Reconstructive

Plastic Surgery
of Pressure Ulcers

Salah Rubayi

123
Reconstructive Plastic Surgery
of Pressure Ulcers
Salah Rubayi

Reconstructive Plastic
Surgery of Pressure
Ulcers

With contributions by Burl R. Wagenheim

and Alicia Mcleland
Salah Rubayi
Rancho Los Amigos National
Rehabilitation Center
Downey, CA
USA

ISBN 978-3-662-45357-5 ISBN 978-3-662-45358-2 (eBook)

DOI 10.1007/978-3-662-45358-2

Library of Congress Control Number: 2015934001

Springer Heidelberg New York Dordrecht London

© Springer-Verlag Berlin Heidelberg 2015
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed. Exempted from this
legal reservation are brief excerpts in connection with reviews or scholarly analysis or material
supplied specifically for the purpose of being entered and executed on a computer system, for
exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is
permitted only under the provisions of the Copyright Law of the Publisher’s location, in its
current version, and permission for use must always be obtained from Springer. Permissions for
use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable
to prosecution under the respective Copyright Law.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
While the advice and information in this book are believed to be true and accurate at the date of
publication, neither the authors nor the editors nor the publisher can accept any legal responsibility
for any errors or omissions that may be made. The publisher makes no warranty, express or
implied, with respect to the material contained herein.

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

In memory of my late beloved parents
Preface

For many years, I had the idea of documenting my vast experience over the
years in the field of surgical management of pressure ulcers in a comprehen-
sive textbook dealing with the science and art of complex reconstructive
surgery of pressure ulcers.
The encouragement from my colleagues has given me the enthusiasm to
bring this book to life. It signifies my experience of more than 30 years in
dealing with the repair of complex wounds to achieve maximum healing and
patient quality of life. My experience evolved as a system and protocol in the
management of pressure ulcers.
This book represents my collective experience over the years performing
over 25,000 reconstructive procedures at Rancho Los Amigos National
Rehabilitation Center in Downey, California. This book is intended to be a
textbook and a reference to the plastic surgery trainee and the practicing
plastic surgeon seeking an answer to repair complex wounds, which may not
be readily available in other standard textbooks of plastic surgery; in addi-
tion, it will be a reference to all the surgical specialties such as general or
orthopedic surgeons dealing with these complex wounds at different stages
of the disease and as a reference for the therapist, physical medicine
specialist, and rehabilitation physician.

Downey, CA, USA Salah Rubayi

vii
Acknowledgments

I would like to express my sincere gratitude to Rancho Los Amigos National

Rehabilitation Center in Downey, California, for their kind support and trust
during the last 30 years of my practice to manage the Pressure Ulcer
Management program. Also, I would like to extend my grateful thanks to all
the nurses in my unit and the operating theater, all the therapists (PT and OT),
my dedicated staff including my surgical P.A. for their exceptional help and
support and my passionate plastic surgery residents and fellows at (USC and
UCLA) whom I trained over the years, and, last but not least, my faithful
patients for their unconditional trust and confidence in me. Finally, I would
like to thank Mr. Khalid Rubayi, MSEE, for his technical support in bringing
this book to life.

ix
Contents

1 Pressure Ulcers: An Important Condition in Medicine

and Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Significance of Pressure Ulcers. . . . . . . . . . . . . . . . . . . . . . . 1
1.2.1 Incidence of Pressure Ulcers. . . . . . . . . . . . . . . . . . . 1
1.2.2 Cost of Pressure Ulcer Management. . . . . . . . . . . . . 2
1.2.3 Medico-Legal Implications . . . . . . . . . . . . . . . . . . . . 2
1.2.4 Advances in Prevention. . . . . . . . . . . . . . . . . . . . . . . 3
1.2.5 Advances in the Management of Pressure Ulcers. . . 3
1.2.6 Complications and Life-Threatening Risks
of Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2 Etiology and Pathology of Pressure Ulcers . . . . . . . . . . . . . . . . . 5
2.1 Pathology of Pressure Forces . . . . . . . . . . . . . . . . . . . . . . . . 5
2.2 Significant Factors in Development of Pressure Ulcers . . . . 5
2.3 Predisposing Factors in Developing Pressure Ulcers . . . . . . 6
2.4 Severe Muscle Spasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.5 Other Factors Contributing to the Development of
Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.6 Site of Pressure Ulcer Development . . . . . . . . . . . . . . . . . . . 8
2.7 Local Pathological Changes and Sequel
in Pressure Ulcer Stage IV . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.8 Sacrococcygeal Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.9 Ischial Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.10 Ischial Bursa and Bursitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.11 Pelvic Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.12 Trochanteric Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3 Comprehensive Clinical Wound Evaluation . . . . . . . . . . . . . . . . 19
3.1 Definition of Pressure Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.2 Staging of the Pressure Ulcer . . . . . . . . . . . . . . . . . . . . . . . . 19
3.3 The Importance of Clinical Staging of Pressure Ulcers . . . . 19
3.4 Patient Medical History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.5 Nutritional Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.6 Physical Therapy Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . 21
3.7 Laboratory Tests and Data . . . . . . . . . . . . . . . . . . . . . . . . . . 21

xi
xii Contents

3.8 Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

3.9 Wound Evaluation and Assessment . . . . . . . . . . . . . . . . . . . 21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4 General and Special Investigation
in Pressure Ulcer Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.1 In Surgical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.2 General Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.3 Specific Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4.3.1 Radiological Imaging Studies . . . . . . . . . . . . . . . . . 26
4.3.2 Sinogram Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.3.3 Computerized Tomography (CT) Scan . . . . . . . . . . 29
4.3.4 Bone Scan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4.3.5 Magnetic Resonance Imaging (MRI) . . . . . . . . . . . 30
4.3.6 Magnetic Resonance Angiogram (MRA) . . . . . . . . 30
4.4 Diagnosis of Osteomyelitis and Bone Biopsy. . . . . . . . . . . . 30
4.5 Wound Bacteriological Swab for Culture, Sensitivitys
and Bacterial Colonization . . . . . . . . . . . . . . . . . . . . . . . . . . 33
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5 Pressure Ulcers from a Psychological Perspective . . . . . . . . . . . 35
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5.2 Psychological Factors and Conditions . . . . . . . . . . . . . . . . . 35
5.3 Personality in General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5.3.1 Antisocial Personality . . . . . . . . . . . . . . . . . . . . . . . . 36
5.3.2 Other Personality Types. . . . . . . . . . . . . . . . . . . . . . . 37
5.4 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
5.5 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
5.6 Cognition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
5.7 Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
5.8 Stress and Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
5.9 Social Support, Resiliency, and Coping . . . . . . . . . . . . . . . . 42
5.10 Clinical Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5.10.1 Psychology Evaluation . . . . . . . . . . . . . . . . . . . . . . 43
5.11 Unit or Program Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.12 Behavioral Agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.13 Substance Abuse Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.14 Pain-Related Considerations . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.14.1 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.14.2 Behavioral Agreements . . . . . . . . . . . . . . . . . . . . . . 46
5.14.3 Harm Reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.15 Other Psychological Considerations . . . . . . . . . . . . . . . . . . . 47
5.15.1 Limiting “High-Maintenance” Admissions. . . . . . . 47
5.15.2 Team Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.15.3 Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Contents xiii

6 Comprehensive Preoperative Management

of Patients with Pressure Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6.1 Wound Preparation and Local Wound Care . . . . . . . . . . . . . . 53
6.1.1 Debridement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6.1.2 Local Wound Management . . . . . . . . . . . . . . . . . . . . 53
6.1.3 Negative Pressure Wound Therapy . . . . . . . . . . . . . . 54
6.2 Nutritional Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
6.2.1 Dietary Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
6.2.2 Anthropometric Measurements . . . . . . . . . . . . . . . . . 56
6.2.3 Biochemical Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
6.2.4 Calories (Energy) and Protein . . . . . . . . . . . . . . . . . . 57
6.2.5 Micronutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.2.6 Methods of Delivering Dietary Intake to
Patients with Pressure Ulcers or Post-surgery. . . . . . 57
6.3 Control of Muscle Spasms and Joint Contractures . . . . . . . . 58
6.4 Medical Management of Spasms . . . . . . . . . . . . . . . . . . . . . 59
6.4.1 Baclofen (Lioresal®) . . . . . . . . . . . . . . . . . . . . . . . . . 59
6.4.2 Diazepam (Valium®) . . . . . . . . . . . . . . . . . . . . . . . . . 59
6.4.3 Dantrolene Sodium (Dantrium®) . . . . . . . . . . . . . . . . 60
6.4.4 Clonidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
6.4.5 Tizanidine (Zanaflex®). . . . . . . . . . . . . . . . . . . . . . . . 60
6.4.6 Cannabis (Marinol®) . . . . . . . . . . . . . . . . . . . . . . . . . 60
6.5 Local Pharmacological Therapy . . . . . . . . . . . . . . . . . . . . . . 60
6.5.1 Phenol/Alcohol Injection. . . . . . . . . . . . . . . . . . . . . . 60
6.5.2 Botulinum Toxin Therapy (Botox®) . . . . . . . . . . . . . 61
6.5.3 Intrathecal Infusion – Intrathecal Baclofen
(Lioresal®) Pump. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
6.6 Surgical Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
6.7 Patient Positioning, Post Surgery, and Type of Bed . . . . . . . 62
6.8 Antibiotic and Intravenous Fluid Administration
Before Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
6.9 Medical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6.10 Urological Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6.11 Bowel Management of Patients with Pressure Ulcer . . . . . . 64
6.12 Patient Compliance with Flap Surgery
in the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6.13 Physical Therapy Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . 65
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
7 General Operative Management and Postoperative Care . . . . . 67
7.1 Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
7.2 History of Reconstructive Surgery in Management
of Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
7.3 The Ladder of Reconstructive Surgery . . . . . . . . . . . . . . . . 69
7.4 Principles of Flap Design and Repair of Pressure Ulcers . . . 69
7.5 Methods and Strategies in Flap Selection . . . . . . . . . . . . . . . 69
xiv Contents

7.6 Type of Anesthesia and Patient Positioning

for Pressure Ulcer Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 71
7.6.1 Type of Anesthesia to Be Administered . . . . . . . . . . 71
7.6.2 Patient Position on the Operating Table . . . . . . . . . . 72
7.7 Principles of the Surgical Methods . . . . . . . . . . . . . . . . . . . . 73
7.8 Postoperative Flap Management . . . . . . . . . . . . . . . . . . . . . . 75
7.8.1 Immediate Postoperative Care. . . . . . . . . . . . . . . . . . 75
7.8.2 Fifth Postoperative Day . . . . . . . . . . . . . . . . . . . . . . . 76
7.8.3 Third Week Post Flap Surgery. . . . . . . . . . . . . . . . . . 77
7.8.4 Fourth Week Post Flap Surgery. . . . . . . . . . . . . . . . . 77
7.8.5 Sixth Week Post Flap Surgery . . . . . . . . . . . . . . . . . . 78
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
8 Reconstructive Surgery for Ischial Ulcer. . . . . . . . . . . . . . . . . . . 81
8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
8.2 Clinical Manifestation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
8.3 Indications for Bowel Diversion (Diverting Colostomy) . . . 81
8.4 Surgery for Single Ischial Ulcer Stage IV. . . . . . . . . . . . . . . 82
8.5 Gluteus Maximus Inferiorly Based
Musculocutaneous Rotation Flap . . . . . . . . . . . . . . . . . . . . . 82
8.5.1 Topographical Landmark. . . . . . . . . . . . . . . . . . . . . 82
8.5.2 Surgical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . 83
8.5.3 Vascular Pattern of the Gluteus Maximus Muscle. . 84
8.5.4 Gluteus Maximus Rotation Musculocutaneous
Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
8.5.5 Flap Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
8.5.6 Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . 85
8.6 Hamstring Muscle Advancement Flap . . . . . . . . . . . . . . . . . 87
8.6.1 Surgical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . 87
8.6.2 Vascular Supply of the Hamstring Muscles. . . . . . . 89
8.6.3 Design of the Flap . . . . . . . . . . . . . . . . . . . . . . . . . . 89
8.6.4 Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . 89
8.7 Gracilis Muscle Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
8.7.1 Surgical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . 91
8.7.2 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . 92
8.8 Gracilis Muscle and Medial Thigh Fasciocutaneous
Rotation Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
8.8.1 Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . 93
8.9 Gracilis Muscle as a Musculocutaneous Flap . . . . . . . . . . . . 95
8.9.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . 95
8.10 Gracilis Muscle and Posterior Thigh Fasciocutaneous
Rotation Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
8.10.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . 97
8.10.2 Flap Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
8.10.3 Flap Elevation Technique . . . . . . . . . . . . . . . . . . . . 97
8.11 Gracilis Muscle Transfer and Tunnel with Direct
Closure of the Wound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
8.11.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . 99
8.12 Recurrent Ischial Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Contents xv

8.13 Complicated Extensive Ischial Ulcer with Extension

into the Male Urethra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
8.13.1 Operative Technique in Male Patients . . . . . . . . . . 102
8.14 Extension of the Ischial Ulcer into the Hip Joint
or Trochanteric Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
8.14.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 106
8.15 Pelvic Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
8.15.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
8.15.2 Options for Operative Repair. . . . . . . . . . . . . . . . . 110
8.15.3 Operative Technique for Biceps Femoris
Myocutaneous Flap . . . . . . . . . . . . . . . . . . . . . . . . 110
8.16 Ischial Bursa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
8.16.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 112
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
9 Reconstructive Surgery for Sacral Ulcer . . . . . . . . . . . . . . . . . . 117
9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
9.2 Options for Repairs of Sacral Ulcer . . . . . . . . . . . . . . . . . . 117
9.2.1 Single Sacrococcygeal Ulcer . . . . . . . . . . . . . . . . . 117
9.2.2 Complex and Recurrent Sacrococcygeal Ulcer . . . 118
9.3 Gluteus Maximus Musculocutaneous Rotation Flap . . . . . 118
9.3.1 Surgical Anatomy of the Gluteus Maximus
Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
9.3.2 Flap Design and Surface Markings . . . . . . . . . . . . 118
9.3.3 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 118
9.4 Bilateral Gluteus Maximus Musculocutaneous
Rotation Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
9.5 Gluteus Maximus Advancement Island Flap . . . . . . . . . . . 122
9.5.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 122
9.6 Bilateral Gluteus Maximus Island Advancement Flap . . . . 123
9.7 Splitting Gluteus Maximus Flap . . . . . . . . . . . . . . . . . . . . . 124
9.7.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 125
9.8 Complex and Recurrent Sacrococcygeal Ulcer. . . . . . . . . . 126
9.9 Vastus Lateralis Muscle Flap . . . . . . . . . . . . . . . . . . . . . . . 127
9.10 Extended Tensor Fascia Lata Rotation Flap . . . . . . . . . . . . 127
9.11 Extended Posterior Thigh Rotation Fasciocutaneous Flap . . . 129
9.11.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 129
9.12 Biceps Femoris Myocutaneous Rotation Flap . . . . . . . . . . 130
9.12.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 131
9.13 Gracilis Muscle Transfer Flap. . . . . . . . . . . . . . . . . . . . . . . 132
9.13.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 132
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
10 Reconstructive Surgery for Trochanteric Ulcer . . . . . . . . . . . . 137
10.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
10.2 The Tensor Fascia Lata V-Y Advancement Flap . . . . . . . . 138
10.2.1 Surgical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . 138
10.2.2 Surface Marking . . . . . . . . . . . . . . . . . . . . . . . . . . 138
10.2.3 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 138
10.3 The Tensor Fascia Lata Rotation Flap. . . . . . . . . . . . . . . . . 139
xvi Contents

10.4 Surface Marking of the Flap . . . . . . . . . . . . . . . . . . . . . . . . 141

10.4.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 141
10.5 Posterior Trochanteric Ulcer . . . . . . . . . . . . . . . . . . . . . . . . 142
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
11 Reconstructive Surgery of the Hip Joint Involved with
Pressure Ulcer, Pathological Conditions, and Trauma . . . . . . . 149
11.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
11.2 Pathological Conditions or Injuries that Can Affect
the Hip Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
11.3 Infection of the Hip Joint and Septic Arthritis . . . . . . . . . . 149
11.4 Girdlestone Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
11.4.1 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
11.4.2 Side Effects of the Girdlestone Procedure. . . . . . . 151
11.4.3 Operative Technique of Girdlestone Procedure. . . 151
11.4.4 Topographical Marking of the Operative Site . . . . 152
11.4.5 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 152
11.5 Vastus Lateralis Muscle Flap . . . . . . . . . . . . . . . . . . . . . . . 154
11.5.1 Surgical Anatomy of the Vastus Lateralis Muscle. . . 154
11.5.2 Operative Technique for Elevation of the Vastus
Lateralis Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . 155
11.6 Rectus Femoris Muscle Flap. . . . . . . . . . . . . . . . . . . . . . . . 158
11.6.1 Surgical Anatomy of the Rectus Femoris Muscle . 158
11.6.2 Operative Technique for Utilizing the Rectus
Femoris Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
11.7 Rectus Abdominis Muscle Flap . . . . . . . . . . . . . . . . . . . . . 159
11.7.1 Surgical Anatomy of the Rectus Abdominis
Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
11.7.2 Operative Technique for Flap Elevation . . . . . . . . 161
11.8 Heterotopic Ossification (HO) of the Hip Joint . . . . . . . . . 163
11.8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
11.8.2 Preoperative Requirement . . . . . . . . . . . . . . . . . . . 165
11.8.3 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 165
11.8.4 Postoperative Management . . . . . . . . . . . . . . . . . . 167
11.8.5 Postoperative Complications from HO
Excision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 169
11.9 Hip Joint Conditions When a Girdlestone Procedure
and Muscle Flap Are Indicated . . . . . . . . . . . . . . . . . . . . . . 169
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
12 Multiple Ulcers Closed by Multiple Flaps
as a Single Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
12.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
12.2 Review of the Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
12.3 The Author’s Experience in Repairing Multiple Ulcers
by Multiple Flaps as a Single Procedure. . . . . . . . . . . . . . . 176
12.4 Examples of Clinical Cases. . . . . . . . . . . . . . . . . . . . . . . . . 178
12.4.1 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
12.4.2 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
12.4.3 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Contents xvii

13 Reconstructive Surgery for Pressure Ulcers

in Special Areas of the Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
13.1 Introduction and Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . 191
13.2 Etiology of the Specific Ulcers . . . . . . . . . . . . . . . . . . . . . . 191
13.3 Reconstructive Surgery for the Specific Ulcers . . . . . . . . . 192
13.3.1 Heel Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
13.4 Ulceration of the Medial and Lateral Plantar
Surface of the Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
13.5 Lateral Malleolus Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
13.6 Ulcers of the Head of the Fibula and Tibial Shin . . . . . . . . 195
13.7 Ulceration Around the Knee Joint. . . . . . . . . . . . . . . . . . . . 196
13.7.1 Surgical Anatomy and Landmark . . . . . . . . . . . . . 200
13.7.2 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 200
13.7.3 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
13.7.4 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
13.8 Elbow Ulcer (Olecranon Ulcer) . . . . . . . . . . . . . . . . . . . . . 213
13.8.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 214
13.9 Occipital Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
13.9.1 Operative Technique . . . . . . . . . . . . . . . . . . . . . . . 217
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
14 Disarticulation and Total Thigh Flap. . . . . . . . . . . . . . . . . . . . . 221
14.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
14.2 Operative Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
14.3 Modification of Total Thigh Flap Procedure. . . . . . . . . . . . 228
14.3.1 Excision of the Anus and Rectal Closure . . . . . . . 228
14.3.2 The Extended Total Thigh Flap
(Below the Knee). . . . . . . . . . . . . . . . . . . . . . . . . . 228
14.4 Postoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . 234
14.4.1 Ulceration and Breakdown in the Total Thigh
Flap Stump. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
14.5 Surgical Options of Repairs . . . . . . . . . . . . . . . . . . . . . . . . 234
14.5.1 The Rectus Abdominis Muscle Flap . . . . . . . . . . . 234
14.5.2 Repair of the Ulcer in Unilateral Disarticulation
and Total Thigh Flap from the
Contralateral Side . . . . . . . . . . . . . . . . . . . . . . . . . 237
14.5.3 Repair of Ulceration in Bilateral Total
Thigh Stump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
15 Complications of Flap Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 243
15.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
15.2 General Systemic Factors That Contribute
to Flap Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
15.2.1 Chronic Open Wounds. . . . . . . . . . . . . . . . . . . . . . 243
15.2.2 Quality of Skin and Deep Tissue . . . . . . . . . . . . . . 243
15.2.3 Location of Flap Surgeries . . . . . . . . . . . . . . . . . . 244
15.2.4 Muscle Spasms . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
15.2.5 Preoperative Nutrition and Anemia . . . . . . . . . . . . 244
15.2.6 Patient Compliance . . . . . . . . . . . . . . . . . . . . . . . . 244
xviii Contents

15.3 Nonspecific Complications That Affect Flap Healing . . . . 244

15.3.1 Postoperative Hypoproteinemia . . . . . . . . . . . . . 244
15.3.2 Deep Venous Thrombosis (DVT) . . . . . . . . . . . . 244
15.4 Specific Complications Related to Flap Wounds . . . . . . . . 245
15.4.1 Major Complications . . . . . . . . . . . . . . . . . . . . . . 245
15.4.2 Wound Infection. . . . . . . . . . . . . . . . . . . . . . . . . . 246
15.4.3 Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
15.4.4 Fat Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
15.4.5 Flap Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
16 Physical Therapy Evaluation and Rehabilitation:
Pre- and Post-reconstructive Plastic Surgery
for Pressure Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
16.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
16.2 Physical Therapy Preoperative Clinical Evaluation . . . . . 249
16.3 Post Myocutaneous Flap Surgery Protocol. . . . . . . . . . . . 251
16.4 Initial Sit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
16.5 Pressure Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
16.6 Functional Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
16.7 Seating Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
16.8 Selecting a Cushion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
16.9 Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
16.10 Sensate Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
16.11 Patient with Above- or Below-Knee Amputation . . . . . . . 265
16.12 Patients with Hip Disarticulation . . . . . . . . . . . . . . . . . . . 266
16.13 Patients with Girdlestone Procedure . . . . . . . . . . . . . . . . . 266
16.14 Patients with Bilateral Hip Disarticulation . . . . . . . . . . . . 267
16.15 Ambulatory Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
17 Prevention of Pressure Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
17.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
17.2 Managing Pressure on the Skin. . . . . . . . . . . . . . . . . . . . . 272
17.3 Special Beds and Positioning . . . . . . . . . . . . . . . . . . . . . . 272
17.4 Sitting Pressure Management . . . . . . . . . . . . . . . . . . . . . . 274
17.5 Bowel and Bladder Function. . . . . . . . . . . . . . . . . . . . . . . 276
17.6 Contributing Factors to Pressure on the Skin . . . . . . . . . . 277
17.7 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
17.8 Psychosocial Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
17.9 Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
 Pressure Ulcers: An Important
Condition in Medicine and Surgery
Salah Rubayi
1.1 Introduction
Pressure ulcers are a condition of the skin and
deep tissue that has been recognized for at least
5,000 years [1–6]. They can affect the human
body at different sites, and many simple remedies
have been prescribed and used to treat these
ulcers. In the eighteenth and nineteenth [7–15]
centuries, an accurate diagnosis of pressure ulcer
was established. In the twentieth century, the eti-
ology, management, and prevention were estab-
lished, and physicians, nurses, and allied health
professionals were expected to have knowledge
of this condition and to manage and prevent pres-
sure ulcers. The standard treatment was set in the
United States in 1994 by the Agency for Health
Care Policy and Research [16], and, in 2000, the
Consortium for Spinal Cord Medicine [17] pub-
lished the standard management of pressure
ulcers. In 1999, the standard was published in
Europe by the European Pressure Ulcer Advisory
Panel [18].
S. Rubayi, MB, ChB, LRCP, LRCS, MD, FACS
Department of Surgery,
Rancho Los Amigos National Rehabilitation Center,
Downey, CA, USA
Division of Plastic Surgery,
Department of Surgery, Keck School of Medicine,
University of Southern California,
Los Angeles, CA, USA
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_1, © Springer-Verlag Berlin Heidelberg 2015
1
1.2 Significance of Pressure
Ulcers
Pressure ulcers are important for the reasons
described below.
1.2.1 Incidence of Pressure Ulcers
The exact incidence and prevalence of pressure
ulcers remain unclear. Data from the National
Pressure Ulcer Advisory Panel (NPUAP) in the
United States [19] indicate that the incidence var-
ies widely, from 0.4 to 38 % in acute care, 2.2–
23.9 % in long-term care, and 0–17 % in home
care. Prevalence rates show the same variability:
10–18 % in acute care, 2.3–28 % in long-term
care, and 0–29 % in home care. Therefore, the
incidence of pressure ulcers is high, especially
among certain high-risk groups of patients. These
groups include elderly patients admitted to a hos-
pital for femoral fractures (66 %) and critical care
patients (33 %); in a study of quadriplegic patients,
the prevalence was 60 % [16]. In spinal cord
injury (SCI) patients, the pressure ulcer preva-
lence rate ranged from 8 % in the first year follow-
ing the onset of spinal cord injury to 33 % for
community resident individuals with SCI [17].
Mawson et al. (1988) reported that 32–40 %
of all individuals admitted to special SCI units in
the United States would develop pressure ulcer(s)
during their initial hospital admission period
[20]. Yarkony and Heinemann in 1995 followed
1
2 1 Pressure Ulcers: An Important Condition in Medicine and Surgery
up on 4,065 individuals with SCI, of whom 2,971
developed pressure ulcers in the following per-
centages: 15 % at their first annual examination,
20 % at year 5 post injury, and 5.23 % at year 20
post injury [21].
Recurrence in spinal cord injury individuals
remains high and is related to many factors. Niazi
et al. in 1997 conducted a retrospective, case-
controlled study on recurrence of pressure ulcers
in a population of 176 veterans with SCI. They
found that there was a 35 % recurrence rate
regardless of whether the treatment was surgical
or medical. Smoking, diabetes, and cardiovascu-
lar disease were associated with the highest rate
of recurrences [22]. Clark et al. (2006) reported
that daily lifestyle of the SCI patient and its rela-
tion to development of pressure ulcers can be
described through various models that vary in
complexity, depending on whether they incorpo-
rate individualization and interrelations among
modeled elements [23].
1.2.2 Cost of Pressure Ulcer
Management
The cost of managing pressure ulcers has
increased dramatically in hospitals and in the
community due to the overall increase in health-
care costs worldwide. The impact of pressure
ulcers is significant in terms of both financial and
nonmonetary costs. In 1999, Beckrich and
Aronovich [24] reported that 1.6 million pressure
ulcers developed in hospitals in the United States
annually, with an estimated cost of $2.2 to $3.6
billion. Pompeo [25] showed the impact of wound
burdens (defined as pressure ulcer stage, wound
size, and number of wounds) on the cost of care at
long-term acute care facilities; as expected, the
higher the wound burden, the greater the cost of
care. The nonmonetary costs, often described as a
hidden cost of pressure ulcers, include the emo-
tional and physical impact on patients and their
families. Braun et al. (1992) [40] reported that the
cost to heal complex pressure ulcers was
$100,000; less serious pressure ulcers cost
$20,000 to $30,000 to heal (National Pressure
Ulcer Advisory Panel 1989, U.S. Department of
Health and Human Services 1990) [26, 16].
1.2.3 Medico-Legal Implications
The medico-legal implications of pressure ulcer
development are an urgent issue all worldwide.
Pressure ulcers are viewed as a quality indicator
of care. Hence, the development of pressure
ulcers can constitute a failure in the healthcare
system. In the United States, federal health agen-
cies regard pressure ulcers as a surrogate for how
well the healthcare team is functioning in moni-
toring the quality of care for the patient.
The growing demand for accountability
among healthcare clinicians for more effective
prevention and management of ulcers has led to
an explosion of national guidelines on pressure
ulcers. In the European countries, guidelines
have been developed that are similar to those
issued by the U.S. Agency for Health Care
Policy and Research for Pressure Ulcer
Prevention [27].
The increasing recognition of pressure ulcer
development as a marker for quality of care has
led to a greater number of pressure ulcer litiga-
tions against clinicians and their employers. The
public has been made aware through the media
like television and Internet that pressure ulcers
can be prevented and treated effectively. The
development of pressure ulcers is considered to
be the result of negligence by the healthcare pro-
vider. Pressure ulcers can cause sepsis and even
death in certain groups of patients, in addition to
causing changes in patients’ quality of life. A
number of lawsuits have been brought against
hospitals, nursing homes, physicians, and even
plastic surgeons. If greater attention were paid to
preventing development of pressure ulcers and to
enforcing some basic rules of prevention, there
would be fewer of these litigations.
In the United States, Bennett et al., in 1981,
reported on the increase in medical malpractice
related to patient pressure ulcer development
[28]. Absence of good documentation in patients’
medical charts concerning preventive measures
taken in action or treatment make it easy for a
plaintiff’s attorney to prove the lack of care that
caused the development of pressure ulcer(s) in
the patient. When there is a national guideline on
how to prevent and treat pressure ulcers, the
expert witness in these litigation cases defends
References
the care according to those guidelines. In the
United States, the federal government and each
state set rules and regulations, including mone-
tary penalties, for nursing home compliance for
patients who develop stage III or IV pressure
ulcers [29].
1.2.4 Advances in Prevention
In the twenty-first century, pressure ulcers are
seen as a preventable disease, and thus, preven-
tion is a priority and a necessity in their manage-
ment. This can be accomplished through
continuing education for all healthcare staff on
detecting the early signs of pressure ulcers and
assessing patients for the risk of pressure ulcer
development. In hospitals, nursing homes, conva-
lescent homes, and patients’ homes, measures for
prevention include: the patient’s repositioning
and turning schedule; preventing and treating
excessive body moisture and fecal and urinary
incontinence; using advanced equipment, such as
special beds, mattresses, and wheelchair cush-
ions; attention towards the patient’s nutritional
intake; and patient and family education. All of
these measures are today’s standard of care and
have become the foundation for pressure ulcer
prevention.
1.2.5 Advances in the Management
of Pressure Ulcers
The surgical and conservative management of
pressure ulcers has advanced dramatically dur-
ing the last 60 years. In the twenty-first century,
there are orthodox standard reconstructive plas-
tic surgery procedures to close pressure ulcers,
which are considered the standard of care for
stage III – IV pressure ulcers. These standard
procedures are documented in the plastic surgery
literature and by the government health policies
[16, 17] and are today considered the standard of
teaching and training for the plastic surgery resi-
dent during training. In addition, this standard of
care is well known by allied health (e.g., physi-
cal and occupational therapists) and nursing
staff.
3
1.2.6 Complications
and Life-Threatening Risks
of Pressure Ulcers
Fifty years ago, pressure ulcers were among the
major diseases predisposing in shortening the life
expectancy in the spinal cord injury patient [30].
In the twenty-first century, advances in antibiotics,
local wound care, and early surgical interventions
have tremendously reduced the morbidity and
mortality rates and prolonged life expectancy in
spinal cord injury patients. However, the medical
literature documents many complications that can
occur in patients with chronic pressure ulcers,
including acute sepsis [31, 32], amyloidosis [31],
heterotopic ossification [32], septic joint [33], per-
ineal and urethral fistula [34], squamous cell carci-
noma changes in pressure ulcers [35], and the
most common complication, acute or chronic
osteomyelitis of the bone underlying the ulcer
[36–39]. To avoid and prevent these complica-
tions, prevention and early detection of pressure
ulcers in spinal cord patients are important for the
patients’ healthcare and to provide quality of life
and longer life expectancy. This responsibility
falls on all healthcare providers.
References
1. Ebbell B (1937) The Papyrus Ebers, the greatest
Egyptian medical document. Oxford University Press,
London
2. Ebers A, Stern L (1875) Papyrus Ebers: Das
Hermetische Buch über die Arzneimittel der alter
Aegypt. JC Henriches, Leipzig; 3 vols
3. Avicenna [Ibn Sina] (1877) Al Knun Fi’l Tibb. Arabic
text. Government Press, Cairo, pp 168–180
4. Rosner F, Munter S (1971) The medical aphorisms of
Moses Maimonides, vol 2. Yeshiva University Press,
New York, p 28
5. Majno (1975) The healing hand. Harvard University
Press, Cambridge, pp 100, 154, 183, 236–238, 298–299,
367, 399
6. The Collective Works of Ambrose Pare (1968)
(Translated from the Latin by Thomas Johnson from
the first English edition, London, 1634) Reprinted by
Milford House, Pound Ridge, p 470
7. Brown-Séquard E (1853) Experimental researches
applied to physiology and pathology. Ballière,
New York. In Gibbon JH, Freeman LW (1946) Primary
closure of decubitus ulcers. Am J Surg 124:1145
8. Paget J (1873) Clinical lecture on bedsores. Student’s
J and Hosp Gaz 1:144. In Gibbon JH, Freeman LW
4 1 Pressure Ulcers: An Important Condition in Medicine and Surgery
(1946) Primary closure of decubitus ulcers. Am J
Surg 124:1149
9. Charcot JM (1879) Lectures on diseases of the ner-
vous system (trans: Sigerson G). Lea, Philadelphia. In
Gibbon JH, Freeman LW (1946) Primary closure of
decubitus ulcers. Am J Surg 124:1149
10. Davis JS (1938) Operative treatment of scars follow-
ing bed sores. Surgery 13:1–7
11. White J, Hudson AH, Kenward H (1945) Treatment
of bed sores by total excision with plastic closure.
Navy Med Bull 45:454
12. Conway H, Griffith BH (1956) Plastic surgery for clo-
sure of decubitus ulcers in patients with paraplegia.
Am J Surg 91:946–975
13. Kostrabola JC, Greeley PW (1947) The prob-
decubitus ulcers in paraplegics. Plast Reconstr Surg
2:403–412
14. Orticohea M (1972) The musculocutaneous flap. An
immediate and heroic substitute for the method of
delay. Br J Plast Surg 25:106–110
15. McGraw JB, Dibbel DG, Carroway JH (1977) Clinical
definition of independent myocutaneous vascular ter-
ritories. Plast Reconstr Surg 60:341–352
16. Treatment of Pressure Ulcer. U.S. Department of
Health and Human Services, Public Health Services,
Agency for Health Care Policy and Research. AHCPR
Publication No. 95–0652, Rockville, Dec, 1994
17. Pressure ulcer prevention and treatment following spi-
nal cord injury: a clinical practice guideline for
health-care professionals, Consortium for Spinal
Cord Med, clinical practice guidelines, (2000)
18. European Pressure Ulcer Advisory Panel (EPUAP)
(1999) Guideline on treatment of pressure ulcers.
EPUAP, Oxford (available from: http://www.epuap.
org, accessibility verified on 27 Feb 2003)
19. National Pressure Ulcer Advisory Panel (2001)
Pressure ulcers in America: prevalence, incidence,
and implications for the future. National Pressure
Ulcer Advisory Panel, Reston
20. Mawson AR, Biundo JJ, Neville P et al (1988) Risk
factors for early occurring pressure ulcers following
spinal cord injury. Am J Phys Med Rehabil 67:
123–127
21. Yarkony GM, Heinemann AW (1995) Pressure ulcers.
In: Stover SL, DeLisa JA, Whiteneck GG (eds) Spinal
cord injury: clinical outcomes from the model sys-
tems. Aspen Publishing, Gaithersburg
22. Niazi ZBM, Salzberg CA, Byrne DW et al (1997)
Recurrence of initial pressure ulcer in persons
with spinal cord injuries. Adv Wound Care 10:
38–42
23. Clark FA, Jackson JJ, Scott MD, Carlson ME, Atkins
MS, Uhles-Tanaka D, Rubayi S (2006) Data-based
models of how pressure ulcers develop in daily-living
contexts of adults with spinal cord injury. Arch Phys
Med Rehabil 87:1516–1525
24. Beckrich K, Aronovitch SA (1999) Hospital-acquired
pressure ulcers: a comparison of costs in medical vs
surgical patients. Nurs Econ 17:263–271
25. Pompeo MQ (2001) The role of “wound burden” in
determining the costs associated with wound care.
Ostomy Wound Manag 47(3):65–71
26. National Pressure Ulcer Advisory Panel (1989) Pressure
ulcers prevalence, cost, and risk assessment: consensus
development conference statement. Decubitus 2:
24–28
27. Panel for the Prediction of Pressure Ulcers in Adults
(1992) Pressure ulcer in adults, prediction and preven-
tion: clinical practice guideline. Public Health
Services Agency for Health Care Policy and Research.
Publication 92–0047, Rockville. United States Census
Bureau Statistics, Washington, DC
28. Bennett RG, O’Sullivan J, DeVito EM, Remsberg R
(2000) The increasing medical malpractice risk
related to pressure ulcers in the United States. J Am
Geriatr Soc 48:73–81
29. Health Care Financing Administration: Investigate
Protocol (2000) Guidance to surveyors – long term
care facilities. Rev 274. U.S. Department of Health
and Human Services
30. Rao DB, Shane PG, Georgiev EL (1975) Collagenase
in the treatment of dermal and decubitus ulcers. J Am
Geriatr Soc 232:22–30
31. Melcher RE, Longe RL, Gelbart AO (1988) Pressure
sores in the elderly: a systematic approach to manage-
ment. Postgrad Med 83(1):299–308
32. Reuler JB, Cooney TG (1981) The pressure sore:
pathophysiology and principles of management. Ann
Intern Med 94(5):661–666
33. Klein NE, Moore T, Capen D, Green S (1988) Sepsis
of the hip in paraplegic patients. J Bone Joint Surg
Am 70(6):839–843
34. Hackler RH, Zampieri TA (1987) Urethral complica-
tions following ischiectomy in spinal cord injury
patients: a urethral pressure study. J Urol 137(2):
253–255
35. Berkwits L, Yarkony GM, Lewis V (1986) Marjolin’s
ulcer complicating a pressure ulcer: case report and
literature review. Arch Phys Med Rehabil 67(11):
831–833
36. Lewis VL Jr, Bailey MH, Pulawski G, Kind G,
Bashioum RW, Hendrix RW (1988) The diagnosis of
osteomyelitis in patients with pressure sores. Plast
Reconstr Surg 81(2):229–232
37. Sugarman B (1984) Osteomyelitis in spinal cord
injury. Arch Phys Med Rehabil 65(3):132–134
38. Sugarman B (1987) Pressure sores and underlying
bone infection. Arch Intern Med 147(3):553–555
39. Allman RM (1989) Epidemiology of pressure sores in
different populations. Decubitus 2(2):30–33
40. Preventing Pressure Ulcers in Veterans With Spinal
Cord Injury, ClinicalTrials.gov Identifier: NCT00105859
 Etiology and Pathology
of Pressure Ulcers
Salah Rubayi
2.1 Pathology of Pressure Forces
It has been observed that the application of con-
stant pressure of 70 mmHg for more than 2 h pro-
duced irreversible tissue damage [1]. Minimal
tissue damage was observed when the pressure
exceeded 240 mmHg, providing there was inter-
mittent pressure relief [2]. Histopathological
changes secondary to pressure on the tissues
include occluding of the blood flow to the tissues.
If occluding occurs for short periods of time, the
result is anoxia of the cells. If the pressure contin-
ues for longer periods of time, complete occlu-
sion of the blood flow results in ischemia of the
cells and then necrosis and, consequently, irre-
versible tissue damage. Muscle fibers are more
sensitive to the ischemia effect of prolonged pres-
sure than the skin [3, 4]. Shear forces are an etio-
logic factor in development of pressure, and
ulcers [5, 6] are caused by movement of boney
prominence against the subcutaneous tissues.
This occurs when the position of the patient, for
example, in bed, is shifted in a way that the skin
remains stationary in relation to the support of
S. Rubayi, MB, ChB, LRCP, LRCS, MD, FACS
Department of Surgery,
Rancho Los Amigos National Rehabilitation Center,
Downey, CA, USA
Division of Plastic Surgery,
Department of Surgery, Keck School of Medicine,
University of Southern California,
Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_2, © Springer-Verlag Berlin Heidelberg 2015
2
the body and, as a result of the movement, the
subepidermal vessels are bent at a right angle.
Shear alone does not cause tissue necrosis; how-
ever, it is a predisposing factor in causing pres-
sure ulcers. Shear forces are seen more frequently
in clinical practice when a patient loses weight
and tissue sliding can occur over the boney prom-
inences. Friction forces relate to rubbing of the
skin against linen or clothing, or even when lift-
ing a patient on a sling. Most abrasion injuries are
caused by friction, although friction does not lead
to all pressure ulcers; it can damage the epider-
mis and make the skin susceptible to pressure
ulcers [1].
2.2 Significant Factors
in Development of Pressure
Ulcers
The most important factor in the development of
pressure ulcers is skin moisture. The skin is the
largest organ of the body and one of its important
functions is to protect the body. There are many
factors that can alter and decrease the resistance
of the skin. Moisture is a contributing factor in
the etiology of pressure ulcers because it macer-
ates the epidermis. The epidermis becomes easily
eroded and tissue necrosis can occur. Moisture is
a condition that can be seen clinically with incon-
tinence of urine and stool, excessive sweating,
excessive vaginal discharge, wound discharge,
and sometimes wound dressings that can cause
5
6 2
skin irritation. Uncontrolled skin moisture by
itself is considered a risk factor in developing
pressure ulcers in certain patients [7]. Because
the skin is an organ, poor nutrition has shown to
be a factor in its breakdown [8, 9]. In addition,
loss of fat and muscle increases the pressure of
the boney prominences. In aging skin, changes
take place in collagen synthesis that result in the
tissue of the body having lower mechanical
strength and increased stiffness [10]. There are
also changes in the barrier properties in aging
skin, reduced immunity, slower wound healing,
and diminished pain reception [11]. The patient’s
physique also plays a role; if pressure is distrib-
uted evenly, the patient is less likely to develop
pressure ulcers. A thin patient with little subcuta-
neous fat and poor muscle bulk will be inclined to
develop pressure ulcers over the boney promi-
nences. An extremely obese individual has much
greater weight but better padding to distribute the
weight; however, these patients have poor circu-
lation and are more liable to be affected by shear
and friction.
In bedridden and immobile patients laying
on a hard surface for a prolonged period of time,
there are areas of minimal soft tissue thickness
where compression of the deeper blood vessels
occurs against boney prominence. This explains
why the sacral, ischial, and trochanteric areas,
the scapula, and also the heels are at high risk of
developing pressure ulcers in bedridden
patients.
Insensate patients, including those with spinal
cord injury, spina bifida, and other generalized
systemic neurological diseases, such as multiple
sclerosis when manifested as paraplegia at its end
stage, when confined to a wheelchair, share a
high risk of developing pressure ulcers. Spinal
cord injured patients are the largest group at risk.
The annual incidence of spinal cord injury varies
according to the source, but today the annual rate
in the United States is between 30 and 32.1 per
million individuals [12]. Between 32 and 40 % of
spinal cord injured individuals develop pressure
ulcers within their lifetime [13] after spinal injury
because many physiological changes take place
in the body. The two most common are have a
Etiology and Pathology of Pressure Ulcers
direct effect in developing pressure ulcers: loss of
sensory perception and loss of the ability to move
the parts of the body that have lost their nerve
connection to the brain via the injured spinal
cord. This explains the loss of pain sensation
when tissue, particularly the skin, becomes
anoxic or ischemic from pressure. A strong sen-
sation of pain is normally sent along the spino-
thalamic tract through the spinal cord to the
thalamus of the brain, where messages are sent to
the somatic sensory area of the cerebral cortex,
creating the feeling of pain [14]. This uncomfort-
able feeling causes the individual to move, thus
relieving the pressure and restoring blood flow to
the skin. In the spinal cord injured individual, this
physiological reaction and action does not exist.
In addition, spinal cord injured individuals tend
to lose alpha adrenergic receptors that are respon-
sible for controlling vascular tone. Decreased
blood pressure creates sluggish venous return,
which increases the chance of occlusion due to
pressure [15].
2.3 Predisposing Factors
in Developing Pressure
Ulcers
Systemic factors include congestive heart failure,
anemia, diabetes, peripheral vascular disease,
dehydration in old age, immune deficiency syn-
drome, and neurological disease. All these fac-
tors decrease the skin blood flow, vascularity, and
skin nutrition, which consequently causes the
skin to break down easily by any form of pressure
forces. Body mechanical factors such as skeletal
deformity of the spine (scoliosis, kyphosis)
(Fig. 2.1) and pelvis deformity (dislocated hips,
heterotopic ossification (H.O.), fracture of the
hip) (Fig. 2.2) cause pelvic obliquity and, conse-
quently, the individual with these types of defor-
mities cannot lay down straight or sit in a proper
way. This abnormal position will exert high pres-
sure in some areas of the body, which results in
skin breakdown. The skeletal deformity factor
should be considered and corrected to the extent
possible.
2.5 Other Factors Contributing to the Development of Pressure Ulcers
Fig. 2.1 Radiograph of a pelvis in a spinal cord injured
patient showing severe lumbo-thoracic spine deformity
Fig. 2.2 Radiograph of a pelvis in a spinal cord injured
patient showing dislocated left hip joint
2.4 Severe Muscle Spasms
Severe muscle spasms are seen in spinal cord
injured patients or those with advanced
neurological diseases. Individuals with this con-
dition cannot lay down or sit in a proper pressure
7
relief position, which leads to development of
pressure ulcers. Severe muscle spasms can create
shearing forces between the skin and the underly-
ing sheets or cushion. This can cause extensive
ulcerations over the heels or ulcerations between
the medial surfaces of each knee. Severe spasms
of the hip flexor can cause hip subluxation or dis-
location and consequently cause ulceration over
the boney prominence (e.g., the greater trochan-
ter). Contracture of the flexor muscles and the
adductor muscles of the hip joint and the ham-
string muscle of the posterior thigh resulting from
the spinal injury or neurological disease second-
ary to neurological imbalance of the muscles
function cause severe spasticity. Contractures pre-
dispose to developing pressure ulcers by prevent-
ing the individual from sitting or lying in a normal
functional position where pressure will be distrib-
uted evenly. Consequently, part of the pelvis will
experience higher pressure than other areas, even-
tually leading to skin breakdown. In addition, the
contracture results in difficulty in performing
hygienic care to the groin and inner thigh area,
which can lead to fungal infection of the skin.
2.5 Other Factors Contributing
to the Development of
Pressure Ulcers
Medical conditions that can break or weaken the
integrity of the skin, for example, skin allergic
disease from medications that are applied locally
and can cause reaction in the skin. This inflamma-
tion or breaking in the skin will be a nidus for
developing pressure ulcers. External materials
applied on the skin, for example, dressing tapes
that can cause blisters and cast applications in
insensate or geriatric patients without protective
padding, will cause pressure ulcers especially
over the heels, shin, patella, and both malleolar at
the ankle site. Careful attention should be paid
when a cast is required in this insensate group of
patients. Tight elastic pressure bandages can
cause the same effect on the skin, resulting in blis-
ters and stage II or III ulcers.
Patients with immune-compromised syn-
dromes like HIV and those on systemic
8 2
medications like steroids can experience changes
in the skin. This can predispose the skin to break
down easily. Patients who smoke or abuse drugs
[16, 17] have a higher incidence of pressure ulcer
than nonsmokers [18–20] as a result of the phar-
macological effect of nicotine that impairs blood
circulation.
Quadriplegic patients are at a higher risk of
developing pressure ulcers than paraplegic
patients. Development of any acute illness in a
quadriplegic patient (e.g., pneumonia, urinary
tract infection) will confine the patient to bed,
whether at home or in hospital, and eventually
leads to development of pressure ulcer. This con-
dition is most commonly seen when a history is
taken from the quadriplegic patient post pressure
ulcer development. A premorbid psychosocial
condition existing prior to spinal injury is a factor
in development of pressure ulcers in this group of
patients.
2.6 Site of Pressure Ulcer
Development
High-risk patients commonly develop a pressure
ulcer when laying down without movement, for
example, in the supine position secondary to ill-
ness, injury, or during surgery on the operating
table, or even during special radiological proce-
dures. The most common sites where pressure
ulcers develop are the bony prominence, of the
body, such as the occipital area, the scapular
ridge, the spinous process, the sacrococcygeal
area, and the calcaneus bone. If the patient is
placed on their side, that is, the lateral position,
the trochanteric area is subject to pressure and
consequently develops skin breakdown.
Remaining in the sitting position for prolonged
periods of time without a proper cushion or pres-
sure relief causes ischial ulceration, in addition to
the predisposing factors existing in this group of
patients.
In spinal cord injured patients, the circum-
stances regarding the site for development of
pressure ulcers differs somewhat because, in the
acute injury phase, there are common sites, and
there are other sites in the post-recovery phase
Etiology and Pathology of Pressure Ulcers
and rehabilitation with integration back into nor-
mal daily life in society.
A study by the model system of spinal cord
injury patient care in the United States [21] found
that during early treatment in the acute phase of
the spinal cord injury at trauma centers, for sta-
bilization of the spinal shock and the spine,
patients were kept in the supine position in bed
for numerous medical reasons. The findings for the
common ulcer site areas were occipital = 2.6 %,
scapular = 4.3 %, spinous process = 1.3 %, iliac
crest = 1.8 %, sacrum = 37.4 %, trochanteric =
3.8 %, ischium = 9.2 %, elbow = 2.0 %, knee =
1.5 %, and malleolar = 3 %. The anatomical dis-
tribution of the ulcer sites somewhat changed
when patients were followed in the first year post
injury, when the common sites were the sacrum =
20 %, ischium = 18.3 %, trochanteric = 12.4 %,
heel = 16.6 %, elbow = 2.6 %, and malleolar
8.7 %. The reasons for the ulcer distribution at
this phase of a patient’s life were sitting in a
wheelchair and resuming normal life without
practicing pressure relief as instructed in reha-
bilitation post injury. Laying down in bed in the
supine position or lateral position without a pres-
sure relief mattress can predispose to ulcer devel-
opment in the sacrococcygeal area and
trochanteric area.
2.7 Local Pathological Changes
and Sequel in Pressure Ulcer
Stage IV
Pressure ulcers in different parts of the body fre-
quently progress with local pathological changes
and manifest clinically with a different appear-
ance than simple stage IV ulcer. This presents a
difficult diagnosis because of the pathological
changes of the ulcer, even with the utilization of
advance diagnostic modalities, and it thus pres-
ents a clinical dilemma to the surgeon and infec-
tious disease specialist. On many occasions, the
diagnosis of complex pathological changes is
discovered accidentally during surgery for ulcer
closure or debridement. Therefore, the pathologi-
cal changes lead to modifications in the manage-
ment plan for the ulcer. Clinical exposure and
2.8 Sacrococcygeal Ulcer
experience with clinical thinking and taking into
account these changes is important for the prac-
ticing specialist dealing with these complex, dif-
ficult wounds. In the following section, the
pathological changes in each anatomical ulcer
location are discussed in details.
2.8 Sacrococcygeal Ulcer
Extensive necrosis and infection of the skin and
the subcutaneous tissue leads to necrosis of the
pre-sacral fascia, which covers the sacrum and
the coccygeal segment, considering the anatomi-
cal fact that gluteus maximus muscle does not
cover this area (Fig. 2.3).
If a pressure condition continues in this area,
ischemia and necrosis extend to involve the glu-
teus maximus muscle, which physiologically is
more sensitive to ischemia than other tissues.
Consequently, necrosis will occur in the muscle
fibers. This condition is difficult to detect if only
part of the muscle is exposed; otherwise, it may
be discovered accidentally during surgery. The
macroscopical pathological appearance of the
muscle is “dull gray” color in appearance.
Incising the affected muscle demonstrates no
Fig. 2.3 Showing extensive necrosis of the pre sacral fas-
cia and ligament
9
bleeding, and the muscle does not contract with
electrocautery touch. Debridement should be
done to all the necrotic muscle parts, which even-
tually leads to a small volume of muscle. A sam-
ple of the muscle should be sent for anaerobic
bacterial culture and sensitivity. The wound
should be irrigated with a high-pressure irriga-
tion system in the operating room. Wounds in this
condition cannot be closed in one stage and
should be closed in two stages to avoid flap com-
plications. Other manifestations of the sacral
wound are the formation of abscesses that result
in pus formation between the gluteus maximus
muscle and gluteus medius muscle (Fig. 2.4).
Also, infection and necrosis can extend to the
sacrotuberous ligament. Eventually, communica-
tion can occur between the sacrococcygeal ulcer
and ischial area with involvement of the ischio-
rectal fossa, which consists of fibro-fatty tissue.
Dissection of the infection can extend around the
Fig. 2.4 Involvement of the gluteus maximus (G.M.)
with sacrococcygeal ulcer
10
Fig. 2.5 Connection between the sacrococcygeal ulcer
and ischial ulcer
anal canal. A diverting colostomy is necessary in
these conditions (Fig. 2.5).
2.9 Ischial Ulcer
Ischial ulcers can extend into the perineum in
the male patients. This pathological change is
seen more frequently than in female patients
because of the existence in males of soft tissue
space between the anus and the scrotal sac. The
result is the involvement of the deep tissue,
which includes the perineal urethra. Clinically,
urine will be seen leaking from the ischial ulcer
(Fig. 2.6). To confirm the clinical diagnosis, a
urethra cystogram study using radio-opaque dye
and x-ray will confirm the extravasation of the
urine outside the perineal urethra. In this condi-
tion, temporary diversion of the urine should be
accomplished by suprapubic cystostomy or per-
manent urinary diversion in recurrent condi-
tions. This allows the surgical repair of the
involved urethra during the flap closure of the
ulcer (Chap. 8).
Another important pathological condition
that can occur, especially in spinal cord injured
insensate patient with diabetes, is Fournier’s
gangrene of the scrotum and perineum second-
ary to descending infection from ischial ulcer.
This type of infection caused by a gas-forming
organism (anaerobic) infection. This serious
condition requires urgent decompression and
2 Etiology and Pathology of Pressure Ulcers
Fig. 2.6 Involvement of the perennial urethra by ischial
ulcer extension and necrosis
debridement, and, later, reconstructive surgery
(Figs. 2.7, 2.8, 2.9, and 2.10).
Extensive infection and necrosis in an ischial
ulcer can extend and dissect in the thigh
compartment (medial, posterior, and lateral)
(Figs. 2.11 and 2.12) and can even extend to the
hip joints with involvement of the hip capsule
and then the hip cavity and the femoral part or the
acetabulum. Necrotizing fasciitis is a serious
condition with a high mortality and morbidity
that requires urgent debridement and decompres-
sion of the thigh compartment.
In the female patient, anatomically, the peri-
neal space is small and restricted by the anus and
the vaginal opening. However, other manifesta-
tions can be seen in the female patient when the
labial tissue is involved in ulceration or infection
in the Bartholin’s glands and sometimes
2.9 Ischial Ulcer 11

Fig. 2.7 Swelling of the scrotum secondary to descend- Fig. 2.9 Operative photograph showing the debridement
ing infection from the ischial ulcer, Q-tip demonstrating and decompression of the scrotal sac
the connection with the scrotal sac

Fig. 2.8 Plain x-ray of the scrotal area showing gas bub-
Fig. 2.10 Operative photograph, 3 weeks post debride-
ble secondary to gas forming organism
ment and decompression of the scrotal sac

formation of Bartholin’s cyst. This condition pubic bone instead of the ischial tubersites and
results from severe forward or anterior rotation of consequently exerts pressure on the labial tissue
the pelvis, where the patient is sitting on the (Fig. 2.13).
12
Fig. 2.11 Descending infection from ischial ulcer into the
thigh compartment resulting in necrotizing fasciitis. The left
thigh shows swelling in comparison with the right thigh size
Fig. 2.12 Operative photograph of the same patient post
debridement and decompression of the thigh compartment
Fig. 2.13 Operative photograph showing labial ulcer-
ation secondary to sitting pressure over the pubic bone
with the formation of a labial cyst or bursa; syringe is used
to aspirate the fluid for diagnostic purposes
2 Etiology and Pathology of Pressure Ulcers
2.10 Ischial Bursa and Bursitis
Anatomically, there is no bursa in the ischial
area, but due to sliding forces over that area and,
in some cases, with loss of weight, an acquired
bursa can develop between the ischium and the
overlaying tissue and skin. This acquired bursa
can become infected, that is, the contents of the
synovial fluid become infected secondary to
blood-borne infection or a small skin breakdown
form over the bursa. The patient will clinically
present with fever and high white cell count of
unknown origin if erythema, swelling, or fluctua-
tion exist (Fig. 2.14a, b). Diagnosis of this condi-
tion can be easily made, but sometimes in spinal
cord injured patients when there is no sensation it
can present a medical problem [22] and may
require more advanced tests such as a leukocyte
scan to detect the source of infection or magnetic
resonance imaging (MRI) study.
Bursa of the ischium has been described in the
literature, and the manifestation of the bursa
sometimes may be confused with a large cyst
extending in the post thigh or under the gluteus
maximus muscle or a loop of bowel [23, 24].
Another clinical manifestation of an ischial bursa
occurs when a patient presents with a chronic
nonhealing stage III ulcer over the ischium and
does not respond to conservative treatment. By
clinical examination, fluctuation is positive sign,
indicating the existence of a bursa under the ulcer
that does not support physiological healing of the
stage III ulcer (Figs. 2.15 and 2.16). The manage-
ment of this condition is by excision of the bursa
and closure by flap surgery. The ischial bursa can
also manifest by a small discharging sinus that
does not heal for a long period of time (Figs. 2.17
and 2.18).
Another pathological presentation of an ischial
ulcer is the development of heterotopic ossifica-
tion (H.O.) of the ischium secondary to chronic
infection, healing of the ischial bone, and recur-
rent ulceration of the ischial area. This can be
detected by plain x-ray of the pelvis (Fig. 2.19).
Even if the ulcer heals, the H.O. can cause an
increase in the bony prominence of the ischium
and consequently increases the sitting pressure on
the skin, which predisposes to skin breakdown
and recurrent ulceration. The treatment of H.O. is
excision and closure of the defect by muscle flap.
2.10 Ischial Bursa and Bursitis 13

a b

Fig. 2.14 (a) Ischial bursa present as a fluctuating mass in the ischial area. (b) Operative photograph showing the
specimen of the bursa excised from the above patient

Fig. 2.15 Nonhealing ischial ulcer stage III over existing Fig. 2.17 Sinus in the ischial area leading to a bursa
ischial bursa

Fig. 2.16 Operative photograph showing underneath the Fig. 2.18 Operative photograph of the ischial bursa sur-
stage III ulcer, there was a bursa that was excised gically exposed; the bursa was colored with methylene
blue dye
14
Fig. 2.19 Plain x-ray of the pelvis showing the develop-
ment of H.O. at right the ischial bone
Fig. 2.20 Plain x-ray of the pelvis showing destruction
of both ischial bone and pelvic bones
On many occasions, the ischial H.O. extends
between the hamstring muscle and involves the
muscle of the thigh.
2.11 Pelvic Ulcer
Chronic extensive ulceration and infection of the
bilateral ischial area and perineum leads to com-
plete destruction of the ischial bone (Fig. 2.20).
Anatomically, in the sitting position, the pressure
is distributed over both ischial tuberosity (I.T.),
but as a result of the destruction, all the sitting
pressure is over the pelvic floor and what remains
of the pelvic bone. The result is extensive ulcer-
ation, called pelvic ulcer (Fig. 2.21), which is dif-
ficult to close because of the lack of muscle and
skin reserve as a result of recurrent ulcerations
and surgeries. The patient is at an end stage in
2 Etiology and Pathology of Pressure Ulcers
Fig. 2.21 Operative photograph showing a typical pelvic
ulcer
which there is a diverting colostomy and urinary
diversion, to close the ulcer and to restore some
functional anatomy for sitting by soft tissue
replacement using limb disarticulation and total
thigh flap.
2.12 Trochanteric Ulcer
Anatomically, there is a trochanteric bursa con-
taining synovial fluid that covers the greater tro-
chanter. If a trochanteric ulcer develops it will
involve the bursa (Fig. 2.22). As a result of this
violation, bacteria invades the bursa, and acute or
chronic infection of the bursa stimulates the for-
mation of granulation tissue. The ulcer may
reduce in size but the final appearance is a dis-
charging sinus that will not heal without surgical
intervention.
2.12 Trochanteric Ulcer
Fig. 2.22 Typical trochanteric ulcer involving the tro-
chanteric bursa
Fig. 2.23 Operative photograph showing extreme patho-
logical changes that can occur in femoral component of
the hip joint when the joint capsule is involved with infec-
tion, which leads to pathological fracture and dislocation
of the bone
Infection of the hip joint occurs when there is
an extension of direct infection caused by the tro-
chanteric ulcer. The extent of the infection
depends on the microbiology and the continuing
pressure over the area. The hip joint capsule
becomes necrotic, leading to infection of the hip
cavity. On clinical examination, it is easy to pass
a finger through the damaged capsule and the
neck of the femur can be felt. If the process con-
tinues, the femoral head and neck can be involved
and represent as acute osteomyelitis. Pathological
fracture or dislocation [25] of the femoral head
(Fig. 2.23) can occur.
The acetabular bone can be involved with the
extension of the infection as an acute or chronic
infection. The diagnosis of this condition can be
achieved by MRI study or operative bone biopsy
of the acetabulum, which determines the need
15
Fig. 2.24 CT scan of the pelvis showing abscess forma-
tion around the inner pelvic bone in the area of the ilio-
psoas muscle
for long-term IV antibiotic treatment. Another
complication of hip infection is the extension of
infection and development of iliopsoas abscess,
which is frequently seen in spinal cord injury
patients. Anatomically, the iliopsoas muscle is
inserted in the lesser trochanter of the femur. The
infection extends from the hip area along the
sheath of the muscle to the pelvic part of the
muscle, and abscess will be formed in that area.
Clinically, it is difficult to diagnose the condi-
tion. Patients present with fever, high white
blood cell count (WBC), and abdominal pain, if
patient has sensation in that area. Therefore, a
high index of suspicion for this condition exists
in spinal cord injured patients with deep pressure
ulcer around the hip or pelvis. Computed tomog-
raphy (CT) scan or MRI are the diagnostic tools
(Fig. 2.24).
Treatment is by drainage under CT scan guided
aspiration or open surgical drainage [26, 27].
Another manifestation of hip joint infection sec-
ondary to trochanteric ulcer is the extension of the
infection from the hip area into the anterior thigh
area over the femoral vessel. The infection site
drains and opens into the groin area (Fig. 2.25).
Heterotopic ossification around the hip joint is
a common manifestation in spinal cord injured
patients or secondary to a pathological changes
due to infection [20].The newly formed H.O. is
infected, which leads to development of
discharging sinuses in the skin. In addition, the
formation of H.O. leads to increased pressure in
the area secondary to the increase of boney mass
around the hip joint, which eventually increases
16
Fig. 2.25 Photograph showing the extension of infection
from the hip area into anterior thigh and open into the
groin. Q-tip indicating the extension from the hip to the
groin area
a b
Fig. 2.27 (a) Operative photograph showing the discharge sinus resulted from infected H.O. of the hip joint. (b) Plain
x-ray of pelvis showing the infected H.O.
the risk for pressure ulcer development. As a
result of the rotation of the hip joint posteriorly,
the patient develops a posterior trochanteric ulcer
(Figs. 2.26 and 2.27a, b).
To diagnose this condition when the patient
presents a swelling in the hip area and limited
range of motion, plain x-ray is informative if
the H.O. has matured. However, if the H.O. is
at an early stage, then a nuclear study scan
called a triphasic bone scan will show an
increase in the uptake by the hip area. The
treatment for mature H.O. is excision of the
H.O., proximal femoral osteotomy, and muscle
flap (see Chap. 16).
2 Etiology and Pathology of Pressure Ulcers
Fig. 2.26 Plain pelvic x-ray showing the development of
H.O. around the hip joint with the deformity of the joint,
which will lead to ulceration
References
1. Dinsdale SM (1974) Decubitus ulcers: role of pres-
sure and friction in causation. Arch Phys Med Rehabil
55:147–155
2. Brooks B, Duncan GW (1940) Effects of pressure on
tissues. Arch Surg 40:696
3. Lindan O (1961) Etiology of decubitus ulcers. Arch
Phys Med Rehabil 2:774–783
4. Nola GT, Vistnes LM (1980) Differential response of
skin and muscle in the experimental production of
pressure sores. Plast Reconstr Surg 66:728
5. Reichel S (1958) Shearing forces as a factor in decu-
bitus ulcers in paraplegics. JAMA 166:762–763
6. Guttman L (1958) Problem of treatment of pressure
sores in spinal paraplegics. Br J Plast Surg 8:
196–213
References
7. Allman RA, Desforges JF (1989) Pressure ulcers
among the elderly. N Engl J Med 320:850–853
8. Pinchafsky-Devin GD, Kaminski MV (1986) Correlation
of pressure sore and nutrition. J Am Geriatr Soc 34:
435–440
9. Allman RM, Lapraede CA, Noel LB et al (1986)
Pressure sores among hospitalized patients. Ann
Intern Med 105:337–342
10. Levine J, Simpson M, McDonald R (1989) Pressure
sores: a plan for primary care prevention. Geriatrics
44:75–90
11. Sacks AH, O’Neill H, Perkash I (1985) Skin blood
flow changes and tissue deformations produced by
cylindrical indentors. J Rehabil Res Dev 22:1–6
12. Kennedy EJ (1986) The facts and figures: spinal cord
injury. University of Alabama, Birmingham
13. Mawson AR, Neville P, Winchester Y (1988) Risk
factors for early occurring pressure ulcers following
spinal cord injury. Am J Phys Med Rehabil 67:
123–127
14. Ganong WF (1989) Review of medical physiology.
Appleton & Lange, San Mateo
15. Rodriguez GP, Claus-Walker J, Kent MC, Stal S
(1986) Adrenergic receptors in insensitive skin of spi-
nal cord injured patients. Arch Phys Med Rehabil
67:177–180
16. Vidal J, Sarrias M (1991) An analysis of the diverse fac-
tors concerned with the development of pressure sores
in spinal cord injured patients. Paraplegia 29:261–267
17. Hawkins DA, Heinemann AW (1998) Substance
abuse and medical complications following spinal
17
cord injury. Rehabil Psychol 43:219–231, {Scientific
evidence-V}
18. Salzberg CA, Byrne CG, Cayten CG et al (1996) A
new pressure ulcer risk assessment scale for individu-
als with spinal cord injury. Am J Phys Med Rehabil
75:96–104
19. Salzberg CA, Byrne DW, Cayten CG (1998)
Predicting and preventing pressure ulcers in adults
with paralysis. Adv Wound Care 11:237–246
20. Reuler JB, Cooney TG (1981) The pressure sore:
pathophysiology and principles of management. Ann
Intern Med 94(5):661–666
21. Stover SL, DeLisa JA, Whiteneck GG (1995) Spinal
cord injury: clinical outcomes from the model sys-
tems. Aspen Publication, Gaithersburg
22. Rubayi S, Montgomerie JC (1992) Septic ischial bur-
sitis in patients with spinal cord injury. Paraplegia
30:200–203
23. Shea JD (1975) Pressure sores. Clin Orthop 112:89
24. Comarr AE (1950) Ischial decubitus ulcer with atypi-
cal features. J Int Coll Surg 13:232
25. Schneider M, Krug AJ (1960) Dislocation of the hip
secondary to trochanteric decubitus, a complication of
multiple sclerosis. J Bone Joint Surg Am 42-A:1165
26. Firooznia H, Rafii M, Golimbu C, Cam S, Sokolow J
(1982) Computed tomography of pressure sores, pel-
vic abscesses and osteomyelitis in patients with spinal
cord injury. Arch Phys Med Rehabil 63:545–548
27. Rubayi S, Soma C, Wang A (1993) Diagnosis and
treatment of illopsoas abscess in spinal cord injury
patients. Arch Phys Med Rehabil 74:1186–1191
 Comprehensive Clinical Wound
Evaluation
Salah Rubayi
3.1 Definition of Pressure Ulcer
Pressure ulcers are skin lesions caused by unre-
lieved pressure or other forces resulting in dam-
age to the underlying tissue. Usually, pressure
ulcers are located over a boney prominence of
the body. Pressure ulcers can be staged accord-
ing to the extent of tissue damage. The staging
was proposed by Shea in 1975 [1] and the Wound
Ostomy Society (International Association of
Enterostomal Therapy) in 1988, and was finally
agreed upon in 1989 by the National Pressure
Ulcer Advisory Panel, United States.
3.2 Staging of the Pressure Ulcer
Stage I. Acute inflammatory response to pressure
with change in the color of the skin.
Nonblanchable erythema in dark skin is diffi-
cult to notice, but indirect signs are induration,
warmth of the skin, and hardness of the skin.
S. Rubayi, MB, ChB, LRCP, LRCS, MD, FACS,
Department of Surgery, Rancho Los Amigos
National Rehabilitation Center, Downey, CA, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_3, © Springer-Verlag Berlin Heidelberg 2015
3
An ulcer at this stage is reversible if the cause
of pressure is removed or corrected.
Stage II. Partial thickness skin loss may involve
all the epidermis and part of the dermis.
Clinically, it appears as a blister or abrasion or
a shallow crater.
Stage III. Full thickness skin loss may extend
into the subcutaneous tissue, but it stops at the
deep fascial layer. Clinically, it appears as a
deep crater with or without undermining.
Stage IV. Full thickness skin loss with extending
necrosis into muscle, bone, joint, or surround-
ing soft tissue. Undermining or sinus tract
may be associated with stage IV ulcer.
Histopathological changes in all the stages of
ulcer(s) are similar to the changes seen in acute
burn injuries. It is probable that the difference
is that in some types of burns the zone of injury
will continue to show tissue damage and necrosis
whereas in pressure ulcers the pathological process
may stop. However, in the incidence of secondary
infection or continuous pressure, the process of
destruction and necrosis will continue to declare
itself as a pressure ulcer (Figs. 3.1 and 3.2a–d).
3.3 The Importance of Clinical
Staging of Pressure Ulcers
Clinically, for every ulcer in a patient in the hos-
pital, clinic, nursing home, or convalescent home
setting, a health care provider (MD, nurse, allied
19
20 3 Comprehensive Clinical Wound Evaluation

health professional) should stage and document 3.4 Patient Medical History
the ulcer for the following reasons:
(a) For ulcer management and treatment basis With pressure ulcers, like any other wounds or
(b) Prognostic point of view illnesses, a complete medical history prior to
(c) Medico-legal issues examination of the wound is important to under-
(d) Reimbursement (financial) by health standing the nature of the wound. The pressure
insurance ulcer is always secondary to the primary illness or
trauma, and consequently a management plan is
developed according to the information obtained
Hair from the patient or the caregiver. Therefore,
examining a wound without a comprehensive
medical history is considered incomplete diagno-
Epidermis
sis or management. History of spinal cord injury,
Dermis
level of injury, and whether it’s a complete or
Glands
incomplete injury should be ascertained to deter-
Fat mine the level of sensation in the patient, the
Muscle level of muscle function, and whether the patient
Bone is ambulatory, walks with aids, or is wheelchair
confined. Other primary diagnosis, for example,
spina bifida, stroke, or neurological disease, will
Normal skin deep tissue histology
help determine how to treat the wound, either by
Fig. 3.1 Normal skin histology conservative or surgical treatment. The medical

a b
Stage 1 Stage 2

Epidermis
Dermis
Fat
Muscle
Bone

c d
Stage 3 Stage 4

Fig. 3.2 (a–d) Diagrams

showing the histopatho-
logical changes of the skin
and underlying tissue with
the clinical appearance of
the ulcers in all stages
3.9 Wound Evaluation and Assessment
history should include a complete history of ill-
nesses and the medications the patient is taking.
Illnesses such as heart disease, lung disease, dia-
betes, and vascular disease [2] affect healing and
the ability of the patient to tolerate general anes-
thesia if surgery is indicated. History of bowel
and urinary control is important knowledge for
the postoperative management of the patient.
History of the existing of muscle spasms should
be investigated and controlled to avoid postoper-
ative morbidities. Psychosocial evaluation [3, 4]
is important for the success of the surgery, as the
compliance of patient is important in the postop-
erative period. In addition, history of smoking,
alcoholism, and drug abuse all factors affect heal-
ing (details are discussed in Chap. 5).
3.5 Nutritional Assessment [5]
A history of food intake and patient appetite should
be determined. In tetraplegia patients, feeding will
depend on the caregiver. It is important that a dieti-
cian be involved in the evaluation (Chap. 6).
3.6 Physical Therapy Evaluation
Patients with pressure ulcers should be evaluated
by a physical therapist as a requirement of the
pre-operative evaluation to determine important
factors that may have contributed in the develop-
ment of pressure ulcers, for example, patient
mobility, range of motion, transfer, sitting, joint
movement, contractures, type of wheelchair and
cushion, and measurement of sitting pressure.
Details of the role of physical therapy in patients
with pressure ulcers are provided in Chap. 16.
3.7 Laboratory Tests and Data
Basic laboratory tests and specific tests should
be ordered when evaluating any patient with
pressure ulcers to determine the patient’s health
21
status. The necessary steps should be taken to
correct the abnormal laboratory data to help the
patient’s healing process or in preparation for
surgery. Details of the laboratory tests required
are provided in Chap. 4.
3.8 Risk Assessment
During evaluation of the patient, risk assessment
should be considered a part of the prevention
plan, with consideration of the factors that pre-
disposed in the development of pressure ulcer.
Details on prevention of pressure ulcers are pro-
vided in Chap. 17.
3.9 Wound Evaluation
and Assessment
Complete examination of any ulcer should
include the following documentation:
• Anatomical location: When examining a
patient with pressure ulcer, the patient should
be in a position that allows the examiner to
view all areas well and to locate the anatomi-
cal landmark. It is easy to misidentify the
location if the patient is not exposed well dur-
ing the examination. Assistance from another
person may be necessary, especially in quad-
riplegia or geriatric patients. It is important to
note, for example, the distance between the
ischioperineal ulcer and the anus. This will
help determine whether to perform a diverting
colostomy prior to flap surgery. The location
documentation should include the side of the
body involved, whether left or right, as in the
case of trochanteric or ischial ulcer. The gen-
eral appearance of the ulcer in the anatomical
location should be documented.
• Size of the ulcer(s): A measuring ruler should
be used, and there are disposable rulers avail-
able for this purpose. Measuring can be done
by direct volume measurement or tracing
planimetry [6, 7]. Length measurement should
22
be along the longest dimension of the wound,
and width measurement should record the
maximum dimension perpendicular to the
length axis.
• Depth of the ulcer(s): A cotton-tipped applica-
tor probe can be inserted to the deepest part of
the ulcer to measure the depth of the ulcer.
• Staging of the ulcer: The system described pre-
viously should be adapted. In some instances,
it is difficult to differentiate accurately between
stage III and IV ulcers. Because of the exu-
date or eschar at the time of examination, it is
advisable to document the stage of the ulcer as
between III and IV. When the ulcer declares
itself post wound care or debridement, the
exact staging can be observed.
• Exudate or odor of the wounds: The wound
should be inspected for the existence of exu-
date or pus. This may indicate a specific bacte-
rial colonization or infection. When wound
dressing is applied with a special cream, this
may mask the real appearance of the wound
and the cream used may look like whitish-
yellowish exudates. Cleaning and irrigating
the wound with normal saline will declare the
true appearance of the wound.
• Necrosis: This appearance is seen in stage
III or IV ulcers as either a dry eschar, as in
gangrene of the skin, or soft wet necrosis of
the skin and the subcutaneous tissue and ten-
don with exposure of the bone. If the bone is
involved with the process as an acute osteomy-
elitis, the feeling of the bone on palpation will
be harsh, spiky, and sometimes a loose piece
of bone is seen in the wound as “sequestrum.”
• Undermining: Undermining may be present
due to the dissection of the ulcer or second-
ary to infection into the surrounding tissue,
such as the muscle or soft tissue. This patho-
logical change is detected either by manual
examination or using a wooden applicator.
The undermining can be missed during sur-
gical closure, eventually causing postopera-
tive complications. Therefore, coloring the
undermining tissue with methylene blue dye
during the surgery prior to excision of the
ulcer is an important step in excising all of
3 Comprehensive Clinical Wound Evaluation
the granulating tissue that covers the under-
mine cavity or bursa.
• Sinus tracts: This appearance is seen when a
stage IV ulcer starts to heal and contracts from
the outside. The entire outside opening con-
tracts, leaving a small sinus opening on the skin
surface. This can deceiving the examiner into
thinking that the ulcer has healed. The actual
pathology, the sinus is leading into a large cav-
ity, is demonstrated using a cotton-tipped appli-
cator or probe to determine the real depth of
the cavity. Some authors recommended doing
sinography to demonstrate the cavity [8, 9].
• Infection: Ulcer infection should be distin-
guished from normal colonization of the
wound. Erythema, cellulites, and warm skin
around the ulcer demonstrate infection. A bac-
teriological swab of the wound for culture and
sensitivity should be taken. Maceration around
the ulcer may indicate the contamination of
the skin by feces, urine, or exudates from the
ulcer. Sometimes the type of the dressing used
to treat the ulcer locally can cause irritation of
the skin as a chemical reaction. As a result of
this maceration, fungal infection of the skin
can develop.
• Presence of granulation tissue and epitheli-
zation: Granulation tissue and epithelization
indicate the ulcer is in the process of healing.
Granulation tissue is a pathological process
to prepare the wound for healing. It also indi-
cates to the clinician to change the type of
local dressing to a different type to stimulate
wound contraction and to overcome exces-
sive granulation tissue formation that is not
beneficial to wound healing. Epithelization at
the margin of the ulcer, which looks “whitish”
in color, indicates healing of the ulcer, espe-
cially in stage III, by migration of epithelium
to cover the healthy looking granulating bed,
in which the tissue is red in color and bleeds
easily. Unhealthy granulation tissue is dull
and “grayish-yellowish” in color due to heavy
colonization with microorganism(s). In this
case, the wound should be treated locally with
antibacterial cream to clean the granulation tis-
sue from microorganisms and to stimulate the
References
process of healing by secondary contraction.
In documenting progress in ulcer healing, a
3.
narrative description may not be enough and
photographs of the wound at different times 4.
are informative. In the age of digital photogra-
phy, it is easy to take a photo of the ulcer and
5.
send it by electronic mail. This is tremendously
helpful in evaluating the progress of the ulcer
and advising the necessary management. It is 6.
important to mention that dark-pigmented skin
may not show hyperemia at an early stage of 7.
ulcer development. In these patients, the areas
of damaged skin may appear darker, shiny and
indurated, and warm to the touch. The color
8.
changes may range from purplish to blue and
pressure damaged skin does not blanch [10].
9.
References
10.
1. Shea JD (1975) Pressure sores: classification and
management. Clin Orthop 172(112):89–100
2. Lazarus GS, Cooper DM, Knighton DR et al (1994)
Definitions and guidelines for assessment of wounds
23
and evaluation of healing. [Review] Arch Dermatol
130:489–493
Rintala DH (1995) Quality-of-life considerations.
Adv Wound Care 8:71–83
Allman RM, Laprade CA, Noel LB et al (1986)
Pressure sores among hospitalized patients. Ann
Intern Med 105:337–342
Ek AM, Unosson M, Larsson J et al (1991) The devel-
opment and healing of pressure sores related to the
nutritional state. Clin Nutr 10:245–250
Cutler NR, George R, Seifert RD et al (1993) Comparison
of quantitative methodologies to define chronic pressure
ulcer measurement. Decubitus 6:22–30
Griffin JW, Tolley EA, Tooms RE et al (1993) A com-
parison of photographic and transparency-based
methods for measuring wound surface area. Phys
Ther 73:117–122
Hooker EZ, Sibley P (1987) A proposed method for
quantifying the area of closed pressure sores in spinal
cord-injured through sonography and digitometry.
SCI Nurs 4:51–56
Hooker EZ, Sibley P, Nemchausky B (1988) A method
for quantifying the area of closed pressure sores by sonog-
raphy and digitometry. J Neurosci Nurs 20:118–127
Bennett MA (1995) Report of the task force on the
implications for darkly pigmented intact skin in the
prediction and prevention of pressure ulcers. Adv
Wound Care 8:34–35
 General and Special Investigation
in Pressure Ulcer Patients
Salah Rubayi
4.1 In Surgical Practice
In surgery, when a wound is evaluated clinically,
certain laboratory and diagnostic tests are ordered
for the following reasons:
• To determine and establish the effect of the
wound on the patient’s general health, taking
into consideration that a pressure ulcer is a
chronic wound.
• To establish the progress of an ulcer with deep
involvement of the underlying bone, joint, or
body organs.
• To determine the status of the patient’s general
health to predict how they will tolerate general
anesthesia and surgery. This is relative to the
patient’s age or the primary disease.
The investigation into pressure ulcers calls for
both general and specific tests.
4.2 General Tests
The following general lab tests should be ordered
for all patients presenting with pressure ulcers as a
basic value before beginning a management plan:
S. Rubayi, MB, ChB, LRCP, LRCS, MD, FACS,
Department of Surgery, Rancho Los Amigos
National Rehabilitation Center, Downey, CA, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_4, © Springer-Verlag Berlin Heidelberg 2015
4
White blood cells and differential white blood
count (WBC) – An abnormal level of white
cells indicates the existence of acute infection
in the soft tissue, bone, or joint.
Erythrocyte sedimentation rate (ESR) – This is
nonspecific, but with abnormality of other tests
ESR may indicate the presence of acute/chronic
bone infection. At present, the C-reactive pro-
tein test may be used instead of the ESR to
demonstrate a nonspecific infection.
Complete metabolic panel – This panel includes
liver function tests, blood urea nitrogen
(BUN), electrolytes, total protein, albumin,
and pre-albumin. These tests are important in
determining the nutritional status of the
patient, which impacts wound healing and
surgery. Nutrition and pressure ulcers are
discussed in detail in the pre-operative require-
ment before flap surgery.
Prothrombin time (PT) and partial thrombin time
(PTT) – In patients who are candidates for sur-
gery, these test are important. On many occa-
sions, this test is observed as abnormal (e.g.,
in liver disease or nutritional deficiency condi-
tions). Abnormal values can predict excessive
bleeding during surgery, hematoma formation
post-surgery, and eventually morbidity. An
abnormal value should be corrected before
surgery or surgery should be postponed.
General urine examination and urine sample for
culture and sensitivity – Especially in spinal
cord injured patients, any evidence of heavy
colonization of the urine or infection should
25
26 4 General and Special Investigation in Pressure Ulcer Patients

be treated before surgery to avoid postopera-

tive complications.
Hepatitis A, B, and C – Screening for hepatitis in
patients who are candidates for surgery is
important, especially if the patient has reported
a history of liver disease. It is vital to know the
status of the hepatitis in a patient when admin-
istering medications or anesthesia agents and
in predicting the stress of the surgery. All of
these factors may cause relapse of the hepati-
tis disease, and accidental cross infection dur-
ing surgery should be prevented. The surgeon
should know the results of the hepatitis screen
before surgery.
Tests for high-risk patients – Patients with a
history of heart disease, hypertension, lung
disease, and diabetes should have chest x-ray,
electrocardiogram (EKG), and Echocardio- Fig. 4.1 X-ray showing severe scoliosis of the spine
graphy (echo) of the heart, pulmonary func- resulting in obliquity of the pelvis
tion test, blood gas tests. These high-risk
patients should be evaluated by an internist or
cardiologist to determine whether these
patients are surgical candidates and can toler-
ate general anesthesia.

