Surgical Closure of Sacral Pressure Sores by

Gluteal Skin Flap –

A Prospective Interventional Study

Prepared By

Major Jubaer Ibn Adil

Grading Trainee in Surgery

Session: July 2020- June 2022

ARMED FORCES MEDICAL INSTITUTE

DHAKA CANTONMENT, DHAKA

i
 Declaration

This dissertation is submitted in partially fulfillment of the requirements of

the final examination of Grading Course in Surgery organized by Armed
Forces Medical Institute, Dhaka Cantonment. The research work was
done in Department of Plastic Surgery, Combined Military Hospital,
Dhaka Cantonment, Dhaka, under guidance of Brig Gen Sayed
Waheduzzaman, Classified Specialist in Plastic Surgery. No portion of
the work referred to in this dissertation has been submitted in support of
any application for another degree or qualification of this or any other
institute of learning.

Major Jubaer Ibn Adil

Grading Trainee in Surgery

AFMI, Dhaka Cantonment.

ii
 Declaration

This dissertation is submitted in partially fulfillment of the requirements of the final

examination of Grading Course in Surgery organized by Armed Forces Medical
Institute, Dhaka Cantonment. The research work was done in Department of
Surgery, Combined Military Hospital, Dhaka Cantonment, Dhaka, under guidance of
Col Ershad Ul Quadir, Classified Specialist in Surgery. No portion of the work
referred to in this dissertation has been submitted in support of any application for
another degree or qualification of this or any other institute of learning.

Major Jubaer Ibn Adil

Grading Trainee in Surgery

AFMI, Dhaka Cantonment.

iii
 Forwarding

Department of Surgery
Combined Military Hospital, Dhaka Cantonment

Major Jubaer Ibn Adil has worked on a subject " Surgical Closure of Sacral Pressure
Sores by Gluteal Skin Flap –A Prospective Interventional Study" in the Plastic
Surgery ward under my direct supervision. I have gone through the dissertation.

This is upto my full satisfaction.

Brig Gen Sayed Waheduzzaman

FCPS, MS
Department of Plastic and ReconstructiveSurgery
Combined Military Hospital, Dhaka.

iv
v
 Acknowledgement

I remain ever greatful to Major General Md Anisur Rahman Howlader, Consultant

Surgeon General, Bangladesh Armed Forces for his suggestion and inspiration for
preparing the dissertation.

I am also greatful to Brigadier General MD kamruzzaman , Chief Surgeon General,

Combined Military Hospital Dhaka for his constant monitoring and valuable directions
for making a better dissertation.

I must express my regards to Brig Gen Sayed Waheduzzaman, Classified Spl in

Plastic Surgery, Combined Military Hospital Dhaka for his valuable guidance and
supervision for this research work.

Finally, I am grateful to all my patients who in their pain, sorrow and distress helped
me their best in getting all my clinical data.
Above all, I thank the Almighty Allah for showering me with his blessings and love,
showing me the way and providing me the insplration throughout my life.

Major Jubaer Ibn Adil

vi
 Acceptance

Certified that the dissertation title " Surgical Closure of Sacral Pressure
Sores by Gluteal Skin Flap –A Prospective Interventional Study"
submitted by Major Jubaer Ibn Adil examined by me and found to be
satisfactory for partial fulfillment of the requirements of the Grading
Course of the Armed Forces Medical Institute.

MD Kamruzzaman

Brigadier General

Chief Surgeon General

CMH Dhaka

vii
 REMARKS

Major General Md. Anisur Rahman Howlader

MBBS, MS (Ortho)

Consultant Surgeon General

Bangladesh Armed Forces

viii
 ABSTRACT

This prospective study was carried out in the Department of Plastic Surgery,
Combined Military Hospital, Dhaka to evaluate the outcome of surgical closure of
sacral pressure sores by Gluteal skin flaps. Patients of any age and either sex,
admitted at the Plastic Surgery Department of Combined Military Hospital, Dhaka
with stage III & IV sacral pressure sores were the study population. A total of 22
cases meeting above enrollment criteria were selected consecutively from the study
population.

Age distribution of the patients show that young adults (2 decade) and elderly (5
decade and onwards) are clearly vulnerable to develop sacral pressure sores, with
mean age of the patients being 34.5 years (range: 1460 years). A male
predominance was observed with male to female ratio being roughly 3:2. Primary
and secondary level educated each comprised about one-third (31.8%) and illiterates
27.3% of the patients. In terms of occupation about one-third (31.8%) was farmer
and 22.7% were student. Nearly three-quarters (72.7%) of the patients were bed-
ridden due to spinal cord compression. Over three-quarters (77.3%) of the patients
received conservative treatment, 18.2% surgical treatment and some 4.5% did not
receive any form of treatment. In terms of nutritional status, 5(22.7%) patients were
underweight and 3(13.6%) were overweight or obese. 86.4% patients were anaemic
(Haemoglobin concentration <10gm/dl).

Over two-thirds (68.2%) of the ulcers were in Stage-III and over three-quarters
(77.3%) had signs of local infection. The average horizontal and vertical lengths of
the defects before excision were 10.4 and 8.8 cm respectively which increased to
12.6 and 10.5 cm respectively after excision of dead and devitalized tissues. The
medial advancement of the flap was 6.3 cm. The mean operative time was 168.4
minutes. Postoperative flap-monitoring did not reveal infection, seroma or hematoma
in any of the patients. Only 2(9.1%) patients had marginal flap loss.

Majority (90.9%) of the patients required> 14 days to stay in the hospital following
operation. The median postoperative hospital stay was 17.3 ± 2.4 days. Marginal flap

ix
losses developed in two cases were excised and direct-suturing (secondary closure)
were done. More than 90% of the patients exhibited good outcome. In two patients
the outcome was considered acceptable.

The study concluded that Gluteal skin flap produces good. result in majority of the
patients with large sacral sores with almost no complications or recurrences. None
but two cases had marginal flap loss. The Gluteal skin flap has the advantages of
muscle sparing, less donor-site morbidity, versatility in design and less effort to
harvest.

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Table of Contents

Chapter and Section Page no.

Chapter 1: Introduction
Chapter 1.1 Background
Chapter1.2 Rationale
Chapter 1.3 Hypothesis
Chapter 1.4 Objectives
Chapter 1.5 Literature Review
Chapter 2 Materials and Methods
Chapter 2.1 Study design
Chapter 2.2 Place and period of study
Chapter 2.3 Study population
Chapter 2.4 Enrolment criteria
Chapter 2.5 Addressing ethical issues
Chapter 2.6 Sample size and sampling procedure
Chapter 2.7 Data Collection
Chapter 2.8 Operational definitions
Chapter 2.9 Detailed procedure
Chapter 2.10 Statistical analysis of data
Chapter 3 Observations and Results
Chapter 4 Discussion
Chapter 4.1 Discussions on the results
Chapter 4.2 Limitations of the present study
Chapter 4.3 Conclusion
References Cited
Appendices
Appendix I Data Collection sheet
Appendix II Consent form (Bangla)
Appendix III Informed written Consent
Appendix IV Patients Pictures
Glossary

xi
 List of Figures

Figure No. Caption Page

Fig. 1 Distribution of patients by etiology of underlying
disease
Fig 2 Distribution of patients by their preliminary
management

xii
 List of Tables

Table Title Page

I Post operative flap monitoring

II Distribution of patients by demographic

characteristics

III Distribution of patients by their BMI

IV Distribution of patients by Anaemia

V Distribution of Patients by Characteristics of lesion

VI Distribution of patients by their per operative findings

VII Distribution of patients by postoperative complications

VIII Management of complications

IX Distribution of patients by postoperative hospital stay

X Distribution of patients by final outcome

Xi Distribution of patients by recurrence

xiii
 Chapter –I

Introduction

1
1.1 Background
Pressure sores have affected humans for ages and addressing the overall
management of pressure ulcers has now become a prominent national healthcare
issue. Despite current interest in surgery, nursing care and self-care education,
pressure ulcers remain a major cause of morbidity and mortality. This is particularly
true for persons with impaired sensation, prolonged morbidity or advanced age.

However, definitive information on the aetiology and the natural history of this
condition is still limited. Unfortunately studies to date have been suffered by
methodologic weaknesses and variablity in describing the lesions (National Pressure
Ulcer Advisory Panel, 1989, Brandies et al., 1990). The incident in hospitalized
patients ranges from 2.7 to 29% (Gerson, 1975). Patients in critical care units have
an increased risk of pressure ulcers. Elderly patients admitted to acute care hospitals
for non-elective orthopaedic procedure, such as hip replacement and treatment of
long bone fractures are at even greater risk of developing the condition and in whom
it is one of the most costly diseases to treat (Versluysen, 1986).

Persons with spinal cord injury and associated co-morbidity are also at increased
risk. The incidence of pressure sores in this population is in the range of 25-66%
(Fuhrer et al., 1993; Okamoto et al., 1963). Pressure ulcers pose a considerable
burden on health care resources and the community (in terms of mortality and
morbidity) with costs estimated to be as much as $6 billion a year. According to
Gosnell and Vanetten, approximately 1 million pressure sores occur in the United
States. Patients predisposed to pressure ulcers are at higher risk of morbidity and
mortality with infection being the most common major complication of pressure
ulcers.

Studies have shown that pressure sores commonly occur on ischlum (28%) sacrum
(17-27%), trochanter (12-19%) and heel (9-18%) (Abrussezze, 1985; Fuhrer et al.,
1993; National Pressure Ulcer Advisory Panel, 1989). Despite current interest and
advances in medical science, sacral sores remain a challenge to medical and

2
nursing staff, for they are reluctant to heal, prone to recur, difficult to operate upon
and costly to treat (Riggs, 2003; Reddy et al., 2003).
.
Many theories have been put forward between the period 1749 and 1940 on the
aetiology of pressure sores without much attention to its treatment. These theories
regarding aetiology of pressure sores dominated the general thinking during the
period and gave little hope for any successful treatment. It has now become an
axiom that in addition to neuropathic factor and shearing forces, the single most
important factor in the netiology of pressure sorus is Ischemia necrosis resulting from
sustained excessive pressure against bany prominences.

