Pressure Sores Flashcards
A 46-year-old man is evaluated for a large grade IV left ischial pressure ulcer. Medical history includes a 6-month history of traumatic T12 paraplegia. Excision of the pressure ulcer and reconstruction with a left inferior gluteal thigh flap are planned. During induction of anesthesia, the patient has the onset of cardiac arrhythmia with peaked T waves and tachycardia. Pulse oximetry is 100% with normal end-tidal CO2. Temperature is 37.0°C (98.6°F). It is discovered that the patient was given succinylcholine for rapid-sequence intubation by the anesthesia resident. Which of the following is the most appropriate initial management of the patient’s condition?
A) Intravenous adenosine
B) Intravenous amiodarone
C) Intravenous calcium chloride
D) Intravenous dantrolene
E) Synchronized cardioversion
The correct response is Option C.
Perioperative complications arising from intravenous paralytics and inhalational anesthetics may have devastating outcomes, including death. Rapid and accurate diagnosis is essential for efficient treatment and maximizing successful outcomes. The paraplegic patient presented in this clinical scenario has developed acute hyperkalemia from the use of succinylcholine. Hyperkalemia after succinylcholine administration may result in paraplegics or any patients with upper or lower motor neuron injury, severe burns, crush injuries, or conditions causing rhabdomyolysis. This phenomenon results from the upregulation of nicotinic acetylcholine receptors in denervated or traumatized muscle.
Initial treatment of acute hyperkalemia causing cardiac compromise involves antagonizing the effects of potassium on cardiac conduction and shifting potassium from the extracellular space back into intracellular fluid. Calcium directly antagonizes the hyperkalemia-induced depolarization of resting membrane potential by increasing the threshold potential to stabilize the membrane. Sodium bicarbonate and glucose combined with insulin will promote cellular uptake of potassium. Acidosis enhances the release of potassium from the cell and can be reversed with sodium bicarbonate. In addition, alkalization of plasma decreases levels of ionized calcium permitting the more liberal use of calcium in the treatment of acute hyperkalemia.
Intravenous dantrolene is appropriate for the initial management of malignant hyperthermia (MH). MH may also arise from the use of succinylcholine or inhalational anesthetics. It is caused by a hereditary abnormality that interferes with calcium regulation within skeletal muscle. Once triggered, an uncontrolled hypermetabolism in the muscle occurs secondary to the buildup of calcium in the skeletal muscle. The earliest sign of malignant hyperthermia is a rapid and unexplained increase in end-tidal CO2 that progresses to the presence of fever. This patient is afebrile and has a normal end-tidal CO2. However, if the patient presentation did indeed suggest MH, intravenous calcium chloride would be contraindicated secondary to the already increased levels of calcium present.
Synchronous cardioversion and intravenous adenosine and amiodarone are modalities to consider in the ACLS algorithm for treatment of unstable and stable tachycardia of unknown etiology. They are not first-line medications in the treatment of the hyperkalemia that is causing this patient’s symptoms.
A 40-year-old man with T3 paraplegia undergoes operative debridement of a stage III ischial decubitus ulcer. In the recovery room, the nurse reports that the patient is saying he has severe headache and nausea. Temperature is 37.0°C (99.0°F), blood pressure is 180/90 mmHg, and heart rate is 50 bpm. He is flushed and diaphoretic. Which of the following is the most appropriate initial management of this patient’s condition?
A) Administer dantrolene 2.5 mg/kg intravenously
B) Administer nitroglycerin lingual spray
C) Insert a Foley catheter
D) Perform carotid massage
E) Place patient in Trendelenburg position
The correct response is Option C.
This patient has autonomic dysreflexia (AD). During an episode of AD, the patient sustains an uncontrolled sympathetic response to a stimulus (precipitant). It usually occurs in patients whose level of paralysis is above T6. AD occurs in 50 to 70% of patients with lesions above T6. Fatal complications may ensue in affected patients.
Common symptoms of AD include headache, hypertension, bradycardia, and flushing, blotching, or sweating above the level of the lesion.
The most common precipitants of AD are urologic (principally bladder distention), gastrointestinal (rectal distention), and musculoskeletal (fractures, dislocations, and heterotopic calcification). Other less common precipitants include skin ulcerations and infections as well as pregnancy and labor.
Primary treatments of AD include removing any stimulus. Remove tight clothing and be sure that a full bladder or rectum is not serving as a precipitant. Sublingual nifedipine may be used secondarily as an oral hypotensive agent. Nitrates are not part of the initial management of AD. A fluid bolus would have no role in the treatment of AD or hypertensive crisis. Dantrolene is used in the management of malignant hyperthermia, not AD. Administration of dextrose in 50% water intravenously is used to manage symptomatic hypoglycemia.
Carotid massage causes vago stimulation and is contraindicated in this patient.
