Pressure Sores

Question 1

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

Answer 1

A) Gluteal fasciocutaneous flap

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

Question 2

First choice flap for trochanteric pressure sores

Answer 2

The tensor fascia lata flap is the best first choice for trochanteric pressure sores

Question 3

Skin grafting for pressure sore of the ischium

Answer 3

Skin grafting only has a 30% success rate in this scenario, as grafting tends to provide unstable coverage.

Question 4

Flap of choice for an ischial ulcer in an ambulatory patient with good nutrition status

Answer 4

The gluteal fasciocutaneous flap is the most appropriate choice because it spares muscle in this ambulatory patient.

Question 5

A 38-year-old man with paraplegia and a Stage IV ischial pressure sore undergoes complete debridement of the soft tissue and bone and coverage with a gluteal rotation flap. Which of the following is the earliest postoperative time to allow sitting in order to promote flap healing and rehabilitation?
A) Limited sitting at 48 hours
B) Limited sitting at 1 week
C) Limited sitting at 3 weeks
D) Unlimited sitting at 4 weeks
E) Unlimited sitting at 6 weeks

Answer 5

C) Limited sitting at 3 weeks

Postoperative bed rest in a pressure-relieving mattress, such as a fluid-air bed, is essential to allow for proper healing of the flap. Standard regimens have suggested avoidance of sitting for 3 weeks, though one small study demonstrated equal outcomes at 2 weeks for patients with no complications during the procedure. Recurrence rates are high despite the best of care, and allowingpatients to place pressure on the suture line prior to a period of 2 to 3 weeks is likely to result in dehiscence. Unlimited sitting may never be possible in many patients. Frequent position changes and inspection for skin breakdown will always be required for proper ulcer prevention

Question 6

When can a patient be allowed to sit after a flap for a stave IV pressure ulcer

Answer 6

Standard regimens have suggested avoidance of sitting for 3 weeks, though one small study demonstrated equal outcomes at 2 weeks for patients with no complications during the procedure

Question 7

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 mellitus
E ) Prolonged bed rest

Answer 7

E ) Prolonged bed rest

The most important factor in the development of pressure sores is excessiveand 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.

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.

Question 8

The most important factor in developing pressure sores:

Answer 8

The most important factor in the development of pressure sores is excessiveand prolonged pressure above end capillary pressure (32 mmHg).

Question 9

Pressure greater than ___ mmHg for __ hours has been shown to cause irreversible tissue ischemia.

Answer 9

Pressure greater than 70 mmHg for 2 hours has been shown to cause irreversible tissue ischemia.

Question 10

Ulcers in the ischium occur from prolonged pressure… :

Answer 10

Ulcers in the ischium occur from prolonged pressure in the sitting position. Proper wheelchair cushioning is a hallmark of prevention.

Question 11

A 35-year-old man with quadriplegia comes to the office because he has a pressure sore over the right elbow. He has limited function of his upper extremities and uses a wheelchair for ambulation. Physical examination shows a 5-cm-diameter ulcer. Culture shows osteomyelitis of the olecranon. After debridement of the wound, coverage with which of the following flaps is the most appropriate next step?
(A)Flexor carpi ulnaris flap
(B)Lateral arm fasciocutaneous flap
(C)Latissimus dorsi free flap
(D)Pedicled latissimus dorsi musculocutaneous flap
(E)Radial forearm flap

Answer 11

(E)Radial forearm flap

Ulcerations or defects on the lateral or medial aspects of the elbow are common in patients with quadriplegia, often following inflammation of the olecranon bursa. A simple and safe method of reconstruction is achieved using a radial forearm fasciocutaneous flap.

A flexor carpi ulnaris transfer would be suboptimal to cover a wound of this size. A lateral arm fasciocutaneous flap, as commonly designed, would not reach this defect because of its size and location. Free tissue transfer is appropriate for more complex elbow reconstructions and unsalvageable deep burns; however, latissimus dorsi free flap transfer is bulky and would not be the first choice in the scenario described. A pedicled latissimus dorsi musculocutaneous flap is a useful distant flap for coverage of the upper arm and can be used to cover the elbow. Although the functional deficit from this transfer is minimal, it is best preserved in a patient who is a wheelchair ambulator and who has limited muscle function of the upper extremity.