Pressure sores almost invariably occur over bony prominences. The most important
factor in the aetiology of pressure sones is ischaemic necrosis resulting from
sustained excessive pressure against bony prominences. Sacral pressure sores are
more common in patients nursing in supine position. It is estimated that in supine
position, sacrum is subjected to maximum pressure in the range of 40 to 60 mm of
Hg. Malnutrition, anaemia, infection and chronic illness can also contribute to their
formation by the impairment of blood supply and delayed wound healing. Resultant
necrosis at the skin level is usually small compared with that of the necrotic area
over bone, which resembles an Inverted cone.

Surgical management of pressure sores gained popularity during the World War-II,
when large number of paraplegic patients was rehabilitated in an organized fashion
(Darvnial, 1992). Most surgeons gave credit to the concept of using flap coverage of
pressure sores to provide bulky and well-padded skin coverage over the bony
prominences.

Gluteus flaps have been used as originally described by Ger (1971). There are
different type of gluteus flaps, which can be based on the method of transfer of the
flap-such as, island flaps, V-Y plasty, rotational flaps and they can be based on the
types of tissue included, such as, cutaneous flaps or myocutaneous flaps. Recently,
Gluteal skin flaps have been used successfully for the coverage of the defects of
sacral sores.

3
1.2 Rationale:
Worldwide pressure-sores are common health problem including our country also, It
presents a difficult challenge because of the high rates of wound complications and
recurrences. Management by free flap coverage is a time-consuming procedure and
requires highly skilled micro-vascular anastomoting technique and expertise on the
part of the surgeon concerned.
The ideal covering of pressure sores is to replace the lost tissue Le. skin and
subcutaneous issue. Since the most common areas of pressure ulceration (e.g. the
sacrum) do not normally have a layer of muscle interposed between the bone and
the skin, coupled with the fact that skin and subcutaneous tissue are less sensitive to
ischemia than muscle, it is preferable to use Gluteal skin flap in closure of sacral
pressure sores. It is considered as the standard first-line treatment for pressure
sores that fall conservative therapy.

The major disadvantage of gluteus maximus myocutaneous flaps is the sacrifice of

the muscle which may lead to functional deformity in ambulatory patients. Excessive
blood loss and limitations in flap design are other drawbacks. Moreover, gluteus
maximus muscle may be atrophic in elderly patients and in those with spinal cord
injuries.
The advantages of gluteal skin flap in sacral pressure sure reconstruction are:
 It provides adequate blood supply with durable coverage
 Less likely to have a functional deformity in the donor site
 Better reconstruction of the normal anatomic arrangement over bony
prominences
 It does not preclude the use of other Saps for recurrent ulcer reconstruction
Versatility of design
 Provides large flap, easy to raise, re-rotation is feasible
Despite the potential disadvantage of this flap that the resultant suture line lies
directly over the sacrum in the midline, bilateral gluteal skin flaps (based on the
superior and inferior gluteal vascular pedicles) slide horizontally to cover the defects

4
of the sacrum in a V-Y advancement manner. The present study is, therefore,
intended to evaluate the outcome of bilateral gluteal skin flaps in the management
of sacral sores.

1.3 Hypothesis:

Closing of sacral pressure sores by gluteal skin flap gives good outcome in majority
of the cases.

5
1.4 Objectives
General objective:
Evaluation of efficacy of surgical closure of sacral pressure sores by Gluteal skin
flaps

Specific objectives:
 To assess the viability of the flap.
 To find out the complications.
 To asses recurrence of sacral pressure sore within the follow up period.

6
1.5 Literature Review
Epidemiology
Predisposing Factors
Pressure sores are an age-old problem, observed at autopsy of Egyptian mummie
by Thompson Rowling (Rowling, 1961), In 1872, Shaw observed that most pressure
sores occur in young persons with chronic illness such as tuberculosis,
osteomyelitis, and renal diseases.

Most surveys point to pressure ulcers as the direct cause of death in 7 to 8% of

paraplegics (Dinsdale, 1974), despite declining mortality rates from spinal cord
injuries in the last 50 years. With the increase in life expectancy there is a increase in
lifetime medical costs. At Rancho Los Amigos Medical Center, the average cost per
pressure sore admission is estimated to be $78,000, with an average length of post
operative hospital stay of 3 months (Capen, 1988).

As the elderly become the fastest growing segment of our population, nursing home
residents are being recognized as being at high risk for pressure sores. Siegler and
Lavizzo-Mourey (1991) recount that, in their experience, 25 to 33% of prospective
residents have pressure sores at the time of their admission to the nursing home,
and at any one time afterwards, approximately 35% of geriatric residents of a nursing
home have pressure ulcers. In contrast, Bennett and coworkers (1989) state that
most studies of nursing home patients have found the prevalence rate of pressure
sores to be 3 to 6%. In one study, the prevalence was as high as 24%.

Among patients admitted to nursing homes, the prevalence has been reported as 35
to 64% (Bennet et al,. 1989). In addition, Barbenel and coworkers (1977) note that 3
to 4.5% of all hospitalized patients will develop a pressure sore at some time during
their hospital stay, and more than two-thirds of these patients are older than 70 years
of age. With an estimated 1.5 million people living in long-term care facilities in the
Unites States, the problem of pressure sores has profound significance.

7
Etiology
In 1870, Charoot suggested that injury to the CNS trophic centers regulate nutrition
decreases tissue tulurance to local pressure and leads to skin necrosis. Sixty years
Inter, Munro (1940) hypothesized that the increased susceptibility to pressure
necrosis was due to interruption of autonomic reflex arcs and loss of protective
circulatory reflex responses following spinal cord injury. This concept came to be
known as the neuropathic theory of pressure sore etiology. Although autonomic
disturbances certainly occur in some patients with neurologic deficit a causative role
for neuropathic factors in the development of pressure sores has not been
substantiated. Currently the generally accepted theory of pressure sore formation
involved a direct effect by one or more extrinsic (primary) factors propitiated and
modified by a number of intrinsic (secondary) factors. This pressure ischemic
therapy holds that pressure some forms as a result of constant pressure on soft
tissue for sufficiently long time.

The exerted pressure must exceed the arterial capillary blood pressure of 32 mmHg
and must be sustained without interruption. Extrinsic factors that exert mechanical
force on soft tissue include pressure, shear and friction. Intrinsic factors include local
Ischemia or fibrosis, diminished autonomic control, infection, small vessel occlusive
disease, hypoproteinemia, anaemia, sensory loss, impaired mobility, age, decreased
mental status, and faecal or urinary incontinence (Makelbust, 1987).

The pressure ischemia theory fails to account for venous capillary closure pressure
of 8 1012 mmHg (Benelt, 1989), Furthermore, susceptibility to pressure sore
formation is different between subjects who have spinal cord damage and those who
are CNS-impaired. Cerebral palsy victims not form pressure sores even when they
are placed in wheel chairs for extended periods and have their pressure- release
behaviour restricted. Clearly, the time-pressure interaction is not the only mechanism
at work in the aetiology of pressure sares.

8
Pathophysiology
Pressure-Induced Ischemia: Pressure is defined as a perpendicular load exerted on
a unit of area; shear is a mechanical stress parallel to the plane; and friction is the
resistance of two surfaces moving across one another. Direct local pressure can
cause tissue deformation, mechanical damage, and blockage of blood vessels.

Shear forces contribute to the injury by stretching and compressing the muscle-
perforating vessels to the skin, which eventually leads to ischemic necrosis of the
adjacent tissues. Friction acts directly on the epidermis by rubbing off the outermost
Layer of skin. This Increases trans epidermal water loss and allows moisture to
accumulate on the surface of the body, which in tum raises the coefficient of friction
and may cause adherence. Stasis of blood in the pressure areas accumulates
bacteria in these areas, if any focus of infection elsewhere in the body. This bacteria
causes multiplication in the favorable condition and Invasion into the circulation that
leads to bacteremia and ultimately local infection and tissue destruction occurs.

Time of Applied Pressure: Clinically, the critical question is: How much pressure and
for how long a time will a body area tolerate before the skin breaks down? In 1943,
Groth hinted at an inverse relation between time and pressure in eliciting changes in
the gluteal muscle of rabbits. Ten years later, Husain (1953) demonstrated histologic
changes in rat leg muscles following application of pressures of 100 mmHg for 2
hours. He concluded that low pressures maintained for long periods induced more
tissue damage than high pressures for short periods; ie., the time factor was more
important than pressure Intensity in the pathophysiology of pressure sores. Koslak
(1950) applied pressure of 70 mmHg continuously for 2 hours produced Irreversible
changes in dog tissues, but if the pressure was released every 5 minutes, few
changes occurred. Finally, Dinsdale in 1974 confirmed the importance of
uninterrupted pressure in decubitus ulcer formation. When pressure is applied over
the same period of time, the likelihood of pressure sore formation rises
proportionately with increasing magnitude of the pressure above 40 mmHg.

However, Daniel et al (1979), reviewing pressure sores noted that the critical
pressures and time applied were not based on the hard scientific data.

9
Effect of Denervation: Nison and colleagues (1962) have studied the effect of
denervation on soft-tissue infection as a contributing factor to pressure sores. Adult
ewes were randomly categorized into three groups and subjected to island pedicle
flap transfer on their buttocks. In Group-l, the cutaneous nerve remained intact. In
Group-ll, the nerve was divided when the flap was raised. Group-lil had the
cutaneous nerve divided 7 days before the flap was elevated. After the flap was
inoculated with staphylococcus aureus, the animals in Group III were noted to have
significantly greater bacterial counts than those in either Group I or Ill. The incidence
of infection in Groups I and it was identical concluding that prolonged denervation
may help neurologically Injured patients to develop infection and pressure sores.

Staging of pressure sore: Staging of pressure sore was done by National Pressure
Uicer Advisory Panel system. The staging system is skewed toward early signs of
ischemia, encouraging early detection and intervention, Stage Persistent
nonblanchable erythema of intact skin. Most common of all pressure ulcers. "At risk"
person.
Stage II: Partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is
superficial and presents as an abrasion, blister, or shallow crater.

Stage III: Full-thickness skin loss involving subcutaneous tissue that may extend
down to, but not through, underlying fascia.

Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or
dam-age to muscle, bone, or supporting structures (e.g. tendon, joint capsule).
Undermining and sinus tracts may also be present.

If an eschar is present, the sore cannot be accurately staged until it is fully debrided.
Skin erythema may be the only visible sign, even when underlying muscle necrosis
has already occurred.

Stage I and II pressure ulcers are usually treated conservatively while stage III and
IV resistant pressure ulcers require flap reconstruction.

10
Reverse staging (The NPUAP Position Statement): In 1989, due to a lack of
research validated tools to measure pressure ulcer healing, clinicians resorted to
using pressure ulcer staging systems in reverse order to describe improvement in an
ulcer.

Pressure ulcers heal to progressively more shallow depth, they do not replace lost
muscle, subcutaneous fat, or dermis before they re-epithelialize. Instead, the full
Thickness ulcer is filled with granulation (scar) tissue composed primarily of
endothelial cells, fibroblasts, collagen and extracellular matrix. A stage IV pressure
uloar cannot become a stage III, stage II, and/or subsequently stage 1. When a
stage IV ulcer has healed it should be classified as a healed stage TV pressure ulcer
not a stage 0 pressure ulcer. Therefore, reverse staging does not accurately
characterize what is physiologically occurring in the ulcer. The progress of a healing
Pressure ulcer can only be documented using ulcer characteristics or by
improvement in wound characteristics using a validated pressure ulcer healing tools.
So, we should not use reverse staging.

Prevention
Techniques for the prevention of pressure sores consist of basic skin care, pressure
Dispersion and alternating weight-bearing sites.

Skin care
Ungar (1971) reviews the appropriate measures for care of the skin in paraplegia
and recommends frequent cleansing with soap and water and an indwelling catheter
or urinary/fecal diversion procedure to avoid soiling of the skin. The bed must be
kept free of particulate matter and every attempt should be made to minimize excess
moisture on the skin.

Pressure dispersion
Pressure dispersion begins with proper patient positioning, which in tum, dictates
relief of spasticity. Pharmacologic options to control spasticity should be tried first
(Reuler and Cooney, 1981). When spasticity is refractory to pharmacologic methods,
surgical release of flexion contractures or neurosurgical ablation with cordotomy or
rhizotomy may be necessary, Putty and Shapiro (1991) described their experience in
11
20 patients who underwent dorsal longitudinal myelotomy for the relief of spasticity.
All enjoyed complete relief of their painful spouras, although 2 later relapsed. In 17
patients it was possible to markedly reduce or completely eliminate antispasmodic
medications, and pressure ulcers in 11 of 14 palunds were subsequently treated
successfully. They believe this approach is superior to chronic
intrathecal baclofen Infusion Since 1873, numerous investigators have sought ways
to relieve pressure in order to prevent tissue damage. Over the yours, various
materials such as moss, straw, feathers, sand, springs, rubber, plaalle, foams, and
plaster of paris have been used for pressure relief (Freedman et al., 1990). Currently
popular measures include gel pads and low air-loss beds.

Houle (1069) studied numerous types of padding, including viscoelastic (gel) pads,
on a variety of wheelchair seats. He noted reduction in effective pressure from 150
mimiig to 75 mmHg using the pad devices, although nene reduced ischial pressures
below capilary pressure. The Investigator concluded that seat pads were not a
substitute for altemating pressure sites and pressure-release behavior on the part of
the patient.

In 1873, Sir James Paget (1873) described a water bed that aimed at dispersing
pressure. Numerous other designs incorporating Archimedes's principle include air-
Buidized beds (air pumped through a bed of fine, silicone-coated soda-lime beads).
mud beds (for a more viscous fluid medium and thus greater stability), and low air-
loss (LAL) beds (where the patient floats on a column of air). All these devices, when
properly used, can maintain pressures below the 30 mmHg range (Redter. 1973;
Kronskop, 1984).

Air-fluidized beds have been available since 1969. These beds contain ceramic
beads covered by a closely woven polyester sheet. Warm, pressurized air is forced
throughout the particulate mass in order to make the particles behave as a fluid. The
patient floats on the bed without pressure on the bony prominences (Freedman et
al., 1990). Costs of the bed range from $30,000 to $128,000, with maintenance
contracts averaging $3,000 annually. The daily rental costs range from $55 to $130,
depending on the type of bed. In short, cost becomes a significant factor in

12
determining the usefulness of some of these devices for pressure dispersion
(Freedman et al, 1990).
Alternating Weight-Bearing Surfaces: The various measures that have been
suggested for alternating pressure sites are based on Kosiak's (1950) principle that
tissue tolerates higher pressures if these prosaurus aro interspersed with pressure-
free recevery periods. The Stykor frame, circle electric tred, ripple mattresses, and
rotating bods are examples of the more sophisticated designs.

At a simpler level, the development of "pressure consciousness" by the patient is an

essential part of the dermal ulcer prevention and rehabilitation process (Ungar,
1971). Seated patients mast lift themselves, if able, or be lifted from their chairs for at
least 10 seconds every 10 minutes, and recumbent patients must be repositioned at
least every 2 hours. Despite conscientious nursing care and patient awareness of
pressure-relieving techniques, one should be quick to identily areas of incipient skin
breakdown to prevent further problems. Electrical neuromuscular stimulation has
been used successfully in diaphragm pacing and urinary bladder function, and is
currently being investigated for the management of complications of immobility. An
electrical stimulus applied to the gluteus maximus muscle alters pressure at the
seating interface, and a change in the shape of the buttocks occurs that may also
assist in preventing ulceration, Electrical stimulation has also been shown to
Increase the rate of contracture and epithelialization of skin wounds.

Risk Groups
Risk factors in pressure sore development can be categorized as environmental or
systemic. Environmental factors include pressure, shear, and friction, Systemic
factors consist of patient age, weight, mobility, nutritional status, moisture problems,
and predisposing diseases. Generally, the more risk factors that are present, the
greater the ikelihood of developing pressure ulcerations. A particularly morbid
combination is that of an elderly patient who suffers from a neurologic disease such
as stroke, paralysis, or dementia.

Norton and colleagues (1962) developed a pressure ulcer risk scale for use in
geriatric patients. The scale is based on general physical condition, mental status,
activity, mobility, and incontinence as independent measures of risk and scores
13
range from 5 (greatest risk) to 20 (least risk). In a series of 250 geriatric patients,
24% developed pressure ulcers at some time during their hospital stay. Patients
with a score of 11 or less had a 48% incidence of pressure ulcer, those with a score
of 12 to 14 had a 32% Incidence, and when the score was 18 or greater, only 5% of
patients developed pressure ulcers. Goanali (1973) added nutritional status of the
patient as a variable in pressure sore risk calculation. His method is often referred to
as the "modified Norton scale".

Stotts (1988) applied the modified Norton scale to 387 adult patients admitted for
elective cardiovascular surgery and neurosurgery, and surprisingly found no
statistically significant predictive value of the scores with regard to pressure sore
development. Of the 20 patients who had scores of 14 or less on admission, 11
developed ulcens during hospitalization. In this sample, the most serious pressure
ulcers occurred in the knee and lateral malleolus. Because of the multifactorial
nature of pressure sores, Stotts concludes that the modified Norton scale has limited
clinical value as a predictor of ulcer development and perhaps functions best in older
populations and known high-risk groups.

Pressure Ulcer Scale for Healing (PUSH) PUSH Tool 3.0

Directions: Observe and measure the pressure ulcer. Categorize the ulcer with
respect to surface area, exudate, and type of wound tissue. Record a sub-score for
each of these ulcer characteristics. Add the sub-scores to obtain the total score. A
comparison of total scores measured over time provides an indication of the
improvement or deterioration in pressure ulcer healing.

o <0.3 0.3-0.6 0.7-1.0 1.1-2.0 21-30 Sub-

In Com 31-40 41-80 81-120 121-240 >24.0 score
Name Light Moderate Heavy Sub-
score
Closed Epllhelial Granulatio Slough Necrotic Sub-
Tissue n Tissue Tissue score

14
15
Length x Width: Measure the greatest length (head to toe) and the greatest width
(side to side) using a centimeter ruler. Multiply these two measurements (length x
width) to obtain an estimate of surface area in square centimeters (cm2). Caveat: Do
not guess! Always use centimeter ruler and always use the same method each time
the ulcer is measured.

Exudate Amount: Estimate the amount of exudate (drainage) present after removal
of the dressing and before applying any topical agent to the ulcer. Estimate the
exudate (drainage) as none, light, moderate, or heavy.

Tissue Type: This refers to the types of tissue that are present in the wound (ulcer)
bed. Score as a "4" if there is any necrotic tissue present. Score as a "3" if there is
any amount of slough present and necrotic tissue is absent. Score as a "2" If the
wound is clean and contains granulation tissue. A superficial wound that is re
epithelializing is scored as a "1". When the wound is closed, score as a "0".

4-Necrotic Tissue (Eschar): black, brown, or tan tissue that adheres firmly to the
wound bed or ulcer edges and may be either firmer or softer than surrounding skin.

3-Slough: yellow or white tissue that adheres to the ulcer bed in strings or thick
clumps, or is mucinous.

2-Granulation Tissue: pink or beefy red tissue with a shiny, moist, granular
appearance.

1-Epithelial Tissue: for superficial ulcers, new pink or shiny tissue (skin) that grows in
from the edges or as islands on the ulcer surface.

0-Closed/Resurfaced: the wound is completely covered with epithelium (new skin)

16
Management
Medical
In general, pressure sores Grades-I & Il can be treated non-surgically, whille Grades-
III & IV pressure sores usually require a more aggressive, surgical approach. Non-
surgical resolution of a pressure sore depends on a number of factors, such as,
severity of the ulcer, patient idiosyncrasies, quality of nursing care, topical agent
used, etc. Ultimate success of treatment, however, rests on certain prerequisites: (1)
control of local and systemic infection, (2) debridement of dead tissue, and (3)
avoidance of pressure.

