The Costs and Outcomes of Treating a Deep Pressure Ulcer in a Patient with Quadriplegia
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K was admitted to the authors’ hospital medical center with an unhealed ischial pressure ulcer that measured 4.5 cm x 3.2 cm with exposed bone (see Figure 1a).
Proposed approach. Considering Mr. K’s history, external tissue expansion was considered. External tissue expansion combines three time-tested principles — tissue approximation, tissue expansion, and secondary wound healing — to close the wound with the patient’s own local site skin and subcutaneous tissue. For the past 12 years, the authors have used external tissue expansion to close 650 dehisced, traumatic, and chronic pressure ulcers.12
It has been the authors’ experience that the prevention or eradication of infection is essential for a successful result with external tissue expansion. Opinions differ as to the role of cultures in the management of bacterial infections, because it is common for wounds to grow a variety of organisms. Nevertheless, certain organisms, such as Staphylococci and Streptococci, may affect healing, and their presence should be noted. The fact that many organisms are merely contaminants is well known, but the onset of a post-procedural infection requires recognition and active treatment. 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.