Question 12

Coverage of pressure sore of the olecranon in a paraplegic

Answer 12

Radial forearm flap

Question 13

A 45-year-old man with T4 paraplegia has an ulcer of the right ischium that extends to the underlying bone. Which of the following stages best describes the wound?
(A)I
(B)II
(C)III
(D)IV

Answer 13

(D)IV

This wound is described as a stage IV pressure ulcer because the depth of involvement extends down into muscle

Question 14

Most widely accepted classification system for ulcers was developed by:

Answer 14

The most widely accepted classification system for decubitus ulcers is that of the National Pressure Ulcer Advisory Panel (NPUAP),

Question 15

Stage I ulcer

Answer 15

Stage I describes pressure ulcers with intact skin with signs of impending ulceration: blanching and/or nonblanching erythema, warmth, and induration. These are reversible and can improve with pressure reduction

Question 16

Stage II ulcer

Answer 16

Stage II describes shallow pressure ulcers with pigmentation changes that may appear as an abrasion, blister, or superficial ulcer. These are also reversible.

Question 17

Stage III ulcer

Answer 17

Stage III describes pressure ulcers with a full-thickness loss of skin with extension through the subcutaneous tissue but no penetration of the underlying fascia.
Usually requires surgical intervention.

Question 18

Stave IV ulcer

Answer 18

Stage IV describes pressure ulcers with full-thickness loss of skin with penetration into the deep fascia, resulting in muscle, bone, tendon, or joint involvement. Osteomyelitis and severe undermining of adjacent tissue are often present,

Question 19

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

Answer 19

(D)Fibrosis

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

Question 20

At what point should NPWT be discontinued for a non improving ulcer?

Answer 20

If the pressure sore deteriorates or fails to progress in two to four weeks, NPWT may need to be discontinued

Question 21

A 49-year-old woman with a 20-year history of paraplegia comes to the office forconsultation regarding a chronic ulcer of the right ischium. She has been treating the wound twice daily with saline-soaked gauze dressings. Wound drainage has increased and become foul-smelling during the past week. The patient has smoked one pack of cigarettes daily for the past 15 years. Height is 5 ft 1 in and weight is 92 lb. The patient breathes comfortably on room air, is afebrile, and is not in acute distress. Physical examination of the ischial region shows a 5-cm-deep wound that is necrotic and extends to the ischial bone. Hip flexion contractures are noted. Culture of the wound shows gram-positive cocci and gram-negative rods.

Laboratory studies show the following:
Hemoglobin 9.1 g/dL
Hematocrit 27%
Leukocyte count 12.5/mm3
Serum albumin 2.4 g/dL
Urine: Leukocytes Many; Leukoesterase Positive

Which of the following is the most appropriate next step in management?
(A)Bone scan
(B)Debridement and closure of the wound with a muscle flap
(C)Excision of the ulcer
(D)In-office debridement and application of collagenase dressings
(E)Intravenous antibiotic therapy

Answer 21

(C)Excision of the ulcer

The patient described has an ischial decubitus ulcer resulting from prolonged pressure in the sitting position. The wound necrosis, elevated white blood cell count, and Gram stain merit immediate surgical intervention. The best immediate surgical option is complete ulcer excision including the underlying bursa and exposed ischium. Bone should be resected until firm, bleeding cortex is encountered and debrided bone should be sent for culture. The extension of the ulcer to bone indicates clinical osteomyelitis, and a bone scan will not change management in this patient.

Office debridement and chemical debridement dressings are not sufficient treatments for a wound of this severity. Although culture-specific antibiotics are an essential part of treatment, this patient’s clinical status will not improve without debridement of all nonviable tissues.

Question 22

A 45-year-old man with paraplegia undergoes closure of a 10-cm-diameter pressure ulcer on the ischium. After debridement, which of the following is the definitive management for wound closure?
(A) Girdlestone arthroplasty
(B) Gracilis muscle flap
(C) Vacuum-assisted closure
(D) Vastus lateralis flap
(E) V-Y hamstring advancement flap

Answer 22

(E) V-Y hamstring advancement flap

Although all of the procedures mentioned may be useful in the treatment of this pressure sore (except the Girdlestone procedure), the most definitive method of wound closure is the V-Y hamstring advancement flap. The Girdlestone procedure involves resection of the proximal femur and is used in certain cases of trochanteric ulcers (but not ischial ulcers). The gracilismuscle flap would be too small to adequately close this 10-cm-diameter pressure ulcer. The vacuum-assisted closure technique may eventually lead to wound closure, but it would be slower than muscle flap transposition and probably would not provide adequate soft-tissue coverage for a stable wound in this pressure-sensitive area. The vastus lateralis flap is well described for trochanteric coverage but is not used for closure of ischial ulcers.