4.3 Specific Diagnostic Tests

4.3.1 Radiological Imaging Studies

Every patient with a pressure ulcer should have

a plain x-ray of the pelvis in the anteroposte-
rior (AP) position and bilateral hip x-rays in
the lateral position. This investigation delivers
important diagnostic information and helps in
preoperative planning. The advantage of a plain
x-ray is that it is a simple, noninvasive test and
is less costly than advanced radiologic testing
such as magnetic resonance imaging (MRI) and
computed tomography (CT) scan. In addition,
most patients can tolerate these tests. In some
patients, it is necessary to order x-rays of the
spinal column when the pelvis x-ray shows
pelvic obliquity secondary to spinal scoliosis.
This condition causes tilting of the pelvis to one
side, which puts pressure on the ischium of that
side, resulting in pressure ulcer development
(Fig. 4.1).
Fig. 4.2 Plain A.P. x-ray of the pelvis showing a free air
below the ischial area. Arrow indicates the location of the
ulcer
The following are examples of radiologic
appearance in the pelvis or hip x-ray that are
related directly or indirectly to pressure ulcer
development and represent pathological changes
in the skeletal system:
In the ischial ulcer area, free air or fistulous
canals can be demonstrated below the ischial
tuberosity, which represent the ulcer extension
(Fig. 4.2).
Heterotopic ossification (HO) can develop at
ischial tuberosity secondary to recurrent ulcer-
ation and infection (Fig. 4.3).
4.3 Specific Diagnostic Tests
Fig. 4.3 Plain x-ray showing H.O. development at the
ischium. Arrow indicates the H.O. location
Fig. 4.4 Plain x-ray of the pelvis showing destruction of
the ischial tuberosity. Arrow indicates the ischial area
Destruction of the ischial tuberosity is seen sec-
ondary to recurrent infection (Fig. 4.4). The
ischial bone can appear, in the case of osteitis,
as an irregular surface of the ischium second-
ary to calcification and chronic infection.
In the trochanteric and hip area, free air can be
demonstrated secondary to the ulcer or tro-
chanteric bursa, Heterotopic ossification of
the greater trochanter with bridging to the pel-
vic bone can be seen on plain x-rays.
Subluxation and rotation of the hip joint as a
pathological condition, which is seen fre-
quently in spinal cord injured patients, can
lead to rotation of the greater trochanter from
anatomical lateral position to posterior posi-
tion. Consequently, the patient, when seated,
sits over the greater trochanter instead of the
ischium, which eventually causes a pressure
ulcer called a posterior trochanteric ulcer
(Fig. 4.5).
27
Fig. 4.5 Plain x-rays of the pelvis showing the subluxed
hip and posterior rotation of the greater trochanter. Arrow
indicates the subluxed hip
Fig. 4.6 Plain x-ray of the pelvis showing dislocation of
the femoral head. Arrow indicates the pathology
In the spinal cord injured patient, fracture of the
intertrochanteric region can occur without
pain or limitation of movement because of the
primary disease of the patient. This condition
is discovered on routine x-ray secondary to
necrotic hip capsule or severe muscle spasms,
which cause dislocation of the head of the
femur (Fig. 4.6).
Necrosis of the head of the femur can be demon-
strated on x-ray secondary to infection or
arthritic changes, avascular necrosis, or con-
genitally undeveloped as in a spina bifida
(Fig. 4.7).
A condition called auto Girdlestone occurs when
the entire femoral head and part of the tro-
chanteric area is destroyed secondary to infec-
tion (Fig. 4.8).
28 4 General and Special Investigation in Pressure Ulcer Patients
Fig. 4.7 X-ray showing necrosis of the femoral head.
Arrow indicates the pathology of the head of the femur
Fig. 4.8 Plain x-ray showing complete destruction of the
femoral head called auto Girdlestone. Arrow indicates the
pathology
The acetabular component of the hip joint can be
affected by acute or chronic infection, causing
a change in acetabular shape from the normal
C-shape to a flat shape (Fig. 4.9).
In spina bifida patients, because of the congenital
deformity of the hip joint, the acetabular rim
on many occasions is not developed into a
C-shape and, as a result, the femoral head is
dislocated. Heterotopic ossification (H.O.)
originating from the greater trochanter, inter-
trochanteric region, and head of the femur can
be extensive, with extension and bridging to
Fig. 4.9 Plain x-ray of the pelvis showing the change of
the acetabular shape from C-shape to flat shape secondary
to destruction by infection. Arrow indicates the
pathology
Fig. 4.10 Plain x-ray of the pelvis showing extensive
H.O. of the hip area involving the pelvic bone. Arrow indi-
cates the pathology
the pelvic bone causing loss of movement at
the hip joint (Fig. 4.10).
In ulcers of the sacrococcygeal area, plain x-ray
examination of the pelvis may show destruc-
tion of the distal segment of the coccygeal
bone. A lateral view x-ray is more useful in the
diagnosis than A.P. of the pelvis when the stool
and gas in the rectosigmoid bowel may block
visualization of the sacrococcygeal bone.
4.3 Specific Diagnostic Tests 29

4.3.2 Sinogram Study

An ulcer that presents as a small opening sinus

of the skin is called a closed ulcer. This type of
ulcer is commonly seen in the ischial area and tro-
chanteric area. Some authors [1, 2] recommend
performing a sinogram study by injecting a radio-
opaque material into the sinus and taking an x-ray
to demonstrate the extent of the sinus and its deep
communication. The author’s experience is that it
is not always necessary to perform a sinogram as
a preoperative test. The sinus extension confirma-
tion is performed during surgery by injection of
methylene blue dye into the sinus, which visual-
izes all the tracts and its communication with other
tissues. The other conclusive test is the injection of
radio-opaque dye into the sinus of the trochanteric
area to exclude communication with the hip joint,
Fig. 4.11 X-ray of arthrogram of a hip joint with normal
which is not always useful because the injection of
capsule appearance. The superior arrows indicates the
the radio-opaque dye does not have enough pres- position of the catheter to inject the hip joint with the dye
sure to enter the hip capsule and the joint cavity. In
this situation, another test is used, an arthrogram,
in which radio-opaque dye is injected directly into
a joint cavity and visualization of the dye is dem-
onstrated by x-ray. This test is very accurate in
the diagnosis of any communication between the
hip joint and the surrounding tissue, such as the
trochanteric ulcer. This test useful in determining
whether the hip joint is involved with the ulcer-
ation or infection process, which indicates a dif-
ferent form of management. The test is performed
by an interventional radiologist or orthopedic
surgeon. In normal hip capsule appearance, the
arthrogram shows a C-shape (Fig. 4.11).
When there is communication between the hip
joint (i.e., involvement of the hip capsule) and the
surrounding tissue, extravasation of the dye can
be visualized on x-ray examination (Fig. 4.12).

Fig. 4.12 X-ray of arthrogram procedure of the hip when

4.3.3 Computerized Tomography
extravasation of dye is demonstrated outside the hip cap-
(CT) Scan sule. Arrow indicate the dye extravasation

CT scans have the advantage of being able to

demonstrate soft tissue structure and fluid-filled tion and also demonstrate and measure inflamed
spaces in their different densities. They can locate tissue and fibrotic reactions. Their most impor-
an air-filled ulcer with its surrounding local reac- tant use, from the author’s experience, is locating
30 4 General and Special Investigation in Pressure Ulcer Patients
Fig. 4.13 CT scan of the pelvis with a contrast showing
deep-seated pelvic abscess in iliopsoas muscle space.
Arrow indicates the location of the abscess
and diagnosing deep-seated pelvis abscesses
resulting from the extension of an infected ulcer
or hip joint into the pelvis with formation of ilio-
psoas abscess (Fig. 4.13).
In the event of diagnosis of a pelvic abscess, it
can be treated conservatively using needle aspira-
tion under CT scan control [3]. Some authors [4]
have documented use of CT scan in the diagnosis
of osteomyelitis resulting from pressure ulcer.
Compared with other modalities, they found that
in four patients, CT scan diagnosed osteomyelitis
in all four patients, plain x-rays in two of four,
gallium scan in three of four, and technetium
scintigram in two of four. The author believes
that clinical suspicion and examination cannot be
substituted with these modalities when planning
the surgical procedure. These modalities will
provide an additional advantage in the diagnosis
and confirm the clinical diagnosis.
4.3.4 Bone Scan
Technetium 99 bone scan has a high false-positive
rate because of the open wound and surrounding
inflammation of the area [5]. However, negative
findings by bone scan do not rule out osteomy-
elitis [6].
4.3.5 Magnetic Resonance
Imaging (MRI)
At present, orthopedic surgeons, infectious dis-
ease specialists, and internists routinely use MRI
to diagnose osteomyelitis underlying pressure
ulcer. Although this test is expensive, it is widely
used. To support the use of MRI in the diagnosis
of osteomyelitis, it has been documented that the
accuracy of MRI was 97 % and the sensitivity
was 98 % in the diagnosis of osteomyelitis of the
hip and pelvis in spinal cord injured patients [7].
Later, it was confirmed that MRI is better than
CT scan in distinguishing between soft tissue and
bone, and MRI was to replace the CT scan in the
diagnosis of osteomyelitis [8]. The problem with
MRI in the absence of bone necrosis is that the
diagnosis of osteomyelitis remains uncertain. In
addition, MRI cannot diagnose small damage to
the hip joint capsule. MRI cannot differentiate
accurately between acute osteomyelitis and
chronic osteomyelitis of the bone; therefore, it is
important to depend on the diagnosis of bone
infection by accurate testing, which is the histo-
pathology of the bone.
4.3.6 Magnetic Resonance
Angiogram (MRA)
Magnetic resonance angiogram is a special test
using MRI to visualize the arterial system of the
pelvis, hip, and thighs. This is a noninvasive pro-
cedure and can provide a good view of the arte-
rial system in the surgical area. The author uses
this test when there is hip heterotopic ossification
to be excised to examine the relationship between
the arterial system of that area and the HO to
avoid any injury to the blood vessels during exci-
sion of the HO (Fig. 4.14).
4.4 Diagnosis of Osteomyelitis
and Bone Biopsy
Many modalities are available to diagnose osteo-
myelitis of the bone underlying the ulcer, but,
unfortunately, they are not 100 % sensitive and
these modalities are expensive and place a tre-
mendous cost on the healthcare system.
Occasionally, they are uncomfortable tests for the
patient. Consequently, many authors [6, 9] con-
clude that the diagnosis of osteomyelitis of the
bone is by needle bone biopsy, and one of these
4.4 Diagnosis of Osteomyelitis and Bone Biopsy
instruments is called a “Jamshidi.” The process
of performing this bone biopsy can be done on
the ward, as in the case of the spinal cord injured
patients when anesthesia is not required. The
relationship between the existence of osteomyeli-
tis with pressure ulcer and closure by muscle flap
is still controversial in regard to the progress of
flap healing. It has been reported [10] that man-
agement of patients with suspected bone involve-
Fig. 4.14 MRA of the pelvis and hip area demonstrating
the relationship between the H.O. and the arterial system
of the area
Fig. 4.15 Cross section of
bone showing acute
inflammatory cells
infiltrate with polymorpho-
nuclear leukocyte and
inflammatory exudates
with destruction of bone
cell structure (hematoxylin
and eosin stain ×400)
31
ment with pressure ulcers involved dealing with
the ulcer in two stages. The first stage is debride-
ment of the ulcer and, at the same time, perfor-
mance of a core needle bone biopsy. If the biopsy
result shows acute osteomyelitis, flap closure is
delayed for 6 weeks and intravenous antibiotic is
administered for 6 weeks. The second stage is
closing the ulcer by flap surgery.
Another study [11] proved that inadequate
debridement of the ulcer and antibiotic adminis-
tration for long periods of time in an attempt to
sterilize the necrotic bone leads to progress of the
osteomyelitis and impairment of surgical out-
come. From the author’s clinical experience and
observation post-management of thousands of
stage IV ulcers with bone involvement, the first
approach to the problem of osteomyelitis, which
is managed clinically by many specialties, is
establishing whether the osteomyelitis is acute or
chronic. Generally speaking, in clinical practice
it is not usually differentiated and only given the
diagnosis of osteomyelitis. Medically speaking,
the management is different for each type of
osteomyelitis; therefore, it is important first to
establish a diagnosis of the type of osteomyelitis
of the bone underlying the ulcer. In the acute pro-
cess, the histopathological picture of the bone
shows infiltration of acute inflammatory cells,
thrombosis of blood vessels, and necrosis of the
bone cells (Fig. 4.15). In chronic bone infection,
32 4 General and Special Investigation in Pressure Ulcer Patients
Fig. 4.16 Chronic
osteomyelitis; bony
trabeculae with osteoblas-
tic reaction and surround-
ing chronic inflammatory
infiltrate including plasma
cells (hematoxylin and
eosin stain ×400)
the histopathological picture demonstrates infil-
tration of chronic inflammatory cells and, in
addition, shows some healing process and fibro-
sis and new blood vessel formation (Fig. 4.16).
It is therefore important to approach the man-
agement of these types of bone infections differ-
ently. Unfortunately, in real medical life, many
specialists deal with pressure ulcers, labeling the
underlying bone as osteomyelitis and eventually
prescribing intravenous antibiotics for a period of
6 weeks without a histopathological examination
of the deep bone. As a result, the author estab-
lished a system and a protocol to deal with the
histopathological diagnosis of the underlying
bone in stage IV pressure ulcer. The logical
approach is to excise and debride the ulcer com-
pletely, first at the base of the ulcer where the
unhealthy granulation tissue covers the underly-
ing bone. Shaving that bone is important, using
an osteotome that is the thickness of the unhealthy
bone, about 5–6 mm. This bone should be sent
for histopathological examination and labeled as
a superficial bone specimen. Second, the exposed
bone should be examined clinically for bleeding,
color of the bone, and consistency to determine
the viability of the bone. Soft brittle bone should
be differentiated between osteoporosis of the
bone or necrotic bone. The macroscopic appear-
ance of the deep bone will provide an idea of
diagnosis to the surgeon. If there is no bleeding
or the color is grayish, another shaving should be
performed until bleeding is observed from the
bone. A sample of the deep bone should be sent
for histopathological examination; labeling is
important and part of the deep bone should be
sent for bacteriological examination for culture
and sensitivity.
Antibiotics are routinely given for 5 days post-
surgery to patients after closure of stage IV ulcers,
according to the preoperative deep soft tissue cul-
ture and sensitivity. The wound is covered with
multiple layers of muscles to close the wound. If
the deep part of the bone demonstrates histopatho-
logically chronic osteomyelitis or healing chronic
osteomyelitis, intravenous (IV) antibiotic should
no longer be given. If the shaved deep part of the
bone shows acute osteomyelitis by histopathologi-
cal examination, 6 weeks of IV antibiotics are
given according to results of the deep bone bacte-
riological culture and sensitivity. Our success rate
in management is to the result of an aggressive
approach in the debridement of the soft tissue and
the bone and covering the shaved bone with muscle
to bring the blood supply to the bone and to help
heal of the bone. This promotes flap wound healing
at an early stage or later on. The author published
his experience and outcome in treating chronic
osteomyelitis and acute osteomyelitis in 2008 [12].
References
4.5 Wound Bacteriological Swab
for Culture, Sensitivitys and
Bacterial Colonization
As a standard in wound management, a swab
should be obtained from the surface of the
wound before surgical management. In the case
of a pressure ulcer that is considered a chronic
wound, it is always colonized with polymicro-
bial organism. The flora consists of aerobic and
anaerobic organisms [13–16]. The common
organisms isolated from pressure ulcers are
Pseudomonas aeruginosa, Proteus mirabilis,
Escherichia coli, Klebsiella sp., Enterobacter
sp., Providencia sp., and Staphylococcus
aureus; the anaerobe is Bacteroides sp. There
are indications for obtaining a bacteriological
swab from the ulcer when local management
of an ulcer continues for a period of time (2–3
weeks) without showing improvement in heal-
ing. In this case, heavy colonization with bacte-
ria greater than 105 is suspected, which prevents
or slows wound healing [17]. Another indica-
tion as a preoperative test is choosing the proper
antibiotic to be given before and after flap sur-
gery. If there is a systemic infection due to the
ulcer with signs and symptoms of cellulitis, high
fever, chills, and elevated WBC, a deep swab
for culture and sensitivity is recommended [18].
Initially, the antibiotic given will depend on the
ulcer location and the odor of the pus or drain-
age from the ulcer. The superficial swab does
not indicate the real colonization of the ulcer.
Therefore, a deep swab or deep tissue biopsy is
necessary in these situations, and the result of
that culture will determine the appropriate anti-
biotic to use [18]. It was found that routine use
of antibiotics in pressure ulcers does not lower
the bacterial colonization, but it will change
the ecology of the wound [18]. In addition,
with increased incidence of methicillin-resis-
tant Staphylococcus aureus in the community
or hospital, it becomes necessary to swab the
wound to screen for MRSA, which is important
from an epidemiological point of view and for
patient isolation in the hospital environment.
Bacteremia can occur post debridement of pres-
sure ulcer [19], therefore administering antibi-
otic is indicated in the procedure. The use of
33
preoperative antibiotic according to preopera-
tive or intraoperative bacteriological culture is
considered therapeutic coverage. The duration
of antibiotic use depends on the extent of the
ulcer, necrotic tissue, and the status of the bone.
In a survey by Salzberg et al. [20], 50 % of sur-
geons stated that they use preoperative antibiotic
for flap surgery, whereas 48 % did not. In regard
to the timing of the preoperative antibiotic, 8 %
stated 48-h preoperatively and 24 % stated 24-h
pre-surgery. The duration of antibiotic coverage
after surgery was between 48-h and 1 week. A
small percentage of the respondents stated that
antibiotic coverage is based on preoperative cul-
ture result. The author agrees with this principle.
References
1. Hooker EZ, Sibley P, Nemchausky B et al (1988) A
method for quantifying the area of closed pressure
sores by sinography and digitometry. J Neurosci Nurs
20:118–127
2. Hooker S, Wells C (1992) Aerobic power of competi-
tive paraplegic road racers. Paraplegia 30:428–436
3. Rubayi S, Soma C, Wang A (1993) Diagnosis and
treatment of iliopsoas abscess in spinal cord injury
patients. Arch Phys Med Rehabil 74:1186–1191
4. Firooznia H, Rafii M, Golimbu C, Lam ST, Sokolow
J, Kung JS (1982) Computed tomography of pressure
sores, pelvic abscess and osteomyelitis in patients
with spinal cord injury. Arch Phys Med Rehabil
63:545–548
5. Sugarman B (1987) Pressure sores and underlying
bone infection. Ann Intern Med 147:553
6. Thornhill-Joynes M, Gonzales F, Stewart CA et al
(1986) Osteomyelitis associated with pressure ulcers.
Arch Phys Med Rehabil 67:314
7. Huang A, Schweitzer ME, Hume E, Batte WG (1998)
Osteomyelitis of the pelvis/hips in paralyzed patients:
accuracy and clinical utility of MRI. J Comput Assist
Tomogr 22:437
8. Ruan CM, Escobedo E, Harrison S, Goldstein B
(1998) Magnetic resonance imaging of non-healing
pressure ulcers and myocutaneous flaps. Arch Phys
Med Rehabil 79:1089
9. Lewis VL, Bailey MH, Ulawski G et al (1988) The
diagnosis of osteomyelitis in patients with pressure
sores. Plast Reconstr Surg 81:229–232
10. Han H, Lewis VL Jr, Wiedrich TA, Patel PK (2002)
The value of Jamshidi core needle bone biopsy in pre-
dicting postoperative osteomyelitis in grade IV pres-
sure ulcer patients. Plast Reconstr Surg 110:118
11. Deloach ED, Christy RS, Ruf LE et al (1992)
Osteomyelitis underlying severe pressure sores.
Contemp Surg 40:25–32
34 4 General and Special Investigation in Pressure Ulcer Patients
12. Marriott R, Rubayi S (2008) Successful truncated
osteomyelitis treatment for chronic osteomyelitis sec-
ondary to pressure ulcers in spinal cord injury patients.
Ann Plast Surg 61(4):425–429
13. Daltrey DC, Rhodes B, Chattwood JG (1981)
Investigation into the microbial flora of healing and
non-healing decubitus ulcers. J Clin Pathol 34:701
14. Ger R, Levine SA (1976) The management of decubi-
tus ulcers by muscle transposition. An 8-year review.
Plast Reconstr Surg 58:419
15. Narsete TA, Orgel MG, Smith D (1983) Pressure
sores. Am Fam Physician 28:135
16. Vasconez LO, Schneider WJ, Jurkiewicz MJ (1977)
Pressure sores. Curr Probl Surg 14:1
17. Stotts NA, Hunt TK (1997) Managing bacterial colo-
nization and infection. Clin Geriatr Med 13:565–573
(Review)
18. Rudensky B, Lipschits M, Isaacsohn M, Sonnenblick
M (1992) Infected pressure sores: comparison of
methods for bacterial infection. South Med J
85:901–903
19. Glenchur S, Patel BS, Pathmarajh C (1981) Transient
bacteremia associated with debridement of decubitus
ulcers. Mil Med 146:482–533
20. Salzberg CA, Gray BC, Petro JA, Salisbury RE (1990)
The perioperative antimicrobial management of pres-
sure ulcers. Decubitus 3:24–26
 Pressure Ulcers
from a Psychological Perspective
Burl R. Wagenheim
5.1 Introduction
Psychology has been defined as the science or
study of behavior. Assuming that behavior
encompasses thoughts, feelings, and actions,
everything that pertains to behaviors that either
facilitate or prevent the development of a pressure
ulcer may be said to come under the purview of
psychology! However, psychology has tended to
limit its scope of investigation into pressure sores
to traditional “bread and butter” psychological
topics such as mood disorders, substance use, and
personality factors, whereas other behaviors such
as urinary incontinence, diet, and personal
hygiene, which conventionally have not been
thought of as being psychological, have been left
for nursing and other disciplines to research.
The purpose of this chapter is to survey what
is “out there” in terms of research on psychologi-
cal aspects of pressure sores and then to look at
clinical implications. It will draw upon research
by psychologists and from other disciplines.
However, it will be limited to behaviors that are
considered to be mediated by mental processes.
They may be volitional, involving thought or
emotions, or involuntary, as in more severe mani-
festations of dementia, brain injury, and addic-
tion. As an example, soiling oneself as the result
B.R. Wagenheim, PhD
Rancho Los Amigos, National Rehabilitation Center,
Downey, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_5, © Springer-Verlag Berlin Heidelberg 2015
5
of being too depressed to use a bedpan or to get
out of bed to use the toilet would be considered
psychological for purposes of this chapter; how-
ever, the mechanical action of lack of control
over the anal sphincter secondary to spinal injury
would not.
As a survey, breadth necessarily trumps depth,
and the goal here is to familiarize the surgeon
with the various psychological issues that come
into play when working with patients with pres-
sure sores. Various vantage points will be taken.
For example, the pressure sore may have a psy-
chological etiology, such as among depressed
persons in a severe vegetative state who stay in
bed all of the time. However, conversely, the sore
itself may trigger a psychological reaction, as
when confinement to bed to promote wound heal-
ing, whether postoperatively or in the hope of
preventing surgery, makes coping so difficult that
depression ensues.
5.2 Psychological Factors
and Conditions
Often, perhaps too often, behaviorally challeng-
ing patients are viewed by physicians and medi-
cal staff as having a problematic personality.
Although personality and personality disorders
will be the starting point for our “tour” of the psy-
chology of pressure ulcers, other psychological
factors will be discussed as well. These include
substance use and addiction, impaired cognition,
35
36
pain, depression, and anxiety. Any of the factors
presented in this section may predispose an indi-
vidual to develop a pressure sore or complicate
the course of treatment when an ulcer already
exists. Further, pressure sore acquisition and
treatment in any given patient may involve more
than one psychological system, e.g., a patient
newly diagnosed with paraplegia becomes
depressed and self-medicates with alcohol and
opioid pain medication, such that addiction to
both substances eventually occurs. Unknowingly,
there also are mild cognitive deficits affecting
memory and problem solving that were acquired
as the result of a brain injury which occurred dur-
ing the motor vehicle accident that resulted in
spinal injury. Skin inspection and pressure relief
procedures, both taught during rehabilitation, no
longer are being practiced and a pressure ulcer
ensues. One or more, perhaps even all, of the
above psychological variables could have led to
the development of the pressure sore.
5.3 Personality in General
Personality disorders are an increasingly contro-
versial topic. The existing nosology of discrete
disorders published in the Diagnostic and
Statistical Manual of Mental Disorders [1] has
received criticism [2], including whether personal-
ity disorders constitute “distinct clinical entities”
[3] and charges that certain personality disorders
are not based on sound science [4]. The etiology of
disordered personality falls under nature versus
nurture arguments, with research supporting both
genetic and social environmental factors, as well
as an interaction effect between biology and expe-
rience [5, 6]. Additionally, the term personality
disorder, used synonymously with character disor-
der, has been abused, such that persons who chal-
lenge authority, deviate from the norm, or behave
in an unconventional manner may be labeled as
being personality disordered.
Personality disorders are chronic and can
interfere with daily functioning. DSM-IV-TR
defines personality disorder as an “enduring pat-
tern of inner experience and behavior that devi-
ates markedly from the expectation of the
5 Pressure Ulcers from a Psychological Perspective
individual’s culture, is pervasive and inflexible,
has an onset in adolescence or early adulthood, is
stable over time, and leads to distress or impair-
ment” [1, p 685]. It is important to note that
personality disorder is not the result of the use of
chemical substances, whether illicit drugs or pre-
scribed medications, nor due to a medical condi-
tion, including head trauma.
Physical injury and medical illness certainly
can result in change of personality. The DSM
indeed recognizes this, defining it as “personality
change” as opposed to personality disorder.
When medical and substance abuse etiologies are
present, personality disorder may be mistakenly
diagnosed. When there are comorbid personality
and “organic” etiologies, the personality disorder
may be missed or underestimated, especially
when the disorder is not severe. Mild personality
disorder may not be initially apparent and only
detected over time.
Psychological research clearly has established
a relationship between personality disorder and
spinal injury; one spinal injury clinical sample
found the personality disorder prevalence rate to
be 70 % [7]. Temple and Elliott [8] found that
72–84 % of persons with recent-onset SCI admit-
ted for hospitalization and between 55 and 90 %
of postoperative pressure sore skin flap patients
met the diagnostic criteria for personality disor-
ders. However, research to confirm a link between
personality and pressure sore acquisition is more
limited.
5.3.1 Antisocial Personality
The one personality disorder most associated with
spinal injury is the antisocial personality disorder,
also known as psychopathic and sociopathic per-
sonality [8, 9], although one study found low
prevalence in a clinical sample [10]. The chief
feature of antisocial personality disorder is disre-
gard for or violation of the rights of others.
Persons with this disorder can be dishonest and
deceitful and as such may use charm or be skilled
in “reading” others to gain their trust for ulterior
motives. Individuals may lack remorse, may be
unable to comprehend that their actions were
5.3 Personality in General
improper, may be hurtful to others or unjustified,
and as such may not be able to recognize, let alone
acknowledge, that they erred or were wrong.
The term antisocial means going against con-
ventional social practices and mores, and as such
there may be little respect for following rules,
procedures, and convention. Other characteristics
associated with antisocial personality disorder
are irritability, aggressiveness, impulsivity, and
disregard for the safety of oneself or of others.
There is a correlation between antisocial person-
ality disorder and criminal behavior. This disor-
der is more prevalent in males than in females.
Though considered chronic, it may tend to flatten
out and even remit over time [1].
From the standpoint of patients with pressure
ulcers, antisocial personality disorder may be
seen as a risk factor for their acquisition and
development, may make hospitalizations chal-
lenging for patient and staff alike, and may
threaten successful postoperative outcomes. A
concern in the medical setting is whether the
patient will be able to successfully follow a treat-
ment plan rather than disregard or challenge it.
The patient may feel “disrespected” if chided for
having engaged in behaviors that resulted in a
sore or increase risk for developing one and may
not be able to recognize that one’s own behaviors
are problematic. On the other hand, the need to
be tied to a healthcare system for treatment of
pressure sores and other medical concerns, which
involves scheduling and showing up for medical
appointments, obtaining prescriptions, and
applying for disability or insurance benefits, may
serve as a means to socialize persons with antiso-
cial personality into following rules and proce-
dures. Perhaps that is a reason why antisocial
personality may flatten or soften over time.
5.3.2 Other Personality Types
Another personality disorder that can threaten sur-
gical intervention and hospitalization is the bor-
derline personality disorder. Persons with
borderline personality have instability in their
self-image and identity and in relationships. They
may idealize others, including their surgeon and
37
treatment team, only to later turn against them,
angry that they have been betrayed, abandoned, or
let down. Borderline personality disorder is asso-
ciated with suicidal and self-mutilating behavior
and is predominantly found in females. It also
may soften over the course of adulthood [1].
Examples of borderline-type behavior are open-
ing a surgical wound as a means to “get back” at
surgeon or staff, to seek medical care to avoid
feelings of abandonment, or attempting suicide by
taking an overdose of pain medication. Patients
with borderline or antisocial personality disorder
may attempt to divide and split staff, playing one
staff member against the other and looking for
inconsistencies—for example, when one nurse
permits a behavior that another does not.
The avoidant personality, characterized with
sensitivity to criticism or disapproval and unwill-
ing to get socially involved if uncertain of being
liked [1], was the most prevalent personality dis-
order in the abovementioned sample of spinal
cord injury persons/patients [10]. Other personal-
ity disorders that may have clinical consequences
are the dependent personality, in which affected
persons may need reassurance and may not be
able to make decisions independently; the para-
noid personality, where the clinician’s actions
may be interpreted as having hidden meanings
and where trust may be difficult to establish; the
flirtatiousness and exaggerated emotionality
masking the insecurity of the histrionic personal-
ity; the grandiosity of the narcissistic personality
(also concealing insecurity); the obsessive-com-
pulsive personality with perfectionistic tenden-
cies, difficulty making decisions, and rigid rules
and routines; and the schizoid personality, lack-
ing relationships with others, and the schizotypal
personality, characterized by odd beliefs and
behaviors, and possible social anxiety [1].
Comorbid impulsivity and poor social judg-
ment were identified in spinal-injured individuals
with pressure sores and personality disorders [8].
Impulsivity and deficient judgment are factors
associated with risk-taking behaviors as is sensa-
tion seeking [11]. Sensation seeking has been
hypothesized as a personality trait composed of
four dimensions. These are seeking thrill and
adventure, seeking new and exciting experiences,
38
disinhibition—the willingness to take risks and
engage in high-risk behaviors—and susceptibility
to boredom. Sensation seekers may appraise risks,
including health risks, as lower than they actually
are [11–13]. Sensation seeking has been linked to
behavioral activation, which has been theorized to
be a component of the antisocial personality and
related to prefrontal cortex functioning [14, 15].
5.4 Substance Abuse
Personality factors are related to the use of chemi-
cal substances. Sensation seeking was found to be
associated with the use of substance in a study of
adult spinal-injured rehabilitation patients [16].
Sensation seeking also is associated with risky
health behaviors other than substance use. High
sensation seeking may be related to an overactive
mesocorticolimbic dopamine system, low levels of
monoamine oxidase activity, and altered dopamine
receptor and dopamine transporter expression and
function [17]. Antisocial behavior correlated with
substance abuse, negative emotionality, and low
behavioral constraint, while being inversely asso-
ciated with socioeconomic status and verbal abil-
ity [18]. Alcohol abuse has been associated with
high extraversion and low conscientiousness, and
cannabis abuse linked to low extraversion and high
openness to experience [19]. However, no signifi-
cant differences on personality-related dimensions
were found, using the Minnesota Multiphasic
Personality Inventory (MMPI), in a study of per-
sons with traumatic paraplegia that compared indi-
viduals with negative and positive blood alcohol
concentrations at the time of injury and which also
compared them to a non-SCI control group [20].
Substance abuse has been termed the “silent
saboteur” in rehabilitation [21]. Premorbid abuse
of illicit substances predicted increased risk of
developing pressure ulcers 30 months after SCI
[22]. In a sample of SCI individuals, 11 %
reported the use of illicit drugs or abuse of pre-
scription medications [23]. History of post-injury,
but not pre-injury, drug abuse was identified as a
factor in post-rehabilitation complications in a
sample of individuals with SCI related to firearm
or car crash injuries [24].
5 Pressure Ulcers from a Psychological Perspective
Alcohol consumption and alcohol abuse
were associated with pressure sore develop-
ment among persons with SCI [25–27]. Elliot
et al. [25] found that pre-injury history of heavy
alcohol abuse increased by 2.5 times the prob-
ability of having a pressure sore diagnosis in
the first 3 years following SCI when compared
with individuals without severe alcohol abuse
histories. They also found that alcohol abuse
history was not related to depression following
admission for SCI rehabilitation nor to accep-
tance of disability at time of discharge.
However, they questioned whether such prob-
lems may develop following community reen-
try and cited other studies [28, 29] that linked
psychological problems to prior substance use
after returning to the community. History of
cigarette smoking also is tied to pressure ulcer
development [26, 30].
Substance use can be a problem during the
long hospitalization required following muscle
flap surgery. After discharge, the mind altering
effects of substance use may result in behaviors
such as sitting in the wheelchair beyond tolerance
and forgetting to perform pressure relief raises
and skin inspections, resulting in breakdown of
the still healing wound area and/or development
of new pressure sores.
5.5 Pain
All pain is psychological in that how one experi-
ences pain is mediated by psychological pro-
cesses. These include depression, anxiety, anger,
coping, and personality. Another variable is his-
tory of substance use, which is associated with
pain tolerance such that persons with drug histo-
ries may require higher dosages of analgesics
[31, 32]. All pain complaints must be considered
“real” until proven otherwise. The “med-seeking”
patient whose complaints of pain are without a
physiological etiology and are solely to obtain
medications for recreational purposes may pres-
ent indistinguishably from the patient that seeks
pain medication for pleasure yet also has under-
lying physical pain or the patient whose requests
for pain medications are solely for relief of pain.
5.5 Pain
Welcome to the challenging world of the psy-
chology of pain!
Because persons with spinal injury may expe-
rience pain below the level of injury, complaints
of persons with pressure sores who are SCI may
be dismissed. One study found that 35 % of per-
sons with SCI had pain below the level of injury
[33]. The experience of pain may not be at the
pressure sore site; rather, there may be a sense of
undifferentiated pain. Burning pain and aching
pain are the most prevalent types of SCI pain,
with burning pain associated with frontal parts of
the torso and genitals, buttocks, and lower
extremities and aching pain correlated with the
neck, shoulders, and back [34].
For the majority of SCI individuals with pres-
sure sores below the level of injury, there may be
no sensation of pain, which perhaps is the key
reason why pressure sores deteriorate to a level
where surgery is required. Awareness of buttocks
pain is negatively related to acquiring a pressure
sore [26], and for that reason, it has been sug-
gested that persons without sensation may engage
in activities that promote wound development,
which stands in contrast to individuals with intact
sensation who restrict movement and activity as
means to reduce pain and suffering [35].
Non-spinal-injured persons with pressure
ulcers can find the experience of the sore to be
excruciating [35], with hot or burning being the
most prevalent descriptor of the pain used by
individuals with intact sensation [36]. A qualita-
tive study of elderly persons with pressure sores
found that restriction of movement would make
pain more bearable and that individuals know-
ingly would go against medical advice and mini-
mize mobility, such as not repositioning
themselves when sitting or in bed. Other findings
were that analgesics provided insufficient relief,
that sleep was interrupted due to pain, that physi-
cians inadequately recognized the severity of
pain, and that alternating pressure mattresses,
wound cleaning, and dressing changes can pro-
voke pain [35]. Even among severely demented
patients with pressure ulcers who could no longer
verbally communicate, facial expressions and
vocalizations during dressing changes clearly
indicated pain [37]. Suffering among end-stage
39
dementia patients was associated with pain and
pressure sore acquisition [38].
Chronic pain is a fact of life for the majority of
spinal cord–injured persons. In one sample of
paraplegics and tetraplegics, 81 % reported at
least one pain problem and 40 % had three or
more areas of pain; 62 % reported experiencing
high-intensity pain. Additionally, 75 % had sen-
sations that were unpleasant, but not painful [33].
Another estimate is that nearly two-thirds of all
persons with SCI live with chronic pain, with a
third of them rating their pain as severe [39], and
pain has been found to have an impact on quality
of life that exceeds the effects of the SCI itself
[40], with spinal-injured persons with low quality
of life also having reduced self-efficacy [41].
It is helpful to keep in mind that SCI pain will
be either nociceptive or neuropathic. Nociceptive
pain is the result of injury, causing nerve activa-
tion at a specific site, and includes visceral pain,
which is the result of internal organ or ligament
damage, irritation, or distention. Neuropathic
pain is injury of the nerve itself, at the level of the
spinal cord lesion, at the nerve root or the site of
a local nerve injury, and includes sympathetic
pain, in which the autonomic nervous system is
activated by a noxious stimulus. Nociceptive pain
has been reported in 15 % of persons with SCI,
with 38 % rating it as severe. Nineteen to twenty-
four percent reported neuropathic pain below the
level of injury, with 27 % perceiving it as severe
[42]. Pressure ulcer pain can represent both noci-
ceptive and neuropathic processes.
Pain catastrophizing is the tendency to mag-
nify or exaggerate the experience of pain and
often other aspects of one’s life [43]. Chronic SCI
pain has been associated with catastrophizing,
which in turn correlated with depression, help-
lessness, and anger. Lower levels of catastrophiz-
ing were related to lower pain intensity, higher
injury level, nontraumatic SCI etiology, and better
health [44]. Catastrophizing was found to be posi-
tively related to pain intensity and to higher levels
of affective distress and depressive symptoms in a
separate study of SCI and other individuals expe-
riencing wound-related pain [45].
SCI pain was associated with lower life satis-
faction [23, 46], loss of sense of control [47],
40
lower self-efficacy and power performance on
lifting and wheel-turning tasks [48], and sub-
stance abuse [23]. In a sample of SCI patients, the
presence of pain and pressure sore acquisition
was negatively related to future time orientation,
a factor also linked to depression [49] and which
involves the ability focus on future events and to
have hopes, plans, and goals.
5.6 Cognition
Cognition involves structures and processes that
are responsible for thought and perception, thus
permitting the acquisition and use of knowledge.
Cognition can be better understood by examining
the domains that constitute the mental status
examination, including level of consciousness,
orientation, attention, language, learning, mem-
ory, reasoning, judgment and insight, thoughts,
and perceptions. Impairment of one or more of
these domains can directly or indirectly play a
role in pressure sore development.
Persons with spinal injury may have undiag-
nosed brain injuries that can affect mental status.
Brain injury secondary to physical trauma, such
as motor vehicle accidents, may have been over-
looked when there is a concomitant spinal injury
[50–53]. Cognitive deficits may be present in
40–50 of persons with SCI due to closed head
injury [54], up to 60 % when other etiologies,
including substance abuse, are included [55].
Neuropsychological testing of persons with spi-
nal injury indicated deficits in attention and con-
centration, memory, and problem solving when
compared to non-SCI controls [55].
Neuropsychological testing was administered
to a sample of spinal-injured patients; over 40 %
had impairments in the areas of verbal learning,
processing speed, and motor speed [56]. Ineffective
social problem-solving abilities were found to be a
risk factor for pressure sore acquisition in a sample
of persons with recent-onset spinal cord injury
[57]. Problem-solving errors are associated with
brain injury as well as with other cognitive factors,
such as dementia and intelligence, as well as with
education, life experience, culture, and mood, anx-
iety, and personality disorders.
5 Pressure Ulcers from a Psychological Perspective
Impulsivity, associated with frontal lobe brain
injuries, impedes regulation of behavior. In patients
where there is premorbid history of high-risk
behavior, such as the use of illicit drugs and racing
cars, the addition of a brain injury may make inhi-
bition of such behaviors even more difficult!
Substance abuse, associated with pressure sore
acquisition, can change brain structures, which in
turn can affect behavior. For example, structural
MRI studies have found changes in volume and tis-
sue structure in the prefrontal cortex among alco-
hol, methamphetamine, and polysubstance abusers
that could adversely influence decision making and
increase impulsivity. Functional MRI studies
implicate cocaine and methamphetamine for
reduced activation in the prefrontal cortex.
Activation of the cingulate cortex from cocaine
affected emotional processing, and activation of the
nucleus accumbens was related to craving [58].
Methamphetamine and cocaine abusers were
found to have reduced concentrations of
N-acetylaspartate, implicated in neuronal dam-
age, according to magnetic resonance spectros-
copy. Cannabis abuse was associated with
glutamate loss in the frontal lobe and increased
levels in the basal ganglia. Positron emission
tomography studies have found that cocaine,
methylphenidate, and methamphetamine result in
surges of dopamine in the striatum, which pro-
duces feelings of euphoria; however, chronic use
can lead to reduced availability of dopamine
transporters and possibly loss of dopamine cells,
which was tied to slowed motor function and
decreased memory in methamphetamine abusers.
It has been hypothesized that persons with low
levels of dopamine receptors, whether as a result
of substance abuse or genetically, obtain less than
average amounts of dopamine-mediated pleasure
from everyday activities and are at higher risk for
substance abuse and addiction so as to feel the
euphoria that others can feel naturally [58].
5.7 Depression
Depression is a misunderstood concept. There is
major depressive disorder, and other less severe
forms of depression, all disorders, and all with
5.8 Stress and Anxiety
their own diagnostic criteria. However, feeling
depressed may not mean that there is a depressive
disorder in the same way that sneezing may not
be indicative of having a cold or influenza.
Depression was predictive of pressure ulcer
acquisition among persons with spinal injury
[59]. Nearly 28 % percent of spinal-injured indi-
viduals developed depression during the first
6 years following injury [60]. Psychological fac-
tors found to be predictive of depression in spinal
injury include helplessness and a lowered sense
of self-efficacy [61].
Among medical/surgical patients aged 65 or
older receiving physical rehabilitation following
hospitalization, it was found that depression and
acquiring a pressure sore and each were indepen-
dent factors were associated with failure to return
to a premorbid functional level [62]. In a com-
parison of patients with breast, esophageal, and
head and neck cancer, depression was signifi-
cantly more likely to occur when depression was
present than when it was absent. The depressed
cancer patients also were significantly more
likely to have fatigue, insomnia, anorexia, and
pain [63], all of which can be related to or exac-
erbated by depression.
The cognitive component of depression is asso-
ciated with sense of mortality, death ideation, and
lack of hope. It has been suggested that physical
disability is negatively associated with death anxi-
ety and to a foreshortened orientation toward the
future, which was confirmed in a sample of spinal-
injured persons that also found that the presence
of depression predicted development of pressure
sores and diminished future time orientation [49].
Another study found suicide to be two to six
times more prevalent among persons with spinal
injury than in the general population. Persons
who later committed suicide, when compared
with a matched sample of spinal-injured persons
who had not killed themselves, scored signifi-
cantly higher on measures that included shame,
hopelessness, despondency, apathy, alcohol
abuse, and destructive behavior [64]. An epide-
miological study of the deaths of spinal-injured
individuals found that, among quadriplegics and
persons aged 55 years or older, pneumonia was
the leading cause of death, with unintentional
41
injuries and suicides as the top causes of death
among paraplegics and persons no older than age
55 years [65]. In another sample, suicide led as
the cause of death among persons with complete
paraplegia and was the second leading cause of
death among individuals with incomplete para-
plegia. Gunshot wound was the most prevalent
means of committing suicide [66].
Elliot et al. [25] found that alcohol abuse his-
tory was not related to depression following
admission for SCI rehabilitation nor to accep-
tance of disability at time of discharge. However,
they question whether such problems may
develop following community reentry and cite
other studies [29, 67] that linked psychological
problems to prior substance use after returning to
the community. Spinal-injured persons who
abstained from alcohol, but once had a history of
problem drinking, were most vulnerable to
depression and had lower acceptance of disability
and greatest risk of medical complications [68].
In geriatric medicine, pressure sores constitute
a “geriatric syndrome.” A literature review of the
risk factors involved in the pressure sore geriatric
syndrome examined 13 studies. Out of the 13, 6
studies identified impaired cognition or dementia
as a risk factor. However, an additional 6 studies
included low weight or nutritional factors as risk
factors for the syndrome. Clearly, compromised
nutritional status can have a devastating effect on
cognition and makes it useful to keep in mind the
concept of the pressure sore as a syndrome, even
with non-elderly populations. Impaired cognition
also was identified as a factor in four other geriat-
ric syndromes—incontinence, falls, functional
decline, and delirium, all of which can have an
impact on pressure ulcer development [69].
Depression, which also has been conceptualized
as constituting a geriatric syndrome [70], can
exacerbate the severity of cognitive impairment.
5.8 Stress and Anxiety
Stress among SCI individuals was found not to be
related to the acquisition of pressure ulcers; how-
ever, stress correlated with depression, life satisfac-
tion, quality of life, and alcohol consumption [71].
42
However, findings from another study suggest the
possibility that stress may play a role in pressure
sore formation among elderly persons newly
admitted to a nursing facility, all free of pressure
ulcers (and without medical conditions or medica-
tions that could affect cortisol level). Serum corti-
sol levels, assayed twice weekly over a 5-week
period, were significantly higher among residents
who later developed pressure sores, with the largest
differences during the second week [72].
Posttraumatic stress disorder (PTSD) is a per-
sistent reaction to the experience of acute stress that
is beyond the realm of normal life experience and
is classified as an anxiety disorder. The acute stress
experienced or witnessed involved “actual or
threatened death or serious injury, or a threat to the
physical integrity of self or others” and a response
of “intense fear, helplessness, or horror” [1, p 463].
Presentation of PTSD includes re-experiencing of
the traumatic event in ways such as flashbacks,
dreams and nightmares, avoidance of thoughts
associated with the trauma, emotional numbing,
and autonomic arousal, including insomnia and
hypervigilance and outbursts of anger.
Kennedy and Duff [73] reviewed the literature
on PTSD among persons with spinal injuries.
They reported the findings of 13 studies in which
the prevalence of PTSD ranged from 10 to 40 %.
Recency of the trauma was not found to be a sig-
nificant predictor of PTSD diagnosis and severity,
and the disorder may take years to present. The
studies cited by them suggested that PTSD was
more prevalent with tetraplegia than with paraple-
gia and, among individuals with paraplegia, asso-
ciated with injuries below T3, possibly due to
nerve fiber impairment modulating memory of the
emotional events. Concomitant brain injury was
reported to correlate with severity of
PTSD. However, if memory impairment occurred,
the traumatic event would have had to have hap-
pened prior to the onset of retrograde amnesia or
following the remission of posttraumatic amnesia.
5.9 Social Support, Resiliency,
and Coping
Social support, including caregiving, may serve
as a “double-edged sword,” for the support sys-
tem can promote and reinforce the practice of
5 Pressure Ulcers from a Psychological Perspective
salutary behaviors or it can encourage or main-
tain behaviors that directly or indirectly affect the
acquisition of new pressure sores or increase the
severity of existing ones. Examples of negative
social support would be friends or relatives who
provide or share in the use of illicit drugs and
alcohol or caregivers who encourage dependency
by assuming responsibility for skin care that the
affected individuals are capable of providing on
their own [59, 74].
Persons with paraplegia with the capacity to
be independent in skin care, but who relied on
others, were more likely to develop pressure
ulcers than individuals with tetraplegia who
required caregivers for skin-related issues [74].
Caregivers may be well intentioned and unaware
that their level of involvement is not required.
Individuals who married prior to becoming spi-
nal injured received more personal care from
their spouses than persons who married after they
acquired an SCI [75].
Problem-solving characteristics of caregivers
of SCI patients were found to predict pressure
sores 1 year following injury, with an impulsive
and careless problem-solving style having
increased the probability of developing a pres-
sure sore by 37 %. Poor caregiver problem also
was related to decreased patient acceptance of
disability [76]. Among the aged, pressure sores
may be a consequence of elder abuse and as such
could be a sign of such abuse [77].
Patients may be seeking secondary gain by
having others provide them with care or may lack
motivation as a result of depression or learned
helplessness. Lengthy hospital stays following
pressure sore surgery may reinforce dependent
behavior [59]. Lack of or poor-quality social sup-
port may result in longer hospitalizations follow-
ing muscle flap surgery, given that an earlier
discharge date could endanger the healing pro-
cess [78].
An individual’s sense of community support
correlated with fewer, less severe, or shorter
recovery time from pressure sores [79].
Bed rest to manage a pressure sore or following
muscle flap surgery, while necessary from a medi-
cal standpoint, may adversely affect psychological
status and has been implicated in learned helpless-
ness, depression, fatigue, and perceptual change.
Recommendations to counteract the effects of sus-
5.10 Clinical Implications
tained bed rest include its restriction (as medically
feasible), outside stimulation, engaging in mean-
ingful activities, occupational therapy, and patient
involvement in decision making [80].
Although a pressure ulcer and its surgical
management may present psychological chal-
lenges, there are individuals who demonstrate
resiliency and cope well. Antonovsky [81–83]
theorized that resiliency is promoted by “salutary
factors” that offset or negate risk factors. It is the
balance of salutary to risk factors that determine
level of resiliency. Factors such as genetic endow-
ment, economic or material status, social support,
cultural stability, knowledge and intelligence,
religion or philosophy, ego identity, and person-
ality either can be salutary or pathological. A
qualitative study of the lifestyles of individuals
with spinal injury with prior pressure sore history
provided evidence that risk of developing a sub-
sequent pressure ulcer depends on the balance of
salutary “buffers” to pathological “liabilities.”
Psychological, social, and environmental factors
that could either serve as a buffer or liability
included level of motivation to avoid pressure
sores, understanding of causes and prevention of
pressure sores, problem-solving ability, planning,
financial adequacy, perceived sense of control,
risk taking, social support, and family stability
and problems [84].
Ability to cope with pressure sores among
elderly individuals tended to involve a fatalistic
acceptance of their situation or rationalizations in
which they compared themselves to others or to
other problems they had experienced, concluding
that they were not as bad off as they could be or
that things could be worse [35].
5.10 Clinical Implications
The purpose of this section is to suggest areas in
which the surgeon and treatment team might be
able to exert a positive effect on patient behavior
or, if it is not possible to change behavior, to at
least better understand how behavior could
impact medical treatment and, as such, be able to
incorporate into the pressure management pro-
gram measures that could contain or counteract
the impact of challenging patient behavior. The
43
topics in this section include the utilization of
psychologists and others trained in behavioral
health, the development of unit protocols that
address behavioral issues, and the use of behav-
ioral agreements (contracts). In addition, special
treatment issues for substance use and pain
patients are addressed.
5.10.1 Psychology Evaluation
Because of the high prevalence of psychological
conditions among persons with pressure sores, it
is recommended to include a psychologist or
other mental health personnel as part of the pres-
sure ulcer treatment team and to involve psychol-
ogy at the earliest stage possible in the treatment
process, preferably in clinic prior to admission.
For example, treatment of depression, anxiety, or
substance use disorders on an outpatient basis
prior to admission can increase the probability of
a successful hospitalization and reduce the risk of
future skin breakdown. Patients with psychosis
or severe depression or anxiety may not be able
to endure the demands of a lengthy hospitaliza-
tion without preadmission treatment with psy-
chotropic medication.
By building psychology into the clinic evalua-
tion process, not only can behavioral and emo-
tional problems be identified early; expectations
are established with the patient as to what consti-
tutes acceptable behavior. Additionally, the role
of the psychologist is normalized, seen by the
patient as a member of the treatment team, rather
than as someone who gets involved only in
response to problems.
Behavioral issues can be addressed directly or
indirectly. Direct approaches involve patient care
and may take the form of utilizing psychologists
or other mental health professionals to provide
specific treatments for psychological conditions
such as depression or addiction to pain medica-
tion or physicians, nurses, and other non-
behavioral staff learning to more effectively
communicate with patients. Indirect approaches
may take the form of psychological support to
staff who work with challenging patients and in
the design of pressure management program pol-
icies and procedures.
44
Routine neuropsychological screening of spi-
nal injury patients has the potential to identify
cognitive problems that could contribute to pres-
sure ulcer development and hinder ability to uti-
lize rehabilitation therapies. For example,
undetected memory deficits may thwart the abil-
ity to independently engage in pressure relief
practices. Had the memory impairment been
known, alternative practices could have been
arranged, such as reminding the patient to per-
form raises at designated times, employment of
an alarm wristwatch, or hiring of a caregiver.
Treatment planning after SCI should include pro-
cedures to identify cognitive deficits that may
complicate adjustment to disability and delay
acquisition of new skills. Neuropsychological
assessment also can be used to determine whether
patients have the cognitive capacity to give
informed consent.
Psychological assessment of patients can con-
tribute to the development of treatment and dis-
charge plans that take into account how patients
actually are coping with their spinal injury and
their potential for change and adjustment [85].
Psychotherapy and psychosocial interventions
have been shown to be of benefit to patients with
spinal injury in the areas of pain [47, 86, 87].
Studies demonstrate the efficacy of depression
treatment among persons with SCI [88] and with
the elderly [89–91], involving psychotherapy,
other psychosocial interventions, and/or antide-
pressant medication. A new use of psychologists
is a part of a “telerehabilitation” team that
includes an internist, registered nurse, nutrition-
ist, and physical therapist that is available for
weekly meetings with spinal-injured patients via
video links [92].
Another promising new approach involves the
use of spinal-injured laypersons or paraprofes-
sionals to deliver psychosocial services. In one
such program, the “peer mentor” is a member of
the SCI rehabilitation team, who is available to
patients, families, and staff for purposes of
encouraging, teaching, advising promoting self-
advocacy, validating feelings and concerns, and
modeling “successful living skills” [93, p 52].
Life coaches, themselves graduates of a life
coaching program, work with patients to improve
5 Pressure Ulcers from a Psychological Perspective
adjustment to SCI through training in goal setting
and self-efficacy [94].
Other innovative programs have utilized the
services of a substance abuse counselor and have
made 12-step meetings available for patients [95]
and have incorporated into the lengthy postopera-
tive hospitalization period classes that address
psychosocial and self-management concerns that
can play a role in the acquisition and exacerba-
tion of pressure sores, including stress, sexuality,
and substance abuse [96].
5.11 Unit or Program Protocols
Every pressure ulcer management unit or service
should have a protocol that addresses behavioral
health issues. The ideal protocol would incorpo-
rate policies, procedures, and existing treatment
protocols that affect or involve patient behavior.
The first goal is that the pressure sore treatment
program speaks with one voice, such that policies
and procedures do not vary from patient to
patient; the second goal is that patients are famil-
iar with the policies and procedures and know
exactly what to expect and the consequences
when they are not followed.
One of the first steps of the protocol would be
to discuss policies and procedures with patients
as early as possible prior to admission and again
as part of the admitting process, preferably by the
psychologist or social worker to assess for poten-
tial barriers or problems that could impede patient
commitment and cooperation and affect eligibil-
ity for admission. Informed consent would be
sought, and patients would be provided with a
written document containing relevant policies
and procedures. After it is clear that the patient
understands and accepts the document, he or she
would sign an agreement to follow the protocol
and abide by policies. Staff would be knowledge-
able about its contents, which would be covered
in new employee orientations and reviewed peri-
odically, possibly as part of the performance
review.
Having a signed agreement holds the patient
to a standard of accountability that can be referred
to in the event that behavioral problems later
5.14 Pain-Related Considerations
occur. Results may be mixed, especially if the
patient was deceitful in giving informed consent.
Patients with antisocial and other personality dis-
orders may attempt to personalize, for example,
accusing or blaming the member of the team who
discovers the problematic behavior. It can be
helpful to refer to the protocol and policies to
attempt to defuse patient efforts to personalize,
by pointing out that the staff member does not
make the rules, but must abide by them, just as
patients are required to do.
5.12 Behavioral Agreements
A behavioral agreement between patient and staff
can be utilized to address violations of hospital or
unit policies and also can be employed as a pre-
ventive measure, as at the time of readmission of
a patient who had been challenging in the past.
The agreement is a contract; however, the use of
that term can provoke hostile reactions in patients
for whom a contract connotes something that
unilaterally is imposed upon them.
A high-quality behavioral agreement is the
result of a joint effort between patient and staff
and involves a process of negotiation that aims to
increase patient sense of control and “buy in.”
Agreements are not meant to punish or to be
aversive; rather, the aim is to motivate change of
behavior through rewarding positive behaviors
[97]. Patients are praised and given extra attention
when they adhere to the agreement, which is the
opposite of what tends to occur, in that the
patients who act out behaviorally typically
receive an increase in staff interaction, which in
effect rewards problematic behavior and rein-
forces patient sense of control over staff [98].
Agreements always should specify realistic and
deliverable consequences; failure to do so will
undermine the effectiveness of the agreement.
5.13 Substance Abuse Issues
It is important to address substance use issues
prior to admission. Preadmission assessment
should include substance use history and poten-
45
tial for abuse during and following surgery, pref-
erably conducted by a psychologist or social
worker, who also can discuss the health and sur-
gical risks of substance use and provide counsel-
ing or refer patients for treatment prior to
admission. Referrals to traditional treatment
facilities or 12-step programs may not be feasible
due to restrictions on sitting, infection, lack of
transportation, and refusal of some treatment pro-
grams to admit medically ill patients. Other
resources are books, CDs, DVDs, home visits by
clergy, and online resources, including Internet-
based Alcoholics Anonymous meetings.
It is recommended that the preadmission
assessment include toxicology screening and that
such screens be part of the written protocol that is
clearly explained to patients at the time of the ini-
tial assessment and for which informed consent
is obtained. The protocol could include repeated
screenings during the preadmission period,
including a screen upon admission, with positive
results as grounds for cancelation of admission or
denial or postponement of surgery. The pread-
mission protocol could be followed by an admis-
sion protocol that also includes toxicology
screening; however, if such testing is conducted,
the consequences of a positive result must be well
thought out, in the event that patient may not be
medically stable for early discharge. Another
consideration is false-positive results from labo-
ratory tests that sacrifice accuracy for cost and
speed of results. It is recommended that any posi-
tive result be followed by a confirmatory screen
using a more exacting test. An additional consid-
eration is the need to factor in the period follow-
ing discontinuation of the substance in which it
(or its metabolites) may continue to be detected.
5.14 Pain-Related Considerations
Pain management is complicated when there is
history of use of psychoactive chemical sub-
stances. What makes pain management with sub-
stance abusers so vigorously challenging is that
pain medication may be sought both for treat-
ment of legitimate pain and for purposes of abuse,
a pattern not uncommon among spinal-injured
46
patients with pressure sores. Clearly, prior or cur-
rent substance abuse is not a reason to deny pre-
scribing pain medications that have psychoactive
effects that abusers seek. Rather, there is a need
to proceed with caution and to attempt to reduce
the potential for risk through a treatment plan that
incorporates measures such as a thorough initial
assessment, behavioral agreements, drug screens,
counseling, and participation in a substance treat-
ment program, adopting a harm reduction
approach toward the patient and building in peri-
odic monitoring of adherence to the treatment
plan.
5.14.1 Assessment
Assessment has many dimensions. First, in
describing pain, four properties need to be
assessed; these are intensity, or the magnitude to
which the patient hurts; affect, or the emotional
response to the experience of pain; the quality of
the pain, e.g., burning or throbbing; and location.
With the use of opioids and other medications
with potential for abuse, addiction, or tolerance,
screening for abuse potential is recommended
[99]. Recent paper and pencil screening instru-
ments have been developed for that purpose. The
Screener and Opioid Assessment for Patients
with Pain-Revised [100, 101] and the Opioid
Risk Tool [102] predict the probability for abuse.
The Current Opioid Misuse Measure [103] is
designed to monitor whether individuals already
on pain medication are exhibiting signs of abuse.
These tools supplement existing measures, such
as the CAGE [104] and Michigan Alcoholism
Screening Test [105, 106] which assess for alco-
hol abuse.
5.14.2 Behavioral Agreements
Pain management agreements have been used to
increase patient adherence to pain treatment
plans [107]. As discussed earlier, behavioral
agreements have been used in pressure manage-
ment programs for purposes other than pain man-
agement—generally to address disruptive
5 Pressure Ulcers from a Psychological Perspective
behavior issues that may occur during the lengthy
hospitalization following flap surgery.
A well-designed and executed pain manage-
ment agreement will spell out expectations and
responsibilities for both patient and provider
alike. Responsibilities typically include a com-
mitment to take medications as prescribed, to not
obtain additional prescriptions elsewhere (“doctor
shopping”), to fill prescriptions at only one phar-
macy, to not lose medications, to seek refills only
during regularly scheduled office visits, to not use
illicit drugs, to limit use of or abstain from alco-
hol, to consent to random drug screens, and, if
requested, to undergo psychological assessment
and participate in 12-step groups, counseling, or
other substance treatment program.
Consequences must be enforceable; if the pro-
vider is unwilling or unable to do so, it will give
permission to the patient that the pain manage-
ment agreement can be violated. That has been
seen in inpatient postoperative situations—for
example, where immediate discharge, the conse-
quence of the violation, would have medically
compromised the patient. To minimize such
problems and to improve “buy in,” it can be help-
ful to involve the patient in devising the agree-
ment, including the identification of
consequences, especially with patients who find
it difficult to abide by rules. Otherwise, the use of
standardized pain management agreements may
suffice.
It obviously is necessary that the agreement be
clearly comprehended and legible. A “low-
literacy” pain agreement has been developed and
validated that is written at a seventh-grade read-
ing level, uses large fonts, and contains illustra-
tions [108]. Outcome data on the effectiveness of
using agreements with pain patients is sparse. In
a retrospective study of 330 chronic pain clinic
patients on opioids, over 60 % adhered to the
agreement, 20 % voluntarily discontinued opioid
treatment, and only 17 % had positive toxicology
screens or abused the prescribed medications.
Male gender and younger age were associated
with probability of violation of the agreement
[109].
Some patients may perceive a pain manage-
ment agreement as akin to a set of rules imposed
5.15 Other Psychological Considerations
on them and compare it to being in jail or in the
military, which can provoke resentment, espe-
cially if there is history of incarceration or diffi-
culty adhering to rules, as with antisocial
personality disorder. For that reason, as discussed
previously, the gentler term agreement is pre-
ferred to contract, as it is less likely to convey
that it is something imposed on the patient.
Harm reduction, as a practice used in sub-
stance abuse treatment, is focused on changing
harmful behaviors while being nonjudgmental,
non-confrontational, and respectful of the per-
son. It recognizes that substance abstinence may
not be possible, at least initially, and that efforts
may be better spent on ways to minimize
substance-related risks or harm. It strives toward
personal responsibility and self-management
such that the user is the primary agent for reduc-
tion of the harms of drug use [110–114]. A
harm-reduction approach has been trialed on a
small scale with spinal-injured patients with
successful results [95].
5.14.3 Harm Reduction
From a pain management perspective, when
there is no history of substance abuse, harm
reduction offers potential for patients to learn to
be vigilant toward the use of medications with
risk of addiction and tolerance and to learn
alternate strategies to handle pain control, such
as relaxation, exercise, distraction, and medita-
tion. On the other hand, pain may make it diffi-
cult for patients to be attentive to learning about
harm reduction. In such situations, it may make
sense to introduce later, once the pain is under
control. For persons who abuse substances and
who report they are experiencing pain, a harm
reduction approach would attempt to abstain
from or reduce use of non-prescribed psychoac-
tive substances, whether licit or illicit, while
using pain medications and to take the medica-
tions as prescribed. Harm reduction clearly
requires a “buy in” from the patient. If that is
not possible, a more directive approach initially
may be required, with harm reduction as the
goal once immediate pain is under control.
47
5.15 Other Psychological
Considerations
5.15.1 Limiting “High-Maintenance”
Admissions
If it is decided to admit patients assessed as being
at high risk, it is strongly recommended that there
be limits on the number of such patients hospital-
ized at any given time. Antisocial personality and
other challenging patients can require a high
level of staff attention, tying up availability of
care for remaining patients. Nursing staff often
will bear the brunt of the behaviors of difficult
patients, affecting morale and contributing to
burnout [115].
5.15.2 Team Meetings
It can be helpful to convene meetings of all staff
involved in the care of a challenging patient.
Such meetings can promote team unity and
reduce the sense of being unsupported and alone.
They are a time to review policy and discuss
strategy for working with the patient. Given that
persons with antisocial and borderline personali-
ties may try to split staff, such meetings can do
much to increase the likelihood that all team
members speak with one voice. Meetings also
can provide an opportunity to vent emotions,
which can reduce tensions but also increase them
if venting becomes the primary activity and there
is a lack of strategy or resolution. Facilitation of
the meeting by a psychologist or social worker is
recommended to keep the meeting focused and to
better address behavioral issues.
5.15.3 Communication
Patients may be more likely to be challenging if
they perceive that physicians or other team mem-
bers do not care, do not take the time to listen, or
are arrogant or disrespectful. Patient-centered
communication can improve patient trust and
involvement [116]. It encompasses being focused
on patient needs, values and expectations, collab-
48
orative decision making, and attending to the
psychosocial context [117, 118].
Conclusion
It is easy to “blame the patient and otherwise
punish him or her for being ‘bad or irrespon-
sible’ because he or she developed a pressure
ulcer” [119, p 60]. It is hoped that the psycho-
logical factors associated with the acquisition,
exacerbation, and treatment of pressure ulcers
that have been presented in this chapter will
facilitate the surgeon’s ability to make
informed decisions and to provide compas-
sionate care.
References
1. American Psychiatric Association (2000) Diagnostic
and statistical manual of mental disorders: DSM-
IV-TR, 4th edn, text revision ed. American
Psychiatric Association, Washington, DC
2. Widiger TA, Trull TJ (2007) Plate tectonics in the
classification of personality disorder: shifting to a
dimensional model. Am Psychol 62(2):71–83
3. Mineka S, Watson D, Clark LA (1998) Comorbidity
of anxiety and unipolar mood disorders. Annu Rev
Psychol 49:377–412
4. Blashfield RK, Intoccia V (2000) Growth of the lit-
erature on the topic of personality disorders. Am J
Psychiatry 157(3):472
5. O’Connor BP, Dyce JA, Hersen M, Van Hasselt VB
(2001) Personality disorders. Advanced abnormal
psychology, 2nd edn. Kluwer Academic Publishers,
Dordrecht, pp 399–417
6. Torgersen S, Battaglia M (1999) Genetics of person-
ality disorders. In: Derksen J, Maffei C, Groen H
(eds) Treatment of personality disorders. Kluwer
Academic Publishers, Dordrecht, pp 1–15
7. Dersh J, Gatchel RJ, Mayer T, Polatin P, Temple OR
(2006) Prevalence of psychiatric disorders in patients
with chronic disabling occupational spinal disorders.
Spine 31(10):1156–1162
8. Temple RO, Elliott TR (2000) Personality disorder
characteristics and adjustment following spinal cord
injury. Top Spinal Cord Inj Rehabil 6(1):54–65
9. Correa GI, Fuentes M, Gonzalez X, Cumsille F,
Pineros JL, Finkelstein J (2006) Predictive factors
for pressure ulcers in the ambulatory stage of spinal
cord injury patients. Spinal Cord 44(12):734–739
10. Bockian NR, Lee A, Fidanque CS (2003) Personality
disorders and spinal cord injury: a pilot study. J Clin
Psychol Med Settings 10(4):307–313
5 Pressure Ulcers from a Psychological Perspective
11. Zuckerman M (2007) Sensation seeking and risky
behavior. American Psychological Association,
Washington, DC
12. Zuckerman M (1979) Sensation seeking: beyond the
optimal level of arousal. L Erlbaum Associates,
Hillsdale
13. Zuckerman M, Kolin EA, Price L, Zoob I (1964)
Development of a sensation-seeking scale. J Consult
Psychol 28(6):477–482
14. Gray JR, Burgess GC (2004) Personality differences
in cognitive control? BAS, processing efficiency,
and the prefrontal cortex. J Res Pers 38(1):35–36
15. Uzieblo K, Verschuere B, Crombez G (2007) The
psychopathic personality inventory: construct valid-
ity of the two-factor structure. Pers Individual
Differences 43(4):657–667
16. Alston RJ (1994) Sensation seeking as a psychologi-
cal trait of drug abuse among persons with spinal
cord injury. Rehabil Couns Bull 38(2):154–163
17. Bardo MT, Williams Y, Dwoskin LP, Moynahan SE,
Perry IB, Martin CA (2007) The sensation seeking
trait and substance use: research findings and clini-
cal implications. Curr Psychiatry Rev 3(1):3–13
18. Benning SD, Patrick CJ, Hicks BM, Blonigen DM,
Krueger RF (2003) Factor structure of the psycho-
pathic personality inventory: validity and impli-
cations for clinical assessment. Psychol Assess
15(3):340–350
19. Flory K, Lynam D, Milich R, Leukefeld C, Clayton
R (2002) The relations among personality, symp-
toms of alcohol and marijuana abuse, and symp-
toms of comorbid psychopathology: results from
a community sample. Exp Clin Psychopharmacol
10(4):425–434
20. Rohe DE, Basford JR (1989) Traumatic spinal cord
injury, alcohol, and the Minnesota Multiphasic
Personality Inventory. Rehabil Psychol 34(1):25–32
21. Pires M (1989) Substance abuse. The silent saboteur
in rehabilitation. Nurs Clin North Am 24(1):291–296
22. Hawkins DA, Heinemann AW (1998) Substance
abuse and medical complications following spinal
cord injury. Rehabil Psychol 43(3):219–231
23. Tate DG, Forchheimer MB, Krause JS, Meade MA,
Bombardier CH (2004) Patterns of alcohol and sub-
stance use and abuse in persons with spinal cord
injury: risk factors and correlates. Arch Phys Med
Rehabil 85(11):1837–1847
24. Waters RL, Adkins RH, Sie I, Cressy J (1998)
Postrehabilitation outcomes after spinal cord injury
caused by firearms and motor vehicle crash among
ethnically diverse groups. Arch Phys Med Rehabil
79(10):1237–1243
25. Elliot TR, Kurylo M, Chen Y, Hicken B (2002)
Alcohol abuse history and adjustment following spi-
nal cord injury. Rehabil Psychol 47(3):278–290
26. Jones ML, Marini I, Slate JR (2005) Prevention
practice differences among persons with spinal cord
injuries who rarely versus frequently sustain pres-
sure ulcers. Rehabil Couns Bull 48(3):139–145
References
27. Schryvers OI, Stranc MF, Nance PW (2000) Surgical
treatment of pressure ulcers: 20-year experience.
Arch Phys Med Rehabil 81(12):1556–1562
28. Kennedy P, Lowe R, Grey N, Short E (1995)
Traumatic spinal cord injury and psychological
impact: a cross-sectional analysis of coping strate-
gies. Br J Clin Psychol 34(4):627–639
29. Young ME, Rintala DH, Rossi CD, Hart KA, Fuhrer
MJ (1995) Alcohol and marijuana use in a
community-based sample of persons with spinal
cord injury. Arch Phys Med Rehabil 76(6):525–532
30. Krause JS, Vines CL, Farley TL, Sniezek J, Coker
J (2001) An exploratory study of pressure ulcers
after spinal cord injury: relationship to protective
behaviors and risk factors. Arch Phys Med Rehabil
82(1):107–113
31. White JM, Hay JL, Miller PM, Kavanagh D (2007)
Opioids, pain and addiction: cause and consequence.
In: Miller PM, Kavanagh D (eds) Translation of
addictions science into practice. Elsevier Science,
New York, pp 39–55
32. Ziegler PP (2005) Addiction and the treatment of
pain. Subst Use Misuse 40(13):1945–1954
33. Turner JA, Cardenas DD (1999) Chronic pain prob-
lems in individuals with spinal cord injuries. Semin
Clin Neuropsychiatry 4(3):186–194
34. Widerström-Noga EG, Felipe-Cuervo E, Yezierski
RP (2001) Relationships among clinical characteris-
tics of chronic pain after spinal cord injury. Arch
Phys Med Rehabil 82(9):1191–1197
35. Hopkins A, Dealey C, Bale S, Defloor T, Worboys F
(2006) Patient stories of living with a pressure ulcer.
J Adv Nurs 56(4):345–353
36. Günes UY (2008) A descriptive study of pressure
ulcer pain. Ostomy Wound Manage 54(2):56–61
37. Manfredi PL, Breuer B, Meier DE, Libow L (2003)
Pain assessment in elderly patients with severe
dementia. J Pain Symptom Manage 25(1):48
38. Aminoff BZ, Adunsky A (2005) Dying dementia
patients: too much suffering, too little palliation. Am
J Hosp Palliat Med 22(5):344–348
39. Siddall PJ, Loeser JD (2001) Pain following spinal
cord injury. Spinal Cord 39(2):63
40. Westgren N, Levi R (1998) Quality of life and trau-
matic spinal cord injury. Arch Phys Med Rehabil
79(11):1433–1439
41. Middleton J, Tran Y, Craig A (2007) Relationship
between quality of life and self-efficacy in persons
with spinal cord injuries. Arch Phys Med Rehabil
88(12):1643–1648
42. Chiodo AE, Scelza WM, Kirshblum SC, Wuermser
L-A, Ho CH, Priebe MM (2007) Spinal cord injury
medicine. 5. Long-term medical issues and health
maintenance. Arch Phys Med Rehabil 88(3 Suppl
1):S76–S83
43. Drahovzal DN, Stewart SH, Sullivan MJL (2006)
Tendency to catastrophize somatic sensations: pain
catastrophizing and anxiety sensitivity in predicting
headache. Cogn Behav Ther 35(4):226–235
49
44. Wollaars MM, Post MWM, van Asbeck FWA, Brand
N (2007) Spinal cord injury pain: the influence of
psychologic factors and impact on quality of life.
Clin J Pain 23(5):383–391
45. Roth RS, Lowery JC, Hamill JB (2004) Assessing
persistent pain and its relation to affective distress,
depressive symptoms, and pain catastrophizing in
patients with chronic wounds: a pilot study. Am J
Phys Med Rehabil 83(11):827–834
46. Budh CN, Österåker A-L (2007) Life satisfaction in
individuals with a spinal cord injury and pain. Clin
Rehabil 21(1):89–96
47. Mathew KM, Ravichandran G, May K, Morsley K
(2001) The biopsychosocial model and spinal cord
injury. Spinal Cord 39(12):644
48. Rudy TE, Lieber SJ, Boston JR, Gourley LM, Baysal
E (2003) Psychosocial predictors of physical perfor-
mance in disabled individuals with chronic pain.
Clin J Pain 19(1):18–30
49. Martz E, Livneh H (2003) Death anxiety as a
predictor of future time orientation among indi-
viduals with spinal cord injuries. Disabil Rehabil
25(18):1024–1032
50. Buchanan KM, Elias LJ (2001) Psychological dis-
tress and family burden following spinal cord injury:
concurrent traumatic brain injury cannot be over-
looked. Axone 22(3):16–17
51. Povolny MA, Kaplan SP (1993) Traumatic brain
injury occurring with spinal cord injury: significance
for rehabilitation. J Rehabil 59(2):23
52. Richards JS, Brown L, Hagglund K, Bua G, Reeder
K (1988) Spinal cord injury and concomitant trau-
matic brain injury. Results of a longitudinal investi-
gation. Am J Phys Med Rehabil 67(5):211–216
53. Richards JS, Osuna FJ, Jaworski TM, Novack TA,
Leli DA, Boll TJ (1991) The effectiveness of dif-
ferent methods of defining traumatic brain injury
in predicting postdischarge adjustment in a spinal
cord injury population. Arch Phys Med Rehabil
72(5):275–279
54. Davidoff G, Doljanac R, Berent S et al (1988)
Galveston Orientation and Amnesia Test: its utility
in the determination of closed head injury in acute
spinal cord injury patients. Arch Phys Med Rehabil
69(6):432–434
55. Roth E, Davidoff G, Thomas P et al (1989) A con-
trolled study of neuropsychological deficits in acute
spinal cord injury patients. Paraplegia 27(6):480–489
56. Hess DW, Marwitz JH, Kreutzer JS (2003)
Neuropsychological impairments after spinal cord
injury: a comparative study with mild traumatic
brain injury. Rehabil Psychol 48(3):151–156
57. Elliott TR, Bush BA, Chen Y (2006) Social problem-
solving abilities predict pressure sore occurrence in
the first 3 years of spinal cord injury. Rehabil Psychol
51(1):69–77
58. Fowler JS, Volkow ND, Kassed CA, Chang L (2007)
Imaging the addicted human brain. Sci Pract
Perspect 3(2):4–16
50
59. Herrick SM, Elliott TR, Crow F (1994) Social sup-
port and the prediction of health complications
among persons with spinal cord injuries. Rehabil
Psychol 39(4):231–250
60. Dryden DM, Saunders LD, Rowe BH et al (2004)
Utilization of health services following spinal cord
injury: a 6-year follow-up study. Spinal Cord
42(9):513–525
61. Shnek ZM, Foley FW, LaRocca NG et al (1997)
Helplessness, self-efficacy, cognitive distortions,
and depression in multiple sclerosis and spinal cord
injury. Ann Behav Med 19(3):287–294
62. Johnson MF, Kramer AM, Lin MK, Kowalsky JC,
Steiner JF (2000) Outcomes of older persons receiv-
ing rehabilitation for medical and surgical condi-
tions compared with hip fracture and stroke. J Am
Geriatr Soc 48(11):1389–1397
63. Chen M-L, Chang H-K (2004) Physical symptom
profiles of depressed and nondepressed patients with
cancer. Palliat Med 18(8):712–718
64. Charlifue SW, Gerhart KA (1991) Behavioral
and demographic predictors of suicide after trau-
matic spinal cord injury. Arch Phys Med Rehabil
72(7):488–492
65. DeVivo MJ, Kartus PL, Stover SL, Rutt RD, Fine PR
(1989) Cause of death for patients with spinal cord
injuries. Arch Intern Med 149(8):1761–1766
66. DeVivo MJ, Black KJ, Richards JS, Stover SL
(1991) Suicide following spinal cord injury.
Paraplegia 29(9):620–627
67. Kennedy P, Marsh N, Lowe R, Grey N, Short E,
Rogers B (2000) A longitudinal analysis of psycho-
logical impact and coping strategies following spinal
cord injury. Br J Health Psychol 5(Part 2):157–172
[serial online]
68. Heinemann AW, Hawkins D (1995) Substance abuse
and medical complications following spinal cord
injury. Rehabil Psychol 40(2):125–140
69. Eachempati SR, Hydo LJ, Barie PS (2001) Factors
influencing the development of decubitus ulcers
in critically ill surgical patients. Crit Care Med
29(9):1678–1682
70. Kennedy GJ (1995) The geriatric syndrome of late-
life depression. Psychiatr Serv 46(1):43–48
71. Gerhart KA, Weitzenkamp DA, Kennedy P, Glass
CA, Charlifue SW (1999) Correlates of stress in
long-term spinal cord injury. Spinal Cord 37(3):183
72. Braden BJ (1998) The relationship between stress
and pressure sore formation. Ostomy Wound
Manage 44(3A Suppl):26S–36S
73. Kennedy P, Duff J (2001) Post traumatic stress disor-
der and spinal cord injuries. Spinal Cord 39(1):1
74. Anderson TP, Andberg MM (1979) Psychosocial
factors associated with pressure sores. Arch Phys
Med Rehabil 60(8):341–346
75. Crewe NM, Athelstan GT, Krumberger J (1979)
Spinal cord injury: a comparison of preinjury and
postinjury marriages. Arch Phys Med Rehabil 60(6):
252–256
5 Pressure Ulcers from a Psychological Perspective
76. Elliott TR, Shewchuk RM, Richards JS (1999)
Caregiver social problem-solving abilities and fam-
ily member adjustment to recent-onset physical dis-
ability. Rehabil Psychol 44(1):104–123
77. Cooper C, Katona C, Finne-Soveri H, Topinkova E,
Carpenter GI, Livingston G (2006) Indicators of
elder abuse: a crossnational comparison of psychiat-
ric morbidity and other determinants in the Ad-HOC
study. Am J Geriatr Psychiatry 14(6):489–497
78. Guihan M, Goldstein B, Smith BM, Schwartz A,
Manheim LM (2003) SCI health care provider atti-
tudes about pressure ulcer management. J Spinal
Cord Med 26(2):129–134
79. Anson CA, Stanwyck DJ, Krause JS (1993) Social
support and health status in spinal cord injury.
Paraplegia 31(10):632–638
80. Norton L, Sibbald RG (2004) Is bed rest an effective
treatment modality for pressure ulcers? Ostomy
Wound Manage 50(10):40
81. Antonovsky A (1979) Health, stress, and coping.
Jossey-Bass, San Francisco
82. Antonovsky A (1987) Unraveling the mystery of
health: how people manage stress and stay well.
Jossey-Bass, San Francisco
83. Antonovsky A, Ornstein RE, Swencionis C (1990)
The salutogenic model of health. The healing brain:
a scientific reader. Guilford Press, New York,
pp 231–243
84. Clark FA, Jackson JM, Scott MD et al (2006) Data-
based models of how pressure ulcers develop in
daily-living contexts of adults with spinal cord
injury. Arch Phys Med Rehabil 87(11):1516–1525
85. Alden P (1992) Psychological aspects of spinal cord
injury. Educ Child Psychol 9(1):34–48
86. Grzesiak RC (1977) Relaxation techniques in treat-
ment of chronic pain. Arch Phys Med Rehabil 58(6):
270–272
87. Umlauf RL (1992) Psychological interventions for
chronic pain following spinal cord injury. Clin J Pain
8(2):111–118
88. Kemp BJ, Kahan JS, Krause JS, Adkins RH, Nava G
(2004) Treatment of major depression in individuals
with spinal cord injury. J Spinal Cord Med 27(1):
22–28
89. Cole MG, Elie LM, McCusker J, Bellavance F,
Mansour A (2001) Feasibility and effectiveness of
treatments for post-stroke depression in elderly inpa-
tients: systematic review. J Geriatr Psychiatry Neurol
14(1):37–41
90. Draper BM (2000) The effectiveness of the treat-
ment of depression in the physically ill elderly.
Aging Ment Health 4(1):9–20
91. McFarland K (2005) Battling late-life depression:
short term psychotherapy for depression in older
adults–a review of evidence-based studies since
2000. Ann Am Psychother Assn 8(4):20–27
92. Galea M, Tumminia J, Garback LM (2006)
Telerehabilitation in spinal cord injury persons: a
novel approach. Telemed J E Health 12(2):160–162
References
93. Young JM, Lawrence W, Quick P (1999) A unique
role: the peer mentor on the spinal cord team at
G.F. Strong Rehab Centre. Healthc Manage Forum
12(3):51–53
94. Thompson G, Tanberg BJ, Requejo PS, Scott M
(2008) Effects of a structured life coaching program
on the quality of life of participants with SCI. Paper
presented at: American Spinal Injury Association,
San Diego, June 2008
95. Young JM, Fish WW, Browne A, Lawrie RS
(2002) Using a harm reduction approach with cli-
ents who have alcohol/drug dependencies in a spi-
nal cord rehabilitation program. J Spinal Cord Med
25(2):81–87
96. LaMantia JG, Hirschwald JF, Goodman CL, Wooden
VM, Delisser O, Staas WE Jr (1987) A program
design to reduce chronic readmissions for pressure
sores. Rehabil Nurs 12(1):22
97. Cupples SA, Steslow B (2001) Use of behavioral
contingency contracting with heart transplant candi-
dates. Prog Transplant 11(2):137–144
98. Gorski JA, Slifer KJ, Townsend V, Kelly-Suttka J,
Amari A (2005) Behavioural treatment of non-
compliance in adolescents with newly acquired spi-
nal cord injuries. Pediatr Rehabil 8(3):187–198
99. Kornbluth ID, Freedman MK, Holding MY, Overton
EA, Saulino MF (2008) Interventions in chronic
pain management. 4. Monitoring progress and com-
pliance in chronic pain management. Arch Phys
Med Rehabil 89(3 Suppl 1):S51–S55
100. Butler SF, Fernandez K, Benoit C, Budman SH,
Jamison RN (2008) Validation of the revised
Screener and Opioid Assessment for Patients with
Pain (SOAPP-R). J Pain 9(4):360–372
101. Butler SF, Budman SH, Fernandez K, Jamison RN
(2004) Validation of a screener and opioid assess-
ment measure for patients with chronic pain. Pain
112(1):65–75
102. Webster LR, Webster RM (2005) Predicting aber-
rant behaviors in opioid-treated patients: prelimi-
nary validation of the Opioid Risk Tool. Pain Med
6(6):432–442
103. Butler SF, Budman SH, Fernandez KC et al (2007)
Development and validation of the Current Opioid
Misuse Measure. Pain 130(1):144–156
104. Mayfield D, McLeod G, Hall P (1974) The CAGE
questionnaire: validation of a new alcoholism
screening instrument. Am J Psychiatry 131(10):
1121–1123
51
105. Selzer ML (1971) The Michigan Alcoholism
Screening Test: the quest for a new diagnostic instru-
ment. Am J Psychiatry 127(12):1653–1658
106. Shields AL, Howell RT, Potter JS, Weiss RD (2007)
The Michigan Alcoholism Screening Test and its
shortened form: a meta-analytic inquiry into score
reliability. Subst Use Misuse 42(11):1783–1800
107. Donovan MI, Evers K, Jacobs P, Mandleblatt S (1999)
When there is no benchmark: designing a primary care-
based chronic pain management program from the sci-
entific basis up. J Pain Symptom Manage 18(1):38–48
108. Wallace LS, Keenum AJ, Roskos SE, McDaniel KS
(2007) Development and validation of a low-literacy
opioid contract. J Pain 8(10):759–766
109. Hariharan J, Lamb GC, Neuner JM (2007) Long-
term opioid contract use for chronic pain manage-
ment in primary care practice. A five year experience.
J Gen Intern Med 22(4):485–490
110. Futterman R, Lorente M, Silverman SW (2005)
Beyond harm reduction: a new model of substance
abuse treatment further integrating psychological
techniques. J Psychother Integration 15(1):3–18
111. Little J (2006) Harm reduction therapy groups:
engaging drinkers and drug users in a process of
change. J Groups Addict Recovery 1(1):69–93
112. MacCoun RJ (1998) Toward a psychology of harm
reduction. Am Psychol 53(11):1199
113. MacCoun RJ (1999) What harm reduction is and
isn’t. Am Psychol 54(10):843
114. Marlatt GA (1998) Basic principles and strategies of
harm reduction. In: Marlatt GA (ed) Harm reduc-
tion: pragmatic strategies for managing high-risk
behaviors. Guilford Press, New York, pp 49–66
115. Duff E, Redhead A, Paxton R, Iceton J, Rochester J
(2006) Challenging behaviour in Mental Health
Services: combining psychological perspectives. J
Ment Health 15(4):475–490
116. Kindler CH, Szirt L, Sommer D, Häusler R,
Langewitz W (2005) A quantitative analysis of
anaesthetist-patient communication during the pre-
operative visit. Anaesthesia 60(1):53–59
117. Epstein RM, Franks P, Shields CG et al (2005)
Patient-centered communication and diagnostic test-
ing. Ann Fam Med 3(5):415–421
118. Epstein RM, Mauksch L, Carroll J, Jaén CR (2008)
Have you really addressed your patient’s concerns?
Fam Pract Manag 15(3):35–40
119. Maynard FM (1996) Ethical issues in pressure ulcer
management. Top Spinal Cord Inj Rehabil 2(1):57–63
 Comprehensive Preoperative
Management of Patients
with Pressure Ulcer
Salah Rubayi
6.1 Wound Preparation and
Local Wound Care
When a pressure ulcer is diagnosed as stage IV or
III and there is an indication for surgery in clini-
cal practice, the ulcer(s) should be given an
opportunity to respond to local wound treatment.
The average time is 4 weeks before a surgical
decision for closure, providing that all other
requirements for wound healing are met. Initially,
the clinical appearance of the ulcer should be
evaluated and then a plan set for local wound care
to prepare the wound for surgical closure.
Clinically, the wound should be as clean as pos-
sible before surgical closure, with a low level of
bacterial colonization (less than 105) and no
necrotic tissue, sign of infection, or purulent dis-
charge present at the time of surgery.
6.1.1 Debridement
When necrotic tissue or eschar is present, sharp
debridement is recommended in the outpatient or
inpatient setting. It is important in insensate
S. Rubayi, MB, ChB, LRCP, LRCS, MD, FACS,
Department of Surgery, Rancho Los Amigos
National Rehabilitation Center, Downey, CA, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_6, © Springer-Verlag Berlin Heidelberg 2015
6
patients to establish that the patient is not on anti-
coagulation medication in order to avoid bleed-
ing. Surgical debridement in the operating room
is indicated for the sensate patient or for exten-
sive necrosis, which can lead to necrotizing fasci-
itis in some cases. The enzymatic debridement
method should be used in special circumstances
when a patient is sensate or insensate on antico-
agulation. This is accomplished by use of differ-
ent types of enzymatic creams, with either
proteolytic or collagenolytic action. The enzy-
matic method of debridement is slow and may
take weeks to achieve results. However, the goal
of debridement is removal of necrotic tissue,
which eventually reduces bacterial colonization
and, consequently, the risk of septicemia [1–3].
Ultimately, debridement promotes healing and
prepares the wound for surgical closure.
6.1.2 Local Wound Management
It is important to keep the ulcer clean and covered
to achieve the maximum goals of healing. There
are a few basic principles in choosing the type of
local wound application that depend on the fol-
lowing factors:
• Clinical status of the ulcer
• Ability of the patient, caregiver, or home nurse
to apply treatment
• Patient location, either at home or in a nursing
facility
• Cost of the treatment
53
54 6 Comprehensive Preoperative Management of Patients with Pressure Ulcer
• Effectiveness of the treatment
• Side effects of or local reactions to the
treatment
There are hundreds of commercial medica-
tions and materials in the market that are recom-
mended for treatment of pressure ulcers. They
can be expensive, as pressure ulcers are viewed
as chronic wounds and may take a long period of
time to heal. Some of these medications are
widely used in nursing homes or by visiting
nurses when specialist physicians are not avail-
able to see a patient on a regular basis. These
medications have advantages and disadvantages
and clinicians should consider the previously
mentioned factors when prescribing these dress-
ings, with consideration to the progress of the
ulcer and patient discomfort and pain with these
dressings. A comprehensive discussion of these
commercial products is beyond the scope of this
book.
The author’s clinical experience of more than
30 years in local management of pressure ulcers
is with a few products, chosen based on clinical
results, used to clean and promote healing of the
wounds. These products are silver sulfadiazine
1 % cream (Silvadene® cream), used in many
clinical ulcers showing unhealthy granulation tis-
sue when the color is pale yellow–grayish and
also when the wound has some necrotic tissue
and slough. The wound should first be cleaned
and irrigated with 0.9 % normal saline solution;
silver sulfadiazine cream is then applied as a
spread over a piece of gauze in a thickness 1/8 of
inch. This dressing should be repeated two or
three times daily. The appearance of the wound
when applying Silvadene® cream resembles a
purulent discharge, however, after cleaning with
normal saline, the wound will show a layer of
healthy red granulation tissue at its base.
Silvadene® cream should not be used for the
entire extent of the wound care because it stimu-
lates excessive granulation tissue formation, that
is, hypertrophic granulation tissue. This is not a
healthy wound status and may cause bleeding of
the wound during cleaning; it also prevents con-
traction of the wound. In this event, the dressing
should be changed to 0.9 % physiologic normal
saline dressing three times per day.
If the ulcer is a deep cavity, Silvadene® cream
can be used by spreading the cream on both sur-
faces of a Kerlix® (coarse roll gauze) and pack-
ing the cavity. Another type of local dressing
used in deep cavity ulcers when the appearance
of the wound is somewhat clinically clean and
granulating is Dakins 0.25 % solution, which is a
sodium hypochlorite solution. Kerlix® soaked in
this solution should be packed in the ulcer cavity.
Dakins has antibacterial activity that also relieves
foul odor in a wound. A wound should always be
lightly packed as tight packing prevents and adds
pressure on newly developed granulating tissue
[4]. When wounds appear flat with granulating
tissue, a physiologic dressing of 0.9 % normal
saline solution is recommended and should be
changed at least three times per day. The disad-
vantage of this type of dressing is that it may
become dry and act as a dry dressing, which does
not help the wound’s physiology. In this case, the
wound requires a moist environment. If there are
any elements of discharge or wound infection,
then this type of dressing does not aid wound
healing. To prevent drying of the normal saline
dressing, we adapted a method by placing a piece
of Xeroform® (impregnated gauze with Vaseline
ointment and mild antiseptic) to cover the saline
dressing. In a commercial product called
Carragauze® (Carrington Laboratories), the
composition of the gauze is normal saline in a
gel, which keeps the dressing moist for a longer
period of time and only needs to be changed once
a day. One other important point is, when a
patient is on a specialty bed such as an air-
fluidized bed, the temperature of the blowing air
into the glass sand beads is about 86−90°F. This
warm air rapidly dries the moist dressing; thus,
normal saline dressings or Dakins are not advis-
able in this situation.
6.1.3 Negative Pressure Wound
Therapy
Negative pressure wound therapy, the application
of negative pressure to a wound, is used to treat
pressure ulcers when indicated. The most com-
monly used type is the VAC® by KCI, in which
6.2 Nutritional Assessment
an open cell polyurethane sponge is applied to
the wound after being formed to take the shape of
the wound or the cavity. Suction is applied to the
surface of the sponge after it has been covered
with an adhesive drape to create an airtight seal.
The power of the suction can be adjusted for
intensity or frequency. The most common setting
is 125 mmHg of negative pressure. The VAC
heals and cleans the wound by removing the
interstitial fluid that is high in cytokines and col-
lagenase, which are well known to inhibit the
development of fibroblast and proliferation [5, 6].
Study results of the wound VAC showed
increased granulation tissue formation and a
decrease in bacterial colonization. Improvement
in wound healing and better quality of soft tissue
changes were also reported [7, 8]. The limitations
of the wound VAC are the restriction of patient
mobility, patient activity, and excessive noise
from the pump. Sensate patients experience some
pain with application of the pump. It is some-
times difficult to seal the area because of the ana-
tomical location of the wound.
There are a few technical problems that may
be encountered when dealing with local wound
treatment for pressure ulcers with special wound
dressings. One is maceration of the local skin
surrounding the ulcer, either from the wound
exudation or reaction of the skin to the dressing
substance. This problem can be prevented by
using a special cream to protect the skin or isolat-
ing the skin with a dressing such as a hydrocol-
loid dressing (DuoDERM®). Another problem is
development of epidermal damage to fragile skin
secondary to adhesive tapes. This may cause
stage II ulcers. To avoid this damage, the dressing
can be sealed with transparent film, such as
Opsite® or Tegaderm®, or by use of a hypoal-
lergenic tape that is kind to the skin. Finally, it is
critical to keep the ulcer dressing intact when the
patient moves or transfers, especially in the peri-
neal area close to the anus, to prevent stool from
contaminating the wound. The author strongly
believes that difficult circumstances that may
impact the progress of the wound healing should
be discussed with the patient, including the risks
involved, and that a temporary diverting colos-
tomy be considered to avoid complications.
55
6.2 Nutritional Assessment
As a principle in surgery, any patient with wounds
should be assessed nutritionally by ordering lab-
oratory tests and an interview and evaluation by a
dietician. A nutritional plan is an important ele-
ment when dealing with wound healing or post-
surgical wounds. Clinically, we observe generally
that most patients with pressure ulcers have poor
nutritional values. This is manifested by weight
loss and poor appetite related to experiencing
open wounds for long periods of time and sepsis.
Therefore, it is important for the surgeon and the
team to recognize the patient’s condition before
surgical intervention and to investigate and
improve the patient’s nutritional status.
There are many studies showing that malnutri-
tion is a risk factor for pressure ulcer develop-
ment and that the stages of the ulcer are related to
the severity of the malnutrition [8–17]. Several
factors should be considered when a patient is
evaluated for nutritional status, including the age
of the patient, gender, hydration, physiologic
stress, injury, infection, and recent illnesses. The
comprehensive nutritional assessment of the
patient should include the following:
• Dietary intake
• Anthropometric measurement
• Biochemical parameters
6.2.1 Dietary Intake
After a full history and interview of the patient by
the dietitian and the physician, factors that inter-
fere with adequate food intake should be investi-
gated and taken into consideration. These include
poor appetite, food intolerance, allergies, and dif-
ficulty in chewing and swallowing, which is prev-
alent in high tetraplegia and advanced
neurological disease patients. Speech patholo-
gists have experience in detecting swallowing
abnormalities. The speech pathologist’s recom-
mendations should be taken into consideration by
adapting another method of food delivery to the
patient (e.g., tube feeding, percutaneous endo-
scopic gastrostomy (PEG tube), or total paren-
teral nutrition (TPN)) or modifying the
56 6 Comprehensive Preoperative Management of Patients with Pressure Ulcer
consistency of the food given to the patient.
Patients with stage IV pressure ulcers or multiple
ulcers have a low calorie/protein intake [10] due
to lack of appetite.
6.2.2 Anthropometric
Measurements
Standard anthropometric measurements include
body weight, body mass index (weight/height)
[2], triceps skin fold, and mid-arm muscle cir-
cumference. A decrease in total body weight by
less than 80 % and lower body mass indicate
severe malnutrition and development of pressure
ulcer [16]. Weight loss reduces fat and muscle
mass and thus reduces the volume of tissue over
the bony prominences; consequently, sitting pres-
sure increases over the boney prominences. The
author’s clinical observation is that these patients
develop acquired bursa over the boney promi-
nences, which eventually leads to skin break-
down and infection. Special consideration should
be taken when anthropometric measurements are
applied to spinal cord injured patients. The stan-
dard measurements are based on a normal indi-
vidual, and, in spinal cord injured patients,
physiological muscle wasting and water shift that
occur secondary to the paralysis should be taken
into consideration.
6.2.3 Biochemical Tests
Biochemical tests indicate the nutritional status
of the patient with pressure ulcer. The normal
values of these tests are as follows:
Serum total protein 6.0–8.0 g/dL
Serum albumin 3.5–5.0 g/dL
Prealbumin 19–43 mg/dL
Hemoglobin Female: 11.5–12.5 g/dL
Male: 14.0–18.0 g/dL
Hematocrit Female: 33–44 %
Male: 39–40 %
Serum transferrin 200–400 mg/dL
Total lymphocyte count 1,500–4,000/mm [3]
These values may vary according to the stan-
dard lab value. In addition, we have observed that
serum cholesterol drops tremendously in patients
with malnutrition. Serum prealbumin determines
the status of patient nutrition at the time of test-
ing; with a short half-life, 2–3 days, it is a very
sensitive test. Patients with pressure ulcer have
been observed to have a low-level value on this
test [18]. The author considers the value of the
test to be an important factor in determining the
nutritional status of the patient and the action
required accordingly.
In patients with pressure ulcers, serum albu-
min is at low levels. For proper healing after sur-
gery ideally, the level should be 3.5 g/dL or above
as a preoperative value. Patients with a level of
serum albumin above 3.5 g/dL have a lower inci-
dence of pressure ulcer development [10]. Low
serum albumin can produce edema under the
skin, and skin becomes less elastic and interferes
with transfer of oxygen and nutrients from blood
to the skin [19]. The edematous area may have a
temporary loss of blood flow secondary to
increased tissue pressure [17]. A diet rich in calo-
ries and protein is recommended to improve
serum albumin level. Our clinical observation is
that, after closing of the pressure ulcer in a patient
with adequate postoperative nutrition, it takes at
least 4–6 weeks for serum albumin to achieve a
normal level.
Hemoglobin and Hematocrit
Low levels of hemoglobin and hematocrit reduce
oxygen supply to the tissue, thus impairing the
healing of pressure ulcers. Anemia is found in
nearly all the patients with deep or multiple
ulcers [20]. This may be caused by the low nutri-
tional status of the patient, including low levels
of protein and albumin. Iron therapy is not rec-
ommended to correct lower levels of hemoglobin
or low hematocrit because the anemia could have
resulted from the inability to use stored iron and
not from iron deficiency [21]. In severe anemia
secondary to sepsis, blood transfusion may be
necessary before surgery. The author recom-
mends that patients should have a hemoglobin
level of at least 10 g/dL before surgery.
Total Lymphocyte Count
A total lymphocyte count less than 1,500 mm [3]
is a risk factor predisposing in development of
pressure ulcer. The cause of this low level could
6.2 Nutritional Assessment
be non-nutritional and associated with over-
whelming infection and the use of steroids that
compromise the immune system of the body.
6.2.4 Calories (Energy) and Protein
Calories are required to fuel all essential body
processes and it is important, when giving a high-
protein diet, to take into consideration that each
gram of nitrogen needs about 150–200 kcal to be
utilized by the body. Patients with pressure ulcers
need more energy than other patients, especially if
they have a spinal cord injury. The explanation for
the increased energy expenditure is the underly-
ing chronic inflammatory process involving cyto-
kines and cortisol [18]. It is estimated that patients
with pressure ulcers need about 30–40 kcal/kg of
body weight/day [22]. Protein is essential for tis-
sue growth and the recommended total protein
requirement for patients with stage IV pressure
ulcers is 1.5 g–2.0 g/kg of body weight [22].
6.2.5 Micronutrients
Deficiencies in micronutrients, zinc, vitamin C,
vitamin A, and vitamin E are associated with
poor wound healing. However, there is no strong
evidence indicating that deficiency in these sup-
plements is a risk factor in pressure ulcer devel-
opment. Zinc is known to be involved in the
structure of protein, particularly collagen. It is
recommended to give oral zinc sulfate in doses of
220 mg/day in the acute stage of wound healing.
Vitamin C plays an important role in the hydrox-
ylation of praline and lysine during collagen for-
mation. Optimal wound healing may occur with
vitamin C intake of 10–20 mg daily, the same as
when 500 mg of vitamin C is given daily [23].
Vitamin A deficiency results in delay of wound
healing, but it is not highly recommended to give
it routinely because of unproven benefits and
potential toxicity.
Vitamin E
There is no strong evidence that vitamin E
improves healing of pressure ulcers. Vitamin E
may work synergistically with antioxidants like
57
vitamin C to promote wound healing. In sum-
mary, vitamins and minerals should be given
when clinical deficiency is suspected in patients
with severe pressure ulcers and post-surgery.
6.2.6 Methods of Delivering Dietary
Intake to Patients with Pressure
Ulcers or Post-surgery
Nutritious high-calorie, high-protein daily meals
will likely be recommended by the dietician.
When a patient is reported as not eating well, a
calorie count should be ordered for three succes-
sive days to determine the exact number of calo-
ries/protein intake per day. Based on the results,
plan should be put in action to overcome dietary
insufficiencies.
Oral Supplements
There are many commercial supplements avail-
able on the market that can be obtained without a
prescription. The usual intake is a can of supple-
ment with each meal. This supplement provides
1.0–2.0 cal/mL. If the patient does not like the
supplement, a milkshake or protein bar can be
substituted. Patients with diabetes or renal failure
require a special supplement designed for these
diseases. It has been observed that providing
these supplements with daily meals helps to heal
pressure ulcers to a greater extent than the unsup-
plemented group of patients [16].
The Use of Anabolic Steroid
In patients in a catabolic state secondary to open
wound and sepsis, a consequent loss of appetite
and weight is commonly seen in clinical practice.
An anabolic steroid is used in these circum-
stances to increase appetite and weight gain. An
examples of a steroid used in clinical practice is
oxandrolone; the starting dose is 2.5 mg by
mouth three times/day, which can be increased
up to a total of 20 mg/day. Another drug is a
derivative of progesterone called Megace®
(megestral acetate), which is given in a dose of
625 mg or 5 mL/day. Side effects of these ana-
bolic hormones are numerous, the most impor-
tant being effects on the liver, requiring
monitoring of liver enzymes for elevation.
58 6 Comprehensive Preoperative Management of Patients with Pressure Ulcer
Tube Feeding (Nasogastric Tube)
When a patient who is required to have a high
calorie/protein intake has a functional gastrointes-
tinal tract but cannot tolerate a high volume of
dietary intake by mouth, a tube feeding is indicted.
There are many tube feeding formulas that can be
used without side effects like diarrhea, which is a
result of quick shift of fluid from the gut second-
ary to hyperosmolarity of the formula used. Tube
feeding can be tolerated for 4–6 weeks. Aspiration
pneumonia is a serious complication, therefore,
patients with tube feeding should be placed in a
semi-sitting position. Our clinical experience
shows that young patients refuse tube feeding.
Tube feeding can be given at night and in the day-
time, and the patient can take regular meals with-
out feeling full. In patients with the need for
long-term feeding due to inability to swallow, for
example, in high tetraplegia and advanced neuro-
logical disease, a PEG tube is recommended. The
same precaution to avoid aspiration pneumonia as
in tube feeding should be considered; however,
sitting too high in the bed, at 90°, increases pres-
sure over the sacral or ischial area even if the
patient is on a specialty bed. This can cause a
breakdown of the skin in the anatomical areas or a
breakdown in the surgical flap.
Total Parenteral Nutrition (TPN)
When tube feeding cannot be used secondary to
mechanical obstruction of the gastrointestinal
(GI) tract (e.g., because of prolonged ileus, severe
GI bleeding, severe diarrhea or vomiting), TPN
should be used to deliver nutrition at this stage.
TPN requires a central line placement and carries
the risk of serious complications, including sepsis
and thrombophlebitis of the vein. Elevated glu-
cose levels in the blood can be controlled by giv-
ing insulin. Frequent lab tests are required to
monitor for elevated liver enzyme, disorders of
mineral and electrolyte balance, and acid base
abnormality. The author’s clinical indication for
using TPN is when patient has a serious catabolic
condition, with severely low level of albumin and
prealbumin, and needs extensive reconstructive
surgery, taking into consideration that the surgery
itself can cause a severe catabolic state. For this
reason, TPN is used for 2–3 weeks before and
after surgery, especially if the patient is required
to have a diverting colostomy prior to flap surgery.
The use of TPN should be followed by close mon-
itoring of all metabolic conditions of the patient.
6.3 Control of Muscle Spasms
and Joint Contractures
The medical history obtained for patients with
spinal injury or neurological disease presenting
with pressure ulcer should include history of
spasticity and type of medication prescribed and
its effectiveness. Muscle spasms are common in
high-level spinal cord injury (upper motor neuron
lesion). Spasms increase in intensity and duration
when the patient suffers from stresses like infec-
tion or pain. Spinal cord injured patients consider
spasms in the lower extremities as a form of
movement to help aid the patient in transfers. The
side effect of muscle spasms in these patients is
that they can predispose in developing pressure
ulcers when the patient cannot sit in a wheelchair
or when laying in bed in an improper position. In
these cases, patients have greater pressure on the
skin in some areas than others, which can pro-
duce skin breakdown. Muscle spasms can act as
shearing forces, for example, over the heel or
medial surfaces of the knee area, where pressure
ulcers can develop. Severe spasticity can cause
subluxation of the hip joints and rotation of the
greater trochanter posteriorly; a pressure ulcer
can develop over the area, as the greater trochan-
ter will become a pressure point in the sitting
position instead of the ischial tuberosity. The
effects of muscle spasms during the operation for
flap surgery can make it difficult to position the
patient on the operating table (Figs. 6.1a, b).
The effect of general anesthesia may some-
times help to control spasticity and allow place-
ment of the patient in the prone position. In the
postoperative period, uncontrolled muscle
spasms risk flap wound dehiscence [24]. The
author’s clinical observation is that the flap
wound may develop serious discharge, prevent-
ing the sealing of the wound and predisposing to
infection. Spasms can also prevent healing of the
flap as a result of development of a seroma under
the flap. This can be observed by an increase in
the amount of drainage in the surgical drainage
6.4 Medical Management of Spasms 59

