Author Archives: Adam Peck

Surgical Treatment of Bed Sores

There are many different types of surgeries used to treat pressure sores, bed sores and decubitus ulcers. Debridement is an option to surgically clean and remove any dead or infected skin and muscle. This debriding creates a larger wound, but the area is healthy and more likely to heal. In many cases a small amount of bone is also removed from the base of the wound to decrease recurrence of infection. In some cases, the hip joint will need to be removed along with a portion of the thigh bone.

Reconstructive surgery involves the removal of healthy tissue from one place on the body to cover a wound somewhere else. The skin and/or muscle (the flap) is usually taken from the back, buttocks or thigh. This flap tissue, which has a good blood supply, is repositioned to cover the wound and help nourish the tissue around the pressure sore. Once the pressure sore is covered, the area where the flap tissue was removed is closed. Sometimes skin grafts are used to close these areas.

Multiple Pressure Sores

Some people have more than one pressure sore. It is not uncommon that surgery on these areas must be spread out over more than one surgery. If reconstruction can be accomplished with a single operation, it may require a more radical treatment option if there are multiple or very large wounds. In severe cases, a leg may be amputated to provide the necessary tissue for the reconstruction. For example, a total thigh flap requires amputation of the leg so the skin and muscle from the front of the thigh is used to fill the wound.

Postoperative Care

After surgery, it is very important take care of the repaired area to reduce the risk for complication. Care starts with transferring from the operating table to the air-fluid bed. Patients are positioned flat in the air-fluid bed for 4 weeks. Movement is limited to prevent shearing and tension across the flap repair. After 4 weeks, patients can be wedged carefully into the semi-sitting position. Six weeks after surgery, patients can begin sitting for 10-minute intervals. After each interval, the flap area is examined for discoloration and wound edge separation. The sitting periods are increased at 10-minute intervals over 2 weeks and reaching up to 2 hours of sitting at a time. Pressure reliefs are needed for 10 seconds at least every 15 minute while sitting. Patients will need to continue using a pressure-reducing mattresses and turn in bed every 2 hours.

Individuals with SCI have other concerns. Involuntary muscle spasms must be well controlled to allow proper healing after surgery. Bacteria, which is the source of infection, is easily brought into the bladder with Intermittent Catheterization, Foley, and Suprapubic methods of bladder management. It is important to prevent infections, and antibiotic treatment is needed if bacteria are present in urinary cultures or urinalysis.

Special equipment is also needed to allow healing to progress normally. Because this is so important, all equipment are secured before surgery is scheduled. The equipment might include a pressure-reducing mattress (such as an air-fluidized bed or low air loss mattress) and a proper seat cushion for patients using wheelchairs. In addition, plans for recovery include setting up home health care or staying in a rehabilitation facility or assisted living center to recover.

In most cases, the area of the pressure sore and reconstructive flap does not have sensation. It is also important to note that reconstruction cannot restore normal sensation. Wound disruption or delayed wound healing is possible, and some areas of the flap skin may heal abnormally or slowly.

Without these precautions, wound breakdown or pressure sore recurrence is extremely likely. Treatment may require frequent dressing changes or further surgery to remove the non-living tissue and an additional reconstructive procedure.

Risks of Flap Reconstruction

Every surgical procedure involves a certain amount of risk, and it is important that you understand the risks involved with the reconstruction of a pressure sore. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience the following complications, you should discuss each of them with your surgeon to make sure you understand the risks, potential complications, and consequences of reconstruction with flap surgery.

Bleeding is possible during or after surgery. If bleeding occurs, it may require emergency treatment to drain accumulated blood (hematoma).

Infection can occur after surgery. Should an infection occur, treatment including antibiotics or additional surgery may be necessary. If an infection does not respond to antibiotics, the reconstruction may need to be opened. After the infection is treated, additional reconstruction may be needed.

Flap Failure is possible despite all best efforts. Failure sometimes occurs when a blockage or compression occurs at the point of blood flow to the flap.

Even though risks and complications occur infrequently, the risks cited above are the ones that are commonly associated with flap reconstruction surgery. Other complications and risks can occur but are uncommon. Should complications occur, additional surgery or other treatments may be necessary.

Every pressure sore, bed sore and decubitus ulcer is unique, and a great deal depends on individual circumstances. Ask your doctor to explain anything you do not understand. Also, you should also ask your doctor for educational information that specifically details the procedure you are considering for yourself.

What Are Bedsores?

Bedsores are also known as pressure sores or pressure ulcers. They occur as a result of prolonged pressure on the skin and underlying tissue in sensitive areas, most often the bony areas of the body such as the back, buttocks, hips, ankles and heels. Bedsores can develop quickly and can be difficult to treat because those who are most often affected are those with mobility issues that keep them from changing positions easily. Those who are bedridden or are confined to a wheelchair are at a high risk for developing bedsores.

Causes and Risk Factors

There are three factors that play a role in bedsores developing:

Sustained Pressure:

When the skin is trapped between a bony surface and the surface of a bed or wheelchair, blood flow can be interrupted because the pressure that depriving the area of blood flow is greater than the body’s ability to pump blood to that area.

Friction:

When someone tries to move after being in a certain position for a long period of time, as is the case with those people in wheelchairs or those who are bedridden, friction between the skin and the surface they are on can contribute to bedsores. Friction is worse if the skin is moist, as in the case of those with urinary incontinence.

Shear:

Shear occurs when two surfaces move in opposite directions, such as when the head of a hospital bed is raised. As the head of the bed moves up, gravity pulls the body downward, resulting in a shear effect between a person’s back and the bed.

Those most at risk for developing bedsores are those who have limited mobility. Immobility can be caused by a number of problems:

• Poor health
• Obesity resulting in immobility
• Sedation
• Injury or illness requiring bed rest or wheelchair use
• Recovery after surgery
• Paralysis
• Coma

Other factors that contribute to bedsores include:

• Lack of sensory perception
• Poor nutrition or hydration
• Age
• Decreased mental awareness
• Weight loss
• Incontinence
• Excessive moisture or dryness of skin
• Smoking
• Decreased circulation
• Muscle spasms