The Surgical Management of Pressure Sores

The Surgical Management of Pressure Sores ROSS M. CAMPBELL, M.D."

THE terms "decubitus ulcer" and "bed sore" to describe the condition to be studied are undesirable for at least two reasons. First of all, decubitus means the position of recumbency, and this state is not necessarily involved in the case of ischial ulcers and many sores of the heels and other parts. Secondly, the term "bed sore" is not inclusive enough because these sores may result from wheel-chair pressure, brace pressure, thermal and friction burns and trauma. More important than this simple error, however, is the psychological induction of an attitude of tolerance toward the development or presence of these lesions resulting from the use of the word "bed" which has comfortable connotations in the minds of most and utterly no shock value to the majority of patients and physicians. Yet shock value is desirable, for these pressure sores can be fatal at their worst and a source of prolonged morbidity and economic waste at best. The surgical management of pressure sores is a comparatively new concept of therapy dating from 1945, at which time Lamon and Alexander! reported on the secondary closure of decubitus ulcers with the aid of penicillin. Prior to this, it is reported by Cannon, O'Leary, O'Neil and Steinsieck2 that Scoville at Cushing Hospital had recommended definitive surgical closure. Whether he followed up his thinking is not made clear. Davis3 is given credit by most writers for recommending the flap replacement of scar epithelium in healed ulcers, thus providing bulky, well-padded skin over bony prominences. From the Institute of Reconstructive Plastic Surgery and the Department of Surgery, New York University College of Medicine and the Manhattan Eye, Ear and Throat Hospital, New York, N. Y. This paper is based on ten years' experience in the treatment of pressure sores encountered on the Rehabilitation and Surgical Wards of Bellevue Hospital.

* Assistant Clinical Professor of Surgery (Plastic Surgery), New York University College of Medicine; Assistant AUending Surgeon, Manhattan Eye, Ear and Throat Hospital. 509

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In 1943, Mulholland and his associates' made a most significant contribution to the nutritional aspect of treating these lesions, securing relatively rapid healing of the sores in a mixed group of general surgical and paraplegic patients by restoration of a positive nitrogen balance through the use of amino acid and dextrose dietary supplements. This principle is of utmost value today in preparation of patients for surgery. Reports of the successful surgical treatment of pressure sores in World War II wounded appeal'ed in rapid succession, including papers by Barker,5 White, Hudson and Kennard,6 Gibbon and Freeman,7 Croce, Schullinger and Shearer. 8 Barker, Elkins and Poer,9 Croce and Beakes,l° White and Hammll and many others. Kostrubala and Greeley12 in 1947 recommended excision of bony prominences underlying ulcers, and a further report by Blocksma, Kostrubala and Greeley13 in 1949 advised the, at that time, radical procedure of removal of the tuberosity of the ischium. By using this technique Conway, Stark, Weeter, Garcia and Kavanaugh14 stated they had increased their operative successes in ischial ulcers from 47 per cent before using ischiectomy to 81 per cent after its adoption. Refinements of technique have been added to the literature on the subject over the years, but it is not the intention nor the purpose of this paper to enumerate all of them except as they may illustrate certain aspects of treatment. Interest in the improvement of the therapeutic measures appears to have been stimulated by a number of factors, some related, others not. World War II with its estimated 2000 to 2500 spinal cord injuries among U.S. troops (Gelb 15 ), the advent of antibiotics which enabled surgeons to risk operation in contaminated areas with an excellent chance of success, the emphasis on reclamation and rehabilitation of the formerly hopeless paraplegic so wisely and widely publicized by Dr. Howard Rusk and others to the ultimate good of patient, community and country, the increasing mechanization and motorization of our daily lives, improved surgical and ancillary services-all have played a role in stimulating the surgical approach to the problem of treating pressure sores. CAUSATION

Pressure is the key word. Not trophic changes, not poor nursing care, not debility, although any combination of these in conjunction with pressure may hasten the breakdown of the tissues. Unrelieved pressure, particularly over thinly padded bony prominences, with its resulting ischemia leading to tissue necrosis can produce a pressure sore in otherwise healthy humans. We have all seen this, infrequently, it is hoped, in poorly fitting plaster casts worn by young, well-nourished adults with fractures. There is general agreement that two to four hours is the longest time that pressure should go unrelieved, but even these time limits may be generous. How much more susceptible, then, is the paraplegic with

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his early flaccid, later spastic paralysis, his sensory pathways interrupted and motor control absent, or the chronically ill, malnourished patient who either lacks incentive or is too sick to change his position in bed or wheel chair and so relieve pressure. Groth16 in a most lucid and scientifically commendable monograph, appa.rently not widely known, has described the results of a series of experiments performed on rabbits, both paralyzed and normal, wherein he subjected the shaved gluteal regions to various pressures transmitted by a simple lever device for varying periods of time. The treated areas were then observed both macroscopically and microscopically, the animals being killed at stipulated intervals. In animals which demonstrated no macroscopic changes, microscopic changes consisting of Zenker's waxy degeneration in individual muscle fibers and capillary hemorrhages were seen. The longer the pressure, the greater was the extent of microscopic change. Animals of 2 to 3 kg. exposed to a surface pressure of 143 mm. Hg for 3 to 4 hours showed macroscopic changes after a few days. These consisted of slight swelling, redness and small hemorrhages and progressed to well-circumscribed foci, light grayish red to yellow gray in color, surrounded by a narrow reddish zone. Sometimes the round foci were missing and the changes appeared as distinct stripes running in the direction of the muscle fibers. No apparent change in the nerves and larger blood vessels of the area occurred. Microscopically, Groth found capillary hemorrhages, Zenker's waxy degeneration, vacuolation, or loss of striation followed 2 to 3 days after the pressure was applied by calcification in some of the dead muscle fibers. Phagocytosis, with beginning interstitial proliferation producing granulation tissue which formed a wall of demarcation around the necrotic musculature, was also observed. After 7 days a collagenous ground substance leading to scar formation developed.