Fig. 6.1 (a) Spinal cord

a
injury patient with severe
spasticity at the hip and
knee joint, even with the
use of abduction pillow.
(b) The same patient post
nerve injection by phenol
to control muscle spasms.
Bilateral limbs are in
relaxed position

system, which indicates that some shearing is
occurring between the flap and its bed secondary
to spasm forces.
6.4 Medical Management
of Spasms
Medical management of spasms should begin at
least 1 month before surgery. Patients should be
given antispasmodic medication and followed to
observe any side effects. Some common medica-
tions used in clinical practice for control of
spasms are discussed below.
moral transmitter in the central nervous system
that causes presynaptic depolarization, baclofen
affects presynaptic hyperpolarization. Its major
side effects are anxiety, depression, and sedation.
Precautions should be taken when prescribing the
drug to the elderly group. Some patients develop
coma secondary to baclofen. The medication
should be started in small doses and increased
gradually. In addition, abrupt discontinuation of
the medication may cause side effects. The usual
dose of baclofen is 20–25 mg four times per day.
6.4.2 Diazepam (Valium®)

Diazepam acts contrary to reticular activity. It

6.4.1 Baclofen (Lioresal®) also may affect the contractile electrical proper-
ties of muscle cell membrane. The main side
Baclofen (Lioresal®) is a gamma-aminobutyric effect of this medication is addiction and depen-
acid derivative. An analog to a natural neurohu- dency. The usual dose of diazepam is 5 mg three
60 6 Comprehensive Preoperative Management of Patients with Pressure Ulcer
times/day. Observation for heavy sedation in the
elderly group and high tetraplegia patients should
be considered when prescribing these medica-
tions. In severe spasticity, doses can be increased
to 10 mg three times/day if the patient can toler-
ate this medication without side effects. Diazepam
and baclofen are the standard antispasmodic
medications given to patients to start with; their
effects on the intensity of muscle spasms are
observed before adding other medications.
6.4.3 Dantrolene Sodium
(Dantrium®)
Dantrolene sodium produces muscle relaxation
through its effect on the release of sacroplasmic cal-
cium, which may affect the cardiac system in high
doses. The drug can also affect the liver and cause
hepatotoxicity. It should be started with small doses
and increased gradually every week as follows:
25 mg 1 dy for 7 days
25 mg t.i.d. for 7 days
50 mg t.i.d. for 7 days
100 mg t.i.d. final dose
6.4.4 Clonidine
Clonidine® is an antihypertensive medication that
has been observed to control muscle spasms in cer-
tain individuals. The control of muscle spasms is
due to enhancement of alpha2-mediated inhibition
of sensory afferent nerve fibers. It is given in a dose
of 0.1 mg b.i.d. Again, it should be titrated accord-
ing to patient blood pressure, especially in tetraple-
gia patients. The drug should not be given if the
patient’s systolic blood pressure is below 90 mmHg.
6.4.5 Tizanidine (Zanaflex®)
Tizanidine is similar to the alpha2-adrenergic ago-
nist clonidine. Tizanidine and clonidine are imid-
azoles with antispasticity properties that affect
alpha2-noradrenalin receptors. Tizanidine has been
tested in clinical trials in the United States and
Europe and found to be safe. It is well tolerated and
can be used in treating spasticity of different eti-
ologies. Side effects include hepatic toxicity, which
should be monitored. Starting doses of 2–4 mg/day
at bedtime and can be increased slowly.
6.4.6 Cannabis (Marinol®)
Cannabis has been used for medicinal purposes
for centuries. The synthetic cannabinoid mar-
keted as Marinol® (dronabinol) is used for nau-
sea resulting from chemotherapy. Some patients
have reported that severe spasticity that has not
responded to traditional antispasmodic medica-
tion have experienced a muscle relaxing effect
when smoking marijuana. Marinol is given in
2.5, 5, or 10 mg capsules.
There are other antispasmodic medications on
the market; neurologists are among the physi-
cians who are most familiar and expert in their
use. The practicing plastic surgeon should be
familiar with the use of the most common anti-
spasmodic medications.
6.5 Local Pharmacological
Therapy
There are other agents that can be injected into a
specific nerve or muscle to produce a relaxing
effect on the muscle. The advantage of these
agents is the obtaining of an immediate effect
without the systemic side effects of antispasmodic
medication. These injections may last up to
6 months. The contraindication for these injec-
tions is in newly injured spinal cord patients, when
there is a chance for return of motor or sensory
function, which can create a medico-legal issue.
6.5.1 Phenol/Alcohol Injection
Phenol acts through denaturation of the nerve
fiber, and alcohol can cause dehydration of the
6.6 Surgical Intervention
nerve fiber and the myelin sheath. The injection
is done by localization of the motor point by a
nerve stimulator. For example, adductor muscle
spasticity is controlled by injection of the femo-
ral nerve, and strong flexor of the hip is controlled
by injecting the iliopsoas muscle through the
lumbar area. Side effects of injection or compli-
cations are pain and arrhythmias. These injec-
tions can be done by the physical medicine
physician or the neurologist.
6.5.2 Botulinum Toxin Therapy
(Botox®)
Botulinum toxin is a powerful neuromuscular
blocking agent. The primary mechanism is pre-
synaptic inhibition of acetylcholine release from
the cholinergic motor nerve terminal. It may also
induce paralysis of the intrafusal muscle fibers.
Botulinum toxin has lasting effects for up to
3–4 months. The amount of Botulinum toxin
required for injection depends on the patient’s
muscle mass.
6.5.3 Intrathecal Infusion –
Intrathecal Baclofen
(Lioresal®) Pump
Intrathecal baclofen infusion increases the
potency of the drug compared with the oral route.
A test of intrathecal injection by lumbar puncture
a b
Fig. 6.2 (a, b) Severe hamstring spasticity and contracture
61
can be done by giving 25 mg by slow injection
and evaluating muscle spasms hourly for 4–6 h.
Another method is the baclofen pump. The pump
is placed in the subcutaneous tissue and attached
to a catheter ending in the intrathecal space. This
pump is calibrated for the amount of baclofen
delivered. The pump is placed by the neurosur-
geon and filled within a period of time. There is
danger of infection, especially from blood borne
pathogens or from pressure ulcer close to the
pump.
6.6 Surgical Intervention
In severe spasticity that does not respond to med-
ication, surgical management is indicated. It is
advisable to perform tendon release or muscle
release before flap surgery. If this is not possible,
some of the release can be performed during the
flap surgery. This applies to hamstring tendons
release when the patient is in a prone position
during flap surgery (Figs. 6.2a, b, 6.3, and 6.4).
Common surgical procedures are hip adductor
muscle release and hip flexor muscle release. For
the knee area, hamstring release and joint capsule
release and quadriplasty help flex the knee. These
procedures are performed by the orthopedic sur-
geon or the plastic surgeon. In extreme spastic
conditions at the hip joint, when all other man-
agement has failed, a Girdlestone procedure will
be required to correct the severe deformity of
flexion contracture (Chap. 11).
62 6 Comprehensive Preoperative Management of Patients with Pressure Ulcer
Fig. 6.3 Post release of the hamstring tendons
Fig. 6.4 Application of serial casting to maintain the
functional position required
6.7 Patient Positioning, Post
Surgery, and Type of Bed
Postoperatively, the patient should theoretically
have no pressure applied over the flap surface.
Any pressure greater than the normal capillary
pressure of 32 mmHg threatens flap survival and
healing. Historically, there has been no ideal
bed, mattress, or surface on which to place the
patient in a supine position post-surgery. In the
past, the mud bed and Stryker frame bed, which
rotates the patient to relieve the pressure on the
flap surface, were used but were not successful
in achieving their function. More than 30 years
ago, prior to the development of the new beds,
the author used to train patients to be in prone
position prior to flap surgery. Many paraplegic
patients did activities in that position, but, unfor-
tunately, tetraplegic patients have difficulty in
proning and the position creates high risk to the
patient in breathing and feeding. In addition,
there may be pain and discomfort in the upper
extremity and pressure on the elbow joint with
a risk of skin breakdown. The development and
introduction of the Clinitron® air fluidized bed
more than 30 years ago was an advancement in
the prevention of skin breakdown and protection
of new flap wounds from breakdown. It allowed
reconstructive surgeries in insensate patients and
placement of the patient in the supine position
on the air fluidized bed made it easy for patients
to eat. It is safer for patients with respiratory dif-
ficulty or swallowing problems (Fig. 6.5) as rais-
ing the head of a patient in bed more than 45°
can cause an increase of pressure at the sacro-
coccygeal and ischial areas, which can lead to
development of skin breakdown and pressure
ulcers over the new flap skin. The author, along
with a physical therapist, measured the pressure
of a normal sensate individual sitting in an air
fluidized bed with an angle of 60–90° and found
the pressure in the air fluidized bed can increase
to 100 mmHg and higher. This can create high
risk in the insensate patient. Our protocol allows
a patient to have two pillows; tetraplegic patients
are allowed to have a small foam wedge in addi-
tion to the two pillows with the head of the
patient 25–30° in elevation. Attention should be
given attention to patients on air fluidized beds,
especially those with muscle spasms, as they
can develop heel ulcers. Therefore, as a standard
protocol, all patients on air fluidized beds should
wear heal protectors (Fig. 6.6). Another problem
encountered with patients on air fluidized beds is
dehydration. To fluidize the glass sand beds, the
air temperature should be between 85 and 95 °F
degrees, and in hot weather this causes evapo-
ration of fluid from the skin. Patients should be
encouraged to drink extra fluids. Patient may
feel a sinking sensation in the air fluidized bed
and psychologically may feel claustrophobia.
In the elderly group, we observed some patients
may become confused.
6.8 Antibiotic and Intravenous Fluid Administration Before Surgery 63

Fig. 6.5 Postoperative

patient position supine in
the air fluidized bed

Fig. 6.6 Soft heel

protectors used for all
patients to prevent
development of heel ulcer

6.8 Antibiotic and Intravenous onization or bacterial infection should be treated

Fluid Administration Before
Surgery
The standard of practice prior to surgery is dis-
cussed in Chap. 4. Patients should have a deep
wound culture and sensitivity, and intravenous
antibiotic should be administered accordingly
before surgery. In the author’s protocol, the patient
is admitted one day prior to surgery and given
intravenous antibiotics, which and postoperatively
for 5–7 days according to the clinical condition of
the wound. In addition, any urinary tract heavy col-
preoperatively. Intravenous fluid usually starts in
the evening prior to surgery, because, as a result of
the requirement of nothing by mouth that usually
starts at midnight before the next day surgery time,
this group of patients is predisposed to concentrate
the urine. Eventually, there is an increase in the
colonization of bacteria in the urine. Because the
majority of these patients have a Foley urinary
catheter, there is a high risk of urinary tract infec-
tion and sepsis, which places the patient at risk.
This clinical picture is seen frequently in spinal
cord injury as a compromised patient.
64 6 Comprehensive Preoperative Management of Patients with Pressure Ulcer
6.9 Medical Assessment
As a standard of care, every patient should be
assessed preoperatively regarding their medical
condition and whether they can tolerate general
anesthesia. This depends on patient age, level of
injury, and medical history. A preoperative
screening for heart and lung disease should be
performed by chest x-ray, EKG, and echo of the
heart in patients with suspected heart disease, and
pulmonary function test and blood gases should
be performed for patients with respiratory prob-
lems (e.g., high tetraplegia patients with trache-
ostomy or neurological diseases). In addition,
kidney function tests should be performed in sus-
pected kidney disease patients. Optimization of
these patients for surgery should be done in
advance by their specialists.
6.10 Urological Assessment
The patient’s primary diagnosis will determine
the status of the urological system: whether the
patient is incontinent, needs intermittent urinary
catheterization, or uses an indwelling urinary
catheter. In our practice, an indwelling urinary
catheter is placed prior to surgery in spinal cord
injured patients and in other types of patients on
the day of the surgery. This catheter is left for
about 4 weeks post-surgery while the patient is on
an air fluidized bed. The purpose of the catheter
is to help the drainage of urine and prevent urine
leakage or mechanical interference with the flap
wound during the intermittent urinary catheteriza-
tion (IC) if used post-surgery. On many occasions,
with advanced extensive ulceration of the ischio-
perineal area, the perineal urethra is involved and
urine leakage is seen coming from the ulcer. In
these cases, the patient should be referred to a
urologist before flap surgery for evaluation and
cystourethrogram study. The patient will need a
urinary diversion by performing temporary supra-
pubic cystotomy to divert the urine and allow the
repair of the urethra during flap surgery. In exten-
sive pelvic ulceration or recurrent ulceration, a
permanent urinary diversion should be performed
by the urologist before flap surgery. Before flap
surgery, a routine urine examination and urine
sample for culture and sensitivity should be per-
formed, and, if there is evidence of infection, it
should be treated accordingly to prevent urinary
tract sepsis after flap surgery.
6.11 Bowel Management of
Patients with Pressure Ulcer
Bowel management of patients with pressure ulcer
is an important part of the preoperative evaluation
that can impact the outcome and progress of flap
surgery healing. It is crucial in spinal cord patients.
When this group of patients has a special regimen
for management of their bowel, this requirement
can be affected by the flap surgery and patient
immobilization in bed post-surgery. Evaluation
begins by taking a history of bowel management
by the patient at home and understanding what
type of program the patient uses on a daily basis.
Another important step in the evaluation of the
ulcer is to estimate clinically the distance between
the ulcer and the anus. This is important in the case
of ischioperineal ulcer or multiple ulcers in close
proximity to the anus. In the author’s clinical expe-
rience, with a distance less than 6 cm between the
ulcer margin and the anus, taking into consider-
ation that the unhealthy skin margin of the ulcer
to be excised during the ulcer excision will bring
the flap margin close to the anus, stool will even-
tually contaminate the suture line. In addition,
mechanical interference during the bowel program
and cleaning of the area by the nurses eventually
leads to wound dehesion and infection at an early
stage of flap healing. In such patients, a discus-
sion should take place preoperatively to recom-
mend diversion of the bowel by loop colostomy.
The author has studied postoperative wound infec-
tion in flap surgery and established that infection
in the flap in the perineal area close to the anus
is common [25]. The author’s protocol of bowel
management in this group of patients is to have a
bowel program the night before surgery and then
no bowel program for 5 days post-surgery to avoid
complications due to mechanical interference with
flap wound healing at the early stages. It should be
noted that bowel impaction can cause autonomic
dysreflexia in spinal cord patients with injury level
above T7, and a bowel program needs to start at an
References
earlier time. In patients who do not undergo colos-
tomy, constipating mediation should be used for
2 days only. When patients have bowel control, a
bed pan is allowed post flap surgery.
6.12 Patient Compliance with
Flap Surgery in the
Postoperative Period
Patient compliance depends on the results of the
psychosocial evaluation in the preoperative clinic
and includes such factors as smoking habit and
drug abuse. These issues are discussed in detail in
Chap. 5.
6.13 Physical Therapy Evaluation
Physical therapy evaluation is discussed in detail
in Chap. 16.
References
1. Witkowski JA, Parish LC (1992) Debridement of
cutaneous ulcers: medical and surgical aspects. Clin
Dermatol 9:585–591
2. Yarkony GM (1994) Pressure ulcers: medical man-
agement. In: Spinal cord injury: medical management
and rehabilitation, 1st edn. Aspen, Gaithersburg, pp
77–83
3. Galpin JE, Chow AW, Bayer AS et al (1976) Sepsis
associated with decubitus ulcers. Am J Med
61:346–350
4. Bergstrom N, Bennet MA, Carlson CE et al (1994)
Clinical Practice Guideline No. 15: Treatment of
Pressure Ulcers. U.S. Department of Health and
Human Services, Agency for Health Care Policy and
Research, Rockville. AHCPR Publication 95–0652
5. Wysocki AB, Grinnell F (1990) Fibronectin profiles
in normal and chronic wound fluid. Lab Invest 63:825
6. Falanga V (1992) Growth factors and chronic wounds:
the need to understand the microenvironment. J
Dermatol 19:667
7. Deva AK, Buckland GH, Fisher E et al (2000) Topical
negative pressure in wound management. Med J Aust
173(3):128
8. Ford CN, Reinhard ER, Yeh D et al (2002) Interim
analysis of a prospective, randomized trail of vacuum-
assisted closure versus the healthpoint system in the
management of pressure ulcers. Ann Plast Surg 49:55
9. Allman RM, Laprade CA, Noel LB, Walker JM,
Moorer CA, Dear MR, Smith CR (1986) Pressure
65
sores among hospitalized patients. Ann Intern Med
105(3):337–342
10. Bergstrom N, Braden B (1992) A prospective study of
pressure sore risk among institutionalized elderly. J
Am Geriatr Soc 40(8):747–758
11. Berlowitz DR, Wilking SV (1989) Risk factors for
pressure sores: a comparison of cross-sectional and
cohort-derived data. J Am Geriatr Soc
37(11):1043–1050
12. Breslow RA, Hallfrisch J, Goldberg AP (1991)
Malnutrition in tubefed nursing home patients with
pressure sores. J Parenter Enteral Nutr
15(6):663–668
13. Hanan K, Scheele L (1991) Albumin vs. weight as a
predictor of nutritional status and pressure ulcer
development. Ostomy Wound Manage 33(2):22–27
14. Holmes R, Macchiano K, Jhangiani SS, Agarwal NR,
Savino JA (1987) Nutrition know-how: combating
pressure sores—nutritionally. Am J Nurs
87(10):1301–1303
15. Pinchcofsky-Devin GD, Kaminski MV Jr (1986)
Correlation of pressure sores and nutritional status. J
Am Geriatr Soc 34(6):435–440
16. Ek A, Unosson M, Larsson J et al (1991) The develop-
ment and healing of pressure sores related to the nutri-
tional state. Clin Nutr 10:245–250, {Scientific
evidence-II}
17. Strauss E, Margolis D (1996) Malnutrition in the
patients with pressure ulcers: morbidity, mortality and
clinically practical assessments. Adv Wound Care
9:37–40
18. Bonnefoy M, Coulon L, Bienvenu J et al (1995)
Implication of cytokines in the aggravation of malnu-
trition and hypercatabolism in elderly patients with
severe pressure sores. Age Ageing 24:37–42
19. Krouskop TA, Garber SL, Reddy NP et al (1986) A
synthesis of the factors that contribute to pressure sore
formation. In: Ghista DN, Frankel HL (eds) Spinal
cord injury medical engineering. Thomas Publisher,
Springfield, pp 247–267
20. Salzberg CA, Byrne DW, Cayten CG et al (1996) A
new pressure ulcer risk assessment scale for individu-
als with spinal cord injury. Am J Phys Med Rehabil
75:96–104
21. Fuoco U, Scivoletto G, Pace A et al (1997) Anaemia
and serum protein alteration in patients with pressure
ulcers. Spinal Cord 35:58–60
22. Breslow RA, Hallfrish J, Guy DG et al (1993) The
importance of dietary protein in healing pressure
ulcers. J Am Geriatr Soc 41:357–362
23. ter Riet G, Kessels A, Knipschild P (1995)
Randomized clinical trial of ascorbic acid in the treat-
ment of pressure ulcers. J Clin Epidemiol
48:1453–1460
24. Ger R, Levine SA (1976) The management of decubi-
tus ulcers by muscle transposition. An 8-year review.
Plast Reconstr Surg 58:419–428
25. Garg M, Rubayi S, Montgomerie J (1992) Post-
operative wound infection following myocutaneous
flap surgery in spinal injury patients. Paraplegia
30(10):734–739
 General Operative Management
and Postoperative Care
Salah Rubayi
7.1 Indications for Surgery
Indications for surgical wound closure are a wound
on the body surface that does not heal, despite
local wound care, or a wound that is extensive in
size or interferes with the daily life of the patient
(e.g., causing pain and discomfort or disability).
Pressure ulcer wounds fall under the same indica-
tions as general wounds, but there are additional
indications to close pressure ulcers in disabled,
geriatric, or neurologic disease patients whom
they have high incident of developing pressure
ulcer wound, causing morbidities and mortality.
1. Pressure ulcers can extend deep into a bone or
joint, causing acute or chronic osteomyelitis
or soft tissue infection and sepsis, in addition
to the metabolic and other effects of open
wounds (hypoproteinemia, anemia).
2. When pressure ulcers develop in insensate
areas of the body, if pressure continues to be
applied on that wound, more necrosis of the
deep soft tissue will result, leading to heavy
colonization with bacteria and, eventually,
sepsis. We have seen many patients come to
the emergency room with soft tissue sepsis
who then require emergency admission to the
S. Rubayi MB, ChB, LRCP, LRCS, MD, FACS
Department of Surgery, Rancho Los Amigos National
Rehabilitation Center, Downey, CA, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_7, © Springer-Verlag Berlin Heidelberg 2015
7
hospital for intravenous antibiotics. This
scenario is repeated many times per year sec-
ondary to pressure ulcer.
3. Complication from open wound and extension
to vital organs (urethra, vagina, hip joint).
4. When a newly injured spinal injury patient is
in need of rehabilitation post trauma and pres-
ents with a pressure ulcer that developed at an
acute trauma center, it is important to close the
ulcer to enable the patient to undertake a reha-
bilitation program.
5. Quality of life and interruption of the patient’s
daily life (e.g., work attendance) should be
considered, as the patient is advised not to sit
and may need to stay in bed. On the other hand,
there is the cost of conservative treatment and
local wound care by the visiting nurse for care
at home, a specialty bed, and use of negative
pressure wound therapy. The author’s view is
that, when conservative treatment for a stage
IV ulcer does not show any sign of healing for
4–6 weeks, surgery should be considered.
7.2 History of Reconstructive
Surgery in Management
of Pressure Ulcers
Historically, the standard treatment for wounds
was to pull the edges together, often with extreme
tension, which frequently would result in necro-
sis, dehesion, or infection. Silver or stainless
steel wire were reportedly used for this purpose.
67
68 7 General Operative Management and Postoperative Care
The breakdown of the wound would lead to a
larger defect than the original ulcer. In 1945,
Lamon and Alexander [1] reported success in
achieving surgical closure of a sacral ulcer using
penicillin coverage of the wound. White and
Hamm [2] in 1946 reported further success in
closing bedsores. In 1947, Conway and others [3]
reported various procedures for surgical closure
of pressure ulcers, including include flaps, skin
graft, and Z-plasty, in paraplegic patients. In
1947, Kostrubala and Greely [4] were the first to
suggest excision of the boney prominence to
allow the wound to be closed without tension. In
1948, Bors and Comar [5] suggested that muscle
transposed into the ulcer defect would help to
distribute pressure and reported the use of the
gluteus maximus as a rotation flap.
Griffith and Schulz [6], in 1961, reviewed a
series of 1,000 cases and found simple wound
excision for trochanteric ulcers, including super-
ficial bone removal, resulted in 83 % healing and
a recurrence rate of 20 %. Radical bone excision
and flap coverage resulted in 92 % wound healing
with 6 % recurrence rate.
The anatomical basis for the vascularized flap,
which contains muscle, subcutaneous tissue, and
skin, was not properly understood at the time that
such flaps were first used. Bailey [7], in 1967,
found on an empirical basis that these soft tissue
layers survived when transposed to cover a pres-
sure ulcer. In 1972, McGregar and Jackson
defined the vascular basis of the groin flap, which
depends on a specific pattern of cutaneous arter-
ies for survival. This flap, which is based on the
axial arterial, became the basis of reconstructive
surgery. The tensor fascia lata as a muscular cuta-
neous flap was developed by Nahai and col-
leagues [8, 9] and became an important flap in
reconstructive surgery for pressure ulcers around
the hip and pelvic area. In 1979 and 1981, Mathes
and Nahai [10, 11] classified all the muscles
according to type of blood supply and divided these
muscles into five types, from Type I to Type V. This
classification of the muscles is important to the
plastic reconstructive surgeon in transferring or
transposition of the muscles from their original
site to other parts of the body. To close a defect,
one needs to consider which blood supply will be
intact so that the muscle survives in the new loca-
Table 7.1 Type of muscle vascularity
Type I One vascular pedicle, e.g., gastrocnemius
muscle, rectus femoris, and tensor fasciae latae
Type II Dominant vascular pedicle and minor pedicle,
e.g., biceps femoris, gracilis, semitendinosus,
trapezius, vastus lateralis
Type Two dominant pedicles, e.g., gluteus
III maximus, rectus abdominis,
semimembranosus
Type Segmental vascular pedicles, e.g., sartorius
IV
Type V One dominant vascular pedicle and secondary
segmental pedicles, e.g., pectoralis major,
latissimus dorsi
tion. This blood supply determines the arc of
rotation of the muscle (Table 7.1).
The concept of taking vascularized tissue
from a distant site for immediate transfer to a
pressure ulcer defect with immediate reconnec-
tion of the axial artery and vein using microsurgi-
cal techniques was described by Chen et al. [12].
This concept, however, is not practical for every
pressure ulcer performed on a daily basis and is
of limited application.
Transfer of sensory tissue to an insensate area
of pressure ulcer in paraplegic patients was
attempted by Cochran et al. [13]. Attempts were
made by Daniel et al. [14] to reinnervate a flap to
restore sensation to the area of pressure ulcer by
using a long nerve graft from above the level of
the cord injury. These techniques have not been
universally successful in achieving and maintain-
ing healing through restoration of sensation.
The introduction of tissue expansion in plastic
surgery more than 20 years ago stimulated sur-
geons to use this technique in closing pressure
ulcers. It was described by Esposito [15], who
claimed the main advantage was to advance sen-
sory skin to cover an insensate pressure ulcer
area. Braddom and Leadbetter [16], Yuan [17],
and Neves et al. [18] reported that unstable skin
resulted from a healed pressure ulcer or graft or
tissue expander are not ideal to cover pressure
ulcer used to close a pressure ulcer. The author
shares the concern of using a tissue expander as a
foreign body near a contaminated wound. In
addition, the expanded skin can only cover flat
surface wounds and not a cavity, and it requires a
long time to achieve expansion of the skin to be
7.5 Methods and Strategies in Flap Selection
utilized for the ulcer closure. From 1980 to the
present, there have been hundreds of articles pub-
lished in plastic surgery journals describing the
use of muscle or musculocutaneous flaps in dif-
ferent forms or shapes to close different pressure
ulcers in various anatomical parts of the body.
Today, the standard surgical method for closing
pressure ulcers, which has become the standard
of teaching and training for plastic surgery train-
ees, is to use a muscle or musculocutaneous flap
[19–21].
7.3 The Ladder
of Reconstructive Surgery
Complex flap
(composite flap)
Skin flap ↑
Skin graft ↑
Direct closure ↑
7.4 Principles of Flap Design
and Repair of Pressure
Ulcers
The specific anatomical details of flap design are
different depending on the location of the pres-
sure ulcer, but the principles are the same. The
design of the flap in plastic surgery depends on
the following considerations:
1. Geometrical design is the way the flap is
moved toward the defect by advancement,
rotation, or transposition (Fig. 7.1a–f). The
flap donor site can be closed directly or, if the
donor site is large enough, it may require a
skin graft.
2. The anatomical content of the flap (i.e., the
composition of the flap) is as follows:
(a) Cutaneous (skin only); fasciocutaneous,
meaning skin and the cutaneous layer
with the deep fascia; muscle only; or
muscular-cutaneous (Fig. 7.2).
69
3. The blood supply to the flap can be random,
axial (arterial pedicle), or free flap microsur-
gical (the artery and vein).
7.5 Methods and Strategies
in Flap Selection
What type of flap should one utilize for a particu-
lar ulcer? The answer depends on the following
factors that should be considered in flap
selection:
Tissue
expansion
Free tissue ↑
transfer
(microsurgery)
↑
1. The patient’s primary disease, whether it is
spinal injury, spina bifida, advanced neuro-
logical disease, or post geriatric disease, and
whether the patient is confined to a wheelchair
is considered. The surgeon should select a flap
that will fill the ulcer defect and heal the
wound in a short time. In addition to excellent
skin surface and good padding over the bone,
consideration of recurrence risk in certain
types of patients requires leaving a reserve of
sufficient skin and muscles, especially if the
patient is in a young age group.
2. In patients who are ambulatory with sensa-
tion, the selection of the flap should not impact
the motor function of the patient in walking,
climbing stairs, or flexion of the hip or knee.
For example, the gluteus maximus muscle in
its upper and lower portion should not be used
as a rotation flap. When the gluteus muscle
tendinous part is detached at the point of
insertion, or in the case of the hamstring mus-
70 7 General Operative Management and Postoperative Care

cle advancement flap rotated from its base

Rotation
a b
3. For each anatomical ulcer location, there is a
Advancement
c d
Transposition
e f
Fig. 7.1 Type of geometrical movement of flap, (a, b)
rotation, (c, d) advancement, and (e, f) transposition
when transaction of the lower part of muscles
is performed. The vastus lateralis muscle is a
powerful component of the quadriceps mech-
anisms and should not be used in ambulatory
patients. The motor defect of this muscle
affects the flexion of the hip and extension of
the knee joint. The appropriate (or suitable)
flap in this circumstance is the fasciocutane-
ous flap from the thigh and gracilis muscle to
repair ischial and perineal defects. For hip
joint defects, the rectus abdominis or rectus
femoris muscle is appropriate.
primary flap to be used for a primary virgin
ulcer, that is, a first-time ulcer should be con-
sidered with attention to the primary disease of
the patient. For example, for a sacrococcygeal
ulcer, the gluteus maximus is used as a muscu-
locutaneous flap in a rotation or island advance-
ment flap. For an ischial ulcer, the lower portion
of the gluteus maximus is used in a rotation flap
or the V-Y hamstring is used in a musculocuta-
neous advancement flap, with or without the
gracilis muscle. For a trochanteric ulcer, the
tensor fascia lata is used in a V-Y advancement
flap or a rotation form. In the case of a hip
defect, the size of the defect or the existence of
another ulcer determines the selection of the
muscle, whether it is the vastus lateralis muscle
flap or the rectus femoris muscle flap.