Trendelenburg is usually used for hypotension, not hypertension.
A 53-year-old man has a Stage III pressure sore on the ischium. Negative-pressure wound therapy is planned. Which of the following wound characteristics is most likely to impair the efficacy of this treatment modality?
(A) Depth
(B) Diameter
(C) Edema
(D) Fibrosis
(E) Undermining
The correct response is Option D.
Chronic, fibrotic pressure sores are characterized by impaired wound healing and, therefore, respond poorly to negative-pressure wound therapy (NPWT). Debridement of fibrotic tissue and devitalized tissue in these pressure sores improves the response to NPWT.
NPWT is most appropriate for management of full €‘thickness pressure sores that are large enough for adequate contact between the foam dressing and the wound bed and for safe removal of the foam. NPWT can be used successfully for management of large pressure sores, shallow or deep pressure sores, and those with undermining or tunneling.
If the patient is a surgical candidate, NPWT can be used to temporize the wound until the patient has been readied for surgery (nutrition, antibiotics, stabilization of coagulopathy, etc.). NPWT may allow wound improvement such that a lesser surgical procedure may be done. If the pressure sore deteriorates or fails to progress in two to four weeks, NPWT may need to be discontinued.
A 50-year-old man with paraplegia and diabetes mellitus is evaluated because of an ischial stage 4 pressure ulcer. Optimizing the patient’s nutrition and diabetic control is attempted, and aggressive resection of the ulcer and underlying bone with a locoregional flap closure is planned. Which of the following characteristics places this patient at increased risk for late recurrence of the ulcer?
A) Age greater than 45 years
B) Defect size greater than 20 cm2
C) Hemoglobin A1c of less than 6%
D) Location of ulcer
E) Osteomyelitis confirmed by bone biopsy
The correct response is Option D.
The risk factor in this patient associated with the greatest risk of late recurrence is ischial ulcer location.
The treatment of pressure ulcers remains a difficult problem for medical practitioners and plastic surgeons. In a recent study, risk factors were identified as predictors of flap failure after resection and reconstruction with a flap. Factors associated with dehiscence include age less than 45 years, history of previous same-site surgery failure, albumin concentration of less than 3.5 mg/dL, and poor diabetic control (hemoglobin A1c of more than 6%). Factors associated with recurrence include ischial wound location, previous same-site surgery failure, and poor diabetic control. Osteomyelitis confirmed by bone biopsy and size of defect were not associated with dehiscence or recurrence. Patients with multiple risk factors showed a dramatic trend toward dehiscence and flap failure.
Other studies corroborate the finding that ischial ulcer location is difficult for achieving coverage. This is most likely secondary to the high pressure over the ischial tuberosities in the seated position. Pressure maps have shown that, when seated, the pressure exceeds 80 to 100 mmHg compared with supine sacral pressures of 60 mmHg.
A 22-year-old man who is a wheelchair-bound paraplegic is evaluated because of a recurrent pressure sore. The patient has had previous surgeries to repair a left trochanteric pressure sore and a large midline sacral pressure sore. A photograph is shown. The most appropriate treatment is debridement followed by coverage with which of the following?
A) Adjacent skin advancement
B) Gluteal fasciocutaneous flap
C) Posterior thigh musculocutaneous flap
D) Split-thickness skin graft
E) Tensor fascia lata flap
The correct response is Option C.
In this patient, a posterior thigh flap consisting of the biceps femoris, semitendinosus, and semimembranosus muscles and overlying skin is the most appropriate treatment option. Advantages of this flap include a reliable vascular supply (first perforating branch of profunda femoris artery), a generous amount of skin, fat, and muscle to obliterate the dead space after ulcer excision, and the ability to re-advance the flap in the event of ulcer recurrence. Additionally, a posterior thigh flap preserves other donor sites such as the medial thigh, lateral thigh, and gluteal muscles for secondary problems or the inevitable pressure sore in another location. The chief disadvantage of the posterior thigh flap is its upward mobility, as maximal movement is 10 to 12 cm. For extensive ischial defects, a second flap or another flap option may be necessary. Generally, this flap is limited to non-ambulatory patients due to the harvest of multiple knee flexors. Transfer of the biceps femoris alone has been described for small defects in ambulatory patients. The posterior thigh flap is a Mathes/Nahai Type II muscle, with a primary dominant pedicle (first perforating branch of the profunda femoris artery) with smaller segmental distal pedicles. These segmental secondary pedicles can typically be divided with little effect on flap survival. It is recommended that the origin and insertion of the muscles be divided to maximize flap mobility and minimize tension at the inset site. These flaps can be designed as a V-Y configuration or designed in a rotational configuration as shown in the perioperative photograph.