Among the conclusions Groth drew were these: 1. Pressure sores simulating those found in humans could be produced experimentally. 2. Decubiti occurred more frequently in flaccid paralytics than in spastics. 3. When a muscle mass in a larger animal is greater, the same pressure force must be applied for a longer time to produce tissue breakdown than in a smaller animal with a smaller muscle mass. 4. The effective pressure force increases toward the smaller surface. Thus, a small trochanter pressing toward a broad bed exerts mild force at the skin's surface, leading to redness with possible moderate necrosis of skin. As the deeper layers are reached there is an increasing and broadening necrosis of fat and muscle as the trochanter is approached. This cone-shaped destruction is seen frequently in both trochanteric and ischial ulcers. 5. Generalized sepsis in an animal led to local infection at the site of pressure with abscess formation, extension of inflammation, thrombosis of larger and larger vessels and consequently, broader and broader distribution of tissue necrosis. However, large vessel thrombosis per se was

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not a cause of ulceration because of the extensive collateral circulation usually present. This extensive detailing of Groth's experimental findings is justified because it explains wholly or in part many hitherto clouded or conjectural concepts of causation of the so-called "deep" or "malignant" ulcer. The superficial ulcer, which can, of course, progress to the deep septic stage unless prompt corrective measures are instituted, may develop in several ways. Carelessness on the part of patient or nurse may produce a "brush burn" or loss of epidermis. Maceration of the skin through contact with wet, soiled bedclothes may induce susceptibility to this type of abrasion. Chafing caused by poorly fitting braces, shoes or even the rhythmic pounding of a dependent heel against the bouncing floor of a motor car can lead to superficial or even deep necrosis of tissue extending from without inwards. The spastic paraplegic lying in bed with knees and ankles periodically approximated by spasm or merely resting against each other may soon develop abraded areas which, unless heavily padded and protected, will progress to deeper sores penetrating the knee joint or exposing the malleoli or tibia. The shearing force exerted on sacral and buttock skin by the paraplegic's sitting up in bed has recently been described by ReicheP7 as a likely major cause of sacral pressure sores. Guttman18 also refers to shearing stress as being more disastrous than vertical pressure, although one might dispute. this inference. STAGES IN CLINICAL APPEARANCE

Certain clinical stages in the formation of a pressure sore may be observed. They are: 1. Redness of skin over a pressure area. This will subside if pressure is relieved. 2. Redness, swelling and induration, with occasional blistering and desquamation of epidermis. This, too, may be reversible if adequate pressure relief combined with local heat therapy is instigated. 3. Necrosis of skin with exposure of fat. This situation, unless very small in area may not heal spontaneously. 4. Skin and fat necrosis extending to muscle. Surgical treatment is indicated after debridement and a trial period of conservative therapy. 5. Skin, fat and muscle necrosis. Invariably this calls for surgical intervention at an early date. 6. Bone involvement in the form of periostitis, osteitis or osteomyelitis. Surgical measures are indicated. 7. Osteomyelitis, septic arthritis, possible pathological fracture, septicemia and possible death. This stage should never be reached in a modern hospital, but unfortunately it is still seen from time to time. Once the patient has attained this condition the problem is almost insurmountable.

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We thus see that, of seven clinically distinct stages in the development of these sores, two are frequently reversible, one is almost always irreversible, and four may be classified as falling within the group in which surgical intervention on a small or large scale may be fairly said to be indicated. LOCATION INCIDENCE

The sites of predilection are variable depending on whether the patient is primarily bed-bound, lying supine or prone, spastic or flaccid, up in a wheel chair or wearing braces. It may also be a combination of any of these. Gelb 16 states that even the relationship of the patient's bed to the walls of the room can determine the development site and goes on to explain that, if the bed is next to a wall, the patient lies generally facing away from the wall and toward his roommates. With so many variables it might seem hard to seek out constants, but this is really not so. In the early weeks after onset of accident or disease, the patient generally lies supine with changes of position to the sides. Thus, it is to be expected that sacral ulcers, followed closely by trochanteric ulcers, should develop. This, too, is generally the stage of flaccidity and loss of vasomotor control-factors contributing to the ease of tissue breakdown. At this time calcaneal ulcers, thoracic ulcers and even occipital sores may develop. The prone position being poorly tolerated by most patients, sores involving the anterosuperior spines, the knees, the tibial crests, and the elbows have a much smaller incidence. With the development of spasticity, the bedridden patient may develop medial condylar and medial malleolar sores with great rapidity in addition to sacral and trochanteric involvement. When this initial period has passed and the patient has reached the stage of sitting in a wheelchair or sitting up in bed, the weight is borne mainly by the ischial tuberosities and these areas may break down readily. The dependent feet resting on a footpiece can, if not well protected, show tissue necrosis on the plantar and posterior aspects of the heels and the lateral margins of the toes. Yeoman and Hardy,19 in a detailed analysis of 240 sores in paraplegics, give the following incidence: SITE

NUMBER

Ischial ....................................... Sacral. ....................................... Heels ........................................ Trochanteric. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. External malleoli .............................. Tibial crests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Antero-superior spine. . . . . . . . . . . . . . . . . . . . . . . . .. Costal margin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