Mechanical scrubbing, forceful irrigation, wet-lo-dry dressings, and occlusive

coverings are common methods of wound debridement (Fowler, 1987). Some
authors report improved healing of Grades I and Il pressure sores beneath oxygen-
impermeable hydrocolloid dressings (Corse & Messner, 1987), while others show
similar healing times with hydrocolloid and saline gauze dressings, and minimal, if
any, cost differential. Enzymatic debridement can be used as the sole treatment of
pressure sores or as an adjunct to sharp debridement (Fowler, 1987), Morgan
(1975), Vasconez et al., (1977) and Fowler (1987) review the spectrum of topical
agents and equipment used in the prevention and treatment of pressure sores. To
date, no specific protocol can be recommended for all cases, even in the cases of
deep, Grade IV pressure sores.

Kucan et al (1989) correlated successful healing of ulcers, either spontaneous or

after surgical reconstruction, with bacterial counts not exceeding 10 per gram of
tissue. In a prospective, randomized study comparing topical therapy with saline,
povidone iodine, and silver sulfadiazine cream, the latter reduced the number of
microorganisms to below 10 in all cases, and its bactericidal effect was faster than
that of povidone iodine or saline. Saline was the least effective agent for wound
cleansing in their study. Meyers et al (1980) conclude that washing with soap and
water or another mild surfactant is a simple yet effective way of cleansing superficial
wounds.

17
Daltrey and associates (1981) examined the bacterial flora of 74 sores in 53 patients
at weekly intervals, and found the common microorganisras to be Staphylococcus
aureus, Proteus mirabilla, Pseudomonas aeruginosa, Bacteroides fragilis, and
Bacteroides asaccharolyticus. Except for the staphylococcus, the pathogens were
frequently associated with necrolic and enlarging tesions. Many sores contained a
mixed flora and anaerobos were always seen together with nerobes. Topical
metronidazole gel has been found useful in eliminating anaerobic organisms and the
odor associated with them in established pressure sores (Witkowsky & Parish,
1991).

Some dinicians suspect that certain pressure ulcers will heal spontaneously without
surgical intervention so long as the wound is cleansed meticulously and pressure on
the area is avoided. Bennett et al (1989) report a 4-year experience with 95 nursing-
home residents who were treated with air-fluidized beds for their pressure sores. The
median trial lerigth was 79 days, and 18% of ulcers required more than 180 days for
healing. Only 14% of deep truncal ulcers healed completely, and only 2 small sores
healed in less than 30 days. The authors could not identify any patient
characteristics that could be used to predict success of treatment. Because of the
long periods of time necessary for treatment and the high costs involved, air-
fluidized beds are not recommended for routine treatment of nursing home patients
with severe pressure sores,

Surgical
Rationale for surgery
Galpin and coworkers (1976) documented bacteremia in 76% of patients whose
sepsis was attributed solely to decubitus ulcers. These Infections typically contain
mixed microorganisms, Including obligate anaerobes, and mortality remains high
despite aggressive surgical debridement and systemic antibiotics. Tribe (1963), on
the other hand, reports only one death from toxemia in a group of 150 paraplegic
patients: 19% died within the first 2 months of injury from causes such as respiratory
failure and pulmonary embolism; and the rest were considered "chronic" and died
primarily from renal failure associated with pyelonephritis, amyloidosis, or
hypertension.

18
Secondary amyloidosis associated with paraplegia results from amyloid formation in
the presence of pressure sores with underlying osteomyelitis and may play a major
role in the development of end-stage kidney disease. Appropriate surgical
debridement and reconstruction may decrease chronic amyloid production and
lessen the risk of progression to kidney failure. Conway and Griffith (1956) reported
30-80% healing of pressure sores without operation after 3 to 4 months of
conservative therapy. Unfortunately 32-77% of these "healed" ulcers from their
series recurred, mostly over the lschium. The high recurrence rates commonly
associated with conservative treatment of pressure sores are the rationale for the
conclusion that surgical coverage of Grade-II and IV pressure sores may be the
appropriate and ultimately the least morbid for therapy.

Preoperative Evaluation and preparation

Stal and coauthors (1983) summarize the perioperative management of patients with
pressure sores at the Institute for Rehabilitation and Research, Preoperative wound
care at TIRR (The Institute for Rehabilitation and Research) consists of debridement
of obviously devitalized tissue. Silver sulfadiazine is used for a short while under
specific circumstances, but should not be used more than one time. If silver
sulphadiazine is used for prolonged period it will develop leucopenia, decreased cell
mediated immunity, nephrotoxicity, pseudoeschar, over growth of opportunistic
microorganisms, initation rather than soothing. The drug of choice for spasticity and
relieve of spasms is baclofen, but diazepam and dantrolen may be used adjunctively
or alternatively.

A negative bone scan can rule out osteomyelitis underlying a pressure sore, but a
positive finding not always diagnostic of bone infection. Sugarman (1987) and Lewis
el al (1988) recommend bone biopsy for definitive diagnosis of osteomyelitis in the
presence of an abnormal bone scan and other suspicious indices before
administration of potentially toxic antibiotics.

19
Principles of Surgery:
The following principles of surgery should be borne in mind

 complete excision of the sore, surrounding scar and underlying burse is first
performed,
 the underlying bony prominences are removed until healthy bleeding bone
resurfacing of the defect with healthy skin, including adequate subcutaneous
Padding.
 it is better to have a large flap design in order to avoid sutures in the pressure
areas and
 avoid violation of adjacent flap territories, which may be needed for future

Procedure selection

The choice of reconstructive procedure depends on many factors, such as, level of
spinal cord injury, location of the ulcer, history of prior ulceration and surgery.
Patients ambulatory status/potential, daily habits, educational status, motivational
level, and other associated medical problems. The tendency of pressure sores to
racur, which argues for safeguarding as many coverage alternatives as possible, has
been discussed above.

The indications for using muscle in pressure sore surgery remain poorly defined.
Testing Kosiak's (1959) observations that muscle is more susceptible to ischemic
necrosis than either skin or subcutaneous tissue, Nola and Vistnes (1980) noted
histologic evidence of muscle necrosis as a response to pressure despite an intact
overlying skis. When muscle was interposed between skin and bone, however, the
incidence of ulceration in their rat model decreased from 100 to 69%.
The authors conduced that the increased mass of musde can help diffuse the effects
of pressure on the skin. Based on their wide experience in pressure sore coverage,
Conway and Griffith advocated the use of a muscle flap to fill in deep holes and
provide a well- vascularized pad of soft tissue. Although susceptible to pressure
necrosis, muscle is still helpful in the reconstructive sequence to accomplish the
following:
 supplement the vascularity of certain flaps
20
  eliminate dead space in a deep wound.
 Enhance perfusion and tissue cooptation in the dead-space of a pressure
sore detect.
 Potentially decrease the incidence of perioperative complications (hematoma,
infection) through a combination of the above.
 Provide at least a temporary pad for wider dispersion of any residual
pressures.

Tissue expansion also plays a role in pressure sore management, Reports by,
Yuan (1989) and Esposito et al (1991) attest to the success of tissue
expansion in the treatment of recalcitrant ulcers in paraplegics. Braddom's
report concerned a recurrent ischial sore after flap coverage and partial
ischlectorny. Because of in- sufficient tissue for resurfacing with the hips in
90° of flexion, an expander was inserted and gradually inflated. After removal
of the expander, wound closure without tension was possible, and the patient
subsequently retumed to the sitting position and was able to resume profitable
employment. The authors concluded that tissue expansion should be
reserved for difficult cases requiring additional tissue for coverage.

Tissue expanders are tolerated very well in paralytics. Yuan (1989) reports the
successful treatment by tissue expansion of two paraplegic patients with lower
extremity ulcers. Despite the apparent contraindication of placing a tissue expander
in subjects at high-risk for pressure-induced dermal wounds, the author claims the
expander actually protects the soft tissues by distributing the pressure evenly and 3-
dimensionally, Instead of concentrating it directly on a small area over a bony
prominence. According to the author the dermal atrophy and weak collagen cross-
linking seen in the expanded tissue of the paralyzed patient can be used to
advantage in the management of pressure ulcers, since the diminished skin elasticity
Lessens resistance to stretching. Yuan (1989) hypothesizes that the new vessels
surrounding the fibrous capsule of the expander enhances the blood supply of the
flap(s). Esposito and colleagues (1991) report 10 patients with pressure ulcers who
Underwent tissue expansion for coverage. Despite 4 wound dehiscence and 3
seromas, the outcome was universally good. According to the authors, the main

21
advantage of tissue expansion in selected cases is the advancement of sensitive
skin that can be used for pressure awareness and future ulcar prevention,
Critics of tissue expansion question the wisdom of inserting a foreign body (the
expander) into a contaminated wound (all pressure ulcers). At this time, the primary
Indication for skin expansion in the management of pressure sores is to cover
shallow ulcers with no dead-space to fill. Tissue expansion is also the method of
choice in the event of an unstable wound secondary to previous skin graft or
secondary healing

Reconstruction techniques of sacral sores:

A comprehensive listing of all surgical techniques applicable to sacral pressure
sores are given below:
A number of surgical techniques are available for closure of sacral pressure sores,
such as wide undermining and primary closure, skin graft, random skin flaps, gluteus
muscle plasty, advancement flaps, island and musculocutaneous pedicled flaps,
sensory flap transfers etc.

Primary closure may be appealing, but the surgeon should remember that these
ulcers represent an absence of tissue and that primary closure almost always leaves
a sub-cutaneous "dead space". In addition, adjacent tissues are usually less
compliant than would be necessary for a tensionless primary closure.

Skin grafting of the pressure sores may be possible with superficial ulceration, but
this tends to provide unstable coverage, doubtful viability, unpredictable outcome
and the success rate is only 30%. Therefore, wound cloures usually require rotation
or advancement of the local skin, skin or musculocutaneous flaps.

Kroll and Rosenfield (1988) describe perforator-based flaps from the parasacral area
for coverage of low pesterior midine defects. Their premise is that there are many
large posterior perforators and that any tissue can be made into a flap if its blood
supply can be identified and surgically isolated so that the tissue can be safely
mobilized and transferred, In practice, this means that it is possible to take skin
based on one or two perforators, with small cuff of muscle, from the low back
(latissimus dorsi muscle) or sacral region (gluteus maximus muscle). This flap
22
combines the advantages of a skin flap with the improved vascularity of a
musculocutaneous flap without sacrificing the muscle unit.