The temptation to perform a primary closure should be resisted, as pressure sores by definition indicate a soft tissue deficiency. Simply pulling tissues together over a bony prominence will very likely fail because of wound tension and dehiscence. In this patient, this was already attempted previously with a predictable outcome. Skin grafts have very limited success in this location because of a lack of bulk and resistance to pressure and shearing forces. The gluteal fasciocutaneous flap is based on the inferior gluteal artery and is a good option in the ambulatory patient with an ischial pressure sore. In this case, however, the pedicle is not available owing to the previous gluteal V-Y flap used to repair the sacral pressure sore. In cases when a gluteal fasciocutaneous flap has been utilized previously, the posterior thigh musculature may still be used in the face of a recurrent ischial pressure sore; however, a skin graft would be required.
The tensor fascia lata (TFL) flap is the first-line choice for trochanteric pressure sores and has already been used in this patient. The TFL has been described for ischial pressure sores, but only after more reliable flaps have been exhausted. Because the distal 6 to 8 cm of the TFL are unreliable, flap delay or pre-transfer expansion are recommended prior to transfer for an ischial reconstruction.
A 52-year-old man with paraplegia presents with a stage IV right trochanteric pressure ulcer. Examination shows appropriate nutrition by history, laboratory values, and weight stability. He doesn’t smoke, has a pressure mattress at home, and has demonstrated compliance with pressure off-loading. At the time of pressure sore excision, which of the following reconstructive options is most appropriate for this patient?
A) Gluteus V-Y musculocutaneous advancement flap
B) Gracilis musculocutaneous flap
C) Posterior thigh musculocutaneous flap
D) Profunda artery perforator fasciocutaneous flap
E) Tensor fascia lata musculocutaneous flap
The correct response is Option E.
The correct flap option for this patient is the tensor fascia lata (TFL) musculocutaneous flap which can be advanced in either a V-Y fashion or as a retropositioned flap if the defect is on the posterior aspect of the trochanter. The pedicle to the TFL flap is the ascending branch of the lateral femoral circumflex artery, and the nerve supply to the skin paddle is through the lateral cutaneous sensory nerve of the thigh. The motor branch to the TFL muscle is a branch of the superior gluteal nerve. This musculocutaneous flap can be re-advanced if there is pressure sore recurrence. In the series referenced, 77% of patients reconstructed with this flap for trochanteric pressure sores healed uneventfully, while two-thirds of the remaining patients healed completely with local wound care. The gracilis and profunda artery perforator flaps have an arc of rotation that makes them more suited to ischial wounds and vaginal reconstructive indications. Gluteal advancement flaps are indicated for sacral pressure sore reconstruction, and posterior thigh flaps could reach the trochanteric surgical site but could not be re-advanced.
A 66-year-old man with paraplegia is evaluated because of a 6-month history of Grade IV pressure ulcer. Medical history includes multiple debridements with appropriate off-loading and good wound care. The patient shows no clinical improvement. Chronic osteomyelitis is suspected. Which of the following is the most appropriate next step in diagnosis?
A) Bone biopsy
B) CT scan
C) Dual energy x-ray absorptiometry (DEXA) scan
D) MRI
E) Triphasic technetium scan
The correct response is Option A.
The accurate diagnosis of chronic osteomyelitis in long-standing wounds can be extremely difficult. The gold standard to diagnose chronic osteomyelitis is bone biopsy. Bone biopsy can provide histopathologic as well as microbiologic data that are sensitive and specific for chronic osteomyelitis.
Triphasic technetium-99 bone scan or scintigraphy is a nuclear study that serves as a functional test to assess bone metabolism. MRI uses a magnetic field and radio waves to reconstruct anatomical structures of interest. CT scan can reveal small areas of osteolysis, small foci of gas, or foreign bodies. Triphasic bone scan, MRI, and CT scan have all been used to evaluate for osteomyelitis clinically. However, these studies lack specificity and can be misleading in the presence of a chronic soft-tissue injury or previous bony injury from prior debridements.
A dual energy x-ray absorptiometry (DEXA) scan is a low-exposure x-ray study measuring bone density in order to assess for osteoporosis. It has no role in evaluating osteomyelitis.
A 55-year-old man with an ulcer of the left ischium (stage 4) undergoes debridement, ostectomy, and transfer of a gluteal myocutaneous flap for closure of the wound. Which of the following risk factors is associated with the highest rate of recurrence?
A) Incontinence
B) Obesity
C) Paraplegia
D) Patient age
E) Vitamin deficiency
The correct response is Option C.