Question 23

Girdlestone procedure

Answer 23

The Girdlestone procedure involves resection of the proximal femur and is used in certain cases of trochanteric ulcers (but not ischial ulcers).

Question 24

A 36-year-old man with paraplegia is brought to the office for evaluation of a pressure ulcer. Physical examination shows a grade IV wound over the trochanter. Which of the following tests is most appropriate to confirm the diagnosis of osteomyelitis?
(A) Bone biopsy
(B) Bone scan
(C) CT scan
(D) MRI
(E) Radiographs

Answer 24

(A) Bone biopsy

Bone biopsy is still the gold standard for confirming osteomyelitis, which is suggested in this patient.

Question 25

Gold standard for confirming osteomyelitis

Answer 25

Bone biopsy is still the gold standard for confirming osteomyelitis, which is suggested in this patient.

Question 26

MRI in diagnosing osteomyelitis

Answer 26

In one study examining MRI of the pelvis in paraplegics, MRI used for the diagnosis of osteomyelitis yielded a sensitivity of 98% and a specificity of 89% compared with bone biopsy.

Question 27

A pressure sore involving full-thickness skin and subcutaneous tissue to the level of the underlying muscle fascia is classified as which of the following?
(A) Grade I
(B) Grade II
(C) Grade III
(D) Grade IV

Answer 27

(B) Grade II

Grade II pressure sores involve full-thickness skin and extend to adipose tissue.

Question 28

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)

Answer 28

(A) Intrathecal administration of baclofen via an implantable pump

To decrease spasticity, baclofen should be administered by an implantable pump before and after flap coverage. Spasticity contribute 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.

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

Question 29

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

Answer 29

(E) Resection of the femoral head

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.

Question 30

When is coverage of a pressure ulcer with a total thigh flap appropriate?

Answer 30

As an end stage procedure in a patient who has undergone amputation of the lower limb

Question 31

The tensor fascia lata flap is appropriate for which pressure ulcers?

Answer 31

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.

Question 32

Antibiotics for a patient with osteomyelitis

Answer 32

Antibiotics will help control wound sepsis, but won’t treat the osteo! Need an operation

Question 33

A 28-year-old man with quadriplegia is undergoing debridement of a massive grade IV sacrococcygeal pressure ulcer. The entire coccyx and a large portion of the sacrum are necrotic. Which of the following is the highest level at which bony debridement can be performed without entering the dural space? 
(A) Juncture of S2-3
(B) Juncture of S3-4
(C) Juncture of S4-5
(D) Juncture of the coccyx and sacrum
(E) Mid coccyx

Answer 33

(A) Juncture of S2-3

The juncture of S2-3 is the highest level at which bony debridement can be performed without risking entry into the dural space. Extensive debridement in the dural space may damage the nerve plexuses of the sacrum and coccyx

Question 34

What is the highest level of bony debridement in the spine, without risk of injury into the dural space?

Answer 34

The juncture of S2-3 is the highest level at which bony debridement can be performed without risking entry into the dural space. Extensive debridement in the dural space may damage the nerve plexuses of the sacrum and coccyx

Question 35

At what level does the conus medullaris lie?

Answer 35

The conus medullaris, which is the terminal end of the neural portion ofthe spinal cord, lies at the level of L2.

Question 36

A 52-year-old man with quadriplegia has pressure ulcers of the left and right ischia after sitting in his wheelchair for prolonged periods. Physical examination of the ulcers shows involvement of the reticular dermis on the left and exposure of underlying muscle with purulent drainage on the right. Which of the following isthe correct clinical staging of these ulcers?

Left vs Right Stage
A) I vs II
B) II vs III
C) II vs IV
D) III vs III
E) III vs IV

Answer 36

B) II vs III

Stage I The skin is intact, but has a red discoloration more than one hour after relief of pressure
Stage II There is a blister or other break in the dermis, with or without infection
Stage III There is subcutaneous destruction into the muscle, with or without infection
Stage IV There is bony or joint involvement, with or without infection

Question 37

Which of the following is the primary advantage of using Integra (artificial skin) for coverage of full-thickness burns?
(A) Allowing for immediate use of cultured epithelial autografts
(B) Allowing for use of thinner autografts
(C) Avoidance of autografting
(D) Complete revascularization within seven days
(E) Prevention of fibroblast ingrowth into the dermal replacement layer

Answer 37

(B) Allowing for use of thinner autografts

In addition to allowing for use of thinner autografts, advantages of Integra include immediate temporary coverage, more rapid healing of donor sites, and improved cosmesis.