Methods of closing defects in the pressure-bearing areas do not normally provide

any sensory function unless the skin flaps are transposed from an area with intact
sensibility (Krupp et al, 1983) or have bean re-Innervated in a first-stage operation
(Mathes & Nahai, 1982). The advantage of using sensory flaps for pressure sore
coverage in patients with distal spinal cord Injuries is the hope that sensation will
prompt behavior modifications by the patient to avoid pressure on ulcer-prone areas
and prevent recurrent ulceration.

Dibbell (1974) and Daniel (1976) describe intercostal Island flaps to bring sensation
to the sacral area. Other reports by Coleman and Jurkiewicz (1984) and Mackinnon
et al (1985) discuss various techniques for reinnervation of the intercostal flap and
the tensor fascia lata lap, including nerve grafts to the intercostal muscles and to the
territory of the lateral femoral cutaneous nerve.

Complications
Common postoperative complications of pressure sore surgery include hematoma,
infection and dehiscence. In addition, recurrence rates with all techniques are high.
To date, there are no studies comparing the complication rates of single-operation
pressure sore treatment with those of a staged reconstruction consisting of wound
and bony debridement followed by flap transfer later. The multiple-stage protocol has
the theoretic advantage of eliminating grossly contaminated tissue that might
adversely affect flap health. Hentz (1979) found a corresponding increase in
pressure sore recurrences when postoperative complications developed. Rolander
and Palmer recount their experience with pressure sore management in 39 patients.

Treatment was by debridement and closure with musculocutaneous or random

cutaneous flap(s); no sensate flaps were used. Forty-eight percent of the operated
sores recurred, more than half of these in patients with spinal cord lesions. Given the
lengthy hospitalizations and the high costs involved, especially when every other
patient will relapse, the authors strongly advise patient education as well as social
and psychological evaluation to try to identify the high-risk groups.
23
Postoperative Care
A standard postoperative regime was followed:
 keeping negative suction drain until they produced less than 10 cc of fluid per
day
 maintaining low residual diet in the first week,
prone or lateral decubitus position to avoid pressure on the flap,
 turn the patient every two hours and use of low-air-loss mattress,
 maintaining nutrition, hydration, oxygenation and correction of anemia to
Expedite wound-healing process,
 Intravenous antibiotic coverage was continued postoperatively according to
Wound swab culture and sensitivity report.

24
 Chapter Two

Materials and Methods

25
 Materials & Methods

The study was conducted with following methods

2.1 Study design:
The study was a prospective interventional study.

2.2 Place and period of study:

The study was conducted in the Department of Plastic Surgery, Combined military

hospital, Dhaka over a period of one year 1st July 2021 to 31st June 2022.

2.3 Study Population:

Patients admitted at the Plastic Surgery Department, Combined military hospital,
Dhaka from 1st July 2021 to 31st June 2022 with stage II & IV sacral pressure sores
were the study population.

2.4 Enrolment criteria:

Inclusion criteria
Patients with following characteristics were included in the study:
 Stage III and IV sacral pressure sores
 Any age group of either sex.

Exclusion criteria
Patients with following characteristics were excluded:
 Poly trauma patent with life support.
 Previous history of radiotherapy in sacral area.
 Co-morbid medical conditions like diabetes mellitus, renal failure, COPD,
CCF.
 Short life expectancy.
 Injuries in the region of the pedicle
 Unwilling to take part in the study.

26
2.5 Addressing ethical issues:
According to Helsinki Declaration for Medical Research Involving Human Subjects
1964, all patients or their legal guardians (in case of minors) were informed verbally
about the study design, the purpose of the study, and their rights to withdraw
themselves or their patients (in case of minors) from the project at any time, for any
reason, what so ever. Witten consent was obtained from the subjects or their
guardians voluntarily consented to participate in the study. All precautions were
taken to protect the anonymity of the participating subjects. The patients were
properly informed of the procedure and complications before obtaining written
consent. No deception was used during counselling. No confidential data was
obtained or accessed. The photographs that were taken during the course of this
study only displayed the affected areas of the body and not the face of the patient.
None of the conversations with the patients or the attendants were tape recorded.

None of the patients were placed in any embarrassing situation due to their
participation in the study. None of the drugs used in the course of this study had
Harmful side effects.

2.6 Sample size and sampling procedure:

A total of 22 cases meeting the enrolment criteria ware selected consecutively from
the study population.

2.7 Data collection:

Data were collected from the selected patients using a pre-designed structured
Questionnaire starting from a demographic characteristic, clinical history, a detailed
clinical examination, per operative findings and postoperative outcome including
complications.

2.8 Operational definitions:

Pressure sores are best defined as soft tissue injuries resulting from unrelieved
pressure over bony prominence.

27
Staging of pressure sore: Staging of pressure sore was done by National Pressure
Ulcer Advisory Panel system. The staging system is skewed toward early signs of
ischemia, encouraging early detection and intervention.

Stage I: Porsistent nanblanchable erythema of intact skin. Most common of all pres-
sure ulcers. "At risk" person.

Stage II :Partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is

superficial and presents as an abrasion, blister, or shallow crater.

Stage III: Full-thickness skin lass involving subcutaneous tissue that may extend
down to, but not through, underlying fascia.

Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or dam-
age to muscle, bone, or supporting structures (e.g. tendon, joint capsule).
Undermining and sinus tract may also be present.

If an eschar is present, the sore cannot be accurately staged until it is fully debrided.
Skin erythema may be the only visible sign, even when underlying muscle necrosis
has already occurred.

Stage I and Il pressure ulcers are usually treated conservatively while stage III and
IV resistant pressure ulcers require flap reconstruction.

Outcome:
The outcome was categorized as follows:

Good
No flap loss
For hematoma/No seroma
No infection
Excellent flap adhesion
Complete wound coverage

28
Acceptable : Marginal flap necrosis
Flap salvageable
Haematoma/Serama developed
Flap adhesion occurs after intervention
Comploto wound coverage after intervention

• Pear : Major flap slab

Flap not salvageable
Allamate procedure required

Flap morbidity was considered when there was flap loss or marginal necrosis.

Donor site morbidity was considered when skin grafting was required to cover the
defect or when hypertrophic scar was formed at the donor site

2.9 Detailed procedure

All patients were prepared with nutritional support, anemia was corrected by blood
transfusion and wounds were freed from infection by antibiotics according to culture
and sensitivity tests and by dally dressings. Serum albumin was achieved >3gm/dl

Equipment’s used:
Regular mathematical scale was used to take the measurements. All
measurements were recorded in centimeters.

Operative procedure
a) Wound preparation
The operation was done under spinal anesthesia. Excision of the ulcer was done in
such a way so as to make the resultant defect into a broad vertical ellipse. It included
excision of all the scared tissue, surrounding bursae and calcified soft fissures well
down to the healthy looking tissues. The bony prominences were osteotomies and
the irregularities resulting from the osteotomy were smoothed with a osteotome to
have an evenly contoured sacrum. Proper hemostasis was ensured by application of
pressure, using diathermy, bone wax. The flap outline was planned based on size
and orientation of excised area.
29
b) Operation proper
The superior and Inferior gluteal arteries were identified using anatomical landmarks
like posterior superior iliac spine, greater trochanter of the femur and ischial
tuberosity as surface landmarks. The superior gluteal artery (SGA) was marked on
the skin of the buttock at a place one-third of the way on a line drawn from the
posterior superior iliac spine to the top of the greater trochanter. Likewise the inferior
gluteal artery (IGA) was marked on the skin of the buttock at a place two-thirds of the
way on a line crown from the posterior superior ilac spine to the ischial tuberosity.
The skin was designed as V-Y advancement, with its base along the sacrum and its
sides along the superior and inferior border of gluteus maximus. converging on its
insertion in the greater trochanter. Skin Incision was given as per design of the taps.
The flaps were advanced medially as per requirement of the defect. The wound was
closed primarily in layers with low negative suction drains.
Postoperative management:
All patients were put on a standard postoperative regime including:
 keeping negative suction drain until they produced less than 10 cc of fluid per
day,
 maintaining low residual diet in the first week,
 Prone or lateral decubitus position to avoid pressure on the flap.
 maintaining nutrition, hydration, oxygenation and correction of anemia to
expedite wound-healing process,
 intravenous antibiotic coverage was continued postoperatively according to
wound swab culture and sensitivity report
 check dressing was done on 3 and 6 postoperative day,
 flap was monitored: first 24 hours 2 hourly, next 48 hours-4 hourly and next 7
days daily

30
 Table-I: Post operative flap monitoring
Monitoring variables Findings
Colour Pink Pale
Temperature Normal Cool medial margin
Tissue Turgor Normal Deceased
Pin-prick test Punctate red blood comes Dusky blood comes out
out
Blister formation Absent Present
Comment Viable flap Nonviable flap

Vascular compromise may be arterial or venous. Venous is more common than

arterial. If any flap shows cyanosis or congesion within
72 hours of surgery, following things should be dane-
 Removal of all dressings
 Removal of any presure over flap pedicle
 Removal of all stitchos
 Avoid any kinking of flap
 Even flap may need return back to its own position or flap delay
may be needed
Normal body temperature, well hydration and pain free state should be maintained
as wall.
If any part of the flap necrosed then excision of necrosed portion as early as possible

c) Removal of stitches:
Stitches were removed at the end of second postoperative weeks. Education for
provention of recurrence continued after discharge. The successful post operative
management of pressure sores depends on two essential conditions: modifying the
factors that contribute to ulcer formation and teaching "pressure consciousness to
the patient.

d) Management of the complications

31
Management of complications was done according to the nature of complications
developed. Medial marginal necrosis (< 1 cm) was salvaged by excising the
necrosed margin and closure of the wound with secondary sutures, Follow up of the
patients

All the patients were advised to come for follow up at 1, 3 and 6 months
postoperatively.

2.10 Statistical analysis of data:

Collected data were processed and analyzed using SPSS (Statistical Package for
Social Sciences) for Windows, version 11.5. Descriptive statistics were used to
analysed the data. The results were presented in the form of tables and figures with
due interpretation.

