Surgical and Other Miscellaneous Topical and Physical Treatments

The introductory information on incidence, prevalence, and impact of pressure injuries solidify the importance of understanding the spectrum of prevention and management of pressure injuries, especially in people with SCI given their neurologically compromised sensation, mobility and cardiovascular functions. Previous sections of this chapter have discussed assessment of risk factors and assessment. The most important factor in the management of all stages of ulcers (i.e. SDTI, stage I, II, III, IV) is a comprehensive assessment of risk factors and co-morbidities to choose the most effective treatment methods. Regular reassessment is also necessary, especially in more severe ulcers (i.e. stage III and IV) that are often persistent and/or recur. There are many non-surgical methods of management that facilitate healing of all pressure injuries but stage IV ulcers almost always require surgery. Before surgery is elected, removal of unhealthy tissue using surgical (and non-surgical) methods is a standard procedure that can also expedite the healing of persistent stage III and IV ulcers. The studies reviewed in this section provide evidence that surgery can reduce rehabilitation costs and time by preventing protein loss from the wound, development of sepsis or osteomyelitis, and development of additional skin conditions, such as Fournier’s gangrene (Backhaus et al. 2011) and necrotizing fasciitis (Citak et al. 2011), secondary to the pressure injury. Some studies also provide data to support surgical choices that improve quality of life of people with severe ulcers by decreasing limitations of daily functioning and improving the hygiene and appearance of the skin. With the many surgical reconstruction options available for wound repair, this section attempts to summarize the potential benefits of surgical repair for pressure injuries in people with SCI.

Summarized Level 5 Evidence Studies

Consistent across the studies included in this review, was the confirmation of the most severe pressure injuries occurring in the buttock and hip areas in individuals with SCI due to being primary wheelchair users. The most common types of severe pressure injuries in people with SCI were confirmed, in descending order: ischial, sacral and trochanteric (Tavakoli et al. 1999; Kierney et al.1998; Ahluwalia et al. 2010; Chen et al. 2011; Mehta et al. 2012; Bertheuil et al. 2013; Josvay et al. 2015; Biglari et al. 2013; Grassetii et al. 2013). Caregiver collaboration (Kierney et al. 1998) and flap type selection (Ahluwalia et al. 2010; Borgognone et al. 2010; Bertheuil et al. 2013) when considering surgical reconstruction of severe pressure injuries, facilitates healing (Grassetti et al. 2013) without undue risk of complications (Ahluwalia et al. 2010; Borgognone et al. 2010) and improves the well-being and satisfaction with the rehabilitation experience (Singh et al. 2010) of people with SCI. Chen et al. 2011 and Grassetti et al. 2013 similar in study size, and pressure injury grade and location suggest an average length of hospitalization of approximately 45 and 16 days, respectively. The study by Chen et al. (2011) was primarily a description and observation of a novel traction closure method that should not be compared with traditional surgical closure. Use of combination flaps (Ahluwalia et al. 2010) or flaps novel in design (Borgognone et al. 2010) have reported even further decreases in recurrence rates. However, use of the biceps femoris flap on its own may be prone to a high complication rate (38.4% for grade IV ischial sores; Bertheuil et al. 2013) which may be reduced if used in conjunction with a posterior medial thigh fascio-cutaneous flap (15% for grade III and IV Ischial sores; Ahluwalia et al. 2010). Tavakoli et al. (1999) reported that 33% and 47.8% of patients had recurrence of ulcers at an average follow-up period of 20 and 62 months, respectively.

Discussion

Before surgical reconstruction is elected as a treatment option, a long-standing preparatory procedure is to excise diseased tissue in and around the wound to reduce the risk of wound progression and infection (Conway & Griffith 1956). Although the most common method of debridement is also surgical, non-surgical debridement methods have also been used to treat pressure sores in people with SCI and are discussed in section 3.9 (Non-Surgical Management and Debridement for Healing of Pressure Injuries Post-SCI).  