Question 38

An ambulatory 75-year-old man has a 6-cm grade IV pressure ulcer on the sacrum. The most appropriate management is reconstruction with which of the following?
(A) Bilateral gluteal myocutaneous advancement flaps
(B) Unilateral superior/inferior gluteal myocutaneous rotation flap
(C) Unilateral superior gluteal artery perforator flap
(D) Thin split-thickness skin graft

Answer 38

(C) Unilateral superior gluteal artery perforator flap

The unilateral superior gluteal artery perforator flap is most appropriate for reconstruction of the area of the sacrum affected by the pressure ulcer. Perforator flaps can be based on either the superior or inferior gluteal artery. They provide adequate myocutaneous coverage and at the same time preserve the gluteal muscles on the involved side. As a result, morbidity at the donor site will be minimized, which is especially important in this patient because he is ambulatory.

Although a bilateral superior/inferior gluteal myocutaneous advancement flap supplies sufficient soft-tissue coverage for pressure ulcers, harvest of the inferior and superior gluteal muscles will result in significant morbidity at the donor site. Harvest of a gluteal myocutaneous rotation flap sacrifices muscle function and also is not the procedure of choice in an ambulatory patient. Thin split-thickness skin grafts do not provide stable coverage of pressure ulcers.

Question 39

The unilateral superior gluteal artery perforator flap for sacral ulcer coverage

Answer 39

The unilateral superior gluteal artery perforator flap is most appropriate for reconstruction of the area of the sacrum affected by the pressure ulcer. Perforator flaps can be based on either the superior or inferior gluteal artery. They provide adequate myocutaneous coverage and at the same time preserve the gluteal muscles on the involved side. As a result, morbidity at the donor site will be minimized, which is especially important in an ambulatory patient.

Question 40

A 50-year-old man with a two-year history of paraplegia develops a grade IV right ischial pressure ulcer with a diameter of 4 cm. Total ischiectomy is performed, and the wound is covered with a gluteal thigh flap. Which of the following complications is most likely in this patient?
(A) Flap loss
(B) Left ischial pressure ulcer
(C) Marjolin's ulcer
(D) Pulmonary thromboembolism
(E) Urethrocutaneous fistula

Answer 40

(B) Left ischial pressure ulcer

Although total ischiectomy decreases the rate of recurrence of ischial pressure ulcers, removal of one ischium transfers the weight to the opposite side when the patient sits, increasing the likelihood of an ulcer on that side.

Necrosis leadingto flap loss is rare in flap transfers involving a major vascular pedicle.

Marjolin’s ulcer, or malignant degeneration, has an incidence of 0.5% in patients with pressure ulcers, and also occurs in other types of chronic wounds. Aggressive squamous cell carcinomas are associated; lymph node involvement is estimated at 60%, and mortality rates are high.

Thromboembolism is a frequent cause of death immediately after the onset of paraplegia but is not common in patients with long-term paraplegia undergoing routine excision and reconstruction procedures.

Question 41

What risk is increased after unilateral ischiectomy?

Answer 41

Although total ischiectomy decreases the rate of recurrence of ischial pressure ulcers, removal of one ischium transfers the weight to the opposite side when the patient sits, increasing the likelihood of an ulcer on that side

Question 42

Risks: Unilateral ischiectomy vs bilateral ischiectomy

Answer 42

Although total ischiectomy decreases the rate of recurrence of ischial pressure ulcers, removal of one ischium transfers the weight to the opposite side when the patient sits, increasing the likelihood of an ulcer on that side.

In contrast, patients who underwent total bilateral ischiectomy, in which weight bearing is transferred to the perineum and pelvis, were more likely to develop perineal ulcers and urethrocutaneous fistulas.

Question 43

Marjorlin’s ulcer in pressure ulcers

Answer 43

Marjolin’s ulcer, or malignant degeneration, has an incidence of 0.5% in patients with pressure ulcers, and also occurs in other types of chronic wounds. Aggressive squamous cell carcinomas are associated; lymph node involvement is estimated at 60%, and mortality rates are high.