In a study out of Johns Hopkins, pressure ulcer patients who underwent reconstruction had a recurrence rate of 82% if they were paraplegic compared with 0% in non-paraplegic patients. Other risk factors for recurrence after repair include factors that predispose patients to prolonged pressure ischemia and/or reduced capacity for tissue repair. These include age greater than 70 years, immobility, poor nutrition, low BMI, anemia, diabetes, end-stage renal disease, cerebrovascular disease, hip fracture within 3 months, and prior pressure ulcer surgery. Although malnutrition is associated with pressure ulcers, micronutrient deficiencies such as vitamin C or zinc are not associated with formation or recurrence. A subsequent Cochrane Database Study showed that nutritional and vitamin supplementation is not associated with improved healing. There is no evidence to show that incontinence is associated with pressure ulcer formation or recurrence.
Elevation of the semimembranosus, semitendinosus, and biceps femoris muscles during flap harvest is most appropriate for coverage of which of the following types of pressure sore?
A) Calcaneal
B) Ischial
C) Sacral
D) Trochanteric
Correct answer is option B.
The semimembranosus, semitendinosus, and biceps femoris muscles constitute a posterior thigh flap. This flap is more commonly used to treat ischial pressure wounds. Ischial pressure sores occur in patients who are sitting, and the vast majority of patients are paraplegic. These wounds are commonly large and require a bulky flap to completely close the defect. There are a wide variety of flaps available to cover defects in this area, but consideration should be given to potential recurrence as well as to the development of pressure sores in other nearby sites when a surgical ladder or algorithm is considered. Therefore, many surgeons choose to address the ischium with leg flaps first. These are reliable, can often be re-advanced, and do not interfere with more superiorly based flaps if needed for the sacrum or trochanter. Small- to medium-sized defects can be addressed with posterior thigh flaps, such as the biceps femoris alone, when a patient is ambulatory, or with the addition of the semimembranosus and semitendinosus when the patient is not ambulatory. These have an excellent blood supply, are typically designed in a V-Y fashion, and can often be re-advanced in the case of recurrence. Fasciocutaneous flaps preserve muscle, providing coverage for shallow wounds. A posteromedial fasciocutaneous flap can also be elevated based on perforators from the gracilis or adductor magnus. It has an excellent arc of rotation and does not contain muscle. The tensor fascia lata flap can also be used and, in fact, can be designed as a sensate flap in some spinal cord–injured patients with an injury below L3. The tissue over the gluteus maximus can be used and can contain either musculocutaneous or fasciocutaneous components. Thoracolumbar and lumbar defects are best reconstructed with flaps based on the latissimus dorsi muscle. Options for closure include musculoskeletal advancement flaps, a latissimus musculocutaneous flap with a thoracolumbar extension, and, for large wounds, a composite latissimus dorsi and gluteus maximus flap. In certain cases, the omentum can be tunneled and used to cover the lumbar region when no other flaps are available. Sacral wounds are usually covered with gluteal muscle flaps. Sacral pressure sores develop from patients lying in a supine position. If these are small and occur as a result of acute or short-term disability, they can often heal with conservative treatment. Skin grafting is usually not successful. The recurrence rates have been reported to be as high as 70% when using these methods in this location; so again, more reliable coverage should be considered. The mainstay coverage is the soft tissue overlying or including the gluteus maximus muscle, depending on the volume of tissue needed. Again, these are commonly designed as rotational flaps but can be advanced. Additional useful options include the use of a perforator island flap, such as the superior gluteal artery perforator described by Lee, et al. Trochanteric wounds are usually covered with tensor fascia lata muscle. Trochanteric defects result most often from patients lying in the lateral decubitus position. Unfortunately, this is often because the patients are debilitated and, in many cases, have hip and lower extremity contractures. This makes a reliable closure difficult and recurrence common. The method that has been used most commonly is the tensor fascia lata flap. It can be raised as a muscle-only flap or with skin and muscle. It can also be used as an island flap, and even a free tensor fascia lata flap has been described. Again, this can be sensate in patients with spinal innervation above L3. Of note, tissue expansion has been attempted in closure in a number of settings to bring in sensate tissue. A secondary option is the vastus lateralis flap, and a number of flaps based on the gluteus muscles have been described.
A frail 89-year-old man is brought to the office because he has had a large pressure sore on the sacrum for the past 2 months. Medical history includes type 2 diabetes mellitus and multi-infarct dementia. He is incontinent of stool and urine. Which of the following factors is the most important contributor to the development of the pressure ulcer in this patient?
A ) Fecal and urinary incontinence
B ) Inadequate cushioning on the wheelchair
C ) Malnutrition
D ) Poorly controlled diabetes mellitu
E ) Prolonged bed rest
The correct response is Option E.
The most important factor in the development of pressure sores is excessive and prolonged pressure above end capillary pressure (32 mmHg). Pressure greater than 70 mmHg for 2 hours has been shown to cause irreversible tissue ischemia. Pressure sores in the sacrum, heel, and occiput occur from lying in the prone position because pressures range from 40 to 60 mmHg. For patients with altered levels of awareness, position changes at least every 2 hours and a pressure-relieving mattress are essential for prevention of ulcers.