Fig. 7.2 Diagram

showing the principle of
flap composition
7.6 Type of Anesthesia and Patient Positioning for Pressure Ulcer Surgery
4. In recurrent ulcers, the selection of flap is
more complicated and depends on the local
tissue available to be used. Taking into consid-
eration the primary disease of the patient, the
choice of fasciocutaneous flap or distant mus-
cle flap depends on which primary muscle
flaps have been used previously. For example,
the vastus lateralis muscle flap is used to
repair extensive recurrent ischioperineal ulcer.
The author’s experience in these circum-
stances is to reuse previous flaps if possible
(e.g., re-rotation of the gluteus maximus flap
or re-advancement of the hamstring musculo-
cutaneous flap). Each time these flaps are
reused, the quality of skin and vascularity is
affected and, consequently, healing is at risk.
The surgeon should explain to the patient the
risk of recurrence of ulceration and skin
breakdown, causing depletion of skin and
muscle reserve in the patient’s body. In raising
flaps in recurrent ulceration, it is important to
consider the vascularity of tissue dissected
and whether the skin and muscle beneath will
survive. It is often possible during surgery to
see that the color of the skin is dull and dusky.
To confirm this observation, a fluorescent dye
is injected intravenously during surgery, and
the perfusion of the tissue is observed by
ultraviolet light, which shows a yellow color-
ation of the skin if it is fully perfused.
Otherwise, the color of the skin is dark and
dull when there is no blood perfusion.
7.6 Type of Anesthesia
and Patient Positioning
for Pressure Ulcer Surgery
7.6.1 Type of Anesthesia
to Be Administered
Most spinal cord injury (SCI) patients do not
have sensation from the chest down, some from
the waist downward, which means that they do
not have feeling over the surgical site. It may
seem easy to perform surgery under intravenous
71
sedation to keep the patient comfortable in a
prone or lateral position, but in clinical practice it
is not always safe, especially in tetraplegic
patients with shoulder pain and limited move-
ment. The important issue is the airway and
breathing when the tetraplegic patient cannot
breathe and expand their chest in a prone position
secondary to the paralysis of the muscle of respi-
ration. In addition, a large percentage of tetraple-
gic patients are sensitive to intravenous sedation,
which depresses their respiration and makes them
unresponsive to stimuli. It is unsafe to place tet-
raplegic or advanced neurologic patients with tra-
cheostomy tube in a prone position and to
administer intravenous sedation, which can carry
a high risk to the patient. For these reasons, tet-
raplegic patients should have general anesthesia
for flap surgery.
In the case of the paraplegic patient group or
other neurological patients, the author’s experi-
ence in performing surgery under intravenous
sedation has lead to the conclusion that there is a
high risk from this practice. When the patient
experiences discomfort and pain in the prone posi-
tion, the anesthetist administers more intravenous
sedation, which leads to the patient becoming
unresponsive. The patient does not breathe well,
resulting in low blood oxygenation. This has lead
the author to change his practice to administration
of general anesthesia for all patients. Another
advantage of using general anesthesia is the moni-
toring of the patient that can be done by the anes-
thetist. A fast blood transfusion can be given if
needed without discomfort to the patient, and
extensive, prolonged surgery can be performed
under general anesthesia. In tetraplegia (above the
level of T-7), a patient can develop autonomic dys-
reflexia secondary to the stress of the surgery,
which causes high blood pressure and can create
extensive bleeding at the surgical field or bleeding
in the brain. Control of this condition is manage-
able when the patient is under general anesthesia
by administering intravenous nitroglycerine. In
our practice, all patients are intubated in a supine
position first and then turned to the prone position
on the operating table over a chest roll. At the end
72
of the surgery, the patient is turned in the supine
position on the postoperative gurney while still
intubated and then extubated safely.
7.6.2 Patient Position
on the Operating Table
The classic location of pressure ulcers is on the
posterior torso of the body, for example, the
sacrococcygeal or ischioperineal ulcer. To have
surgical access to these ulcers, the patient is
placed in the prone position. When a patient has
a trochanteric ulcer in addition to one of the
ulcers mentioned above, the prone position is
ideal for closing all the ulcers in one stage
(Fig. 7.3). When a patient has only a trochanteric
ulcer or hip infection, the lateral position is good.
The patient can be supported in the lateral
Fig. 7.3 Patient in prone position with multiple ulcers in
different anatomical locations. This position facilitates the
surgical approach to close these multiple ulcers in one
stage
7 General Operative Management and Postoperative Care
position by a bean bag; suctioning the air from
the bag will convert it into a hard support for the
patient. The author always places a foam pad
between the patient and the bean bag to prevent
any pressure from the hard bean bag (Fig. 7.4)
and uses a kidney rest on both sides. Whatever
the position of the patient – prone, lateral, or
supine – complete protection of the areas of skin
over the boney prominences should be provided
using foam padding over these areas during sur-
gery, including the patient’s face. It is the
responsibility of the operating room team (sur-
geon, anesthetist, and nurses) to check these
pressure points while the patient is in the supine
position on the operating table. A patient under-
going surgery to close a pressure ulcer should not
awake with a new pressure ulcer.
There are some circumstances when a patient
cannot be placed in the prone position due to
excessive obesity, when the chest and abdomen
cannot expand during mechanical ventilation.
This may cause technical difficulties with the
anesthesia machinery, increasing the risk of ven-
tilating the patient. In such cases, it is safer to
place the patient in the lateral position. This posi-
tion allows closure of an ischial or coccygeal
Fig. 7.4 Placing a foam pad over the hard bean bag to
prevent pressure ulcer development, arrow indicates the
position of the bean bag
7.7 Principles of the Surgical Methods 73

ulcer. When placing tetraplegic patients with or
without tracheostomy tube in the prone position,
it is critical to support the head using a mechani-
cal extension from the operating room table,
called a Myfield® support extension (Fig. 7.5),
which is used in cervical spine surgery.
The author’s opinion is that the prone position
is the ideal position to close pressure ulcers as long
as the important safety points are recognized and
taken into consideration. When operating in the
perineum or ischial area, it is advisable to place the
patient in the “jackknife” position (Fig. 7.6). The
advantage of this position is that it exposes the sur-
gical field well to the surgeon and allows the flap
to be advanced and closed in the maximum of the
functional position of the patient, which is the flex-
ion at the hips when sitting in a wheelchair.
7.7 Principles of the Surgical
Methods
There are basic standard surgical technical steps
that should be applied in pressure ulcer surgery
before flap dissection and mobilization. These
rules are applied in all types of ulcers and flap
surgeries. An important clinical requirement is
that the ulcer appearance should be clean and

Fig. 7.5 Modified

extension (Mayfield®)
attached to the operation
table to support the head of
a tetraplegic patient with
tracheostomy and proper
rolls to support patient
chest and abdomen. Arrow
indicates the location of
the extension

Fig. 7.6 Patient in a

“jackknife” position to
expose the surgical area
and closure in maximum
flexion position
74 7 General Operative Management and Postoperative Care
a b
Fig. 7.7 (a) Coloring the ulcer by methylene blue dye using a Q-tip applicator. (b) Ulcer colored by methylene blue
dye
granulating. If not, the wound should be prepared
in several stages of debridement. This can be per-
formed in the clinic or the hospital ward before
surgery. In some cases, it is necessary to bring the
patient to the operating room for extensive
debridement, especially if the patient has full
sensation in that area.
In the operating room, the first step is to place a
temporary purse string suture using silk suture
around the anal verge to prevent any contamina-
tion of the surgical field during surgery, even if the
patient has a diverting colostomy. The second step
is to color the ulcer cavity and all the undermining
by methylene blue dye using a cotton swab appli-
cator (Fig. 7.7a, b). In the case of a discharging
sinus from a bursa, such as the ischial or trochan-
teric bursa, the methylene blue is injected by a
syringe attached to an angiocatheter into the cavity
of the bursa. The unhealthy skin margin of the
ulcer should be marked by a marking pen; this will
represent the new, healthy margin of the surgical
defect. A surgical scalpel is used to incise the skin
deep to the subcutaneous tissue layer. Then, an
electrocautery is used in the coagulation mode to
dissect the ulcer wall in the same manner as dis-
section of a cyst. The unhealthy surrounding fat
tissue or scars should be excised. The ulcer should
be excised in one piece when possible. At the end
of this dissection is the base of the ulcer, which
covers the exposed bone with unhealthy granula-
tion tissue. If technically possible, this layer should
be excised. Otherwise, this layer should be
removed with bone shaving. The third step is to
shave the bone. This performed with a curved
osteotome. The size of the osteotome depends on
the size of the bone to be shaved. The average size
of the bone is between 2 and 4 cm2. The direction
of the bone shaving should be from the superior to
the inferior border of the bone. The next surgical
step is to determine how much bone should be
shaved. This depends on how prominent the bone
is as a pressure point and the extent to which the
bone is involved with the ulcer. The average shav-
ing is about 1–2 layers of bone, with an average
thickness of 0.4 cm. The healthy looking bone
should be a bleeding layer of bone. The first
shaving of the bone should be sent for histopatho-
logical examination and labeled “superficial
bone.” The second shaving procedure is performed
and part of that bone is sent for histopathological
examination and labeled “deep bone.” Another
part is sent for bacteriological examination for cul-
ture and sensitivity of the bone (Fig. 7.8a). The
author considers these steps important in the diag-
nosis of the osteomyelitis type (acute vs. chronic),
and the management of the bone infection will be
directed accordingly [22]. The next step is to
smooth the bone surface and its edges, which is
achieved using a nasal rasp. Because the size of the
rasp is small, it can be manipulated in a small size
bone (Fig. 7.8b, c). The wound then is irrigated
with at least a 2,000 ml of normal saline mixed
with the antibiotic preferred by the surgeon. The
author uses bacitracin in a concentration of
100,000 (I.U.) to 1,000 ml of normal saline. A lap
pad soaked in epinephrine solution 50,000 (unit)
mixed with 1,000 ml of normal saline is placed in
the wound to stop the bleeding.
7.8 Postoperative Flap Management 75

a b

Fig. 7.8 (a) Shaving of the bone (ischium) by an osteotome. (b) Smoothing the bone by a nasal rasp. (c) The com-
pletely excised ulcer and shaved bone, arrow indicates the specimen

The next step is dissection and mobilization of
the flap. This is discussed in detail for each ana-
tomical area in later chapters.
7.8 Postoperative Flap
Management
The following is a summary of the protocol for
postoperative management used at the pressure
ulcer management program at Rancho Los
Amigos National Rehabilitation Center, Downey,
California, USA [19].
7.8.1 Immediate Postoperative Care
Before turning the patient from the prone posi-
tion and while patient is still anesthetized, a
foam abduction pillow and heel protector
(Fig. 7.9) is applied. The patient is then turned
to the supine position on the postoperative gur-
ney, which has a special mattress to protect the
flap from pressure. Afterwards, the patient is
transferred to the recovery room. An electric
drain sump pump is activated. The patient posi-
tion on the gurney is supine with two pillows
under the head; in high quadriplegia, elevation
of the head is allowed. If the patient had a
Girdlestone procedure or excision of hetero-
topic ossification of the hip, an anteroposterior
(AP) pelvis x-ray is performed while the patient
is in the recovery room. When the patient’s con-
dition is stable, the patient is transferred to the
ward or the intensive care unit, depending on the
extent of the surgery. In the ward, the patient is
transferred gently from the postoperative gur-
ney onto an air fluidized Clinitron® bed
(Fig. 7.10). The patient is allowed to have two
pillows under the head. Tetraplegia patients
with respiratory difficulty or tracheostomy are
allowed to have 15–25° of head elevation. An
electric drain sump pump is activated and the
output is measured and recorded once per day.
A urinary Foley catheter is connected to
a drainage bag that is drained by gravity
76
a b
Fig. 7.9 (a) Patient in supine position on the air fluidized bed showing the position of the abduction pillow and the heel
protector. Arrow indicates the abduction pillow. (b) The type of soft heel protector used for all patients post-surgery
Fig. 7.10 Air fluidized bed (Clinitron® bed)
(Fig. 7.11). Vital signs are checked every 4 h,
and intravenous fluid is given for 24–48 h.
Intravenous antibiotic is given for 5 days, except
in special conditions when it is extended. In
quadriplegia patients, if there is a respiratory
problem and a risk of aspiration, a different type
of bed (called a Rite Hite®) is used, the top half
of which is an air loss mattress and the lower
half, where the patient’s operative site is located,
is an air fluidized bed (Fig. 7.12). The back rest
of this bed can be controlled electronically,
which allows placement of the patient’s head in
an upright position. When allowed, it can be in
the 15–25° upright position after flap surgery. If
the angle is increased, there will be excessive
pressure over the flap site. The appropriate
laboratory tests are performed on the first
7 General Operative Management and Postoperative Care
postoperative day and then repeated on a weekly
basis. Nutritional supplement is given from the
first operative day; for diabetic and renal patients
a special supplement is given.
7.8.2 Fifth Postoperative Day
The initial surgical dressing is removed by the
surgeon and replaced with a new dressing, con-
sisting of an application of bacitracin ointment
covered with impregnated gauze (Xeroform®),
surgical gauze, and a padded pad (ABD®). If the
patient’s wound is colonized with methicillin-
resistant Staphylococcus aureus (MRSA),
mupirocin (Bactroban®) ointment is used.
Orders are given to the nurses to apply this
dressing to the wound once daily or twice
weekly. Drain removal depends on output: if it
is 0–5 ml/day, the drain is removed. The average
time of draining for a single flap is 5–7 days. In
the case of a Girdlestone procedure or bone
excision (HO), the drain may need to remain in
place for between 10 and 14 days, depending on
the output. Orders should be given to the occu-
pational therapist to begin upper extremity
strengthening while the patient is in bed.
Antibiotic is discontinued at the end of the fifth
post-operative day, except in the case of positive
bone histology of acute osteomyelitis and a pos-
itive bacteriological culture, in which case anti-
biotic should be given for a total of 4–6 weeks.
The surgeon should inspect the surgical wound
7.8 Postoperative Flap Management 77

Fig. 7.11 Patient post flap

surgery in supine position
showing the sump pump in
place and urinary bag
hanging to gravity. Arrow
indicates sump pump
location

Fig. 7.12 Rite Hite® bed, the top part is air loss and lower Fig. 7.13 Air loss mattress, Eclipse®, step down bed
part is air fluidized from the Clinitron

at least twice weekly. In spinal cord injured
patients without colostomy, a bowel program
should be resumed on the fifth postoperative day
and performed by nurses. The patient should be
turned gently to prevent any mechanical impact
on the flap, with appropriate support by a sec-
ond nurse in the lateral position for performing
the bowel program.
7.8.3 Third Week Post Flap Surgery
All surgical wound sutures are removed and
wound dressing continues as before. The patient
remains on an air fluidized bed.
7.8.4 Fourth Week Post Flap
Surgery
If the flap wound is intact, the bed is changed to
an air loss mattress (Fig. 7.13). Tetraplegia
patients are kept on an air fluidized bed until the
sitting program is initiated. Paraplegia patients
may be turned from side to side and are allowed
to be prone on a gurney to attend physical therapy
exercises for upper extremity strengthening,
which is done in special gym (Fig. 7.14). The
patient is cleared to have a shower administered
by the nurses. Wound care is performed accord-
ing to the healing process. If the wound is com-
pletely healed, lubrication of the surgical site is
78 7 General Operative Management and Postoperative Care
Fig. 7.14 Special gym for
the patient at the fourth
week post-surgery to
strengthen the upper
extremities
applied three times a day by nurses. If there is a
small breakdown or nonhealed area, a conven-
tional dressing is applied, supported by electrical
stimulation around the wound to accelerate heal-
ing, which is performed by a physical therapist.
7.8.5 Sixth Week Post Flap Surgery
Our protocol is to begin a sitting program at 6
weeks post flap surgery and expose the freshly
healed flap wound to pressure and mechanical
stress. This clinical practice is based on the phys-
iology of wound healing and the tensile strength
of the wound at 6 weeks post-surgery, which is
equal to 80 % of normal. At 4 or 5 weeks post-
surgery, the tensile strength of the wound is about
40–50 % of normal [23, 24]. Our clinical
experience has shown that a flap wound can be
dehisced at any time up to 6 weeks post-surgery
if subjected to excessive mechanical stress.
If the wound clinically is completely healed, a
sitting program in a wheelchair should begin under
the supervision of a physical therapist. The patient
starts a sitting program with an appropriate wheel-
chair cushion, according to the physical therapist’s
evaluation. The sitting program lasts for a half or
one hour on the first day, increasing in increments
of s half hour more each day until the patient
reaches 6 h of sitting tolerance without skin break-
down. The patient can then be discharged home.
When the sitting program reaches 3 h, the physical
therapist should measure the sitting pressure to
compare it with the preoperative sitting pressure
and to observe any improvement in pressure post-
operatively. If the patient develops a small break-
down or blisters during the sitting program, the
sitting program should be modified to a slower pro-
gram (e.g., increased in half hour increments every
2 days) or suspended until healing is achieved. The
chapter on physical therapy after flap surgery pro-
vides further details on the rehabilitation program.
References
1. Lamon JD Jr, Alexander E Jr (1945) Secondary clo-
sure of decubitus ulcers with the aid of penicillin. J
Am Med Assoc 127:396
2. White JC, Hamm WG (1946) Primary closure of
bedsores by plastic surgery. Ann Surg
124:1136–1147
3. Conway H, Kraissl CJ, Clifford RH (1947) The plas-
tic surgical closure of decubitus ulcers in patients with
paraplegia. Surg Gynecol Obstet 85:321–332
4. Kostrubala JG, Greeley PW (1947) The problem of
decubitus ulcers in paraplegics. Plast Reconstr Surg
2:403–412
5. Bors E, Comarr E (1948) Ischial decubitus ulcer.
Surgery 24:680–694
6. Griffith BH, Schultz RC (1961) The prevention and
surgical treatment of recurrent decubitus ulcers in
patients with paraplegia. Plast Reconstr Surg
27:248–260
7. Bailey BN (1967) Bedsores. Edward Arnold, London,
pp 88–89
8. Nahai F, Silverston JS, Hill HL (1978) The tensor fas-
cia lata musculocutaneous flap. Ann Plast Surg
1:372–379
References
9. Nahai F, Hill HL, Hester TR (1978) Experiences with
the tensor fascia lata flap. Plast Reconstr Surg
63:788–799
10. Mathes S, Nahai F (1979) Clinical atlas of muscle and
musculocutaneous flaps. The CV Mosby Co., St.
Louis
11. Mathes SJ, Nahai F (1981) Classification of the vas-
cular anatomy of muscles: experimental and clinical
correlation. Plast Reconstr Surg 67(2):177
12. Chen H, Weng C, Noordhoff MS (1986) Coverage of
multiple extensive pressure sores with a single filleted
lower leg myocutaneous free flap. Plast Reconstr Surg
78:396–398
13. Cochran JH Jr, Edstrom LE, Dibell DG (1981)
Usefulness of the innervated tensor fascia lata flap in
paraplegic patients. Ann Plast Surg 7:286–288
14. Daniel RK, Terzis JK, Cunningham DM (1976)
Sensory skin flaps for coverage of pressure sores in
paraplegic patients: a preliminary report. Plast
Reconstr Surg 58:317–328
15. Exposito G, DiCaprio G, Ziccardi P, Scuderi N (1991)
Tissue expansion in the treatment of pressure ulcers.
Plast Reconstr Surg 87:501
16. Braddom RL, Leadbetter MG (1989) The use of a tis-
sue expander to enlarge a graft for surgical treatment
of a pressure ulcer in a quadriplegic. Case report. Am
J Phys Med Rehabil 68:70
79
17. Yuan RT (1989) The use of tissue expansion in lower
extremity wounds in paraplegic patients. Plast
Reconstr Surg 83:892
18. Neves RI, Kohler SH, Banducci DR, Manders EK
(1992) Tissue expansion of sensate skin for pressure
sores. Ann Plast Surg 29:433
19. Rubayi S, Cousins S, Valentine WA (1990)
Myocutaneous flaps surgical treatment of several
pressure ulcers. AORN J 52(1):40–55
20. Pressure ulcer prevention and treatment following spi-
nal cord injury: a clinical practice guideline for
health-care professionals. Consortium for Spinal
Cord Med Clinical practice guidelines, Paralyzed
Veterans of America, Aug 2000
21. Janis JE, Kenkel JM (2003) Pressure sores. Sel Read
Plast Surg 9(39):1–42
22. Marriott R, Rubayi S (2008) Successful truncated
osteomyelitis treatment for chronic osteomyelitis in
spinal cord injured patients. Ann Plast Surg
61(4):425–429
23. Levenson SM, Geever EF, Crowley LV, Oates JF,
Berard CW, Rosen H (1965) The healing of rat skin
wounds. Ann Surg 161:293
24. Madden JW, Peacock EE Jr (1968) Studies on the
biology of collagen during wound healing. I Rate of
Collagen synthesis and deposition in cutaneous
wound of the rat. Surgery 64:288
 Reconstructive Surgery
for Ischial Ulcer 8
Salah Rubayi

8.1 Introduction In an acute ulcer that develops in a short

Ischial ulcer is common among spinal cord injury
patients as a result of sitting for prolonged peri-
ods of time without pressure relief or without a
proper wheelchair cushion, which is an important
tool to relieve pressure on insensate skin in that
area. This ulcer accounts for about 23 % of all
pressure ulcers. This type of ulcer is seen in the
active stage of a patient’s life after injury, when
the patient is discharged to home after rehabilita-
tion to start a new life and adapt to sitting in a
wheelchair.
8.2 Clinical Manifestation
period of time, necrotic tissue is seen clinically or
is covered with dry, necrotic skin (Fig. 8.2).
The ulcer base can represent the necrotic peri-
osteum of the ischial bone. The ulcer can extend
under the gluteus maximus muscle and the hip
joint, and infection can descend into the posterior
thigh compartment to form a necrotizing fasciitis.
Ischial ulcer can extend superiorly into the coc-
cygeal area or inferiorly in the perineal area to
involve the urethra in male patients.
8.3 Indications for Bowel
Diversion (Diverting
Colostomy)

The ulcer can appear clinically as a stage IV ulcer There are some circumstances when bowel diver-
over the ischial area. The ischial bone can be seen sion, performed by a colostomy, is indicated
exposed in the base of the ulcer, and the appear- before flap surgery, such as when there are
ance depends on the age of the ulcer. If it is a
chronic ulcer, the base of the ulcer is covered
with granulation tissue, which covers the ischial
bone (Fig. 8.1).

S. Rubayi, MB, ChB, LRCP, LRCS, MD, FACS,

Department of Surgery, Rancho Los Amigos
National Rehabilitation Center, Downey, CA, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com Fig. 8.1 Chronic ischial ulcer, stage IV

S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers, 81

DOI 10.1007/978-3-662-45358-2_8, © Springer-Verlag Berlin Heidelberg 2015
82
Fig. 8.2 Acutely developed ischial ulcer, stage IV,
necrotic skin and deep tissue
multiple ulcers within the vicinity of the anus,
including bilateral ischial ulcer, coccygeal ulcer,
or perineal ulcer. In the author’s experience, the
minimal clear distance between the flap edge and
the anal verge should be at least 6 cm or more,
taking into consideration the excision of the
unhealthy ulcer margin during surgery. Any dis-
tance smaller than that may lead to certain mor-
bidities in flap healing. A possible consequence
of close proximity of the flap wound to the anal
verge is contamination of the clean flap wound
with frequent stool and the risk of bacterial colo-
nization [1] of the wound, especially in the early
stage of wound sealing. Another important con-
sideration is mechanical interference with wound
healing resulting from frequent cleaning of the
anal area by nurses after a bowel program or
movement that causes breaking in the wound
sealing and wound sutures, which eventually
causes dehesion and separation of the flap wound.
The diverting colostomy became part of our pre-
operative requirement for these reasons. The
diverting colostomy procedure can be temporary
or permanent, according to the patient’s wishes.
A temporary colostomy can be reversed within 6
months after flap surgery to demonstrate com-
plete healing and no breakdown in the new flap,
which indicates patient compliance to prevent
flap breakdown. A double-loop type colostomy is
indicated when the patient is at an end stage for
flap surgery and the anus is to be closed perma-
nently during the procedure of disarticulation and
total thigh flap.
8 Reconstructive Surgery for Ischial Ulcer
8.4 Surgery for Single Ischial
Ulcer Stage IV
The following options for flap procedures can
be used:
• Inferiorly based gluteus maximus musculocu-
taneous flap (in a rotation or island sliding
flap)
• Hamstring muscles advancement musculocu-
taneous flap in V-Y closure
• Gracilis muscle transfer and posterior thigh
fasciocutaneous advancement flap
• Gracilis muscle musculocutaneous rotation
flap
• Gracilis muscle transfer and medial thigh fas-
ciocutaneous rotation flap
• Gracilis muscle transfer and posterior thigh
fasciocutaneous rotation flap
• Gracilis muscle transfer and direct closure
• Advancement of gluteus maximus flap as an
island flap
• A nonhealing stage III ulcer can be closed by
skin graft or local fasciocutaneous flap
The choice of these options depends on many
factors, including whether the ulcer is primary or
recurrent, the size of ulcer, and whether the
patient is ambulatory or sensory.
8.5 Gluteus Maximus Inferiorly
Based Musculocutaneous
Rotation Flap
8.5.1 Topographical Landmark
It is important to locate the vascular supply of the
muscle on the skin surface that covers the mus-
cle. The bony landmark is palpated and marked
on the skin by a marking pen. The iliac crest,
which represents attachment of the gluteal fascia
or lumbar fascia where the gluteus maximus orig-
inates, and the prominent superior posterior iliac
spine (PSIS), which is easy to feel in thin patients,
are marked. It is sometimes not possible to feel
the bone if the bone has been used previously as
a bone graft in spine surgery; a scar in that area
will be an indication. After location of the PSIS,
a line is drawn laterally about 6 cm in length with
8.5 Gluteus Maximus Inferiorly Based Musculocutaneous Rotation Flap 83

a 45° angle from the PSIS. The end of the line
represents the location of the superior gluteal
artery [2]. The inferior gluteal artery and nerve
are located by placing a width of about four fin-
gers below the marked location of the superior
gluteal artery in a lateral direction (Figs. 8.3 and
8.4a, b). The location of the sciatic nerve is lat-
eral to the inferior gluteal artery and nerve.
8.5.2 Surgical Anatomy
The gluteus maximus muscle originates from
many bony landmarks superiorly from the lumbar
fascia, which is called the gluteal fascia below the
iliac crest. The muscle originates from the sacrum
at the level of the posterior superior iliac spine and
Fig. 8.3 Topographical marking for the gluteal blood
vessel, the arrow indicates the location of the superior
gluteal artery
the lateral edge of the lower part of the sacrum and
from the coccygeal segment. The gluteus maxi-
mus muscle is inserted into a wide area, the greater
trochanter, which extends into the iliotibial tract
and lateral intramuscular septum (Fig. 8.5a, b).
The muscle acts as an external rotator and extensor
of the hip joint. It is in relationship to other mus-
cles as its superior part covers the gluteus medius
and below it covers the piriformis muscle, obtura-
tor, and quadratus femoris muscle.
The sciatic nerve passes beneath the pirifor-
mis muscle and over the obturator internus mus-
cle and obturator externus muscle. The inferior
gluteal nerve originates from the sciatic nerve
(L5, S1, S2), which is the motor nerve to the
muscle and passes to the inferior portion of the
muscle. The superior gluteal nerve supplies
the gluteus medius and gluteus minimus muscle.
There are two ways to identify the plane
between the gluteus maximus muscle and the
gluteus medius muscle. The first approach is at
the superior posterior iliac spine by detaching the
muscle from that bone and passing a finger in the
inferolateral direction to separate the plane
between the two muscles. The confirmation that
the finger is in the anatomical plane is observing
the superior gluteal artery passing under the inner
gluteal muscle surface. A complete detachment
from the gluteal fascia superiorly and laterally
from the tendinous part will then open the plane
and release the muscle for medial rotation. The
other is the lateral approach to the muscle by

a b

Fig. 8.4 (a) Marking the location of the inferior gluteal artery. Arrow indicates the location of the inferior gluteal
artery. (b) Marking of the superior gluteal artery and inferior gluteal artery lateral view
84
a b
Fig. 8.5 (a) Origin of the gluteus maximus muscle, sciatic nerve is lateral to the inferior gluteal artery, see arrow. (b)
Origin of the gluteus maximus muscle lateral view
making a perpendicular incision in the skin and
subcutaneous tissue and into gluteal fascia and
then using electrocautery into muscle fibers until
approaching the plane between the gluteus maxi-
mus and medius. The loose areolar tissue can be
separated with a finger to complete the plane
separation between the two muscles.
8.5.3 Vascular Pattern
of the Gluteus Maximus
Muscle
The gluteus maximus muscle is a dual blood sup-
ply type III muscle. The superior gluteal artery
originates from the internal iliac artery. The infe-
rior gluteal artery is located medial to the sciatic
nerve. The lower portion of the gluteus maximus
muscle receives additional vascular supply from
the medial circumflex artery and perforator ves-
sels from the lateral intermuscular septum of the
lateral thigh compartment (Fig. 8.6).
8.5.4 Gluteus Maximus Rotation
Musculocutaneous Flap
The skin territory covering the muscle has an
excellent vascular supply from the muscle under-
neath it. It is a durable flap and is the orthodox
flap for closing a single ischial ulcer in a patient
without sensation or motor (i.e., nonambulatory).
This flap is based on the inferior portion of the
gluteus maximus muscle [3] and can be used
8 Reconstructive Surgery for Ischial Ulcer
alone or with another muscle such as the gracilis
muscle. The choice of the other muscle depends
on the size and depth of the ulcer and whether the
ulcer is a first-time or recurrent ulcer. Some
authors believe that the gluteus maximus flap
should not be used for closure of ischial ulcer and
should be reserved for closure of sacrococcygeal
ulcers. The author’s experience is that using the
inferior portion of the gluteus maximus muscle
does not interfere when using the upper portion
of the muscle for repair of the sacral area, whether
at a later stage or simultaneously when the patient
has sacral and ischial ulcer. The author has used
the entire muscle simultaneously without major
difficulty. The inferiorly based gluteus maximus
flap can be revised and re-advanced later in case
of recurrent ulceration. Lax, soft skin and subcu-
taneous tissue will make this revision and re-
advancement easier; in a tight and scared area, it
is more difficult to accomplish.
8.5.5 Flap Design
The ulcer site is marked in a triangular shape,
with the apex superiorly located. A semicircular
line (French curve) is drawn, extending from the
lateral angle of the ulcer triangle, passing through
the gluteal crease, and curving laterally over the
greater trochanter. The curve extends laterally up
to the level below the iliac crest and, if needed, a
back cut can be made to facilitate the rotation of
the flap medially to cover the defect without ten-
sion (Fig. 8.7a, b).
8.5 Gluteus Maximus Inferiorly Based Musculocutaneous Rotation Flap 85

Fig. 8.6 Vascular supply lIiac crest

of the gluteus maximus
muscle
Posterior superior
lIiac spine

Superior gluteal n. & a.

Piriformis

Inferior gluteal n. & a.

Sacrotuberous lig.

Pudendal n.
Internal pudendal a. Sciatic n.

Posterior femoral
N. to obturator internus
cutaneous n.

a b

Fig. 8.7 (a) Flap design for inferiorly based gluteus maximus flap, patient in prone position. (b) Flap design for infe-
riorly based gluteus maximus flap, lateral view of the flap design

8.5.6 Operative Techniques
Excision of the ulcer and shaving of the bone are
as described in Chap. 7. The skin is incised along
the marked line with a scalpel, then, using an
electrocautery, the subcutaneous layer and the
gluteal fascia are incised, exposing the muscle
fibers. The muscle fibers are incised with an elec-
trocautery, preferably about 2–3 cm below the
level of the skin incision to allow the muscle
fibers, when the flap is rotated, to cover the ulcer
defect. The next stage is finding the plane
86 8 Reconstructive Surgery for Ischial Ulcer

between the gluteus maximus and the hamstring

muscle. In chronic ulceration, there is usually
scarring and adhesions over the medial border of
the gluteal muscle secondary to reaction from the
ulcer. This scarring can be dissected down by
blunt dissection to visualize the normal plane.
When it is found, a finger is passed in the plane
and, with the electrocautery, the transection of
the muscle is completed. When approaching lat-
erally, the plane becomes tight because of the ten-
dinous fibers of the gluteal muscle. When the
muscle approach its insertion, this needs to be
incised, exposing the greater trochanter with the
Fig. 8.8 Disposable electric pump drainage system
trochanteric bursa. The gluteus maximus fibers (sump pump)
are then incised laterally until approaching the
level below the iliac crest. The plane can be seen
at this stage between the gluteus maximus and
gluteus medius muscle. The flap can be lifted
upward and the attached loose areolar tissue is
then divided. Care should be taken to avoid injury
to the hip capsule. If there are still adhesions
medially near the ulcer defect, they should be
divided to allow mobility of the flap. At this
stage, the inferior gluteal artery should be identi-
fied passing on the posterior surface of the mus-
cle and the sciatic nerve running laterally at the
lateral border of the biceps femoris. This area is
Fig. 8.9 Anteroposterior x-ray of the pelvis showing air
vascular and vascular injury and bleeding can over the ischium and bony changes as indicated by the
occur during dissection; therefore, care should be arrow secondary to the ulcer
taken to avoid this injury. The flap is rotated to
cover the defect, and a check should be made to
determine whether there are any tension areas. If
there is a tension area medially, a back cut should
be made to free the flap. Hemostasis and irriga-
tion should be performed on the flap wound. The
type of irrigation the author uses is warm normal
saline mixed with an antibiotic solution such as
bacitracin. If there is bleeding from the shaved Fig. 8.10 Ulcer excised completely
ischial bone, biological collagen (Avitene®) is
used to cover the bone. A good drainage system Vicryl® suture, dermal layers using 3–0 Vicryl®
should be used to drain the area over the bone and suture, and skin with interrupted 0° polypropyl-
under the flap. The exits of the drains should be ene sutures. The wound is dressed with bacitracin
away from the ulcer defect, in this case at the lat- ointment and covered with Xeroform® gauze,
eral gluteal area below the iliac crest area. The dry surgical gauze, and an ABD pad. A foam
author uses closed system drains attached to a abduction pillow is placed between the thighs of
disposable electric pump (Fig. 8.8). the patient to prevent mechanical movement
The closure of the flap should be done in three during nursing care in the postoperative period
layers, the deep fascia and muscle using 0° (Figs. 8.9, 8.10, 8.11, 8.12, and 8.13).
8.6 Hamstring Muscle Advancement Flap
Fig. 8.11 Gluteus maximus flap fully dissected and
lifted upward
8.6 Hamstring Muscle
Advancement Flap
The hamstring muscle advancement flap is a
musculocutaneous flap. The skin island territory
of the flap is supplied with excellent perforators
from the hamstring muscles beneath the skin.
The muscles are the biceps femoris, semitendino-
sus, and semimembranous muscles [4–7]. These
muscles are supplied by five main perforators
from the profunda artery. The flap can be
advanced to cover the ischial defect and some-
times can be rotated medially to cover some of
the perineal defect. The resulting donor site of the
advanced flap can be closed in a V-Y closure.
This flap is excellent for a single ulcer defect
in insensate and nonambulatory patients because,
when the hamstring muscles are transected dis-
tally for flap advancement, this may cause a func-
tional deficit in ambulatory patients, especially in
87
flexion of the knee joint. The disadvantage of this
flap if the ischial ulcer does extend superiorly in
the gluteal areas in this situation, technically, it is
difficult to advance the flap over longer distances.
Another drawback is that the proximal part of the
flap, which is a few centimeters in length, is fas-
ciocutaneous, which is not ideal for covering a
deep defect. For this reason, a layer of muscle
should be used first to cover the bone and the
dead space and to prevent complications of a
dead space. The gracilis muscle is the ideal mus-
cle as a first layer of repair. If the gracilis muscle
is not present, for example, because it has been
utilized in previous surgery, the author’s recom-
mendation is to dissect the biceps femoris muscle
from the surrounding muscles and sacrifice by
transect the first perforator and advance the
biceps femoris muscle to cover the ischial bone
and act as a first layer of repair. If the biceps mus-
cle cannot be advanced, deepithelialization of the
proximal part of the hamstring flap can be per-
formed to create a soft tissue filler of the defects.
In some circumstances, when a longer distance of
advancement is required, the donor area of the
flap cannot be closed with a V-Y closure and, if
the closure is under tremendous tension, necrosis
of the skin may result. Therefore, a skin graft is
used to close the flap defect distally. The ham-
string flap has excellent vascularity, which allows
the flap to be revised and advanced at least twice
in recurrent ulceration.
8.6.1 Surgical Anatomy
The biceps femoris muscle is the most lateral and
largest of the hamstring muscles. The biceps fem-
oris has a long and a short head. The long head of
the biceps femoris and the semitendinosus and
semimembranosus muscles originate from the
ischial tuberosity. In extensive ulceration, the ori-
gin of these muscles will be destroyed by the
ulceration and the tendinous part of the muscles
becomes part of the ulcer bed and needs to be
excised during ulcer excision. The short head of
the biceps femoris has a deeper origin from the
linea aspera of the femur. The biceps femoris is
inserted distally in the head of the fibular bone
88 8 Reconstructive Surgery for Ischial Ulcer

a b

Fig. 8.12 (a) Operative photograph showing complete rotation of the flap to close the ulcer defect. (b) Rotation of the
flap and flap sutured in place

a b

Fig. 8.13 (a) Flap completely healed at 6 weeks post-surgery. (b) Flap healed at 6 weeks post-surgery, lateral view

and the lateral condyle of the tibia. The biceps
femoris muscle is fused medially with the semi-
tendinosus and the semimembranosus muscle
through their combined origin from the ischial
tuberosity in the mid-thigh area, and the sciatic
nerve separates the two groups of muscles
(Fig. 8.14). When the hamstring muscles are con-
tracted, the sciatic nerve is involved with the
process and becomes tight. This condition is seen
frequently in paraplegic and tetraplegic patients.
Therefore, advancement of the hamstring flap
cannot be accomplished without transection of
the muscle and the sciatic nerve. The functional
importance of the biceps femoris muscle remains
unclear, but it stabilizes and tightens the flexed
iliotibial tract, which is an important lateral knee
8.6 Hamstring Muscle Advancement Flap 89

Gracilis

Semimembranousus Biceps femoris

long head
Semitendinousus
Biceps femoris
short head

Fig. 8.15 Design of the hamstring advancement flap

Fig. 8.14 The anatomical relationship of the hamstring
muscles
stabilizer. The biceps femoris muscle is a major
external rotator of the knee and knee flexor in
ambulatory patients and, therefore, this type of
flap should not be used in ambulatory patients to
avoid functional deficit.
8.6.2 Vascular Supply
of the Hamstring Muscles
The biceps femoris and the other hamstring mus-
cles are a classical example of muscles supplied
by segmental vessels. These deep perforator ves-
sels at the upper two thirds of the thigh originate
from the profound femoris vessel, while in the
lower third of the thigh they originate from
the popliteal vessel. There are total of about five
perforators. In the author’s experience, the first
perforator can be transected for the purpose of
advancement of the biceps femoris to fill a defect
in the ischial area when the gracilis muscle is not
available. The motor nerve of the entire ham-
string muscle is the sciatic nerve.
8.6.3 Design of the Flap
Two semi-curved lines are drawn over the poste-
rior thigh skin, each line from each side medially
and laterally of the ulcer. The two lines extend
inferiorly and meet at the lower third of the pos-
terior thigh, like a large “V.” The lateral line
should not extend over the lateral intermuscular
septum and the medial line should not extend into
the medial thigh compartment (Fig. 8.15).
8.6.4 Surgical Technique
The patient is placed in the prone position on the
operating table, with the table in the jackknife
position (Fig. 7.6) to ensure that, at the end of
90
Fig. 8.16 V-Y hamstring flap designed to close ischial
ulcer
the procedure, the flap is not closed under tension.
Excision of the ulcer and bone shaving are per-
formed as described in Chap. 7. Using a scalpel,
the skin is incised on each side of the v-line. The
deeper tissue is incised on each side of the v-line
using an electrocautery. An assistant should retract
using two skin hooks, avoiding excessive pulling
on the island side to prevent separation of the skin
edge from the underlying muscle. When the sub-
cutaneous layer is incised, the deep fascia that cov-
ers the muscles is exposed. On the lateral side,
when the deep fascia is incised, the muscle will be
exposed with freeing of the skin island. The glu-
teus maximus muscle superiorly should then be
incised to free the flap completely and allow
advancement proximally toward the defect.
Medially, the fibrofatty tissue in the perineal area
should be incised to expose the proximal part of
the gracilis muscle and the semimembranosus
muscle. In addition, the scars at the base of the
8 Reconstructive Surgery for Ischial Ulcer
Fig. 8.17 The ulcer excised completely
ulcer should be incised to free the flap and allow
medial advancement. If the flap cannot be freed to
be advanced, two maneuvers can be performed to
transect the hamstring muscle distally. Care should
be taken not to injure the main blood vessel at the
level above the popliteal fossa. The second maneu-
ver is to release the origin of the hamstring muscle
from the ischium, which allows the hamstring flap
to be advanced without tension.
The author’s recommendation, as described
earlier, is to use a first layer of muscle to cover
the ischium. The gracilis muscle is ideal for utili-
zation as a muscle flap through the already exist-
ing medial incision, and the gracilis tendon is
transected distally and the muscle transposed to
the ischial defect. Two drains should be placed,
one under the muscle and the other over the mus-
cle and the exit of these drains are at the lower
part of the thigh (Figs. 8.16, 8.17, 8.18, 8.19,
8.20, and 8.21). The wound should be closed in
three layers, as described previously.
8.7 Gracilis Muscle Flap
The gracilis muscle flap is an excellent recon-
structive option for simple, uncomplicated pres-
sure ulcers in ambulatory and sensory patients
and as a primary surgical management alternative
to utilizing the gluteus maximus muscle flap or
the hamstring advancement flap, reserving these
flaps for recurrent ulceration or complicated
cases. In the author’s opinion, the practice of
using any fasciocutaneous flap (i.e., posterior
thigh fasciocutaneous flap or medial thigh
8.7 Gracilis Muscle Flap
Fig. 8.18 Operative photograph showing the hamstring
flap dissected completely, the proximal part is deepitheli-
alized and gracilis muscle utilized (long arrow), short
arrow indicates the shaved ischial bone
fasciocutaneous flap) alone is not sufficient to fill
the defect and to cover the ischial bone. Utilizing
the gracilis muscle is vital for immediate healing
and, in the remote period, for the bone and wound
healing. The gracilis muscle can be identified in
surgery and it can be determined whether it has
been used previously. In some instances, it can be
reused to fill a defect. The gracilis muscle donor
site can be closed easily. The use of the gracilis
muscle has been described in the literature in
closing the ischial and perineal ulcer defect [8–
11]. The author’s practice is to utilize the gracilis
muscle in all ischial ulcer closures when the
patient is in the prone position. The contralateral
gracilis muscle can be used when the gracilis of
the same ulcer side was previously utilized. The
contralateral gracilis can be tunneled in the
perineum of the male and even in the female
perineum to cover an ischial defect as a first layer.
91
Fig. 8.19 Advancement of the hamstring flap
8.7.1 Surgical Anatomy
The gracilis muscle is located in the medial thigh
compartment; it is part of the adductor
compartment. It is the most superficial muscle of
the group and can be palpated if the patient is
lying in the supine position and the hip is
abducted and the knee is flexed at the same time.
It originates from the pubic tubercle and the
medial segment of the inferior pubic ramus. The
muscle belly is flat and ends with a round tendon
that is inserted in the medial surface of the upper
end of the tibial body. The muscle vascularity is
classified as type II. The vascular supply is a
dominated artery originating from the profunda
artery system as a branch from the medial femo-
ral circumflex artery, about 8–10 cm below the
pubic tubercle. At the mid and lower third of the
muscle, the muscle receives one to two vascular
92
Fig. 8.20 The flap is sutured in place
pedicles. These are branches of the superficial
femoral artery. The motor nerve supply from the
anterior branch of the obturator nerve enters the
muscle near the vascular pedicle entry. There are
a few anatomical points that should be consid-
ered when the patient is in the prone position.
The medial incision over the thigh should not be
placed too medial, otherwise the gracilis muscle
will be missed and the dissection is in the adduc-
tor muscle compartment. Another anatomical
landmark is the long saphenous vein, which, if it
is observed in the incision, indicates that the inci-
sion is too medial over the adductor muscles. To
differentiate between the gracilis muscle and the
hamstring muscle, one follows the origin of
the muscle to confirm the identity. In addition,
8 Reconstructive Surgery for Ischial Ulcer
Fig. 8.21 Six weeks post-surgery shows complete flap
healing
the gracilis muscle is smaller in size and covered
with fascia. If the patient has been paralyzed for
a long period of time, the muscle appearance is
small and the fibers are replaced with fatty tissue.
In patients with muscular spasm, the muscle will
be large in volume and have hypertrophic fibers
(Fig. 8.22).
8.7.2 Operative Technique
The patient is placed in the prone position and
the operating table is in the jackknife position.
Excising the ulcer and shaving the bone are per-
formed as described in Chap. 7. The skin mark-
ing extends from the medial side of the excised
ulcer, over the medial posterior thigh in a curved
way, extending distally, and ends above the knee.
The skin incision is performed with a scalpel and
8.8 Gracilis Muscle and Medial Thigh Fasciocutaneous Rotation Flap
Fig. 8.22 Topographical anatomy and location of the
gracilis muscle. Short arrow indicates the main pedicle of
the muscle, long arrow indicates the secondary pedicle of
the muscle
the subcutaneous layer with an electrocautery. If
the patient is thin, the fascia that covers the grac-
ilis muscle is easily observed. The fascia is then
incised with an electrocautery. This step is per-
formed distally when the muscle is more superfi-
cial than the proximal end. When the tendon of
the gracilis is identified and then transected at
the lower end, prior to its insertion, a clamp is
placed at the distal end and lifted up. A blunt or
electrocautery dissection continues proximally
until approaching the main vascular pedicle of
the muscle. Dissection can be performed later-
ally to obtain extra length of the muscle. The
location of the main pedicle determines the arc
of rotation to transpose the muscle to the ischial
defect. The next step is the covering the muscle
surface by the posterior thigh flap as a fasciocu-
taneous flap or the medial thigh fasciocutaneous
flap; both are discussed later in the chapter.
Operative photographs are illustrated in the fol-
lowing sections.
93
8.8 Gracilis Muscle and Medial
Thigh Fasciocutaneous
Rotation Flap
The medial thigh fasciocutaneous rotation flap is
an excellent option for closing ischioperineal ulcers
[12, 13] and recurrent ischial ulcer, when the option
of utilizing the gluteus maximus flap and hamstring
flap is not available because they were utilized in
the past. This is an appropriate flap for use in ambu-
latory sensory patients without causing any func-
tional deficit. In spina bifida patients in which skin
sensation is patchy, the medial thigh skin has excel-
lent sensation, and, therefore, utilization of this flap
will transfer a sensory area to an insensate area
over the ischial area, which eventually prevents
breakdown of their skin in the future. The blood
supply of this flap originates as a perforator from
the gracilis and the adductor muscles, which pro-
vides excellent blood supply to the deep fascia of
the flap. This flap, when used alone, is not suffi-
cient to cover the bone without a first muscle layer;
the gracilis muscle is ideal for this purpose. If the
gracilis muscle was used in a previous surgery,
the biceps femoris muscle is advanced to cover the
ischium as the first layer and then it is covered by
the medial thigh flap.
The drawback of this flap is that, when rotated
medially, a “dog ear” results. Some patients may
complain about it, and attempts to excise the
“dog ear” may reduce the blood supply to the
flap. Another disadvantage is, if the flap is
designed with a wide width, it may be difficult to
directly close the flap donor site.
8.8.1 Operative Techniques
The patient is placed in the prone position on the
operating table. A temporary purse string suture is
placed in the anus to prevent soiling during sur-
gery and should be removed at the end of the sur-
gery. The ulcer is excised as described in Chap. 7.
Marking of the flap is performed from the mid-
lower margin of the ulcer defect over the medial
thigh side and the extension of the line inferiorly in
a length equal to the length required when the flap
is rotated medially, with the arc of rotation in the
94
perineum. The length should be adequate to cover
the entire defect and the width of the flap equal to
the width of the ulcer defect. The medial marking
of the flap is in the inner surface of the thigh and it
extends as long as needed for the rotation. If the
gracilis muscle is utilized, the marking extends
over the medial side of thigh and stops above the
knee (Fig. 8.28). The dissection first raises the fas-
ciocutaneous flap by incising the skin with the
scalpel and then goes deeper into the subcutaneous
layer using an electrocautery. To identify the fas-
cial layer, it is easy to incise and dissect the lower
border of the flap, which is in the superficial area.
After identifying the deep fascia, the dissection of
the flap continues in all directions. An important
point is that there should be sufficient deep fascia
to carry the skin flap. The inner thigh dissection
depends on how long the flap needs to be in order
to be rotated without tension to cover the defect. If
the gracilis muscle is utilized, the dissection con-
tinues inferiorly to identify the gracilis muscle
when the covering fascia is opened. Dissection of
the gracilis from its bed is as described in the
Fig. 8.23 Operative photograph showing the design of the
medial thigh fasciocutaneous flap to cover the large defect of
the ischial cavity and to cover the vastus lateralis muscle
8 Reconstructive Surgery for Ischial Ulcer
previous section. The gracilis muscle is transposed
at the level of its blood supply, which represents
the arc of rotation. Two drains are used, one below
the muscle and one over the muscle, and the exits
of these drains are above the knee. The gracilis
muscle is folded on itself and sutured to the sur-
rounding tissue to seal the entire defect, and the
medial thigh flap is rotated medially to cover the
gracilis muscle and sutured in three layers (deep,
dermal, and skin). If the donor area of the flap can-
not be closed, dissection of the posterior thigh skin
as a fasciocutaneous flap is freed to allow closure
of the defect. Figures 8.23, 8.24, 8.25, and 8.26
illustrate the steps of the operative procedure of
raising the medial thigh flap.
Fig. 8.24 Operative photograph showing the dissected
medial thigh fasciocutaneous flap, arrow indicates the
deep fascia of the flap
Fig. 8.25 Operative photograph showing the rotation of
the fasciocutaneous flap to cover the defect, the other side
was closed directly over the vastus lateralis flap
8.10 Gracilis Muscle and Posterior Thigh Fasciocutaneous Rotation Flap
Fig. 8.26 Operative photograph showing the insetting
and suturing of the medial thigh fasciocutaneous flap
8.9 Gracilis Muscle
as a Musculocutaneous Flap
This flap is not commonly used by the author for
repair of ischial ulcer for many reasons. In these
pressure ulcer surgeries, patients are placed in the
prone position, making it technically difficult to
locate the gracilis muscle to design a skin island
over the muscle as a myocutaneous flap. Many
patients have abnormalities in the gracilis muscle
anatomy due to rotation of the thigh. In patients
with a primary diagnosis of paraplegia, the mus-
cles become atrophic over time, and the gracilis
is a small muscle by itself. Therefore, it will not
support the vascularity of the skin island. The
gracilis muscle is used as a musclocutaneous flap
for reconstruction of the perineum or genitalia.
When the patient is ambulatory, in the supine
position it is technically possible to design the
flap, especially if the patient is placed in the
lithotomy position.
8.9.1 Operative Technique
The patient is placed in the prone position on the
operating table. Excision of the ulcer or the
ischial bursa and bone shaving are performed as
described in Chap. 7. The width of the excised
ulcer defect is measured, which determines the
width of the flap. The flap is designed over the
medial thigh surface. The length of the flap
depends on the size of the flap needed to cover
95
the defect and to be rotated around the arc of rota-
tion, which is at the level of the gracilis muscle
vascular pedicle. To identify the gracilis muscle
distally, the usual approach is as described previ-
ously. The gracilis muscle is identified and then
the location of the island of skin that is to be
located over the muscle belly; the muscle is in the
mid-position of the skin island. The gracilis is
dissected distally from its bed and then transec-
tion of the muscle tendon is performed distally; it
should be longer than the skin island. The muscle
is dissected by blunt dissection from its bed.
When approaching the distal end of the skin
island, the muscle and the skin area should be
dissected as one unit. As a precaution, a suture is
placed between the end of the skin edge and the
muscle to prevent separation between the skin
island and the muscle. At this stage, the skin
island is incised with a scalpel and then, using an
electrocautery, the deep tissue is dissected on
both sides of the flap to the level of the arc of
rotation and the required length to cover the
defect. The flap is rotated to see whether it fills
the defect without tension. The wound is irri-
gated and a drain is placed distally to drain the
ulcer defect and flap donor site at the same time.
The distal free part of the gracilis is used to cover
the bone as a first layer and then the myocutane-
ous flap to cover the entire defect. The flap is
closed in three layers (Figs. 8.27, 8.28, 8.29,
8.30, and 8.31).
8.10 Gracilis Muscle and Posterior
Thigh Fasciocutaneous
Rotation Flap
This flap is useful in repairing ischioperineal
defects. The flap has been described by many
authors [14–17] in repair of an ulcer defect as a
single flap. The requirement for this flap is that
the posterior thigh skin should be intact and not
involved with the ulcer to be closed (i.e., the
blood supply to the skin is intact). The disadvan-
tage of this flap is that it leaves the donor site
closure as scar in the middle of the posterior
thigh, which is an obstacle in performing a V-Y
hamstring flap in the future in case of recurrent
ulceration. As a fasciocutaneous flap, it can
96
Fig. 8.27 Operative photograph showing the ischial
sinus leading to bursa over the ischium
Fig. 8.28 Design of the skin island over the gracilis mus-
cle location. The proximal skin mark is the location of the
muscle pedicle, which is the arc of rotation of the flap
cover the ulcer defect but not the dead space of
the excised ulcer. For this reason, the author
uses the gracilis muscle as a first layer flap to
cover the ischial bone. In addition, if the design
8 Reconstructive Surgery for Ischial Ulcer
Fig. 8.29 Operative photograph showing the dissection of
the gracilis muscle with the skin island attached to the
muscle
Fig. 8.30 Operative photograph showing the flap is rotated
to cover the defect showing the extra muscle distally
of the flap is too long, there is a high risk of
losing the distal part of the flap, as with many
fasciocutaneous flaps.
The main blood supply of this flap is by a
descending branch from the inferior gluteal
artery and a branch from the first hamstring per-
forator. In addition, the lower portion of the glu-
teus maximus muscle provides blood supply to
the posterior thigh skin. If the flap is designed
more laterally, the lateral intermuscular septum
provides perforator branches to the posterior
thigh skin. The composition of the flap consists
of skin, subcutaneous layer, and deep fascia of
the posterior thigh.
8.10 Gracilis Muscle and Posterior Thigh Fasciocutaneous Rotation Flap
Fig. 8.31 Flap is sutured to cover the ischial defect and
flap donor side is closed directly
8.10.1 Operative Technique
As described in the previous procedures, the
patient is placed in the prone position; the ulcer
and the ischial bone are dealt with as described in
Chap. 7.
8.10.2 Flap Design
The skin marking of the flap over the posterior
thigh is marked with a line extending from the
lateral border of the ulcer defect. The length of
the line depends on the arc of rotation required to
cover the defect without tension. The width of the
flap is equal to the longitudinal width of the ulcer
defect. The other line of the flap extends in an
upward direction from the base of the flap to the
gluteal area (Fig. 8.32).
8.10.3 Flap Elevation Technique
The first skin incision is the medial marking of
the flap, extending to the base of the flap and
then into the lateral marking of the flap. When
the skin incision is completed, an electrocau-
tery is used for the subcutaneous layer, expos-
ing the deep fascia covering the hamstring
muscles, which is incised. Care should be
97
Fig. 8.32 Operative photograph of a patient in prone
position with bilateral ischial ulcer and coccygeal ulcer.
In this case, we elected to close one side with the poste-
rior fasciocutaneous thigh flap and on the other side we
used the medial thigh fasciocutaneous flap. For the coc-
cygeal ulcer, the standard gluteus maximus sliding flap
was used
taken to keep the fascia intact with the skin, as
with blunt dissection the fascia can be sepa-
rated from the hamstring muscles. The flap is
freed from the gluteus maximus muscle by
dividing some muscle fibers and is rotated to
see whether it covers the medial border of the
ulcer defect without tension. If not, further
division at the gluteus maximus area is per-
formed. The gracilis muscle is utilized when a
deep, large defect exists, as described previ-
ously, and the author prefers to make a subcu-
taneous tunnel to pass the gracilis to the ischial
defect. The tunnel should admit two fingers to
allow free passage of the muscle to the ischial
defect. Two drains are used, as described previ-
ously; one under the gracilis muscle and the
other above the muscle. The exit of the drains
is inferiorly above the knee area. The gracilis
muscle is sutured to the surrounding deep tis-
sue. The fasciocutaneous flap is rotated from a
longitudinal position into a horizontal position.
The flap is closed in three layers, and the flap
donor site is closed directly. If it is difficult
to close the defect dissection, lateral and
medial closure at the fascial level will help.
Figures 8.32, 8.33, 8.34, 8.35, 8.36, 8.37, 8.38,
8.39, and 8.40 show the operative steps of rais-
ing the flaps.
98
Fig. 8.33 Operative photograph showing the ulcers
excised and the ischial bone shaved. The posterior thigh
flap and the medial thigh flap have been dissected, and the
gracilis muscle is exposed. Arrows indicate dissected flaps
Fig. 8.34 Operative photograph showing the raised bilat-
eral fasciocutaneous flap (posterior and medial thigh flap)
Fig. 8.35 Operative photograph showing the raised bilat-
eral gracilis muscles
8 Reconstructive Surgery for Ischial Ulcer
Fig. 8.36 Operative photograph showing the gracilis muscles
placed in the required position. The left gracilis was tunneled
to the coccgyeal area because of the existing communication.
Arrow indicates the tunneled left gracilis muscle
Fig. 8.37 Operative photograph showing the trial of the rota-
tion of both bilateral flaps (posterior and medial thigh flap)
Fig. 8.38 Operative photograph showing the advance-
ment of the gluteus maximus flap to cover the coccgyeal
defect, the medial part of the flap was de-epithelized
8.11 Gracilis Muscle Transfer and Tunnel with Direct Closure of the Wound
Fig. 8.39 Operative photograph showing the completed
suturing of all flaps
Fig. 8.40 Operative photograph lateral view showing the
complete advanced and sutured gluteus maximus flap
8.11 Gracilis Muscle Transfer
and Tunnel with Direct
Closure of the Wound
When the gracilis muscle is available and has not
been used in a previous surgery, and if the ulcer is
not extensive, this option can be utilized to close
an ischial ulcer when the patient’s skin has the
advantage of laxity, which is helpful in this
method. Our observations indicate that direct clo-
sure of the ulcer defect without muscle is rarely
successful, even if the ulcer is stage III. When the
gracilis or another muscle is used, it acts as vas-
cular tissue to support the healing of the bone and
skin wound when it is closed directly above the
99
Fig. 8.41 Operative photograph of the ischial sinus lead-
ing to ischial bursa
muscle. This surgical option is indicated when
the patient is ambulatory because this procedure
does not lead to a functional deficit for the patient.
8.11.1 Operative Technique
Excision of the ulcer and shaving of the bone if
needed are performed as in the standard procedure.
The utilization and raising of the gracilis muscle
are performed as described in the section on the
gracilis muscle flap. The main step is tunneling the
gracilis muscle through the subcutaneous tissue to
transfer it to the ischial defect. Transfer of the grac-
ilis to the ischial defect through continuation of the
medial thigh incision to the ischial area is not rec-
ommended because of slow healing in the perineal
area, which may lead to skin breakdown.
Figures 8.41, 8.42, 8.43, 8.44, and 8.45 illustrate
the steps of the procedure to close ischial ulcer.
100
Fig. 8.42 Operative photograph showing the excision of
the ischial sinus, bursa, and gracilis muscle is raised from
its bed
8.12 Recurrent Ischial Ulcer
It is common to see this condition in insensate
patients such as those with spinal cord injury.
Patients with spina bifida, when they are confined
and sit in a wheelchair for long periods of time
without pressure relief, eventually develop pres-
sure ulcer. It is important that the plastic surgeon
responsible for closing these ulcers be aware that,
in this group of patients, repeated ulceration lim-
its the available options in closing the ulcer. The
increased magnitude of scarring and wasting of
the muscles make it difficult to mobilize the local
muscles or the fasciocutaneous flap to close the
defect. As a result, there is an increase in mor-
bidities, for example, skin necrosis and infection,
after flap surgery in this group of patients. The
available options to close a recurrent ulcer of the
ischium are:
8 Reconstructive Surgery for Ischial Ulcer
Fig. 8.43 Operative photograph showing the gracilis
muscle transferred and tunneled through subcutaneous
perineal tunnel to cover the ischial defect
• Re-advancement of the hamstring and use of
another flap as a first layer of repair. The
gracilis muscle has usually already been
used in a previous surgery, therefore, one
option is to advance the biceps femoris mus-
cle by dissection of the muscle and sacrifice
of the first perforator. In male patients, the
gracilis muscle of the contralateral side can
be tunneled under the perineal skin to the
other side as a first layer. The other option is
to deepithilize the proximal part of the ham-
string flap and use it to fill the ischial (dead
space) defect.
8.13 Complicated Extensive Ischial Ulcer with Extension into the Male Urethra
Fig. 8.44 The ischial wound closed directly over the
gracilis muscle and the gracilis donor site is closed
• Medial thigh flap as a fasciocutaneous flap, if
it has not been used in the repair of previous
primary ulcer.
• Gluteus maximus muscle sliding island flap.
This flap is described in detail in the Chapter 9
on sacral ulcers. The flap is designed so that
the advancement of the flap is in the inferior
direction toward the ischial defect. The blood
supply of this flap is the muscle perforators,
which derive from the superior or the inferior
gluteal artery. The donor site of the flap is
closed in a V-Y fashion (Figs. 8.46, 8.47, 8.48,
8.49, 8.50, and 8.51).
• The vastus lateralis muscle is utilized and
dissected with rotation from vertical to a
horizontal direction and tunneled to cover
both ischial defect (Figs. 8.52, 8.53, 8.54,
and 8.55).
101
Fig. 8.45 Photograph of the surgical area completely
healed 6 weeks post-surgery
8.13 Complicated Extensive
Ischial Ulcer with Extension
into the Male Urethra
Ischial ulcer can extend into the perineum, espe-
cially in males, and the perineal urethra can be
involved with the ulcer when, clinically, urine
can be seen leaking from the ulcer site and the
Foley catheter can be seen in the ulcer site. In
females, the perineum is small in size and the
opening of the vagina is in the middle of the
perineum; therefore, the pathological manifesta-
tion of the ulcer is somewhat different from the
ulcer extension in males. For clinical diagnosis of
urethral involvement in male patients, a radio-
logical test, a urethrocystogram, should be per-
formed. The diagnosis is confirmed by showing
the extravasations of the dye outside the urethra.
102
Fig. 8.46 Operative photograph showing recurrent
ischial ulcer with the design of the gluteus maximus island
flap
Fig. 8.47 Operative photograph showing the complete
dissection of the ischial bursa, which extends under the
gluteus maximus muscle
Fig. 8.48 Operative photograph showing two specimens that were excised; the first one is the bursa and the second is
the base of the ulcer
8 Reconstructive Surgery for Ischial Ulcer
If the extension of the ulcer is occurring for the
first time, a simple urinary diversion should be
performed by the urologist, which is s suprapubic
cystotomy before flap surgery. If the urethra is
involved in a recurrent ulceration, a permanent
urinary diversion should be performed before
flap surgery.
8.13.1 Operative Technique in Male
Patients
The patient is placed in the prone position.
A penile Foley catheter should be left in place to
visualize the communication of the ulcer with
the urethra. If there is a suprapubic tube and no
penile Foley catheter, injection of methylene
blue dye into the suprapubic catheter can be
done to visualize the area of the damage. When
the methylene dye appears in the ulcer, it indi-
cates the site of communication with the ure-
thra. The ulcer is excised as described in a
previous chapter. Then the penile urethra is
identified with catheter in, and the urethral wall
is dissected from both sides of the catheter to
allow sufficient mucosa to be closed around the
catheter without tension. Closure is done by
continuous 3–0 Vicryl® suture. This repair
should be covered with vascular tissue. The
gracilis muscle is the appropriate tissue for this
purpose. The gracilis muscle is raised from its
compartment as described previously and turned
8.13 Complicated Extensive Ischial Ulcer with Extension into the Male Urethra 103

Fig. 8.51 Operative photograph showing the complete

Fig. 8.49 Operative photograph showing the complete suturing of the gluteal flap to close the defect
dissection of the gluteal island flap

Fig. 8.52 Operative photograph of the patient in the

prone position with extensive ischial ulcer and prominent
contralateral ischial bone. The decision, in this case, was
to use the vastus lateralis muscle flap to cover both ischial
areas because of the quality of the skin and nonavailable
local muscles

in a way to cover the repair, then sutured in all

directions to seal the area of the urethral repair.
Fig. 8.50 Operative photograph showing the advance- If there is no urethral wall to be used, the graci-
ment of the gluteal flap into the defect lis can be used to cover the Foley catheter and
104
Fig. 8.53 Operative photograph showing excision of the
ischial ulcer and the contralateral side of the prominent
ischium; the gracilis is a small muscle to cover both
defects
Fig. 8.54 Operative photograph showing the vastus late-
ralis muscle completely dissected and the prominent tro-
chanteric bone shaved
Fig. 8.55 Operative photograph showing the tunneling
of the vastus lateralis muscle to cover both ischial defects
8 Reconstructive Surgery for Ischial Ulcer
Fig. 8.56 Operative photograph showing the patient with
extensive ischioperineal ulcer extending into the perineal
urethra with exposed perineal catheter. The patient had
multiple flaps in the past. Arrow indicates the position of
the urinary catheter
sutured in all directions as a posterior wall of
the urethra. If the gracilis muscle is not avail-
able because it has been used previously, local
tissue on both sides of the urethra is dissected as
a flap and advanced to cover the urethra and
sutured in place. A second flap is used to cover
this repair of the urethra and the ischial defect,
which will depend on the available options.
A V-Y hamstring flap can be used with medial
advancement to cover the perineum, or the pos-
terior or medial thigh fasciocutaneous flaps are
used in recurrent cases when all the previously
mentioned flaps have been used in the past. The
vastus lateralis muscle flap is transferred to
cover the defect (Figs. 8.56, 8.57, 8.58, 8.59,
8.60, 8.61, 8.62, 8.63, and 8.64).
8.14 Extension of the Ischial Ulcer
into the Hip Joint or
Trochanteric Area
It is not uncommon to see the extension of ischial
ulcer infection under the subcutaneous tissue and
over the hamstring muscle, eventually extending
into the hip joint capsule. In this situation, the
joint cavity and the femoral head are involved,
resulting in septic arthritis and osteomyelitis of
the femoral head. In the acute condition, the
patient presents with signs and symptoms of sep-
sis that are usually treated by intravenous antibi-
otics. The diagnosis of the source of sepsis may
8.14 Extension of the Ischial Ulcer into the Hip Joint or Trochanteric Area 105

Fig. 8.59 Operative photograph showing the vastus late-

ralis utilized to cover the extensive defect

Fig. 8.57 Operative photograph showing the extensive

dissection of the ulcers with the exposure of the damaged
perineal urethra

Fig. 8.60 Operative photograph showing the tunneling

Fig. 8.58 Operative photograph showing the Girdlestone
of the vastus lateralis muscle to the ischioperineal defect
procedure performed and the vastus lateralis dissected

head and neck of the femur can be felt, which

remain a mystery until a proper physical exami- confirms the diagnosis. In chronic cases, hetero-
nation is performed. When a manual examination topic ossification formation and destruction of
is performed, it will demonstrate the extension of the femoral head are seen on plain x-ray; this
a cavity from the ischium to the hip joint and the finding is called an “auto Girdlestone” (Fig. 8.65).
106
Fig. 8.61 Operative photograph showing suturing of the
vastus lateralis to the surrounding tissue and covering of
the urethral repair
The principle approach to this difficult problem is
to explore the entire gluteal area and hip joint and to
perform a Girdlestone procedure or proximal femo-
ral osteotomy and close all the defects by muscle
flap in a one-stage surgical procedure. In special
cases, when there is obvious infection with the pres-
ence of pus, the procedure must be performed in two
stages.
8.14.1 Operative Technique
The patient is in the prone position on the operating
table. The excision of the ischial ulcer and ischial
bone shaving are performed as described in Chap. 7.
8 Reconstructive Surgery for Ischial Ulcer
Fig. 8.62 Operative photograph showing a split-
thickness graft placed over the muscle
An incision is made from the lateral border of the
ulcer defect, extending into the gluteal crease to the
hip and trochanteric area. To expose the extending
tract or the communication between the ischial
ulcer and the hip joint, methylene blue dye can be
used to color the tract using a Q-tip applicator.
Excision of the tract should be performed. The
extension into the hip joint is visualized. The
Girdlestone procedure or proximal femoral osteot-
omy with heterotopic ossification is performed as
discussed in detail in Chap. 16. The first layer of
reconstructive tissue for this extensive area, which
includes the ischial defect and hip cavity, depends
on the size of the defects. If the cavity is extensive
and there is no other muscle available, the vastus
lateralis muscle is the ideal option (Chap. 16). The
vastus muscle can cover the entire defect from hip
8.14 Extension of the Ischial Ulcer into the Hip Joint or Trochanteric Area 107

Fig. 8.64 Photograph showing complete healing at 6

weeks post-surgery
Fig. 8.63 Operative photograph showing a tie-over
dressing of the skin graft

joint to perineum. The hip cavity, which includes

the acetabulum, can be filled with the rectus femoris
muscle. The choice of the second flap to cover the
vastus lateralis muscle depends on which flap is
available in the area and has not been used in the
past, such as the extended tensor fascia lata rotation
flap. It is well documented that, in some cases, the
distal 5–6 cm of the extended tensor fascia lata flap
may develop epidermolysis and eventually isch-
emia and necrosis. If the hamstring flap is available,
it can be used to cover the vastus lateralis muscle
flap as it can be advanced as a wide flap designed
over the posterior thigh. In extreme cases, when Fig. 8.65 Anteroposterior x-ray of the pelvis showing
destruction of the left hip with heterotopic ossification
there is no second flap available, skin grafts have
(HO) formation secondary to infection of the hip, which
been used to cover the vastus lateralis muscle with is called “auto Girdlestone.” Arrow indicates left hip
good results. Drains and flaps closure are performed involvement
108
Fig. 8.66 Operative photograph showing patient with
extensive ischioperineal ulcer with extension into the
hip joint; in addition, the patient had a coccygeal ulcer.
Arrow indicates the extension of the ulcer into the hip
joint
Fig. 8.67 Anteroposterior x-ray of the same patient
showing the left hip with the formation of heterotopic
ossification (HO) secondary to infection. Arrow indicate
the development of HO in the hip region
Fig. 8.68 Operative photograph, lateral view, of the
patient with the marking for the approach to harvest the
vastus lateralis muscle
8 Reconstructive Surgery for Ischial Ulcer
Fig. 8.69 Operative photograph showing complete exci-
sion of the coccygeal ulcer and raising the gluteus maxi-
mus flap
as in previous flaps. Figures 8.66, 8.67, 8.68, 8.69,
8.70, 8.71, and 8.72 show examples of flaps used.
8.15 Pelvic Ulcer
8.15.1 Description
Pelvic ulcer is an extensive recurrent ischial ulcer
with extension in the bilateral ischioperineal area
and involvement of the urethra in males or the
anus. These ulcers are commonly observed in
insensate patients such as spinal cord injury
patients who have had multiple flaps in the past
and even the Girdlestone procedure. Options for
closure are severely limited because of previous
exhaustion of the local muscles. Some of these
patients may end in disarticulation and total thigh
flap. The majority of these patients end with
8.15 Pelvic Ulcer 109

Fig. 8.70 Operative photograph showing excision of the Fig. 8.72 Operative photograph showing the transfer of
heterotopic ossification (HO) of the femur (short arrow); the vastus lateralis from the vertical position to the hori-
the vastus lateralis muscle flap was dissected and the zontal position to cover the entire defect; the surface was
ischium was shaved (long arrow) covered with a split skin graft

Fig. 8.71 Operative photograph showing a lateral view

of a complete dissection of the vastus lateralis muscle

permanent urinary diversion and colostomy. It is

called a pelvic ulcer because of recurrence of mul-
tiple ulcers with involvement of the ischial bone
and destruction of the pelvic bone architecture.
Fig. 8.73 Anteroposterior x-ray of the pelvis showing
Plain x-ray of the pelvis will show a thin layer of destruction of the pelvic bone and bilateral Girdlestone
bone covering the pelvic viscera (Fig. 8.73). procedure secondary to previous multiple ulcers
110 8 Reconstructive Surgery for Ischial Ulcer

8.15.2 Options for Operative Repair
If the patient is young and the duration of time
since the spinal injury is short, the muscles are usu-
ally still healthy and have not atrophied or been
replaced with fat. In such cases, the hamstring mus-
cles are the optimal choice for use as a myocutane-
ous flap. In the operating room, if the hamstring
muscles, especially the biceps femoris, do not
appear healthy enough to be raised and to support
the vascularity of the island of skin above it, the
posterior thigh is raised as a fasciocutaneous flap
and the donor site of the flap can be closed directly
or by skin graft. If the vastus lateralis has not been
used previously, it can be raised with or without
performing a Girdlestone procedure and trans-
ferred from the vertical position to a horizontal
position to cover the bilateral ischioperineal ulcer.
The surface of the muscle is covered with an avail-
able fasciocutaneous flap or skin graft. In extreme
cases, if involved with the ulceration, the anus must
be excised and a rectal closure performed.
while at the same time separating the muscle by
blunt dissection from the other hamstring muscles.
Dissection should be stopped at a level below the
first or second perforator, which provides the
blood supply of the flap. At this stage, a trial is
performed to check that the transposition and rota-
tion of the flap can reach the contralateral side
without tension. Care should be taken to avoid
separating the skin island from the muscle under-
neath. The donor site can be closed directly with
some dissection medially and laterally at the deep
fascia layer. If it is difficult to close directly, a split
skin graft can be used to close the defect. Drains
are used for both defects. The flap is sutured in
three layers (deep, dermal, and skin) (Figs. 8.74,
8.75, 8.76, 8.77, 8.78, 8.79, and 8.80).

8.15.3 Operative Technique

for Biceps Femoris
Myocutaneous Flap

The patient is placed in a prone position, and exci-

sion of the extensive bilateral ischioperineal ulcer Fig. 8.74 Anteroposterior x-ray of the pelvis showing
is performed as a standard procedure. If there is a destruction of both ischium with heterotopic ossification
prominent bone present, shaving is performed. In (HO) formation of the pelvic
the majority of these cases, the ischial tuberosity is
absent secondary to previous ulceration and necro-
sis. The design of the flap is based on the posterior
thigh; the width of the flap is equal to the longitu-
dinal width of the defect and the length of the flap
should be adequate to reach the contralateral side
and cover the defect without tension. The arc of
rotation starts from the lower edge of the gluteus
maximus muscle. The surgical skin incision later-
ally and medially is performed using a scalpel, and
the dissection is deepened through the subcutane-
ous layer and deep fascia. The biceps femoris is
identified, which is the largest of the hamstring
group, and it is transected at its lowest part at its
Fig. 8.75 Operative photograph, patient in prone position
insertion around the knee. Then dissection contin- (close view), showing extensive bilateral ischioperineal
ues with dissection of the lower muscle perforator, ulcer with the design of the bilateral biceps femoris flaps
8.16 Ischial Bursa 111

Fig. 8.76 Operative photograph showing the patient in Fig. 8.79 Operative photograph showing the final stage
the prone position with the design of the bilateral poste- of insetting the flap and suturing in three layers; flap donor
rior thigh flaps site closed directly

Fig. 8.77 Operative photograph showing the ulcers

where excised and bilateral dissection of the biceps with
skin island attached to the biceps Fig. 8.80 Photograph showing healing of the flap 6
weeks post-surgery

If the posterior thigh is used as a fasciocutane-

ous flap, the same procedure is applied and, in the
male, if the urethra is involved, closure of the ure-
thra is performed as described previously.
In extensive ulceration, when there is no
option available, disarticulation and total thigh
flap are performed (see Chap. 16).

8.16 Ischial Bursa

This pathological condition over the ischium is

Fig. 8.78 Operative photograph showing the trial and seen often and presents clinically as a soft swelling
transposition of the flaps to cover the surgical defects over the ischial area with fluctuation and multiple
112 8 Reconstructive Surgery for Ischial Ulcer

cyst-like formations or loculations inside. The
bursa can open to the outside and present as a dis-
charging sinus. Sepsis can occur when the bursa
becomes infected, either by the blood stream or
due to small skin ulcerations over the bursal area.
On some occasions, it may represent a mystery in
diagnosis, and is of unknown etiology of the
patient’s sepsis. The pathology of bursal forma-
tion, which is acquired bursa, is a history of patient
weight loss and the sliding and shearing of the soft
tissue over the ischial bone, resulting in a sac for-
mation containing synovial fluid. It may extend
anatomically under the gluteus maximus muscle
or the perineum. Diagnosis is usually performed
clinically [17]. In spinal cord injury patients, this
bursa should be excised because it leads to sepsis
and stage IV pressure ulcer formation.
muscle is tunneled to the ischial cavity. The skin
bridge between the bursal incision and the gracilis
muscle donor site should be at least 5–6 cm in
width. The gracilis tunnel is under the skin bridge,
which is in the subcutaneous layer, and the gracilis
muscle is passed to the ischial cavity. Two drains
are used to drain under and over the muscle and
are passed with the muscle through the tunnel. The
skin edges can be closed directly over the muscle.
If this is not possible, either the medial thigh flap
or the posterior thigh flap are used as a fasciocuta-
neous flap and closed in three layers.
In the illustrated case, the gluteus maximus
rotation flap was chosen to close the defect
(Figs. 8.81, 8.82, 8.83, 8.84, 8.85, and 8.86).