Question 44

In a patient who has a large, deep, chronic grade III pressure ulcer of the ischium, calcium alginate dressings are most likely to be used because they have which of the following properties?
(A) Ability to absorb exudate
(B) Ability to provide a moist environment for epithelialization
(C) Antiinflammatory activity
(D) Antimicrobial activity
(E) Hemostatic activity

Answer 44

(A) Ability to absorb exudate

Calcium alginate dressings are xerogels, or dry dressings that become gel-like in the presence of exudate; therefore, they are commonly used for grossly exudative wounds, such as deep ulcers, because they are able to absorb a large quantity of exudate. These dressings contain mannuronic and guluronic acids and are derived from Laminaria seaweed. Patients with exudative wounds typically require frequent dressing changes with other types of dressing because maceration (resulting from the excess moisture) can develop around the margins of the wound. In contrast, alginate dressings need to be changed only every 24 to 48 hours.

Question 45

Application of alginate dressings

Answer 45

Alginate dressings provide a moist environment that is conducive to wound healing, but secondary bio-occlusive dressings should also be applied to prevent drying. They provide an environment that is favorable to epithelialization.
They only need to be changed every 24-48 hours in patients with exudative wounds.

Question 46

Alginates and infection

Answer 46

Alginates are thought to decrease infection by trapping microorganisms and cellular debris, but do not have inherent antimicrobial properties.

Question 47

Alginates and coagulation

Answer 47

Calcium alginates have procoagulant activity and have been used to cover skin graft donor sites

Question 48

A 20-year-old man with paraplegia has a large grade IV pressure ulcer of the left ischium. He previously underwent ligation of the profunda femoris artery on the left. Which of the following flaps is most appropriate for reconstruction in this patient?
(A) Gluteal thigh flap
(B) Gracilis flap
(C) Rectus femoris flap
(D) Tensor fascia lata flap
(E) Vastus lateralis flap

Answer 48

(A) Gluteal thigh flap

The gluteal thigh flap is most appropriate for reconstruction of this paraplegic patient’s ischial pressure ulcer because this is the only flap of those listed whose regional arterial vascularity is provided by a source other than the profunda femoris artery, namely the inferior gluteal artery and venae comitantes.

Question 49

Vascular supply to the gluteal thigh flap

Answer 49

The gluteal thigh flap is supplied by the inferior gluteal artery and venae comitantes.

Question 50

Size/logistics of the gluteal thigh flap

Answer 50

As much as 10 cm x 35 cm can be harvested with this flap. It is frequently transferred as a fasciocutaneous flap with elevation of the inferior portion of the gluteus maximus muscle to the lateral edge of the sacrum.

Question 51

Vascular supply of the gracilis myocutaneous flap

Answer 51

Circulation is provided by the profunda femoris artery via the ascending branch of the medial circumflex artery and venae comitantes

Question 52

Circulation of the rectus femoris flap

Answer 52

Circulation is provided by the profunda femoris artery via the descending branch of the lateral circumflex artery and venae comitantes

Question 53

Circulation of the tensor fascia lata flap

Answer 53

Vascularity of the tensor fascia lata flap is provided by the profunda femoris via the ascending branch of the lateral circumflex artery and venae comitantes

Question 54

In paraplegic patients with chronic pressure ulcers, which of the following is the most common cause of death?
(A) Pulmonary sepsis
(B) Pulmonary thromboembolism
(C) Renal failure
(D) Sepsis secondary to pressure ulcers
(E) Urosepsis

Answer 54

(C) Renal failure

In paraplegic patients with chronic pressure ulcers, renal failure secondary to chronic amyloidosis is the most common cause of death. Pulmonary sepsis, thromboembolism, and respiratory failure are frequent causes of death immediately following the traumatic onset of paraplegia but not in patients with long-standing paraplegia who subsequently develop pressure ulcers. Sepsis secondary to pressure ulcers is uncommon. Although urosepsis is a common problem for patients with long-standing paraplegia, antibiotics decrease the likelihood of death.

Question 55

In paraplegic patients with chronic pressure ulcers, the most common cause of death:

Answer 55

In paraplegic patients with chronic pressure ulcers, renal failure secondary to chronic amyloidosis is the most common cause of death.

Question 56

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

Answer 56

D) Location of ulcer

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.