Ulcers in the ischium occur from prolonged pressure in the sitting position. Proper wheelchair cushioning is a hallmark of prevention.
Diabetes, incontinence, and malnutrition are common exacerbating factors in pressure sores, although they are secondary to pressure as the most important factor in ulcer development. The patient described is likely to have decreased serum protein levels, which will result in inhibited wound healing. Incontinence can result in skin maceration, contamination of open sores, and delayed healing. Without strict glucose control, chronic wounds are unlikely to heal normally.
A 24-year-old man with T11 paraplegia is scheduled to undergo reconstruction of a Stage IV ischial pressure sore with an inferior gluteal artery thigh flap. Medications include intravenous administration of empiric clindamycin every 6 hours for osteomyelitis. To determine the presence of osteomyelitis in this patient, which of the following is the most appropriate next step?
A ) Bone biopsy
B ) CT scanning
C ) Indium scanning
D ) Plain-film x-ray study
E ) Swab culture
The correct response is Option A.
Bone biopsy is the definitive diagnostic method to determine the presence of osteomyelitis. The pathologic examination of bone biopsy specimen remains the most accurate method of diagnosing osteomyelitis underlying pressure ulcers. Lewis et al. demonstrated that core needle bone biopsy is both sensitive and specific for the diagnosis of osteomyelitis, 73% and 96% respectively. Bone biopsy has been shown to be highly sensitive and specific in predicting which patients undergoing reconstruction with a flap are at an increased risk for developing postoperative complications consistent with osteomyelitis.
CT scanning can be useful in identifying a more detailed extent of bone involvement, but the sensitivity and specificity are 50% and 88%, respectively.
Indium scanning uses radiolabeled leukocytes that accumulate in sites of infection and inflammation. Inflammation and infection in the bone marrow have very high sensitivity but low specificity, 100% and 50%, respectively.
Plain-film x-ray study can be confirmatory but not very specific with a sensitivity and specificity of 88% and 32%, respectively.
A result of more than 10 organisms per gram of tissue is diagnostic for invasive infection and is predictive of failure of surgical closure. Swab cultures are generally unreliable and discouraged. They often represent only surface contaminants and do not correlate well with bone cultures.
Elevation of the semimembranosus, semitendinosus, and biceps femoris muscles during flap harvest is most appropriate for coverage of which of the following types of pressure sore?
A ) Calcaneal
B ) Ischial
C ) Sacral
D ) Trochanteric
The correct response is Option B.
The semimembranosus, semitendinosus, and biceps femoris muscles constitute a posterior thigh flap. This flap is more commonly used to treat ischial pressure wounds. Ischial pressure sores occur in patients who are sitting, and the vast majority of patients are paraplegic. These wounds are commonly large and require a bulky flap to completely close the defect. There are a wide variety of flaps available to cover defects in this area, but consideration should be given to potential recurrence as well as to the development of pressure sores in other nearby sites when a surgical ladder or algorithm is considered. Therefore, many surgeons choose to address the ischium with leg flaps first. These are reliable, can often be re-advanced, and do not interfere with more superiorly based flaps if needed for the sacrum or trochanter. Small- to medium-sized defects can be addressed with posterior thigh flaps, such as the biceps femoris alone, when a patient is ambulatory, or with the addition of the semimembranosus and semitendinosus when the patient is not ambulatory. These have an excellent blood supply, are typically designed in a V-Y fashion, and can often be re-advanced in the case of recurrence. Fasciocutaneous flaps preserve muscle, providing coverage for shallow wounds. A posteromedial fasciocutaneous flap can also be elevated based on perforators from the gracilis or adductor magnus. It has an excellent arc of rotation and does not contain muscle. The tensor fascia lata flap can also be used and, in fact, can be designed as a sensate flap in some spinal cord–injured patients with an injury below L3. The tissue over the gluteus maximus can be used and can contain either musculocutaneous or fasciocutaneous components.
Thoracolumbar and lumbar defects are best reconstructed with flaps based on the latissimus dorsi muscle. Options for closure include musculoskeletal advancement flaps, a latissimus musculocutaneous flap with a thoracolumbar extension, and, for large wounds, a composite latissimus dorsi and gluteus maximus flap. In certain cases, the omentum can be tunneled and used to cover the lumbar region when no other flaps are available.
Sacral wounds are usually covered with gluteal muscle flaps. Sacral pressure sores develop from patients lying in a supine position. If these are small and occur as a result of acute or short-term disability, they can often heal with conservative treatment. Skin grafting is usually not successful. The recurrence rates have been reported to be as high as 70% when using these methods in this location; so again, more reliable coverage should be considered. The mainstay coverage is the soft tissue overlying or including the gluteus maximus muscle, depending on the volume of tissue needed. Again, these are commonly designed as rotational flaps but can be advanced. Additional useful options include the use of a perforator island flap, such as the superior gluteal artery perforator described by Lee, et al.