8.16.1 Operative Technique

The patient is placed in the prone position. If the

bursa is not open to the skin surface, the bursa and
its extension should be located. A syringe and a
needle are used to aspirate fluid from the bursa and
fluid, which should be tested for culture and sensi-
tivity. Usually, the fluid is serosanguineous in
color and thick in consistency. The needle is left in
the bursal wall and the syringe is filled with meth-
ylene blue dye, which is injected into the bursal
sac to color the entire sac and make it visible dur-
ing excision of the bursa. If the bursa has a sinus,
the same procedure is used, however, instead of a
needle, an Angiocath is used, attached to a syringe
containing methylene blue, and injection is into
the bursal cavity. A transverse incision is made in
the skin over the bursal sac, usually in the gluteal
area. Deep dissection of the bursal sac from sur-
rounding tissue is performed, either by electrocau-
tery or by scissors. The bursal sac is dissected like
a cyst; attention should paid not to puncture the
bursal sac during dissection. When the dissection
is completed, the ischial bone is examined. If it is
prominent, shaving of the ischial bone is per- Fig. 8.81 Operative photograph showing the patient in a
formed. The final product is a large cavity or dead prone position. There is extensive left ischial bursa, which
space in the ischial area. To fill the cavity, the most was clinically identified. Methylene blue was injected into
common muscle used is the gracilis, which has the bursa. There is a scar over the medial thigh, showing
that the gracilis muscle was utilized previously. The con-
been described previously in the section on graci- tralateral side was marked in case of the need for the grac-
lis muscle flap. In this circumstance, the gracilis ilis muscle
8.16 Ischial Bursa 113

Fig. 8.82 Operative photograph showing the surgical Fig. 8.83 Operative photograph showing the post exci-
exposure of the entire bursa and complete dissection of sion of the bursa and incision for the utilization of the glu-
the bursa; the color of the bursa is blue secondary to the teus maximus rotation flap
injection of methylene blue
114
Fig. 8.84 Operative photograph showing the post com-
plete excision of the bursa with exposure of the shaved
ischium. In this case we, elected to utilize the gluteus
maximus as a rotation flap because the gracilis muscle
was previously used
8 Reconstructive Surgery for Ischial Ulcer
Fig. 8.85 Operative photograph showing the complete
dissection of the gluteus maximus flap with rotation of the
flap without tension to cover the defect
References 115

3. Mills RL (1990) Gluteus maximus musculocutaneous

flap. In: Strauch B, Vasconez LO, Hall-Findlay EJ
(eds) Grabb’s encyclopedia of flaps, vol 3. Little
Brown, Boston, Ch 370
4. Baker DC, Barton FE Jr, Converse JM (1978) A com-
bined biceps and semiteninosus muscle flap in the
repair of ischial sores. Br J Plast Surg 31:26
5. Conway H, Griffin BH (1956) Plastic surgery for clo-
sure of decubitus patients with paraplegia. Am J Surg
91:946
6. James JH, Moir IH (1980) The biceps femoris muscu-
locutaneous flap in the repair of pressure sores around
the hip. Plast Reconstr Surg 66(5):736
7. Tobin GR, Sanders BP, Mann D, Weiner LJ (1981)
The biceps femoris myocutaneous advancement flap:
a useful modification for ischial pressure ulcer recon-
struction. Am Plast Surg 6(5):395
8. Mathes SJ, Nahai F (eds) (1979) Clinical atlas of mus-
cle and musculocutaneous flaps. Mosby, St. Louis,
pp 13–31
9. Mathes SJ, Nahai F (eds) (1982) Clinical application
for muscle and musculocutaneous flaps. Mosby, St.
Louis, pp 438–439
10. Wingate GF, Friedland JA (1978) Repair of ischial
pressure ulcers with Gracilis myocutaneous island
flaps. Plast Reconstr Surg 62:245
11. Labandter HB (1980) The Gracilis muscle flap and
musculocutaneous flap in the repair of perineal and
ischial defects. Br J Plast Surg 33:95
12. Yamamoto Y, Tsutsumida A, Nuravumi M et al (1997)
Long term outcome of pressure sores treated with flap
coverage. Plast Reconstr Surg 100:1212
13. Homma K, Murakami G, Fujioka H et al (2001)
Treatment of ischial pressure ulcers with a posterome-
Fig. 8.86 Operative photograph showing the gluteus dial thigh fasciocutaneous flap. Plast Reconstr Surg
maximus flap sutured in place 108:1990
14. Hurwitz DJ, Swartz WM, Mathes SJ (1981) The glu-
teal thigh flap: a reliable sensate flap for the closure of
References buttock and perineal wounds. Plast Reconstr Surg
68:521
15. Campbell RM, Converse JM (1954) The saddle-flap
1. Garg M, Rubayi S, Montgomerie J (1992) Post-
for surgical repair of ischial decubitus ulcers. Plast
operative wound infection following myocutaneous
Reconstr Surg 14:442
flap surgery in spinal injury patients. J Paraplegia
16. Hallock GG (1994) The random upper posterior thigh
30(10):734–739
fasciocutaneous flap. Ann Plast Surg 32:367
2. Botte MJ, Nakai RJ, Waters R, McNeal DR, Rubayi S
17. Rubayi S, Montgomerie J (1992) Septic ischial bursi-
(1991) Motor point delineation of the gluteus medius
tis in patients with spinal cord injury. Paraplegia
muscle for functional electrical stimulation and in
30(3):200–203
VNO anatomic study. Arch Phys Med Rehabil
72:112–114
 Reconstructive Surgery
for Sacral Ulcer
Salah Rubayi
9.1 Introduction
The sacral ulcer is a common occurrence in certain
groups of patients. It can develop at different
stages of a patient’s life, whether after acute injury
or acute illness. The ulcer occurs when a patient is
kept in a supine position without turning or using
a special bed or mattress. It can also occur after
the rehabilitation stage when an insensate patient
is sent home to integrate back into normal life and
begins sitting in a wheelchair, as seen in spinal
cord injured patients (see Chap. 2). In a review of
the literature on reconstructive options for sacral
ulcer, some authors advise using the fasciocuta-
neous flap from the lumbar area to close a sacral
defect [1–3]. The author’s experience in dealing
with patients with spinal cord injury or spina bifida
is that this flap is not suitable for these groups of
patients because of the multiple surgeries they have
had over their back and lumbar area. It is techni-
cally difficult to raise the fasciocutaneous lumbar
flap because of the scarring and limited number of
spinal perforators, which eventually subjects these
flap to vascular compromise, ending in necrosis.
The main muscle used for the repair of the sacro-
S. Rubayi MB, ChB, LRCP, LRCS, MD, FACS
Department of Surgery, Rancho Los Amigos National
Rehabilitation Center, Downey, CA, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_9, © Springer-Verlag Berlin Heidelberg 2015
9
coccygeal ulcer is the gluteus maximus muscle
in different design of flaps – musculocutaneous,
muscular, and fasciocutaneous. The muscle can
be used in rotation, advancement, and splitting.
The gluteus muscle is the most durable muscle
for closing a sacral defect and provides a soft tis-
sue padding for the bony area that is anatomically
not covered by muscle. The sacrum and coccygeal
bone are covered by skin and subcutaneous tissue
[4–9]. The method in which the gluteus maximus
muscle is used depends on the primary diagnosis
of the patient and whether the goal is to preserve
muscle function after recovery [10, 11]. For ambu-
latory and sensory patients, the gluteus maximus
island advancement flap is recommended more
than the fasciocutaneous flaps, which are based
on the gluteal muscle perforator [12–16]. The
author’s experience is that these flaps cannot be
revised or reused in cases of ulceration recurrence,
as in patients with spinal cord injury.
9.2 Options for Repairs
of Sacral Ulcer
9.2.1 Single Sacrococcygeal Ulcer
• Gluteus maximus musculocutaneous rotation flap
• Bilateral gluteus maximus musculocutaneous
rotation flap
• Gluteus maximus advancement island flap
(single or bilateral flap)
• Gluteus maximus splitting transposed flap
117
118
9.2.2 Complex and Recurrent
Sacrococcygeal Ulcer
• Reuse of the gluteus maximus rotation flap
• Gracilis muscle tunneled around the anal
canal to the coccygeal area
• Vastus lateralis muscle flap covered with
extended tensor fascia lata flap, posterior thigh
flap, or skin graft
9.3 Gluteus Maximus
Musculocutaneous
Rotation Flap
The gluteus maximus musculocutaneous rotation
flap is a fundamental flap for repair of a sacral
defect. Operatively, it requires extensive dissec-
tion, resulting in blood loss. This flap is indicated
for extensive sacrococcygeal defects in nonambu-
latory and nonsensory patients. This flap is not
recommended for ambulatory patients because
the lower attachment of the gluteus muscle is
detached, which can result in functional loss. This
flap can be revised and reused in recurrent ulcer-
ation. The procedure carries the risk of damaging
the superior gluteal artery secondary to the dissec-
tion in extensive scarring caused by previous sur-
gery. When the gluteus maximus rotation flap is
rotated to cover the sacral segment, the part of the
flap that covers the sacrum is the fasciocutaneous
part of the flap and not the gluteus muscle itself,
which results in less padding over the bone.
a b
Fig. 9.1 (a) Patient in the prone position with coccygeal
ulcer; the essential topographical marking is on display.
(b) Patient in the prone position in the lateral view,
9 Reconstructive Surgery for Sacral Ulcer
9.3.1 Surgical Anatomy
of the Gluteus Maximus
Muscle
Please refer to Chap. 8 for a detailed description.
9.3.2 Flap Design and Surface
Markings
The surface or topographical markings are as
described in Chap. 8. It is important that these
anatomical marks be made on the skin (Fig. 9.1a)
and then the ulcer excised as marked in a triangu-
lar way, with the apex inferiorly. The flap is
marked in a semicircular line extending from the
outer angle of the ulcer and passing along the
other side of the midline, extending below
the iliac crest for about 3–4 cm, and then curving
laterally until approaching the greater trochanter,
where the marking is stopped (Fig. 9.1b). The
part of the flap that is across the midline is the
fasciocutaneous part of the main flap; it is uti-
lized to cover the ulcer defect and the sacral bone.
9.3.3 Operative Technique
The patient is placed in the prone position on the
operating table. The ulcer is excised and the sacral
bone is shaved as described in Chap. 8. When the
coccygeal segment is prominent (especially at the
sacrococcygeal angle) and is the direct cause of
demonstrating the marking for the semicircular design
passing over the greater trochanter for the gluteus maxi-
mus flaps
9.3 Gluteus Maximus Musculocutaneous Rotation Flap 119

pressure or there is sign of infection, the distal seg-

ment of the coccygeal bone should be excised. The
pelvic floor that covers the rectum is exposed, indi-
cating the requirement for a durable coverage by
muscle flap. The author’s recommendation in thin
patients with a prominent posterior superior iliac
spine is to shave these bones bilaterally for two rea-
sons: to prevent development of a pressure ulcer at
the site and so that the rotation flap used will not be
under tension due to the prominent bone. The dis-
section of the gluteus maximus flap is performed as
described in Chap. 8. The fasciocutaneous part of Fig. 9.2 Patient in the prone position after excision of the
ulcer and shaving of the coccygeal bone
the flap that crosses the midline should be dissected
from the strong fascia of the supra spinatus muscle
and care should be taken not to raise the fascia or
the muscle with the fasciocutaneous part of the glu-
teus maximus muscle. The supra spinatus muscle is
identified by its fiber running in a longitudinal
direction and it is covered by a strong sheath of
fascia. The gluteus maximus fibers originate from
the sacrum at the level of the posterior superior
iliac spine and inferiorly from the lower part of the
sacrum and the coccygeal bone. The muscle is dis-
sected from these bones by an electrocautery with
gentle tension on the muscle. To find the plane
between the gluteus maximus and gluteus medius
muscle, there are two options: the site of the poste-
rior superior iliac spine or the lateral approach, as
described in Chap. 8. At this stage of the dissection,
the superior gluteal artery should be identified as it
runs over the posterior surface of the muscle and is
covered by transparent fascia. When the pedicle is Fig. 9.3 The excised ulcer
identified, the dissection is directed laterally to
release the muscle from its tendinous part. The
extent of the dissection depends on the length
required to rotate the flap medially as a musculocu-
taneous flap to cover the defect without tension. If
there is tension, a back cut is made laterally and
inferiorly. Two drains should be used, with the
drains exiting laterally and inferiorly, one for the
upper part of the defect and the other for the coc-
cygeal part of the defect. The author recommends
placing a few deep sutures between the posterior
surface of the flap and the base of the defect to pre-
vent the formation of bursa under the flap. The flap
Fig. 9.4 Dissection of the gluteus maximus flap, short
wound should be closed in three layers (deep, der-
arrow showing the fasciocutaneous part of the flap, long
mal, and skin). Figures 9.2, 9.3, 9.4, 9.5, 9.6, and arrow indicates the anatomical demarcation of the gluteus
9.7 show operative details of the flap. maximus muscle
120 9 Reconstructive Surgery for Sacral Ulcer

Fig. 9.5 Complete rotation of the gluteus maximus flap

to cover the defect

Fig. 9.8 Operative photograph showing the patient in the

prone position with extensive recurrent sacrococcygeal
ulcer. This patient had previous flap surgery; for this rea-
son, we chose to utilize the bilateral gluteus maximus
rotation flap

procedure cannot be performed in ambulatory

patients because of the residual functional deficit
in the muscle’s function. The operative technique is
the same as when utilizing the gluteus maximus as
a musculocutaneous flap. When an extensive ulcer
Fig. 9.6 Sutured flap in place is present, there is a strong indication for a diverting
colostomy, which should be performed before flap
surgery. One method of insetting the bilateral flap
to cover the defect is accomplished by rotating the
two flaps toward the midline, with each flap cover-
ing half of the ulcer defect. The only disadvantage of
this method is that the seam of the two flaps is in the
midline, which may become a weak point for break-
down. The posterior surface of the two flaps should
be sutured to the base to prevent sliding of the flaps
and the formation of bursa under the flaps. Another
method of insetting the flaps, which the author pre-
fers to avoid the previously mentioned risk of a mid-
line breakdown, is to transpose the flaps. The flap
Fig. 9.7 Photograph showing complete healing at
6 weeks post-surgery that is more mobile is rotated all the way inferiorly to
cover the defect and the other flap is rotated to cover
the superior defect of the inferiorly rotated flap.
9.4 Bilateral Gluteus Maximus Another technique that can be adapted to pre-
Musculocutaneous vent breakdown between the seam of the two flaps
Rotation Flap is to deepithilize the medial side of one flap and
to inset that part under the other flap’s edge, like a
In many cases, an extensive sacrococcygeal ulcer “double-breasted” closure, to promote healing at an
cannot be closed by a single gluteus maximus early and later stage of the flap surgery (Figs. 9.8,
flap and it is necessary to raise bilateral flaps. This 9.9, 9.10, 9.11, 9.12, 9.13, 9.14, and 9.15).
9.4 Bilateral Gluteus Maximus Musculocutaneous Rotation Flap 121

Fig. 9.12 Operative photograph showing the dissected

bilateral gluteal flap with the transposition of the flaps,
one flap to cover the ulcer and the other flap to cover the
Fig. 9.9 Operative photograph showing excision of the
rest of the defect
ulcer and dissection of bilateral gluteal flap

Fig. 9.13 Operative photograph showing complete

Fig. 9.10 Operative photograph showing dissection of suturing of the flaps
the gluteus maximus and separation between the maximus
and the medius, arrow indicates the plane

Fig. 9.11 Operative photograph showing the dissected Fig. 9.14 Operative photograph showing complete
gluteus maximus of the other side suturing of the flap, lateral view
122
Fig. 9.15 Photograph showing complete healing of the
flaps 6 weeks post-surgery
9.5 Gluteus Maximus
Advancement Island Flap
The gluteus maximus advancement island flap is
a musculocutaneous flap. The vascularity of the
skin island is based on the perforators from the
gluteus maximus muscle underneath it. The flap
can be utilized as a single, one-sided flap or a
bilateral flap in extensive ulceration. This flap has
been described with many modifications for
different indications in ambulatory and nonam-
bulatory patients to close sacrococcygeal ulcer-
ation [8, 17–19]. If the defect is greater than 8 cm
in diameter, a bilateral island flap should be uti-
lized to close the defect. This flap is technically
easy to perform compared with a gluteus maxi-
mus rotation flap. In addition, with less blood
loss and shorter operative time, the author’s opin-
ion is that this flap is an excellent option for
ambulatory and elderly patients.
9.5.1 Operative Technique
The patient is placed in the prone position on the
operating table. If the ulcer is extensive and there
is close proximity to the anus, then a diverting
colostomy should be performed before flap
9 Reconstructive Surgery for Sacral Ulcer
Fig. 9.16 Operative photograph patient in the prone
position showing the design of the island flap for the clo-
sure of the coccygeal ulcer
surgery. A temporary purse string suture is placed
around the anus to close it during surgery to
prevent soiling on the wound. The ulcer and the
bone are excised and shaved as described in
Chap. 8. The marking for important landmarks is
performed as described for the gluteus maximus
rotation flap, and the design of the flap as an
island of the skin is marked in an oval shape in
the horizontal direction. The base of the flap is
within the border of the ulcer and the apex of the
flap is in the lateral landmark of the muscle
(Fig. 9.16).
Which side to mark the flap on depends on the
side the where the ulcer is undermined, which is
the appropriate side to utilize. A scalpel is used
for skin incision and then an electrocautery is
used for incising the subcutaneous layer and the
deep fascia that covers the gluteus maximus mus-
cle. When the muscle is exposed, the gluteal fibers
are incised against the fibers’ direction in the
muscle. It is important to release the muscle at the
apex of the flap laterally. The flap is then tested to
see whether it can be advanced medially without
tension and if more muscle fibers need to be tran-
sected laterally. In addition, the origin of the mus-
cle medially from the sacrococcygeal segment
should be released. This step makes it possible to
advance the flap medially to cover the defect.
Care should be taken in ambulatory patients not to
transect all the muscle fibers at the flap apex
(i.e., laterally). This helps to preserve the function
9.6 Bilateral Gluteus Maximus Island Advancement Flap
Fig. 9.17 Operative photograph showing the excision of
the ulcer, shaving of the bone, and dissection of the island
flap
Fig. 9.18 Operative photograph close-up view showing
the shaving of the coccygeal bone. Arrow indicates the
location of the bone
of the muscle. Two drains are placed, one superi-
orly and the second inferiorly. The exit of these
drains should be placed laterally near the apex of
the flap. The flap is advanced into the defect. The
deep sutures are important to approximate
between the gluteus maximus muscle of both
sides passing the midline. If this step is difficult to
achieve, mobilization of the gluteus maximus of
other side is performed to assist in closing the
deep layer without tension. The flap donor site is
closed in a V-Y fashion and the flap is closed in
three layers. Figures 9.16, 9.17, 9.18, 9.19, and
9.20 show steps in the surgical procedure.
123
Fig. 9.19 Operative photograph showing the complete
dissection of the island laterally and the advancement of
the island to cover the defect
Fig. 9.20 Operative photograph showing complete clo-
sure of the flap
9.6 Bilateral Gluteus Maximus
Island Advancement Flap
When the defect is extensive and a unilateral flap
is not adequate to close the defect, a bilateral
island flap is used. The operative technique is the
same as described previously. Both flaps are
advanced toward the midline and the two side
muscles are sutured together in the midline. As a
result, the defect is covered by muscle.
Anatomically, there is no muscle covering the
area; therefore, by this method a healthy tissue
padding is added to cover the sacrococcygeal
area. The donor site of both flaps is closed in a
124 9 Reconstructive Surgery for Sacral Ulcer

Fig. 9.21 Operative photograph showing the design of a

bilateral gluteus maximus island flap for an extensive
sacrococcygeal ulcer. Note: patient had recent surgery for
a Girdlestone procedure and ischial ulcer, which are
closed by multiple flaps

V-Y fashion. Two drains are used and the exit is Fig. 9.22 Operative photograph showing the excised
laterally on one side. Figures 9.21, 9.22, 9.23, ulcer and the shaving of the coccygeal bone
9.24, 9.25, 9.26, and 9.27 show the surgical
steps.

9.7 Splitting Gluteus

Maximus Flap

The splitting gluteus maximus flap was described

by the author in 1995 [20]. The idea for this flap
design originated from observing morbidities in
closing coccygeal or low sacral ulcers when the
ulcer is close to the anus. These morbidities were
observed when utilizing the gluteus maximus as
rotation flap, when the distal part of the flap
Fig. 9.23 Operative photograph showing the complete
being under tension resulted in necrosis and dissection of the bilateral island flap
breakdown in the flap tip near the anus. This flap
was evolved to solve this technical problem.
This flap is a musculocutaneous flap and it has gluteus maximus insertion; therefore, the func-
many advantages. It provides muscle padding tion of the muscle remains intact post-surgery,
when anatomically there is no muscle covering which is important for the ambulatory patient.
the coccygeal area. Blood loss during surgery is Finally, the bulk of the gluteus maximus is not
less than with the gluteus maximus rotation flap. utilized in this procedure and can be reserved for
Functionally, this flap has no detachment of the future use.
9.7 Splitting Gluteus Maximus Flap
Fig. 9.24 Operative photograph showing the lateral dis-
section of the island flap
Fig. 9.25 Operative photograph showing the approxima-
tion of the two islands to the midline
Fig. 9.26 Operative photograph showing complete clo-
sure of the two islands
125
Fig. 9.27 Operative photograph showing the lateral clo-
sure of the flap donor side in a V-Y fashion
Fig. 9.28 Operative photograph showing the design of
the bilateral gluteus splitting flap. The ulcer was excised
in a longitudinal elliptical fashion
9.7.1 Operative Technique
Flap Design and Marking
The ulcer with the unhealthy margin is marked in
an elliptical vertical fashion. Two opposing semi-
circular lines are marked, one from the top of the
ulcer and the other from the lower margin of the
ulcer. The two opposing lines in a horizontal
fashion. Figures 9.28, 9.29, 9.30, 9.31, and 9.32
show the surgical procedure.
Operative Technique
The patient is in placed in the prone position and
a purse string anal stitch is applied. The ulcer
and bone are excised as usual. If the distal seg-
ment of the coccygeal bone is prominent,
126
Fig. 9.29 Operative photograph showing the ulcer
excised and the two flaps dissected
Fig. 9.30 Operative photograph showing the gluteus max-
imus flap dissected and the drains in the base of the wound
Fig. 9.31 Operative photograph showing the transposi-
tion of the flaps
9 Reconstructive Surgery for Sacral Ulcer
Fig. 9.32 Operative photograph showing the completed
sutured bilateral flaps
excision of that segment is performed. To raise
the flap, a skin incision is made using a scalpel,
and an electrocautery is used to incise the subcu-
taneous layer and expose the gluteal fascia. The
gluteal fibers are then split in the direction of the
fibers. The skin flap should have enough muscle
bulk underneath, and the gluteus at that side is
released from its lower origin to free the flap.
The same procedure is performed on the other
side. When the two flaps are freed completely,
transposition of the opposing flap is performed.
Two drains are used, one on each side. The two
transposed flaps are closed in three layers and
the two muscles cover the defect. The final
wound resembles an “H.” Figures 9.28, 9.29,
9.30, 9.31, and 9.32 show the steps in the surgi-
cal procedure.
9.8 Complex and Recurrent
Sacrococcygeal Ulcer
When there is recurrent ulceration, the first
option is to utilize the unused gluteus maximus
flap. In future breakdowns, if the gluteus maxi-
mus flap is not available, the previously utilized
gluteus maximus flap should be revised.
Unfortunately, there are limitations with this pro-
cedure because of the extensive scarring from
repeated surgeries. There is a high risk of dam-
age to the vascular pedicle because of the
9.10 Extended Tensor Fascia Lata Rotation Flap 127

difficulty in identifying the vascular pedicle

because previous dissection and extensive scar-
ring. When a patient has extensive recurrent
ulceration over the sacrococcygeal area, some-
times involving the entire gluteal area, other
ulcerations can occur at the same time in differ-
ent areas such as the pelvis or hip joint. In such
situations, the options are limited and a complex
repair may be necessary by transferring tissue
from distant areas. In extreme cases, disarticula-
tion and total thigh flap becomes the only avail-
able option. However, other options, when they
are available, are as follows:
• Vastus lateralis muscle flap
• Extended tensor fascia lata rotation flap
Fig. 9.33 Operative photograph with the patient in the
• Extended posterior thigh rotation flap prone position showing extensive multiple ulcers and a pre-
• In recurrent or nonhealing coccygeal ulcer, the vious left Girdlestone procedure secondary to an infected
gracilis muscle is tunneled around the anal hip. In this case, there were limited options to close the
ischial gluteal ulcer, and we elected to use the vastus latera-
canal to the coccygeal area
lis to close this ulcer with the coccygeal ulcer. Design for
multiple flaps to close the other ulcers. Arrow indicate the
extension of the ischial area into the gluteal area
9.9 Vastus Lateralis Muscle Flap

The vastus lateralis is a large volume muscle,

with an average length of about 25 cm, and it has
an excellent blood supply. The entire length of
the vastus lateralis muscle can be utilized when
the hip joint is involved with a pathological con-
dition and the femoral component of the hip has
been removed by a Girdlestone procedure. In this
case, the vastus lateralis muscle is utilized as an
island flap and is only attached to its main pedi-
cle. The operative procedure for using the vastus
lateralis muscle is discussed in detail in Chap. 11.
If a Girdlestone procedure is not indicated, the
vastus lateralis muscle is dissected from its femo-
ral origin to gain extra length. In addition to scor- Fig. 9.34 Anteroposterior x-ray of the pelvis showing a
left Girdlestone procedure
ing the vastus fascia by scalpel to achieve extra
length, the muscle can be tunneled to the sacral
area if there is a skin bridge. Otherwise, it is
passed to cover the defect and, most importantly, 9.10 Extended Tensor Fascia Lata
sutured to the surrounding tissue available to Rotation Flap
cover the exposed bone. The muscle surface can
be covered by a second flap, such as the rotation When muscle is not available to cover the sacral
tensor fascia lata; otherwise, a split skin graft is defect, the extended tensor fascia lata rotation flap
adequate. Figures 9.33, 9.34, 9.35, 9.36, 9.37, can be used and raised as a fasciocutaneous flap.
9.38, 9.39, 9.40, 9.41, and 9.42 show the steps in The average length of the flap is about 20–30 cm,
the surgical procedure. but there is always a risk of necrosis of the distal
128
Fig. 9.35 Operative photo showing the extent of the
wound after a left Girdlestone procedure
Fig. 9.36 Operative photograph showing the debride-
ment and excision of all ulcers. The options for closing
these ulcers were limited to using a large volume muscle
such as the vastus lateralis muscle
Fig. 9.37 Operative view showing the dissection of the
gracilis muscle as a first layer for closure of the left ischial
ulcer. Arrow indicates the gracilis muscle
9 Reconstructive Surgery for Sacral Ulcer
Fig. 9.38 Operative view showing the dissection of the
right vastus lateralis muscle to be used to cover the ulcers
Fig. 9.39 Operative photograph showing the method
when the vastus lateralis is tunneled under a skin bridge to
reach its destination in the sacrococcygeal area
few centimeters of the flap secondary to vascular-
ity problems, as the blood supply to that part of
the flap is by a local perforator. The width of the
flap should be not more than 10 cm. The details of
raising this flap are discussed in Chap. 10 on the
trochanter ulcer. This is a useful flap for repair of
the ischioperineal area when there is no available
traditional flap. The arc of rotation of this flap is at
the level of the trochanter area, where the tensor
fascia lata muscle is located medially to the
greater trochanter. The inset of the flap should not
be under tension; otherwise, it exposes the flap to
greater risk of distal necrosis. To prevent this
9.11 Extended Posterior Thigh Rotation Fasciocutaneous Flap
b of the surgery when the vastus lateralis has been tunneled
Fig. 9.40 (a) Operative photograph showing an example
of the scoring of the vastus lateralis fascia to obtain the
maximum length and width of the muscle. (b) Operative
photograph lateral view showing the dissection of the left
vastus lateralis muscle to close the hip defect
Fig. 9.41 Operative photograph showing the method
used to inset the vastus laterals into the hip defect
complication, a delay procedure can be per-
formed. Injection of fluorescent dye into the
patient’s vein and then use of ultraviolet light
129
Fig. 9.42 Operative photograph showing the final stage
to cover the gluteal defect and a skin graft placed over the
muscle surface. The bilateral thigh wound was closed
directly. Arrow indicates the skin graft area over the
muscle
provides a better picture of the flap perfusion. The
donor site of the flap can be closed directly if it is
possible; if not, a split skin graft is applied.
9.11 Extended Posterior
Thigh Rotation
Fasciocutaneous Flap
The extended posterior thigh rotation fasciocuta-
neous flap is discussed in Chap. 8 for closing an
ischial ulcer. The author considers this a myofas-
ciocutaneous flap because there is a double blood
supply. The first blood source originates from a
branch of the inferior gluteal artery, which sup-
plies the deep fascia of the posterior thigh, and
the second blood supply originates from the infe-
rior part of the gluteus maximus muscle. When
raising the flap, the proximal part of the flap con-
sists of part of the gluteus maximus muscle and
the remainder of the flap is fasciocutaneous.
9.11.1 Operative Technique
The patient is placed in the prone position. The
flap is marked over the posterior thigh in a
longitudinal rectangular shape. The width of the
flap is preferably not more than 10–12 cm, and
130 9 Reconstructive Surgery for Sacral Ulcer

the length can be the entire posterior thigh, stop-

ping above the popliteal fossa. If there is a scar in
the middle of the thigh secondary to previous
surgery, the design should be in a virgin area of
the posterior thigh, lateral to the scar. The skin is
incised with the scalpel and an electrocautery is
used for the subcutaneous layers. It is easy to
identify distally the deep fascia of the posterior
thigh when there is less subcutaneous tissue.
When the deep fascia is identified, the plane
between the deep fascia and the hamstring mus-
cle is easily separated with blunt dissection. The
dissection continues proximally on both sides of
the flap margin. When approaching the lower part
of the gluteus maximus muscle fibers, the dissec-
tion stops. These fibers should be included with
the flap. The flap is then rotated into the sacral Fig. 9.43 Operative photograph of the patient in the
defect. Extra tissue is seen at the arc of rotation as prone position, with sacral and bilateral ischioperineal
a dog ear that can be excised. Two drains are ulcers. The patient had previous bilateral amputation at
different hospitals, and the options for closing the ulcers
placed with the exits laterally. If there is extra tis-
were limited. Design for posterior thigh fasciocutaneous
sue laxity, the donor site of the flap can be closed flap is marked
directly; if not, a split skin graft is used to cover
the surface of the hamstring muscles. To reduce
the size of the donor site, a continuous suture is
applied between the skin edge and the base of the
donor site and then a skin graft is applied.
Figures 9.43, 9.44, 9.45, 9.46, 9.47, and 9.48
show the steps in the surgical procedure when the
posterior thigh fasciocutaneous flap is used for
closure of the bilateral ischial defect. In this case,
we utilized the posterior thigh fasciocutaneous
flap to close an ischial defect. The same principle
is utilized to close a sacral defect by rotating the
flap superiorly and passing the flap to the sacral
area by excising a skin bridge equal to the width
of the flap. Care should be taken to consider the
Fig. 9.44 Operative photograph showing the excision of
length of the flap. If it is too long, there is a the ulcers and raising of the posterior thigh fasciocutane-
chance of losing the distal part of the flap, because ous flap. The flap can be rotated to the sacral area through
the flap is fasciocutaneous, and this outcome has a skin defect to cover the sacral wound using the same
been observed in other fasciocutaneous flaps. principle

vastus lateralis, are not available because they

9.12 Biceps Femoris
Myocutaneous Rotation Flap
The biceps femoris myocutaneous rotation flap is
used to cover an extensive gluteal-sacral coccy-
geal defect, when other muscles, such as the
have been used previously. The biceps femoris
flap is more reliable in terms of vascularity com-
pared with the posterior fasciocutaneous flap.
The viability of this flap depends on the age of
the patient, duration of the paralyses, as this
affects the muscle structure, and vascular disease
9.12 Biceps Femoris Myocutaneous Rotation Flap
Fig. 9.45 Operative photograph showing the transfer of
the posterior thigh fasciocutaneous flap to cover a bilateral
defect. Arrow indicates the location of the biceps femoris
muscle
Fig. 9.46 Operative photograph showing the suturing of
the flap in its position, the scrotal wound closed directly,
and the flap doner side closed directly
and diabetes, both of which can affect the viabil-
ity of the flap.
9.12.1 Operative Technique
The patient is placed in the prone position.
When proning is not suitable because of an
131
Fig. 9.47 Operative photograph showing the closure of
the sacral defect with a bilateral gluteus maximus sliding
island flap
Fig. 9.48 Operative photograph showing complete clo-
sure of the wounds
existing medical condition, the patient is placed
in a lateral position with the side of the muscle
donor in the upright position. The design of the
flap is the same as in the posterior thigh fascio-
cutaneous flap. The width of the flap should not
be more than 10–12 cm, and the length can
extend distally to a level of few centimeters
above the popliteal fossa. The first incision
using the scalpel is the distal transverse line of
the flap to identify the deep fascia and the distal
end of the bicep femoris muscle. The flap inci-
sion extends proximally on each side of the flap
marking. When the deep fascia is incised on
both sides, exposing the gracilis muscle
132 9 Reconstructive Surgery for Sacral Ulcer

Fig. 9.49 Operative photograph showing the patient in

the prone position with an extensive sacral ischioperineal
and trochanteric ulcer. This patent had no traditional mus-
cles available to close the defect; therefore, the biceps
femoris myocutaneous flap was chosen

medially, if not utilized previously, the border of

the lateral incision is the lateral intermuscular
septum, which is identified if the flap was
designed more on the lateral side.
The next step is to transect the bicep femoris
distally using a right-angle forceps, which is
inserted under the entire muscle body. Using an Fig. 9.50 Operative photograph showing the patient in
electrocautery, the transection is completed. the prone position and showing the design of the biceps
femoris flap, which extends from the lower gluteal area to
Care should be taken not to separate the muscle
the popliteal fossa
from the deep fascia; a stitch can be applied
between the muscle and the skin at the distal end
of the muscle to prevent any separation. Raising
the flap is performed by dissection from each 9.13 Gracilis Muscle Transfer Flap
side, and posteriorly the dissection crosses the
distal perforator of the muscle, which should be In many situations, a breakdown can occur after
coagulated. The dissection continues proximally flap surgery in the coccygeal area and attempts to
until reaching the sciatic nerve, and the proximal close by a gluteal flap alone are not successful,
perforator should be identified and preserved. At especially when the ulcer is close to the anal verge
least one to two proximal perforators should be or in other situations seen after excision of the dis-
kept to maintain the vascularity of the flap. The tal coccygeal segment, resulting in a large residual
flap is rotated from a vertical position to a hori- cavity. To manage this difficult situation and return
zontal position toward the sacral defect. In some the retracted anus to a normal position, the gracilis
cases, this flap cannot close the entire defect and muscle can be used. A single muscle can be uti-
a skin graft is performed to cover the exposed lized or, in some cases, bilateral muscles are used.
area. The donor site of the flap can be closed
directly, in the majority of cases, by retention
sutures under a draining system. The flap is 9.13.1 Operative Technique
insetted into the defect and sutured by multiple
layers (Figs. 9.49, 9.50, 9.51, 9.52, 9.53, 9.54, The patient is placed in the prone position on the
9.55, and 9.56). operating table. The gracilis muscle is raised and
9.13 Gracilis Muscle Transfer Flap
Fig. 9.51 Operative photograph showing the biceps fem-
oris flap dissected on both sides and distally. Arrow indi-
cates the position of the gracilis muscle medially. Small
arrow indicates the lateral boarder of the flap, which is the
lateral intermuscular septum
dissected proximally, preserving as much as pos-
sible of the pedicle, which is about 6–10 cm
below the level of the pubic tubercle. Detailed
operative descriptions are provided in Chap. 8.
The tunnel is then made in the subcutaneous
layer extending from the perineal area into the
ischiorectal fossa, where resistance to the dissec-
tion is felt due to fibro-fatty tissue. This tunnel
extends around the lateral wall of the rectum and
133
Fig. 9.52 Operative photograph showing the gracilis
muscle dissected and identified in the medial boarder of
the biceps femoris flap. The tissue clamp indicates the dis-
tal end of the muscle
ends in the coccygeal area. A single gracilis is
usually used, but if the defect is large, the bilat-
eral gracilis muscle is used. The muscle is sutured
to the base of the defect. Two drains are used,
passing through the tunnel to the coccygeal area
and exiting at the lower thigh area. To cover the
muscle, a final flap is used, which is the gluteus
muscle in any form or modification, such as a
sliding island flap or a split of the gluteus, as
described previously see an example Fig. 9.57.
134 9 Reconstructive Surgery for Sacral Ulcer

Fig. 9.53 Operative photograph showing the utilization Fig. 9.54 Operative photograph showing the complete
of the gracilis muscle to fill part of the deep wound defect. dissection of the biceps femoris flap lifted up from its bed
Arrow indicates the position of the gracilis muscle
9.13 Gracilis Muscle Transfer Flap
Fig. 9.55 Operative photograph showing the completed
dissection of the biceps femoris flap and trial of rotation of
the flap from the vertical to horizontal position to cover
the defect
135
Fig. 9.56 Operative photograph showing the complete
rotation of the flap, which was sutured into the defect,
leaving two small areas not covered with the flap, which
would be grafted in the future. Donor side of the flap was
sutured directly
136
Fig. 9.57 Operative photograph showing the gracilis
muscles were placed in the required position. The left
gracilis was tunneled to the coccygeal area because of the
existing communication (indicated by arrow). See Chap. 8
for complete operative details of the procedure
References
1. Kroll SS, Rosenfield L (1988) Perforator-based flaps
for low posterior midline defects. Plast Reconstr Surg
81:561
2. Hill HL, Brown RG, Jurkiewicz MJ (1978) The trans-
verse lumbosacral back flap. Plast Reconstr Surg
62:177
3. Kato H, Hasegawa M, Takada T et al (1999) The lum-
bar artery perforator based island flap: anatomical
study and case reports. Br J Plast Surg 52:541
4. Baek SM, Williams GD, McElhinney AJ, Simon BE
(1980) The gluteus maximus myocutaneous flap in
the management of pressure sores. Ann Plast Surg
5:471
9 Reconstructive Surgery for Sacral Ulcer
5. Cederna JP (1977) Modification of the gluteus maxi-
mus musculocutaneous flaps for repair of pressure
sores. Plast Reconstr Surg 60:242
6. Minami RT, Mills R, Pardoe R (1981) Gluteus maxi-
mus island musculocutaneous flap for closure of
sacral and ischial ulcers. Plast Reconstr Surg 68:533
7. Scheflan M, Nahai F, Bostwick J III (1981) Gluteus
maximus island musculocutaneous flap for closure of
sacral and ischial ulcers. Plast Reconstr Surg 68:533
8. Stevenson TR, Polock RA, Rohrich RJ, VanderKolk
CA (1987) The gluteus maximus musculocutaneous
island flap: refinements in design and application.
Plast Reconstr Surg 79:761
9. Fisher J, Arnold PG, Waldorf J, Woods JE (1983) The
gluteus maximus musculocutaneous V-Y advance-
ment flap for large sacral defects. Ann Plast Surg
11:517
10. Ramirez OM, Orlando JC, Hurwitz DJ (1984) The
sliding gluteus maximus myocutaneous flap: its rele-
vance in ambulatory patients. Plast Reconstr Surg
74:68
11. Ramirez OM, Swartz WM, Futrell JW (1987) The
gluteus maximus muscle: experimental and clinical
considerations relevant to reconstruction in ambula-
tory patients. Br J Plast Surg 40:1
12. Allen RJ (1998) The superior gluteal artery perforator
flap. Clin Plast Surg 25:293
13. Cheong E, Wong M, Ong W, Lim J, Lim T (2005)
Sensory innervated superior gluteal artery perforator
flap for reconstruction of sacral wound defect. Plast
Reconstr Surg 115:958
14. Ichioka S, Okabe KTO, Nakatsuka T (2004) Distal
perforator-based fasciocutaneous V-Y flap for treat-
ment of sacral pressure ulcer. Plast Reconstr Surg
114:906
15. Verpaele AM, Blondeel PN, Van Landuyt K et al
(1999) The superior gluteal artery perforator flap: an
additional tool in the treatment of sacral pressure
sores. Br J Plast Surg 52:385
16. Koshima I, Moriguchi T, Soeda S et al (1993) The
gluteal perforator-based flap for repair of sacral pres-
sure sores. Plast Reconstr Surg 91:678
17. Maruyama Y, Nakajima H, Wada M et al (1980) A
gluteus maximus myocutaneous island flap for the
repair of a sacral decubitis. Br J Plast Surg 33:150
18. Parry SW, Mathes SJ (1982) Bilateral gluteus maxi-
mus myocutaneous advancement flaps for ambulatory
patients. Ann Plast Surg 8:443
19. Darnberger F (1988) The nontypical gluteus maximus
flap. Plast Reconstr Surg 81:567
20. Rubayi S, Doyle BS (1995) The gluteus maximus
muscle splitting myocutaneous flap for treatment of
sacral and coccygeal pressure ulcer. Plast Reconstr
Surg 96:1366
 Reconstructive Surgery for
Trochanteric Ulcer
Salah Rubayi
10.1 Introduction
Trochanteric ulcer is an ulcer which is located
at the lateral part of the hip joint over the promi-
nent bony part of the femur which is the greater
trochanter. This ulcer is rarely seen in post-acute
spinal cord injury or in other acute illnesses,
because the patient is always in the supine posi-
tion; however, this type of ulcer is commonly seen
in chronic insensate patients which results from
lying down on his/her side of the body. The harder
the surface the patient is lying on, the deeper the
damage to the skin and deep tissue. Anatomically,
the greater trochanter is covered with anatomi-
cal bursa and skin; therefore, if ulceration occurs,
it will involve the skin and the underlying bursa
exposing the tendinous part of the vastus lateralis
muscle origin. Healing in a stage IV ulcer may not
occur because of the nature of the tissue and the
formation of granulation tissue in the bursal cav-
ity which is colonized by bacteria; consequently,
surgical closure is indicated in this condition.
Another condition is seen in spinal cord injury
patients when the greater trochanter is rotated pos-
teriorly secondary to subluxation of the hip joint
Salah Rubayi, MB, ChB, LRCP, LRCS, MD, FACS
Department of Surgery,
Rancho Los Amigos National Rehabilitation Center,
Downey, NY, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_10, © Springer-Verlag Berlin Heidelberg 2015
10
which results from the paralysis and spasticity of
the muscle. This abnormal position of the greater
trochanter will create a new pressure point when
patient is in the sitting or supine position which
can cause skin ulceration. In repairing the trochan-
teric ulcer, it is important to excise the entire bursa
and the surrounding tissue to help the healing
process of the area. In addition to the important
step of shaving the prominent trochanteric bone,
the common flap available in the area to be uti-
lized for repair of this ulcer is the tensor fascia lata
flap which was described long time ago by Nahai
in 1978 [1–4], as musculocutaneous flap or with
modifications followed by Lewis in 1981 [5, 6] as
V-Y advancement flap. The tensor fascia lata flap
can be described as a myofasciocutaneous flap. In
many instances, the muscle itself will not cover
the defect because of the small size of the muscle,
but the fasciocutaneous component of the flap will
cover the defect. Taking into consideration that the
blood supply of the fascia will be derived from the
muscle and the skin island which covers that fas-
cia will derive its blood supply from the fascia and
muscle. The tensor fascia lata flap can be used as
an island flap, V-Y advancement flap, or a rotation
flap. All these modifications and their utilization
depend on the size and location of the defect.
Another flap option to close the trochanteric
ulcer defect is to use the gluteus maximus flap
[7–9] particularly if the ulcer is located posteriorly
secondary to the trochanteric rotation. When the
trochanteric ulcer is extensive and communicating
with the hip joint, the Girdlestone procedure
137
138
and muscle flap are indicated [10–13]. The usual
muscle utilized in this circumstance is the vastus
lateralis muscle or the rectus femoris muscle
depending on the size of the defect.
10.2 The Tensor Fascia Lata V-Y
Advancement Flap
10.2.1 Surgical Anatomy
The tensor fascia lata muscle originates partially
from the anterior superior iliac spine but more
extensively from the greater trochanter. The mus-
cle is small in size about the size of the palm. The
muscle has a long fascia which inserts in the lateral
aspect of the knee joint which gives stability to the
knee joint. Care should be taken in athletic patient
when utilizing this fascia to avoid extensive dam-
age to this mechanism. The adjacent muscles to
the TFL superiorly and medially are the rectus
femoris and sartorius muscle. Laterally is the
insertion of the gluteus maximus muscle in the
iliotibial tract. The biceps femoris muscle is sepa-
rated from the iliotibial tract by the lateral inter-
muscular septum. The vastus lateralis muscle is
under the iliotibial tract. When the iliotibial tract is
incised longitudinally, this will expose the vastus
lateralis muscle. The blood supply of the muscle is
the transverse branch from the lateral circumflex
artery which is a branch from the profunda femo-
ris; the vascular pedicle to the muscle is located
about 8–10 cm below the anterior superior iliac
spine when it is marked and the patient is in supine
position. The muscle is type I muscle; the lower
third of the fascia is supplied by perforators from
the vastus lateralis muscle. This explains that
when utilizing a long flap based on the fascia, the
distal part of the flap may not survive, and in that
circumstance, a delay procedure is recommended.
10.2.2 Surface Marking
When patient is in the supine position, a few
important landmarks can be marked because in
the lateral position they will not be accurate. The
prominent anterior superior iliac spine is marked
10 Reconstructive Surgery for Trochanteric Ulcer
with a line extending from the ASIS to the lat-
eral condyle of the femur. This line represents the
anterior border of the iliotibial tract. A posterior
marking line over the thigh is located over the lat-
eral intramuscular septum which is a depression
in the skin area between the lateral thigh and post
thigh muscle compartments; this represents the
posterior border of the fascia lata. The vascular
pedicle to the TFL muscle is located at a level of
8–10 cm below the anterior superior iliac spine
which is marked (Fig. 10.1a, b).
When the patient is turned into the lateral posi-
tion which is the ideal position for this type of
surgery, the patient is maintained in the lateral
position by using a bean bag. The ulcer is marked
in a triangular shape with the apex directed ante-
riorly. A line is drawn from the inferior lateral
angle of the ulcer and extended inferiorly to a
level about 10 cm above the knee. From this point,
the other triangle limb is extended superiorly and
stopped below the marking of the vascular pedi-
cle. If the patient has more ulcers to operate upon
at the same time with the trochanteric ulcer, then
the patient is placed in the prone position.
10.2.3 Operative Technique
The lateral position of the patient is used when
operating on a solitary trochanteric ulcer. The
general principle of excision of the ulcer and the
trochanteric bursa is performed as described in
Chap. 7. The prominent greater trochanter is
shaved to reduce the size of the bone to eliminate
the pressure point. Care should be taken not to
cause an intertrochanteric fracture during the
excision of the prominent bone. Post completion
of this procedure, flap raising is performed; it is
advisable to start distally the incision and dissec-
tion at the level of V apex because the fascia is
superficial. Post incising the skin and the thin sub-
cutaneous layer, the fascia of the iliotibial tract is
exposed; then with a scalpel, it is incised and the
vastus lateralis muscle is exposed to prevent
detaching the fascia from the skin above it. An
absorbable stitch is placed between the fascia and
the skin; with a blunt dissection using the finger,
it will make it easy to find the plane between the
10.3 The Tensor Fascia Lata Rotation Flap
a b
Fig. 10.1 (a) Operative photograph showing the patient
in semi-supine position with a trochanteric ulcer marking
of the important landmarks, interior superior iliac spine,
the vascular pedicle to the muscle, and the anterior terri-
tory of the TFL fascia, arrow pointing to the line. The type
of flap used in this case is TFL in a V-Y fashion. (b)
Operative photograph showing the patient in semi-supine
position with marking of the posterior trochanteric ulcer
two fascias (iliotibial and vastus lateralis muscle
fascia), and the skin of the marked flap is incised
with a scalpel and the fascia can be incised with
electrocautery or scalpel. The dissection is con-
tinued laterally dividing part of the fibers of the
gluteus maximus at the level of the lower angle of
the ulcer defect, and this step concludes the free-
ing of the flap laterally. Medially the dissection of
incising the skin and the fascia continues until
approaching a point where the pedicle is marked.
If there is difficulty in advancing the flap in that
circumstance a small division of the tensor fascia
lata muscle to allow complete advancement of the
flap into the ulcer defect. Two drains are placed
under the flap, and the exits of these drains are
distally above the knee joint and sutured to the
139
(Q-tip) and the marking of the posterior territory of the
TFL fascia. Arrow indicates the lateral intermuscular sep-
tum. The type of flap used in this case is the V-Y advance-
ment flap. (c) Operative photograph showing the marking
for trochanteric ulcer and the V-Y TFL flap, in addition to
other markings of the interior territory of the TFL fascia.
Arrow indicates the interior territory of the TFL fascia
skin by purse-string silk suture. When the flap is
advanced in the defect, the flap donor site is
closed in a V-Y fashion. It is very rare that the
donor site cannot be closed; in that situation, a
split skin graft is used. The flap is closed in three
layers, the deep layer, dermal layer, and the skin.
Figures 10.1, 10.2, 10.3, 10.4, 10.5, 10.6, and
10.7 show the steps of the surgical procedure.
10.3 The Tensor Fascia Lata
Rotation Flap
When the great trochanter is not located in the
lateral anatomical position, secondary to patho-
logical changes in the hip joint, the trochanter
140
Fig. 10.2 X-ray of AP pelvis showing some calcification
over the greater trochanter which can cause high pressure
on the skin resulting in pressure ulcer
Fig. 10.3 Operative photograph showing the excised
ulcer and the shaved trochanteric bone
is rotated and located posteriorly. As a result,
the V-Y advancement flap will not be suitable
for this situation; therefore, the option is to uti-
lize the tensor fascia lata in a rotation form. It
is worth mentioning that it is well documented
in literature that the length of tensor fascia flap
10 Reconstructive Surgery for Trochanteric Ulcer
Fig. 10.4 Operative photograph showing the defect of
the excised ulcer and the shaved bone and complete dis-
section of the flap
will determine the viability of the distal part of
the flap. It is recommended that when design-
ing such a flap, it should not exceed 18 cm in
length or it should be 8–10 cm above the femo-
ral condyle; for vascular reason, the distal part
of the fascia is supplied by perforators from the
vastus lateralis muscle. Consequently, if a flap is
designed, for example, to close an ischial area,
the clinical picture of the vascular compromise
may show as an epidermolysis of the skin and
then will convert into a full-thickness skin loss.
The recommendation in such circumstance is
to delay the flap and then to raise the flap after
3 weeks. This procedure will direct the blood
supply to be derived from the main pedicle to
the distal part of the flap. Unfortunately, in our
busy clinical practice, sometimes it is difficult to
take the patient twice to the operating room, and
sometimes we take the risk with minor morbidi-
ties because of the patient’s medical condition.
10.4 Surface Marking of the Flap
Fig. 10.5 Operative photograph showing the reflected
flap to demonstrate the TFL fascia. The large muscle in
the photo is the vastus lateralis muscle (long arrow). The
short arrow indicates the TFL fascia
10.4 Surface Marking of the Flap
The anterior superior iliac spine is marked
8–10 cm; below that mark is the location of the
vascular pedicle of the tensor fascia lata muscle.
As mentioned previously, the tensor fascia bound-
ary consists of the anterior border, a line drawn
from the anterior superior iliac spine (ASIS) to
the lateral condyle of the femur, and the poste-
rior border located over the lateral intramuscular
septum; the design of the flap is between the two
borders as a rectangular-shaped flap. The width
of the flap should be according to the diameter of
the defect, the acceptable width is about 10 cm,
and the length is not to exceed 8–10 cm above
condyle of the femur; the arc of rotation of the
flap is located at the vascular pedicle of the
muscle.
141
Fig. 10.6 Operative photograph showing the complete
closure of the TFL flap in a V-Y fashion
10.4.1 Operative Technique
The ideal position of the patient on the operating
table is lateral position, but if the position of the
ulcer is more posterior and there are other ulcers
to be closed at the same time, the prone position
is preferred. The ulcer is excised and the bone
is shaved as described in Chap. 7. The first step
of the dissection is to find the tensor fascia lata
tendon distally by making the transverse incision
at the end of the flap by utilizing the scalpel to
incise the skin and the fascia exposing the vastus
lateralis muscle as described in the V-Y flap; dis-
section is continued anteromedially and laterally
by dividing the skin and the fascia. The medial
dissection is stopped at the level of the vascular
pedicle, and this point represents the arc of the
flap rotation; the dissection is carried on pos-
terolaterally including dissection into the gluteus
142 10 Reconstructive Surgery for Trochanteric Ulcer

maximum muscle and part of the lateral inter-

muscular septum which is a rich vascular area.
The flap is freed completely from the trochanteric
area; the trochanteric bursa can be seen under the
flap which should be excised completely to pro-
mote the flap healing and adhesion. Care should
be taken not to violate the lateral intermuscular
septum of the thigh which will expose the poste-
rior thigh muscle; at this stage, the flap is rotated
posteriorly to ensure if it can cover the defect
without tension. This flap can be used to cover
the posterior thigh and ischial defect. When the
distal part of the flap shows doubtful perfusion
especially if the flap was too long, to check the
tissue perfusion, injection of (IV) fluorescence
dye and utilizing ultraviolet light (wood light)
intraoperatively to demonstrate the perfusion of
the distal part of the flap by showing a yellow
coloration of the skin which indicates sufficient
vascularity and perfusion; when the color of the
skin is dusky, it does indicate not a viable tis-
sue. The flap donor site closure depends on the
patient’s skin laxity and the width of the flap;
if the donor site cannot be closed directly, skin
graft should be applied. Two drains should be
Fig. 10.7 Photograph 6 weeks post-surgery showing
used and the exits of these drains located distally complete healing of the flap
from the flap arc of rotation. Flap is closed in
three layers, the deep layer, dermal, and skin.
Figures 10.8, 10.9, 10.10, 10.11, 10.12, 10.13,
10.14, 10.15, 10.16, and 10.17 show the surgical
steps in raising the flap.

10.5 Posterior Trochanteric Ulcer

This ulcer is frequently seen when the hip joint is

subluxed secondary to patient paralysis. The
greater trochanter is rotated from the normal ana-
tomical lateral position to a posterior position.
Consequently, when the patient is in a sitting
position, the greater trochanter will be a pressure
point instead of the ischium which will lead to
skin breakdown and development of pressure
ulcer. This can be demonstrated by clinical exam-
ination and X-ray of the hip joint in a lateral posi-
tion which demonstrates the rotation of the
greater trochanter. In addition, measuring the sit-
ting pressure by the physical therapy will demon-
Fig. 10.8 Operative photograph showing the patient in
prone position with bilateral posterior trochanteric ulcer.
Ulcers are marked
strate the high pressure over that area instead of
the ischial area (Fig. 10.18).
The management of the ulcer surgically
depends if the ulcer occurred for the first time; in
that instance, excision of the ulcer and shaving of
the prominent part of the greater trochanter are
10.5 Posterior Trochanteric Ulcer
Fig. 10.9 Operative photograph of the right side showing
the marking of the TFL rotation flap
Fig. 10.10 Operative photograph of the left side showing
the marking of the TFL rotation flap
Fig. 10.11 Operative photograph showing the ulcer is
excised and the trochanteric bone was shaved and the flap
is raised. Short arrow indicates the location of the TFL
fascia. Long arrow indicates the vastus lateralis muscle
performed. Care should be taken not to cause
intertrochanteric fracture of the femur during
bone shaving; the closure of the ulcer defect is
achieved by using either the inferior gluteus max-
143
Fig. 10.12 Operative photograph showing the bone spec-
imen which was shaved off the bilateral trochanteric bone
Fig. 10.13 Operative photograph showing the method of
rotation of the TFL flap to cover the defect
Fig. 10.14 Operative photograph showing the rotation
and suturing of the left TFL flap to cover the defect. Flap
donor site was not able to close directly; therefore, a skin
graft is used
imus rotation flap where the operative procedure
is similar in utilizing the lower portion of the glu-
teus maximus rotation flap for closure of the
ischial ulcer or the TFL rotation flap as described
under Tensor Fascia Lata Rotation Flap section.
Figures 10.19, 10.20, 10.21, 10.22, 10.23, 10.24,
144 10 Reconstructive Surgery for Trochanteric Ulcer

Fig. 10.15 Operative photograph showing the rotation

and closure of the right TFL flap. Donor site managed to
be closed directly
Fig. 10.18 Computerized pressure mapping of the
patient in sitting position showing high pressure over both
posterior trochanteric locations; arrows indicate high-
pressure points

Fig. 10.16 Photograph 6 weeks post-surgery showing Fig. 10.19 X-ray AP pelvis showing prominent bilateral
complete healing of the left flap and skin graft trochanteric bone. Arrows indicates the rotation and
prominent greater trochanter

Fig. 10.17 Photograph 6 weeks post-surgery showing Fig. 10.20 Operative photograph showing patient in
complete healing of the right flap prone position with bilateral posterior trochanteric ulcers
10.5 Posterior Trochanteric Ulcer
Fig. 10.21 Operative photograph lateral view showing
the design of the right gluteus maximus flap
Fig. 10.22 Operative photograph lateral view of the left
side showing the design of the gluteus maximus flap and
possible TFL rotation flap
Fig. 10.23 Operative photograph showing the excised
ulcer and shaving of the trochanter with raising the right
gluteus maximus flap. Short arrow indicates the inferior
surface of the gluteus maximus muscle. Long arrow indi-
cates the gluteus medius muscle
145
Fig. 10.24 Operative photograph of the left side showing
post-excision of the ulcer and shaving of the prominent
trochanteric bone and dissection of the left gluteus maxi-
mus muscle from the gluteus medius muscle
Fig. 10.25 Operative photograph showing rotation and
closure of the right gluteus maximus flap
10.25, and 10.26 show the surgical steps of
the procedure.
The other surgical option is to utilize the ten-
sor fascia lata flap in a rotation form as described
previously. The author’s experience that the ten-
sor fascia lata flap as a fasciocutaneous flap is
not sufficient to cover the shaved bone and to
achieve soft tissue padding over the bone; for
this reason, a tunneled gracilis muscle or a rectus
femoris muscle can be utilized to cover the bone
as a first layer of repair and then covered by the
tensor fascia lata. Figures 10.27, 10.28, 10.29,
10.30, 10.31, 10.32, 10.33, 10.34, and 10.35
show the surgical steps for utilizing the rectus
femoris muscle.
In recurrent ulceration in the posterior tro-
chanteric area on many occasions, it dictates to
perform the Girdlestone procedure to eliminate
the pathological skeletal deformity which is the
146 10 Reconstructive Surgery for Trochanteric Ulcer

Fig. 10.26 Operative photograph of the left side showing Fig. 10.29 Operative photograph showing the exposed
the closure of the gluteus maximus flap posterior trochanteric ulcer; the blue coloration by methy-
lene blue is showing the extent of the ulcer and the tro-
chanteric bursa

Fig. 10.27 Operative photograph of patient in the lateral

position with extensive posterior trochanteric ulcer, show-
ing the design of the TFL flap as a second layer to cover
the ulcer defect
Fig. 10.30 Operative photograph showing the ulcer was
excised and raising the TFL flap

Fig. 10.28 Operative photograph of the same patient

showing the design of the TFL flap and the margins of the
TFL fascia

etiology for the recurrent ulceration and possible

bone infection. The appropriate muscles to be
used in the resulted defect post-Girdlestone pro-
cedure are the vastus lateralis muscle and rectus
femoris muscle (Chap. 11).
Fig. 10.31 Operative photograph showing the com-
pletely raised TFL flap and also the vastus lateralis and the
transected rectus femoris muscle. Short arrow indicates
the transected rectus femoris. Long arrow indicates the
dissected TFL flap
References
Fig. 10.32 Operative photograph showing complete dis-
sected rectus femoris and rotated to cover the posterior
trochanteric ulcer defect. Arrow indicates the position of
the rectus femoris
Fig. 10.33 Operative photograph showing the rotation of
the dissected TFL flap to cover the defect
Fig. 10.34 Operative photograph showing complete
suturing of the flap
It is worth mentioning that the author once uti-
lized the vastus lateralis muscle to close trochan-
teric ulcer in a very obese patient when the defect
was very deep, about 15 cm. Otherwise, all the
trochanteric ulcers can be closed surgically with
the standard flaps described.
147
Fig. 10.35 Six weeks post-surgery showing complete
healing of the flap wound utilized to close the right
posterior trochanteric ulcer
References
1. Nahai F, Silverton JS, Hill HL et al (1978) The tensor
fascia lata musculocutaneous flap. Ann Plast Surg
1:372
2. Hill HL, Nahai F, Vasconez LO (1978) The tensor fas-
cia lata myocutaneous free flap. Plast Reconstr Surg
61:517
3. Nahai F, Hill HL, Hester TR (1979) Experiences with
the tensor fascia lata flap. Plast Reconstr Surg 63:788
4. Nahai F (1980) The tensor fascia lata flap. Clin Plast
Surg 7(1):51
5. Lewis VL Jr, Cunningham BL, Hugo NE (1981) The
tensor fascia lata V-Y retroposition flap. Ann Plast
Surg 6:34
6. Siddiqui A, Wiedrich T, Lewis VL Jr (1993) Tensor
fascia lata V-Y retroposition myocutaneous flap: clin-
ical experience. Ann Plast Surg 31:313
7. Becker H (1979) The distally-based gluteus maximus
muscle flap. Plast Reconstr Surg 63:63
8. Ramirez OM (1987) The distal gluteus maximus
advancement musculocutaneous flap for coverage of
trochanteric pressure sores. Ann Plast Surg 18:295
9. Hurwitz DJ (1988) Re Ramirez: the distal gluteus
maximus advancement musculocutaneous flap for
coverage of trochanteric pressure sores (letter). Ann
Plast Surg 20:198
10. Drimmer MA, Krasna MJ (1987) The vastus lateralis
myocutaneous flap. Plast Reconstr Surg 79:560
11. Rubayi S, Pompan D, Garland D (1991) Proximal
femoral resection and myocutaneous flap for treat-
ment of pressure ulcers in spinal injury patients. Ann
Plast Surg 27:132
12. Schmidt AB, Fromberg G, Ruidisch M-H (1997)
Applications of the pedicled vastus lateralis flap for
patients with complicated pressure sores. Spinal Cord
35:437
13. Mathes SJ, Nahai F (1997) Reconstructive surgery,
principles, anatomy, and technique. Churchill
Livingstone, New York
 Reconstructive Surgery of the Hip
Joint Involved with Pressure Ulcer,
Pathological Conditions,
and Trauma
Salah Rubayi
11.1 Introduction
The hip is a powerful joint in the human body.
In ambulatory patients, the hip joint is necessary
for standing, walking, and sitting. In paralyzed
individuals (those with paraplegia or tetraple-
gia), the hip joint has an important function,
depending on the extent of the paralysis, when
sitting in a wheelchair. The hip joint acts to sta-
bilize the sitting position, in transferring from
the wheelchair to another surface and vice versa,
and when turning from side to side. The hip
joint acts to stabilize the lower extremities. It
has a powerful muscle attachment and strong
capsule. Unfortunately, in paralyzed individu-
als, the hip joint can be affected directly or indi-
rectly by pathological conditions close to the
hip joint or by traumatic conditions, for exam-
ple, the direct extension of infection or necrosis
from pressure ulcers such as the trochanteric
ulcer or ischial ulcer. These are common exam-
ples of conditions that can affect the hip by
causing septic hip and eventually osteomyelitis
of the femoral bone or pelvic bone or abscess of
the iliopsoas muscles.
S. Rubayi, MB, ChB, LRCP, LRCS, MD, FACS
Department of Surgery, Rancho Los Amigos National
Rehabilitation Center, Downey, CA, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_11, © Springer-Verlag Berlin Heidelberg 2015
11
11.2 Pathological Conditions
or Injuries that Can Affect
the Hip Joint
• Septic arthritis and osteomyelitis of the bone
• Heterotopic ossification of the femoral bone
and pelvic bone
• Fracture of the femoral bone
• Dislocation of the femoral head
11.3 Infection of the Hip Joint
and Septic Arthritis
This condition is encountered frequently in spinal
cord injury patients secondary to extension of infec-
tion from pressure ulcers by direct extension from
the trochanteric ulcer or ischial ulcer. On rare occa-
sions, the hip joint becomes infected secondary to
blood-borne infections commonly resulting from
urinary tract infections. Sometimes, the hip infec-
tion can present a diagnostic dilemma for specialists
in infectious disease and internal medicine and even
orthopedic surgeons. In such patients with a history
of hospitalization for treatment of sepsis, a plastic
surgeon will eventually be involved in the manage-
ment of the wound or open hip cavity. There are a
few important points that should be considered in
achieving a diagnosis of the hip infection. These are
long-standing ulcers with chronic infection, history
of sepsis, and frequent intravenous antibiotic treat-
ment. The main diagnostic indicator on physical
examination is the free movement at the hip second-
149
150 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma
ary to destruction of the hip joint component, which
is called an auto Girdlestone. Sometimes the femur
is ankylosed in an abnormal position secondary to
the development of infected heterotopic ossifica-
tion. Other physical signs are that, by manual exam-
ination of the ulcer, the examiner can feel that his or
her finger is in the hip joint cavity and parts of the
femur, such as the femoral head or the lesser tro-
chanter, can be felt. In some cases, the infection can
extend from the hip joint into the anterior thigh area
and eventually present as an ulcer in the groin.
X-ray (radiologic examination) of the pelvis and hip
confirms the physical clinical finding. However,
magnetic resonance imaging (MRI) of the pelvis
and hip can be utilized to confirm the destruction
and infection of the hip joint (see Chap. 4). An
arthrogram of the hip is not informative at later
stages, but it is a useful test in the early stages of
infection to demonstrate whether the hip joint cap-
sule is communicating with the ulcer or soft tissue.
These patients present clinically with anemia, hypo-
proteinemia, and loss of weight and appetite. These
conditions should be corrected and treated before
reconstructive surgery.
11.4 Girdlestone Procedure
11.4.1 History
Gathorne Robert Girdlestone was a British ortho-
pedic surgeon who introduced this procedure in
the early 1940s for treatment of polyarthritis and
tuberculosis of the hip joint. The procedure was
used in the Second World War to treat injuries to
the hip joint, and its application was extended for
management of osteoarthritis with intractable
pain, before the era of total hip replacement, which
was introduced by Sir John Charnley in 1962. The
initial description of the Girdlestone procedure [1]
(Fig. 11.1) was limited to the head of the femur,
part of the greater trochanter, and a wedge from
the acetabular bone. Later, the Girdlestone proce-
dure was utilized and modified as described in the
literature for treatment of failed and infected total
hip replacement [2–4]. The procedure was
described in the management of pressure ulcer by
O’Hare in 1964 [5]. Stewart and Comarr [6], in
Fig. 11.1 Operative photograph of a patient in the semi-
lateral position showing the marking for the Girdlestone
procedure and vastus lateralis or rectus femoris muscle for
utilization to close the hip defect
1971, reported on it in their 25-year review of
excision of the femoral head and neck in patients
with spinal cord injury. Eltoria [7], in 1983, pre-
sented his experience using this procedure in
patients with spinal cord injury.
The main technical obstacle in the Girdlestone
procedure was how to close the defect resulting
from removal of the head, neck, and trochanter of
the femur. The problem was finding soft tissue to
close the defect. Girdlestone and the other authors
described various different local tissues to close
the defect, for example, the gluteus maximus
muscle and deepithelization of the skin and
insertion into the defect. Unfortunately, all these
procedures were unsuccessful and eventually left
a defect or discharging sinus. In 1983, however,
Arnold and Witzke [8] described the use of the
vastus lateralis muscle flap to repair a failed total
hip arthroplasty. This technique had been
described previously by Minami et al. [9] to close
a trochanteric ulcer. The main postoperative
complication for the surgeon was how to immo-
bilize the pelvis and the lower extremity to pre-
vent hematoma resulting from mobility of the
proximal femur against the inserted muscle into
the defect. Klein et al. [10], in 1988, presented a
group of patients who had a Girdlestone proce-
dure and vastus lateralis muscle flap by stabiliz-
ing the pelvis and the proximal femur using an
external fixture. They claimed this method
stopped the pistoning effect of the femoral shaft
against the muscle. The wounds healed, but,
unfortunately, there were complications from
using the external fixture, such as pin track infec-
tion with loosening of the pin. In addition, an
orthopedic surgeon was needed to place and
11.4 Girdlestone Procedure
remove the external fixture, and it was difficult to
place the patient in a specialized bed postopera-
tively with the external fixture.
The author [11], in 1991, presented a larger
series of patients with a Girdlestone procedure and
vastus lateralis muscle flap with modified operative
procedures and postoperative management. The
Girdlestone procedure was performed in a radical
way by excising the head of the femur and greater
trochanter to a level below the lesser trochanter to
eliminate the entire infected bone and to detach the
insertion of the iliopsoas muscle, which eliminated
the source of severe spasticity or contracture of the
muscle. This step of the procedure enabled straight-
ening of the lower extremity of the patient. The
author, at that time, performed this procedure in
three stages – debridement, bone excision, and then
insetting the muscle in the defect. The final stage
was placement of the skin graft over the muscle
surface. The main modification by the author was
replacing the external fixture with a foam abduc-
tion pillow placed between the lower extremities of
the patient to maintain stability of the surgical site
until healing was achieved 4 weeks postopera-
tively. To prevent any residual postoperative mus-
cle spasms, antispasmodic medication was given.
This approach achieved good healing of the hip
wound. Years later, the author modified the entire
procedure, as a result of extensive exposure and
experience in at least 1,000 Girdlestone procedures
for different etiologies, by performing the proce-
dure in one stage, that is, debridement and bone
excision, insetting the muscle, and closure by local
fasciocutaneous flap or direct wound closure. This
modification resulted in excellent healing and
decreased the number of trips to the operating room
to one, in the end shortening hospitalization time.
This practice became the standard protocol at our
center and part of the teaching curriculum to plastic
surgery residents in training.
11.4.2 Side Effects of the Girdlestone
Procedure
This procedure is lifesaving as it eradicates the
infection with debridement of the involved bone.
Pathological specimens are obtained for histology
151
and bacteriology of the pelvic bone to determine
the type and extent of infection and the duration of
antibiotic treatment that is indicated. Unfortunately,
there are a few side effects from the procedure,
listed below, that the surgeon and the patient should
be aware of, especially if the patient has a spinal
cord injury and understands the importance of the
hip joint for their function as a wheelchair sitter:
• The lower extremity becomes loose and the
leg can be rotated up to 360°
• Shortening of the leg, which may not be
important or functional in wheelchair sitters
• Loss of stability during sitting and transfer-
ring. Normally the hip joint provides the
patient with stability during transfer
• Pelvic obliquity may result, and eventually
this predisposes to development of pressure
ulcer over the contralateral ischium
• Heterotopic ossification can develop between
the end of the proximal femur and the pelvis,
which limits the range of motion in the hip area
• Educating the patient on the outcome protects
the surgeon from medico-legal liability post-
surgery. The Girdlestone procedure is an
important procedure in the life of the patient
with spinal cord injury, which was advanced
with the utilization of the muscle flap, and it is
one of the important reconstructive surgery
procedures around the pelvis. The author
strongly believes that plastic surgery trainees
should be exposed and trained to perform this
procedure. The plastic surgeon should be the
team leader in the management of these diffi-
cult reconstructive surgery cases.
11.4.3 Operative Technique
of Girdlestone Procedure
Patient Position
If the Girdlestone procedure is performed for
femoral fracture, dislocation, or heterotopic ossi-
fication, the appropriate position is the supine
position with a pelvic tilt toward the contralateral
side or the complete lateral position using a bean
bag for patient support. The prone position is
used when the hip joint is affected with the exis-
tence of a pressure ulcer.
152 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma
11.4.4 Topographical Marking
of the Operative Site
The most important markings for the surgical
approach to the vastus lateralis muscle are the ana-
tomical markers of the greater trochanter and the
hip joint. A vertical line extends a few centimeters
above the lateral condyle of the femur in the mid-
lateral thigh, which is midway between the ante-
rior and posterior territory of the tensor fascia lata
fascia. Proximally, the line divergies into a T-shape
where the lateral line of the T is over the lower part
of the gluteus maximus muscle. This approach is
important when dealing with a dislocated hip or
femoral fracture. The medial part of the T-line
extends anteriorly. This extension is important
when excising heterotopic ossification of the hip,
which usually extends anteriorly (Fig. 11.2). When
there is an existing trochanteric ulcer, the design of
the incision should involve ulcer excision and
repair by a tensor fascia lata flap. The vascular
pedicle of the vastus lateralis muscle should be
marked to avoid the risk of damaging the pedicle
during the dissection, which is 10 cm below the
anterior superior iliac spine.
11.4.5 Operative Technique
The author prefers to begin incising the skin dis-
tally because the iliotibial tract is superficial at
that site. After incising the skin and the subcuta-
neous layer, the deep fascia, which is the iliotibial
Fig. 11.2 Operative photograph showing the exposure of
the vastus lateralis muscle and the greater trochanter.
Arrow indicates hip joint location
tract, is identified. When the fascia of the vastus
lateralis muscle is observed, a scalpel is used to
incise the fascia. The incision extends proximally,
exposing the vastus lateralis muscle to the level of
its origin from the greater trochanter. Above that
point, the gluteus maximus and the tensor fascia
lata muscles are observed. Using an electrocau-
tery, separation between the two muscles is per-
formed. By completing this dissection, two flaps
are raised. A self-retaining retractor can be placed
superiorly and inferiorly. The hip joint is exposed
(Fig. 11.2). Depending on the pathology of the hip
joint, the superior incision can extend anteriorly
toward the groin or posteriorly through the glu-
teus maximus muscle. To expose the proximal
femur, a transverse incision is made over the ori-
gin of the vastus lateralis muscle using an electro-
cautery about 2 cm below the greater trochanter.
The vastus lateralis muscle fibers are dissected
from the proximal femur using a periosteal eleva-
tor. The lateral attachment of the vastus lateralis
muscle from the lateral inter muscular septum is
dissected and transected by an electrocautery for
about 5 cm inferiorly or to a level below the lesser
trochanter of the femur. A noncrushing tissue
clamp is placed over the free edge of the vastus
lateralis muscle to expose the proximal femoral
shaft (Fig. 11.3). Two protector instruments,
called a cobb elevator or Chandler, are placed
under the shaft of the femur to protect the soft tis-
sue from injury during the bone cutting (Fig. 11.4).
Fig. 11.3 Operative photograph showing the reflection
of the vastus lateralis muscle from its origin to expose the
proximal femur when a cobb elevator instrument is
inserted underneath the femur to prepare for the femur
transection by oscillating saw
11.4 Girdlestone Procedure
Fig. 11.4 Operative photograph showing the osteotomy
of the proximal femur has been performed. The proximal
component of the hip is lifted by a bone forceps for dis-
section. Arrow indicates the location of the proximal
femur post osteotomy
Fig. 11.5 Operative photograph showing the soft tissue
attachment and the capsule of the joint dissected and the head
of the femur is nearly dislocated from the acetabular cavity
A transverse osteotomy below the level of the
lesser trochanter is made over the femoral shaft
using a bone oscillating saw. Complete division of
the bone can be performed using a bone osteo-
tome. A bone ring forceps is placed over the prox-
imal femoral component and is lifted up using
electrocautery dissection, or transection of the
soft tissue attachment is completed (Fig. 11.5).
The tissue holding the femoral head in place is the
capsule, which is a strong tissue. Multiple longi-
tudinal incisions are made and then a transverse
incision is made to transect the entire capsule
from the acetabular attachment and the attach-
ment at the neck of the femur. At this stage, the
head of the femur is still in the acetabulum. Using
the cobb elevator, which can be slipped between
153
Fig. 11.6 Operative photograph showing the actual spec-
imen of the head of the femur, greater trochanter, and
lesser trochanter removed by Girdlestone procedure
Fig. 11.7 Operative photograph showing the proximal
femur and the cavity resulting from removing the femoral
component. Short arrow indicates the proximal femur
after osteotomy, long arrow indicates the location of the
acetabulum
the head and the acetabulum with a retraction
maneuver, the head can be dislocated from the
acetabular cavity. The ligamentum teres (ligament
head of the femur) keeps the head attached to the
acetabular cavity and can be transected, which
completes the Girdlestone procedure (Fig. 11.6).
The end of the proximal femur can be
smoothed using a flat bone file (Fig. 11.7). If the
medullary cavity continues to bleed, pieces of
collagen hemostat (Avitine®, Bard) are packed in
the medullary canal to stop bleeding. The author
prefers not to use bone wax because it may act as
154 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma
Fig. 11.8 Operative photograph showing the dissection
of the rectus femoris muscle for use to close the defect
a foreign body. The acetabular cavity treatment
depends on the original pathology of the hip
joint. If the the hip joint was infected, curetting
the cavity is performed and then a deep bone
biopsy is taken for histopathology and bacterio-
logical examination for culture and sensitivity.
The acetabular cavity should be irrigated well
with normal saline and bacitracin solution. The
resulting large cavity from removal of the femo-
ral component or bone destruction must be filled
with muscle to fill the dead space and maintain
healing (Fig. 11.9).
The main difference between the approach
used in the 1940s and the one today is the repair of
the defect resulting from the Girdlestone proce-
dure by muscle flap. The next step is for the plastic
surgeon to determine which muscle to use to repair
the defect. This depends on the patient’s primary
disease, whether they are nonambulatory or ambu-
latory, the size of the defect, and the age of the
patient. The main muscles available locally for
repair of the defect are the vastus lateralis muscle,
the rectus femoris muscle, and the rectus abdomi-
nis muscle. Figures 11.1, 11.2, 11.3, 11.4, 11.5,
11.6, 11.7, 11.8, 11.9, and 11.10 show the opera-
tive technique for the Girdlestone procedure.
11.5 Vastus Lateralis Muscle Flap
11.5.1 Surgical Anatomy
of the Vastus Lateralis Muscle
The vastus lateralis muscle is a powerful muscle
in function and volume with a reliable blood
Fig. 11.9 Operative photograph showing the method by
which the rectus femoris muscle is insetted to cover the
hip defect. The proximal part of the vastus lateralis muscle
will be advanced to cover the free proximal femur
Fig. 11.10 Operative photograph showing the complete
closure of the wound
supply. It is one of the important muscles in the
formation of the quadriceps mechanism, which is
responsible for extension of the leg at the knee
joint. When utilizing the vastus lateralis muscle
in ambulatory patients, this should be taken into
consideration. The author usually repairs the
resulting defect between the rectus femoris and
the vastus medialis. The vastus lateralis muscle
originates from the lateral surface of the greater
trochanter and the trochanteric line of the femur,
and posteriorly from the lateral intermuscular
septum and the lip of the linea aspera of the
femur. It is inserted with the other tendons of
the rectus femoris and the vastus medialis to form
the common quadriceps tendon, which is inserted
into the patella. The vastus lateralis muscle has a
relationship to the other muscle of the lateral
thigh muscle group. It is situated between the
rectus femoris muscle and the biceps femoris
muscle. The vastus lateralis covers the vastus
intermedius, which is a thin sheath of muscle
11.5 Vastus Lateralis Muscle Flap
covering the entire femoral shaft. When raising
the vastus lateralis it is difficult to separate the
plane between the vastus lateralis and the vastus
intermedius muscle, as it is not well defined. For
this reason, the vastus intermedius muscle is
always raised as a part of the vastus lateralis
muscle.
The vastus lateralis muscle is supplied with
the main pedicle from the lateral circumference
artery, which is a branch from the profunda
artery. The vascular pedicle is the descending
artery at a level about 10 cm below the anterior
superior iliac spine. The lower portion of the
muscle is supplied by branches from the femo-
ral artery, which are branches from the lateral
geniculate artery. The author’s clinical observa-
tion is that, when utilizing the entire muscle,
the main pedicle can support the entire muscle
bulk. For this reason it is rare to encounter isch-
emia or necrosis of the distal part of the muscle.
The motor nerve of the vastus is a branch from
the femoral nerve. The vastus lateralis muscle,
with its excellent blood supply and volume, is
used to reconstruct the hip and pelvic region. In
addition, it can be used to repair the sacral area
when the gluteus maximus muscles are not
available. When there is extensive ischial peri-
neal ulceration, it can be used to reconstruct the
entire perineal area, even to the contralateral
side.
The vastus lateralis can be raised as an island
flap and rotated in a large arc of rotation. It can be
covered with a skin graft with scoring of the mus-
cle fascia to increase the size of the surface. A
skin graft is acceptable functionally, otherwise,
the muscle can be covered with a fasciocutaneous
flap, such as the tensor fascia lata as a rotation
flap, or a posterior thigh flap. The donor site of
the vastus lateralis muscle flap can be closed pri-
marily without any major complications. In the
author’s experience, in closing a hip defect it is
not a standard to utilize the vastus lateralis mus-
cle, especially in a patient with spinal cord injury,
because this group of patients has a high rate of
ulcer recurrence and they need a reserve of mus-
cles. Therefore, the vastus lateralis muscle is an
excellent muscle to close different anatomical
locations and, for this reason and considering the
155
size of the defect, the rectus femoris muscle is
recommended as a substitute.
11.5.2 Operative Technique
for Elevation of the Vastus
Lateralis Muscle
The position of the patient on the operating table
depends on the pathology of the hip joint or the
existence of a pressure ulcer as described in the
section on the Girdlestone procedure. When a
pressure ulcer and other hip pathology exists, the
prone position is used. If the vastus lateralis mus-
cle is to be used for a hip joint defect resulting
from heterotopic ossification or a traumatic con-
dition such as fracture or dislocation, the supine
or lateral position is used.
The standard skin incision is in the mid-lateral
thigh extending from above the knee and passing
the greater trochanter. Depending on the pathol-
ogy of the hip, it can be extended medially or
posteriorly. If the tensor fascia lata flap is needed
for a trochanteric ulcer, the design can accommo-
date the flap. The skin is incised deep to the ilio-
tibial tract, exposing the vastus lateralis muscle.
Blunt dissection is performed to raise two flaps
for complete exposure of the vastus lateralis mus-
cle. There are many perforators originating from
the muscle to supply the deep fascia that need to
be coagulated. The pathology of the hip or the
ulcer is then dealt with (see under Girdlestone
procedure and heterotopic ossification or tro-
chanteric ulcer). Two self-retaining retractors are
placed on the upper and lower parts of the wound.
The author prefers to first identify the plane
between the vastus lateralis and the rectus femo-
ris superiorly with blunt dissection; the two mus-
cles can be easily separated. Inferiorly, the plane
becomes tendinous and an electrocautery is used
for dissection. Dissection is stopped above the
suprapatellar bursa. Care should be taken not to
open it. Dissection then continues to separate the
vastus lateralis muscle from the trochanteric and
femoral attachment. A transverse incision is
made over the origin of the muscle from the
greater trochanter. Care should be taken not to
extend too medially to avoid injury to the vascu-
156 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma

lar pedicle. The muscle is lifted from the proxi-

mal femur, leaving behind the periosteum intact.
Dissection continues laterally to detach the mus-
cle from the lateral intermuscular septum. There
are many large perforators that sometimes are
difficult to coagulate and they retract behind the
septum. Small amounts of muscle fiber can be
left behind to help coagulate these perforators.
The muscle is detached inferiorly and transected
horizontally at a level above the condyle of the
femur and the formation of the quadriceps ten-
don. Care should be taken to avoid opening of the Fig. 11.11 Plain x-ray of the pelvis of a patient with spi-
suprapatellar bursa. If it is opened accidentally, it nal cord injury showing a previous right femoral fracture
should be closed. When the muscle is completely and left dislocated hip
free laterally, it can be easily dissected from the
entire femoral shaft, leaving the periosteum
intact.
As described previously, the vastus interme-
dius is a thin muscle and the author’s practice is
to leave the muscle intact with the vastus latera-
lis as one component. The dissection of the vas-
tus lateralis medially is to locate the
interdigitation between the vastus lateralis mus-
cle and the vastus medialis, which is difficult to
find as a real plane, although there is a demarca-
tion of tendinous part. Using an electrocautery in
a perpendicular fashion on the femoral shaft, dis-
section between the two muscles is performed
starting inferiorly and proceeding superiorly.
The dissection is stopped when approaching the
level of the muscle pedicle, which enters the
muscle surface medially. After obtaining a suffi-
cient length of the vastus lateralis muscle to
cover the defect or to be rotated to cover ulcers, Fig. 11.12 Operative photograph showing the patient in
the dissection is stopped. When the muscle is the supine position with skin marking for the surgical
needed to cover a hip or pelvic defect, the mus- procedure of a Girdlestone and muscle flap. Arrow indi-
cates the anterior territory of the tensor fascia lata (TFL)
cle is rolled on itself without tension and inset fascia
into the defect, including the acetabulum. As a
standard, two drains are used, one under the
muscle in the acetabular cavity and the other thigh wound is closed in three layers (deep, der-
over the muscle. The exits of these drains are mal, and skin). See Chaps. 8 and 11 (Figs. 11.11,
above the knee. At the same time, they will drain 11.12, 11.13, 11.14, 11.15, 11.16, 11.17, 11.18,
the vastus lateralis donor site. A third drain can 11.19, and 11.20).
be used to drain the superior part of the field, The vastus lateralis muscle can be rotated in a
especially if the gluteus maximus muscle was 90° angle to cover the ischioperineal or sacral
incised during the surgery. The vastus lateralis area. In this circumstance, the muscle can be cov-
muscle is sutured to the surrounding soft tissue, ered with a fasciocutaneous flap or a skin graft if
which is the gluteus maximus muscle, and the a flap is not available. The thigh wound is closed
11.5 Vastus Lateralis Muscle Flap
Fig. 11.13 Operative photograph, lateral view, showing
the marking for the exposure of the vastus lateralis. Arrow
indicates the topographical marking of the vascular pedicle
Fig. 11.14 Operative photograph showing the exposure
after the Girdlestone procedure and dissection of the vas-
tus lateralis distally from the rectus femoris muscle.
Arrow indicates the vastus lateralis muscle
Fig. 11.15 Operative photograph showing complete dis-
section of the vastus lateralis muscle from the entire femo-
ral shaft and other attachments
in three layers (deep, dermal, and skin).
Figure 11.21 shows the use of the vastus for the
ischioperineal and sacral area.
157
Fig. 11.16 Operative photograph showing the complete
detachment of the vastus lateralis
Fig. 11.17 Operative photograph showing the insetting
of the vastus lateralis into the hip defect
Fig. 11.18 Operative photograph showing the surgical
specimen from the bilateral Girdlestone procedure
Note that the author never harvests a skin graft
in patients with spinal cord injury from the thigh
or other areas (pressure areas). To prevent com-
plications from nonhealing skin at a graft donor
site in a pressure area, only the lower leg is used.
158 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma
Fig. 11.19 Operative photograph showing the final clo-
sure of the wound and the position of the drains
Fig. 11.20 Postoperative anteroposterior (AP) pelvis
x-ray showing the bilateral Girdlestone procedure
11.6 Rectus Femoris Muscle Flap
11.6.1 Surgical Anatomy
of the Rectus Femoris Muscle
The rectus femoris muscle is part of the anterior
thigh muscle group. It is considered the second
most important muscle, after the vastus lateralis
muscle, for reconstruction of the hip and pelvis.
The author uses the rectus femoris muscle in
reconstruction of deep or recurrent trochanteric
ulcer or small hip defects, reserving the vastus
lateralis muscle for future use, especially in
patient swith spinal cord injury. When the rectus
femoris muscle is used in ambulatory patients, it
does not result in a functional deficit.
The surface marking of the muscle is a line
drawn from the anterior superior iliac spine to the
patella. The muscle originates from the anterior
superior iliac spine and is inserted with the other
muscles’ (vastus lateralis, vastus medialis) tendons
Fig. 11.21 Operative photograph showing the use of the
vastus to cover ischioperineal ulcers
into a common tendon called the quadriceps ten-
don or mechanism into the patella. The function of
the muscle is extension of the leg at the knee joint.
The relationship with the other muscles, the vastus
lateralis and medialis, are parallel with the muscle.
The tensor fascia lata muscle covers part of the
rectus femoris muscle, and the sartorius muscle
crosses the proximal part of the muscle. The rectus
femoris muscle is supplied by one vascular pedicle
from the lateral circumflex artery, which is a
branch of the profunda femoris artery. The pedicle
enters the deep surface of the muscle about
8–10 cm below the anterior superior iliac spine.
When utilizing the rectus muscle in the ambula-
tory patient, attention should paid to repairing the
defect between the vastus lateralis muscle and vas-
tus medialis to reconstruct the quadriceps tendon
and maintain the extension at the knee.
11.7 Rectus Abdominis Muscle Flap 159