Question 57

A 47-year-old man with complete T12 paraplegia presents with a 5 × 5 × 4-cm stage IV sacral pressure ulcer. Physical examination shows the wound is clean with granulation tissue. Coverage with a local tissue flap is planned. In designing the flap, careful consideration must be made regarding which of the following?
A) Avoiding incisions near the anus to minimize bacterial contamination
B) Confining scar to a cosmetically acceptable location
C) Designing incisions allowing for future re-advancement
D) Localizing individual perforators
E) Preserving sensory innervation

Answer 57

C) Designing incisions allowing for future re-advancement

A systematic review of the literature was performed by Sameem et al., to determine the relative efficacy of musculocutaneous versus fasciocutaneous versus perforator flaps in the treatment of pressure ulcers. In their analysis, they concluded that all flaps had a significant recurrence and complication rate; however, there was no difference between the types of flaps used. Their paper did not specifically address the issue of how patients’ conditions were subsequently managed when they did develop a recurrence. This is important, because a key surgical strategy is to consider the need for subsequent surgical procedures; in fact, perhaps more critical than the composition of the flap and the nature of its blood supply is the design of the flap and where the incisions are planned. A fundamental principle in surgical management of pressure ulcers is being able to provide healthy vascularized tissue into the wound bed and to completely obliterate dead space. Furthermore, the flap should be designed such that if a recurrence develops, the patient continues to have surgical options available, such as re-advancement or re-rotation of the prior flap(s).

Preservation of sensory innervation is important for patients who still have sensation in this area. However, in patients who are completely paraplegic, there is a lack of adequate sensory innervation and a lack of the ability to ambulate, which is what ultimately leads to the development of pressure ulcers.

Confining the scar to a cosmetically acceptable location is not a major priority in managing pressure ulcers. The cosmetic appearance of scars in this area is relatively unimportant in light of the presence of an open wound.

Localizing individual perforators is not necessary when large rotation or advancement flaps are designed. In those situations, a broad blood supply is maintained, and multiple perforators are typically kept intact and do not require individual localization or dissection. However, it is important when a single perforator flap is being designed. Perforator flaps when used as pedicle flaps may be more prone to venous congestion and slightly higher complication rates due to the delicate dissection and isolation of the sole blood supply, which in turn is more prone to mechanical twisting and kinking. Perforator flaps ideally preserve the muscular function of the donor site, which may not be important in a patient who is paraplegic.

Question 58

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

Answer 58

A) Gluteal thigh

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.

Question 59

A 50-year-old woman is scheduled to undergo debridement and reconstruction of a Stage IV sacral pressure sore. Which of the following is the most appropriate method of reconstruction?
A) Free tissue transfer
B) Full-thickness skin grafting
C) Inferior gluteus maximus island flap
D) Split-thickness skin grafting
E) V-Y fasciocutaneous flap

Answer 59

E) V-Y fasciocutaneous flap

Local flaps in the gluteal region are the first choice for reconstruction of sacral pressure sores. Various designs of gluteal fasciocutaneous and musculocutaneous flaps are commonly used. The gluteal fasciocutaneous V-Y advancement flap is a method that has been preferred for management of these ulcers. Use of this type of flap conserves the gluteus maximus muscle and does not preclude ambulation in a mobile patient. Fasciocutaneous flaps, which are less sensitive to ischemia and more resistant to pressure than muscle flaps, have high mechanical resistance. These flaps are especially useful in wounds of limited depth, as are many in the sacral area.

Traditional wound closure of back defects under tension, with skin (split- or full-thickness) grafts or local random transposition flaps, is a poor choice for the patient with a complicated posterior trunk wound. These treatment options fail because of the poor tissue vascularity and the presence of a significant zone of injury that produced the wound breakdown in the first place.

The majority of the defects encountered in the posterior trunk can be reconstructed with local flaps. In cases of irradiation of the spine, extensive trauma, or significant debridement of surrounding tissue, the patient may be left with poor local solutions for providing vascularized tissue to the wound. In these rare cases, free tissue transfer is used to provide coverage.

Question 60

A 53-year-old ambulatory man comes to the office because of a chronic pressure ulcer of the inferior portion of the left buttock that developed during a prolonged hospitalization 1 year ago. Repeated packing and dressing changes have not been successful in healing. Which of the following is the most appropriate surgical option?
A) Excision of ulcer bursa and primary closure
B) Reconstruction with a posterior thigh fasciocutaneous rotation flap
C) Reconstruction with a superiorly based gluteal musculocutaneous rotation flap
D) Reconstruction with a tensor fasciae latae island rotation flap
E) Reconstruction with a V-Y hamstring musculocutaneous advancement flap

Answer 60

B) Reconstruction with a posterior thigh fasciocutaneous rotation flap

The best choice for managing an ambulatory patient with a chronic pressure sore is using a posterior thigh fasciocutaneous rotation flap. Fasciocutaneous flaps offer an axial blood supply with durable coverage and minimal potential for a functional deformity. The flap more closely reconstructs the normal anatomic arrangement over bony prominences. Disadvantages include limited bulk for large ulcers that have a significant three-dimensionality.