Trochanteric wounds are usually covered with tensor fascia lata muscle. Trochanteric defects result most often from patients lying in the lateral decubitus position. Unfortunately, this is often because the patients are debilitated and, in many cases, have hip and lower extremity contractures. This makes a reliable closure difficult and recurrence common. The method that has been used most commonly is the tensor fascia lata flap. It can be raised as a muscle-only flap or with skin and muscle. It can also be used as an island flap, and even a free tensor fascia lata flap has been described. Again, this can be sensate in patients with spinal innervation above L3. Of note, tissue expansion has been attempted in closure in a number of settings to bring in sensate tissue. A secondary option is the vastus lateralis flap, and a number of flaps based on the gluteus muscles have been described.
A 21-year-old ambulatory man with spina bifida at the level of S2 is scheduled to undergo closure of a stage IV ischial decubitus ulcer. Rotational flap closure is planned. Which of the following flaps is most appropriate considering wound closure and ambulation?
A) Gluteal thigh
B) Gluteus muscle
C) Hamstring
D) Reverse latissimus dorsi
E) Vastus lateralis
The correct response is Option A.
This patient, who has S2 paraplegia, has complete muscle function in the upper extremities, thoracic musculature, hips, and knees. Thus, detachment and relocation of hamstring muscles, the primary flexors of the knee, would greatly decrease this patient’s ability to ambulate. Although the vastus lateralis is a significant knee extender, and the use of this muscle would weaken the function of the quadriceps, other quadriceps muscles (vastus intermedius, vastus medialis, and rectus femoris) can sufficiently compensate for its loss.
Reverse latissimus dorsi can be useful for lower back and sacral coverage, but it does not have sufficient reach to cover the ischium. Tensor fascia lata assists in femoral flexion and abduction, but it is a minor muscle and has little functional impact. Gluteal thigh flaps are based on the descending gluteal artery and are typically raised as fasciocutaneous flaps. Thus, it would have little effect on ambulation or lower extremity motion.
A 45-year-old quadriplegic woman is scheduled to undergo reconstruction of a Stage IV left ischial pressure sore that is next to the anus with a tensor fascia lata flap. Which of the following is the most appropriate treatment before flap reconstruction in this patient?
A ) Administration of baclofen
B ) Administration of ferrous sulfate
C ) Diverting colostomy
D ) Local application of collagenase
The correct response is Option C.
Alteration of the bowel routine or even a diverting colostomy should be considered in patients with perineal wounds to reduce fecal soiling of the wound. This minimizes the bacterial contamination of the wound, thus making the wound suitable for closure and reducing the likelihood of reconstructive failure.
Involuntary muscular spasms contribute significantly to pressure sore development, especially in spinal cord–injured patients. This damage occurs through shear forces on soft tissues. Medical therapies include the use of diazepam, baclofen, and dantrolene.
Special considerations in the paraplegic or quadriplegic patient include the management of fecal soilage of the wound and treatment of spasm and contractures. Medical management of spasticity should be optimized.
Anemia is common in the pressure sore population and is caused by an inability to use relatively normal iron stores. For this reason, iron treatment is useless, and it may lead to iatrogenic hemochromatosis.
For all patients with pressure sores, regardless of whether they will progress to surgical closure or not, the principles of wound management apply. Debridement of devitalized tissue and dressing care to gain control of the wound are important.
A 45-year-old paraplegic man with a history of type 1 diabetes mellitus comes to the physician because of a stage 3 trochanteric pressure sore. The wound has been adequately debrided, and myocutaneous flap reconstruction is planned. Albumin concentration is 3.8 mg/dL, and hemoglobin A1c concentration is 6.3%. Diet includes protein intake of 2.5 g/kg daily. Which of the following factors is most likely to be associated with failure of the reconstruction?
A) Albumin concentration
B) Hemoglobin A1c
C) Patient age
D) Pressure sore location
E) Protein intake
The correct response is Option B.
Preoperative optimization is essential in patients undergoing pressure sore reconstruction. This includes adequate nutrition (albumin greater than 3.5 g/dL, 1.5 to 3.0 g/kg/day of protein intake, 25 to 35 cal/kg of nonprotein calories daily), eradication of infection, treatment of spasms/contractures, smoking cessation, urinary/stool diversion in select circumstances, and an appropriate postoperative plan of care including pressure off-loading. A multivariate analysis of risk factors for failure of pressure sore flap reconstruction included hemoglobin A1c greater than 6%, younger age, albumin concentration less than 3.5 g/dL, and ischial location. In this patient, the primary risk factor for failure of reconstruction would be a high hemoglobin A1c
A 65-year-old man with a spinal cord injury and a chronic ischial pressure sore undergoes preoperative optimization with pressure offloading and nutritional supplementation. Medical history includes type 2 diabetes mellitus and chronic ischialosteomyelitis. The patient undergoes thorough debridement of the ulcer and myocutaneous flap reconstruction with appropriate intravenous antibiotic therapy. Four months after surgery, he presents to the clinic with a new wound in the same region as the previous reconstruction. Which of the following factors most likely led to the recurrence of the ischial pressure wound?