11.6.2 Operative Technique

for Utilizing the Rectus
Femoris Muscle

The position of the patient depends on the loca-

tion of the pathological condition. The rectus
femoris muscle can be utilized for repair of
extension or recurrent posterior trochanteric
ulcer when the hip joint is subluxed and the
greater trochanter is rotated posteriorly. In such
cases, the patient is in the prone position on the
operating table. The lateral position is ideal for Fig. 11.22 AP pelvis x-ray showing right hip infection and
repair of a hip joint defect and lateral trochanteric destruction of the head of the femur in a patient with low-
level paraplegia. Arrow indicates the right hip pathology
ulcer. The skin incision depends on whether the
rectus femoris muscle is to be utilized with the
vastus lateralis, in which case, a lateral thigh inci-
sion is used. If the rectus muscle is utilized alone
and the patient is in the lateral or supine position,
the incision extends a few centimeters below the
anterior superior iliac spine, extending inferiorly
to about 4–5 cm above the patella. When the skin
is incised, the deep fascia is exposed, which rep-
resents the anterior territory of the tensor fascia
lata (iliotibial tract). When it is completely
incised, the medial border of the vastus lateralis
muscle is exposed, and a self-retaining retractor
is placed superiorly and inferiorly. The author Fig. 11.23 Operative photograph of the patient in the
supine position showing the extent of the hip wound after
prefers to identify the plane between the two
initial debridement. Arrow indicates the location of the prox-
muscles superiorly, which is easy to separate imal femur after debridement and Girdlestone procedure
with blunt dissection and continues inferiorly
when the muscle becomes tendinous for inser-
tion. At this point, an electrocautery is used for distally above the knee. The donor site of the
dissection and transection of the muscle is per- muscle is closed in three layers.
formed. The muscle is then lifted up and dissec- Figures 11.22, 11.23, 11.24, 11.25, 11.26,
tion continues to complete the separation from 11.27, 11.28, 11.29, and 11.30 show operative
the vastus lateralis muscle to the level of the vas- photographs of the utilization of the rectus femo-
cular pedicle of the muscle, which can be seen ris muscle to close a hip defect secondary to hip
entering the muscle medially over the posterior infection.
surface of the muscle belly.
If extra length of the muscle is needed for a
large defect, careful dissection is performed to 11.7 Rectus Abdominis
free the muscle from the fascia and loose tissue Muscle Flap
superiorly. Sometimes it is necessary to dissect
superiorly to the origin of the muscle and free the The rectus abdominis muscle is not the first
muscle completely. The muscle is inset in the choice for repair of pressure ulcers or hip and
defect or over the greater trochanter. Two drains pelvic defects in patients with spinal cord injury,
are placed, one under the muscle and the other but there are some indications for use of this mus-
over the muscle. The exits of the drains are cle. The author’s experience is that, in ambulatory
160 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma
Fig. 11.24 Operative photograph showing the extent of
the debridement and excision of the wound
Fig. 11.25 Operative photograph of the patient in the
supine position showing the marking for the options of the
hip wound repair. Because the patient had low-level para-
plegia, the rectus abdominis muscle or rectus femoris
muscle were selected for use
Fig. 11.26 Operative photograph showing the incision
for the utilization of the rectus femoris muscle from the
quadriceps tendon and the vastus lateralis muscle
Fig. 11.27 Operative photograph showing complete dis-
section of the rectus femoris muscle
Fig. 11.28 Operative photograph showing the tunneling
of the rectus femoris muscle to the hip defect wound
Fig. 11.29 Operative photograph showing the complete
closure of the wounds
patients, when the goal is to preserve the quadri-
ceps muscles, the rectus abdominis muscle can
be used in wound or hip defects. Other instances
are when the vastus lateralis and the rectus femo-
ris muscle have already been used and there is no
available muscle to close a defect resulting from
excision of recurrent heterotopic ossification or
when there is breakdown of skin and ulceration
after disarticulation and total thigh flap.
Unfortunately, on many occasions, this muscle is
11.7 Rectus Abdominis Muscle Flap
Fig. 11.30 Photograph showing the complete healing of
the wound at 6 weeks post-surgery
not available in patients with spinal cord injury
who are at the end stage when there is a colos-
tomy and urinary diversion stoma in the abdomi-
nal wall at the muscle site. The rectus abdominis
muscle is an important muscle and its use is well
documented in the literature for reconstructive
surgery of the breast. It can be used vertically or
horizontally in the reconstruction of the abdomi-
nal or thoracic wall or in a groin defect resulting
from trauma, for example, to cover an important
blood vessel. It can be used as a free flap for
reconstruction in head and neck or lower extrem-
ity surgery, and it is used in hip reconstruction for
a defect secondary to osteomyelitis [12]. Here the
discussion of use of the rectus abdominis muscle
is limited to the scope of this book.
11.7.1 Surgical Anatomy
of the Rectus Abdominis
Muscle
The rectus abdominus muscle originates from a
broad area of the chest wall from the cartilages of
the 6th, 7th, and 8th ribs. It is inserted in the
pubic tubercle and pubic crest. It has an important
fascial coverage: the anterior rectus sheath and
the posterior rectus sheath, where the peritoneum
is underlying the posterior sheath. The function
of the rectus abdominis is to flex the torso.
Removal of one muscle seldom leaves any func-
tional deficient, but loss of both muscles may
weaken the abdominal wall and lead to loss of the
pelvic tilt. In patients with spinal cord injury, los-
ing the rectus abdominis muscles may lead to
161
weakness in wheeling the wheelchair. However,
the author has never noticed this deficit in patients
in whom the rectus abdominis was utilized. The
muscle is supplied by two main blood vessels.
The deep inferior epigastric artery originates
from the common femoral artery and travels to
the posterior surface of muscles. This vessel is
considered the dominant vessel of the rectus
muscle and it supplies the entire muscle. The
superior epigastric artery branches from the
internal mammary artery and supplies the upper
two thirds of the muscle. In addition to these
blood vessels, there are perforators that enter the
posterior sheath to supply the muscle. The motor
nerve is from the intercostal nerve 5 through 12.
11.7.2 Operative Technique for Flap
Elevation
The patient’s position to harvest the muscle is the
supine position, or the muscle is first harvested in
the supine position and the patient is then turned to
the lateral position, depending on the defect loca-
tion. Marking a line between the costal margins
superiorly and the pubic ramus inferiorly repre-
sents the muscle location. A paramedian incision
is made in the skin and extends into the anterior
rectus sheath, with blunt dissection to separate the
sheath from the muscle. The muscle then is sepa-
rated gently from the lateral and medial part of the
rectus sheath. In this situation, the muscle is inferi-
orly based, and, therefore, the muscle is divided
from the costal margins. A tissue clamp is then
placed at the free margin and the muscle is dis-
sected gently from the posterior rectus sheath.
Care should be taken not to injure the sheath when
the peritoneum is closely behind and a peristaltic
bowel movement is visible. In addition, genital
dissection is at the level of the tendinous intersec-
tions of the muscle, which are located at the
xiphoid, umbilicus, and below the umbilicus.
At this stage, the inferior epigastric artery and
vein are seen at the posterior surface of the muscle.
Dissection continues inferiorly to free the muscle
from the transversalis fascia to obtain extra length
of the muscle. The author prefers to tunnel the
muscle subcutaneously toward the defect of
the hip or the pelvic area. At this operative stage,
162 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma

Fig. 11.31 AP pelvis x-ray showing recurrent heterotopic

ossification (HO) of the right hip. The vastus lateralis muscle
was used in a previous initial HO excision of the hip, there-
fore, the only option available was the rectus abdominis

Fig. 11.33 Operative photograph of the patient in the

supine position showing a close-up view of the anterior
hip wound

Fig. 11.32 Operative photograph of the patient in the

supine position showing the marking for the rectus abdomi-
nis and the open hip wound resulting from recurrence of HO

the defect of the ulcer or hip defect results from

heterotopic ossification or another pathology, for
example, covering a metal hip prosthesis that has
already been placed. The muscle is inset in the
defect without tension and sutured to soft tissue.
Two drains are placed, one under the muscle and
the other over the muscle and extending to drain
the muscle donor site. The muscle donor site is
closed by suturing the anterior rectus sheath, and
at the lower end of the sheath attention should be
paid to not close too tight around the muscle. The
skin is then closed in layers to restore the anatomy
Fig. 11.34 Operative photograph showing the exposure
of the rectus abdominis muscle
of the abdominal wall and prevent tension or her-
nia development. The rectus abdominis muscle
surface is either covered with a split skin graft or a
local fasciocutaneous flap.
Figures 11.31, 11.32, 11.33, 11.34, 11.35,
11.36, 11.37, and 11.38 show examples of opera-
tive procedures using the rectus abdominis
muscle.
11.8 Heterotopic Ossification (HO) of the Hip Joint
Fig. 11.35 Operative photograph showing complete
detachment of the rectus abdominis from its origin and
raising of the muscle completely
Fig. 11.36 Operative photograph showing the rectus
abdominis muscle tunneled under the skin to the hip defect
11.8 Heterotopic Ossification
(HO) of the Hip Joint
11.8.1 Introduction
There is a pathological condition, called myosi-
tis ossificans secondary to direct muscle injury,
in which a new bone formation can develop and
deposit in the muscle. It can develop around a
joint, such as the hip joint, and extend to bridge
to the pelvis, causing ankylosis of that joint.
This abnormal condition can develop in patients
163
Fig. 11.37 Operative photograph showing the abdomi-
nal wound closed in layers and the rectus abdominis mus-
cle insetted in the defect
Fig. 11.38 Operative photograph showing a skin graft
placed to cover the muscle surface; the graft will be
dressed with a tie-over dressing
with spinal cord injury, which can have a
tremendous impact on their quality of life.
Heterotopic ossification can develop secondary
to trauma and it has been described in thermal
injury, when it develops around the elbow joint
causing limitation of movement [13, 14]. In
addition, it has been reported to occur in adult
164 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma
brain injury and it correlates to the Glasgow
coma scale. A heterotopic ossification in a
mature stage is considered morphologically a
normal bone, that is, it consists of medulla and
cortex, and this bone formation is developed
through the main stages of osteogenesis as in
skeletal bone. The clinical classification of HO
by Brooker is as follows:
Class I Attached bone island
Class II <1 cm between opposing ossification center
Class III >1 cm between opposing ossification center
Class IV Bony ankylosis of the joint
Class V This is the HO that can cause a functional
disability in the patient, when surgical
excision is indicated.
The clinical manifestation of acute HO is
acute inflammation, swelling, redness, warmth,
and pain. These signs can be confused with
deep vein thrombosis (DVT), osteomyelitis, or
septic joint. This inflammatory process stabi-
lizes within 6 months, when the HO becomes
mature, solid, and causes ankylosis of the joint.
HO development can occur in patients with
spinal cord injury later in life, and the major
joints involved are the hip joint (60 %) and the
medial side of the knee joint (30 %). About
20–30 % of patients with spinal cord injury
develop Class IV HO during their life span
[15]. The clinical effect of HO on patients with
spinal cord injury is that they cannot sit in a
balanced position. Later, when the HO becomes
mature, it forms a cortex and medulla and is
well demonstrated.
The most sensitive test at an early stage for
acute HO formation is a three-phase technetium
bone scan, which can be positive as early as
2–3 weeks after injury [16]. There are medications
that can be given to prevent the onset of HO and
stop the progression of acute HO. For mature HO,
surgical resection is the first choice for treatment,
but it carries some risks. The author’s clinical
experience and observation is that African-
American patients have the highest risk of HO
recurrence after excision, followed by Hispanic
patients and then Caucasian patients. Medical
intervention can suppress immature HO, prevent-
ing recurrence of HO in the post-resection phase.
Serum alkaline phosphatase enzyme is considered
a marker for early HO development. Its level is
very high in the acute phase and, when the HO
becomes mature, the level of the enzyme begins to
drop. The preventive medication used is a nonste-
roidal anti-inflammatory drug (NSAID), such as
indomethacin, which should be given for at least
6–8 weeks. Another medication is ethane-1-
hydroxy-1 1-diphosphonic acid (EHDP), known
as Didronel® (etidronate), which has been used
since 1960, and acts by demineralization of oste-
oid. Clinically, the drug should be used to prevent
recurrence of HO. Some reports show no recur-
rence or a small recurrence after use of this medi-
cation for at least 1 year. The side effects of the
drug include severe osteoporosis, which has been
seen in patients with spinal cord injury and may
result in pathological fractures.
Not every HO seen on x-ray film is medically
important, only those that can cause a functional
disability that can be demonstrated on physical
examination of the patient’s range of motion. An
alternative medical treatment to prevent HO
recurrence post-surgical excision is a low dose
of radiation therapy. The radiation alters the
DNA of the dividing bone cells that give rise to
osteoblasts, osteoclasts, and osteocytes. It is rec-
ommended that treatment be given within
24–48 h post-surgery. The result of treatment in
that period of time is more successful than when
the treatment is delayed 4–5 days post-surgery.
The practical difficulty in radiation therapy is, if
the hospital does not have this modality, the
patient must be transferred in the acute phase
after major surgery to another hospital for radia-
tion therapy. Consequently, this may carry some
risks on the surgical site and the flap. The
author’s cases of HO excision are treated by
medication post-surgery.
The indication for HO excision, especially in
the hip joint area, is when the hip joint is anky-
losed with the pelvis and there is no movement at
the hip joint. This results in severe functional dis-
ability, when HO is the underlying etiology of an
ulcer. In infected HO with destruction of the pel-
vic and femoral bones, it is indicated to excise
these bones and repair the defect with a muscle
11.8 Heterotopic Ossification (HO) of the Hip Joint
flap [17]. Excision of the HO should be done
after evidence of complete maturity of the HO,
usually between 6 and 12 months after incidence
of the acute HO based on radiological evidence
and alkaline phosphatase and C-reactive protein
levels.
11.8.2 Preoperative Requirement
Before surgery, a few tests are important to assist
the surgeon in performing a safe surgery without
major complications.
• Magnetic resonance angiography (MRA) of the
arterial system of the pelvis and thigh area to
demonstrate the relationship between the HO
and the main vessels in the area. This shows
whether there is any pressure or occlusion
caused by the HO on the main blood vessels.
Doppler use preoperatively and operatively is
essential in some difficult cases of HO.
• Plain x-ray of the pelvis in the anterposterior
(AP) position and hip joint in AP and lateral
positions demonstrates the complete maturity
of the HO and the extent of the HO between
the hip joint and bridging to the pelvic.
• Laboratory blood test such as alkaline phos-
phatase enzyme levels, which is used to deter-
mine the maturity of the HO.
If there is no ulcer associated with the HO or
infected HO, a cell saver can be used during surgery
to reduce the blood volume to be transfused during
the surgery, as this surgery is characterized by a
large volume of blood loss. Patients should be
informed that, in this type of surgery, there is a large
volume of blood loss and blood transfusion will be
necessary, with the accompanying risks such as
transmission of hepatitis C and HIV, although the
chances of acquiring these viruses from blood trans-
fusion today is low compared with the risk 25 years
ago. Another risk of the HO excision surgery is
recurrence at the same site, despite the preventative
use of the medication post-surgery.
The reader may wonder how the plastic sur-
geon is involved in this type of surgery. The
answer is that, today, the plastic surgeon is
involved with all parts of the body. Another rea-
son is that this type of surgery requires the use of
165
muscle to repair the defect after HO excision, and
this is within the reconstructive surgeon’s scope
of practice.
11.8.3 Operative Technique
The position of the patient is either supine with
tilting of the pelvis of the affected side or in the
complete lateral position, using a bean bag to
stabilize the patient position, with consideration
to the pressure points to prevent development of
pressure ulcers during surgery. The femoral
artery is marked by feeling the pulsation, or
arterial Doppler is used. The level of the vastus
lateralis muscle pedicle is marked. Marking of
the skin incision site is in the mid-lateral thigh,
starting superiorly over the greater trochanter
and ending inferiorly a few centimeters above
the condyle of the femur (the same approach as
for the Girdlestone procedure and vastus latera-
lis muscle utilization). The superior end of the
incision curves medially toward the anterior
thigh and stops at the level of the femoral vessel.
Laterally, the marking extends across the glu-
teus maximus muscle. The mid-thigh skin inci-
sion exposes the iliotibial tract, which is incised
to expose the entire vastus lateralis muscle.
Proximally, the greater trochanter and origin of
the vastus lateralis is exposed, then two flaps are
raised medially and laterally and a self-retaining
retractor is placed inferiorly and superiorly. To
expose the HO mass, an incision between the
tensor fascia lata and the gluteus maximus is
performed posterolaterally, taking care not to
transect through the vastus lateralis muscle and
its pedicle. To expose normal anatomy, the same
principle as in the Girdlestone procedure is used
by dissecting the origin of the vastus lateralis
muscle from the femur and the lateral intermus-
cular septum to expose the normal femoral
shaft. In some instances, the HO involves the
proximal femur shaft. When the femoral shaft is
exposed, two cobb elevator are inserted under
the shaft of the femur to protect the soft tissue
underlying of the femoral shaft. Then, using an
oscillating bone saw, a proximal osteotomy is
performed.
166 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma

It is impossible to excise the entire HO in one

piece, as in the Girdlestone procedure. There is a
high risk of injury to the main arteries. Multiple
longitudinal and transverse markings are made
on the entire exposed HO. An oscillating bone
saw is then used to make multiple cuts across the
markings in a longitudinal and transverse direc-
tion, taking care not to cut so deep medially to
prevent injury to the blood vessel located
medially. Because the vascular tree is in close
proximity to the medial border of the HO, to
complete the excision, a straight osteotome is Fig. 11.39 AP pelvis x-ray showing extensive HO and
used to mobilize the bone cubes and an electro- complete ankylosis of the right hip in a patient with spinal
cord injury
cautery is used to divide the soft tissue from the
bone. The medial part of the HO should be
removed carefully, avoiding injury to the femoral
artery. In some cases, if the excision of the HO
achieved a 90° flexion at the hip area, the medi-
ally located HO can be left in place. The femoral
head in some cases can be identified in the ace-
tabular cavity, which can be dislocated and
removed. If the HO extends to the pelvic bone
superiorly to the anterior iliac crest, the surgeon
must decide at what level to abort excision of the
HO without injury to the pelvic bone, leaving the
superior part of the HO as long as it does not cre-
ate a functional limitation in the range of move-
ment at the hip area. During the procedure of the
HO excision, a cell saver should be used to mini-
mize the volume of blood needed to be
transfused.
At the end of the procedure, the wound
should be well irrigated. Any bleeding from the
Fig. 11.40 Operative photograph of the patient in the
bone at the pelvic site or femoral site should be semi-lateral position showing the marking of the femoral
controlled by using argon cautery or pieces of artery medially and the vastus muscle vascular pedicle
collagen hemostat (Avitine®). Thrombin solu- with dotted lines representing the extent of the anterior
tion can be used as a spray over the bleeding HO. Arrow indicates the position of the femoral artery
area. The cavity resulting from HO excision
needs to be filled with muscle. In this case, the superior part of the wound under the gluteus
muscle of choice is the vastus lateralis muscle muscle. The two raised flaps are closed in three
because of its large volume and vascularity. To layers over the muscle and the femoral shaft.
raise the vastus lateralis muscle, the same proce- A foam abduction pillow is placed between
dure is used as described previously. Insetting both the lower extremities. A plain x-ray of the
the muscle is performed by rolling the muscle in pelvis and hip is performed in the postoperative
the cavity. Three drains are used in this proce- recovery area.
dure, the first under the muscle and the second Figures 11.39, 11.40, 11.41, 11.42, 11.43,
over the muscle; the exits of these drains are 11.44, 11.45, 11.46, 11.47, 11.48, and 11.49
distally above the knee area. The third drains the show details in operative photographs.
11.8 Heterotopic Ossification (HO) of the Hip Joint 167

Fig. 11.41 Operative photograph showing the marking

for lateral exposure of the vastus lateralis muscle and the
posterior and anterior marking for the exposure of the HO Fig. 11.44 Operative photograph showing the surgical
specimen of the excised HO and femoral head

Fig. 11.45 Operative photograph showing the HO after

Fig. 11.42 Operative photograph showing the exposure excision; at the top of the photograph, the acetabulum is
of the vastus lateralis muscle with the dissection of the indicated by the arrow
muscle superiorly and laterally exposing the HO mass

Fig. 11.46 Operative photograph showing the operative

achievement of 90° flexion at the hip after HO excision.
Arrow indicates the proximal femoral osteotomy

11.8.4 Postoperative Management

Fig. 11.43 Operative photograph showing the complete
excision of the HO. Arrow indicates the position of the This surgery is characterized by a large volume
acetabulum of blood loss in the drainage system from the
168 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma
Fig. 11.47 Operative photograph showing the raised
vastus lateralis muscle
Fig. 11.48 Operative photograph showing the insetting
of the vastus lateralis into the hip defect
Fig. 11.49 Operative photograph showing the closure of
the surgical wound
surgical site, which is particularly high in the first
few days post-surgery. The patient may require a
blood transfusion in the postoperative period. In
Fig. 11.50 Photograph showing the continuous passive
motion (CPM) machine in action. The patient is in the
supine position and the machine is adjusted to the required
flexion degree at the knee and hip
some cases, about half of the patient’s blood vol-
ume has been lost. In such patients, fresh frozen
plasma and vitamin K are given. Laboratory tests
should be ordered daily to exclude postoperative
clinical syndrome of disseminated intravascular
clotting (DIC), which is a serious condition.
Patients with spinal cord injury are placed on an
air fluidized bed (Clinitron®) to prevent develop-
ment of pressure ulcers while in the supine posi-
tion for 4 weeks post-surgery. Etidronate, 400 mg
three times daily, is started in the first day post-
surgery. Indomethacin is given when the amount
of surgical drainage decreases to a small volume.
The medication is started before removal of the
drains in case it causes excessive bleeding and is
continued for 6 weeks. At 4 weeks post-surgery,
gentle range of motion movement is started using
a continuous passive motion (CPM) machine. If a
CPM machine is not available, a physical thera-
pist can gently perform the range of motion
movement (Fig. 11.50).
At 6 weeks post-surgery, the physical therapist
starts a sitting program using the proper sitting
cushion and wheelchair. The sitting program
begins with a half hour in the wheelchair for the
first day and then additional increments of a half
hour each day. When the patient reaches 6 h per
day sitting with no breakdowns of skin, he or she
can be discharged home. The physical therapist
measures the sitting pressure with a computer-
ized pressure pad to demonstrate whether the
excision of the HO has made a difference by
comparing pressure measurements from before
and after the surgery. Didronel® should be used
11.9 Hip Joint Conditions When a Girdlestone Procedure and Muscle Flap Are Indicated
by the patient for 1 year and the indomethacin
continued for 6–8 weeks post-surgery.
11.8.5 Postoperative Complications
from HO Excision Surgery
The immediate postoperative complication is
bleeding and hematoma. Later, within a few
weeks postoperatively, the complication is the
recurrence of the HO as an acute development
that manifests clinically with a swollen thigh,
warmth, and a hot feeling to the touch. This
should be clinically differentiated from DVT or
infection. After several months, the formation of a
mature HO is manifested with a hard, swollen hip
area. X-ray of the hip and pelvis will confirm the
diagnosis. The author’s experience with recur-
rence of mature HO is that re-excision of the HO
is not the major problem, but the technical point is
finding a muscle to fill the new dead space when
all the local muscles have been utilized in previ-
ous surgeries. If the rectus abdominis has not been
used previously, it may be used for this purpose
(see the section of the rectus abdominis muscle).
The other secondary complication after HO recur-
rence is the development of pressure ulcer sec-
ondary to high pressure over the HO site or caused
by obliquity of the pelvis. To manage this prob-
lem of recurrence, it is important to break the
cycle at an early stage after excision using physi-
cal therapy or a CPM machine to work on the
range of movement in the hip area. The prone
position is not recommended for these patients as
it stimulates the bone to bridge between the hip
area and the pelvis. Medication Etidronate
(Didronel) usage for a long period of time may
prevent the recurrence of HO.
11.9 Hip Joint Conditions When
a Girdlestone Procedure
and Muscle Flap Are
Indicated
In patients with spinal cord injury secondary to
their primary disease, a fracture of the femur may
occur resulting from trauma or pathological frac-
169
Fig. 11.51 AP pelvis x-ray of a patient with spinal cord
injury with dislocated and atrophic head of the femur sec-
ondary to previous infection and pressure ulcer
ture secondary to osteoporosis. On many occa-
sions, these fractures are discovered accidentally
by x-ray or physical examination because the
patient is insensate. In some cases, these frac-
tures cannot be fixed by the orthopedic surgeon.
Another condition is dislocation of the hip joint
secondary to severe spasticity and muscle imbal-
ance at the hip joint, when the head of the femur
is dislocated. The common type of dislocation is
posterior dislocation, when the head of the femur
presents a pressure point to the patient when sit-
ting and exerts pressure in that area, which may
develop into a pressure ulcer. In all these condi-
tions, a Girdlestone procedure and muscle flap
are indicated to correct the deformity.
Figures 11.51, 11.52, 11.53, 11.54, 11.55, 11.56,
11.57, and 11.58 show operative procedures for a
dislocated hip.
In patients with spina bifida, when the acetab-
ulum is not developed secondary to the congeni-
tal deformity, the femoral head is in an abnormal
position. This leads to abnormal movement at the
hip, with a fixed flexion deformity. In this condi-
tion, a Girdlestone procedure and muscle flap are
indicated (Fig. 11.59). In some unusual circum-
stances, when severe spasticity and contracture
of the hip muscle leads to severe deformity and
pressure development, this deformity cannot be
corrected by medication or nerve injection or
even muscle release. The only management avail-
able to correct this deformity is a Girdlestone
procedure and muscle flap, which will allow the
straightening of the lower limb and correction of
170 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma

Fig. 11.53 Operative photograph of the exposed acetab-

ulum, after Girdlestone procedure and vastus lateralis
Fig. 11.52 Operative photograph showing the patient in
muscle mobilization. Arrow indicates the position of the
the semi-lateral position with skin markings for exposure
acetabulum
of the vastus lateralis muscle and the hip joint

the pelvic obliquity, which helps the patient to sit

in the wheelchair without a pressure point.
In a simple, straightforward Girdlestone pro-
cedure without a large defect, the author prefers
to use the rectus femoris muscle and preserve the
vastus lateralis for future reconstructive proce-
dures for the patient, especially in those with spi-
nal cord injury.

Fig. 11.54 Operative photograph showing the excised

femoral component showing the atrophic head of the
femur
11.9 Hip Joint Conditions When a Girdlestone Procedure and Muscle Flap Are Indicated 171

Fig. 11.55 Operative photograph showing complete dis- Fig. 11.56 Operative photograph showing the inset of
section of the vastus lateralis muscle from the femoral the muscle into the hip defect
shaft. Arrow indicates the femoral shaft
172 11 Reconstructive Surgery of the Hip Joint Involved with Pressure Ulcer, Pathological Conditions, and Trauma

Fig. 11.59 AP pelvis x-ray of a patient with spina bifida

with dislocation of the right hip secondary to an underde-
veloped acetabulum. Arrow indicates the pathology

References
Fig. 11.57 Operative photograph showing complete
wound closure
Fig. 11.58 Photograph showing complete healing
6 weeks post-surgery
1. Girdlestone GR (1943) The classic acute pyogenic
arthritis of the hip: an operation giving free access and
effective drainage. Clin Ortho Relat Res 170:3
2. Bittar ES, Petty W (1982) Girdlestone arthroplasty for
infected total hip arthroplasty. Clin Orthop Relat Res
170:83
3. Bourne RB, Hunter GR, Rorabeck CH et al (1984) A
six-year follow-up of infected total hip replacement
managed by Girdlestone arthroplasty. J Bone Joint
Surg Br 66B:340
4. Bohlere M, Salzer M (1991) Girdlestone’s modified
resection arthroplasty. Orthopedics 14(6):661
5. O’Hare JM (1964) Excision of the femoral head in the
management of pressure ulcers. Proc Annu Clin
Spinal Cord Inj Conf 19:97
6. Stewart JC, Comarr AE (1971) Resection of head and
neck of femur in spinal cord injury patients, a 25-year
review. In: Proceedings of 18th spinal cord injury con-
ference of VA and the International Medical Society
of Paraplegia, Boston, 5–7 Oct 1971
7. Eltorai I (1983) The Girdlestone procedure in spinal
cord injury patients: a ten-year experience. J Am
Paraplegia Soc 6:85
8. Arnold GP, Witzke DJ (1983) Management of failed
total hip arthroplasty with muscle flaps. Ann Plast
Surg 11:973
References
9. Minami RT, Hentz VR, Vistness LM (1977) Use of
vastus lateralis flap for repair of trochanteric pressure
sores. Plast Reconstr Surg 60:364
10. Klein NE, Luster S, Green S et al (1988) Closure of
defects from pressure sores requiring proximal femo-
ral resesction. Ann Plast Surg 21:246
11. Rubayi S, Pompan D, Garland D (1991) Proximal
femoral resection and myocutaneous flap for treat-
ment of pressure ulcers in spinal injury patients. Ann
Plast Surg 27:132
12. Irons GB (1983) Rectus abdominus muscle flaps for
closure of osteomyelitis hip defects. Ann Plast Surg
11:469
13. Evans EB (1991) Heterotopic bone formation in ther-
mal burns. Clin Orthop Relat Res 263:94–101
173
14. Elledge ES, Smith AA, McManus WF, Pruitt BA
(1988) Heterotopic bone formation in burned patients.
J Trauma 28:684
15. Subbatao JV, Garrison SJ (1999) Heterotopic
ossification: diagnosis and management, current con-
cepts and controversies. J Spinal Cord Med 22(4):
273–283
16. Bravo-Payno P, Esclarin A, Arzoz T et al (1992)
Incidence and risk factors in the appearance of hetero-
topic ossification in spinal cord injury. Paraplegia
30:740–745
17. Garland DE, Rubayi S, Harway EC et al (1995)
Proximal femoral resection and vastus lateralis flap in
the treatment of heterotopic ossification in patients with
spinal cord injury. Contemp Orthop 31(6):341–347
 Multiple Ulcers Closed by Multiple
Flaps as a Single Procedure
Salah Rubayi
12.1 Introduction
In clinical practice, it is common to evaluate a
patient with multiple stage IV ulcers. Multiple
ulcers are defined as clinical manifestations of
more than two pressure ulcers. Patients with mul-
tiple ulcers commonly have a primary diagnosis
of insensate secondary to spinal cord injury or
advanced neurologic disease. The plastic surgeon
with limited exposure in this field faces a chal-
lenge in the approach to repairing these ulcers,
whether to close one or two ulcers at a time or all
at one time. The choice depends on experience
and the exposure in this field. For this reason, the
author considers this subject important, and the
plastic surgeon requires exposure to the concept
of management of multiple ulcers in one stage. In
this chapter, the discussion focuses mainly on the
advantages and disadvantages of this practice
based on a review of the literature and the author’s
experience in this surgical practice.
S. Rubayi, MB, ChB, LRCP, LRCS, MD, FACS
Department of Surgery, Rancho Los Amigos National
Rehabilitation Center, Downey, CA, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_12, © Springer-Verlag Berlin Heidelberg 2015
12
12.2 Review of the Literature
In reviewing the clinical literature describing the
use of single-stage surgery to close multiple
ulcers, there are few articles describing this prac-
tice. In 1988, Tizian et al. [1] described 14 cases
of multi-located pressure ulcers, Campbell’s stage
IV–VI, in patients with paraplegia and their expe-
rience of using one-stage repair for sacral, ischial,
and trochanteric pressure ulcers in the period
between 1982 and 1986. The main flaps used
were gluteus maximus and hamstring flaps. They
presented their preoperative protocol with the use
of the prone position to train the patient to con-
tinue that position postoperatively. In the opera-
tive procedure, the ulcer was excised and there
was some bone resection of the ischium or sacral
spine. The sacral defect was then closed with the
gluteus maximus island flap and the ischial defect
was closed by the biceps femoris or myocutane-
ous advancement flap. In the postoperative period,
the patient was kept in the prone position, drains
were removed after 7 days, and sutures were
removed 2 weeks postoperatively. Diet was given
to the patient with resorbable feeding and, after
the sutures were removed, a normal diet was given
in the 3rd postoperative week. Sitting tolerance
was started by sitting the patient for 30 min daily
then sitting tolerance was increased by 40 min
twice daily. If no problems arose, the sitting time
was extended to 4 h in the morning and the after-
noon. The patient was then transferred to rehabili-
tation. The pre- and postoperative protocol in this
175
176 12 Multiple Ulcers Closed by Multiple Flaps as a Single Procedure
presentation is completely different from the
author’s protocol. There are a few important
points missing in the study, such the need for
more surgical team members, amount of blood
loss, and surgery time, and the maximum num-
bers of ulcers in the study was three ulcers.
A study by Lari and Rajacic [2] was published
in 1992, with a series of nine patients with mixed
primary disease (insensate and sensate) who had
multiple pressure ulcers that were closed in a sin-
gle surgery. The authors describe four cases, but,
unfortunately, there are no details of preoperative
or postoperative management. There is no men-
tion of diverting colostomy if the ulcer is close to
the anus, nor is there mention of how they man-
aged the bowel in these patients. The blood loss in
their surgical series was between 500 and
2,000 ml. The operative time was longer than the
average surgery. The main benefit presented in the
study from closing multiple ulcers in a single pro-
cedure was to close the ulcers without presenting
any other benefits. In this study, the advantage of
closing multiple ulcers is a basic principle, which
is to close the ulcers either by using a single stage
or multiple stage surgeries. However, the methods
and time used for closure of multiple ulcers in a
single stage have advantages and disadvantages
compared with the multiple-stage surgery, which
should be discussed in detail. In both studies, the
authors did not elaborate on these points. Both
studies had small groups of patients and numbers
of ulcers. The flaps used were limited varieties of
local flaps and, therefore, the conclusions from
these previous studies are not comprehensive.
However, they were a good start and attempted an
aggressive approach in management of multiple
pressure ulcers and how to deal with them by sin-
gle-stage surgery.
12.3 The Author’s Experience
in Repairing Multiple Ulcers
by Multiple Flaps as a Single
Procedure
Between 1985 and the present time, the author
has changed the practice of closing multiple pres-
sure ulcers in a single-stage procedure, which has
become the standard of practice in the pressure
ulcer management program. In 1999, this was
presented [3] as a 10-year experience (between
1986 and 1996) in a large series of 120 patients
with multiple pressure ulcers, stage IV. In addi-
tion to ulcers, some patients presented with
infected hip joint or heterotopic ossification. The
primary diagnosis of these patients was spinal
cord injury and some had advanced neurological
diagnosis. The average number of ulcers was 3.5
per patient. The total of 420 ulcers were treated in
these 120 patients, and the distribution of the
ulcers according to their anatomical location was
220 ischial, 150 trochanteric, and 50 of sacral
ulcers. The flaps used for repair were mixed:
myocutaneous, muscles, and fasciocutaneous.
Twenty of the 120 patients had the Girdlestone
procedure.
The clinical presentation of these patients, in
addition to the ulcers, included anemia of chronic
disease, hypoproteinemia with low albumin and
prealbumin blood levels, and wounds colonized
with multimicrobial organisms. Sepsis can occur
when there is tissue necrosis and heavy bacterial
colonization of the wound. Infected bone can
occur in the base of the ulcer. The type of bone
infection can be acute osteomyelitis or chronic in
nature. The majority of these patients had a uri-
nary tract infection with positive nitrate in the
urine secondary to the chronic urinary catheter.
Preoperative treatment of these infections is
essential in this compromised group of patients.
All other factors should be corrected and the
patient should be optimized for this major surgery
as described in Chap. 7. Diverting colostomy is
essential for patients with multiple ulcers in close
proximity of the anus. If the perineal urethra is
involved with extensive ulceration or the Foley
urinary catheter can be seen exposed in the
perineum of the patient, either simple urinary
diversion by suprapubic cystostomy or a perma-
nent urinary diversion should be performed before
surgery. Nutritional support is given to the patient
by oral intake or total parental nutrition (TPN)
before surgery. Anemia is corrected with blood
transfusion to bring the level of hemoglobin to at
least 10 g/dl. A central line placement is required
for these patients, considering the magnitude of
the surgery and the requirement for blood transfu-
sion or TPN and long-term antibiotics.
In regard to the surgical team in this type
of surgery, two teams are required but it is not
12.3 The Author’s Experience in Repairing Multiple Ulcers by Multiple Flaps as a Single Procedure
necessary to have two surgeons. If a plastic sur-
gery resident is available in training, it is good
experience for the resident to work on one side,
with the physician assistant, and the attending
surgeon on the other side, with close observation
and direction of the resident’s work. This helps to
build the surgical ability of the resident. If no res-
ident is available, the use of two surgeons and an
assistant on both sides shortens the surgical time
and reduces the risk of prolonged anesthesia.
In the author’s experience, dissection of the
flaps usually takes less time than closure of the
flaps and their donor sites. The operative
approach and selection of flaps depends on the
size of the ulcer and whether the ulcer is first time
or recurrent. For a first-time ulcer in the classical
location, the flap selection is the standard flap for
that location, as described in previous chapters.
The challenge is when these ulcers are recurrent
and the classical flaps have already been used. In
this situation, the choice of flap is either the sec-
ond choice for that particular anatomical area or
revision and reuse of old flaps, which carries a
risk of damaging the vascularity of the tissue sec-
ondary to extensive dissection. Another option
the author uses when there are no available flaps
is to use the vastus lateralis muscle if not utilized
previously. The vastus lateralis muscle is raised
as an island and rotated to cover the ischioperi-
neal area or the sacrococcygeal area. A skin graft
may be needed to cover the muscle surface. In
this circumstance, there is always a hip pathol-
ogy or hip involvement, therefore, a Girdlestone
procedure is performed. In extreme cases when
all the muscle options have been used, which is
called end stage, the option is disarticulation and
the total thigh flap is used to cover the pelvic
bone and build a layer of soft tissue cushion for
the patient.
The average operative time in single-stage
surgery is 4–6 h, although sometimes a longer
time is needed, especially if the Girdlestone pro-
cedure is performed. When comparing the time
of surgery for multiple ulcers to single ulcer
surgery, it has been shown that the latter con-
sumes much less time. If the patient has three to
four ulcers, the patient will have three to four
interval surgeries to close all the ulcers. This is
one of the foremost advantages of the single-
stage surgery. A disadvantage of single-stage
177
surgery is the longer surgical time, which means
prolonged anesthesia exposure for the patient,
with some adverse reactions, especially in
patients with medical problems, who have quad-
riplegia, or are older. Extra members on the sur-
gical team help to reduce surgical time, especially
in the closing stage of the flaps.
An analysis of data from the author’s study
showed that blood loss during surgery is greater
in single-stage surgery than in single-flap sur-
gery. The average volume of blood loss was about
1,000 ml in single-stage surgery, whereas in
single-flap surgery the average loss was 575 ml,
and in many cases no blood transfusion was
given. In the study of Lari and Rajacc, they
reported blood loss of 500–2,000 ml, which is
more than the author’s average data. Our rule is
that we replace the blood loss volume with an
equal volume of blood transfusion. In addition, if
we transfuse four units of packed cells, we
administer two units of fresh frozen plasma. This
group of patients presents with prolonged pro-
thrombin (PT) and partial thromboplastin time
(PTT), therefore, fresh frozen plasma (FFP) and
vitamin K should be given to help to correct this
condition.
In surgical practice, one should take into con-
sideration the risks of blood transfusions. The
most important is the transmission of the HIV
virus, which currently is one in two million, and
the hepatitis C virus transmission, which is one in
1.6 million.
The author, in his study, compared the hospi-
talization time between the two groups. In single-
stage surgery, hospitalization time was reduced
by 10 weeks, resulting in a savings in hospital
costs. In addition to reducing the hospital stay,
the patient returns to their normal life or work
more quickly, which has a great effect on the
quality of life and the psychological status of the
patient.
Another advantage of the single-stage surgery
is reduction in anesthesia exposure. In the single-
flap interval surgery there is risk from repeated
exposure to anesthesia. Another disadvantage of
single-interval surgery is that the nonoperated
ulcers require management with wound care two
to three times a day, which means turning the
patient at least twice daily, which may cause a
mechanical impact on the operative site and
178 12 Multiple Ulcers Closed by Multiple Flaps as a Single Procedure

cause breakdown in the new flap. The single-

interval surgery is indicated when the patient has
anterior and posterior ulcer locations, as the sin-
gle stage is difficult to perform in this situation.
Another indication for the single-interval surgery
is when the medical condition of the patient does
not permit a prolonged anesthesia time. Also, in
obese patients with large body mass (BMI), the
surgery is performed in two stages because the
patient cannot be placed in the prone position
during surgery because of ventilatory problems
during anesthesia.
The postoperative care protocol adopted by the
author for patients with single-stage surgery is the
same as in the single-interval surgery. If all flaps
are healed, a sitting program begins in both groups
at the same time. The rate of breakdown in the
immediate or later stage post-surgery was the
same rate in both groups, due to the rigid protocol
and interdisciplinary team approach. Examples of
different types of single-stage cases are presented
in this chapter. Some of the cases required a
Girdlestone procedure because of hip pathology
in addition to closure of multiple ulcers. Other
cases needed repair of the urethra or anal excision Fig. 12.2 Operative photograph of the patient in the
and rectal closure in addition to flap surgery. prone position with multiple pressure ulcers, stage IV,
sacral, left ischial, and right trochanteric ulcers showing
the marking of the design of the flaps to close these ulcers

12.4 Examples of Clinical Cases

12.4.1 Case 1

Fig. 12.3 Operative photograph, left lateral view, of the

same patient showing the marking of the left gluteus max-
imus sliding island flap

Fig. 12.1 Anteroposterior (AP) x-ray of the pelvis of a

patient with multiple pressure ulcers showing destruction
of both ischial bones secondary to chronic ulceration and
infection
12.4 Examples of Clinical Cases 179

Fig. 12.4 Operative photograph, right lateral view, of the

patient showing the design of the rotation tensor fascia
lata flap

Fig. 12.5 Operative photograph showing the excision of

the left ischial ulcer, the left ischium shaved, and excision
of the coccygeal bone. There was communication between
the ischial and the coccygeal ulcer and, for this reason, the
gluteus maximus flap was utilized as a rotation flap
Fig. 12.6 Operative photograph showing the complete
dissection of the gluteus maximus to expose the entire
area. The metal wire indicates the position of the sciatic
nerve. The gracilis muscle was dissected and exposed.
Arrow indicates the position of the gracilis muscle
180 12 Multiple Ulcers Closed by Multiple Flaps as a Single Procedure

Fig. 12.7 Operative photograph showing the gracilis Fig. 12.8 Operative photograph showing the position of
muscle tunneled to the left ischiococcygeal area the gracilis muscle, which covers the ischium and the coc-
cygeal bone in the same time
12.4 Examples of Clinical Cases 181

Fig. 12.11 Operative photograph showing the dissection

of the lower portion of the gluteus muscle to be the first
layer covering the trochanteric bone. The right tensor fas-
cia lata (TFL) flap was raised. Arrow indicates the TFL
fascia. Short arrow indicates the vastus laterals muscle

Fig. 12.9 Operative photograph showing the medial

rotation of the gluteus maximus flap to cover the defect

Fig. 12.12 Operative photograph showing the dissected

tensor fascia lata (TFL) flap with rotation to cover the
entire defect

Fig. 12.10 Operative photograph showing the excision

of the right posterior trochanteric ulcer and bursa with
shaving of the right trochanteric bone
182 12 Multiple Ulcers Closed by Multiple Flaps as a Single Procedure

Fig. 12.15 Operative photograph, right lateral view,

showing the closure of the right tensor fascia lata (TFL)
flap and the donor site of the flap

Fig. 12.13 Operative photograph showing the complete

closure of the left gluteal flap and left gracilis donor site.
On the right side, the two incisions were used to release
the hamstring muscles to treat contractures. The right side
shows the sutured TFL flap
Fig. 12.16 Photograph, 6 weeks post-operative, showing
healed right tensor fascia lata (TFL) flap

Fig. 12.14 Operative photograph, left lateral view,

showing the closure of the left gluteal flap

Fig. 12.17 Photograph, 6 weeks post-operative, showing

healed left gluteus maximus flap
12.4 Examples of Clinical Cases
12.4.2 Case 2
Fig. 12.18 Operative photograph of patient in the prone
position showing bilateral posterior trochanteric ulcer and
sacrococcygeal ulcer, stage IV
Fig. 12.19 Operative photograph close-up of the patient
in the prone position showing right posterior trochanteric
ulcer, stage IV, with the right posterior trochanteric ulcer
more extensive than the left posterior trochanteric ulcer
183
Fig. 12.20 Operative photograph, left side view, show-
ing the posterior trochanteric ulcer and the design of the
left tensor fascia lata rotation flap
Fig. 12.21 Operative photograph, right side view, show-
ing the right posterior trochanteric ulcer and the designed
right tensor fascia lata rotation flap
Fig. 12.22 Operative photograph, close-up, right poste-
rior trochanteric ulcer post-excision, to exclude any com-
munication of the right hip joint capsule with the ulcer.
Methylene blue dye was injected in the joint intraopera-
tively. No extravasation of the dye was observed in the
wound, which indicates there is no communication
between the ulcer and the hip joint
184 12 Multiple Ulcers Closed by Multiple Flaps as a Single Procedure

Fig. 12.23 Operative photograph of the patient in the

prone position, showing the excision of the ulcers and the
designed tensor fascia lata (TFL) flap dissected. Fig. 12.25 Operative photograph demonstrating the
Considering the extent of the ulcer on the right side, a rotation of the raised total fascia lata flap to cover the
large defect resulted after excision of the ulcer. Two mus- defect
cles were utilized, the gracilis muscle and the biceps fem-
oris muscle, and transferred into the defect. Short arrow
indicates the gracilis muscle and the long arrow indicates
the location of the biceps femurs muscle

Fig. 12.24 Operative photograph of the patient in prone

position, showing the transferred and tunneled right graci-
lis muscle and the biceps femoris transferred to the defect
to cover the trochanter. This procedure of transferring
these muscles avoids performing a Girdlestone procedure
in this instance

Fig. 12.26 Operative photograph demonstrating the

rotation of the left raised tensor fascia lata flap to cover the
defect
12.4 Examples of Clinical Cases 185

Fig. 12.27 Operative photograph, left lateral view,

showing the sutured left tensor fascia lata flap to close the
defect. The sacral defect was closed by gluteus maximus
rotation flap

Fig. 12.29 Operative photograph showing the completed

sutured flaps and the sutured gracilis muscle donor site

Fig. 12.28 Operative photograph, right lateral view,

showing the sutured right tensor fascia lata flap to close
the defect

Fig. 12.30 Operative photograph showing the rotated

gluteus maximus flap to close the sacral ulcer sutured in
place
186 12 Multiple Ulcers Closed by Multiple Flaps as a Single Procedure

12.4.3 Case 3

Fig. 12.31 Photograph, six weeks post-operative, left

lateral view, showing healed left tensor fascia lata flap

Fig. 12.34 Anteroposterior (AP) x-ray of pelvis showing

abnormalities in both ischium secondary to previous
ulceration and heterotopic ossification (HO) formation of
right hip joint with shaved right greater trochanter second-
ary to previous ulceration and surgery. Arrows indicate the
location of the HO of the right ischium and right hip

Fig. 12.32 Photograph, six weeks post-operative, show-

ing healed right tensor fascia lata flap and gluteus maxi-
mum flap

Fig. 12.35 Anteroposterior (AP) x-ray of pelvis of the

same patient, in view of the deformity of the right hip and
extensive right trochanteric stage IV ulcer an arthrogram
was performed for the right hip, which showed normal
appearance and no extravasation of the dye outside the
Fig. 12.33 Photograph, six weeks post-operative, show-
capsule of the hip joint
ing healed right tensor fascia lata flap
12.4 Examples of Clinical Cases 187

Fig. 12.38 Operative photograph, right lateral view,

Fig. 12.36 Operative photograph of the patient in the showing the extent of a posterior trochanteric ulcer and
prone position with multiple pressure ulcers, stage IV, the design of the gluteus maximus rotation flap to close a
showing scars of previous flap surgeries sacrococcygeal ulcer

Fig. 12.37 Operative photograph of the patient in a Fig. 12.39 Operative photograph showing the excision
close-up view of the ulcers (sacrococcygeal ulcer, bilat- of the ulcers and bone shaving. The right gracilis muscle
eral post trochanteric, and right ischioperineal ulcer) was dissected and the right tensor fascia lata rotation flap
was raised. Arrow indicates the gracilis muscle
188 12 Multiple Ulcers Closed by Multiple Flaps as a Single Procedure

Fig. 12.42 Operative photograph showing the dissected

gluteus maximus flap rotated to close the sacrococcygeal
defect and showing the gracilis muscle transferred to the
ischial area. Arrow indicates the position of the gracilis
muscle

Fig. 12.40 Operative photograph, right lateral view,

showing shaved right trochanteric bone and dissected
right tensor fascia lata rotation flap. The right gluteus
maximus as a rotation flap was dissected. Arrow indicates
the rotation of the greater trochanter posteriorly, which
was shaved

Fig. 12.43 Operative photograph showing the final

sutured flaps, the gluteus maximus to sacral coccygeal,
the right gluteus maximum to right ischioperineal, and the
right tensor fascia lata rotation flap. The left trochanteric
ulcer was stage III, which was grafted as indicated by
arrow

Fig. 12.41 Operative photograph showing the trial of

flap closure after flap dissection. The right gracilis was
transferred to cover the right ischium, the right inferior
gluteus maximus rotated medially to cover the right
ischial defect, and the right tensor fascia lata flap rotated
to close the trochanteric area and the donor site of the glu-
teus flap
References 189

Fig. 12.46 Photograph, six weeks post-operative, show-

Fig. 12.44 Operative photograph, right lateral view,
ing complete healing of the flap and skin graft, right lat-
showing the tensor fascia lata rotation flap. The donor site
eral view
of that flap was difficult to close directly, therefore skin
graft was placed as indicated by arrow

References
1. Tizian C, Brenner P, Berger A (1988) The one-stage
surgical treatment of multilocated pressure sores using
various myocutaneous island flaps. Scand J Plast
Reconstr Surg 22:83
2. Lari AR, Rajacic N (1992) One-stage repair of multi-
ple bed sores. Br J Plast Surg 45:540
3. Rubayi S, Burnett CC (1999) The efficacy of single-
stage surgical management of multiple pressure sores
in spinal cord injured patients. Ann Plast Surg 42:533

Fig. 12.45 Photograph, six weeks post-operative, show-

ing complete healing of the flaps, with the patient in the
prone position
 Reconstructive Surgery
for Pressure Ulcers in Special Areas
of the Body
Salah Rubayi
• Heel ulcer
• Malleoli ulcer
• Plantar surface of the foot
• Head of the fibular bone and tibial shine
• Knee ulcer
• Olecranon ulcer
• Occipital ulcer
13.1 Introduction and Etiology
These ulcers can develop in insensate patients
over bony, prominent areas of the body and are
different from ulcers developed from pressure on
sitting areas. They occur at different stages of a
patient’s life, whether during an acute accident or
illness or later on. The etiologies result from
some factors that predispose for pressure applica-
tion on a particular part of the body. These ulcers
are outside the pelvic girdle, which means they
are not the result of weight-bearing activities like
sitting. The majority of these ulcers heal if treated
locally and the causative agent is eliminated.
These ulcers are not seen clinically on a frequent
basis, but they do occur from time to time,
S. Rubayi MB, ChB, LRCP, LRCS, MD, FACS
Department of Surgery, Rancho Los Amigos National
Rehabilitation Center, Downey, CA, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_13, © Springer-Verlag Berlin Heidelberg 2015
13
secondary to special etiologies. They are seen in
insensate patients (patients with spinal cord
injury) and in patients with diabetes, peripheral
vascular diseases, or neuropathies.
13.2 Etiology of the Specific
Ulcers
Heel ulcers result from direct pressure from mat-
tresses or shoes that are too small. They occur in
spastic patients, where shearing forces can cause
different stages of pressure ulcers, resulting in
skin blisters that can lead to necrosis. This condi-
tion is seen even if the patient is in an air fluidized
bed (Clinitron®). Protection and prevention are
important in this type of ulcer. Every patient
should wear heel protectors all the time, whatever
the type of bed they are in.
Foot plantar surface ulceration is caused by
deformity in the heads of the metatarsal bones.
This deformity is secondary to muscle wasting
and paralysis of the foot, with spasticity and con-
tracture of the foot. This condition results in
prominent bone and development of ulceration of
the skin over that bone. Dislocation of the meta-
tarsal head from the proximal phalanges bone
can occur. These pathological conditions are seen
commonly over the 5th metatarsal phalangeal
joint.
Malleolar ulcers are common and occur over
the lateral malleolus bone as a result of the prom-
inent distal end of the fibula. This ulcer is caused
191
192 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body
by direct pressure on the skin from sleeping in
the lateral position, ill-fitting shoes, or direct
injury to the skin from the foot of the wheelchair.
These ulcers can develop when the head of the
fibula is prominent as a result of tissue wasting
around the area, secondary to paralysis. The etio-
logic factors in ulceration in this area are direct
pressure on the prominent fibular head resulting
from laying on one side or spasticity with shear-
ing forces.
The common site of knee joint ulcers is the
medial side of the kvnee. With severe spasticity,
both knees lock in one position, which can cause
shearing between the medial surface of each
knee. Skin breakdown can result and can prog-
ress to deep ulceration connected with the knee
joint, eventually leading to sepsis and knee joint
infection. Patellar ulcer is seen secondary to the
patient lying in the prone position with direct
pressure on the skin over the patella. Another fac-
tor is when both hip joints are ankylosed second-
ary to heterotopic ossification (HO) and both
knees are locked together, resulting in direct
pressure of each knee against the other, which
leads to skin breakdown over the medial aspect of
the knee.
Anatomically, the tibial shin can be promi-
nent, especially in thin persons. In paraplegic
patients, when the prone position is used to pre-
vent pressure ulcer development, breakdown in
the skin of the tibial shin, tibial shin ulcer, can
occur. Another etiologic factor is injury to the
tibial shin in insensate patients, which can result
in skin breakdown without the patient feeling the
injury and may lead to stage IV ulcer.
Olecranon ulcers are mostly seen in patients
with spinal cord injury, especially in tetraplegia,
when sensation over the elbow joint is dimin-
ished. In addition to limited mobility, spasticity
plays an important role when shearing forces
break down the skin over the elbow joint.
Anatomically, there is a small bursa over the
elbow joint that can become infected, resulting in
bursitis or skin breakdown. This can lead to
development of a discharging sinus or an open
wound, in the case of a stage IV ulcer. Bone can
be involved in this pathological process at a later
stage. Paraplegic patients can develop this ulcer
from proning and placing direct pressure on the
area of the elbow joint, causing skin breakdown.
Occipital ulcers are commonly seen in the
acute phase of spinal cord injury, especially in
patients with tetraplegia when their position in
bed is supine. To avoid risk of damage to the cer-
vical spine, no movement is permitted and the
patient remains in one position. When pressure is
exerted over the occipital area, ulceration of the
skin can occur. Another etiologic factor is the use
of a halo to stabilize the cervical spine. Without
regular inspection of the area by the clinical staff,
it is easy to miss these ulcers, which may be cov-
ered by the patient’s hair. This issue can involve
medico-legal liability.
13.3 Reconstructive Surgery
for the Specific Ulcers
13.3.1 Heel Ulcer
Heel skin is thick and can tolerate pressure. For
this reason, a blister or superficial ulceration
should first be treated conservatively. The main
aim in wound management is to protect the deep
dermal layer from dehydration and necrosis;
therefore, a moist dressing should be used.
Blisters should be left intact, except to aspirate
any excess fluid, leaving the blister skin intact as
a biological dressing. In addition, the causative
pressure should be removed. When the blister
becomes dry and dark in color it should be left
intact. When healing of the deep layer is com-
plete, the dry blister layer can easily be lifted,
leaving healed new epidermis. Exposing the deep
dermal layer at early stages leads to necrosis of
the pad of fat that covers the calcanium. In this
situation, the ulcer is converted to a stage IV
ulcer. When granulation tissue develops in a heel
ulcer, it indicates to the surgeon to close the ulcer
with a split skin graft. At this stage, local wound
care can be changed to an antibacterial cream
such as Silvadene®. The majority of these ulcers
heal eventually, even if a skin graft procedure is
not performed, but in some patients it is a practi-
cal and safe procedure. In some cases, conserva-
tive treatment is not effective in healing the heel
13.3 Reconstructive Surgery for the Specific Ulcers
Fig. 13.1 Operative photograph showing a granulating
heel ulcer and exposed tendon calcaneal (Achilles)
ulcer and the longer the wound is open, the
greater the chance that osteomyelitis will develop
in the bone. For this reason, surgery is indicated
(Figs. 13.1 and 13.2).
There are many procedures described in the
literature for repair of ulcers of the heel and sole
of the foot using the small muscles of the plantar
aspect of the foot [1–5]. It is the author’s experi-
ence that, in paralyzed patients, these muscles are
atrophic and small in size, making them techni-
cally difficult to mobilize, which may result in
vascular necrosis of the muscles. For this reason,
the author prefers to use a local fasciocutaneous
flap to close a stage IV heel ulcer. This has been
described as a superficial arterialized flap [6, 7].
The author uses a random medially based
193
Fig. 13.2 Surgical photograph showing a split skin graft
applied to the ulcer after debridement of the granulation
tissue
fasciocutaneous flap. The main arterial supply for
this area is the posterior tibial artery. The flap is
designed over the sole below the level of the
transverse metatarsal arch. This flap is raised as a
fasciocutaneous flap deep to the level of the small
muscles and includes the plantar fascia. The flap
is rotated to cover the ulcer defect and the
calcaneus bone. The calcaneus bone is shaved if
it is prominent or involved clinically with the
ulcer as acute osteomyelitis, as proved by histo-
pathological examination. The donor site of the
flap is closed with a split thickness skin graft. The
author has used Vacuum Assisted Closure
(V.A.C.) to fix the skin graft to its bed with excel-
lent results. This type of flap is indicated for
young patients without peripheral vascular
194 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

Fig. 13.3 Plain x-ray of a foot, lateral view, of a patient

with a heel ulcer showing a periosteal reaction of the cal-
caneus bone secondary to the ulcer. Arrow indicates the
pathological changes in the calcaneus

Fig. 13.4 Operative photograph, lateral view, showing a

heel ulcer with marking of the ulcer

disease or diabetes and with incomplete paraple-

gia and functional capacity for ambulation.
Complications with this flap are seen in older
patients and patients with diabetes or vascular
disease, in which necrosis and infection of the
flap can occur. Figures 13.3, 13.4, 13.5, 13.6,
13.7, 13.8, 13.9, and 13.10 show the surgical pro-
cedure for the fasciocutaneous flap.
13.4 Ulceration of the Medial
and Lateral Plantar Surface
of the Foot
Ulcers of the medial and lateral plantar surface of
the foot are seen commonly over the 1st and 5th
metatarsal head. The surgical treatment is to
excise the ulcer first at the metatarsophalangeal
joint. It is common that the head of the metatarsal
Fig. 13.5 Operative photograph, plantar view, of the heel
ulcer with markings of the flap over the plantar surface of
the foot
bone is dislocated secondary to ulceration or
infection. Management of this ulcer requires
excision of the head of the metatarsal bone,
which is the cause of the pressure and eventual
ulceration. The operative technique utilizes a
small phalanges retractor, usually used for hand
surgery, which is placed on both sides of the
metatarsal shaft to cover the deep tissue under the
shaft. An osteotomy is performed using a small
oscillating saw such as that used in hand surgery.
In some cases, excision of the entire metatarsal
13.6 Ulcers of the Head of the Fibula and Tibial Shin
Fig. 13.6 Operative photograph showing the resulting
wound after excision of the ulcer and the calcaneus bone,
which was shaved to a healthy layer and the flap incised
bone is performed when it is the cause of ulcer-
ation. If the base of the proximal phalanges is
prominent, excision of that phalanges is per-
formed. When the wound is small in size, it can
be closed directly; if not, a small rotation flap is
designed over the plantar surface of the foot. The
donor site of the flap can be closed directly or a
195
skin graft is applied (Figs. 13.11, 13.12, 13.13,
13.14, 13.15, 13.16, 13.17, 13.18, 13.19, 13.20,
13.21, 13.22, 13.23, 13.24, 13.25, and 13.26).
13.5 Lateral Malleolus Ulcer
As previously discussed, the lateral malleolus is a
common site for ulceration secondary to any
form of direct pressure. Surgical repair includes
the excision of the ulcer or the bursa and then
shaving of the lateral malleolus bone, which is
usually prominent. A fasciocutaneous flap is
designed and raised over the lateral aspect of the
lower leg. The flap is semicircular in shape. The
dissection of the flap should include the deep fas-
cia and the skin as one layer. The flap can be
rotated to cover the defect and back cut if needed.
The donor site of the flap is closed by skin graft.
This procedure is very satisfactory for closing the
defect. Figures 13.27, 13.28, 13.29, and 13.30
show the steps of the surgical procedure.
13.6 Ulcers of the Head
of the Fibula and Tibial Shin
The surgical repair of this ulcer is by excision of
the ulcer and shaving of the prominent bone. To
achieve a flat surface of the bone, a semicircular
fasciocutaneous flap is designed to cover the fibu-
lar head defect. The flap is located over the
medial surface of the knee and rotated inferiorly
to close the defect. The donor site of the flap is
grafted or closed by primary closure, which may
put tension on the flap wound. Figures 13.31,
13.32, 13.33, 13.34, 13.35, 13.36, and 13.37
show the steps of the surgical procedure.
In the case of tibial shin ulcers, the same prin-
ciple is applied and a fasciocutaneous flap is
designed and raised from the lateral upper leg area
and rotated medially to cover the defect. In some
cases, the local muscle is dissected to cover the
shin of the tibia and then the flap is rotated to cover
the defect. The donor site of the flap can be closed
primarily or, in some cases, may need a skin graft
(Figs. 13.38, 13.39, 13.40, 13.41, and 13.42).
196 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

Fig. 13.7 Operative

photograph showing the
plantar sole flap as a
fasciocutaneous flap
completely dissected and
lifted out

Fig. 13.8 Operative photograph showing the sole flap

rotated to cover the defect of the heel ulcer

Fig. 13.9 Operative photograph showing the sutured flap

13.7 Ulceration Around in place to cover the defect and the grafted flap donor site
the Knee Joint

The etiology of ulceration around the knee joint treated before performing flap surgery. The com-
is skin ulceration leading to soft tissue infection mon communication site of these ulcers with the
extending into the knee joint, with possible osteo- knee joint is the medial surface of the knee or the
myelitis of the bone. This condition should be popliteal area. If the diagnosis is in doubt con-
13.7 Ulceration Around the Knee Joint 197

Fig. 13.11 Anteroposterior (AP) x-ray of a foot showing

destruction and disarticulation of the 5th metatarsopha-
langeal joint, which corresponds to the anatomical loca-
tion of the ulcer. Arrow indicates the pathology of the 5th
phalangeal joint

Fig. 13.10 Photograph of the foot 6 weeks postsurgery

showing complete healing of the flap and donor site

cerning the communication between the ulcer

and the knee joint, a simple test can be performed
before surgery. Methylene blue dye is injected in
the knee joint; a blue coloration of the ulcer con-
firms the diagnosis. McCraw, in 1978 [8], and
Arnold, in 1983 [9], described the use of the gas-
trocnemius muscle as a muscle flap to cover the
wound of the knee joint. The choice of using the
medial head of the muscle or the lateral head of
the muscle depends on the patient’s primary Fig. 13.12 Operative photograph showing a stage IV
diagnosis. The author prefers to use the medial ulcer located at the lateral foot surface, corresponding to
gastrocnemius muscle because of its longer arc of the location of the 5th metatarsophalangeal joint
198 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

Fig. 13.13 Operative

photograph showing the
excised ulcer and the fifth
metatarsal bone removed
surgically

Fig. 13.14 Operative photograph showing the excised Fig. 13.15 Operative photograph showing surgical
5th metatarsal bone wound closure
13.7 Ulceration Around the Knee Joint 199

rotation. In ambulatory and sensory patients, the which may cause foot drop. In nonambulatory
use of the medial gastrocnemius muscle is pre- patients, this risk does not functionally affect the
ferred over the lateral gastrocnemius muscle to patient.
avoid the risk of injury to the peroneal nerve,

Fig. 13.16 Anteroposterior (AP) x-ray of a foot showing

dislocation and destruction of the 1st metatarsophalangeal Fig. 13.18 Operative photograph showing the excised
joint, which corresponds to the clinical ulcer over that 1st metatarsal head and 1st proximal phalanx. Arrow indi-
joint. Arrow indicates the destruction of the joint cates the osteotomy of the first metatarsal head

a b

Fig. 13.17 (a and b) Operative photograph showing ulceration over the 1st metatarsophalangeal joint and dislocation
of the big toe
200 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

Fig. 13.19 Operative photograph showing the excised

proximal part of the 1st metatarsal head, the base of the
1st phalanx, and the ulcer

Fig. 13.21 Operative photograph of the foot of a patient

with spinal cord injury with a stage IV pressure ulcer over
the lateral side of the foot related to the base of the 5th
metatarsal bone

Fig. 13.22 Anteroposterior (AP) x-ray of the foot showing

some destruction of the 5th metatarsal base corresponding
to the ulcer location. Arrow indicates the bone pathology

lateral muscle bellies join the distal soleus mus-

cle belly in the mid-lower leg. The short saphe-
nous vein and sural nerve are identified in the
Fig. 13.20 Operative photograph showing the closure of
posterior midline raphe. The great saphenous
the wound vein location is medial to the medial gastrocne-
mius muscle, and the peroneal nerve is lateral to
the edge of the lateral muscle head close to the
13.7.1 Surgical Anatomy head of the fibular bone.
and Landmark

Each muscle belly of the gastrocnemius muscle 13.7.2 Operative Technique

originates from the condyle of the femur. The
medial and lateral heads have a long, tendinous The patient is placed in the supine position,
insertion in the Achilles tendon. The medial and except in cases of ulcer or infected sinus in the
13.7 Ulceration Around the Knee Joint
Fig. 13.23 Operative photograph showing the excised
ulcer, the shaved bone, and the dissected plantar fasciocu-
taneous flap
Fig. 13.24 Operative photograph showing the rotation of
the plantar fasciocutaneous flap
popliteal fossa, when the patient is placed in the
prone position. The ulcer is excised as discussed
previously to expose the medial gastrocnemius
muscle anterior incision about 2 cm medial to the
edge of the tibia. That incision extends from the
medial side of the knee joint and curves toward
the popliteal fossa, inferiorly extending to above
the ankle. The muscle fascia is exposed and the
dissection starts at the medial edge of the muscle.
The medial part of the muscle is separated from
the soleus muscle, and the dissection then pro-
ceeds inferiorly, reaching the Achilles tendon.
201
Fig. 13.25 Operative photograph showing complete
suturing of the flap to close the defect, with a split skin
graft placed over the flap donor site
Half of the Achilles tendon is incised and the ten-
don is transected transversely, leaving a few cen-
timeters attached to the muscle belly. After the
deep surface of the muscle is identified, the raphe
between the medial and lateral heads is identified
and the raphe is incised. This frees the medial
head and dissection is carried on proximally to
free the muscle, taking care not to injure the vas-
cular pedicle. The extent of the dissection
depends on the length of muscle needed to be
able to rotate the flap to cover the defect without
tension.
To raise the lateral gastrocnemius muscle a ver-
tical incision is made 2 cm lateral to the posterior
border of the fibula or in the posterior midline of
the leg. The superficial surface of the muscle is
exposed and the lateral part of the muscle is identi-
fied. The muscle is separated from the soleus mus-
cle in the proximal third of the leg. The muscle
fibers that are inserted in the Achilles tendon are
divided, leaving a small length of tendon attached
to the muscle. The deep surface of the muscle is
exposed and the raphe between the two heads of
202 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

Fig. 13.26 Photograph of the foot 6 weeks postsurgery

showing complete healing of the flap Fig. 13.27 Operative photograph showing a lateral mal-
leolus ulcer and the design of the transposition local fas-
ciocutaneous flap
the muscle is divided. This allows one to free the
muscle proximally from its origin. Care should be
taken not to injure the peroneal nerve as it passes
close to the fibular head. The muscle can be rotated
on its arc of rotation and the defect closed. When
the muscles are rotated to cover the defect over
the knee, it is sutured to surround soft tissue. If the
muscle is found to be under tension, incising of the
muscle fascia in the longitudinal and transverse
directions is performed to increase the length and
size of the muscle to cover the defect. Two drains
are used to drain the area under the muscle and the
donor site. The exits of these drains are at the distal

Fig. 13.28 Operative photograph showing the excised

ulcer, the shaved bone, and the dissected flap. Short arrow
indicates the dissected flap. Long arrow indicates the
shaved malleolar bone
13.7 Ulceration Around the Knee Joint 203

Fig. 13.29 Operative photograph showing the direction

of the flap, which is transposed to cover the defect

Fig. 13.31 Operative photograph of a patient with spinal cord

injury in the prone position with an ulcer over the fibular head

Fig. 13.32 Operative photograph showing the design of a

Fig. 13.30 Operative photograph showing the flap medially based rotation fasciocutaneous flap. The ulcer has been
sutured in place to cover the defect and the grafted flap excised. Short arrow indicates the anterior part of the knee,
donor site which is the patella. Long arrow indicates the excised ulcer
204 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

Fig. 13.35 Operative photograph showing the raised fas-

ciocutaneous flap. Arrow indicates the shaved fibular head

Fig. 13.33 Operative photograph showing the shaved

fibular bone

Fig. 13.34 Operative photograph showing the shaved Fig. 13.36 Operative photograph showing the rotation of
fibula and the dissected fasciocutaneous flap the dissected flap to cover the defect
13.7 Ulceration Around the Knee Joint 205

a b

Fig. 13.37 (a) Operative photograph showing the complete closure of the flap and the grafted flap donor site. (b)
Photograph showing complete healing 6 weeks postsurgery
206 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

Fig. 13.38 Operative photograph showing an ulcer at the

level of the tibial shin below the patella and the design of
the rotation fasciocutaneous flap. Arrow indicates the
position of the patella

third of the leg. The donor site is closed primarily.