32
 Chapter Three

Observations and Results

33
 Result
3.1 Demographic characteristics:
Age distribution shows that 3(13.0%) patients were below 20 years old, 6(27.3%) in
their 2 decades of life, 4(18.2%) in 3 decades, another 4(18.2%) in 4th and 5(22.7%)
in 5 decades and onwards. The mean age of the patients was 34.5 years and the
youngest and the oldest patients were 14 and 60 years old respectively. A male
predominance was observed with male to female ratio being 3:2. Primary and
secondary level educated each comprised about one-third (31.8%) and illiterates
formed 27.3% of the patients. In terms of occupation about one-third (31.8%) was
farmer and 22.7% were student (Table 1).
Table II. Distribution of patients by demographic
Demographic characteristics Frequency Percentage
Age (Yrs)
<20 03 13.6
20-300 06 27.3
30-40 04 18.2
40-50 04 18.2
≥50 05 22.7
Sex
Male 13 59.1
Female 09 40.9
Education
Illiterate 06 27.3
Primary 07 31.8
Secondary & higher Secondary 07 31.8
Graduate and above 02 9.1
Occupation
Service 02 9.1
Business 04 18.2
Famer & day laborer 07 31.8
Student 05 22.7
Housewife 04 18.2
*Mean age=(34.5±15.1) years; range=(14-60) Yeas.
3.2 Etiology of primary disease:

34
Nearly three-quarters (72.7%) of the patients were bed-ridden due to spinal cord
compression (12 patients had spinal cord injury, 2 patients had spinal cord infection
and 2 patients had tumor), 4.5% due to fracture of the femur or pelvis and 22.7% due
to other reasons (Fig.1).

80 72.7

70
60
Percentage

50
40
30 22.7

20
4.5
10
0
Spinal cord compression Femoral pelvis fracture Others
Etiology of primary disease

Fig. 1: Distribution of patients by etiology of primary disease (underlying disease)

35
3.3 Preliminary management:
Investigating about the past treatment of underlying disease for developing sacral
pressure sores revealed that over three-quarters (77.3%) of the patients received
conservative treatment, 18.2% surgical treatment and some 4.5% did not receive
any form of treatment (Figure 2).

90

80 77.3

70

60
Percentage

50

40

30

20 18.2

10
4.5
0
Surgical Non-surgical None
Preliminary management

Fig. 2: Distribution of patients by their preliminary management.

36
3.4 Nutritional status:

In terms of nutritional status, 5(22.7%) patients ware underweight and 3(13.6%) were
overweight or obese. The rest 14(63.7%) were of normal weight for their height
(table III). 86.4% patients were anemic (hemoglobin level <10gm/dl) (table IV).
Serum albumin level wore >3gm/di in 3 patient and <3gmidi in rest of the patients.

Table III. Distribution of patients by their BMI (n=22) BMI (kg/m²)

BMI* (kg/m2) Mean±SD Range

<18.5 (Underweight) 05 22.7
18.5-25 (Normal) 14 63.7
≥25 (Overweight & obese) 03 13.6

*Mean BMI = (22.8±2.2) kg/m²; range (18.5-29.1) kg/m³,

Table IV. Distribution of patients by anemia (n=22)

Anemia Mean±SD Range

Present 19 86.4
Absent 03 13.6

37
3.5 Physical characteristics of lesion:

Study of characteristics of the lesion shows that over two-thirds (68.2%) of the ulcers
were in Stage-III and the rest in Stage-IV. The average horizontal and vertical
lengths of the defect before excision were 10.4 and 8.8 cm respectively. Discharge
were invariably present in the sores (12 patients showed light exudates, 10 patients
showed moderate exudates and none showed heavy exudates). Over three-
quarters (77.3%) of those had signs of local infection which was confirmed by wound
swab culture and sensitivity test. In about one-third (31.8%) lesions the underlying
bone was exposed (Table V).

Table V. Distribution of patients by characteristics of lesion (n = 22)

Characteristics of lesion Frequency Mean ±SD Range

(%)
Stage of ulcer
Stage –III 15(68.2) ---- ----
Stage-IV 7(31.8)
Horizontal length of defect ---- 10.4±2.6 7-15
Before excision (cm)
Vertical length of defect ----- 8.8±2.6 5-12
Before excision (cm)
Local infection 17(77.3) --- ---
Exudates 22(100.0) ---- -----
None 0
Light 12
Moderate 10
Heavy 0
Bone exposed 7(31.8) ---- ------

38
3.6 Per operative findings:
The average horizontal and vortical lengths of the defect after excision of dead and
devitalized fissues were 12.6 and 10.6 cm respectively. The medial advancement of
the flap was 6.3 cm. The mean operative time was 168.4 minutes. All of the patients
required blood transfusion before or during operation (Table VI).

Table VI. Distribution of patients by their per-operative findings (n = 22)

Per operative findings Mean±SD Range

Horizontal length of defect after excision 12.6±2.4 10-16

(cm)

Vertical length of defect after excision (cm) 10.6±2.4 7-14

Medial advancement of flap (cm) 6.3±1.2 5-8

Operative time (min) 168.4±38.3 100-245

39
3.7 Complications developed:
In-hospital outcome of the patients demonstrates that only 2(9.1%) patients had
medial marginal flap loss (<1 cm). Postoperative flap-monitoring did not reveal
infection, seroma, hematoma or wound dehiscence in any of the patients (Table VII)

Table VII. Distribution of patients by postoperative complications (n = 22)

In-hospital outcome Frequency (%) Median ±SEM Range

Flap loss

Marginal loss 2(9.1) -- --

No loss 20(90.9)

Infection 0(0.0) --- ---

Seroma 0(0.0) --- ---

Hematoma 0(0.0) --- ---

Wound dehiscence 0(0.0) --- ---

40
3.8 Management of complications:
In two patients marginal flap loss ware excised and secondary suturing were done
(Table Vill). Medial marginal necroses were salvaged by excising the necrosed
margin and closure of the wound with secondary sutures.

Table VIII. Management of complications (n = 22)

Management of complications Frequency Percentage

Conservative 0 00.0

Excision and secondary suturing 2 9.1

Excision and advancement 0 00.0

Reconstruction with altemate procedure 0 00.0

41
3.9 Postoperative hospital stay:
Majority (90.9%) of the patients required> 14 days to stay in the hospital following
operation. The median postoperative hospital stay 17.3 ± 2.4 days and the shortest
and the longest stays in the hospital following operation were 13 and 22 days
respectively (Table (X).

Table IX. Distribution of patients by postoperative hospital stay (n = 22)

Postoperative hospital stay" (days) Frequency Percentage

>14 20 90.0

<14 02 9.1

Mean±SD=17.3±2.4; range=(13-22)days.

42
3.10 Final Outcome:
More than 90% of the patients exhibited good outcome. In two patients the outcome
was considered acceptable (Table X).

Table X: Distribution of patients by final outcome (n=22)

Final outcome Frequency Percentage

Good 20 90.9

Acceptable 2 9.1

Poor 0 00.0

43
3.11 Recurrence of sacral pressure sores:

None of the patients developed recurrence with in the follow up period (Table XI).

Table XI: Distribution of patients by recurrence (n=22)

Recurrence Frequency Percentage

At 1st month 00 0.0

At 3rd month 00 0.0

At 6th month 00 0.0

44
 Chapter: Four

Discussion

45
 Discussion
4.1 Discussions on the results
In the search for improved result in reconstruction surgery, surgeons have used a
variety of flap techniques to achieve excellence in form and function (Geddes et al.,
2003). Sacral pressure sores are the common "sores" seen in patients confined to
bod during medical and surgical emergencies where the patient is comatose and
particularly common in patients with paraplegia. Most of these patients are found to
have been nursed in supine position without timely and adequate change of posture
because of ignorance and callousness.

There are so many surgical options for closure of sacral sores but the principles in
the treatments of sacral pressure sores are same, include total excision of the ulcer,
complete removal of all infected bones, careful hemostasis and closure of The
wound with well vascularized flap. Appropriate low negative suction drainage with
obliteration of all potential "dead spaces" is mandatory (Conway H and Griffith BH,
1956)

Today a great variety of techniques are available to reconstruct sacral pressure

sores. Because of this, one should select an appropriate method and not use a
particular technique for all defects. We found Gluteal skin flap to be suitable and
advantageous for closure of sacral pressure sores.

The present study was done to qualify the gluteal skin flap as a sacral sore
coverage. This is a prospective interventional study carried out at the department of
Plastic Surgery, Dhaka Medical College and Hospital from January 2012 to
December 2012. The sample size was 22.
The mean age of the patients was 34.5 years and the youngest and the oldest
patients were 14 and 60 years old respectively. Twenty seven percent of the patients
were between 20-30 years age group and twenty three percent of the patients were
>50 years age group. A male predominance was observed with male to female ratio
being 3:2. Educational status and nature of occupation do not carry any impact on
pressure sore development & management. These demographic data of this study

46
runs more or less similar with the observations of the SH Khundker and MA Kalam
(2000) and Serhan Tuncer et al (2004).

Regarding the etiology of the primary diseases for which patients were bed ridden for
long time sufficient to develop sacral sores in this study were observed as follows:
more or less 72.7% ware due to traumatic spinal cord compression, 4.5% due to
fracture of femur & pelvis and 22% due to other causes like meningitis, cardio
vascular disease, transverse myelitiss etc. For those primary diseases about three
quarters received conservative treatment, less than one quarter received surgical
treatment and few patients did not receive any treatment.This etiological study is
very much consistent with the study of Edberg et al. (1973), Kosiak M (1959) and
Maklebust J. (1987).
Nutritional status including BMI, percentage of hemoglobin, serum albumin level is
very important parameter for flap take up & survivality. In present study, 22.7%
patients were underweight and 13.6% were overweight or obese and the rest 63.7%
were of normal weight for their height. 86.4% patients were anemic. So most of the
patients were prepared with nutritional support and anemia was corrected by blood
transfusion.

Physical characteristics of the lesion are very much important to quality the severity
of the lesion. Not only is the dimension of the wound but deeper involvement like
muscle and bone also important. It is being mentioned earlier that classification of
Shee is followed in this study to qualify the severity of pressure sore, starting from
stage I to stage IV. Here two thirds of the defects were in stage III & rest in stage IV.
Discharge was invariably present in the sores and over three-quarters (77.3%) of
them had signs of local infections. None of the lesions was fixed to the underlying
structures.