68 64 44 27 20 10 5 2 240

PERCENTAGE

28% 27% 18% 12% 8% 4% 2% 1%

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Generally speaking, however, the major problem areas are ischial, trochanteric and sacral, not necessarily in that order. PREOPERATIVE PREPARATION

General Measures

1. Restoration of the nutritional status by the administration of a high protein, high caloric, high vitamin diet is of prime importance. Mulholland and his co-workers4 demonstrated the real influence of the nutritional state on both the development of ulcers in the presence of hypoproteinemia and their healing when a positive nitrogen balance was restored. This observation is readily confirmed in any clinic. Pressure sores have been likened to third degree burns, wherein there is an extensive protein loss from the weeping surfaces. Measures to correct the nutritional imbalance must be instituted early and must show results before any but actual life-saving surgery is performed in these cases. Protein intake should be about 135 grams daily and it may be given in the form of lean meat, cheese, skimmed milk, protein hydrolysate and amino acids. A high caloric, high vitamin diet is generally desirable. The appetite is usually poor and it takes the combined efforts of all who attend the patient to stimulate adequate ingestion. There are times when the fat content should be reduced and the carbohydrates increased because we have found numerous patients who were simply unable to handle increased fat. In some, ingestion of much fat lowered the general desire for food and resulted in a diminished protein intake. Gordon 20 states that a poor appetite may be improved by administration of insulin and we have used this with effective results on occasion. We have also found testosterone propionate, ACTH and Nilevar of some limited value in this regard. Forced tube feeding has been resorted to in some of these cases. But the greatest aid of all has been the psychological stimulation of a desire to prepare themselves for the operation and thus get started sooner on their rehabilitation program. By all these means, the level of plasma proteins is brought above 6 mg. per 100 ml. before operation. 2. Correction of anemia is carried out by repeated transfusions of whole blood. We transfuse before, during and after operation to the extent indicated. We have found that this promotes more rapid healing after operation. A level of 80 per cent or 12 grams of hemoglobin should be reached preoperatively. 3. Correction of underlying infection in related or unrelated areas needs no further elaboration except to make a plea for greater cooperation between hospital services, especially the genitourinary, dermatology and dental services. The latter is often overlooked, or may be impossible to obtain for patients in many hospitals.

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4. Elimination of spasm is essential and one may encounter great difficulty in this regard. Cannon and his associates2 reported that 40 per cent of the patients in their series had reflex spasms and 30 per cent of these had them severely enough to interfere with surgical closure of the ulcer. This is particularly true of trochanteric closures where the continued erratic movement at the hip joint may disrupt a carefully covered wound. Some patients resist anterior rhizotomy or alcohol washes because they fear interruption of automatic bladder control or loss of erectile power. Nonetheless, they can and should be convinced of the necessity for the procedure. The alternative is failure of the flap coverage in many instances or a bleak period of slow granulation of the wound by conservative measures over many months. 5. Assumption of the prone position for increasing lengths of time prepares the patient for his postoperative period in the case of sacral, ischial and in some instances, trochanteric repairs. Most patients find the position disagreeable to intolerable at first, but they can be coaxed and cajoled into assuming it. 6. Relief of pressure over the ulcer area and protection of all other pressure points by frequent turning and the judicious use of pillows and bulky dressings are essential. For the latter, we favor mechanic's waste held in place by elastoplast, thus producing a light, airy, springy dressing which diffuses weight, allows air to circulate and does not become sodden and flat. The skin under the elastoplast may require protection by painting with tincture of benzoin. Montgomery straps may be useful where soiling necessitates the frequent changing of dressings. The use of foam rubber rings is not, in our opinion, a good practice. First of all, they lead to a false sense of security on the part of both nurses, attendants and patient, with a possible reduction in the frequency of position changes ordered by the doctor. In addition, while relieving pressure at one point, they create an annular area of pressure around this point which can lead to vascular constriction with disastrous results. 7. The patient should be conditioned by every means possible to look forward to his operation with eagerness and optimism. He must be advised of the enormous saving in time that will result-time which he will be able to spend profitably in regaining a large measure of mobility and independence. To this end one can employ to great advantage the services of the rehabilitation department, members of which can outline the program which the patient will follow and the things he will be able to do that are impossible for him at the present time. We have never seen a patient whose over-all attitude did not respond to this therapy.

Local Measures Local treatment is aimed at securing a surgically clean, not a sterile, wound. All necrotic skin fat and muscle should be d~brided surgically in the

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beginning. All septa should be broken down and unilocular and multilocular infected bursae opened for free drainage. It may be necessary to repeat this surgical debridement either in the operating room or, more usually, on the ward, several times. Fascia should be trimmed away if it appears to be devitalized. We have always placed our greatest reliance on these surgical measures, although we have had a modest success with enzymatic debridement, as reported by Morrison and Casali,21 in the form of a papain-urea-chlorophyll formula applied twice daily for a week, then once daily. Some patients have shown skin irritations with the prolonged use of this preparation but the irritation vanished when the medication was stopped and saline dressings substituted. Satisfactory results with dried blood plasma have been reported by Clark and Rusk. 22 Streptokinase-streptodornase ointment has also been used successfully on our patients, but it is our belief that such biochemical debridement is of more value in the final cleaning up of the sores before operation. Daily dressing changes must be insisted upon. The wound that is bathed in its own products of infection and tissue breakdown remains a stagnant, foul-smelling lesion, which actually becomes more extensive and the over-all condition of the patient becomes worse. Irrigation of the depths of the ulcer, particularly those in the trochanteric and ischial areas, should be carried out daily, or with each dressing change. It matters little what irrigant is used, but our preference is a mixture of hydrogen peroxide and saline in equal parts. It is relatively bland and the foaming action of the hydrogen peroxide yields a good mechanical flushing effect. Packing deep wounds with I-inch gauze strip, shortened slightly each day, not only keeps the enzymatic ointment in contact with the depths, but appears to promote growth of granulation tissue. Local application of antiseptic substances or antibiotic solutions has shown no appreciable superiority over the aforementioned measures. However, we have no serious aversion to the use of such agents, even though we prefer simple measures which we know to be effective, economical and relatively certain. If sinus tracts and infected bursae are present, x-rays are taken with a contrast medium instilled and the devious roots of the sinuses identified before operation. An ischial ulcer may show osteomyelitis of the tuberosity, but in addition, the infection may track medially and anteriorly toward the pubis, especially in a patient who has been placed in the prone position to relieve pressure. In the trochanteric ulcers there may be extensions up, down and around the thighs along the fascial and muscle planes. Some will track from the trochanter to the femoral neck and on into the hip joint, producing a septic arthritis. Heterotopic bone will be revealed in many ulcers of long standing, some deposits reaching an amazing size. Simple superficial periostitis or osteitis is no contraindication to operation of a conservative nature, but when joints are in-