The muscle surface is always covered with a split
skin graft. Figures 13.43, 13.44, 13.45, 13.46,
13.47, 13.48, 13.49, 13.50, 13.51, 13.52, 13.53,
13.54, 13.55, and 13.56 show the operative steps Fig. 13.39 Operative photograph showing the excised
of the procedures. ulcer and the dissected flap
13.7 Ulceration Around the Knee Joint 207

Fig. 13.40 Operative photograph showing the com-

pletely dissected and raised flap

Fig. 13.42 Operative photograph showing complete clo-

sure of the defect by the flap

Fig. 13.41 Operative photograph showing the rotation of

the flap to cover the defect
208 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

13.7.3 Case 1

Fig. 13.44 An x-ray of the knee, lateral view, shows no

gross pathology in the bone

Fig. 13.43 An x-ray of the knee, anteroposterior (AP)

view, shows no gross pathology in the bone
13.7 Ulceration Around the Knee Joint 209

Fig. 13.47 Operative photograph showing the marking

for the incision to utilize the medial gastrocnemius flap

Fig. 13.48 Operative photograph showing the excision

of the ulcer and the communication with the knee joint

Fig. 13.45 Operative photograph showing extensive

ulceration over the anterior knee surface, which confirms
communication with the knee joint. Injection of methy-
lene blue was performed

Fig. 13.46 Operative

photograph showing the
extravasation of the dye
through the ulcer, which
confirms communication
with the joint
210 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

Fig. 13.52 Operative photograph showing the insetting

of the gastrocnemius muscle and suturing of the muscle to
the surrounding deep tissue. To increase the size of the
muscle, the muscle fascia was incised transversely and
longitudinally

Fig. 13.49 Operative photograph showing the complete

dissection of the medial gastrocnemius muscle

Fig. 13.53 Operative photograph, lateral view, showing

a split skin graft applied over the muscle surface

Fig. 13.50 Operative photograph showing the extent of

the knee joint defect. Arrow indicates the communication
with the knee joint

Fig. 13.51 Operative photograph showing the transfer of

the gastrocnemius muscle to cover the knee joint defect
Fig. 13.54 Operative photograph, anterior view, show-
ing the split skin graft application
13.7 Ulceration Around the Knee Joint 211

Fig. 13.56 Close-up view, 6 weeks postsurgery

Figures 13.57, 13.58, 13.59, 13.60, and 13.61 are

operative photographs showing closure of an
ulcer over the patella bone.

Fig. 13.55 Photograph 6 weeks postsurgery showing

complete healing
212 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

13.7.4 Case 2

Fig. 13.57 Operative

photograph showing an
ulcer over the patella bone.
In patients with spinal cord
injury, excision of the
patella causes a functional
deficit. To preserve the
patella, it was covered with
a muscle flap

Fig. 13.58 Operative photograph showing the patella

ulcer excised and debrided and the medial gastrocnemius
muscle utilized

Fig. 13.59 Operative photograph showing the transfer of

the medial gastrocnemius muscle to cover the patella area
13.8 Elbow Ulcer (Olecranon Ulcer) 213

Fig. 13.60 Operative

photograph showing the
muscle insetted and
sutured to deep tissue and
covered with a split skin
graft. The muscle donor
site was closed directly

Fig. 13.61 Photograph 6

weeks post surgery
showing complete healing

13.8 Elbow Ulcer (Olecranon

Ulcer)

For an olecranon bursa that is infected or filled

with excessive fluid and is clinically obvious with
fluctuating swelling, conservative treatment
includes aspiration of excessive fluid and sys-
temic antibiotic treatment when infection is diag-
nosed. When a large bursa is present that does not
respond to conservative management, surgical
excision and direct closure are indicated. For an
olecranon ulcer, if the ulcer is small and superfi-
cial in depth, local wound care should be applied
to heal the ulcer. The elbow is immobilized to
Fig. 13.62 Operative photograph of an olecranon ulcer
help healing of the wound. Unfortunately, immo- in a tetraplegic patient
bilization in some cases may cause loss of
function at the elbow joint, especially in tetraple-
gic patients. When these patients have limited the author has used this method for some patients.
function at the elbow that is essential for their Its disadvantages are that multiple stage surgeries
daily life, any loss of function can be a serious are required, and the patient must keep the elbow
problem. When the olecranon ulcer is stage IV in a flexed position for 3 weeks, until division of
with bone exposure, this is an indication for the flap, which may lead to loss of some function
surgery. at the elbow joint. In addition, spasticity in these
There are many types of surgeries described in patients can lead to flap separation at the attach-
the literature. Unfortunately, not all of them are ment and, occasionally, hinder healing of the flap
suitable for patients with spinal cord injury. The donor site. Figures 13.62, 13.63, 13.64, 13.65,
cross chest or abdominal flap procedure described 13.66, 13.67, 13.68, 13.69, 13.70, and 13.71 show
by Fisher, in 1985 [10], uses a pedicle flap, and the operative procedure for the cross chest flap.
214 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body
Fig. 13.63 Operative photograph showing the design of
a cross chest flap
Fig. 13.64 Anteroposterior (AP) x-ray of an elbow joint.
No gross pathology of the bone is noted
The author prefers to perform the procedure
with a local fasciocutaneous flap, which was
described by Bunkis, in 1985 [11], Lazarous, in
1983 [12], and Jawad, in 1990 [12–14]. The
author summarized his experience in the man-
agement of olecranon ulcers in 2001 [15, 16].
The local fasciocutaneous flap, based on the per-
forator from the radial recurrent collateral artery,
is the ideal flap in this group of patients.
Fig. 13.65 (a) Operative photograph of the olecranon
ulcer after excision and debridement. (b) Operative photo-
graph showing the dissected chest fasciocutaneous flap.
The probe indicates the position of the perforator vessels
13.8.1 Operative Technique
The ulcer or the bursa is first colored with methy-
lene blue dye, then the bursa or ulcer is excised
completely. The exposed bone should be shaved
to a bleeding level and the shaved bone sent for
histopathological examination. The flap is
designed in a semicircular fashion over the lateral
surface of the arm. The flap is then elevated as a
fasciocutaneous flap that includes the deep fascia
over the muscle. The flap is rotated to close the
13.8 Elbow Ulcer (Olecranon Ulcer) 215

Fig. 13.68 Operative photograph after division of the flap 3

Fig. 13.66 Operative photograph showing the attach- weeks after surgery, showing active bleeding from the flap site
ment of the cross chest flap to the ulcer defect and direct
flap donor site closure

Fig. 13.69 Operative photograph showing closure of the

flap at the division site

Fig. 13.67 Operative photograph 3-weeks after flap sur-

gery at the time of flap division. A bowel clamp placed over
the flap pedicle demonstrates the vascularity of the flap

defect. A small drain is placed under the flap with

the exit placed distally. The flap donor site is
closed by skin graft. The arm is placed in a func-
tional position using a cast, which should be
changed weekly until the wound is healed, 3–4
weeks after surgery. At the end of 4 weeks post-
operatively, range of motion at the elbow joint is
applied by an occupational therapist to maintain
adequate range of motion. The common compli-
cation is bursa formation under the flap, which
can occur if excessive movement is applied Fig. 13.70 Photograph 6 weeks after flap surgery show-
before the flap is completely healed. ing complete flap healing
216 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

Fig. 13.71 Operative photograph showing an elbow

(olecranon) ulcer and the design of the rotation local fas-
ciocutaneous flap
Fig. 13.74 Operative photograph showing the coloring
of the bursa with methylene blue dye

Fig. 13.72 Anteroposterior (AP) x-ray of the elbow joint

showing some periosteal reaction over the olecranon bone
secondary to the ulcer. Arrow indicates the site of the
pathology
Fig. 13.75 Operative photograph showing complete
excision of the ulcer, bursa, and bone debridement. The
local fasciocutaneous flap was dissected completely.
Arrow indicates the location of the dissected flap

Fig. 13.73 Operative photograph showing the olecranon

ulcer. The Q-tip indicates the communication of the ulcer
with the olecranon bursa

Figures 13.71, 13.72, 13.73, 13.74, 13.75, 13.76,

13.77, and 13.78 show the operative procedures
for a local fasciocutaneous flap to close an olec- Fig. 13.76 Operative photograph showing the rotation of
ranon ulcer. the local fasciocutaneous flap
13.9 Occipital Ulcer
Fig. 13.77 Operative photograph showing the closure of
the elbow defect with the local flap and the flap donor site
closed by split skin graft, which does not cover the olecra-
non ulcer defect
Fig. 13.78 Photograph of the same elbow 6 weeks post-
surgery showing complete healing of the flap and the skin
graft
13.9 Occipital Ulcer
The scalp is known for its excellent vascularity,
however, ulcers can develop when pressure is
applied for long periods of time over the occipital
area. This vascularity is a beneficial factor in
ulcer healing as long as the causes of the
ulceration, such as a halo, have been removed. It
is important to shave the hair surrounding the
wound to keep the wound clean and to prevent
hair as foreign body in the wound. Application of
local wound treatment, such as an antibacterial
cream (e.g., silver sulfadiazine cream
(Silvadene®)), at an early stage, in addition to
debridement of necrotic skin, will help to heal the
ulcer. The depth of the ulcer determines the
217
prognosis and indication for surgery. If the skull
bone is exposed and the clinical appearance of
the bone appears with no granulation tissue for-
mation, this is an indication for surgery. If the
ulcer is granulating over an exposed bone, this is
good indication for closure by a split skin graft;
unfortunately, this will result in an area of alope-
cia on the scalp. Wounds under 3 cm in size can
be excised and primary wound closure per-
formed. When surgery is indicated, a scalp rota-
tion flap is used to close the ulcer, which is a
successful method for scalp or cranium recon-
struction surgery [17–20].
13.9.1 Operative Technique
The scalp hair should be shaved in the area
where the flap is utilized. The patient should be
informed preoperatively of this action. The ulcer
to be excised is marked either in a circular or a
triangular fashion. A semicircular flap is
designed from the top of the circle or the trian-
gle and curved over the scalp area. The ulcer is
excised and the exposed bone is shaved with an
osteotome to a bleeding layer of the skull bone.
If there is no bleeding, the bone necrosis is deep
into the outer table of the skull, which should be
removed to expose the inner bleeding table of
the skull. Bleeding is controlled by low-voltage
electrocautery. The author does not recommend
the use of bone wax, as it acts as a foreign body.
Using collagen such as Avitine® helps to stop
the bleeding. The scalp flap is incised along the
marked area and the flap is then dissected by a
curved scissor from the galea or the pericra-
nium, depending on the flap thickness required
to close the defect. The flap is then rotated to
cover the defect. If the flap is found to be under
tension, a back cut is applied in the scalp. A
small drain tube is placed under the flap and the
exit of the drain is in the opposite side of the flap
rather than the base of the flap. The flap is
sutured in two layers, the deep or dermal and
skin layer. Figures 13.79, 13.80, 13.81, 13.82,
13.83, and 13.84 show the operative steps in the
scalp flap.
218 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body

Fig. 13.81 Operative photograph showing excision of

the ulcer, shaving of the bone to a healthy bleeding layer,
Fig. 13.79 Operative photograph showing the occipital and the incised scalp rotation flap
ulcer stage IV and the designed scalp rotation flap

Fig. 13.80 Lateral x-ray of the skull showing reaction in

the cortex of the skull bone secondary to the ulcer. Arrow
indicates the bone changes
References 219

Fig. 13.82 Operative photograph showing the complete dissection of the scalp flap

References
Fig. 13.83 Operative photograph showing the rotation of
the scalp flap to close the defect
10. Fisher J (1985) External oblique fasciocutaneous flap
11. Bunkis J, Ryu RK, Walton RL (1985) Fasciocutaneous
Fig. 13.84 Operative photograph showing the suturing
of the flap into the scalp defect
1. Ger R (1975) The surgical management of ulcers of
the heel. Surg Gynecol Obstet 140:909
2. Ger R (1976) The management of chronic ulcers of
the dorsum of the foot by muscle transposition and
free skin grafting. Br J Plast Surg 29:199
3. Bostwick J III (1976) Reconstruction of the heel pad
by muscle transposition and split-skin graft. Surg
Gynecol Obstet 143:972
4. Sommerlad BC, McGrouther DA (1978) Resurfacing
the sole: long-term follow-up and comparison of
techniques. Br J Plast Surg 31:107
5. Hartrampf CR Jr, Scheflan M, Bostwick J III (1980)
The flexor digitorum brevis muscle island pedicle
flap: a new dimension in heel reconstruction. Plast
Reconstr Surg 66:264
6. Reiffel RS, McCarthy JG (1980) Coverage of heel and
sole defects: a new subfascial arterialized flap. Plast
Reconstr Surg 66(2):250
7. Scheflan M, Nahai F, Hartrampf CR Jr (1981) Surgical
management of heel ulcers—comprehensive approach.
Ann Plast Surg 7:385
8. McCraw JB, Fishman JH, Scharzer LA (1978) The
versatile gastrocnemius myocutaneous flap. Plast
Reconstr Surg 62:15
9. Arnold PG, Mixter RC (1983) Making the most of
the gastrocnemius muscles. Plast Reconstr Surg
72:38
for elbow coverage. Plast Reconstr Surg 75:51
flap coverage for periolecranon defects. Ann Plast
Surg 14:361
220 13 Reconstructive Surgery for Pressure Ulcers in Special Areas of the Body
12. Jawad AS, Harrison DH (1990) The ulnar island sen-
sate ulnar artery flap for reconstruction around the
elbow. Br J Plast Surg 43:695
13. Woltering EA, Thorpe WP, Reed JK Jr, Rosenberg
SA (1979) Split-thickness skin grafting of the
plantar surface of the foot after wide excision of
neoplasms of the skin. Surg Gynecol Obstet
149:229
14. Lazarou SA, Kaplan IB (1993) The lateral arm
flap for elbow coverage. Plast Reconstr Surg
91:1349
15. Rubayi S, Kiyono Y (2001) Flap surgery to cover
olecranon pressure ulcer in spinal cord injury patients.
Plast Reconstr Surg 107:1473
16. Rubayi S, Kiyono Y (2003) Flap surgery to cover
olecranon pressure ulcer in spinal cord injury patients.
Year Book of Plastic and Esthetic Surgery, pp 70–72
17. Heimburger RA (1977) Single-stage rotation of arteri-
alized scalp flaps for male pattern baldness. Plast
Reconstr Surg 60:789
18. Juri J, Juri C, Arufe H (1978) Use of rotation scalp flaps for
the treatment of occipital baldness. Plast Reconstr Surg 61:23
19. Panje WR (1987) Physiological aspects of wound
healing. In: Scott-Brown’s otolaryngology, vol 1, 5th
edn. Butterworths, London
20. Rageer B, Ahua MS (1988) Geometric consideration
in the design of rotation flaps in the scalp and fore-
head region. Plast Reconstr Surg 81:900
 Disarticulation and Total
Thigh Flap
Salah Rubayi
14.1 Introduction
This flap is considered a lifesaving procedure
especially in the spinal cord–injured patient. This
flap is performed as an end-stage procedure for
patients with recurrent extensive pressure ulcers
when the patient has had a history of many pre-
vious flaps to repair the ulcers; as a result, the
reserves of muscles and skin become exhausted.
Clinically, the patients at this stage have a bowel
diversion (colostomy), urinary diversion, and pre-
vious bilateral Girdlestone procedure with radio-
logical evidence of destruction of the pelvic bone
architect. When the patient is in a sitting position
at this stage, the actual location is over the flat
thin pelvic floor instead of his/her bilateral ischial
bone. These patients unquestionably had many
flaps in the past with some being reused twice or
three times. The reconstructive surgeon faces a
dilemma at this stage when there is no available
muscle or skin in the patient’s body to use for
repair of this multiple complex ulceration. When
the ulcers involve the entire perineum and pel-
vis, the clinical picture is more complicated; as a
Salah Rubayi, MB, ChB, LRCP, LRCS, MD, FACS
Department of Surgery,
Rancho Los Amigos National Rehabilitation Center,
Downey, CA, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_14, © Springer-Verlag Berlin Heidelberg 2015
14
result, the patient psychologically feels disturbed
and disappointed to lose a leg. Even if the leg has
no function for ambulation, it serves for a differ-
ent purpose which is the psychological and emo-
tional effect on the patient besides stability for
sitting in a wheelchair and transferring. In addi-
tion to these factors, the patient feels threatened
that if he/she loses a leg, this will indicate the end
of options available to close future pressure ulcers
should they occur, which is a common occur-
rence in spinal cord injury patients. The author’s
clinical practice is to explain to the patient prior
to approaching the stage of disarticulation and
total thigh flap that if the patient develops future
pressure ulcers, the next stage will be losing his/
her leg. This will mentally prepare the patient for
this extensive surgery. The terminology of dis-
articulation does not apply literally on the pro-
cedure because these patients already lost their
hip in a previous Girdlestone procedure. The
disarticulation and total thigh flap is not a com-
mon procedure like a simple flap which is done
on a routine basis. The total thigh procedure was
described first by Georgiade in 1956 [1]; at that
time, muscle flap was not described and utilized
as today. Initially, therefore, this procedure was
utilized as a first line to repair multiple ulcers and
hip infection, but at present with the utilization
of the Girdlestone procedure and various muscle
flaps, this has postponed the use of the total thigh
procedure for a future time and reserved it as an
end-stage procedure. The total thigh flap was
reported by Berkas in 1961 [2] to close multiple
221
222
ulcers; Spira in 1963 [3] described his experi-
ence with amputation in spinal cord–injured
patients. Steiger in 1968 [4] described the use of
total thigh flap procedure to treat chronic infec-
tion, and then Royer in 1969 [5] described his
16-year experience in closing extensive pressure
ulcers with total thigh flap. The author’s experi-
ence in total thigh flap is to reconstruct extensive
perineopelvic ulcers when the patient already has
lost both ischia secondary to chronic ulceration
and infection. The total thigh flap will create a
soft tissue padding over whatever bony structure
is left in the pelvis. The author’s early experience
with total thigh flap is to perform the procedure
in two stages because of concerns of infection.
The first stage is to debride and remove the entire
femur and amputate the thigh within the level
of the knee area followed by local wound care
to the open total thigh flap. A few weeks later,
the second stage is to inset the flap in the large
defect; unfortunately, it was found that the inset-
ting of a flap was technically difficult because
of the development of immature heterotopic
ossification in the muscle group which was very
difficult to dissect all the immature heterotopic
ossification from the muscles. This procedure
is associated with prolonged surgical time and
large volume of blood loss. This experience was
reported in 1992 [6]. The author’s practice since
then has changed into a single-stage total thigh
procedure. In addition, the author, in 1994 [7],
successfully attempted splitting the total thigh
flap into two parts based on the vascularity of
the total thigh flap. This procedure is not always
easy to perform and poses a risk of flap necro-
sis. The purpose of the flap division was to cover
multiple separate defects. This procedure needs
meticulous dissection and accurate identification
of the vascular pedicles with a vascular Doppler
intraoperatively to identify the superficial femo-
ral artery and the deep femoral artery prior to
division of the flap. The author currently utilizes
an extended total thigh flap which includes the
skin and muscle of the calf. This additional part
is used to cover the distal sacrococcygeal area.
Boyd in 1947 [8] described the anterior approach
to hip disarticulation, and Slocum in 1949 [9]
described the posterior approach to disarticula-
tion of the hip joint. Their surgical indications
14 Disarticulation and Total Thigh Flap
were different from our indications to close
multiple recurrent ulcerations, taking into con-
sideration our patients’ condition with previous
multiple flaps. As a result of this clinical history,
the appearance of the entire thigh flap will show
scarring all around the muscle groups and occa-
sional heterotopic ossification formation which
will make it very difficult, technically, to iden-
tify and utilize anterior or posterior thigh flap.
Another important point to mention is that the
step of insetting the total thigh flap is more diffi-
cult than the dissection of the femoral bone from
the muscles because of extensive scarring from
previous surgeries. Therefore, folding the flap to
accommodate the defect is technically difficult.
Release of the scars over the inner surface of the
total thigh flap (T.T.F) may carry risk of divi-
sion to a vital blood supply. Minimum amount
of scar release should be performed to facilitate
the inset of the flap. Another point the surgeon
will face when insetting the total thigh flap to
cover the sacrococcygeal area is that the anus
will be in the pathway of the T.T.F. For this rea-
son, the patient should be informed regarding the
procedure which is to excise the anus and close
the rectum in layers, providing the patient has a
double-loop colostomy. If not, prior to this proce-
dure, a mucous fistula is performed by bringing
the defunctioning bowel loop to the skin surface.
In summary, the total thigh flap procedure is a
challenge to the reconstructive surgeon and not a
rewarding procedure like the flap surgery. On the
other hand, it is a procedure to prolong the life of
the patient and improve the quality of life of the
patient by permitting sitting in a wheelchair and
moving around.
14.2 Operative Procedure
The patient is placed on the operating table in the
prone position. Marking of all the extensive ulcers
to be excised is performed. The author prefers to
mark the lateral approach to the femoral shaft as
the majority of these patients had previously
Girdlestone procedures and vastus lateralis mus-
cle flaps; therefore, the existing lateral thigh scar
can be utilized for that purpose; if not, a marking
over the lateral intermuscular septum will be the
14.2 Operative Procedure 223

approach to the femoral shaft. All the ulcers remained of the pelvic bones. Drains are placed
should be excised and debrided in the usual man- under the total thigh flap. In some occasions, if it
ner, and shaving of the prominent and the is found that the thigh flap was short to reach the
unhealthy bone should be performed. Then an superior area of the sacrum, in this case, modifi-
incision is made to approach the femoral shaft lat- cations need to be done to utilize a longer thigh
erally with the electrocautery dissection carried flap which will be discussed below. The author’s
on deeply to raise two flaps on each side of the practice at present is to perform the total thigh
femur shaft. The dissection starts superiorly and flap [6, 10] as a one-stage procedure. Two clini-
then carries inferiorly in the direction of the knee cal cases are presented below with surgical
joint. Due to previous surgeries, an extensive scar- options (Figs. 14.1, 14.2, 14.3, 14.4, 14.5, 14.6,
ring will be seen during the dissection. Then a 14.7, 14.8, 14.9, 14.10, 14.11, 14.12, 14.13,
bone clamp is placed over the proximal end of the 14.14, 14.15, 14.16, 14.17, 14.18, 14.19, 14.20,
femoral shaft and retracted laterally. This maneu- 14.21, 14.22, and 14.23) of operative procedure
ver will expose the tissue which is still attached to of disarticulation and total thigh flap.
the femoral shaft medially which can be dissected
with an electrocautery to free the entire length of Case 1
the femoral shaft from all the muscle groups in the
total thigh flap. At this stage, the distal end of the
femur is still attached to the knee joint, and at this
point, a decision should be taken on how long the
total thigh flap is needed. If the choice is at the
knee level, then an amputation is done by making
a circumferential incision around the lower end of
the thigh. The popliteal artery is ligated with the
vein, and the long saphenous vein is also ligated.
The final specimen which will be sent to the
pathologist including the entire femoral shaft
attached to the knee and the leg.
The acetabular cavity should be debrided by
curate. If there is heterotopic ossification, it needs Fig. 14.1 AP pelvis of a patient showing bilateral previous
to be excised. The next step is the difficult stage Girdlestone procedure and destruction of both ischial bones
of the insetting of the total thigh flap which looks with a thin pelvic bone prior to previous disarticulation
like an “open book.” If there is extensive scar-
ring, a simple release in a longitudinal direction
should be performed to aid in bending of the flap
to be insetted into the defect. The author’s experi-
ence is to excise some of the skin from the distal
end and leave the muscle exposed. This part of
the total thigh flap will be the filler of the distal
defect. In addition, the total thigh flap is a very
heavy flap; therefore, at this step when suturing
the flap to the superior edge of the defect and to
prevent dehiscence of the flap secondary to its
weight, the author uses retention sutures in that
area of the total thigh flap. The total thigh flap is
arranged in a way to cover all the defects of the
Fig. 14.2 X-ray of AP pelvis of the same patient with
perineum, ischium, and trochanter. Any extra previous disarticulation of the right hip, and the patient is
skin or scar tissue is excised so that the flap can for left disarticulation procedure. Notice the destruction
fit nicely and create padding over whatever is of the pelvic bone architect
224 14 Disarticulation and Total Thigh Flap

Fig. 14.5 Operative photograph of patient in prone posi-

tion lateral view showing the lateral marking for the dis-
Fig. 14.3 Operative photograph showing extensive bilat-
section of the entire femur; the marking is over the scar of
eral ischioperineal ulceration involving the anus with pre-
the old Girdlestone procedure
vious disarticulation and total thigh flap on the right side
with previous multiple flaps

Fig. 14.4 Operative photograph showing patient in Fig. 14.6 Operative photograph showing that the entire
prone position with the marking for amputation and femur was dissected from the entire thigh and amputation was
disarticulation performed above knee level and dissection to excise the anus
14.2 Operative Procedure 225

Fig. 14.10 Operative photograph showing the insetted

muscle part of the total thigh flap in the defect

Fig. 14.7 Operative photograph showing the entire fem-

oral shaft which was dissected and attached to the knee
and leg. The entire specimen was sent for pathology

Fig. 14.11 Operative photograph showing complete clo-

sure of the total thigh flap to cover the entire defect

Fig. 14.8 Operative photograph of close-up view showing

the dissection to excise the anus and closures of the rectum
in this case. Arrow indicates location of rectal stump

Fig. 14.12 Postoperative photograph 6 weeks post sur-

gery showing complete healing of the flap

Fig. 14.9 Operative photograph showing excision of the

skin of the posterior thigh flap to expose a group of mus-
cle to be insetted into the defect
226 14 Disarticulation and Total Thigh Flap

Case 2

Fig. 14.13 Photograph of a spinal injury patient pre-

sented with extensive necrosis and infection of the entire
gluteal and trochanteric area

Fig. 14.15 Operative photograph of the same patient in

prone position showing the extent of the ulcer with evi-
Fig. 14.14 Operative photograph of the same patient in dence of previous multiple flaps. Few weeks post debride-
prone position about 4 weeks post debridement and ment of the extensive ulceration
wound care (right lateral view)
14.2 Operative Procedure 227

Fig. 14.19 Operative photograph lateral view showing

the exposure of the entire femoral shaft and the hip hetero-
Fig. 14.16 Operative photograph of the same patient in
topic ossification (H.O.) through a lateral approach
prone position showing the extent of ulceration (left lat-
eral view)

Fig. 14.20 Operative photograph lateral view showing

the amputation at above-knee level and the dissection of
the entire total thigh flap from the femoral shaft

Fig. 14.17 X-ray of AP pelvis of the same patient show-

ing heterotopic ossification of the right hip with ankylosis,
which is one of the indications to perform disarticulation
of the right limb

Fig. 14.18 Operative photograph postsurgical debride-

ment of the entire ulceration
Fig. 14.21 Operative photograph of patient in prone
position post complete disarticulation of the entire femur
and hip H.O. excision from the total thigh flap
228
Fig. 14.22 Operative photograph of patient in prone
position, post insetting of the total thigh flap to cover the
entire open areas
Fig. 14.23 Photograph of 6 weeks post total thigh flap
showing complete healing (patient in prone position)
14.3 Modification of Total Thigh
Flap Procedure
14.3.1 Excision of the Anus and
Rectal Closure
As mentioned previously, to inset the total thigh
flap across the sacrococcygeal area, anatomi-
cally, the anus will be in the pathway of the total
thigh flap inset. In this circumstance, there is
indication to excise the anus and close the rec-
tum, preoperatively. If the type of colostomy is
not known, a special radiological test should be
done by injecting a Gastrografin radio-opaque
dye either through the colostomy or the anus and
14 Disarticulation and Total Thigh Flap
taking X-rays which will demonstrate the type of
colostomy the patient has. If the colostomy is not
a double loop, the general surgeon will need to
perform a mucous fistula by bringing the defunc-
tioning loop of the sigmoid colon to the abdomi-
nal wall prior to the total thigh flap surgery. The
excision of the anus is done by marking the inci-
sion around the anus with the electrocautery
around the anal verge; then the incision is deep-
ened and tissue clamps are placed over the
mucocutaneous junction. The dissection contin-
ues around the anus to dissect it from the soft
tissue for a length of 6–8 cm; then the anus is
transected from the rectum. Tissue clamp is
placed around the rectal edges, and then the rec-
tal stump is closed by two layers; the first layer is
by through-and-through continuous stitches by
using 3-0 Vicryl suture on GI needles, and then
the invagination of this layer is by the seromus-
cular layer closure. Using the same type of
sutures, the rectum is dropped in the cavity and
soft tissue is closed over the stump. If the gracilis
muscle was not used previously, it can be uti-
lized to cover the rectal stump. Then the total
thigh flap is insetted to cover the defect area
including the excised anal area (Figs. 14.24,
14.25, 14.26, 14.27, 14.28, and 14.29), showing
the operative procedure of the anal excision dur-
ing disarticulation and total thigh procedure.
14.3.2 The Extended Total Thigh
Flap (Below the Knee)
We have observed on many occasions that the
standard total thigh flap when the amputation is
above the knee is short and does not reach to
cover the sacral area; in this circumstance, the
author utilizes extra length to add to the total
thigh flap by utilizing the posterior leg muscle
compartment of both the gastrocnemius muscle
and the skin attached to the muscles. The mark-
ing of the extended flap is over the tibial shin and
then extends inferiorly and then circumferentially
above the level of the Achilles tendon. The proce-
dure will involve dissection of the femoral
14.3 Modification of Total Thigh Flap Procedure
Fig. 14.24 Operative photograph showing patient in
prone position with multiple extensive stage IV ulcer
involving the anus. Patient with history of multiple flap
surgery in the past with the only option available to disar-
ticulate and total thigh flap and closure of the anus. Arrow
indicates anus position
Fig. 14.25 Operative photograph of the same patient in a
lateral view
229
Fig. 14.26 Operative photograph showing post-excision of
all the ulcers showing the incision around the anus with trac-
tion on the anal verge to start dissection around the anus
Fig. 14.27 Operative photograph showing complete dis-
section around the anus; the transection of the anus and
closure of the rectal stump in layers was performed
condyle and the tibia and fibula from the entire
muscles of the posterior compartment of the leg.
Care should be taken not to injure the popliteal
vessel; the final specimen will be sent to the
pathologist including those of the femoral shaft,
tibia, and fibula which are attached to the foot.
The muscle of the leg with attached skin will be
utilized to cover the sacral and coccygeal defect
(Figs. 14.30, 14.31, 14.32, 14.33, 14.34, 14.35,
14.36, 14.37, 14.38, 14.39, 14.40, 14.41, 14.42,
and 14.43) during surgical modification proce-
dure of extended total thigh flap.
230 14 Disarticulation and Total Thigh Flap

Fig. 14.30 AP X-ray view of the pelvis showing the right

side was disarticulated and extensive skeletal changes in
the pelvic bone secondary to multiple ulceration

Fig. 14.28 Operative photograph showing post closure

of the rectum and post disarticulation and total thigh flap

Fig. 14.29 Operative photograph showing the complete

insetting of the total thigh flap covering the entire defect
and the rectal closure area and completely sutured in
Fig. 14.31 Operative photograph of the patient in prone
layers
position showing the extensive ulceration of the entire
pelvic area. The patient had a previous disarticulation of
the right side with anal excision and closure
14.3 Modification of Total Thigh Flap Procedure 231

Fig. 14.34 Operative photograph showing a close-up of the

Fig. 14.32 Operative photograph of the same patient dissection, debridement of pelvic area, and sacrolumbar area
showing lateral view of the ulceration which extends into
the sacrolumbar area

Fig. 14.35 Operative photograph of the dissected entire

femur attached distally to the knee joint and the leg with
extended disarticulation of the soft tissue in the calf area. The
specimen sent to pathology. Arrow indicates the dissection of
the posterior leg muscles as a part of the extended T.T.F

Fig. 14.33 Operative view showing post disarticulation

and removal of the entire femur from the total thigh flap
muscles. The total thigh flap showing extended area from
the posterior leg which includes part of the calf muscle.
Arrow indicates the extended part of the total thigh flap

Fig. 14.36 Operative photograph showing the insetting

of the extended total thigh flap into the defects
232 14 Disarticulation and Total Thigh Flap

Fig. 14.39 Operative photograph, lateral view of the left

side of the sutured total thigh flap

Fig. 14.37 Operative photograph showing the extended

total thigh flap sutured to the defect area

Fig. 14.38 Operative photograph, lateral view showing

the sutured total thigh flap Fig. 14.40 Photograph 6 weeks post-surgery showing
complete healing of the extended total thigh flap. Arrow
indicates the healed extended part of the total thigh flap
14.3 Modification of Total Thigh Flap Procedure 233

Fig. 14.41 Photograph 6 weeks post-surgery lateral view

showing complete healing of extended total thigh flap as
indicated by the arrow

Fig. 14.43 Photograph of the same patient post disarticu-

lation and total bilateral thigh flap sitting in a wheelchair
with bilateral cosmetic foam legs and he is crossing his
foam leg

Fig. 14.42 Photograph of the same patient 8 weeks post

bilateral thigh flap showing the patient sitting in a wheelchair
on a special gel cushion to take the conformity of the pelvis.
In addition, showing the patient with bilateral foam leg for
the purpose of psychological and cosmetic appearance
234
14.4 Postoperative Management
The standard postoperative flap management is
applied which requires a specialized bed confine-
ment for 4 weeks in the air-fluidized bed
(Clinitron®). The main critical point at the early
stages in healing is the heavy weight of the total
thigh flap which may predispose to wound dehis-
cence. This justifies the author’s preference to use
retention sutures to protect the wound from sepa-
ration which can be removed at 10–14 days post-
op. Another important challenge to the surgeon,
physical therapist, and the patient is to find the
appropriate method for sitting of the patient in a
wheelchair, considering the patient’s loss of both
hips and leg, and the challenge is to balance and
stabilize the patient in the sitting position.
Historically, we used to sit this group of patients in
a custom-made bucket, but there is always the risk
of developing skin breakdown and a pressure area.
At present, with advancement in cushion design,
we manage to achieve a better cushion option to
suit the new bodily changes in the patient. This
management will be discussed in detail in the
chapter of physical therapy and rehabilitation. We
should not forget the psychological effect of the
disarticulation and total thigh flap on the patient’s
emotion, body image, and self-esteem; for this
reason, our physical therapy and occupational
therapy designed a custom leg made from foam so
that the patient can wear it inside his/her pants
when sitting in a wheelchair. The only drawback
of this customized leg is that sometimes it does not
stay in one position and rotates in a different direc-
tion which can cause embarrassment to the patient.
14.4.1 Ulceration and Breakdown in
the Total Thigh Flap Stump
This is not an unusual condition and it develops
post total thigh flap. The author has experienced
operation on some patients 3–4 times secondary
to development of new ulceration on the stump.
This condition does create a dilemma to the sur-
geon as he/she attempts to repair these ulcer-
ations when anatomically there is no definite
14 Disarticulation and Total Thigh Flap
named flap to use. The problem will become
more complicated if the patient has bilateral total
thigh flap. We should stress here that despite all
the education the patient received from the mem-
bers of the treating team regarding the risks
involved in skin ulceration and the difficulty in
repairing the defect, unfortunately, we continue
to see ulceration occurs in clinical practice and is
a moral and ethical issue when there is no clear or
definite answer to this problem.
14.5 Surgical Options of Repairs
This depends on the important fact that the
patient has a unilateral or bilateral disarticulation
and total thigh flap. The other important factor is
if the patient has bowel or urinary diversion
which means the loss of abdominal muscle
reserves. In the unilateral disarticulation, there is
a good possibility of transferring flap from the
intact side to the disarticulated side especially if
the patient has no Girdlestone procedure. In this
case, the vastus lateralis muscle can be trans-
ferred to repair the ulcer on the stump of the dis-
articulated side.
14.5.1 The Rectus Abdominis
Muscle Flap
If one of the rectus abdominis muscles is still
available, it can be utilized and raised as a muscle
flap. The muscle is tunneled subcutaneously to
cover the defect in the total thigh stump which is
secondary to a bursa or ulceration; when the mus-
cle is placed in the defect, then either local skin
flap is mobilized to cover the muscle or skin graft
is placed over the rectus abdominis muscle sur-
face. The donor site of the muscle is closed in
layers of the anterior rectus sheath and then the
skin layer. The area of the donor site and the mus-
cle bed is drained (Figs. 14.44, 14.45, 14.46,
14.47, 14.48, 14.49, 14.50, 14.51, 14.52, and
14.53) during surgical procedure to close a defect
in the total thigh flap stump utilizing the rectus
abdominis muscle.
14.5 Surgical Options of Repairs 235

Fig. 14.44 AP X-ray of the pelvis showing absence of

the left femoral head secondary to previous disarticulation
and total thigh flap

Fig. 14.46 Operative photograph showing patient in

supine position and marking on the abdominal wall for the
Fig. 14.45 Operative photograph showing patient in incision to utilize the rectus abdominis muscle
supine position, lateral view with left disarticulated stump
and a deep sinus and bursa in the total thigh flap

Fig. 14.47 Operative photograph showing the excision

of the sinus and bursa in the total thigh flap and the inci-
sion for harvesting the rectus abdominis muscle
236 14 Disarticulation and Total Thigh Flap

Fig. 14.48 Operative photograph showing the excised

bursa

Fig. 14.50 Operative photograph showing the dissection

for the subcutaneous tunnel to transfer the muscle to the
defect

Fig. 14.51 Operative photograph showing the rectus

abdominis muscle transferred through the subcutaneous
tunnel

Fig. 14.49 Operative photograph showing the complete

harvesting of the left rectus abdominis muscle
14.5 Surgical Options of Repairs
Fig. 14.52 Operative photograph showing the rectus
abdominis muscle insetted in the cavity and the total thigh
flap closed over the muscle
a b
Fig. 14.53 (a, b) Six weeks post-surgery complete healing of the total thigh wound and the donor site of the rectus
abdominis (the abdominal wound). (Lateral and supine view)
237
14.5.2 Repair of the Ulcer in
Unilateral Disarticulation
and Total Thigh Flap from
the Contralateral Side
In this situation when the patient has one side dis-
articulated and total thigh flap and the other side is
available with an intact leg, the repair of the stump
ulcer will be possible by transferring tissue from
the contralateral side. In this, repair is to utilize
the common large-volume muscle which is the
vastus lateralis muscle, providing no Girdlestone
procedure was performed in the contralateral side.
The procedure is raising the vastus lateralis mus-
cle and transferring the muscle in a horizontal
direction across the perineum to the other side
where the defect over the stump is covered which
is most common over the ischial area. The muscle
surface can be covered with split skin graft or by
a fasciocutaneous flap, if available, which can be
used to cover the muscle surface. The usual flap
used for that purpose is the posterior thigh flap or
tensor fascia lata flap. The principle in excising
the ulcer and raising the flaps is the same principle
described in the specific chapter. An important
point to mention is that the percentage of the male
gender in this patient group who has had
238
disarticulation and total thigh flap is the highest
percentage than the female gender. As the male
represents about 99 % and the female about 1 %,
this gender percentage difference makes the repair
in male possible by transferring the muscle from
the contralateral side through the male perineum
to the ischium of the other side, while in the
female patient this procedure is not possible
because of the anatomical fact of the presence of
Fig. 14.54 Operative photograph of patient in prone
position showing disarticulated stump, and patient devel-
oped extensive ulceration extending from left to right
ischium involving the perineum
14 Disarticulation and Total Thigh Flap
the vagina and anatomically there is a small space
between the vagina and the anus. When no flaps
are available in the contralateral side, the option
will be to close the ulcer by random local flap
(myocutaneous or fasciocutaneous) from the
residual stump (Figs. 14.54, 14.55, 14.56, 14.57,
14.58, 14.59, 14.60, 14.61, 14.62, 14.63, 14.64,
and 14.65) which is the surgical procedure used to
close ulcer in a uni-disarticulated stump.
Fig. 14.55 AP X-ray of the pelvis of the same patient
showing destruction of pelvic bone secondary to previous
ulceration and old fracture of left femur with fixation by
nail with development of heterotopic ossification and hip
ankylosis in view of this pathological condition decision
to perform Girdlestone procedure to utilize the vastus
lateralis muscle to be transferred to the other side
Fig. 14.56 Operative photograph showing the exposure of
the left femur to perform Girdlestone procedure (lateral view)
14.5 Surgical Options of Repairs 239

Fig. 14.59 Operative photograph showing the dissection

and the utilization of the vastus lateralis muscle (lateral view)

Fig. 14.57 Operative photograph showing the excised

head of the left femur with the metal used to fix old
fracture

Fig. 14.60 Operative photograph showing the transfer of

the vastus lateralis across the defect of the ulcer to the
contralateral side (lateral view)

Fig. 14.58 Operative photograph showing the amount of

heterotopic ossification excised from around the hip area

Fig. 14.61 Operative photograph showing the insetting

of the vastus lateralis muscle into the defect of the contra-
lateral side (lateral view)
240 14 Disarticulation and Total Thigh Flap

Fig. 14.64 AP pelvis postoperative X-ray showing the

Girdlestone procedure of the left hip

Fig. 14.62 Operative photograph showing complete clo-

sure of the wound over the vastus lateralis muscle

Fig. 14.65 Six weeks post-surgery showing complete

healing of the wound

Fig. 14.63 Operative photograph showing the closure of

the Girdlestone wound (lateral view)
14.5 Surgical Options of Repairs
14.5.3 Repair of Ulceration in
Bilateral Total Thigh Stump
When ulcerations occur in a bilateral total thigh
stump for the first time, it can be closed by local
flap which is a random flap from the group of
muscle of the total thigh stump. The random flap
can be designed in a rotation form or advance-
ment to cover the ulcer. The patient at this stage
already had his anus excised and closed. The dis-
section of the muscle flap which is a part of the
total thigh flap should be very meticulous not to
detach the muscle completely from the group;
Fig. 14.66 Operative photograph showing patient in
supine position post bilateral disarticulation, showing
extensive ulceration bilaterally in the total thigh flap
Fig. 14.67 Operative photograph of the same patient
showing the extent of the ulcer into the scrotal sac
241
otherwise, it may lose its vascularity and end
with muscular necrosis. Therefore, the detach-
ment should be not complete from the group of
muscles, and this muscle will act as a perforator
flap. In recurrent ulceration of bilateral total thigh
flap at this stage, all the skeletal form of the pel-
vis is lost and patient is sitting on his/her soft tis-
sue and there is great danger of exposing the
abdominal viscera. At this stage, wound care and
local direct wound closure may be attempted
(Figs. 14.66, 14.67, 14.68, 14.69, and 14.70) sur-
gical procedure to close ulcer in bilateral total
thigh flap case.
Fig. 14.68 Operative photograph post excision of the
ulcer and dissection of the local tissue
Fig. 14.69 Operative photograph showing the excision
of the ulcer with exposure of the pelvic bone and the expo-
sure of the bilateral testis. Arrow indicates the remains of
the bone pelvic floor
242
Fig. 14.70 Operative photograph showing the complete
rotation of the local flap to cover all the exposed area, and
flap closed in layers and the drains are on the lateral side
of the field
References
1. Georgiade N, Pickrell K, Maguire C (1956) Total
10.
thigh flaps for extensive decubitus ulcers. Plast
Reconstr Surg 17:220
2. Berkas EM, Chesler MD, Sako Y (1961) Multiple
decubitus ulcer treatment by hip disarticulation and
14 Disarticulation and Total Thigh Flap
soft-tissue flaps from the lower limbs. Plast Reconstr
Surg 27:618
3. Spira M, Hardy SB (1963) Our experience with high
thigh amputations in paraplegics. Plast Reconstr Surg
31:344
4. Steiger R, Curtiss P (1968) The use of a total thigh
flap procedure for chronic infection of the hip joint. J
Bone Joint Surg 50:1429
5. Royer J, Pickrell K, Georgiade N et al (1969) Total
thigh flaps for extensive decubitus ulcers: a 1-year
review of 41 total thigh flaps. Plast Reconstr Surg
44:109
6. Rubayi S, Ambe MK, Garland DE, Capen D (1992)
Heterotopic ossification as a complication of the
staged total thigh muscles flap in spinal cord injury
patients. Ann Plast Surg 29:41
7. Berger SR, Rubayi S, Griffin AC (1994) Closure of
multiple pressure sores with split total thigh flap. Ann
Plast Surg 33:548–551
8. Boyd HB (1947) Anatomic disarticulation of the hip.
Surg Gynecol Obstet 84:346
9. Slocum DB (1949) Atlas of amputations. Mosby, St.
Louis
Capen DA, Nelson RW, Zigler J et al (1988) Staged
total thigh rotation flap for coverage of chronic recur-
rent pressure sores. Contemp Orthop 16:23–30
 Complications of Flap Surgery
Salah Rubayi
15.1 Introduction
As with any other type of surgery, there are com-
plications specific to flap surgery and there are
other complications that are general in nature.
The author’s experience in dealing with this type
of surgery is that there are particular factors that
play an important role in developing these spe-
cific flap complications. These specific factors
differ from other specialities of surgery because
of the patients’ primary disease. Complications
in flap surgery can result in medico-legal issues.
Plastic surgeons are responsible for their actions
and can be sued by the patient for these compli-
cations in malpractice cases that sometimes reach
a court of law.
15.2 General Systemic Factors
That Contribute to Flap
Complications
Patients who develop pressure ulcers often have a
medical condition such as lung, heart, kidney, or
liver disease or diabetes [1] and are bedridden in
S. Rubayi, MB, ChB, LRCP, LRCS, MD, FACS,
Department of Surgery, Rancho Los Amigos
National Rehabilitation Center, Downey, CA, USA
Division of Plastic Surgery, Department of Surgery,
Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
e-mail: srubayi@hotmail.com
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_15, © Springer-Verlag Berlin Heidelberg 2015
15
a hospital or nursing home. These organ diseases
cause slow healing of ulcers or complications in
healing after flap surgery. Other factors that affect
healing are smoking and alcohol or drug abuse,
which may affect the body and mental status of
the patient.
15.2.1 Chronic Open Wounds
Polymicrobial infection may be present in
a pressure ulcer and affects wound healing.
Healing outcome is different compared with
a clean surgical wound. Even with the highest
standard of operative technique in excision and
debridement of the ulcer, frequent mechanical
wound irrigation during surgery, and pre- and
postoperative antibiotic coverage, wound infec-
tion can occur in a certain percentage of these
wounds [2].
15.2.2 Quality of Skin and Deep
Tissue
In areas with scars from previous surgeries, some
vascular necrosis of the skin and the deep tissue
is likely to be present. In patients who have had
previous surgeries for pressure ulcers, there may
be a shortage of skin and deep tissue reserve. In
such circumstances, when the flap is closed it is
under tension, which may result in an undesirable
outcome.
243
244
15.2.3 Location of Flap Surgeries
The majority of these flaps are located around
the perineum and in close proximity to the anal
area [2]. In spite of precautions, the flap wound
can be subject to bacterial contamination result-
ing from stool in the area. A diverting colostomy
may reduce bacterial contamination of the flap
wound. Urine leakage can lead to maceration of
the skin, which leads to breakdown in the wound
edges and an inflammatory reaction due to the
toxicity of the urine. Mechanical cleaning after a
bowel program in patients with spinal cord injury
may affect the sealing of the wound at the early
stages of flap surgery.
15.2.4 Muscle Spasms
Some patients with pressure ulcers have neuro-
logic injuries or diseases that manifest with mus-
cle spasms. Muscle spasms need to be controlled
before and after flap surgery (please see this sec-
tion in chap. 6). Muscle spasms affect the flap
wound by creating shearing forces with a direct
mechanical pull on the flap edges. The result is
either wound separation and dehesion or forma-
tion of bursa under the flap bed.
15.2.5 Preoperative Nutrition
and Anemia
Serum protein and hemoglobin levels are impor-
tant factors in wound healing. If levels are below
the normal ranges and are not corrected or supple-
mented, slow healing or nonhealing of the flap
wound can result. It is therefore important to have
acceptable levels of prealbumin, 18–20mg/dL,
and hemoglobin above 10 g preoperatively.
15.2.6 Patient Compliance
It is important that patients understand the nature
of their flap surgery and the requirement for no
movement in this elective type of surgery. The
author’s experience and observation has been
that the noncompliant patient carries a higher
15 Complications of Flap Surgery
percentage of morbidities in healing of flap sur-
gery. Noncompliant behavior includes vigorous
movement in bed or sitting too high, even in an
air fluidized bed, which can eventually lead to
high pressure over the new flap and results in skin
necrosis or ulceration.
15.3 Nonspecific Complications
That Affect Flap Healing
Blood loss during surgery leads to postoperative
anemia, which requires treatment with iron tab-
lets. In severe cases, blood transfusion is needed,
especially where there is excessive drainage of
the wound bed postoperatively, which is seen
with the Girdlestone procedure or heterotopic
ossification excision surgeries.
15.3.1 Postoperative
Hypoproteinemia
Low levels of albumin and prealbumin may be
seen in the first 1–2 weeks postoperatively as a
result of the catabolic affect and the insult of the
surgery on the patient’s body. This condition is
also related to the magnitude of the surgery.
Management is a high protein/calorie diet. Our
experience shows that when the ulcers are closed,
the albumin and prealbumin levels rise around
3–4 weeks postsurgery. In severe depletion, espe-
cially if the patient started preoperatively with
low albumin and prealbumin levels, this condi-
tion seriously affects flap healing. Therefore, in
many cases, we treat the patient with total paren-
teral nutrition (TPN) for an average period of
2 weeks. In addition, we may prescribe an ana-
bolic steroid such as oxandrolone or the female
hormone Megace® (megestrol acetate) to
increase the appetite and to help in the anabolic
phase of patient recovery after flap surgery [1].
15.3.2 Deep Venous Thrombosis (DVT)
Deep vein thrombosis can occur because of the
confinement of the patient in bed in the post-
operative period and the lack of mobility. The
15.4 Specific Complications Related to Flap Wounds 245

author’s observation is that, in chronic spinal when the deep sutures migrate to the surface of
cord injured patients, DVT occurrence is low the flap wound and causes multiple small holes.
in the period after flap surgery because of their Management is local wound care and removal of
history of long-term paralysis and limited ambu- these deep sutures, which act as a foreign body
lation. Consequently, the venous muscle pump in the wound. If this complication is extensive
system is accustomed to pumping the venous and around the entire flap, management is local
blood while the patient is in sitting position in a antibacterial cream, such as Silvadene®, and sys-
wheelchair (i.e., the patient is not ambulatory). temic antibiotic by mouth (Figs. 15.1, 15.2, and
Therefore, surgery does not increase the risk of 15.3). If no healing occurs, surgical management
DVT unless if there is a change in the coagula- should be performed.
bility of the patient’s blood, an increase in the
viscosity of the blood (e.g., from dehydration or
extensive hip and pelvic surgery), or a history of 15.4.1 Major Complications
DVT. When operating on a newly injured spinal
cord injury patient or an ambulatory patient, the Seroma is a frequent complication, which is
author recommends giving these patients a low detected after removal of the sutures when there
molecular weight heparin injection. Anti-DVT
prophylaxis should begin while the patient still
has the drainage system intact and before its dis-
continuation to demonstrate whether this prophy-
laxis is causing extra bleeding in the flap site, in
which case the drain serves as a safety valve to
protect the flap from hematoma formation.

15.4 Specific Complications

Related to Flap Wounds

Minor complications include wound dehesion, Fig. 15.1 Photograph of a patient in the prone position
which is common in flap surgery, usually occur- about 3 weeks after a gluteus maximus rotation flap was
used to close a sacrococcygeal ulcer. A breakdown in the
ring in the second or third week after flap sur- medial side of the flap can be seen, with some undermin-
gery and at the time of the suture removal. An ing as demonstrated by the Q-tip for about 3 cm under the
area of frequent occurrence is the perineal area. flap. This indicates the formation of bursa under the flap
Management is local wound care and the use of
electrical stimulation of the wound, which accel-
erates healing [3, 4]. Local wound edge necrosis
can occur if the skin suturing is under tension (it is
commonly seen when the flap donor site is closed
under tension) or the quality of the skin is poor due
to scarring from previous surgery. Management is
debridement of the necrotic skin edges followed
by local wound care. When the vascularity of the
skin is in doubt, it is advisable to use a skin graft
to close a large defect rather than direct closure
under tension. A large wound defect after debride-
ment may require negative pressure wound ther- Fig. 15.2 Photograph of a patient in the prone position
about 3 weeks after a gluteus maximus rotation flap was
apy (vacuum assisted closure, or VAC) and then
used to close a sacrococcygeal ulcer. Major skin necrosis
surgical closure and flap revision. Another minor and dehesion can be seen. The patient required a revision
complication is the formation of small pustules of his flap to close this open wound
246
Fig. 15.3 Photograph of a patient in the prone position
about 3 weeks after a hamstring advancement flap. There
is dehesion of the proximal part of the flap secondary to
severe spasticity. This patient required revision of the flap
with addition of a second flap, such as the gracilis
muscle
is discharge leaking from the flap wound. Seroma
development under the flap is secondary to bursal
formation under the flap, which may result from
severe uncontrolled spasticity, early removal of
the drainage tube, a clog in the drainage tube
caused by a clot, or when dead space under the
flap is not closed completely. Management of this
complication is aggressive irrigation of the space
under the flap with normal saline, using a cathe-
ter inserted under the flap. The open area is then
packed with a small strip of gauze soaked in nor-
mal saline or Dakin’s solution and changed twice
per day. This management decreases the bacterial
colonization of the space under the flap, which
eventually will help to heal the open flap, and the
flap will adhere back to its base. If conservative
management is unsuccessful in closing the bursa,
surgical management is indicated and entails
opening part of the flap, debridement of all the
granulating tissue or excising the bursa, and flap
closure under a drainage system.
15.4.2 Wound Infection
The author’s experience is that wound infection
is not a common complication, but it can occur
when there are certain factors predisposing to
infection. In 1992 [2], the author reported his
15 Complications of Flap Surgery
experience in flap infection. In a 1-year period of
time with a total of 76 flaps, 6 % became infected
despite pre- and postoperative antibiotic cover-
age, adequate surgical excision and debridement
of the ulcer, and aggressive intraoperative wound
irrigation. The conclusion of the study showed
that flaps close to the anus and perineum are
more prone to develop infection than flaps in
other areas of the body. Management is wound
drainage and irrigation and wound packing with
0.25 % Dakin’s solution. Intravenous antibiotic is
used if clinical signs of sepsis are present, such as
fever or high white blood count.
15.4.3 Hematoma
Hematoma is uncommon, however, it can occur
after flap surgery secondary to inadequate hemo-
stasis during surgery, if patient has abnormal
coagulopathy that was not corrected preopera-
tively, or if there is inadequate drainage of the
flap postsurgery. Postoperative deep venous
thrombosis (DVT) prophylaxis can cause bleed-
ing and hematoma formation under the flap. In
the past, it was believed that a hematoma can
cause pressure on the flap tissue and eventually
flap necrosis. However, it was later found that the
end products of the hematoma are toxic to the tis-
sue of the flap and can cause tissue necrosis. The
management of this condition if the patient is
insensate is opening the flap, performing a man-
ual evacuation of the hematoma, and irrigating
the wound with normal saline. The wound should
be packed with normal saline or Dakin’s pack
and changed at least twice a day. If the cavity is
small, the hematoma is evacuated well, and the
wound is kept clean, there is a good chance that
the flap wound will heal. If not, the patient should
be returned to the operating room to undergo
curetting of the wound. The flap is then closed
under closed drainage system. When the drainage
system is not working well in the flap donor site,
for example, the vastus lateralis muscle, if the
drain is removed early because of a lack of output
from the flap wound, unclotted old blood is usu-
ally observed coming from the site of the drains.
To manage this problem, the thigh should be
15.4 Specific Complications Related to Flap Wounds
Fig. 15.4 Photograph of a patient in the prone position
3 weeks after a gluteus maximus rotation flap. The patient
developed hematoma under the lateral part of the flap,
which was evacuated, underwent local wound care, and
then was closed directly
Fig. 15.5 Photograph of the same patient in the prone
position showing the extent of the damage to the flap
plane secondary to the hematoma, which was evacuated
pressed gently to evacuate the accumulated fluid.
This process is repeated daily. The majority of
these cases settle conservatively within a few
days (Figs. 15.4 and 15.5).
15.4.4 Fat Necrosis
Fat necrosis can occur in patients with thick sub-
cutaneous layers of fat. This is commonly seen in
fasciocutaneous flaps. The manifestation of this
complication is yellow discharge with fat drop-
lets coming from the flap wound. This is usually
observed in the first week after flap surgery and
will affect the healing of the flap wound. This
complication occurs when fat tissue becomes
devitalized during dissection of the flap. The
author usually trims the extra fat from the flap
247
Fig. 15.6 Photograph of a patient in the lateral position
3 weeks after a tensor fascia lata advancement flap to
close a trochanteric ulcer. The patient was obese and dia-
betic. These factors caused fat necrosis, as shown in the
photograph
edges to minimize and prevent this complication.
When wound dressing is not adequate to deal
with this complication, debridement of the
necrotic fat should be performed. Wound care
should allow granulation tissue formation, which
indicates vascularization of the residual fat. If no
sign of healing occurs, flap revision is necessary
(Fig. 15.6).
15.4.5 Flap Necrosis
Complete necrosis of a flap is not a common
complication, but it can occur occasionally in the
distal part of a flap. It is mainly due to extended
flap design or a flap being sutured under tension.
The clinical picture starts with the appearance of
epidermolysis and the dermal layer then becomes
dry and necrotic. This complication is seen
mainly in fasciocutaneous flaps such as the
extended tensor fascia lata flap or medial thigh
fasciocutaneous flap. The factors that can predis-
pose to this complication are systemic diseases
like diabetes, peripheral vascular disease with
heavy smoking, and previous surgery with exten-
sive scarring. Extensive dissection to mobilize
the flap and muscle may result in damage to the
pedicle or perforator during that process, which
results in necrosis of the skin and subcutaneous
tissue deep to the muscle (Fig. 15.7). Management
of this complication at an early stage is to keep
the epidermolysis part of the flap well hydrated
248
Fig. 15.7 Photograph of a patient in the lateral position
3 weeks after a gluteus maximus island sliding flap to
close an ischial ulcer. The patient developed necrosis of
the distal part of the muscle secondary to extensive disec-
tion to advance the flap inferiorly. The patient had a previ-
ous gluteus maximus rotation flap
Fig. 15.8 Operative photograph of a patient in the lateral
position immediately after a tensor fascia lata rotation flap
to close a trochanteric ulcer. The donor site of the flap was
grafted. The flap does not appear well perfused. The
patient smoked two packs of cigarettes per day
by moisturizing the area well with bacitracin
ointment to protect the deep dermal layers from
dehydration. If the epidermis and dermis declare
15 Complications of Flap Surgery
Fig. 15.9 Photograph of the same patient in a lateral
position about 1 week after a tensor fascia lata muscle flap
showing two thirds of the flap with necrosis secondary to
the factors previously mentioned
as full skin necrosis, debridement should be per-
formed and local wound care or wound negative
pressure therapy (VAC) used when the wound is
granulating. A skin graft can be applied. If bone
is exposed, a local flap should be used to cover
the bone (Figs. 15.8 and 15.9).
References
1. Keys KA, Daniali LN, Warner KJ, Mathes DW (2010)
Multivariate predictors of failure after flap coverage of
pressure ulcers. Plast Reconstr Surg 125(6):1725–1734
2. Garg M, Rubayi S, Montgomerie J (1992) Post opera-
tive wound infections following myocutaneous flap
surgery in spinal injury patients. Paraplegia 30(10):
734–739
3. Edwards S, Potter J, Baker L, Rubayi S (1992) The
effects of electrical stimulation on transcutaenous
oxygen supply in spinal cord injured adults with decu-
biti. Phys Ther 72:6(Suppl):15–18
4. Baker L, Rubayi S, Villar F, Demuth SK (1996) Effect
of electrical stimulation waveform on healing of
ulcers in human beings with spinal cord injury. Wound
Repair Regen 4:21–28
 Physical Therapy Evaluation
and Rehabilitation:
Pre- and Post-reconstructive
Plastic Surgery for Pressure Ulcer
Alicia Mcleland
16.1 Introduction
How an individual moves or does not move, the
environment in which he/she moves, and the
qualities of this movement can all have an impact
on individual’s skin. Physical therapy involves
the study of movement and factors that may
enhance or decrease functional movement. In the
rehabilitation of myocutaneous flap surgery
patients, physical therapy is a beneficial member
of the rehabilitation team. A physical therapist
should be involved from preop to post-op and
discharge home. This chapter will look at the role
of physical therapy in the pressure ulcer manage-
ment program at Rancho Los Amigos National
Rehabilitation Center in Downey, California.
16.2 Physical Therapy
Preoperative Clinical
Evaluation
The physical therapist first makes contact with
the patient, prior to surgery, as part of his/her
preop visit. The preop evaluation consists of
the patient’s history, physical exam, functional
evaluation, equipment evaluation, and seating
Alicia Mcleland, MPT, PT, NCS
Rancho Los Amigos, National Rehabilitation Center,
Downey, CA, USA
Kaiser Permanente, Oakland, CA, USA
e-mail: amclelland2020@att.net
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_16, © Springer-Verlag Berlin Heidelberg 2015
16
evaluation. The history should include the per-
son’s diagnosis and onset of injury. It should
include if the sore is reoccurring or there is a
new sore and how the individual believes he/
she developed this sore. This is also the time to
identify other factors that may increase the risk
of reoccurrence of pressure sores. Factors such as
incontinence of bowel or bladder; other comor-
bidities such as diabetes; lifestyle choices such as
smoking, alcohol, or drug use; and activity level
[1, 2]. This information provides the therapist
and the team with insight into this individual’s
risk factors so that a plan of care can be tailored
to meet his/her needs [2, 3].
The physical exam should include range of
motion testing of all extremities and trunk with
specific testing for the lower extremities and
spine for those individuals requiring a wheelchair
for upright mobility. The therapist should iden-
tify if the individual has enough hip flexion to sit
in his/her wheelchair (at least 90° for an upright
wheelchair) and if he/she has enough range of
motion in his/her knees and ankles to allow for
proper positioning of his/her feet on the footrest.
Any irregular or excessive curvature of the spine
should be noted and identified as fixed or flexible.
The exam should include an assessment of spas-
ticity. Strength and sensation are also important
measures, especially in individuals with incom-
plete spinal cord injuries.
Transfers can contribute to the severity of a
sore, especially in the greater trochanter areas, if
the individual is not clearing the wheel of his/her
249
250 16 Physical Therapy Evaluation and Rehabilitation: Pre- and Post-reconstructive Plastic Surgery
Fig. 16.1 Computerized pressure mapping of an individual sitting on a Jay 2 cushion. The dark blue indicates area of
low pressure <10 mmHg. The red indicates areas of high pressure >100 mmHg
chair or dragging his/her buttocks. This would
increase the shear effects on the skin and create
or perpetuate the sore. Assessing the transfers
can give insight into a potential cause of the sore.
This can identify if an individual will need more
transfer training or strengthening to prevent
recurrence. Pressure relief is another important
functional assessment. It is important to identify
if they are able to perform effective pressure
relief, the kind and frequency of the pressure
relief they are performing, and if they have been
practicing this outside of the exam room. If an
individual is ambulatory, gait analysis should be
performed. It should be determined if the myocu-
taneous flap surgery would affect the individual’s
ability to ambulate.
The next area to evaluate is the equipment that
the patient is using. The cushion is of importance,
as it may be a potential cause of the sore. The age
and condition of the cushion should be evaluated.
The wheelchair should be evaluated for any nec-
essary repairs that could be done while the indi-
vidual is in the hospital. If the individual is
ambulatory and uses any bracing or adaptive
equipment for mobility, the therapist should eval-
uate the fit of this equipment and if it will be safe
to use post-reconstruction. This information is
important as it allows the time the individual is
on bed rest or in the hospital setting to begin
planning for his/her discharge. The best chance
of success at discharge begins with education and
planning.
Lastly, in the preoperative evaluation, the
physical therapist performs a seating assessment
that includes computerized pressure mapping to
assess sitting pressures (Fig. 16.1). The measure-
ment of seated pressures has been a practice of
physical therapists on the pressure ulcer manage-
ment service for many years. Historically, pres-
sure assessment was performed with only the use
of the therapists’ hands to identify bony promi-
nences. Then therapists started using blood pres-
sure manometers. Later there was the development
of pressure transducers, inflatable plastic blad-
ders that were connected to mercury manome-
ters. The bladders were inflated using an air bulb;
when contact was broken, a light would signal
and the manometer would give a pressure [3, 4].
This later developed into multiple transducers
and became commercially available. Later the
transducer pads have been replaced by force-
sensing arrays. There are many manufacturers of
the computerized pressure mapping system.
These systems have not been shown in the litera-
ture to give an absolute pressure reading but are
an easy clinical method to identify and compare
16.3 Post Myocutaneous Flap Surgery Protocol 251

sitting pressures [5, 6]. When used with the thera- Table 16.1 Post myocutaneous flap surgery protocol
pist’s palpation skills, pressure mapping is a 1–4 weeks Strict bed rest on Clinitron bed
valuable tool for gaining information on the 3 weeks Stitches removed
patient’s anatomical sitting structures and his/her Electrical stimulation if necessary
seating system. 4 weeks Change bed to air mattress
The seating assessment identifies any bony Evaluate PROM of LE
deformities that may affect the patients’ sitting Cleared for prone gurney
position. Is there a pelvic obliquity, scoliosis, or Cleared for weight training on gurney
6 weeks Initiate sitting program
rotation of the hips or pelvis? Is there adequate
8 weeks Discharge from unit
contact of the thighs in the cushion? Is there neu-
tral alignment of the spine? Do they have a poste-
rior pelvic tilt? Are these fixed or flexible
deformities? The computerized pressure map- Table 16.2 Protocol for electrical stimulation for wound
ping system is performed on the patients’ every- healing
day cushion and on standard 2” foam. The system TENS
captures pressure over the seating area in mmHg. Mode Normal mode
This should be used with palpation skills to iden- Intensity Below palpable muscle
contraction
tify which bony areas are having higher
Rate 50 pps
pressures.
Wave form Asymmetrical biphasic
The information gathered from the pre-op
Phase width 100–225
evaluation is presented to the surgeon and other Electrode Around wound within 1 cm or in
team members in presurgery conference. In this placement wound
arena any potential barriers to healing (such as Electrode type Disposable
incontinence, lifestyle issues, smoking) are dis- Treatment 1 h per day 5–7 days per week
cussed as well as the surgical plan [6]. A printout Timer Set with unit on continuous and
of the pressure mapping is given to the surgeon then set 60 min
and correlated with X-rays; with this he/she
determines the best surgical approach. The team
sets up a plan of care to address the factors that ing on equipment issues; however, the therapist is
may increase the patients’ risk for recurrence. still following the patient and monitoring the
patients’ progress through rounds and team con-
ferences. After 3 weeks the surgeon removes the
16.3 Post Myocutaneous Flap sutures, at this time the therapist becomes more
Surgery Protocol active in the patients’ daily program. At 3 weeks
we begin a strengthening program in bed using
The patient is generally admitted one day prior to elastic bands. This program focuses mainly on
surgery. At this time it is important to discuss any the muscles needed for transfers: the pectoralis
equipment issues that will be addressed as the muscle group, the latissimus dorsi, the triceps,
patient is on bed rest. This frequently entails and shoulder stabilizers. In addition, if the suture
ordering new parts such as tires and upholstery or line has any openings, the therapist may initiate
even sending the entire wheelchair to a vendor to electrical stimulation to the wound to help accel-
be evaluated for repairs. It is important that this erate healing. Baker et al. [7] found that electrical
happen as soon as possible as repairs often take stimulation applied to the wound can accelerate
several weeks to get approved and delivered. healing time of wound by more than 25 %. The
The majority of myocutaneous flap patients protocol used for electrical stimulation follows
follow a post-surgery protocol (Table 16.1). the guidelines from this study (Table 16.2).
The first 3 weeks are strict bed rest. During Electrical stimulation is generally applied
this time the physical therapist is primarily work- until the wound is completely healed. Wound
252 16 Physical Therapy Evaluation and Rehabilitation: Pre- and Post-reconstructive Plastic Surgery
Fig. 16.2 Example of electrodes placed around the wound. Arrows indicate location of wound
Fig. 16.3 Example of a wound with the electrode placed
over a gauze soaked with saline. The second electrode is
placed distal to the wound
measurements are taken weekly to show progress
(Figs. 16.2 and 16.3).
At 4 weeks post-surgery, if the surgical wound
is stable, the patients are generally cleared for
range of motion evaluation. At this time the
patient’s lower extremities are assessed to deter-
mine if they have enough passive range of motion
to sit. During the evaluation the therapist is look-
ing not only for hip joint range of motion but also
skin tautness. The observation of the skin is very
important as often the skin becomes taut prior to
feeling an end-feel in the joint. This is especially
true for individuals with low tone who have been
independently dressing themselves prior to sur-
gery. The patient needs a minimum of 70° of
flexion to sit in a reclining wheelchair and would
need to do recline or tilt pressure relief. At least
90° of hip flexion is necessary to sit in an upright
wheelchair. If the patient does not have adequate
range of motion or is at risk for losing his/her
passive range of motion, then he/she is put on a
passive range of motion program 3–5 days a
week. At this time the patient is usually cleared to
begin getting on a prone gurney. The gurney
allows them to spend time off of their surgical
areas, get out of their rooms, and begin weight
training to improve their strength (Fig. 16.4).
The weight training program has two compo-
nents, a power program to address the muscle
used mainly during transfers and an endurance
program for the muscles involved in wheelchair
propulsion. The weight training class is held five
times per week. The weight training program is
supervised by a physical therapist or physical
therapy assistant to ensure that proper lifting
technique is being practiced.
16.4 Initial Sit
At 6 weeks the patient is generally cleared to
initiate a sitting program, if the surgical site is
stable and he/she is cleared by the surgeon. The
sitting program begins with a half hour of
sitting. On a regular program this increases a
half of an hour every day until the patient
16.5 Pressure Relief 253

Fig. 16.4 Individual on a

prone gurney doing the
Rickshaw machine. He
presses down on the arm
bars to raise weight. This is
one exercise performed in
the weight training class

