Treatment of pressure sores

Treatment of bedsores should be aimed at restoring the skin in the area of the bedsore. Depending on the stage of the process, this can be achieved by conservative measures (cleaning the wound, stimulating the formation of granulation, protecting them from drying out and secondary infection) or surgically (surgical removal of necrosis and plastic closure of the soft tissue defect). Regardless of the method of treatment, properly organized care is of great importance: frequent changes in the patient's position, the use of anti-bedsore mattresses or beds, preventing trauma to the granulation tissue of the bedsore wound, adequate nutrition with sufficient proteins and vitamins.

When choosing a treatment strategy, the goal and tasks to be solved should be clearly formulated. At the stage of the primary reaction, the goal is to protect the skin; at the stage of necrosis - to reduce the duration of this stage by removing necrotic tissues that support the inflammatory process and intoxication; at the stage of granulation formation - to create conditions that promote more rapid development of granulation tissue; at the stage of epithelialization - to accelerate the differentiation of young connective tissue and the production of epithelial tissue.

Most pressure ulcers are infected, but routine use of antibiotics is not recommended. Indications for antibacterial therapy are pressure ulcers of any stage, accompanied by systemic inflammatory response syndrome and development of purulent-septic complications. Given the polymicrobial nature of the infection caused by aerobic-anaerobic associations, broad-spectrum drugs are empirically prescribed. Protected beta-lactam antibiotics [amoxicillin + clavulanic acid (augmentin), ticarcillin + clavulanic acid, cefoperazone + sulbactam (sulperazone)], fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) or third- and fourth-generation cephalosporins in combination with clindamycin or metronidazole, carbapenems [imipenem + cilastatin (tienam), meropenem] and other regimens are usually used. After receiving the data on the sensitivity of the microflora, they switch to schemes of targeted antibacterial therapy. Such practice in most cases of complex treatment allows to achieve the cure of local and general inflammatory phenomena, demarcation of necrotic tissues or prevent their development. The use of antibacterial drugs without taking into account the sensitivity of the microflora does not reduce the number of complications, but only leads to a change in the composition of microorganisms, the selection of strains resistant to antibiotics.

Local treatment of bedsores is a rather complex problem, since it is not always possible to completely eliminate the causes that lead to their development; in addition, patients with bedsores are often weakened by a long-term severe illness, accompanied by anemia and exhaustion. All phases of the wound process in the presence of a bedsore are sharply extended in time and can last for many months and even years. Local changes are heterogeneous, often simultaneously observing areas of both necrotic and granulation tissue.

The treatment result largely depends on adequate local action, which is one of the most important components of complex therapy for patients with bedsores. Treatment of bedsores currently uses the entire arsenal of dressings, which are used in accordance with the indications for the use of a particular dressing, taking into account the stage and characteristics of the wound process.

In combination with anti-bedsore measures and local therapy, physiotherapy, general strengthening therapy, and adequate enteral and parenteral nutrition are widely used.

Stages III-IV bedsores are characterized by the development of necrotic skin lesions throughout the entire depth with the involvement of subcutaneous fat, fascia, muscles, and, in more severe cases, bones in the destructive process. Spontaneous cleansing of bedsores from necrosis occurs over a long period of time; Passive management of a purulent wound is fraught with the development of various complications, the progression of purulent-necrotic changes, and the development of sepsis, which becomes one of the main causes of death in patients. In this regard, in patients with such bedsores, treatment should begin with a full surgical treatment of the purulent focus with excision of all non-viable tissue, wide dissection and drainage of pockets and purulent leaks.

Surgical treatment of bedsores is determined by the stage and size of the bedsore, the presence of purulent-septic complications. In the case of development of a bedsore according to the type of wet progressive necrosis, surgical treatment is carried out according to urgent indications, which allows preventing the spread of putrefactive destruction to surrounding tissues, reducing the level of intoxication and achieving faster delimitation of necrosis. In other cases, necrectomy should be preceded by anti-inflammatory therapy (antibacterial and local therapy, physiotherapy), which allows achieving demarcation of the necrosis zone and stopping inflammatory phenomena in the surrounding tissues. Otherwise, incorrectly and untimely surgical intervention can only increase the area of the ulcer and provoke the progression of necrosis.