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volved, the problem of treatment may be quite complex, requiring orthopedic consultation, and at times assistance at the operation. Throughout the period of local preparation, relief of pressure over the sore through the use of bulky dressings previously mentioned is mandatory. All other pressure areas are likewise protected since of necessity they bear more of the burden of body support. Daily tub baths in tepid water with plenty of suds are instituted three to seven days before operation if sufficient ward help can be mustered to handle the patient. The bottom of the tub can be padded to provide a certain measure of protection. Moist saline dressings or saline containing an antibiotic when applied for 24 to 48 hours before operation have been effective in providing a clean, granulating surface with a relatively low bacterial count. SURGICAL TREATMENT

Choice of Procedure

The object of surgery is to secure a well-padded covering over the site of the former pressure sore and it is the contention of this writer that this is best obtained by the use of large local flaps of skin, fat and occasionally muscle. We do not believe that to encourage the slow development of a thin, sometimes avascular epithelial covering over a large ulcerated area is a commendable practice, generally speaking. Such a covering is always subject to easy breakdown, through even mild trauma, and on each such occasion it takes longer and longer to reepithelize. Split-thickness skin grafts which may act as a life-saving measure by preventing the massive loss of protein from large wounds may stand up a little better, but should be considered temporary and preparatory unless used to cover small depressed superficial sores, as for example in the region of the heel. If there is any likelihood that they will be exposed to trauma or pressure, they should not be considered as permanent coverage. Simple excision with undermining and approximation of the edges is a tempting procedure in small ulcers, but is really a surgical compromise (Campbell and Converse;23 Berger24 ). Usually some tension persists, and even if healing occurs, which it frequently does not, the scar is located over the most vulnerable site. It is therefore surprising to see this procedure recommended as the method of choice by Yeoman and Hardy 19 in their otherwise excellent paper. The use of a single pedicle large rotation or transposition flap has yielded the most satisfactory results in our hands. The donor sites can frequently be closed without a skin graft, a desirable objective in itself, where the flaps are large, broadly based and planned according to accepted principles.

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The stellate closures produced by sliding flaps toward the central area, as described by Croce, Schullinger and Shearers and in a somewhat similar manner by White, Hudson and Kennard,6 have not given satisfactory results on our service, because these multiple suture lines and angles are often slow to heal and prone to slough. If they do heal, the patient has a varying number of cicatrices located directly over probable pressure points, and infringing on possible flap donor sites for future sores. This placing of a scar over the bone would also weaken the effectiveness of double rotation flaps as used by Kilner and described by Osborne25 in the case of sacral sores. By this method two large buttock flaps based inferiorly are raised, moved medially and sutured to each other in the midline. The donor sites can be closed without a skin graft in many instances. Bipedicled flaps have two disadvantages which are: firstly, presence of excessive tension when moved laterally to cover the ulcer site, and secondly, the donor site requires a split graft. V-Y advancements and suture are unsatisfactory because of puckering of scars and the location of the scars over underlying bone. In criticizing so many widely accepted methods of treatment, the writer does so in a spirit of humility engendered by sad experience and it should go without saying that there will be occasions when any and all of these measures may have to be tried. The patient with multiple sores (Fig. 135, A-E) may represent a nearly insurmountable problem, so that only conservative measures and surgical stopgaps may be employed. Quadriplegics are perhaps the most extreme examples of such problem cases and they are a bitter test of our surgical ability and ingenuity. In spite of all-out efforts, they can and do literally disintegrate in astoundingly short periods of time. Perhaps for such problems the radical-seeming technique of body suspension via Kirschner wires, inserted through the anterosuperior spine regions, which were used by certain German surgeons during World War II and were described by Neil, 26 may be the answer. Anesthesia

Weare in complete accord with Gordon20 in the matter of using general anesthesia rather than sedation and/or local infiltration for the operation. The anesthesia, usually endotracheal, need not be deep, but should be sufficient to eliminate any residual spasm. A competent anesthesiologist, supervising the electrolyte and whole blood replacement, able to give ample warning to the surgeons of the beginning of shock or the development of cardiac complications, is an extremely important member of the surgical team. Blood loss is considerable in spite of our best efforts to minimize it, and the unstable neurovascular mechanism can be both vexatious and dangerous. The psychological discomfiture of the con-

