reconstruction of the lower extremity".)
Immobile patients with severe pressure-induced heel injuries, limb ischemia, flexion contractures, poor physiologic condition, and significant comorbidities may be better served by primary amputation, rather than attempting reconstruction [81,82]. (See "Lower extremity amputation", section on 'Indications for amputation'.)
Less common sites and atypical injuries
●Occiput – Pressure-induced injury to the posterior scalp is not uncommon in patients with a history of prolonged immobilization in a critical care setting, especially those being mechanically ventilated or with special head stabilization requirements in place, such as neck collars or intracranial pressure-monitoring equipment . Most occipital pressure sores can be treated conservatively with wound care and usually heal with improvement in the patient's condition and removal of the risk factors. A common long-term sequel of healed scalp pressure-induced injury is alopecia at the injury site , the treatment of which is excision and either primary closure, local flap coverage, or tissue expansion when all tissues are sufficiently healed.
Occasionally, an occipital pressure-induced injury is extensive enough to warrant acute surgical intervention. This may consist of debridement followed by appropriate wound care for smaller or less complex injuries, or debridement with flap coverage for larger and more complex wounds. Skin grafts may be used in the presence of a viable soft tissue bed after debridement, especially if the patient is ambulatory. Deeper pressure injuries that expose cranial bone or that are complicated by underlying osteomyelitis will require debridement and coverage with flaps, including locoregional transposition or rotation scalp flaps.
●Elbow – Pressure-induced injury of the elbow may involve the olecranon or medial elbow bony prominences, and special care should be taken to examine for damage to the ulnar nerve as well as for the presence of bursitis, which may or may not be infected .
Flap coverage for elbow wounds resulting from pressure-induced injuries include a selection of local random-pattern rotation or transposition fasciocutaneous flaps, perforator flaps from the dorsal aspect of the upper forearm , the radial forearm flap, or reverse lateral arm flaps based on the posterior branch of the radial collateral artery [87,88]. (See "Surgical reconstruction of the upper extremity".)
●Atypical pressure injuries – Atypical pressure injuries occur in a multitude of locations and may be associated with medical equipment. Some examples are chin (especially with neck collar use), ears (neck collar, bilevel positive airway pressure [BiPAP] machine, endotracheal tube ties, or head position), nose (columella with prolonged nasogastric tube use), tracheostomy site, gastrostomy site, scapular prominences, spinal prominences, urethra (prolonged urinary catheter use), medial knees, inguinal region (picture 7), and malleoli .
Treatment of these injuries is overwhelmingly conservative, with relief of pressure and removal of medical equipment if feasible. In the case of deep stage ulceration, surgery for debridement and reconstruction following the same algorithms as with typical pressure injuries are performed.
Adjunctive orthopedic procedures
Femoral resection (Girdlestone procedure) — The femoral head is implicated in the development and recurrence of pressure-induced injury in nonambulatory patients, especially those with hip pathologies such as contractures, subluxations, or dislocations . A malpositioned femoral head can erode through overlying soft tissue, causing reconstructive failure and recurrence. The Girdlestone resection arthroplasty is a procedure that excises the proximal femoral head. First described in 1928 as a salvage procedure in the context of septic arthritis of the hip (image 1), its indications have expanded to include recurrent pressure-induced injury due to a malpositioned femoral head [1,74,75,90]. The ambulatory ability of patients is severely limited after the Girdlestone procedure: 45 percent of geriatric patients are unable to ambulate after the procedure, and among those who can, only 29 percent can ambulate independently . This procedure should therefore only be considered an option for nonambulatory patients who demonstrate a significantly malpositioned femoral head that exacerbates pressure wounds and complicates reconstruction.
Disarticulation/hemipelvectomy — Selected patients who are paraplegic who have multiple, recurrent, or nonhealing pressure injuries, often with underlying osteomyelitis, may eventually be offered definitive wound closure with femoral disarticulation, pressure injury excision, and use of thigh/leg muscles for defect coverage and padding [1,75,92,93]. In a review of a database of 43,136 patients with spinal cord injury and pressure sores, only 8 patients underwent hemipelvectomies for their severe wounds. The mortality rate for these patients was as high as 25 percent .
POSTOPERATIVE MANAGEMENT — The authors' postoperative protocol is summarized in the table (table 3). Important considerations relate to the following areas.