Erba et al. (2010) confirmed the pyramidal shape of severe pressure injuries (i.e. grade III and IV) by analyzing silicone imprints of the ulcer cavity and provided evidence of more pronounced deep muscle tissue pressure sensitivity relative to resilience to pressure in the superficial layers of ectodermal tissue. Therefore, the surface opening of the wound is quite small relative to base of the pyramidal cavity. Even with active pressure relief strategies counteracted by the almost sole reliance on the wheelchair for mobility, grade IV ulcers are at constant risk for persistence and progression. It is not uncommon that grade IV ulcers in the buttock and hip regions are large and require careful considerations of surgical flaps to provide enough coverage and vascularization for effective closure. Diaz et al. (2013) provide a listing of the types of flaps best suited for different types of pressure injuries and although the authors providing evidence in this current review, echo the matching of flap type to defect type, some flaps appear to be more commonly chosen for defect correction in people with SCI. Specifically, the subset of flaps reported in this current review include thigh (posterior, lateral, medial) and buttocks (gluteus maximus, tensor fascia latae), fascio-cutaneous, myofascio-cutaneous, bi-planer, and flaps perforated with inferior and superior gluteal artery and profunda femoris artery. An informed comparison of all the types of flaps used to close the various types of pressure injuries (e.g., severity grade and location) is beyond the scope of this chapter. Instead, a table detailing the flap type and pressure injury characteristics is provided for those who wish to look into further comparisons.

Velasco et al. (2015) performed a comparative study to evaluate the effectiveness and costs of fibrin sealant to improve postoperative outcomes including hematoma-seroma rate, days until drain removal, drainage volume, length of hospital stay, and detertmine surgical failure and relapse rates after 6 mo. Lower rates of hematoma-seroma were observed in the study group (3.7% vs 33.8%; P<0.05), drain removal occurred earlier (10 vs 15 days; P<0.05), and the average drain volume was also lower (155 vs 360 mL; P<0 .05) for this group. The mean length of hospital stay was significantly lower in the study group and was the main contributing factor to the overall costs.

Kuo et al. (2014) investigated three cohorts through pressure sore reconstruction using free-style perforator flap (group A), fasciocutaeous flap (group B), and musculocutaneous flaps (group C). Wound complications such as wound infection, dehiscence, seroma formation of the donor site, partial or complete flap loss, and recurrence were reviewed. The overall complication rate was 22.9%, 32.4%, and 22.2% in groups A, B, and C, respectively. The flap necrosis rate was 11.4%, 13.5%, and 0% in groups A, B, and C, respectively. There was no statistical significance regarding complication rate and flap necrosis rate among different groups. A case series by Tadiparthi et al. (2016) assessed the surgical outcomes following reconstruction using the team approach and to compare inpatient stay and readmissions for complications before and after the multidisciplinary protocol was introduced. In total, 45 patients with 60 pressure sores (grade 3 or 4) were reviewed. Flap reconstruction was required in 32 patients (71%); after a mean follow-up time of 33 months (range 25-72 months), there were three (9%) major complications (two recurrences of pressure sores and one sinus) and seven (22%) minor complications. Similiarly, Wettstein et al. (2015) analysed the effectiveness of an interdisciplinary cooperation between conservative and surgical disciplines for the treatment of pressure sores. Defect size, grade, method of reconstruction, complication and recurrence rate as well as average length of hospitalisation were studied. The overall complication and recurrence rate was 26% and 11%, respectively. If no complication occurred, the average duration of hospitalisation stay after the first debridement was 98±62days. The study authors concluded the treatment concept to be reliable, effective and results in a low recurrence rate. The complication rate, even though favourable when compared with the literature, still needs to be improved. Kim et al. (2014) found that the combination of a profunda femoris artery perforator fasciocutaneous flap and muscle flap favorable for the treatment of ischial pressure sores provided pliability, adequate bulkiness and few long-term complications. Thus, it may be used as an alternative treatment method for ischial pressure sores.

With the aim to improve the outcomes for spinal cord-injured patients undergoing surgery for pressure injuries, Ljung et al. (2017) investigated a structured treatment program regulating pre- and postoperative care and rehabilitation was introduced in 2002 in Stockholm. At one month postoperatively, 49 out of 51 (96%) patients were completely healed. Five patients (5/44, 11%) developed recurrent or new ulcers within 3 years of surgery. Two patients were re-operated on (2/44, 5%). Between 3 and 10 years after surgery, 9 patients (9/33, 27%) had a history of recurrent ulcers, and 6 (6/33, 18%) had a history of new ulcers, a total of 15 patients (15/33, 45%). Of these, three needed re-operation (3/33, 9 %). The health status values using a visual analogue rating scale were 70 (median) at 3 and 10 years compared with 30 (median) preoperatively. The good initial healing, the low ulcer recurrence rate and the raise in health status indicate the value of a structured treatment programme, especially for the first few postoperative years.