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Fig. 135. A, Quadriplegic with multiple pressure sores-sacral, bilateral trochanteric, bilateral ischial, as well as smaller ones on knees, ankles and feet. B, Two weeks after sacral ulcer treated by large rotation flap and skin graft. Partial failure lower end. C, Three months after B and one week preceding death. Loss of lower half of flap with wide extension of sacral sore involving both buttocks. D, Same time as in C. Left knee joint completely open. Right knee was similar. E, Same time as in C and D. Multiple ulcers of left foot.

scious patient is in itself a source of marked concern to the surgeon, therefore we advise general anesthesia. Positioning and Preparation of the Patient

The patient is positioned properly on a well-padded operating table, care being taken to relax the operative area and surrounding skin and to interpose padding between adjacent pressure surfaces, such as knees, ankles and other prominences. A catheter is generally led into a bottle, but we have clamped them

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off for two to three hours without ill effect. Some writers have stressed the possibility of inducing urinary infection by clamping. While this may occur, its likelihood is remote. The operative site is prepared with ether, Phisohex and water followed by aqueous Zephiran. This has proved to be entirely satisfactory in our hands and avoids the possibility of a chemical burn. In draping, towel clamps are not inserted into the skin and a very wide area is left exposed. Outlining the Ulcer and the Flap

The extent of the sore is outlined in Bonnie's blue or other ink, and no attempt is made to follow every irregularity that presents. An effort is made to convert an ulcer into a round or oval defect. Where the edges are undermined and the cavity beneath is wide, we have found it useful to use a curved clamp, which is inserted into the cavity to its lateral limit and, when the tip is gently pushed upward, some bulging of the skin will be observed and ink marks are laid on the skin at these points all around the ulcer (Fig. 136, B, C). They are later joined into a continuous line (Fig. 136, D). The clamp used in the ulcer bed is discarded and every effort is made to reduce or eliminate contact with the ulcer to reduce the hazard of contamination of the skin. The entire wound is then packed with gauze, soaked in a dye such as methylene blue. This will be of distinct assistance in visualization when we proceed to excise the entire lesion en bloc without entering the ulcer cavity (Fig. 136, D-G). Before the lesion is excised the surrounding skin on all sides is tested for laxity and for natural lines of force and play, so that the flap may be fashioned in an area where these lines will facilitate transposition or rotation. As far as the blood supply to the flap is concerned, we notice very little difference whether it is based superiorly or inferiorly, nor have we noticed a great deal of difference other than a thinning out when the middle line has been crossed in raising a flap. We try to maintain the proper ratio of length to base, which may approach 272 to 1, to avoid uncovering another bony prominence, to try to place the suture lines in soft tissues rather than near superficial osseous structures, and to allow maximum flap size and thickness. Sometimes the most desirable flap location cannot be utilized because of old scarring, which interferes with blood supply. Compromise is necessary, and this may take the form of a delay of the flap, a procedure we do not, under ordinary circumstances, carry out or favor. When al(these factors have been considered, a tentative outline of the flap to be raised is then marked in ink. Excising the Ulcer

This is done by following the ink lines going wide and deep into normal skin and fat and muscle. A peripheral incision is made to the required

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Fig. 136. A, Ischial pressure sore of moderate duration. B, Extent of ulcer cavity outlined on skin surface in Bonnie's blue marking ink. C, Cross section of B showing cavity and fairly dense, moderately thick scar tissue in walls. Periostitis of ischial tuberosity. D, Gauze packing strip (1 inch) wrung out in methylene blue and packed into cavity. F, Methylene blue gauze in place. E, G, Excising ulcer en bloc.

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Fig. 136. (Continued). H, Ulcer being separated from ischial tuberosity if possible. If not dissection stops at bone. I, Osteotomy of protuberance of ischial tuberosity. J, Rough edges of bone rasped and rounded off. Bleeding controlled by Gelfoam soaked in thrombin. This is left in situ. K, Muscle flap from gluteus maximus to lessen depth of defect.

depth and the excision proceeds centripetally (Fig. 136, E, F, G). The blue gauze packing will be a helpful guide as we approach the active part of the ulcer. Usually an ulcer can be excised without entering the cavity. The base is carefully raised from the underlying bone, if possible (Fig. 136, H), but if it is not possible, it is left attached and the bone is removed with an osteotome (Fig. 136, J). Enough bone is removed to present a flat or gently curved bleeding surface. We do not believe in performing the so-called "total prophylactic ischiectomy," although our failure to do so has been mildly criticized by Conway and Griffith.27 Support for our practice of partial ischiectomy is presented by Comarr and Bors28 who report an incidence of 46 per cent of development of perineal urethral diverticula in patients with spinal cord injuries who had the ischium removed while undergoing operation for decubitus ulcer. Where bilateral ischiectomy was done the incidence was 58 per cent. All other bone chips, deposits or spurs are similarly trimmed off and the surfaces smoothed by rasping. Bone hemostasis is satisfactorily accomplished by applying Gelfoam soaked in thrombin (Fig. 136, J). Other bleeding points not secured in the course of excision are clamped and either electro coagulated as in the case of smaller bleeding points or tied with 3-0 or 4-0 plain catgut ligatures, if large vessels are involved.

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Fig. 136. (Concluded). L, Flap of skin and subcutaneous fat, based medially, ready for transposition. M, N, "Creeping advancement" sutures of 3-0 or 4-0 chromic catgut. Each row of sutures advances flap a few millimeters, securing added length without tension. 0, Over-all view distribution of buried sutures. P, Q, Skin closure using either continuous or interrupted sutures of 5-Q dermalon, no tension on suture line. R, S, If small defect is left, close with split-thickness graft. Height of wound edges is greatly diminished by placing interrupted sutures around periphery. Subcutaneous fat is displaced centrifugally, dermis sutured to fascia or muscle. Sutures left long and tied over bolus dressing for pressure on graft and without pressure to flap.