Wound care — The dressing applied at the conclusion of the surgery usually remains in place for 5 to 10 days. Incisional (prophylactic) negative pressure wound therapy (NPWT) on a setting of -75 mmHg offers an excellent bolstering effect without applying too much pressure on the suture line. NPWT can be applied using a double-sided hydrogel tape to protect the skin and then covered with NPWT foam cut to size; several commercial incisional NPWT devices are also available for this purpose. Thereafter, the suture line can be cleaned daily with saline (or alternate daily with an antiseptic such as povidone iodine) and covered with a simple absorbent dressing.
We place closed suction drains of 1/4 to 1/2 cm diameter caliber prior to wound closure. These may require routine milking to prevent occlusion. Drains can usually be removed at about two weeks postoperatively, or earlier if drainage is minimal. We generally use a layered closure with a braided absorbable suture, followed by interrupted nylon sutures to the skin. For areas where eversion of skin edges is easy to obtain, staples may also be used, but the leading edge of the flap is almost always closed with everting simple uninterrupted or combination horizontal/vertical mattress sutures (to obtain epidermal and dermal approximation). Wounds are never closed under tension. Sutures or staples are usually left in place for two to three weeks; every other suture/staple can be removed initially, with the remainder removed a few days later.
Pressure care — For proper wound healing following reconstruction of pressure-induced injury, the inciting pressure should be eliminated from the reconstructed area. This is managed by vigilant attention to patient positioning and frequent repositioning, and mobility limitations to avoid tension on suture lines and flap pedicles. Most surgeons advocate an initial period of complete bed rest followed by gradual mobilization. Evidence is lacking for exact time frames for immobilization, and this is usually left to the surgeon's discretion, but it is usually for about two to four weeks. Much like immobilization, solid evidence for time frames as to when and over what period to initiate reseating is lacking, although it is agreed that it should be undertaken gradually and progressively .
Pressure-relieving air fluidized or low air loss mattresses have been adopted in many institutions to prevent pressure-induced injury recurrence, but high-quality evidence for their efficacy is still lacking . Some advocate for managing the patient prone for a period to eliminate pressure during the initial period, but this is difficult for feeding, and its success also depends on the spinal cord level in patients who are paraplegic as well as patient tolerance and compliance. For patients who rely on using a wheelchair, it is also important to adapt a patient's cushioned seat to provide adequate pressure relief, considering the new suture lines and high-risk areas. Frequent evaluation of wounds, pressure areas, and suture lines at the initial mobilization/seating stage is critically important to intervene and prevent complications before their escalation into major concerns, recurrence, and potentially the need for further surgery. The efficacy of various support surfaces and therapies to redistribute pressure is discussed in detail separately. (See "Prevention of pressure-induced skin and soft tissue injury", section on 'Pressure redistribution' and "Prevention of pressure-induced skin and soft tissue injury", section on 'Supportive interventions'.)
Rehabilitation — Prior to surgical management of pressure sores, it is preferable to have a plan as to the ideal rehabilitation program for the patient based on all considerations, including age, socioeconomic factors, family or other support, baseline level of function and employment, domestic circumstances, comorbid factors, and underlying spinal cord level, if applicable. (See 'Preoperative considerations' above.)
The patient should be transferred to a facility accustomed to managing their postoperative needs as the focus from acute postoperative care to rehabilitation changes. The multidisciplinary team involved in the perioperative care should remain involved during the rehabilitation process, and follow-up should continue for several months to years postoperatively. Should the focus be too heavily on the acute phase of care, patients can become deconditioned very quickly, prolonging the rehabilitation phase and increasing the risk for complications.
COMPLICATIONS AND RECURRENCE — Reconstructive surgery for pressure-induced injuries is well known for its high complication rates due to patient demographic factors, the presence of multiple comorbidities, significant mobility limitations, and previous failed surgeries. The data below emphasize the need for careful selection of informed and compliant surgical candidates in the context of a well-organized multidisciplinary system where the surgical team is adequately supported to provide surgical closure that has a reasonable chance of durable success. (See 'Preoperative considerations' above.)
Different studies cite various complication rates, ranging from 0 to 80 percent with respect to hematoma, wound dehiscence, infection, sepsis, seroma, and partial or total flap loss [1,10,13,41,54,94]. In a review of 421 flaps performed for 352 patients with ischial, pelvic, sacral, trochanteric, and lower limb pressure sores, the complication rate was 21 percent. The most frequent complication was suture line dehiscence, typically associated with dead space within the wound and shear forces applied to the closure . In another review of 157 musculocutaneous flaps used to reconstruct ischial pressure-induced injuries, the complication rate was 8.9 percent , which was lower than the 21 percent complication rate reported in another review for ischial wounds reconstructed using fasciocutaneous or musculocutaneous flaps .