Table 16.3 Sitting program which chair the patient can safely sit in. The ther-
Day 1 ½h apist should select a cushion (if on preoperative
Day 2 1h evaluation the patients’ cushion was found to
Day 3 1½ h have low sitting pressures, this cushion can be
Day 4 2h used) that will reduce shear and peak sitting pres-
Day 5 2½ h sures. In addition, the therapist should determine
Day 6 3h what form of pressure relief and what type of
Day 7 3½ h transfer is safest for the patient. Typically,
Day 8 4h patients who have lower-level injuries (T8 and
Day 9 4½ h below) with good strength and more than 100° of
Day 10 5h hip flexion are allowed to perform assisted
Day 11 5½ h
depression transfers. Individuals that do not meet
Day 12 6 h discharged
the above criteria are generally transferred using
a mechanical lift. If it was suspected during the
reaches 6 h (generally 12 days after the start of pre-op evaluation that transfers were a cause of
the sitting program). See Table 16.3. If the the sore, then a mechanical lift may be the best
patient is placed on a slow program, he/she option for the initial sit.
would increase one-half hour every other day.
Prior to sitting the therapist should inspect the
patient’s skin and after sitting repeat the inspec- 16.5 Pressure Relief
tion to ensure that no openings occurred as a
result of sitting. The therapist should note any Pressure relief should be practiced every 15 min
area of increased redness and modify the and must be maintained for at least 15 s [8]. There
patients’ cushion or seating system to reduce are a variety of pressure relief options; again it is
this pressure. Once the patient reaches 6 h of important to take into account the patients’ hip
safe sitting, he/she can be discharged home and range of motion. Forward lean pressure relief
will remain on the 6 h/day sitting limitation for requires more than 110° of flexion. If teaching the
at least 30 days until he/she is reevaluated by the forward lean pressure relief method, it is necessary
surgeon in the outpatient clinic. to palpate the ischial tuberosities and ensure they
Prior to the initial sitting, the therapist should are lifting off of the sitting surface. Depression and
determine based on range of motion evaluation side lean pressure relief are other options; again
254 16 Physical Therapy Evaluation and Rehabilitation: Pre- and Post-reconstructive Plastic Surgery
Right
Back
Right
Fig. 16.5 (a) The sitting pressures of an individual in
upright position. (b) A pressure mapping of the same indi-
vidual at 45° and (c) the same individual at full recline.
The red again indicates high sitting pressures, and the
dark blue and green indicate lower sitting pressures. The
the therapist should palpate the ischial tuberosities
and educate the patient that those bones must be
completely unweighted to ensure proper blood
flow. During a depression pressure relief, it is
important that the patient control the lift and
descent. Landing on the cushion after a pressure
relief can cause damage to the surgical site. If
teaching the side lean pressure relief, the patient
must be instructed on the need to do pressure relief
on both sides. Individuals with power wheelchairs
may use tilt in space or recline functions for pres-
sure relief. A patient using a tilt in space must be
able to tilt more than 50° for effective pressure
relief; this may vary depending on patients’ posi-
tion and type of cushion [8]. Research completed
by Coggrave and Rose [8] suggested that 65° of tilt
was necessary for the TcPO2 to return to prior pre-
load levels. It is standard practice to perform a
pressure mapping of the patient in the tilted posi-
c
Right
Back
figure shows higher pressures over the ischial area at full
upright position and over the coccyx area with 45° of
recline only. The pressures during the fully reclined posi-
tion are lower and will allow for pressure relief in this
position
tion to ensure that he/she is getting adequate pres-
sure relief from his/her tilt in space seating system.
Recliners must be reclined fully for adequate pres-
sure relief. It is important to note any potential
shear affects with recline pressure relief and to
identify if the patient is sitting appropriately in
cushion and has not shifted after recline. The use
of power recliner and power tilt in space seating
systems is most often utilized by individuals with
tetraplegia. However, the spinal cord injury popu-
lation is aging and developing more symptoms of
overuse syndromes and weight gain. There are an
increasing number of individuals with paraplegia
needing power chairs and even power seating sys-
tems (Fig. 16.5).
Pressure relief is of utmost importance, and
the therapist needs to identify if the patient can
perform pressure relief adequately and what
equipment he/she needs to do so. There have
16.6 Functional Evaluation
been some dynamic seat cushions that use a form
of alternating air to increase and decrease pres-
sure providing a form of pressure relief [9]. These
cushions are often expensive, are bulky, and have
not mapped well. The low pressure is comparable
to some cushions but peak pressures were signifi-
cantly higher. These cushions may be an alterna-
tive to adding a power seating component, but
thorough evaluation and trials need to be per-
formed prior to ordering this cushion for a patient
post-reconstructive surgery. Education on the
importance of pressure relief cannot be reviewed
enough with the patients, as the lack of effective
pressure relief is a primary cause of pressure
sores. The therapists have discovered that audi-
tory cues are helpful in reminding patients to per-
form pressure relief. We have issued watches
with countdown timers set to go off every 15 min
to patients and found that the watches increased
the frequency with which the patients remem-
bered to do their pressure relief.
On the first few days of a sitting program, the
therapist will continue to make small modifica-
tions to the cushion or wheelchair to manage any
area of redness that may occur. The focus during
the first few days is patient education on pressure
relief and skin inspection. The patients are trained
to inspect their own skin before and after sitting,
and long-handled mirrors are given to assist with
this task. If a patient is not able to perform skin
inspection, education on how to instruct a care-
giver is provided. In addition, the patients are
educated what to do should an opening or redness
occur. Bed positioning to reduce pressure over
different areas is demonstrated, and the patients
are encouraged to continue prone positioning
when in bed.
16.6 Functional Evaluation
When the patient reaches 3 h of sitting, they are
generally cleared to begin transfer training and
functional evaluation. Transfers to and from the
mat are assessed first to ensure that the patient
can safely transfer. If a patient uses a transfer
board, they will begin practicing this task. The
patient should be educated on lifting his/her body
255
and moving it across to other surface. The patient
should be discouraged from sliding across a
board. If they are unable to lift and clear buttocks
during a depression transfer, assistance will need
to be provided until the patient has regained the
strength and balance to return to independent
depression transfers. A transfer board may be
recommended at this time to reduce the distance
and allow for small controlled lifts. It is impor-
tant that the patient control the descent of his/her
transfer as to not land hard. Landing with exces-
sive force can damage the new flap site. When the
patient can safely perform transfer to and from
the bed, more advanced transfers should be per-
formed such as wheelchair to commode, to car,
and to tub bench. Evaluation of these transfers
not only allows the therapist to assess the transfer
but also gathers more information about the
patient’s life and activities outside of the hospital.
Can the patient access his/her toilet? How much
time does he/she sit on his/her toilet for bowel
care? Does he/she have a padded toilet seat?
Does he/she do pressure relief during his/her
bowel program? Where does he/she spend major-
ity of his/her time? Is he/she driving? Does he/
she use his/her cushion in his/her car seat when
driving? One patient that had come through the
pressure ulcer management unit seemed to be
doing everything correctly. His transfers were
good, his wheelchair was in good shape and fit
him appropriately, and his cushion provided good
pressure distribution with very low peak pres-
sures. Although he had a scoliosis and pelvic
obliquity, his seating system seemed to be accom-
modating for this. Upon practicing transfers, the
therapist discovered that the patient had to trans-
fer forward into his van seat and that on average
the patient was spending approximately 4 h per
day driving in his van. When the patient transfers
were evaluated in his personal setting, it was
found that he had to transfer forward out of his
wheelchair and slide across onto his seat as the
swivel portion of his van seat was not working.
This caused a great deal of shearing over the
surgical site. In addition, when his car seat was
pressure mapped with him sitting in it, it was
found to have very high peak pressures over sur-
gical area. The therapist added a low-profile air
256 16 Physical Therapy Evaluation and Rehabilitation: Pre- and Post-reconstructive Plastic Surgery

Fig. 16.6 (a) Pressure map

of an individual sitting in his a
car. He has higher pressures
over his left ischial areas.
(b) Pressure mapping of the
same individual in his car
after adding a 2 in. Roho
cushion. The pressures over
his left ischial area have been
greatly reduced

cushion and reduced the pressure significantly
(Fig. 16.6a).
The patient was able to see using the pressure
mapping system how much pressure he was get-
ting from sitting in his van, and he was able to
verbalize the need for pressure relief when
driving.
Many times evaluating a patient in his/her
environment can give the therapist a great deal
more insight into the problems and risks they
face when discharged from the hospital. Home
evaluations are good source of information,
although it is not possible or necessary to per-
form evaluations on all patients when the patient
has identified a barrier or the situation seems pre-
carious; it can be helpful to evaluate the home.
One patient that had returned just 3 months after
his first flap surgery warranted an evaluation.
During this evaluation we were able to look at the
setup of his home. In talking with the patient, he
had said that he had a padded toilet seat and he
was able to transfer to it. During practice trans-
16.7 Seating Evaluation
fers onto the hospital commode, his transfers
were good, without shearing or trauma to surgery
site. However, with the home evaluation, the
occupational and physical therapist found that
the patient had to get on the floor and scoot across
his bedroom, the hallway, and bathroom floors to
the toilet on his bottom, as his wheelchair would
not fit in the bathroom. From there he raised him-
self up to the toilet or the bath bench. This is a
very high-risk activity post reconstructive sur-
gery, and paired with the patient’s incontinence,
it was probably the activity that led to the pres-
sure sore or at the very least the reoccurrence.
Lastly, outings can be another source of infor-
mation about the patients’ practices outside of
the hospital. Does he remember to do his pres-
sure relief? Can he manage himself in the envi-
ronment? Does he plan in advance to avoid
over-sitting? Is he prepared to manage his bowel
or bladder? This is not only important informa-
tion for the therapist, but it also allows the patient
to be educated on activities and behaviors that
may increase his/her risk. With this increase
awareness, the patient can then change a behavior
and reduce their risk. Many listed that perform-
ing pressure relief when in a group of their able-
bodied peers was uncomfortable; they complained
of standing out more. For those individuals, iden-
tifying other inconspicuous methods of pressure
relief (i.e., leaning forward to pick up something)
to use so that they would not feel self-conscious
was important to ensure they would continue to
practice timely pressure relief at discharge in all
situations.
16.7 Seating Evaluation
A seating evaluation is performed on all patients,
who use a wheelchair for upright mobility, prior
to discharge. The seating evaluation is completed
first on a mat, if the person can sit upright, and
then in their equipment. The first portion of the
evaluation looks at the patient’s sitting align-
ment. The ideal sitting position is with the pelvis
in a neutral tilt and level, the spine in an upright
position maintaining the neutral curvature of the
spine, and the head upright with the patient’s ears
257
aligned over the shoulders. The patient’s hips
should be at 90° of flexion with the thighs in con-
tact with the sitting surface. This is important for
pressure distribution. The knees should be flexed
about 90° with the feet rested completely on foot-
rest. The pelvis is the key to the position of the
trunk. It is important to identify if the patient sits
in neutral pelvis and if he or she has the available
anterior and posterior range of motion for move-
ment. If the patient sits in a posterior or anterior
pelvic tilt, is the deformity fixed or flexible? The
tilt of the pelvis will determine the position of the
ischial tuberosities. An anterior pelvic tilt will
place the ischial posterior and make them more
prominent where a posterior pelvic tilt will move
them more forward and generally bring the coc-
cyx in contact with the sitting surface. The coc-
cyx has very little tissue and has very low
tolerance to pressure [4]. It is at greater risk for
skin breakdown in individuals who have a fixed
posterior tilt deformity. In addition to a neutral
anterior posterior alignment, it is important to
identify if there is a pelvic obliquity. If one side
of the pelvis is higher or lower, then it could
affect the trunk alignment and decrease pressure
distribution and increase the risk for skin break-
down [10]. Most often, the lower side has more
pressure over it. Again, it is important to identify
if the obliquity is fixed or flexible. This will
require looking at the alignment of the spine.
Frequently with an obliquity there will be scolio-
sis of the spine. Identifying if it is fixed or flexible
is important as it dictates how the patient’s equip-
ment should be modified to allow for good pres-
sure distribution and reduced peak pressures.
To identify a fixed or flexible deformity, try to
move the patient out of that position. If the defor-
mity does not change with movement, then it is a
fixed deformity. If it can be lessened, then it is a
flexible deformity. It is possible to have some
flexibility in a fixed deformity. If an individual
has a fixed deformity, the cushion should try to
accommodate for this; if the deformity is flexible,
then the seating system should try to correct for
it. For example, if the patient has a fixed pelvic
obliquity with the left ischial being lower than
the right, the cushion should have a buildup on
the right to bring the seating surface up to the
258 16 Physical Therapy Evaluation and Rehabilitation: Pre- and Post-reconstructive Plastic Surgery
Fig. 16.7 The proper way to manage a scoliosis using a
3-point seating and positioning system. The red pads rep-
resent areas that would want to be stabilized in the seating
system to prevent further collapse and maintain a level
pelvis
higher ischial tuberosities so it can bear weight
and the pressure becomes more evenly distrib-
uted over-sitting surface. If this same obliquity
was flexible, the cushion should have a buildup
on the left to elevate the downside and redistrib-
ute the pressure to entire sitting surface. If the
flexibility is a result of a flexible scoliosis, then
using a solid back and trunk support to correct
the scoliosis will fix the pelvis, and no modifica-
tion may be necessary to the cushion (Fig. 16.7).
Proper assessment is the key to successful equip-
ment modification.
Hip flexion is important as it will allow the
patient to sit without forcing a pelvic tilt. If an
individual only has 70° of hip flexion and is
placed in a chair with a 90° seat to back angle, he/
she will have to sit in a posterior pelvic tilt to
accommodate for the lack of flexion in the hip
joint. It is also important that the thighs are in con-
tact with the sitting surface and that they are in
neutral position. Excessive external rotation will
rotate the greater trochanters down and increase
the pressure over this area. Excessive internal
rotation rotates the trochanters upwardly and may
increase pressures over the ischial tuberosity. In
addition, internal rotation with adduction could
lead to pressure breakdown between knees. Knee
flexion is important to evaluate as it dictates what
angle the hangers for the footrest need to be set at.
If the hangers are at 80° and the patient only has
70° of flexion, then his/her feet will not rest
securely on footrest. This could lead to foot drop
or scraping of the feet and potentially pull the
patients’ pelvis into a posterior pelvic tilt. Knee
flexion is important as it allows for the front end
of a wheelchair to be more compact and allow for
greater access to the environment. Many veteran
wheelchair users tuck their feet under their knees
to angles greater than 90°. This requires not only
knee range of motion but also ankle dorsiflexion.
It is important that the patients’ feet rest com-
pletely on the footrest. Foot drop is a common
secondary condition in individuals with spinal
cord injury. If a person has fixed plantar flexion
contractures, his/her feet may slip off of a stan-
dard foot plate or rest on the footplate with the
pressure placed over the toes. This could lead to
breakdown in the metatarsal area. In addition, a
plantar flexion contracture will typically elevate
the knees and lift the thighs off of the sitting sur-
face. This will cause decreased pressure distribu-
tion and increased pressure over the ischial areas.
Adjustable angle foot plates, serial casting, or sur-
gery all may be treatment options for individual
with plantar flexion contractures to improve foot
placement, improve sitting alignment, and reduce
the risk of skin breakdown.
The next step in the seating evaluation is com-
puterized pressure mapping. A mat with multiple
small pressure-sensing dots is placed under the
patient between his/her buttocks and the seat
cushion. Each cell measures pressure in mmHg.
There are many different types of pressure map-
ping systems available. Each is able to perform
pressure mapping; however, the number of mea-
suring cells, the material of the mat, and how the
software interprets or presents the data may be
different (Fig. 16.8).
The mat is connected to a computer, and with
the specialized software it is able to present a
16.8 Selecting a Cushion
a b
Fig. 16.8 (a) Example of the pressure mat with the multiple cells. (b) The system: mat and computer on an individual’s
seating system
visual map of the sitting pressures (it is possible
to use color or topographical presentations). With
this the therapist can identify the bony structures
(ischial tuberosities, coccyx, and greater trochan-
ters) that may be at risk for skin breakdown if
sitting pressures are too high. It is important that
the therapist palpate any areas of high pressure to
ensure that the mapping is correct and reduce risk
for errors within the system (mat is creased,
clothing bundled, object on the cushion or large
dressing). In addition, palpation will help iden-
tify which bony area is involved. If an individual
has a pelvic deformity, it may be easy to assume
that an area is one bone and upon palpation find
that it is a different one (the high-pressure spot
that occurs closer to the middle would lead one to
believe it was the coccyx when upon palpation it
may be the ischial tuberosity if the individual has
a pelvic obliquity). The ideal pressure mapping is
all blue (with the scale set with the ceiling of
100 mmHg), with a large distribution of pressure
over the entire sitting surface including the lower
extremities, and the pressures are evenly distrib-
uted bilaterally.
There are some general guidelines for the
amount of pressure each bony surfaces can safely
manage [4]. Their research suggests that the
ischial tuberosities can safely manage sitting
pressures at 30–40 mmHg. The greater trochanter
area and coccyx areas were able to manage 60
and 10 mmHg, respectively. These are only
259
guidelines and may be affected by other factors
such as increased atrophy of the muscles around
the bony surface, increased scar tissue, and a his-
tory of multiple pressure sores. Pressure mapping
is a tool used to help identify which cushion and
seating system best suits the patient’s needs.
16.8 Selecting a Cushion
Cushion selection is a key component to the seat-
ing system of an individual post myocutaneous
flap surgery. A pressure-reducing cushion should
be used for any individual that is at high risk for
pressure sores, including but not limited to those
individuals post myocutaneous flap. There are
two principles commonly used in cushion manu-
facturing. The first is elimination. Elimination of
pressure occurs when the surface the bony area
comes in contact with is removed so that there is
essentially no pressure there (Figs. 16.9a–c and
16.10). Elimination is typically seen with differ-
ing types of foam. The Ish-Dish is a cushion that
was designed to eliminate all pressure over the
ischial tuberosities. With a foam cushion of ade-
quate density, it is possible to eliminate pressure
over all bony sitting surfaces. The benefits of
foam cushions are that they are lightweight, inex-
pensive, and very modifiable. One negative
aspect of the foam cushion is that it needs to be
replaced frequently as foam breaks down, unless
260 16 Physical Therapy Evaluation and Rehabilitation: Pre- and Post-reconstructive Plastic Surgery
a b
Fig. 16.9 (a) Pressure mapping with low peak pressures
and good pressure distribution. (b) has high peak pres-
sures; after palpation, the therapist identifies the structures
as ischial tuberosities. (c) illustrates the ischial tuberosities
Fig. 16.10 Window in a foam cushion to reduce the pres-
sure over the trochanter area
it is sealed foam. Foam generally is not
waterproof, so individuals with incontinence will
need to use special barriers or incontinence
sitting within the cutout of a foam cushion; this will
remove pressures from the ischial tuberosities. This is an
example of elimination of pressure
covers to protect the cushion. It is important to
note that the use of special covers can affect the
flexibility of the fabric cover. This can affect how
far the bony prominence is allowed to penetrate
the foam and apply an upward force on the sitting
surface, a hammock affect. This may reduce the
effectiveness of the cushion. It is important that
the cushion cover fit properly and have the appro-
priate flexibility. If the foam is somehow soiled, it
cannot be cleaned.
The second principle is submersion. The idea
of submersion is that the bony prominence is
allowed to sink into a substance (aqueous and air
are the most common substances) and the pres-
sure is distributed through a larger sitting area.
There are many types of cushions in distribution
that work on this principle. Jay and Roho are two
manufacturers that are well known for their
16.8 Selecting a Cushion
Fig. 16.11 The ischial of
a skeleton submerged in
the gel of Jay 2 deep
contour. This is an example
of the principle of
submersion. The picture is
taken from the posterior
view
pressure-reducing cushions. These cushions were
frequently used for the high-risk patients. The
Jay 2 cushion (patent Sunrise Medical) uses a gel
solution over a solid sealed foam base. The base
is designed so that the ischial area is cut deeper to
form a bowl; the majority of the gelatinous mate-
rial will lie in this area. The gel pad is made up of
foam and gel combination. The foam lines the
thigh area, and the gel is placed posterior to allow
submersion of the ischial tuberosities. The Jay 2
relies on the greater trochanters and the individu-
als’ thighs to help maintain the alignment of the
ischial tuberosities and keep them from bottom-
ing through to the solid foam base (Fig. 16.11).
This design minimizes peak pressures over bony
areas and distributes pressures over the thighs
and soft tissue areas.
When considering a cushion that uses a pre-
constructed solid base, it is important to note
where the tuberosities fall within this area. An
individual that sits in a posterior pelvic tilt will
position his/her tuberosities more anteriorly in
the cushion and may not get adequate submer-
sion. The solid foam base in a Jay can be cut to
allow for elimination of pressure in certain areas.
For example, a patient who had a myocutaneous
flap to close the greater trochanter pressure sore
was using a Jay cushion. On his Jay cushion, the
therapist cut out the greater trochanter area and
effectively eliminated the pressure in this area.
261
With any modification of the base, it is important
to check to ensure that there is adequate submer-
sion of the tuberosities. The benefit of the Jay
cushion is that it provides a stable base for trans-
fers; this is important for individuals who have
difficulties with transfers. It will last an average
of 3–5 years and is relatively maintenance free.
The Jay 2 is waterproof so that it is easily cleaned
if soiled. The drawbacks to the Jay cushion are
that it is more expensive when comparing to the
foam cushion and that it is heavier than some of
the other cushions on the market.
The Roho cushion (patent the Roho Group) is
constructed of individual air cells that range in
size depending on the model selected. It too
works on the principle of submersion. The Roho
is inflated, then the patient sits on it, and air is
released through the air valve. The patient or
therapist should palpate the ischial tuberosities
and release enough air to the point where the
ischial tuberosities are within one to two inches
of the base of the cushion. This concept is impor-
tant to note as many individuals believe that more
air is best; however, if overinflated, the individu-
als’ bony structures are not submerged and will
have increased pressure. If the cushion is under-
inflated, then the individual will be at risk for bot-
toming through the cushion and will have
increased pressure. It is important that the patient
is able to identify the appropriate amount of air in
262 16 Physical Therapy Evaluation and Rehabilitation: Pre- and Post-reconstructive Plastic Surgery
Fig. 16.12 Posterior view
of a skeleton on the Roho
cushion. It illustrates the
submersion of the bony
surfaces of the pelvis into
the air cells
the cushion and know how to adjust it. This point
is important when considering the best cushion
for a patient. It is possible to define the number of
valves placed in the Roho cushion. This increases
the modifiability of his/her cushion. A bivalve
cushion can be used to build up one side of the
pelvis to compensate or correct a pelvic obliq-
uity. It is also possible to combine the principle of
elimination as a custom cushion can be ordered
with the cells removed to eliminate pressure in a
specific area. The Roho is also great in that a
patient can sit on any section of this cushion and
get pressure distribution (Fig. 16.12).
This differs from the Jay. If the patient sits on
the front of his/her chair or the cushion is some-
how placed in reverse, the patient will be sitting
on the hard foam in a Jay cushion, whereas the
Roho can be placed any way and have effective
pressure distribution (this may not be true if the
Roho is modified). The Roho cushion is great for
pressure distribution, is modifiable, and is light-
weight. It has been shown to reduce shear effects
with movements such as wheelchair propulsion
[11]. It can be easily cleaned if soiled. In addi-
tion, it has some ability to wick moisture away
from the sitting surface. The drawback to a Roho
is that the air needs to be properly maintained in
order for it to be effective. In addition, it is made
of air cells that can be punctured which would
render the cushion useless. Another drawback is
that the Roho is an unstable surface from which
to transfer. Individuals who have poor trunk con-
trol will have a more difficult time balancing on
the Roho cushion. The Roho cushion is more
expensive but can last with proper maintenance
3–5 years.
Cushion selection is not based solely on the
best sitting pressures. It is important to take into
consideration the individual. How does the indi-
vidual transfer? Does he/she require a firm base
to push from? Is he/she capable of managing the
maintenance required to use a Roho? Does he/
she keep his/her equipment in good working con-
dition or does he/she require more durable equip-
ment? Is he/she incontinent? Does he/she have
access to resources that can replace and custom-
ize a cushion for him/her once a year? Where else
may this cushion be used (the car, the tub)? Will
he/she be transferring this cushion to a different
surface? Does it need to be lightweight? Are
there alternative cushions that may better suit
him? For example, Invacare makes a foam air
cushion. It provides a firm foam base with an air
insert in the ischial area. This allows for the
pressure-reducing submersion in air but a firm
base of support with which the patient may trans-
fer. Although a cushion may be excellent for
pressure reduction, unless the patient is able to
use it easily and it fits into his/her lifestyle, it may
fail to reduce the patients’ risk of reoccurrence.
16.9 Patient Education
Fig. 16.13 Example of modifying a cushion to correct
and compensate for bony deformities that cause high-
pressure areas. The foam on the left posterior area of
cushion is to build up the cushion to allow for improved
weight bearing on the left ischial area and better weight
distribution; this was done to accommodate a fixed pelvic
obliquity. The cutout over the right well is to decrease the
pressure over the proximal femur after a Girdlestone
procedure
At discharge the patient may not have the
ideal cushion or seating system, as equipment
ordering can take several weeks to get justified
and delivered. At this point it is important that
the patient’s equipment is modified to make sure
that the pressures are minimal. If a patient has no
cushion available to them or their current equip-
ment is not suitable nor can be made suitable, our
program had been able to secure loaner cushions
from the vendor or have placed a patient on the
lesser expensive foam cushions with cutouts to
use as temporary cushions until their equipment
is approved and delivered. Many vendors are
willing to provide loaner equipment if they can
verify insurance and eligibility. Figure 16.13 is
of a modified Jay 2 cushion. The individual had
a Girdlestone procedure; he had a pelvic obliq-
uity and scoliosis that was worsened after the
Girdlestone. His cushion was no longer provid-
ing adequate pressure relief and distribution. His
cushion was modified with a buildup on the left
and a cutout on the right to reduce the pressure
over his distal femur and increase pressure distri-
bution across sitting surface.
Lastly it is important to evaluate an individu-
als’ mobility with any new seating system. If an
individual is pushing a manual wheelchair, is he/
263
she capable of pushing his/her wheelchair, and
does he/she have shoulder pathology that is limit-
ing his/her mobility? Is he/she able to perform
adequate pressure relief after pushing his/her
wheelchair larger distances? Some changes to an
individual’s sitting posture can affect their mobil-
ity (i.e., reducing the bucket of the chair can
reduce the sitting pressures over the ischium but
decrease the responsiveness of the wheelchair or
an individual’s balance in his/her wheelchair). So
it is important that both household and commu-
nity mobility be evaluated before an individual is
discharged.
16.9 Patient Education
The most important responsibility for every mem-
ber of the rehabilitation team is patient education.
Physical therapy has the responsibility to educate
about pressure relief. We have recommended that
an individual do pressure relief every 15 min for
15 s. This means that an individual would need
to stay in a wheelchair push-up for 15 s. If this
is not possible, then an alternative pressure relief
method would need to be evaluated. When educat-
ing different individuals, it is important to iden-
tify the best method for learning. Visual aids are
sometimes useful. The pressure mapping system
is a good tool to provide visual feedback regarding
adequacy of pressure relief. Is the individual effec-
tively removing the pressure from their bottoms?
This is especially true for individuals who prac-
tice forward lean or tilting pressure relief. Other
feedback devices that have been used as reminder
to perform pressure relief were watches with
countdown timers. Many individuals reported that
they were doing pressure relief much more fre-
quently after receiving the watch. The countdown
timer would be on a continuous 15 min countdown
and would send an audible or vibratory alarm
every 15 min. In addition, to the above, handouts
were also provided that provided information as
to why pressure sores developed and how pres-
sure relief was important in reducing the risk of
developing future sores. Lastly, we tried to provide
group activities or outings with peer groups to help
improve awareness of the situations in which they
may be more at risk for not doing pressure relief.
264 16 Physical Therapy Evaluation and Rehabilitation: Pre- and Post-reconstructive Plastic Surgery
Another area of education is skin inspection.
Physical therapy is involved in the initial sit and
much of the sitting program. The physical thera-
pist has a unique opportunity to practice the
education given by nursing and occupational
therapy regarding inspecting the patient’s skin
before and after sitting. This gives valuable
information about the patient’s seating system
but also demonstrates the importance of this
activity to the patient. This education should
include the stages of a pressure sore. The patient
should be able to identify a stage I and II pres-
sure sore. In addition, the patient needs to know
what to do should he/she identify a pressure
sore. He/she needs to be educated with handouts
and visual aids what positions are safe for him/
her to resume while trying to heal the sore so
that it does not get larger or become a greater
stage. The prone position is demonstrated and
practiced. If an individual can attain the prone
position, the staff recommends this position for
sleeping as this alleviates all pressure from the
sitting area. If an individual is proning to heal a
pressure sore and is not sitting, it is important
that they know how to do range of motion exer-
cises of the lower extremities to ensure they do
not develop extension contractures of the hips or
knees.
Other areas of education that physical therapy
can reinforce involve the factors that may increase
an individual’s risk for reoccurrence. Smoking
can increase the chance of recurrence by greater
than ten times. Lifestyle activities that alter a per-
son’s judgment such as excessive alcohol or drug
use should be discussed. This is important as
these activities can lead to decreased pressure
relief, over-sitting, or inadequate maintenance of
equipment. Incontinence is an area generally
managed by nursing; however, physical therapy
can generally identify by inspection of equip-
ment or when assisting an individual in and out of
bed if incontinence is an issue. It is important that
the patient know that sitting in bowel and bladder
waste can cause a great deal of damage to the
skin and if an accident should occur he/she
should clean and dry his/her skin as soon as
possible. If a bowel or bladder accident occurs
during a physical therapy activity, it is important
to reinforce this by assisting the patient to bed for
appropriate cleanup as soon as possible. Assisting
the individual with developing a plan to maintain
himself/herself when in the community can be
helpful in his/her transition back to the
community.
The surgeon limits the amount of time an indi-
vidual can sit to 6 h for the first month following
a myocutaneous flap surgery. It is important that
the patient fully understands that his/her surgical
area is still healing and that over-sitting can cause
an opening of the newly healing site. In addition,
it is important that the patient understand that the
more he/she sits the greater his/her risk of devel-
oping a pressure sore and that it will take more
than a year for his/her surgical area to be at full
strength. Setting up scenarios and role-playing
ideas for solving them can be very helpful in the
safe transition back to the community. For exam-
ple, one of our patients was going to school and
needed to take a full load to finish his degree. We
discussed ways to set up his schedule to provide
time to get off of his sitting surface, such as split-
ting his classes so he had a break in the middle
that he could lay down. We discussed using the
health clinic bed to lay down when he had breaks.
We discussed a plan, should he get a small sore,
what he could do to still get his work and neces-
sary education materials should he need to stay
home from school to allow his wound to heal.
This reduced the need for him to sit on a sore. He
was able to identify individuals in each class that
he could rely on to get information and made
contact with the disabled services on campus.
Practicing the potential problems before they
arise can give the patient more possible solutions
should the problem occur.
Lastly, education on the patient’s equipment is
of great importance. If the patient understands
how and why the equipment is set up, it is more
likely to be used correctly. The visual feedback
provided by the computerized pressure mapping
system is a great tool for seeing how the equip-
ment especially cushions used inappropriately or
in the wrong position can affect pressure.
Knowing how to maintain the correct air in the
cushion or what to do if they experience a leak of
the gel or air in their cushion is very important
16.11 Patient with Above- or Below-Knee Amputation
prior to the situation occurring. Maintaining the
wheelchair in good condition so they are not
stranded with flat tires can prevent over-sitting.
Performing poor transfers because the brakes do
not work properly can be prevented by general
maintenance and replacing tires as they become
worn. Sitting with poor posture secondary to
worn or torn upholstery can be prevented with
awareness so that problems can be prevented
before they occur. The more information the
patient has, the more power he/she has to make
better decisions regarding his/her health and
well-being.
16.10 Sensate Patients
There are several populations of patients that
deserve special consideration. The first to be dis-
cussed is the patient with sensation that requires
a reconstructive surgery. This is not a common
occurrence as sensation is a protective mecha-
nism of the skin and usually individuals with
intact sensation do not get pressure sores. The
more common patient may have incomplete or
patches of intact sensation that can make cush-
ion selection more challenging. The sensate
patient that sits for upright mobility may not tol-
erate some of the same pressure-reducing cush-
ions as an individual without sensation. Many
individuals with sensation find foam cushions
with cutouts difficult to tolerate for prolonged
periods of time. This may be due to the increase
pressure over non-bony areas, or it may be the
sensation of sitting in a hole that makes the foam
cushions a less desirable choice for the sensate
patient. Many gel or aqueous cushion selections
have been labeled as less comfortable. A fre-
quent complaint with this cushion selection is
that it feels warm or hot and the patient com-
plains that it increases moisture in this area.
Many individuals with sensation are more com-
fortable on air cushion such as the Roho. This
cushion allows for excellent pressure distribu-
tion, can wick heat and moisture away from the
body, and comfortably support the sitting sur-
face. In addition, if the individual has limited
mobility, small movements of the trunk can shift
265
air and sitting position enough to improve dis-
comfort in an area. Not all individuals with intact
sensation who sit need pressure-reducing cush-
ion; however, if they have a history of a pressure
sore that required surgical closure, they are at
high risk for a reoccurrence and should be on a
pressure-reducing cushion.
16.11 Patient with Above- or
Below-Knee Amputation
Another population that requires special consid-
erations is the individual with amputations. The
individual with a spinal cord injury and a lower
extremity amputation may have a more challeng-
ing time with transfers. Many individuals with
spinal injuries place their feet on the ground to
transfer; this increases their base of support and
aids in balance. An amputation below knee can
affect a person’s balance and ability to transfer.
Increase practice may be necessary to regain
independent transfers. If the individual has an
above-knee amputation and has paraplegia above
L2, then he/she will have increased difficulty
managing the leg. The residual limb may fall into
extension and block the person as he/she is trying
to transfer. This can lead to shearing or damage to
the residual limb or the patient landing on the
wheel shearing the sitting area. Teaching com-
pensatory techniques, like placing the leg onto
the surface to be transferred to prior to the trans-
fer or transferring away from amputation, may be
necessary. If the residual limb is shortened, it can
also reduce the sitting surface area and provide
less area for distribution of pressure. This may
affect the distribution of pressure and increase
the pressure over the ischial tuberosities on the
involved side. Although many of the patients may
not be ambulatory, losing a limb could cause
depression and self-image issues. If symptoms
are observed, it is important to refer the patient to
psychology or social services for treatment.
Many insurance companies will not pay for cos-
metic prosthetic limbs. Working with occupa-
tional therapy, we have fabricated cosmetic limbs
that have for individuals to use at discharge. The
patients are shown how to don and doff the limbs
266 16 Physical Therapy Evaluation and Rehabilitation: Pre- and Post-reconstructive Plastic Surgery
with occupational therapy and transfer with
physical therapy.
16.12 Patients with Hip
Disarticulation
If the individual has a hip disarticulation, this
greatly reduces the sitting surface. In addition,
some cushions (such as the Jay 2) use the greater
trochanter area to suspend the ischial tuberosities
and reduce pressure over this area. Figure 16.14
shows a method of using foam to decrease the
well size so that the ischial tuberosities are sus-
pended using the individual’s pelvis and adipose
tissue when the greater trochanters are not pres-
ent for adequate suspension of the ischia.
The hip disarticulation would remove this
bony structure and could increase the pressure
over the ischium on the affected side. It is
important with this population that a good cush-
ion evaluation is performed. The individual
should be reassessed using the computerized
pressure mapping system after sitting at least an
hour to identify if the cushion is maintaining the
patient’s sitting position and if he/she does not
bottom through the cushion. If the patient is
Fig. 16.14 Jay 2 deep contour cushion that has been mod-
ified with foam to decrease the well size so that the ischial
tuberosity do not bottom through the gel to firm foam
using a foam cushion with a cutout, it is impor-
tant that he/she know how to identify when he/
she is sitting appropriately within the cutout so
that he/she is not bottoming through to the foam
below or that his/her noninvolved ischial tuber-
osities are seated in the cutout. Air cushions can
provide good pressure distribution, but the
patient may find them even more of a challenge
to balance and transfer from an air cushion
without the presence of their lower extremity.
The other area to consider with new amputa-
tions is the psychosocial aspect of losing a limb.
Although many of the patients may not be
ambulatory, losing a limb could cause depres-
sion and self-image issues. If symptoms are
observed, it is important to refer the patient to
psychology or social services for treatment.
Many insurance companies will not pay for cos-
metic prosthetic limbs. Working with occupa-
tional therapy, we have fabricated cosmetic
limbs that have for individuals to use at dis-
charge. The patients are shown how to don and
doff the limbs with occupational therapy and
transfer with physical therapy.
16.13 Patients with Girdlestone
Procedure
A population with similar seating concerns as the
individual with a hip disarticulation is the patient
that has a portion of his/her hip joint removed.
Most often this involves the femoral head and
part of the neck including the greater trochanters.
As mentioned above, certain cushions may not be
as effective, as biomechanically they rely on the
greater trochanter to assist in the suspension of
the ischial tuberosities. These cushions should be
used only after careful evaluation. In addition,
the posterior aspect of the distal femur can now
become a weight-bearing bony surface. It is
important to identify this bony surface when
evaluating the cushion and determine if it is get-
ting proper pressure distribution. Cushions like
the Jay 2 and Invacare cushions that have a pre-
fabricated well may need to be modified as the
posterior distal femur may contact the anterior
portion of the well (Figs. 16.13 and 16.14). This
16.15 Ambulatory Patients
area typically has less pressure-distributing mate-
rial and can create increased pressure with
improper or prolonged sitting. Lastly the patient
with a Girdlestone procedure may have difficulty
with transfer and can have increase movement of
the femur downwardly when lifting his/her but-
tocks off of the sitting surface. There have been
incidents of pressure ulcer development from the
femur bumping the wheel during transfers or get-
ting caught between the wheel and the transfer
surface. The patient will need to lift higher to
clear his buttocks during transfers. Adequate
transfer training to a variety of surfaces is impor-
tant to prepare the patient for discharge out of the
hospital.
16.14 Patients with Bilateral Hip
Disarticulation
Patients who have had bilateral hip disarticulation
pose a challenge for functional retraining and
seating systems. With the loss of both lower
extremities, there is substantially less pressure
distribution, thus more pressure over the sitting
surface. It is common that these patients may have
had several surgeries before amputation is
required, so their skin in this area will have more
scar tissue. Scar tissue is weaker with less blood
supply than intact skin; therefore, it will be at
greater risk for skin breakdown. The Roho cush-
ion may be best to accommodate this patient pop-
ulation; however, balance can be greatly affected
by the loss of the lower extremities. Physical ther-
apy may need to concentrate more on balance
activities prior to transfer training and discharge.
There has been some success with custom-fitted
prosthetic seating systems, thoracic suspension
orthosis. These seating systems are fit to a patient
so that the rib cage is used to suspend the sitting
area (similar to the mechanics of the socket of the
above-knee prosthetic). The bony structures are
suspended without contact to any surface. These
should only be made by individuals who have
experience in this area. These seating systems are
very expensive and will need constant assessment
as a patient may have changes in weight that can
affect the fit of the prosthetic.
267
16.15 Ambulatory Patients
Lastly, the patient that is ambulatory requires spe-
cial consideration. It is not common for someone
who is ambulatory to require myocutaneous flap
surgery on his/her buttock area; it is more com-
monly done over his/her leg or foot. We will dis-
cuss the issues with each group. It is important to
have performed a gait evaluation prior to surgery
if possible. This allows the therapist to identify
any gait deviations, muscle weakness, or compen-
satory techniques used during gait. In addition, it
allows the therapist to evaluate the patient’s brac-
ing and adaptive equipment prior to surgery. This
will be important as any problems with the equip-
ment or bracing can be addressed during the
recovery time. Any gait deviations or muscle
weakness should be discussed with the surgeon
prior to surgery during pre-op conference. After
surgery the therapist should know what muscles
were used and what muscles remain for functional
ambulation. The therapist should begin strength-
ening all muscles as soon as the surgeon has
cleared this activity. Generally, an individual that
is ambulatory can begin a walking program prior
to a sitting program and may not require the same
length of time than the individual who requires a
wheelchair for upright mobility. If the patient was
ambulating with an assistive device and bracing, a
few other issues may be involved. It is important
to ensure that the brace is not going to place pres-
sure over the surgical sight as may be the case
with KAFO (knee-ankle-foot orthosis) or HKAFO
(hip-knee-ankle-foot orthosis). Should this occur,
the surgeon may require a longer recovery period
prior to ambulation. In addition, it is important
that the patient be stable and not a high risk for
falling on the surgical site.
It is more common to develop pressure sore
over the foot or leg in individuals who ambulate
for mobility. This is common in individuals who
have sensory and/or motor changes in the lower
extremity. Individuals that have injuries below
L3 may have muscle wasting in the lower legs as
well as absent or impaired sensation. This makes
them at increased risk for pressure ulcers. Many
of these individuals also use bracing. It is impor-
tant that your patient knows when his/her braces
268 16 Physical Therapy Evaluation and Rehabilitation: Pre- and Post-reconstructive Plastic Surgery
and equipment are working and fitting properly.
If a patient has a flap to his/her foot, he/she may
be required to be non-weight bearing for a greater
period of time in order to have adequate healing.
It is important that they are evaluated for appro-
priate footwear and possible orthotic inserts that
reduce and distribute pressure. It is important that
the patient be evaluated for alternative mobility
such as a wheelchair if ambulation is limited after
discharge. If the patient has had a flap over his/
her buttock area and will be using a wheelchair
greater than 4 h a day, he/she should also be eval-
uated for a pressure-reducing cushion.
There are many factors that can increase an
individual’s risk for reoccurrence of pressure
sores. The more of these factors that can be
addressed through education, equipment, or prac-
tice, the greater the likelihood that the individual
will make a successful transition back into the
community. It is important that the entire team be
involved in this process.
Case Study
The following case study is an example of an
interdisciplinary approach.
J.M. was a 49-year-old male with L1 complete
paraplegia secondary to a fall 15 years ago. He
was admitted for surgical closure of a stage IV
pressure sore over his greater trochanter area. He
was independent in all aspects of his daily care,
transfers, and wheelchair mobility. He has no
movement below his waist and absent sensation
below his hip bones. He has no limitations in pas-
sive range of motion of his lower extremities. He
has adequate hamstring and external rotation
range for dressing. He uses a Roho cushion that is
well adjusted to his buttocks. The sitting evalua-
tion shows a slight pelvic obliquity to his right;
this is well accommodated for on his Roho cush-
ion. At this point we needed to look at other areas
that J.M. was sitting as it was less likely a result
of his current seating system. We were able to
establish that J.M. went to the gym daily but used
his cushion on the equipment. In addition, he
used his cushion in his car on this way to and
from work. He was able to transfer in a controlled
fashion without trauma to surgical area. J.M. had
already limited many factors that can lead to
pressure sores. Occupational therapy did a review
of his day and identified that J.M. required greater
than 90 min to complete his bowel program. We
pressure mapped J.M. on the padded commode
seat he used, and he had significantly high pres-
sures over both greater trochanters with the right
having a greater pressure area secondary to the
obliquity. A custom commode seat was fabri-
cated with foam and cutouts to decrease the pres-
sure over the greater trochanters. J.M. worked
with nursing to improve his bowel program by
changing medication and his suppository. In
addition to the above, J.M. was instructed in pres-
sure relief when on the commode every 15 min.
During the hospitalization, he was able to reduce
his bowel program to just under an hour. He had
a successful discharge and reintegration into his
community. He has remained pressure sore free
for more than 5 years.
Physical therapy can play a large role in pres-
sure ulcer rehabilitation. The knowledge of move-
ment and the mechanics of sitting can be useful in
setting up a patient to be successful at discharge.
Education and empowering our patients to take
responsibility for themselves and their skin is
another role physical therapy has in post myocu-
taneous flap rehabilitation. The more information
that we can provide, the more likely our patients
are to understand what will prevent a reoccur-
rence of a pressure sore. Practice in a structured
environment will give them more tools to succeed
in the less structured environment of life.
References
1. Pownell PH (1995) Pressure sores. SRPS 7(39):1–27
2. Consortium for Spinal Cord Medicine (2000) Pressure
ulcer prevention and treatment following spinal cord
injury: a clinical practice guideline for health-care profes-
sionals. Paralyzed Veterans of America, Washington, DC
3. Rogers JE (1973) Annual report of progress tissue
trauma group. Rancho Los Amigos Hospital, p 71–77
4. Peterson MJ, Adkins HV (1982) Measurement and
redistribution of excessive pressures during wheelchair
sitting: a clinical report. Phys Ther 62(7):990–994
5. Van Dijk D, Aufedemkampe G, van Langeveld S, The
QA (1999) Pressure measurement system: an accu-
racy and reliability study. Spinal Cord 37:123–128
6. Brienza DM, Karg PE, Geyer MJ, Kelsey S, Trefler E
(2001) The relationship between pressure ulcer
References
incidence and buttock-seat cushion interface pressure
in the at-risk elderly wheelchair users. Arch Phys Med
Rehabil 82:529–533
7. Baker LL, Rubayi S, Villar F, Demuth SK (1996)
Effect of electrical stimulation waveform on healing
of ulcers in human beings with spinal cord injury.
Wound Repair Regen 4(1):21–28
8. Coggrave MJ, Rose LS (2003) A specialist seating
assessment clinic: changing pressure relief practice.
Spinal Cord 41:692–695
269
9. Burns SP, Betz KL (1999) Seating pressures with
conventional and dynamic wheelchair cushions in tet-
raplegia. Arch Phys Med Rehabil 80:566–571
10. Drummond D, Breed AL, Narechania R (1985)
Relationship of spine deformity and pelvic obliquity
on sitting pressure distributions and decubitus ulcer-
ation. J Pediatr Orthop 5:396–402
11. Bar CA (1991) Evaluation of cushions using dynamic
pressure measurement. Prosthet Orthot Int 15:
232–240
 Prevention of Pressure Ulcer
Alicia Mcleland
17.1 Introduction
The number of hospital patients who develop
pressure sores has risen by 63 % over the last
10 years, and nearly 60,000 deaths occur annually
from hospital-acquired pressure ulcers. It has been
estimated that it costs between 1.5 and 5.0 billion
dollars a year to manage pressure ulcers in the
United States [1]. In the United States in October
of 2008, the Centers for Medicare and Medicaid
Services announced that it will stop reimbursing
hospitals for treating reasonably preventable con-
ditions—pressure ulcers are among these condi-
tions. That announcement has put hospitals into
a state of anxiety, and with good reason, up until
now, the majority of hospitals focus on the treat-
ment of pressure ulcers, rather than preventing
them. Section 5001(c) of the DRA required the
Secretary to identify, by October 1, 2007, at least
two conditions for which hospitals under the IPPS
(Inpatient Prospective Payment System) would
not receive additional payment beginning on
October 1, 2008, if the condition was not present
on admission. The conditions (a) must be of high
cost or high volume or both, (b) must result in the
assignment of a case to a DRG that has a higher
payment when present as a secondary diagnosis,
Alicia Mcleland, MPT, PT, NCS
Rancho Los Amigos National Rehabilitation Center,
Downey, CA, USA
Kaiser Permanente, Oakland, CA, USA
e-mail: amclelland2020@att.net
S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers,
DOI 10.1007/978-3-662-45358-2_17, © Springer-Verlag Berlin Heidelberg 2015
17
and (c) could reasonably have been prevented
through the application of evidence-based guide-
lines. For discharges occurring on or after October
1, 2008, hospitals would not receive additional
payment for cases in which one of the selected
HACs was not present on admission. That is, the
case would be paid as though the secondary diag-
nosis was not present. Pressure ulcers are one of
the hospital-acquired complications that CMS
deems to be preventable, and as a result, preven-
tion is on the forefront of all hospital policies.
Pressure ulcers can affect any patient that has lim-
ited mobility due to illness or disease. There are
some patient populations that are at greater risk
than others. Individuals with spinal cord injuries
have a high incidence of pressure ulcer develop-
ment. It has been estimated that 25 % of individu-
als will develop a pressure ulcer in a year, with
85 % having at least one pressure ulcer in his/her
lifetime [1]. Individuals aging with spinal cord
injuries will have increased risk as age-related
changes affect the strength and elasticity of the
skin. Niazi et al. found that the recurrence rate
for patients with spinal cord injuries who develop
pressure ulcers was 35 % [1]. The treatment of
pressure ulcers is approximately 25 % of the cost
of caring for individuals with spinal cord injury.
The cost of prevention is approximately 10 % the
cost of treatment [1, 2]. Another population at
greater risk for pressure ulcer development is the
elderly especially those in long-term care facili-
ties. Twenty-five to thirty-five percent of elderly
patients in these facilities develop pressure ulcers
271
272
during their length of stay. Prevention is the key
to improving these patients’ quality of life and
reduces the burden that pressure ulcers place on
our healthcare systems.
It is agreed that the development of pressure
ulcers is multifactorial and that simply reducing
pressure will not prevent pressure ulcers. This
chapter will discuss some of the risk factors com-
monly identified in the literature: pressure man-
agement, bowel and bladder incontinence, medical
comorbidities, and nutrition and psychosocial
issues. Prevention not only involves identifying
risk factors associated with pressure ulcer develop-
ment but also educating the patient about his/her
risk factors. It is a good practice to identify the way
your patient learns (i.e., is he/she a visual learner
or auditory, does he/she need practice or demon-
stration, can he/she carry over to other areas, or
does each environment need to be practiced?) and
provide that learning environment. This may lead
to better understanding and improved ability to
modify behavior when necessary in the commu-
nity. It is important to assist the patient in identify-
ing his/her risk factors and to develop a regimen of
behavior that will work in that individual’s life to
prevent future pressure ulcers [2]. It has been a
common practice to instruct a patient what is nec-
essary for them to do without looking at whether it
is feasible in his/her environment [3].
17.2 Managing Pressure on
the Skin
Pressure management has been the source of
much research in the area of pressure ulcers. It is
important that peak pressures over bony areas are
low, that good pressure distribution is achieved
regardless of the position of the patient, and that
the individual is performing pressure relief on a
routine basis. In assessing pressure in a patients’
life, it is necessary to look at all environments
that the patient functions. Where does the patient
sleep? Is he/she able to turn herself/himself every
2 h? Does the surface provide adequate support
or does it bottom out? Asking detailed questions
about this is important. It may be that most of the
time the patient sleeps on his/her water bed at
home and is able to sleep through the night with-
17 Prevention of Pressure Ulcer
Fig. 17.1 A computerized pressure mapping of an indi-
vidual sitting on a Jay 2 cushion. The dark blue indicates
areas of low pressure (<10 mmHg). The red indicates
areas of high pressure (>100 mmHg)
out turning; however, once a month he/she visits
his/her parents and sleeps on the couch. It is
important for him/her to understand that this one
occurrence without proper consideration of pres-
sure relief or distribution can lead to a pressure
ulcer. Educating the patient on peak pressure and
pressure distribution should always be empha-
sized and stressed to the patient (Fig. 17.1).
Identifying potential risks already in his/her
environment and then brainstorming solutions
with the patient will increase his ability to iden-
tify other risks that he/she may encounter.
17.3 Special Beds and Positioning
If an individual has good skin integrity, a sup-
portive mattress should be sufficient with proper
turning for pressure relief. For those individuals
who are not able to turn themselves, it is neces-
sary to look at other alternatives. One alternative
is prone positioning (Fig. 17.2).
A patient can lay on the stomach with pillows
positioned under his/her chest, hips, thighs, and
anterior lower leg to bridge the hip bone, knee,
and dorsum of the foot. In order to sleep this way,
most individuals will need to be able to freely
move his/her head so that breathing is easy. Most
individuals with paraplegia or lower level tetra-
plegia can be in a prone position. It may be impor-
tant to show the patient how to set up his/her
pillows, and some patients may need to work on
progressing to a full night’s sleep in this position.
A higher level of tetraplegia with weakened neck
muscles or individuals with fusions and limited
range of motion will have difficulty in this
17.3 Special Beds and Positioning
Fig. 17.2 A person in prone position, pillows placed under the chest and thighs to eliminate pressure over anterior iliac
crest, the thighs and lower leg to eliminate pressure on the knees, and dorsum of the foot to eliminate pressure on toes
position. For these individuals, alternative mat-
tress options will need to be explored. Water beds
that are appropriately filled can reduce peak pres-
sure and provide good pressure distribution; it is
important that the water level be appropriate as
too low can lead to bottom to firm surface and too
high could increase peak pressure and lead to
ulcers [4]. It is also important with the water bed
to assess that the individual can transfer from it
without shear or trauma to the skin during trans-
fer. Low air loss mattress will provide for good
pressure distribution and may allow for longer
time before the patient needs to be repositioned;
however, they do not eliminate the need for turn-
ing. For the individual that cannot position in
prone and does not have the ability to turn him-
self/herself, a turning or alternating air mattress
may be a better option. The Volkner System® has
been tested in our facility and has been an effec-
tive product for home use to assist our clients who
need a turning mattress at home (Fig. 17.3).
It is important for the patient to be able to try
this mattress to ensure that they can sleep on it
and that the mattress provides effective pressure
through the night. Additionally, an individual that
develops a pressure ulcer may need to use an air
mattress to assist with healing if prone position-
ing is not an option.
As an individual is more at risk for pressure
ulcers after an initial occurrence, it is important
that the medical staff take the necessary steps to
prevent pressure ulcers when patients are in acute
care and long-term care settings. There has been
an increased awareness of pressure ulcers in the
acute care setting with greater emphasis on pre-
vention in recent years. Most hospitals have
guidelines in place to assess individuals at risk
for pressure ulcers. Once an individual at risk has
been identified, it is important that that individual
273
Fig. 17.3 The Volkner Alpha® mattress overlay for
home use. It alternates a person’s position over time to
reduce prolonged pressure over bony areas
be placed on a turning schedule (at least every
2 h), that he/she is not bowel or bladder inconti-
nent, and if so, that prompt hygiene is performed
to prevent skin maceration and breakdown. There
are a variety of beds that can be used in this set-
ting to assist with the prevention of pressure
ulcer. The standard mattress will produce greater
than 30 mmHg over the bony areas in supine,
specifically the sacrum/coccygeal area, heels,
and scapula. A low air loss bed will provide a
reduction of pressure and improved body contact
to improve pressure distribution (Fig. 17.4).
There are several different manufacturers of
low air loss beds, but essentially the bed uses air
as flotation device to provide full contact through-
out the body surface and reduced pressure over
peak areas; the air system can also be monitored
for temperature control. Ryan et al. found that the
low air loss mattress greatly reduced pressure
over all bony surfaces in an individual in a supine
position, with the exception of the occiput. The
pressure over the occiput was still much lower
274
Fig. 17.4 Flexicare Eclipse® from Hill-Rom®. This is
an example of low air loss mattress used at the 4 weeks
post flap wound care in the pressure ulcer management
unit. It reduces peak pressure allowing a patient to stay in
one position longer prior to being turned. This reduction
reduces risk but a patient will still need periodic turning to
eliminate risk for pressure ulcer
than the standard bed but had higher pressures
than other bony surfaces [4].
The use of the turning mattress is becoming
more common in hospitals and long-term care
facilities. The Volkner Alpha® (Fig. 17.3) is an
example of a turning mattress that can be used at
home. The turning mattress will alternate pres-
sure from one side to the other, effectively turn-
ing the individual from side to side. It is important
to monitor the individual’s position to ensure that
he/she is maintaining position at the center of
the bed. The rotation cycle varies from different
manufacturers and can be programmed in some.
The turning mattress is especially important for
the acute care setting where pain or severe medi-
cal complications may limit the ability to turn
a patient effectively, for example, a tetraplegic
patient on a mechanical ventilator. A turning mat-
tress may also be a solution to managing a bariat-
ric patient to reduce the risk of injury to the staff.
17.4 Sitting Pressure
Management
A person that uses a wheelchair for mobility will
need to have his/her seating system evaluated. The
individual should be educated on the importance of
each piece of equipment from the upholstery to the
footrest to the cushion. He/she should be educated
on the importance of sitting alignment on pressure
17 Prevention of Pressure Ulcer
distribution and assisted in identifying other areas
that he/she may sit. Does he/she transfer to the
couch for family time or to watch the game? Does
the couch bottom out when he/she sits on it? Is he/
she doing pressure relief when sitting? What is the
frequency of his/her pressure relief? Does it change
when he/she is sitting on different surfaces? In
every place that he/she sits, does he/she need to do
pressure relief? If the surface is harder than his/her
cushion (i.e., padded toilet seat), should he/she do
pressure relief more frequently? As part of our
rehabilitation program, the occupational and phys-
ical therapists discuss a patient’s typical and atypi-
cal day. We go on outings and have discussions to
assist the patient in identifying their own risk fac-
tors and ways to reduce them.
Pressure relief (eliminating the pressure over
bony areas) is a component of pressure manage-
ment that needs to be addressed routinely. It is
important that the patient understands that there
is always a need to do pressure relief and give
several options on how to perform pressure
reliefs in a variety of settings. Pressure relief in
sitting needs to be done every 15–30 min [2, 4].
The recommendation from the rehabilitation
team following reconstructive surgery is every
15 min when sitting in the prescribed seating sys-
tem. Sitting on a surface that is not their pre-
scribed seating system should warrant even more
frequent pressure relief and should only be done
when necessary and for short period of time. For
example, when sitting on the toilet to complete
bowel program, the toilet seat should be padded,
but this will not distribute pressure as well as his/
her own cushion; therefore, pressure relief should
be done more frequently to prevent pressure
ulcers. Whenever possible an individual should
sit on his/her own cushion, for example, if he/she
transfers to the couch to sit with his/her family,
he/she should transfer his/her cushion to the
couch and sit on it or into the car seat. Pressure
relief should be done in all of these activities.
It may be necessary for individuals to have audi-
tory (alarm clock or watch) or visual reminders
for pressure relief. In our rehabilitation program,
it was common for individuals to overestimate
their ability to keep track of time, especially when
engaged in social activities. Making them aware of
their inability to track time assisted in their ability
17.4 Sitting Pressure Management 275

to identify activities that would put them at greater
risk for not performing their pressure reliefs and
to make better choices to prevent future pressure
ulcers. Many of our patients chose to use watches
that had countdown timers set at 15 min to assist in
reminding them to do their pressure relief. Some
would modify the positioning of the watch to the
wheelchair if it interfered with wheelchair propul-
sion or when transferring, while others had sought
out other products such as watches that vibrated
so that the alarm would notify them without inter-
rupting their class or work environment. There are
several methods of pressure relief in seated posi-
tion (Fig. 17.5a–c). The more traditional among
individuals with paraplegia is the wheelchair
push-up. An individual can also lean forward far
enough to elevate his/her ischial tuberosities off
the sitting surface allowing for good blood flow or
lean side to side alleviating pressure on one ischial
and greater trochanter at a time.
Educating an individual of the alternative
pressure relief is important as it will allow him/
her options of pressure relief should the social
situation he/she is in limit his/her ability to do a

a b

Fig. 17.5 (a–c) Illustrations of push-up pressure relief on the upper left, side lean pressure relief on the right, and
forward lean pressure relief on the lower left
276
a b
Fig. 17.6 (a, b) Are examples of power-aided pressure
relief. In the left is the tilt-in-space and in the right hand
side is the power recline. Both assist in reducing pressure
certain form of pressure relief. Regardless of the
method, pressure relief should be done at least
every 15 min. If a person cannot perform pres-
sure relief in the seated position, it may be neces-
sary for him/her to have a power seating system
to reduce risk for pressure ulcer reoccurrence.
The power seating system would need to be eval-
uated to meet the individual’s needs; the most
common seating system used for pressure relief
is a power tilt system. The tilt-in-space
(Fig. 17.6a, b) maintains the individual’s sitting
position while shifting the weight from the ischial
tuberosities to the back area. Although not all
pressure is alleviated, it is enough to allow for
adequate blood flow to skin. The tilt-in-space
must tilt back enough to shift pressure onto the
back of the individual for adequate circulation.
Another option for pressure relief is the
power recliner. This system reclines the back
and elevates the legs to shift pressure off of the
ischia to the back and thighs. The recliner may
require that the patient reposition after pressure
relief, as the back moving back to the upright
position can sometimes slide an individual for-
ward in the seating system. The new technology
has worked to reduce the shear component of
the recliner and reduce the forward push of the
individual, but the patient should be evaluated in
seated position after a recline pressure relief to
ensure he/she is not sitting with the sacrum in
posterior tilt as this could increase pressure on
the sacrum and coccyx.
17 Prevention of Pressure Ulcer
enough to allow adequate blood flow and should be per-
formed as frequently as the wheelchair push-up or other
forms of pressure relief
17.5 Bowel and Bladder Function
Urinary tract dysfunctions are common issues in
individuals with spinal cord injury. Urinary incon-
tinence can have detrimental effects to the skin and
to pressure ulcer development. Urinary leakage
can lead to maceration and erosion of the skin.
Managing urinary incontinence is an important
part of prevention in individuals with spinal cord
injury [5]. For an individual with a pressure ulcer
or a history of pressure ulcers, it may be necessary
to have an interdisciplinary approach to prevention
that includes the urologist, plastic surgeon, nurses,
and the patient. It is important that whatever the
approach to bladder management, the patient
understands and is able to follow through with the
plan of care. Education is a key element to ensure
future compliance with urologic management.
Bowel incontinence is of equal or greater impor-
tance. Individuals with bowel incontinence have a
greater risk for pressure ulcers [6]. The motility of
the bowel is affected in spinal cord injury, and it is
imperative that an individual with spinal cord
injury have a good bowel program. The individual
should be educated on the technique, the expected
results, and the importance of pressure relief when
performing bowel program on a padded toilet seat.
The individual may need to change his/her bowel
program as he/she ages, and he/she should be edu-
cated on resources that can assist him/her should
he/she identify problems with his/her bowel pro-
gram. There was an individual that was seen for
17.7 Nutrition
reconstructive surgery to heal a stage IV ulcer over
his/her trochanter area. This individual was requir-
ing nearly 90 min to complete his/her bowel pro-
gram. This was a longer than necessary amount of
time on a padded toilet seat and may have contrib-
uted to his/her pressure ulcer. Through assistance
with nurses, the patient was able to change the
suppository he/she was using and with some posi-
tioning techniques was able to complete his/her
bowel program in less than 30 min. It is also
important that the patient understand the impor-
tance of cleaning his/her skin immediately should
an accident occur. Salzberg et al. found that indi-
viduals with incontinence who were able to keep
themselves clean were less likely to have pressure
ulcers. Another example of reduced occurrence
following improved bowel continence was a
patient of the pressure ulcer management service
that had frequent admissions, four in 2 years. On
his/her last admission, his/her ulcer was close to
the anus and it was recommended that he/she have
a colostomy in order to close his/her ulcer surgi-
cally. The patient was initially resistant to the
colostomy but agreed when he/she learned he/she
could have it reversed 6 months after he/she was
healed. At his/her 6-month follow-up, the patient
was still pressure ulcer free and felt that the colos-
tomy added to his/her quality of life as he/she was
not having bowel accidents that limited his/her
social activities.
17.6 Contributing Factors to
Pressure on the Skin
There are several comorbidities that can increase
the risk of reoccurrence. It has been found that
individuals who smoke and have had a pressure
ulcer are 50 % more likely to have a recurrence
than individuals who do not smoke. It was deter-
mined that the longer a person had been smok-
ing, the greater the risk for recurrence, as much as
60 % in those who smoked for 30 years or more
[1]. In addition, smokers had a greater incidence
of ulcers involving the heels. It is known that
smoking can lead to cardiovascular and periph-
eral vascular disease. Research done in aging with
spinal cord injury suggests that individuals with
277
spinal cord injury have a higher incidence and
an earlier age of onset for cardiovascular disease
compared to their non-injured cohorts. Niazi et al.
found that individuals with cardiovascular disease
were 1.8 times more likely to have a recurrence
of pressure ulcer [1]. Diabetes which also has an
effect on cardiovascular health was also found to
have a higher rate of recurrence. Although diabe-
tes and cardiovascular disease may not be cured,
it is important to take necessary steps to manage
these comorbidities to minimize the effects they
can have on the patient’s skin health. Patients
should be educated on these risk factors and how
they can minimize the effects of these health
issues. Smoking cessation counseling needs to
be made available and resources given to assist
when a patient is discharged into the community.
The patient’s education should include how to
improve their cardiovascular health through diet
and exercise. Exercise programs can be developed
during an individual’s rehabilitation program.
Providing community resources available to them
to continue this exercise program can assist in the
successful transition into the community. Exercise
programs should encompass both strength train-
ing and endurance training. Individuals who are
active and exercise regularly have less incidence
of pressure ulcer development [4]. Other factors,
e.g., severe spasticity, can cause shearing forces
resulting in skin breakdown in certain areas of
the body. In addition, its effect on the hip joint is
rotation, dislocation, and subluxation which can
cause deformity of the pelvis and increase pres-
sure on certain areas and pressure ulcer develop-
ment; therefore, spasticity should be controlled
accordingly.
17.7 Nutrition
Nutrition is a key component to everyone’s health
and well-being. This is especially true for indi-
viduals with spinal cord injury. Individuals who
develop pressure ulcers have a significantly lower
calorie and protein intake [4]. There may be many
factors that can lead to decreased caloric intake,
and a thorough assessment should be done to
identify factors influencing nutritional health.
278
Nutrition also affects other areas that can have an
impact on skin health. A good nutritional regimen
is important in establishing an effective bowel
program including proper hydration and a bal-
anced diet with fruits and vegetables. In addition,
a balanced diet low in salt is important for cardio-
vascular health and a low-sugar diet is recom-
mended in managing diabetes. The calories
needed for the average individual with spinal cord
injury will be less than his/her ambulatory coun-
terpart. The decrease in activity level will decrease
the caloric demands, and too much intake can lead
to obesity. Obesity can decrease mobility, add
stress to overused shoulder and wrist joints, and
increase risk for pressure ulcer development.
However, when an individual gets an ulcer, he/she
will need to increase her caloric intake to assist in
repairing the damaged skin. Protein is essential
for tissue growth and repair. Adequate hydration
is also an important part of skin health.
Dehydration can lead to dry skin; dry skin is less
flexible and more prone to cracks and breakdown
[4]. Education is a key to good nutritional health.
The patient should understand how the food he/
she eats will be used by his/her body and skin. It
is important to assess what limitations to good
nutrition the patient may have and try to find solu-
tions to these barriers. Is the patient able to do his/
her own shopping or food prep? What options
does he/she have to prepare his/her food? What
resources does he/she have available to him/her?
Assisting him/her with a plan to get more protein
or calories should an ulcer occur or he/she need to
limit his/her sitting. An important member of the
pressure ulcer management interdisciplinary team
is the dietician. Their assessments and education
will be a valuable part of the patient education and
necessary for a successful transition back to the
community. Losing excessive weight in this group
of patients will lead to sliding of the loose tissue
over the bone and formation of acquired bursa and
eventually lead to skin breakdown.
17.8 Psychosocial Issues
Major depression can lead to recurrence of pres-
sure ulcers. Depression has been associated with
inactivity, self-neglect, and poor compliance.
17 Prevention of Pressure Ulcer
These three behaviors could definitely lead to the
recurrence of pressure ulcer. It is important that
psychological services be part of the interdisci-
plinary team and that referrals are made by any
team member suspecting that the patient may be
suffering from depression. The patient should be
educated on symptoms of depression and given
resources to assist him/her when he/she transi-
tions to the community. When appropriate, medi-
cations may be necessary to ensure psychological
health and well-being. This is also important in
the individual that is newly injured as he/she may
be trying to deal with the changes in his/her life
including social roles, employment, and physical
limitations and frustrations. It is important that
this individual get help prior to flap surgery.
17.9 Patient Education
Education is the key to prevention. The more
knowledge we can impart to our patients, in a
way that they can understand, the better they
will be able to make decisions about their well-
being. It is important to investigate learning
styles in each patient to ensure that the cor-
rect methods of teaching are being utilized. It
is important that each patient education plan is
specific to his/her set of circumstances. Making
a risk factor assessment and plan of care more
relevant will assist in the carry-over from the
hospital environment to that individual’s com-
munity. McDonald [2] suggested establishing
a regimen or preventive routine: participate in
an active lifestyle, keep skin free of dryness or
excessive moisture, check the skin twice daily,
eat a well-balanced diet and maintain a healthy
weight, choose a mattress that allows for pres-
sure reduction and establish a positioning rou-
tine, utilize and maintain prescribed seating
equipment, and establish a pressure relief rou-
tine. Clark et al. go on to establish that there are
daily risk factors and that there are episodes or
irregular occurrences that can lead to behaviors
that increase a person’s risk of recurrence [7].
With increased knowledge and a better plan that
is specific to their own lifestyle, our patients
should be able to make decisions that will
have less risk for pressure ulcer development.
References
They will understand the consequences of their
behavior and can hold themselves accountable
for the decisions they make. In addition, they
will know how to manage more effectively to
prevent a small pressure ulcer from becoming
a severe one. This knowledge needs to be given
not only to those that have already had a pres-
sure ulcer but also to the newly injured so that
they may prevent the initial onset of a pressure
ulcer.
It is important that this knowledge be given to
medical staff in long-term care and acute care
settings so that pressure ulcers can be prevented
before they start. The above practices of pressure
management and relief should be a priority for
everyone at risk for pressure ulcers. With the
availability of different mattress to assist with
pressure management and turning mattress that
can assist with pressure relief, the incidents of
pressure ulcers should be very rare. In addition, it
is important that these facilities look at other fac-
tors such as incontinence and nutrition that can
also have a profound impact on skin health. This
should also translate to other areas of health ser-
vices such as the spine stabilizer boards used
when there is possibility of spinal cord involve-
ment. This board is very hard and a patient may
be on it for hours while waiting clearance to be
moved, or operating tables may be another source
of high-pressure areas that an individual may be
maintained in the same position for prolonged
time frames. There are instances when the care of
the patient is priority over skin care; however, if
as a healthcare industry we can identify these
areas, then we can work toward developing new
methods or products that can both provide care
and reduce the risk to the skin. If all healthcare
staff can identify and address the risk factors,
then there should be a significant reduction in
279
pressure ulcer occurrence, healthcare costs, and
suffering to our patients.
What causes a pressure ulcer is a very compli-
cated multifactorial question, with the answer
being different for each ulcer. Therefore, prevention
must also be multifactorial and individualized to
each patient’s daily life. As healthcare providers, it
is our job to understand an individual’s life circum-
stances and, with the individual, establish a regi-
men that can be incorporated into his/her life
situation. It is our job to educate them on what is
necessary for good skin health and assist in provid-
ing solutions to the risks that affect their well-
being, so that they can make educated and good
decisions. This approach to prevention will require
an interdisciplinary team of healthcare profession-
als partnered with our patients.
References
1. Niazi ZBM, Salzberg CA, Byrne DW, Viehbeck M
(1997) Recurrence of initial pressure ulcer in persons
with spinal cord injuries. Adv Wound Care 10:38–42
2. McDonald H (2001) Preventing pressure ulcers.
Rehab Manage 10:5–20
3. Maynard FM (1996) Ethical issues in pressure ulcer
management. Top Spinal Cord Inj Rehabil 2:57–63
4. Webster JG (1991) Prevention of pressure sores.
Adam Hilger, New York
5. Strebis JR, Lewis VL, Bushman W (2003) Urologic
and plastic surgical collaboration for continent diver-
sion when urine leakage is complicated by pressure
ulcers or obesity. J Spinal Cord Med 26:124–128
6. Salzberg CA, Byrne DW, Cayten CG, Kabir R, Van
Niewerburg P, Viehbeck M, Long H, Jones EC (1998)
Predicting and preventing pressure ulcers in adults
with paralysis. Adv Wound Care 11:237–246
7. Clark FA, Jackson JM, Scott MD, Carlson ME, Atkins
MS, Uhles-Tanaka D, Rubayi S (2006) Data-based
models of how pressure ulcers develop in daily-living
contexts of adults with spinal cord injury. Arch Phys
Med Rehabil 87:1516–1525
 Index

A E
Air fluidized bed, 54, 62, 64, 76, 77, 168, 191, Excision of the anus and rectal closure, 228
234, 244 Extended tensor fascia lata rotation flap, 107, 127–129
Anesthesia for pressure ulcer surgeries, 21, 25, 26, 31, Extended total thigh flap, 222, 228–229
58, 64, 71–72, 177, 178
Antisocial personality, 36–37
Arthrogram, 29, 150 F
Fat necrosis, 247
Flap design
B principle of, 69, 84, 97, 107, 118, 124, 125, 247
Baclofen (Lioresal), 64 Flap necrosis, 222, 246–248
Bartholin's cyst, 11 Fournier's gangrene, 10
Bartholin's glands, 10
Biceps femoris myocutaneous flap, 110–111
Biochemical tests, 56–57 G
Bone biopsy, 15, 30–32, 154 Girdlestone procedure, 27, 61, 75, 76, 105, 106, 108,
Bone scan, 16, 30, 164 110, 127, 137, 145, 150–155, 165, 169–170, 177,
Botulinum toxin therapy (Botox), 61 221, 234, 237, 244, 263, 266–267
Bowel management of patients with pressure Gluteus maximus advancement island flap, 117, 122–123
ulcer, 64, 77, 81–82, 161, 176, 221, 222, Gluteus maximus flap, 9, 12, 68, 70, 81, 83, 84, 86,
234, 244, 249, 255, 257, 264, 268, 272, 90–91, 96, 97, 110, 112, 117–119,
274, 276–277 122–124, 139, 152
Gracilis muscle as a musculocutaneous flap, 95–96
Gracilis muscle flap, 90–91, 99, 112
C
Cannabis (Marinol), 60
Clonidine, 60 H
Cognition in spinal cord injury patients, 40 Hamstring muscle advancement flap, 87–89
Computerized tomography (CT-Scan), 29–30 Head of the fibular bone and tibial shine, 191
Continuous passive motion (CPM) machine, 169 Heel ulcer, 62, 191–194
Control of muscle spasms and joint Hematoma, 25, 150, 169, 245–247
contractures, 58–59 Heterotopic ossification, 3, 12, 15, 26, 28, 30, 75,
Cost of pressure ulcer management, 2 105, 149, 150, 152, 155, 160–163, 176,
192, 222, 244
Hip joint
D infection of, 15, 149–150
Dantrolene sodium (Dantrium), 60
Debridement, 8, 10, 22, 31, 74, 151, 159, 217, 243,
245, 246, 248 I
Depression, 35, 38–44 Intrathecal infusion-intrathecal baclofen
Diazepam (Valium), 59–60 (Lioresal) pump 61, 61
Disarticulation and total thigh flap, 14, 82, 108, 111, Ischial bursa, 12–14, 95, 111–112
127, 160, 221–242 and bursitis, 12–14

S. Rubayi, Reconstructive Plastic Surgery of Pressure Ulcers, 281

DOI 10.1007/978-3-662-45358-2, © Springer-Verlag Berlin Heidelberg 2015
282 Index

Ischial ulcer, 9, 10, 12, 21, 26, 70, 81–115, 129, 149 Planter surface of the foot, 194–195
extension into the hip joint or trochanteric Posterior thigh fasciocutaneous flap, 90, 130, 131
area, 104–106 Posterior trochanteric ulcer, 16, 27, 142–146, 159
with extension into the male urethra, 101–104 Predisposing factors in developing pressure ulcer, 6
Pressure forces
pathology of, 5
J Pressure relief, 5, 7, 8, 36, 38, 44, 81, 100, 250,
Jamshidi, 31 252–255, 257, 263, 264, 268
Pressure ulcer
advances in prevention of, 3
K advances in the management of, 3
Knee amputation ambulatory patients with, 70, 87, 89, 118, 120, 122,
patient with above or below, 265–266 149, 154, 158, 199
Knee ulcer, 191, 196–199 bowel management of patients with, 64, 77, 81–82,
161, 176, 221, 222, 234, 244, 249, 255, 257, 264,
268, 272, 274, 276–277
L complication and life threatening risk of, 3
Local pathological changes and sequel in pressure ulcer definition of, 19
stage IV, 8–9 importance of clinical staging of, 19–20
Local wound management, 53–54 incident of, 1–2
laboratory tests and data for patient with, 21, 25–26
physical therapy evaluation of patient with, 21, 65,
M 249–251
Magnetic resonance angiogram (MRA), 30, 165 prevention of, 21, 271–279
Magnetic resonance imaging (MRI), 12, 15, psychology evaluation of patient with, 43–44
26, 30, 40, 150 staging of, 19
Malleoli ulcer, 191 Pressure ulcer program
Medial thigh fasciocutaneous rotation team meeting of, 47
flap, 82, 93–94 Pressure ulcer program protocol, 44–45
Medico-legal implications of pressure ulcer, 2–3 Pressure ulcer surgery
Multiple ulcers, 56, 64, 82, 109, 175, 177, 178, 221 basic principle of, 73–75
Multiple ulcers closed by multiple flaps, 175–189 Psychologial factors and conditions, 35–36
Psychology evaluation of patient with pressure
ulcer, 43–44
N
Negative pressure wound therapy, 54–55
Nutritional assessment, 21, 55, 57 R
Radiological imaging studies, 26–28
Rectus abdominis, 68, 70, 154, 159–162, 169, 234
O Rectus abdominis muscle flap, 159–161, 234
Occipital ulcer, 191, 192, 217 Rectus femoris muscle flap, 70, 158–159
Olecranon ulcer, 191, 192, 213–215
Osteomyelitis
diagnosis of, 30–32 S
Sacrococcygeal ulcer, 9, 70, 84, 117–118, 120, 122,
126–127
P Seating evaluation, 249, 257–259
Pain in spinal cord injury patients, 38–40 Selecting a cushion, 259–263
Patient education, 255, 263–265, 278–279 Seroma page, 58, 245, 246
Patient position on the operating table, 72–73 Severe muscle spasms, 7
Pelvic ulcer, 14, 108–111 Sinogram study, 29
Personality in general, 36–38 Site of pressure ulcer development, 8
Phenol/alcohol injection, 60–61 Sitting pressure management, 274–276
Physical therapy, 21, 65, 77, 78, 142, 169, 234, 249, 250, Special beds and positioning, 272–274
252, 263, 267, 268 Splitting gluteus maximus flap, 124
Physical therapy evaluation Staging of the pressure ulcer, 19
for patients with bilateral hip disarticulation, 267 Stress and anxiety in SCI patients, 35, 37, 38, 40, 41, 42,
for patients with Girdlestone procedure, 266–267 43, 59, 271
for patients with hip disarticulation, 266 Substance abuse, 38, 45
Index 283

T V
Tensor fascia lata Vastus laterals, 68, 70, 101, 104, 106, 110, 118, 127, 130,
rotation flap, 107, 127, 139–140, 143 138, 141, 146, 150, 152, 154–156, 158, 165, 177,
V-Y flap, 138–139 234, 237, 246
Tizanidine (Zanaflex), 60
Total parenteral nutrition (TPN), 58
Trochanteric ulcer, 14–16, 27, 29, 68, 70, 72, 137–147, W
149, 150, 152, 155, 158, 159 Wound bacteriological swab, 33
Tube feeding (nasogastric tube), 58 Wound evaluation and assessment, 21–23

U
Urological assessment, 64