The whole cavity is then packed with a laparotomy pad rung out in warm saline to take care of the rather extensive capillary oozing due to lack of vasomotor control in these patients. At this point, it may be apparent that the size of the original area of excision was underestimated and its general outline has changed in shape. It will then be necessary to revise the size, or even the direction and location of the previously outlined flap.

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Raising the Flap

Once the size is determined, the flap is incised along the ink lines (Fig. 136, L). The incision should be vertical, not beveled, and sharp angles should be avoided. In some locations it may be necessary to undermine only at the level of the superficial fascia, whereas in others, where a deep defect must be filled, undermining at the level of the deep fascia is carried out. Gentleness in handling must be observed at all times in all areas. Skin hooks and saline-soaked laparotomy pads are used to facilitate the handling. Hemostasis is carried out in the same fashion as previously described. The mobility of the flap is tested periodically until it has been raised sufficiently so that it will slide over into the defect without tension. To accomplish this, the skin edges of both ulcer area and donor site will likely require undermining (Fig. 136, L). The objective is to secure tensionless closure of both the recipient defect and the donor defect with the avoidance of the use of a skin graft, if possible. A large flap, with widely undermined areas, will almost always allow this to be done. At this stage it is advisable to trim away all loose tags of fat and to irrigate the entire wound with copious amounts of normal saline. Covering the Ulcer Defect

In the ischial site and sometimes in the trochanteric region the defects are very deep. To make these defects shallower, flaps from the adjacent musculature can be fashioned (Fig. 136, K). These are slid or transposed over the deepest portions of the defect and sutured to adjacent muscle, fascia and sometimes subcutaneous tissue using 3-0 or 4-0 chromic catgut (Fig. 136, L, M). Every bit of ingenuity must be exercised in eliminating the dead spaces and reducing the total depth of the wound. In suturing the flap into position, we have found that the second most important factor in eliminating tension (first is a flap of adequate size) is the use of what has been termed the "creeping advancement suture" (Fig. 136, M, 0). Using 3-0 or 4-0 chromic catgut sutures to approximate the underside of the flap to the underlying bed sequentially from the base toward the free end of the flap, a gentle advancement with each suture is obtained. This may amount to 2 or 3 mm. per row of sutures which may yield 1 to 2 cm. of added length without tension. By this method, the potential space for hematoma collection is markedly diminished. The flap is firmly anchored to its bed, full use of the real length of the flap is obtained without tension and there is no need to use wire, silkworm gut or any other type of tension suture. The final suturing of the wound edges is done without difficulty, using one or two deep layers of 4-0 or 5-0 chromic catgut and skin closure of interrupted or running sutures of 5-0 dermalon (Fig. 136, P, Q).

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Fig. 137. A, Trochanteric ulcer apparently healed but with history of repeated breakdown when subjected to pressure. Outline of area to be excised and flap to be transposed. A', Three weeks postoperative, no skin graft needed to close donor site. No further trouble (5 year follow-up). B, Trochanteric ulcer with undermined edges and exposed bone. B', Correction by excision en bloc with removal of part of greater trochanter, muscle flap to fill deep defect, rotation skin flap (should have been larger) and split graft to donor site. C, Sacral ulcer with bare bone at base and wide undermining of edges. C' , Large rotation flap without skin graft covering defect.

The flap donor site can be closed in most instances by a T or S closure, but very occasionally a split graft is required. This is sutured into place and secured using a bolus dressing. It is useful to convert the steep perpendicular sides of the remaining defect into shelving beveled edges as illustrated in Figure 136, R, S. Drains in the form of Penrose tubes are used for 48 to 72 hours. We

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have also used small plastic catheters with multiple holes in the sides attached to a suction machine of low power. This method has proved useful, but the need for drainage has been markedly reduced since employment of the advancement suture. The creeping advancement suture has, to a large extent, eliminated the need for pressure dressings to approximate the flap to its base. It is obvious that this is a very great advantage, because even mild pressure can, in certain cases, be harmful to the delicate distal circulation. Some patients are returned to the ward without dressings but usually, a lightly secured dressing is applied. In sacral ulcers occurring in stout patients, the gravitational pull on the suture line, due to the weight of the buttocks and flanks, can be excessive. Elastoplast from buttock to buttock can help to circumvent this by exerting a gentle upward pull. Care is taken to make certain that no pressure of an excessive amount occurs on the flap covering the sacrum. Examples of treated ischial, trochanteric and sacral ulcers are shown in Figure 137. POSTOPERATIVE CARE

It is generally advantageous to give patients a broad-spectrum antibiotic for five to seven days after operation. All pressure to the operative site is avoided, of course. This may necessitate the assumption of the unpleasant prone position, but even this position can be varied somewhat, from side to side, by the judicious use of pillow props under the chest and hips. Although position changes of slight degree every two hours, day and night, are made, no excessive movements can be permitted. The patient forced to lie on his side can be positioned a little to the prone and a little to the supine side, giving a much needed variation in position. Pressurebearing skin surfaces should be protected by padding. It is desirable that patients do not have to use a bed pan and consequently the postoperative diet should be of a constipating nature. Sometimes the diet is purely liquid, but a high protein, high caloric, soft, low residue diet is preferable. Bowel movements are discouraged for five to seven days postoperatively, in spite of almost unanimous complaints. Drains are removed in 48 to 72 hours and frequently the operated areas are left open at this change of dressing. In 10 to 14 days, the skin sutures are removed. Because of the fine suture material used and the general absence of tension along suture lines, reaction around the sutures is negligible. Blood transfusions are ordered as indicated. After 14 days the patient is allowed to assume more varied positions in bed, but direct pressure is not allowed. Where it is absolutely essential; either because of the presence of other pressure sores or the danger of their development, some weight may be borne in the area if it is thickly padded with mechanic's waste or combines fastened in place with elastoplast.