Recurrence rates after surgical reconstruction of pressure-induced injuries vary. In a review of 268 flaps in 158 patients with mean follow-up of over three years, the overall recurrence was 19 percent . By contrast, recurrence rates of 69 and 41.4 percent were reported in separate reviews [96,97].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pressure-induced skin and soft tissue injury" and "Society guideline links: Chronic wound management".)
SUMMARY AND RECOMMENDATIONS
●Pressure-induced injuries – Pressure-induced skin and soft tissue injuries are the result of sustained force on soft tissue typically overlying bony prominences, which leads to tissue hypoxia, ischemia, and eventual necrosis. They are common, potentially life-threatening and debilitating complications of severe acute or chronic illness or spinal cord injury. (See 'Introduction' above.)
●Stage-based management – The management of pressure-induced skin and soft tissue injury depends on the clinical stage (table 1 and figure 1). Apart from higher injury stage, other indications for surgical management include significant necrosis in the wound, osteomyelitis, wounds causing systemic infection as well as deterioration in the patient's functional status, and persistent nonhealing wounds. (See 'Indications for surgery' above.)
•For stage I and II pressure-induced injuries, treatment is generally conservative with appropriate wound care and elimination of causative factors that led to the initial injury.
•For stage III and IV pressure-induced injuries, conservative measures are unlikely to result in wound healing necessitating definitive surgical management.
●Surgical management – Surgical management begins with wound debridement to achieve a viable wound bed devoid of necrotic, ischemic, and infected tissue that will impede healing and increase the risk of wound recurrence. Bedside debridement can be used for selected small pressure-induced injuries that have a clearly delineated eschar. Operative debridement of larger pressure-induced injuries has many advantages, is more thorough, and allows for adequate planning of potential surgical closure options. (See 'Debridement' above.)
•Fecal or urinary diversion – Patients with long-standing and deep sacral and ischial pressure-induced injuries may benefit from fecal and sometimes urinary diversion to minimize wound soiling. Diversion improves healing times, hospital stays, and required number of surgeries. For some patients with pressure-induced injuries (eg, paraplegia, incontinence), permanent fecal diversion may facilitate care and potentially improve patient quality of life. Temporary nonsurgical diversion may be an option for some patients. (See 'Fecal/urinary diversion' above.)
•Negative pressure wound therapy – Negative pressure wound therapy (NPWT) is a useful adjunct and improves the local wound environment through direct and indirect effects that accelerate healing and reduce time to wound closure. A caveat to implementing NPWT for pressure-induced injuries is potential difficulties ensuring a seal in some anatomical locations (eg, proximity to genitalia and anus). (See 'Negative pressure wound therapy' above.)
●Reconstruction – Definitive reconstruction of pressure-induced injury usually involves creation of a flap. Flap reconstruction can be performed during the same surgery following debridement or in a subsequent procedure depending upon the amount of tissue loss, completeness of debridement, presence of infection (cellulitis, osteomyelitis), the nutritional status and general condition of the patient, and surgeon discretion. Adjunctive orthopedic procedures may be needed in selected populations. (See 'Surgical wound closure' above and 'Adjunctive orthopedic procedures' above.)
•The use of locoregional flaps is the standard technique for closure of pressure-induced skin and soft tissue injuries (table 2). Most plastic surgeons favor fasciocutaneous flaps as the initial option for wound coverage. While there are few contraindications in selecting the type of flap, to preserve upper body strength, full muscle latissimus dorsi flaps should not be used in patients who are paraplegic. Specific flap closure techniques for the commonly reported sites for pressure-induced injury (ischium, sacrum, trochanter, heel) are described above. (See 'Surgical wound closure' above and 'Surgical management by site' above.)
•While reconstructive surgery offers tremendous benefits when successful, it is well-known for its high rate of complications. Recurrence rates vary widely, likely reflecting patient demographics and comorbidities and the many pressure-induced injury sites. Complications can be reduced with careful perioperative care and rehabilitation within a coordinated multidisciplinary system at centers accustomed to managing these difficult wounds. (See 'Complications and recurrence' above.)
●Preventing future injury – For optimal long-term success following flap reconstruction of pressure-induced skin and soft tissue injuries, it is imperative that inciting sources of pressure are eliminated from the reconstructed area. Most surgeons advocate an initial period of complete bed rest followed by gradual mobilization. (See 'Pressure care' above.)
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