A) Hemoglobin A1c greater than 6%
B) Osteomyelitis
C) Patient age
D) Prealbumin less than 20 mg/dL
The correct response is Option A.
The presence of poor glycemic control, as indicated by a Hemoglobin A1c greater than 6%, is a predictor of recurrence of pressure ulcers. Age less than 45 years old at the time of surgery is a predictor of recurrence. Older age at the time of surgery appears to be protective against recurrence. The presence of osteomyelitis at the time of surgery does not appear to contribute to disease recurrence. A low prealbumin (less than 20 mg/dL) does not appear to contribute to recurrence when evaluated on multivariate models. Poor glycemic control contributes to disease recurrence as well as early return to the operating room for wound dehiscence.
An otherwise healthy 55-year-old man with paraplegia is evaluated because of a recurrent ischial pressure ulcer. History includes previous coverage of the ulcer with a posterior thigh rotation-advancement flap. After appropriate optimization of both patient and wound, which of the following is the most appropriate surgical intervention for reclosure of the wound?
A) Gracilis musculocutaneous flap
B) Inferior gluteal flap
C) Re-rotation of posterior thigh flap
D) Tensor fascia lata flap
E) V-Y hamstring flap
The correct response is Option C.
The most appropriate surgical treatment option would be to re-rotate the posterior thigh flap.
One of the main principles in surgical flap closure of pressure ulcers (PUs) is to utilize large rotation flaps so that they may be re-rotated in the case of recurrences. Although it is debatable whether to re-flap a patient who has a PU recurrence, some clinical situations require a redo flap closure. In those circumstances, instead of using a new flap or donor site, re-elevation of the original flap and re-advancing it is usually the first-line flap option. The posterior thigh flap is a fasciocutaneous flap based on the descending branch of the inferior gluteal artery (if elevated as a purely V-Y flap, or if raised as a superiorly based “tongue” flap). However, if elevated as a rotation-advancement flap, it also has blood flow from medial or lateral thigh skin perforators depending on where the flap incisions are made on the posterior thigh.
In all forms of the flap, the entire posterior thigh skin and fascia is elevated off the hamstring muscles (semitendinosus, semimembranosus, biceps femoris), thus severing all the musculocutaneous perforators from those muscles to the overlying skin and fascia. Therefore, the V-Y hamstring flap (a musculocutaneous flap) is not available after a posterior thigh flap has been raised. Though the inferior gluteal artery flap, gracilis, and possibly the tensor fascia lata flaps may be used, they are not the most appropriate surgical option when a re-rotation thigh flap is still available.
A 28-year-old man with a 10-year history of paraplegia has septicemia and a large grade IV pressure ulcer over the greater trochanter. MRI shows communication with the hip joint. After excision of the ulcer, which of the following is the most appropriate next step in management?
A) Administration of a culture-specific antibiotic for six weeks
B) Coverage with a tensor fascia lata flap
C) Coverage with a total thigh flap
D) Coverage with a vastus lateralis flap
E) Resection of the femoral head
The correct answer is option E.
The most appropriate management of this patient’s pressure ulcer is resection of the femoral head, also known as Girdlestone arthroplasty. The sinogram finding of communication of the ulcer with the hip joint is consistent with osteomyelitis, which typically occurs in association with pyarthrosis. Resection of the femoral head will effectively remove the infected tissue in this patient, and vascular tissue should be used to obliterate the dead space. The vastus lateralis flap can be advanced into the acetabular fossa as a muscle or musculocutaneous flap. Administration of an antibiotic for six weeks will control wound sepsis but will not treat osteomyelitis. The tensor fascia lata flap is a sensate flap that is appropriate for coverage of less extensive trochanteric ulcers. This flap lies proximal to the site of the ulcer and can be easily transferred. Its vascular pedicle is based on perforating vessels from the tensor fascia lata muscle. However, it cannot be used alone in a patient with osteomyelitis. Coverage with a total thigh flap is appropriate only as an end-stage procedure in a patient who has undergone amputation of the lower limb.
A 20-year-old ambulatory man with a history of prolonged hospitalization presents with an evolving sacral wound. The patient has adequate nutrition, and the wound is covered with a foam dressing. Which of the following is an independent risk factor for the development of a pressure ulcer in this patient?