The average horizontal and vertical lengths of the defects before excision were 10.4
and 8.8 cm respectively and after excision of dead & devitalized tissues the
horizontal and vertical lengths were increase to 12.6 and 10.6 cm respectively. The
medial advancement of the flaps was 6.3 cm. The mean operative time was 168.4
minutes. The above observation of the study runs more or less parallel to the study
of SH Khundker & MA Kalam (2000) and Yuan Sheng Tzeng et al. (2007).
47
Complications of gluteal skin flap surgery were observed vary carefully in the early
post operative period in terms of flap loss, infection, seroma, haerrnatama & wound
dehiscence. The data were collected as follows: only two patients exhibit medial
marginal flap necrosos which wore salvaged by minor surgical procedures but none
of the patient revealed seroma, infection, haematoma or wound detiscence. It can be
concluded that complications were very minimal & negligible. This observation is
consistent with the study of SH Khundker & MA Kalam (2000) and Constantian M
(1980). But the study does not coincide with the study of Serhan Tuncer et al (2004)
where the incidence of post operative complication was higher. This may be due to
selection of the patients with co morbid conditions and larger sample size.

The final outcome of the patients was assessed in terms of good, acceptable & poor.
The outcome categorized as good when there was no flap loss, no infection, no
haematoma/seroma, excellent flap adhesion and complete wound coverage. On the
other hand, the flap was categorized as acceptable when them was marginal flap
necrosis, flap salvageable, developed haematoma/seroma, flap adhesion occurs
after intervention and complete wound coverage after intervention. And the outcome
was categorized es poor when there was major flap loss, flap was not salvageable
and alternate procedure was required. The present study conducted to evaluate the
outcome of Gluteal skin flap, composed of skin and subcutaneous fat, sparing
gluteus maximus muscle, which demonstrated good outcome in more than 90%
cases, acceptable outcome in rest (9.1%) of the cases & none of them exhibit poor
outcome.

In this study, majority (90.9%) of the patients required 14 days hospital stay following
operation. The shortest and the longest stays in hospital following operations were
13 and 22 days respectively. In other study done by Capen, 1988 the average length
of post operative hospital stay was 3 months.

None of the patients developed recurrence within the follow up period. Hentz (1979)
found that pressure sore recurrence is proportionate to post operative complications.
48
As no significant complications developed in the present study, recurrence at 6
month follow up was absent. There was no recurrence after four years of surgical
closure of sacral pressure sore by SH Khundkar and MA Kalam
(2000). Thus the success rate of the present study is consistent with the study done
by SH Khundkar and MA Kalam (2000). This similarity may be due to similar patter
of geographical status and post operative management was adoquato and sample
size of both study were excluded from distinct co morbid pathology. In other studies
the outcome was poor than that of present study in terms of recurrence, like Serhan
Tuncer et al. (2004), Remirez et al. (1990), Conway and Griffith et al. (1956). This
inay be due to inclusion of patients with distinct co morbid diseases, patients with
recurrences and poorly nourished patients, large sample size and longer duration of
follow up.

Pressure sore management has been Improved through the development of

musculocutaneous flaps causing significant reduction in the incidence of wound
complications. The use of gluteus maximus muscle or musculocutaneoaus flaps to
close sacral pressure sores considered to be a revolutionary method because of the
reliability of blood flow. However, mobilization of gluteus maximus muscle is little bit
complicated and causes much blood loss. In addition, in case of paraplegic patients
the gluteus maximus muscles may have been already atrophied. On the contrary.

gluteus maximus muscle is an important muscle in ambulatory person because it is

the primary extensor and abductor of the hip. It is necessary for climbing, rising from
a stooped position and standing on one leg. So gluteus maximus muscle is not an
expendable muscle. Therefore, using gluteus maximus myocutaneous flap in
ambulatory patients should be avoided (Fisher et al., 1983; Ramirez et al., 1987 and
Stevenson et al., 1987).

A number of similar studies conducted in 1980s showed that a passive muscle

carrier is not necessary for flap survival if careful dissection of the musculocutaneous
perforator vessels is accomplished. By selective harvesting of the skin above the
underlying muscle, a reduction of donor-site morbidity has been demonstrated
(Constantian, 1980). If only skin is needed for a specific reconstruction, it is logical to

49
transfer skin only to the recipient site, preserving the integrity of the muscle at the
donor-site.

In case of perforator flap, dissection of the perforator is tedious, require the use of
loupe magnification and the aid of bipolar diathermy and vessel microdips to control
the tiny musculature branchos of the perforators. Sometimes fil skeletonization of the
perforator vessel is required to help the flap to reach to the recipient site which carry
the risk of stretch, kink or twist that can lead to complications such as vasospasm or
even blockage of blood flow with total loss of the flap (Yuan-Sheng Tzeng et al.,
2007 and Kroil and Rosenfield, 1988).

Free flap coverage is a time-consuming procedure. Reconstruction by free flap

requires highly skilled micro vascular anastomoting technique and needs expertise.
Microsurgical free flap can only be considered where local tissue is not available
(Foster RD, 2006).

Therefore, advantages of gluteal skin flaps over the musculocutaneous flaps include
muscle sparing, less donor-site morbidity, versatility in flap design improve
postoperative recovery of the patients. Although the flap is thinner than it's
myocutaneous variant, which is considered by some authors as a drawback of the
gluteal skin flap, yet it meets the reconstructive requirement of the defect as the
parasacral area is naturally devoid of muscles (Geddes et al., 2003). In addition to
the fact that skin and subcutaneous tissue are less sensitive to ischemia than
muscle, therefore, Gluteal skin flap in closure of sacral pressure sore is preferable.

50
4.2 Limitations of the present study

a) The sample size was smell.

b) For any statistical analysis large sample is required.
c) Short period of post-operative follow up.
d) Distinct comorbid patients were excluded.
e) No control group.

51
4.3 Conclusion
From the findings of the study and discussion thereof, it can be concluded that
Gluteal skin flap produces good result in majority of the patients having large sacral
sores with almost no complications or recurrences. None but two cases had medial
marginal flap loss. These findings are almost comparable to those obtained from
musculocutaneous, and perforator flaps with the advantages of muscle sparing
which could be kept preserved for management of recurrences if occurs in future,
less donor-site morbidity and versatility in design.

52
 References Cited

53
References
Alan WE, 1982. The effect of denervation on son-lisaune infection pathophysiology
Plast Recool Borg 10, 101-1033

Bauer D, Manncall 5, Phillipe G, 2007. Pressure sores. In CH Thome, ed. Grabb &
Smith's Plastic Surgery, 6 edtion, Prisladolphia: Lippincott & Wilkins, 722-729.

Brown-Sequard E, 1852. Experimental research applied to physiology and

pathology. Med Exam Rec. MedScl, 10, 4101.

Capen DA et al., 1988. Staged total thigh rotation flap for coverage of chronic
recurrent pressure sores. Contemp Orthop, 16,23-26.

Coleman JJ and Jurkiewicz MJ., 1984. Methods of previding sensation to

Anestheticareas.Ann Plast Surg, 12, 177-180

Constantian M, 1980, Pressure Ulcers: Principles and Techniques of Management

Boston: Little Brown.

Conway H and Griffith BH. 1966. Plastic surgery for closure of decubitus ulcers in
patients with paraplegia: Based on experience with 1000 cases. Am J Surg, 91,946-
940

Culliferd T, Levine P.2006. Pressure sores. In Joseph G. McCarthy, Robert D.

Galiono, Sean G. Boutros, eds. Current therapy in plastic surgery. Ptiladelphia:
Elsevier, 383-389

Daltrey DC, Rhodes B, and Chattwood JG., 1981. Investigation into the microbial
flora of healing and nonhealingdecubitus ulcers. I Clin Palhol, 34,701-705.

Danniel RK, Faiblosoff B., 1902. Muscle coverage of pressure points: the role of
myocutaneous flap, Ann Pist Surg, 8,446-450.

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Dharmarajan TS, Ahmed S.,2003. The growing problem of pressure ulcers.
Evaluation and management for an aging population, Postgrad Med, 113(5):77-78,
81-84, and 88- 190.

Dibbell DC., 1974.Use of a long island flap to bring sensation to the sacral area of
young paraplegics. Plast Keconstr Surg, 54,220-227.

Dinsdale SM., 1974.Decubitus ulcers: Role of pressure and friction in causation,

Arch Phys Med Rehab,55,147-157.

Edberg EL, Cerny K, and Stauffer ES., 1973. Prevention and treatment of pressure
sores. Phys Thar, 53,246-251.

Esposits G., 1001.Tissue expansionin the nannt of pressure ulcers. Pland Recoest
Surg, 87,501-511.

Fisher 1 Amold PG, Waldorf Woods JE, 1083. The glutnus maximus
miesculbcutaneous V-Y Rap for larga sacral defacis. Ann Plast Surg, 11,517-622.

Foster R D, 2006. Pressure sores. In Stephen J. Mathes, ed. Mathes Plastir,

Surgery. Vol-&. 2. Philadelphia: Elsevier, 1317-1363

Fowler EM, 1987.Equipment and products used in management and trentinent of

prasaune ulcers. Nurs de North Am, 22,440-452.

Ger R., 1971. The surgical managerment of decubitus ulcers by muscle

transposition. Surgery, 69(1): 106-110

Geans DJ, 1973. An assesment tool to identify pressure sores Nurs Res, 22,55-58.

Hents VR 1979 Management of pressure sonss in a specialty center: A reappraisal

Plast Reconstr Surg, 64,683-600.

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Hurwitz DJ, Swartz WM, Mathes SL., 1991. The gluteal flap: a reliable sesale flap for
the coverage of buttock and perineal wounds. Plast Reconstr Surg 68,521-524.

Khundker SH, Kalem MA, 2000, Gluteus maximus myocutaneous lap for closure of
targe sacral soren in paraplegic patients. Journal of Bangladesh College of
hysicians & Surgeons, 18(2),66-9.

Koshima 1, Moriguchi T. Soeda S, Kawata S, Ohta S, Ikeda A., 1988. The gluteal
perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg,
1,678- 681.