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Limited use of the operated area is allowed after four to six weeks. The patient must be reminded repeatedly to avoid prolonged periods of pressure to the surgical site. It is often helpful to massage the incisional scars and the flap with lanolin ointment. This helps to soften the scars and to lubricate the surface. POSTOPERATIVE COMPLICATIONS

If cyanosis of the flap occurs and is early and extensive it should be treated by return to the operating room where all sutures are removed .and the flap is resutured into its original bed. Saline dressings are applied to the ulcer site and in one to two weeks the flap transfer is repeated. If cyanosis is confined to the distal end, or scattered small areas, release of a few sutures in the adjacent areas may be enough. Even good-sized wound separations can be corrected frequently by adhesive tape butterflies used after circulation has been shown to be adequate. Sometimes there may be a superficial cyanosis at the end of the flap which may lead to necrosis and desquamation of the skin edge. If it is not too extensive and is confined to the skin this will epithelize, resulting in delay but not failure. Necrosis of the distal e~d can be variable in extent, from half a centimeter to half the flap. Naturally, treatment must be flexible and adjusted to the situation. In a narrow, marginal necrosis one can wait for a line of demarcation to develop then debride in the operating room and perhaps resuture the edges if the gap is not too wide. In more extensive losses it is preferable to await demarcation, then, under general anesthesia, to debride and rotate another flap, if available, from the opposite side to fill the defect. If no such flap can be obtained, it may be necessary to bring full-thickness skin into the region in the form of a tubed pedicle. Disruption of the suture line may occur in a nutritionally depleted patient with little or no wound-healing power, and there is little one can do for this, since the cause is general, not local. The patient should not have been operated on in the first place. Another cause of disruption is spastic activity in a joint. It is useless to try to resuture. The flap will retract to a certain point and become adherent. The defect may require another flap or sometimes a skin graft can be used if the residual defect is depressed and does not have to bear weight. Hematoma or seroma may develop. It is rarely necessary to evacuate these by removing sutures but if they are so extensive that the survival of the flap is in jeopardy, suture removal can be done in the operating room, the bleeding point, or bleeding points captured and ligated and the wound resutured. In most instances, where the hematoma is small, it will liquefy in a few days, and it can be aspirated with ease. Aspiration is best carried out with a large-gauge needle, inserted through the flap, rather than the suture line. A light pressure dressing is then applied. Infection in and around the operative site is generally insignificant or

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absent unless basic principles of reconstructive surgery have been violated. If it does develop, it is handled as circumstances dictate. SPECIAL PROBLEMS

It is perhaps unnecessary to remind the reader that throughout the entire period of treatment the ultimate goal is the restoration of the patient to a state of self-sufficiency, and to do this the services of all the available modalities must be utilized. The rehabilitation agency must make known what it expects to be able to accomplish and the manner of doing so. Is the patient going to be confined to a wheel chair? Will he be able to walk with the aid of braces? What is his potential? If it is necessary to straighten knees, flex hips, arthrodese joints, the orthopedic service should be invited to express its views and to undertake the necessary procedures. At all times the psychological effect on the patient of the decision made must be borne in mind. The patient who, for example, has developed a septic arthritis of the hip or a pathological fracture of the neck of the femur as a result of osteomyelitis must have a total assessment. It seems unduly drastic to subject a man with an already heavy burden to the crushing blow of an amputation of one or both legs and yet there are occasions when such an operation might be indicated. Georgiade, Pickrell and Maguire29 have recommended a procedure of amputation for just such a situation, where a well-padded weight-bearing stump is left, utilizing the muscles and skin of the thigh. This operation would seem to have a definite place in our armamentarium. On the other hand, it might be simpler and less traumatic physically and psychologically to remove the affected head and neck of the femur and leave a flail leg, which is actually no greater inconvenience to the patient than a paralyzed limb. It might even be an advantage if perchance the patient's hip had been fixed in the extended position, thus preventing the assumption of a sitting position. Penetration of an ulcer into a joint, while serious, can be handled very satisfactorily in many instances by the use of local rotation or transposition flaps in concert with skin grafts (see Fig. 138, A, B). In such cases the deep fascia on the underside of the flap seems to be a reasonably satisfactory substitute for the defect in the synovial membrane and capsule. There are many other special situations which will present themselves to the surgeon handling these severe problems and for nearly all there can be found a solution. Ingenuity, resourcefulness and imagination in addition to medical knowledge and surgical skill are required-in these as in all other major surgical problems. SUMMARY

The term "pressure sore" is considered to be more accurate than and preferable to the terms "decubitus ulcer" and "bed sore."

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Fig. 138. A, Pressure sore with penetration into knee joint. B, Repair by transposed flap and split skin graft.