A) Dry wound environment
B) Intact sensorium
C) Male sex
D) Serum prealbumin 20 mg/dL
E) Young age
The correct response is Option C.
Pressure sores develop from unrelieved pressure over a bony prominence. There are nearly 2.5 million pressure ulcers treated each year in the United States. They represent an 11-billion–dollar, labor-intensive task for our health care system. Prevention is key. Medical and socioeconomic conditions affect outcomes and these factors cannot always be controlled. However, mechanical prophylaxis, good nutrition, and prevention of underlying infection form the cornerstones of management. Independent risk factors for pressure sores include advanced age, male sex, altered sensorium, moisture, immobility, malnutrition, and friction/shear injury.
Nutritional status can be measured by the concentration of serum prealbumin. It is now preferred over albumin because of its shorter half-life and ability to show relative changes of the nutritional state. Prealbumin, also named transthyretin, is a transport protein for thyroid hormone and is synthesized by the liver and partly catabolized by the kidneys. Normal concentrations are 16 to 35 mg/
An 18-month-old boy has a 25-cm pigmented lesion on his back. Which of the following is the most appropriate management?
(A) Observation with photographic mapping
(B) Intralesional injection of interferon gamma
(C) Dermabrasion
(D) Tunable dye laser ablation
(E) Excision
The correct response is Option E.
This 18-month-old boy has a giant congenital nevus on the back. Congenital nevi can be classified as “giant” according to several criteria, including those lesions that are larger than 20 cm in diameter, lesions that are greater than twice the size of the patient’s palm, and those nevi for which excision and primary closure cannot be performed as a single procedure. Because of the potential for malignant transformation, surgical excision of the entire lesion is recommended. Although the actual risk for melanoma is controversial, one study reported that approximately 8% of patients with giant congenital nevi developed melanoma during the first 15 years after the initial appearance of the nevus.
Although observation with serial photographic mapping is advocated in patients with familial dysplastic nevus syndrome, it is not appropriate in a patient with a giant congenital nevus because of the association with malignancy. Intralesional injection of interferon gamma is indicated for patients who have confirmed malignant melanoma. Dermabrasion and laser ablation will not remove all of the immature melanocytes within the lesion. In addition, the resultant hypopigmentation seen following treatment may hinder any future monitoring for signs of malignant degeneration.
A 40-year-old ambulatory man comes to the office because of a Stage IV pressure sore over the left ischium. He has no history of pressure sores, adheres to a nutritional diet, and does not smoke cigarettes. He is motivated to avoid recurrence. The most appropriate treatment is debridement followed by coverage with which of the following?
A) Gluteal fasciocutaneous flap
B) Gracilis muscle flap
C) Posterior thigh musculocutaneous flap
D) Split-thickness skin graft
E) Tensor fascia lata flap
The correct response is Option A.
The gluteal fasciocutaneous flap is the most appropriate choice because it spares muscle in this ambulatory patient.
Musculocutaneous flaps provide blood supply and bulky padding and are effective in treating infected wounds. Fasciocutaneous flaps offer an adequate blood supply, durable coverage, and minimal potential for a functional deformity. They more closely reconstruct the normal anatomic arrangement over bony prominences. The surgeon should consider the need for subsequent surgical procedures.
Skin grafting only has a 30% success rate in the scenario described, as grafting tends to provide unstable coverage.
The tensor fascia lata flap is the best first choice for trochanteric pressure sores. The tensor fascia lata flap typically is too thin to offer adequate padding in the scenario described.
A 45-year-old man with paraplegia (Ashworth 5 spasticity) recently underwent coverage of a superficial, cleanly debrided trochanteric hip ulcer with a tensor fascia lata transposition flap (shown above). Which of the following interventions is most appropriate to ensure stable coverage of the wound?
(A) Intrathecal administration of baclofen via an implantable pump
(B) Parenteral administration of a broad-spectrum antibiotic for six weeks
(C) Retrogasserian rhizotomy
(D) Ten weeks of bed rest on an air-fluidized mattress (Clinitron)
The correct response is Option A.
To decrease spasticity, baclofen should be administered by an implantable pump before and after flap coverage. Spasticity contributes to flap breakdown by shearing force and should be controlled to ensure stable coverage of the wound. In some studies, flap failure has occurred in nearly 90% of patients with pressure sores. Prevention of this serious complication requires close control of all variables, including nutrition and postoperative pressure management. Long-term parenteral administration of antibiotics plays no role in the stability of coverage of a clean superficial wound. Ten weeks of bed rest on an air-fluidized mattress is not likely to be useful for a pressure ulcer in a lateral area. Retrogasserian rhizotomy, which interrupts the trigeminal (V) nerve, is not appropriate for this patient.