Kosiak M., 1959. Etiology and pathology of ischemic ulcans. Arch Phys Med Rehab,
40,62-68.

Kroll SS and Rosenfield L., 1988, Perforator-based flaps for tow posterior midline
defects. Plast Reconstr Burg, 81,561-666.

Lewis VL. Jr., 1988. The diagnosis of osteomyelitis in patients with pressure sores.
Plast Reconstr Surg, 81,229-232.

Mahboob T.,2004.Superior gluteal artery perforator flap for closure of large sacral
defects. Egypt J Plast Reconstr Surg, 28(2),175-9.

Maklebust J., 1987, Pressure ulcers: Etiology and prevention. Nurs Clin North Am,
22,359-262.

McGregor Alan D, McGregor lan A. Eds. 2000. Fundamental techniques of plastic

surgery. 10 edilion. Philadelphia: Elsevier, 135-141.

National Pressure Ulcer Advisory Panel Pressure ulcers: incidence, economics, risk
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Publications, 1980;

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Norton D. McLaren R, and Exton-Smith AN., 1962. An Investigation of Geriatric
Nursing Problems in Hospital. London: Churchill Livingstone, 194-230

Ramirez OM, 1990. The sliding placation gluteus maximus musculocutaneous fiap
for reconstruction of sacrococygeal wound. Ann Plast Surg. 24,223-228.

Reddy M, Keast D, Fowler E, Sibbald RG., 2003. Pain in pressure ulcers. Ostomy
Wound Manage, 40(4),30-5.

Riggs A, 2003. Pressure ulcers lead to increased mortality, liability. Prevention,

treatment require planning, team work. J Arc Med Soc, 100(5), 160-1,

Serhan Tuncer et al., 2004. Outcomes for reconstruction of sacral defects using
superior gluteal artary perforator flap: comparison with random pattern
fasciocutaneous flaps, Clin Plast Surg 30,371-382

Sugarman 8,1987.Pressure sores and underlying bone infection. Arch Intern Med,
147,553-557,

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Ungar GH, 1971. The care of the skin in paraplegia. Practitioner, 206,507-510

Yuan RTW, 1988. The use of tissue expansion in lower extremity wounds in
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57
 Appendices

xiii
Appendix-I

Data Collection Sheet

(Dept. of Plastic Surgery, Combined Military Hospital, Dhaka)

Title: Surgical closure of sacral pressure sores by Gluteal skin flap-a

prospective interventional study.
SL No. ...................................
Name:.........................................................................................................
Address : .......................................Unit..........................Reg.No................
Baseline characteristics:
Demographic Characteristics:
1 Age: ........................................yrs
2 Sex: 1= Male 2=Female
3. Education: 1= Illiterate 2=Below primary 3=Primary
4=Secondary 5=Higher secondary 6=Graduate and above
7= Non-formal
4. Occupation 1=Service 2=Business 3=Farmer 4=Day laborer
5=Student 6=Housewife 7=Others
5. Weight .......................kg
6. Height ......................cm
7. Reasons of being bed-ridden: 1=CVA2=Vertebral column disorder
(2a=spinal cord injury, 2b= spinal cord infection, 2c= tumour)
3=Traumatic brain injury 4= Fracture femur/pelvis 5= Others
8. Past treatment received: 1=Surgical 2= Non-surgical
3= Others 4= None

xiv
Baseline characteristics of the patients and lesion :
9. Anemia: 1=Yes 0= No
10. Serum albumin 1=<3gm/dl 2=>3gm/dl
11. Stage of ulcer: 1=Stage-III 2=Stage-IV
12. Horizontal length of the defect:.......................cm
13. Vertical length of the defect:.............................cm
14. Local infection : 1= Present 0=Absent
15. Exudates : 1=None 2=Light 3=Moderate 4=Heavy
16. Foul smell: 1=Present 0=Absent
17. Bone exposed : 1= Yes 0=No

Per-operative findings :
18. Horizontal length of the defect (after exclusion) :............cm
19. Vertical length of the defect (after excision):..............cm
20. Medial advancement of flap: ...........................cm
21. Operative time ...........................min
22. Blood transfusion needed: 1=Yes 0=No

Postoperative complications
23. Wound Infection 1=Developed 0= Not developed
24. Wound Infection 1=Developed 0=Not developed
25. Flap loss 1= Major loss 2= Marginal loss 3= No loss
26. Postoperative hospital stay: ........................days

Follow up at month 3
27. Recurrence of sore: 1=Yes 0=No

xv
Follow up at month 3
28. Recurrence of sore: 1=Yes 0=No

Follow up at month 6
29. Recurrence of sore: 1=Yes 0=No

Management of complications :
30. Management : 1= Conservative 2=Excision & secondary suturing
3= Excision & advancement 4= Reconstruction with alternate
procedure 5= Not applicable
Final comment:
31. Outcome : 1= Good 2=Acceptable 3= Poor

xvi
Appendix-II
Consent Form (Bangla)

AewnZKviY cye©K m¤§wZcÎ

 cÖ‡UvKj AvBwW-wc.G.Gb-0019

 M‡elbvi wk‡ivbvg- Surgical Closure of Sacral Pressure Sores by Gluteal

Skin Flap –A Prospective Interventional Study
 M‡el‡Ki bvg –Wv. †gvnv¤§` iweDj Kwig Lvb|
 cÖwZôvb- XvKv †gwW‡Kj K‡jR nvmcvZvj|
 M‡elbvi jÿ¨-‡Kvg‡ii Sacral wcQ‡bi ÿZ ¯’vbwU MøywUqvj w¯‹b d¬¨vc
Gluteal skin flap †U‡b G‡b Uvb gy³ Ae¯’vq †mjvB K‡i eÜ Kiv n‡e|
Acv‡ik‡bi c~‡e©, Acv‡ik‡bi mgq I Acv‡ik‡bi c‡i wewfbœ Z_¨ msMÖn
Kiv n‡e I Qwe DVv‡bv Ges d¬¨vc Gi djvdj wbiæcb Kiv n‡e|
 †ivMx wbe©vPb-Avgv‡`i wKQz evQvB c×wZ Av‡Q| Avcbvi †ivMxi
ÿZwPüwU GB c×wZi Dchy³ nIqvq GB M‡elYvi Rb¨ wbe©vPb Kiv
n‡q‡Q|
 †ivMxi Kibxq- Avgiv Avkv Kwi †h, Avcwb Avgv‡`i wb‡`©k
Abymi‡Yi gva¨‡g Avgv‡`i mn‡hvwMZv Ki‡eb| wewfbœ mg‡q cixÿvi
Rb¨ Avgv‡`i mv‡_ †hvMv‡hvM Ki‡Z n‡e|
 SuywK-M‡elYvKv‡j AÁvb I Acv‡ikb RwbZ Kvi‡b wewfbœ RwUjZv
†`Lv w`‡Z cv‡i, ÿZwP‡üi Pvgov AvswkK ev m¤ú~©b bó n‡Z cv‡i| Z‡e
Giæc RwUjZvi m¤¢vebv Ab¨ †h †Kvb c×wZ‡Z GB †iv‡Mi A¯¿cPv‡ii
†P‡q †ekx bq †Kvbiæc RwUjZv †`Lv w`‡j Zvi cÖwZKv‡ii e¨e¯’v AÎ
nvmcvZv‡j MÖnb Kiv n‡e|
 †MvcbxqZv-Avcbvi / †ivMxi cwiPq ev e¨w³MZ Z_¨vw` GB M‡elYvq
cÖKvk Kiv n‡e bv| ïaygvÎ ÿZwP‡üi, Gi A‡¯¿vcPvi Ges Gi djvdj msµvšÍ
Z_¨vw` e¨envi Kiv n‡e|
 bvg cÖZ¨vnv‡ii AwaKvi-Avcwb GB M‡elYv n‡Z †h †Kvb mq bvg
cÖZ¨vnv‡ii AwaKvi ivL‡eb| Avcwb Avgv‡`i M‡elYvq AšÍf’w³i

xvii
 cÖ¯Ív‡e m¤§Z _vK‡j Avcbvi ¯^vÿi A_ev evg e„×v½yjxi Qvc wbw`©ó
¯’v‡b cÖ`v‡bi gva¨‡g Zv cÖKvk Kiæb&

†ivMxi/Awffve‡Ki ¯^vÿi ev wUcmn M‡el‡Ki ¯^vÿi

ZvwiL

xviii
Appendix-III
Informed Written Consent (English)
1. Protocol ID: PSN-0019
2. Title of the study: "Surgical closure of sacral pressure sores by Gluteal
skin flap - a prospective interventional study.
3. Investigator's name: Dr. Mohammad Rabiul Karim Khan.
4. Institution: Dhaka Medical College Hospital.
5. Purpose of the study: Evaluation of efficacy of surgical closure of sacral
pressure sores by Gluteal skin flaps.
6. Selection of the participant: By Inclusion and exclusion criteria among the
admitted patients in Plastic Surgery Department of Dhaka Medical College &
Hospital during the study period who has stage III & IV sacral pressure sores.
7. Expectation from and involvement of the participant: Clinical
assessment, performing operation under spinal anaesthesia, regular follow up
after operation and taking photographs are expected from participant
8. Risks and benefits: There is no risk of this study. Flap will provide durable
coverage. If any complication does occur regarding anaesthesia and flap,
necessary care shall be provided until the recovery.
9. Privacy, anonymity and confidentiality: Patient's identity or any personal
information shall not be disclosed in this study. Only the data regarding the
surgical procedure and outcome of surgery will be used..
10. Right to withdraw: Participant shall have the right to withdraw from this
study at any point of time.
If you agree to our proposal of enroling you / your patient in our study and
giving permission for taking photograph, please indicate that by putting your
signature or your left thumb impression at the specified space below.

Thank you for your cooperation.

Signature or left thumb impression Signature of investigator

of participant or guardian Date:

xix
 Patient’s Pictures

xx
 Glossary
CMH : Combined Military Hospital
RTA : Road Traffic Accident
cm : Centimeter
SGA : Superior Gluteal Artery
IGA : Inferior Gluteal Artery
PSIS : Posterior Superior Iliac Spine
GT : Greater Trochanter
IT : Ischial Tuberosity
BMI : Body Mass Index

xxi