| PRE-TREATMENT
OF PRESSURE ULCERS USING SUBATMOSPHERIC PRESSURE DRESSINGS ENHANCES PLASTIC
SURGICAL COVERAGE
Professor Raymund E Horch MD with Jürgen
Kopp MD, Alexander D Bach MD and Ulrich Kneser MD
Introduction
Pressure ulcers represent a major medical and socio-economic problem.
They significantly impair a patient’s quality of life and may even
become life-threatening if left untreated or treated inadequately.1 Although
a number of innovative conservative and operative treatment options have
been developed, definitive coverage of pressure ulcers remains a challenge.2
The most common sites of predilection are the ischium, sacrum, trochanter
and heel. Many factors such as medical conditions, psychological situation
and social circumstances have to be considered for an adequate treatment
of pressure ulcers. The prognosis of the patient with regard to his mobility
and recovery is important for decision making.
Figure
1: Infected right hip joint with loss of both parts of the joint
and
chronic osteomyelitis beneath a 4th ° ischial pressure ulcer.
Treatment of pressure ulcers includes several
conservative and surgical approaches. In many instances, medical care
and maintaining patient comfort should be the goals rather than the institution
of major invasive procedures. Generally speaking conservative therapy
is appropriate for superficial ulcers in transiently immobilized patients,
whereas deep ulcers above bony prominences in long-term immobilized patients
such as paraplegic patients require surgery with a flap reconstruction
to achieve sufficient and durable coverage. Wound healing and prevention
of recurrence become the goals following successful closure of a pressure
sore. In addition, reconstruction of any pressure ulcer is aimed at improvement
of patient hygiene and appearance, prevention or resolution of osteomyelitis
and sepsis, reduction of fluid and protein loss through the wound, and
prevention of future malignancy (Marjolin ulcer). Surgical debridement
is almost always indicated in advanced ulcers with involvement of the
deep tissue, and when conservative wound dressings fail to clean the wound,
or when deep ulcers contain significant amounts of necrotic tissue. Surgical
debridement may also be carried out to accelerate conservative treatment
of more superficial ulcers. Longstanding ulcers are bacterially contaminated.
In order to prepare the recipient site for successful plastic surgical
flap coverage, the wound bed has to be optimized. The vacuum-assisted
closure (V.A.C.®, KCI, Europe) technique is widely used to induce
and promote wound healing.3 Surgical debridement combined with topical
negative pressure therapy using the VAC device represents a promising
tool to facilitate definitive surgical closure with grafts and flaps.4,7,8,9
Figure 2:Typical
pressure ulcers with the hip joint still affected after three months
of conservative treatment and first aggressive surgical debridement.
Figure 3: Following surgical debridement
a V.A.C. device is applied to a pressure ulcer with
continuous negative pressure until proper wound bed preparation has been
achieved.
Methods
and Techniques
Since pressure ulcers are analogous to an iceberg (small visible surface
with a more extensive unknown base), those more advanced ulcers presenting
with muscle involvement and exposed bone (stage III and IV) were selected
to receive surgical debridement and plastic surgical closure (Figures
1 and 2). The ulcer’s extent was marked with methylene blue prior
to excision. The ulcer was then excised en bloc with the surrounding skin,
underlying bursa and soft tissue calcifications as well as the underlying
infected bone. Affected bony tissue was radically removed. Accurate haemostasis
was always ensured since blood loss may be significant during and after
debridement. After excision the bone was carefully recontured in order
to prevent recurrence of the ulcer. In our trial surgical reconstruction
was attempted after radical surgical debridement followed by continuous
Vacuum therapy (V.A.C.®, KCI Int., Amsterdam) until the wound bed
was ready for flap surgery (Figures 3 and 4). Continuous negative pressure
was applied with –125mm Hg and the wound effluent was collected
in a canister. Dressing changes were performed every 48 hours during the
wound treatment period. Sequential debridement of necrotic tissue took
place when considered clinically needed.
Figure 4: Principles
of action of the V.A.C. therapy device (with kind permission of KCI Europe).
Reconstruction
was only carried out after complete and radical ulcer excision and adequate
preparation of the wound. Tension-free closure of the defect and donor
site was always achieved. Preferably, scars were avoided in the region
of the former ulcer and above bony prominences. Local fasciocutaneous
or myocutaneous flaps were raised and placed in the defect. The choice
of flaps followed an ‘escalation scheme’ from simple procedures
to more complex coverage techniques (so called ‘reconstructive ladder’)
to allow for secondary surgery of relapses in the future. Therefore, for
many posterior pressure ulcers of the ischial and trochanteric regions
an axially vascularized posterior thigh flap was the flap of first choice
for many of our patients (Figures 5 and 6). However, a stepwise approach
for any specific defect site was chosen according to individual needs.
Free flaps remained as an ultimate solution. Closed suction drainage and
perioperative antibiotics administration as well as pressure-relieving
positioning in air fluidized beds for three weeks followed by three more
weeks on an alternating pressure mattress were generally performed.5 Sutures
were left in place for 21 days following flap coverage.