The history of the surgical treatment of this serious condition has been reviewed. Special attention has been paid to the experimental work on animals because it has contributed greatly to a clearer understanding of the mechanism of production and the resultant pathology. Stages in the clinical appearance, sites of predilection and the importance of nutrition in general preoperative preparation have been described. Local measures and methods that have proved useful preoperatively have also been touched upon. The use of large local flaps has been advocated strongly and certain conservative and operative methods criticized. A technique of operation applicable to most areas has been described and illustrated. The most important points described concern the need for careful planning and meticulous execution of the ulcer excision, the elevation and transposition of the flap and the closure of the donor defect. Certain small refinements of technique, chief of which is the "creeping advancement" suture on the underside of the flap, are stressed, so that tension may be avoided and postoperative complications minimized to the end that primary healing will occur and adequate coverage be provided. It is submitted that the surgical treatment of pressure sores carried out at an early stage, in collaboration with other services as indicated, is preferable to all other forms of therapy. The ideal of early physical, mental and vocational rehabilitation of these gravely handicapped men and women should be paramount in our thinking, but we must not lose sight, either, of the heavy economic waste which we can do much to alleviate. The contributions of all previous writers in this field are most sincerely acknowledged. REFERENCES 1. Lamon, J. D. Jr. and Alexander, E. Jr.: Secondary Closure of Decubitus Ulcers

with Aid of Penicillin. J.A.M.A. 127: 396, 1945.

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2. Cannon, B., O'Leary, J. J., O'N~il, J. W. and Steinsieck, R.: An Approach to Treatment of Pressure Sores/Ann. Surg. 132: 760, 1950. 3. Davis, J. S.: Operative Treatment of Scars Following Bedsores. Surgery 2: 1, 1938. 4. Mulholland, J. H., CoTui, F., Wright, A. M., Vinci, V. and Shafiroff, B.: Protein Metabolism and Bedsores. Ann. Surg. 118: 1015, 1943. , 5. Barker, D. E.: Surgical Treatment of Decubitus Ulcers. J.A.M.A. 129: 160, 1945. 6. White, J. C., Hudson, H. W. and Kennard, H. E.: Treatment of Bedsores by Total Excision with Plastic Closure. U. S. Naval M. Bull. 45: 445,1945. 7. Gibbon, J. H. and Freeman, L. W.: Primary Closure of Decubitus Ulcers. Ann. Surg. 124: 1148, 1946. 8. Croce, E. J., Schullinger, R. N. and Shearer, T. P.: Operative Treatment of ,: \' Decubitus Ulcer. Ann. Surg. 123: 53, 1946. 9. Barker, D. E., Elkins, C. W. and Poer, D. H.: Methods of Closure of Decubitus Ulcers in Paralyzed Patient. Ann. Surg. 123: 523, 1946. 10. Croce, E. J. and Beakes, C. H. C.: Operative Treatment of Decubitus Ulcer. New England J. Med. 237: 141, 1947. 11. White, J. C. and Hamm, W. G.: Primary Closure of Bedsores by Plastic Surgery. Ann. Surg. 124: 1136, 1946. 12. Kostrubala, J. and Greeley, P. W.: Problem of Decubitus Ulcers in Paraplegics. Plast. & Reconst. Surg. 2: 403,1947. 13. Blocksma, R., Kostrubala, J. G. and Greeley, P. W.: Surgical Repair of Decubitus Ulcer in Paraplegics; Further Observations. Plast. & Reconst. Surg. 4: 123, 1949. 14. Conway, H., Stark, R. B., Weeter, J. C., Garcia, F. A. and Kavanaugh, J. D.: Complications of Decubitus Ulcers in Patients with Paraplegia. PIast. & Reconst. Surg. 7: 117, 1951. 15. Gelb, J.: Plastic Surgical Closure of Decubitus Ulcers in Paraplegics as a Result of Civilian Injuries. Plast. & Reconst. Surg. 9: 525, 1952. 16. Groth, K-E.: Clinical Observations and Experimental Studies of Pathogenesis of Decubitus Ulcers. Acta chirurg. Scandinav. 87: 207, 1942. 17. Reichel, S. M.: Shearing Force as a Factor in Decubitus Ulcers in Paraplegics. J.A.M.A. 166: 762, 1958. 18. Guttman, L.: Problem of Treatment of Pressure Sores in Spinal Paraplegics. Brit. J. Plast. Surg. 11: 196, 1955. 19. Yeoman, M. P. and Hardy, A. G.: Pathology and Treatment of Pressure Sores in Paraplegics. Brit. J. PIast. Surg. 11: 179, 1954. 20. Gordon, S.: Surgical Treatment of Pressure Sores. PIast. & Reconst. Surg. 2: 557, 1947. 21. Morrison, J. E. and Casali, J. L.: Continuous Proteolytic Therapy for Decubitus Ulcers. Am. J. Surg. 93: 446, 1957. 22. Clark, A. B. and Rusk, H. A.: Decubitus Ulcers Treated with Dried Blood Plasma; Preliminary Report. J.A.M.A. 153: 787, 1953. 23. Campbell, R. M. and Converse, J. M.: Saddle Flap for Surgical Repair of Ischial Decubitus Ulcers. Plast. & Reconst. Surg. 14: 442, 1954. 24. Berger, J. C.: Surgical Treatment of Decubitus Ulcers. Plast. & Reconst. Surg. 20: 206, 1957. 25. Osborne, R.: Treatment of Pressure Sores in Paraplegic Patients. Brit. J. Plast. Surg. 111: 214, 1955. 26 .. Neil, J. F.: Apparatus for Treating Bed-Sores. Brit. M. J. 2: 390,1945. 27. Conway, H. and Griffith, B. H.: Plastic Surgical Closure of Decubitus Ulcers in Patients with Paraplegia. Am. J. Surg. 91: 946, 1956. . 28. Comarr, A. E. and Bors, E.: Perineal Urethral Diverticulum-Complication of Removal of Ischium. J.A.M.A. 168: 2000, 1958. 29. Georgiade, N., Pickrell, K. and Maguire, C.: Total Thigh Flaps for Extensive Decubitus Ulcers. Plast. & Reconst. Surg. 17: 220,1956. 500 First Avenue New York 16, N. Y.