The Costs and Outcomes of Treating a Deep Pressure Ulcer in a Patient with Quadriplegia
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Infected wounds should not be closed because doing so will entrap infected material and increase the risk of wound dehiscence and resultant complications.
Similarly, before applying external tissue expanders, the wound must be free of pus, urine (piss), feces (poop), particles, and pressure (“Schessel’s five Ps”). The wound should be irrigated (cleaned), surgically debrided (cut), and either covered with a graft or closed, preferably with local tissue (“Schessel’s 4 Cs”). Because culture results from Mr. K’s pressure ulcer showed the presence of Klebsiella pneumoniae and Enterococcus faecalis, a 14-day course of amoxicillin clavulanic potassium and vancomycin every 12 hours was prescribed.
External tissue expansion is contraindicated for sacral pressure ulcers located 2 cm from the anus unless a temporary diverting colostomy is in place. In Mr. K’s case, the ulcer was not too close to the anus, inflammation and infection were controlled, he was medically stable, and his albumin level was >2. He was considered a good candidate for minimally invasive surgical repair of the pressure ulcer by external tissue expansion.
Procedure. Expansion of local skin and subcutaneous tissue was achieved utilizing Proxiderm™ (Progressive Surgical Products, Westbury, NY) external tissue expanders (see Figure 1b). The external tissue expander consists of two tissue hooks that are inserted through the epidermis and dermis and deeply into the subcutaneous tissue. One tissue hook is inserted 2 cm from the wound margin; the other tissue hook is inserted 2 cm from the opposing wound margin. A mechanism slowly brings the wound margins together over a period of time.
The procedure is performed in the operating room or at bedside. On January 11, 2010, Mr. K’s wound was cleansed and surgically debrided under local anesthesia. Extensive ostectomy also was performed in the OR, and a muscle flap was rotated over the bone (see Figure 1c). Per standard procedure, a line of 2/0 nylon sutures was placed 2 to 3 cm from the wound margin, 2 cm apart. Sutures were tied alternately, leaving the ends about 7 cm long or left untied and secured by steri-strips. The tied sutures decrease the size of the wound and assist in obliteration of potential dead space. The tissue hooks of the external tissue expanders were inserted through the skin into deep subcutaneous tissue 2 to 3 cm from the wound margins and secured to the patient by encircling and tying the long ends of the previously untied sutures around the tissue expander. External tissue expanders were placed 2 to 3 cm apart (see Figure 1d) and combine dressings were placed between, under the ends and on top of the expanders, and held in place with Elastoplast (Smith & Nephew, London, UK). In general, clean wounds are evaluated every 2 days and contaminated wounds are evaluated daily; in Mr. K’s case, the wound was evaluated every 2 days. At that time, the tissue expanders were removed, the wound cleansed, debrided, and irrigated, and the untied sutures tied. If granulation tissue formation is insufficient to facilitate final closure, the process of suture and tissue expansion is repeated.
On the fourth day post-expansion, a French catheter with multiple holes was placed subcutaneously for deep irrigation through the catheter twice per day for 5 days (see Figure 1e). Mr. K was discharged home on January 27, 2010.