Figure 5: To allow for further surgical
options in case of relapse a fasciocutaneous axially vascularized flap
(here: posterior thigh flap) is always the method of first choice in our
treatment algorithm.
Results
Between 1983 and 2004 a total of 89 patients with single or multiple pressure
ulcers were treated with flaps. From 2001 we used the vacuum device in
14 pressure ulcer patients to prepare the wound bed after surgical debridement
and prior to transposition of fasciocutaneous or myocutaneous pedicled
flaps. In these patients the use of the vacuum sealing technique following
irrigation and debridement decreased the dimensions of the initial wound,
thus facilitating healing and the eradication of any pre-existing infection.
We found that the period of wound bed preparation was significantly shortened
after the introduction of VAC pre-treatment. The majority of patients
(93%) with stage III and IV ulcers achieved sufficient wound closure within
six weeks of debridement and continuous vacuum pretreatment. Secondary
healing occurred in 3.5% of the patients, whereas in the historic control
group without VAC pre-treatment the rate was 7.9%. One of the patients
with partially secondary wound healing was irradiated in the flap area.
Figure 1f: After
inset of the posterior thigh fasciocutaneous flap the donor site can be
primarily closed.
Note that the tip of the flap has been desepithelialized and buried to
fill up the cavity of the ulcer.
Discussion
Whereas for chronically- or terminally-ill patients with long-standing
or recurrent ulceration a conservative approach is best suited to deal
with a pressure ulcer, aggressive surgical treatment remains in the best
interest of the patient when the therapeutic aim of treatment is either
to resolve an acute infection with septic conditions or to close the wound
and reintegrate the patient into social life. Once the decision has been
made to treat a pressure ulcer surgically the mainstay of any procedure
is a thorough surgical debridement before surgical closure can be achieved.
Very few pressure ulcers can or should be closed primarily following debridement
due to unacceptably high complication rates. However, this period of wound
bed preparation can be tedious and time consuming. Both factors contribute
to some of the major socio-economic problems in pressure ulcer treatment.
With the advent of negative topical pressure application following surgical
debridement a significant enhancement of this wound bed preparation period
has been noticed.
Although the exact mechanism is not yet known in detail, it is hypothesized
that negative pressure contributes to wound healing by reducing the bacterial
load and removing excess interstitial fluid thereby reducing oedema, increasing
vascularity of the wound and creating force to draw the edges of the wound
closer together.6 Complications of flap reconstruction include haematoma,
seroma, wound separation, flap necrosis, flap dehiscence and infection
and these have contributed in part to the bacterial load of the ulcers.
The technique of vacuum pre-treatment after surgical debridement and before
a definitive wound closure with surgical flaps has resulted in a high
flap survival rate (93%) and fewer immediate infection complications.
Furthermore, in our experience, it has reduced the rate of seroma formation.
We have yet to analyze thoroughly the long-term results of our reconstructed
complex pressure ulcer wounds, but we expect this analysis to confirm
the long-term efficacy of these reconstructions. In conclusion, the vacuum
sealing technique represents an effective option in the management of
chronic pressure ulcers and allows efficient and safe plastic surgical
reconstruction.
References:
1. Horch, R. E. Treatment of decubitus ulcers in the geriatric patient.
MMW Fortschr Med 145, 42–4, 46, 2003.
2. Brem, H. ,and Lyder, C. Protocol for the successful treatment of pressure
ulcers. Am J Surg 188, 9–17, 2004.
3. Mullner, T., Mrkonjic, L., Kwasny, O. ,and Vecsei, V. The use of negative
pressure to promote the healing of tissue defects: a clinical trial using
the vacuum sealing technique. Br J Plast Surg 50, 194–9, 1997.
4. Wanner, M. B., Schwarzl, F., Strub, B., Zaech, G. A., and Pierer, G.
Vacuum-assisted wound closure for cheaper and more comfortable healing
of pressure sores: a prospective study. Scand J Plast Reconstr Surg Hand
Surg 37, 28–33, 2003.
5. Guy, H. Preventing pressure ulcers: choosing a mattress. Prof Nurse
20, 43–6, 2004.
6. Ballard, K. and Baxter, H. Vacuum-assisted closure. Nurs Times 97,
51–2, 2001.
7. Kopp, J., Kneser, U., Bach, A.D. and Horch, R.E. Buried chip skin grafting
in neuropathic diabetic foot ulcers following vacuum-assisted wound bed
preparation: enhancing a classic surgical tool with novel technologies.
Int J Low Extrem Wounds. 3: 168–71, 2004
8. Kopp J, Strnad V, Bach AD, Sauer R, Horch RE. Vacuum application increases
therapeutic safety and allows intensified local radiation treatment of
malignant soft-tissue tumors. Strahlenther Onkol. 181: 124–30, 2005
9. Horch RE: Basics foundation and results of the vacuum therapy in the
reconstructive surgery. Zentralbl Chir. 129 Suppl 1: S2–5, 2004
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