Musculocutaneous flaps offer excellent blood supply and bulky tissue and can be re-rotated like fasciocutaneous flaps. However, in an ambulatory patient they may cause functional impairment.

The tensor fasciae latae flap is occasionally used to close the ischial ulcer. Unfortunately, the distal aspect of the flap that is used to reach the ischial region is usually too thin to offer adequate padding to be effective. Therefore, this flap is not the best option.

Primary closure is associated with a high recurrence rate. A large dead space is usually present due to the absence of tissue, and the induration of adjacent areas makes them difficult to mobilize for a tension-free closure.

Question 61

A 60-year-old man with paraplegia who lives in an assisted care facility is evaluated because of a Stage II pressure sore of the right ischium. He spends each day sitting in a wheelchair. He smokes one pack of cigarettes daily. Which of the following is the most appropriate treatment?
A) Coverage with a lumbosacral flap
B) Coverage with a posterior hamstring musculocutaneous flap
C) Coverage with a tensor fasciae latae flap
D) Excision and direct closure
E) Placement of a hydrocolloid dressing

Answer 61

E) Placement of a hydrocolloid dressing

Stages I and II pressure sores usually can be managed nonsurgically. Stage I pressure sores are non-blanchable erythema of intact skin and usually resolve after 1 hour. Stage II is partial-thickness skin loss presenting clinically as a blister, abrasion, or shallow crater. Stage III pressure sores are full-thickness tissue loss down to, but not through, fascia. Stage IV pressure sores are full-thickness loss with involvement of underlying muscle, bone, tendon, ligament, or joint capsule.

A tensor fasciae latae flap would usually be the flap of choice for a Stage III or IV trochanteric pressure sore.

A lumbosacral flap would usually be used for a Stage III or IV sacral decubitus ulcer.

With reported recurrence rates up to 82%, cessation of smoking would be recommended before operating on a Stage III or IV pressure ulcer. Unless predisposing factors can be controlled, there is no reason to provide treatment to a clean Stage III or IV decubitus ulcer.

Excision and closure has a high failure rate and would not be indicated for a Stage II pressure sore

Question 62

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

Answer 62

A ) Bone biopsy

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.

Question 63

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

Answer 63

C ) Diverting colostomy

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.

Question 64

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

Answer 64

B ) Ischial

Question 65

Trochanteric flap coverage

Answer 65

Usually with tensor fascia lata muscle

Question 66

Sacral wound flap coverage

Answer 66

Usually with gluteal muscle flaps

Question 67

Thoracolumbar and lumbar defect flap coverage

Answer 67

Usually 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.

Question 68

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

Answer 68

A) Gluteal fasciocutaneous flap

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.

Question 69

A 38-year-old man with paraplegia and a Stage IV ischial pressure sore undergoes complete debridement of the soft tissue and bone and coverage with a gluteal rotation flap. Which of the following is the earliest postoperative time to allow sitting in order to promote flap healing and rehabilitation?
A) Limited sitting at 48 hours
B) Limited sitting at 1 week
C) Limited sitting at 3 weeks
D) Unlimited sitting at 4 weeks
E) Unlimited sitting at 6 weeks

Answer 69

C) Limited sitting at 3 weeks

Prevention of pressure sore recurrence following flap coverage requires careful attention at every stage of care – from patient selection and preoperative preparation to intraoperative technique and postoperative care. Postoperative bed rest in a pressure-relieving mattress, such as a fluid-air bed, is essential to allow for proper healing of the flap. Standard regimens have suggested avoidance of sitting for 3 weeks, though one small study demonstrated equal outcomes at 2 weeks for patients with no complications during the procedure. Recurrence rates are high despite the best of care, and allowing patients to place pressure on the suture line prior to a period of 2 to 3 weeks is likely to result in dehiscence. Unlimited sitting may never be possible in many patients. Frequent position changes and inspection for skin breakdown will always be required for proper ulcer prevention.