The Costs and Outcomes of Treating a Deep Pressure Ulcer in a Patient with Quadriplegia
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In addition, surgical approximation of the wound edges results in more durable tissue than the scar tissue that typically forms following secondary intention healing.7
In the 1970s, the need for more expedient and resilient skin coverage of large and/or deep wounds led to the development of tissue flap techniques. Tissue flaps involve detaching the tissue from its original site, transferring the tissue flap to the wound by advancement or rotation, and suturing the tissue flap to cover the wound. This major operative procedure is performed under general anesthesia7 and contraindicated in many elderly patients.
In the 1990s, a minimally invasive surgical technique that uses external skin expansion and dedicated wound care was introduced to close chronic and traumatic wounds. A clinical series11 of 125 patients with lower extremity wounds closed by external tissue expansion confirmed that tissue expansion stimulates angiogenesis. In vitro models12 also have demonstrated that tissue expansion increases the production of growth factors that include epidermal, fibroblast, transforming families, platelet-derived growth factor, and angiotensin II. A study13 of 20 patients subjected to breast reconstruction by means of tissue expansion indicated substantial mitotic activity, suggesting the formation of new tissue. Results of the recent study8 support 1- to 2-week healing and desired skin characteristics. A clinical series14 of 52 decubitus ulcers (sacral, trochanteric, ischial, and heel), a clinical series15 of 74 pressure ulcers (foot and ankle), and a clinical series16 of 16 dehisced abdominal wounds — all supported using tissue expansion to close the wounds.
When a Stage III or Stage IV pressure ulcer develops, a basic management decision has to be made. Nonsurgical secondary intention healing can take months. A 1990 study17 of 19,889 elderly patients at 51 nursing homes showed that, when using traditional gauze-based dressings, 29% of Stage III pressure ulcers and 38% of Stage IV pressure ulcers remained unhealed after 2 years. A 2-year study18 in a Canadian urban health region involving seven healthcare organizations (acute, home, and extended care) revealed a pressure ulcer can increase nursing time up to 50%, as well as increase direct costs. In addition to its effect on patient quality of life, an open wound also remains at risk for the development of complications including infections, anemia, and osteomyelitis that, as illustrated by the passing of Christopher Reeves, can lead to death. Emotional suffering and physical pain are an important cost often quantified in litigation. A review19 of medical malpractice cases regarding patients at risk for pressure ulcers in long-term care facilities indicated that the patient achieved a verdict or settlement in 68% of cases, and the median monetary recovery was $250,000. In a 2003 case in California, a jury awarded $3 million in damages against a nursing home for allowing an elderly woman to die of bedsores.20 Using external tissue expansion, most pressure ulcers are closed in 7 to 14 days.8
In this case study, Mr. K was discharged after 16 days, sutures were removed after 1 month, and he returned to work 6 weeks following surgery. Insurance company costs for his treatment were $43,814. This is in stark contrast with attempted wound closure during a period of 15 months at a cost of $242,350, of which $52,992 were rental charges for the NPWT system. The final result was an unhealed pressure ulcer. If the ulcer initially had been closed by external tissue expansion, $198,356 would have been saved.