A case study of 3 individuals who underwent elective proximal lower limb amputations was studied by Yusmindo et al. (2014). The clinical impact and functional outcome of the patients were reviewed by comparing the length of hospital stay, the short version of the World Health Organiza- tion Quality of Life (WHOQOL- BREF) score and the Spinal Cord Independence Measures (SCIM) score be- fore and after amputation. After amputation, all patients have marked reduction in hospital stay (mean reduction of 208 days), improvement in WHOQOL-BREF scores (mean increment of 14.68 scores) and minimal improvement in SCIM scores (mean increment of 3 scores) compared to before amputation.

Two case series (Bilagri et al. 2014; Grassetti et al. 2014) described flap complications after pressure injury surgery in SCI patients. The common theme of these studies recognizes that pressure injuries in SCI patients are very common and difficult and expensive to treat. The high rate of complications and the associated costs suggest the importance of evaluating the efficacy of treatment options. Conservative procedures have been standardized, but there still has been limited success in establishing guidelines on how to manage complications arising from flap surgery.

This table is intended to help identify the flap types used for the most common severe pressure injuries (i.e., grade III and IV, ischial, sacral and trochanteric) in people with SCI and echos a subset of a much longer list of flap types presented by Diaz et al. (2013). Specifically, the subset of flaps reported in this current review include thigh (posterior, lateral, medial), buttocks (gluteus maximus, tensor fascia latae), fascio-cutaneous, myofascio-cutaneous, bi-planer, and flaps perforated with inferior and superior gluteal artery and profunda femoris artery.

In all studies considered here, reported recurrence rates continue to decline as surgical reconstruction methods evolved over the last 75 years (Davies 1938). The use of flaps with varying degrees of vascularization and tissue layers chosen to match the type of wound requiring repair has been of benefit to recurrence rates. Relander and Palmer (1988) reported no difference in recurrence rate between pressure injuries treated with cutaneous and musculo-cutaneous flaps despite better initial healing response to musculo-cutaneous flaps (e.g., muscle tissue eventually undergoes atrophy). However the high recurrence rate for these flap types reported 25 years ago (48%; Relander & Palmer 1988) has fortunately continued to decrease (17%, Lin et al. 2010), likely due to the improvement in collaboration between caregivers and also in patient education.

The study by Grassetti et al. (2013) can be favourably compared to length of stay data for general pressure injury reconstruction surgery patients reported at 20 days (Larson et al. 2012; Foster et al. 1997) and even up to 79 days (Marriott & Rubayi 2008; Isik et al. 1997; Srivastava et al. 2009; Relander & Palmer 1988). Considering the significant costs associated with pressure injury healing in the hospital (Zoutman et al.1998) and in the community (Chan et al. 2013) a reduction in healing time is also of benefit to health care systems. Surgical reconstruction of pressure injuries in people with SCI can also improve Barthel Index scores (Srivastava et al. 2009), feelings of well-being (76.6%) and satisfaction with rehabilitation (83.3%) as reported after patients underwent surgical repair of severe pressure injuries (Singh et al. 2010).

Conclusion

There is level 2 evidence (from one cohort study: Velasco et al. 2015) that the application of Tissucol Duo during surgical treatment of PrUs in patients with SCI has been shown to be effective in reducing postoperative complications and in shortening the duration of the hospital stay with a consequent savings in costs.

There is level 3 evidence (from one post-test: Ljung et al. 2017) thata structured treatment programme regulating pre- and postoperative care and rehabilitation can help raise health status of SCI pressure injury patients.

There is level 4 evidence (from one case series: Yusmindo et al. 2014) that proximal amputations of the lower limbs are procedures that can be considered as part of the treatment for complicated pressure injuries. In properly selected patients, it can reduce the number of hospital stay, improve the quality of life and functional outcome.

There is level 5 evidence (multiple studies: Table 27) that supports various surgical repair methods for persistent, severe thigh and buttock pressure injuries secondary to SCI, as a beneficial treatment option.