When performing necrectomy, it is most difficult to determine the viability of tissues. The main goal of surgical treatment is surgical removal of only clearly devitalized tissues up to the area of bleeding. Wide excision of a bedsore within visually unchanged, but already ischemic tissues often becomes a mistake and is not always advisable, since it often leads to the formation of an extensive zone of secondary necrosis.

Further treatment aimed at cleaning the pressure ulcer from purulent exudate and necrosis residues, absorbing the discharge and maintaining a moist environment in the wound is associated with adequate local therapy. When secondary necrosis forms, repeated surgical treatments are performed until the pressure ulcer is completely cleansed from necrotic tissue. Treatment of pressure ulcers in phase I of the wound process consists of using various methods of additional wound treatment (ultrasonic cavitation, laser ablation of necrosis, use of a pulsating stream of antiseptics and vacuum aspiration).

In patients with lower paraplegia and occlusive lesions of the arteries of the lower extremities, in some cases it is necessary to decide on amputation or exarticulation of the limb. Multiple extensive bedsores of the lower extremity that do not respond to conservative treatment for a long time and are accompanied by persistent intoxication are an indication for amputation of the limb at the level of the shin or thigh, depending on the prevalence of purulent-necrotic changes and the zone of guaranteed good blood flow. When the above changes are combined with a decubital ulcer of the greater trochanter complicated by purulent coxitis and osteomyelitis of the femoral head, the limb is exarticulated in the hip joint. In the presence of bedsores in the area of the ischial tuberosities, perineum and sacrum, it is advisable to use skin-muscle flaps of the salvage limb for plastic surgery of the above defects.

Spontaneous closure of pressure ulcers occurs over a long period of time, it is associated with the development of various complications that are dangerous to the patient's life and is possible only in a small proportion of patients. In most cases, spontaneous healing of a decubital ulcer is impossible or difficult, since the causes leading to ulcer formation remain, or the size of the pressure ulcer is too large.

Randomized clinical studies have not revealed any significant differences in the healing time of pressure ulcers using surgical treatment of the purulent-necrotic focus and skin-plastic interventions compared to conservative treatment methods. Meanwhile, the analysis of these studies shows not so much the ineffectiveness of these methods as the insufficient evidence of their effectiveness.

The surgical method in some cases remains the most radical, and sometimes the only possible treatment for bedsores. In our country, to date, only a few surgical departments have been specifically engaged in surgical treatment of bedsores, while in most developed countries there are centers for plastic surgery of bedsores. In the United States, $2 to $5 billion is spent annually on the treatment of bedsores in spinal patients. It is noteworthy that direct costs associated with surgical intervention make up only 2% of the cost of the entire treatment, while a significant portion of the funds is spent on conservative measures and rehabilitation of patients.

Most leading surgeons professionally treating bedsores are convinced that at the present stage of medicine, the priority in treatment should be surgical treatment with the use of plastic methods of wound closure. Such tactics can significantly reduce the frequency of complications and relapses of bedsores, reduce the mortality rate and rehabilitation periods of patients, improve the quality of life and reduce treatment costs. This should be preceded by adequate preparation of the patient and the wound for plastic surgery. The successful outcome of the treatment of decubital ulcers is closely related to a comprehensive approach to treatment. It is necessary to completely eliminate pressure on the area of the bedsore, purposefully carry out other anti-bedsore measures and quality care. The patient should receive adequate nutrition. Anemia and hypoproteinemia should be eliminated, other foci of infection should be sanitized.

Skin grafting as a treatment for bedsores should be used when there are no general or local contraindications to surgery and faster healing of the wound defect and fewer complications are predicted compared to spontaneous wound healing.

Indications for skin plastic surgery

• large size of the pressure ulcer, which does not allow us to expect its spontaneous healing;
• lack of positive dynamics (reduction in size by 30%) in the healing of pressure ulcers with adequate conservative therapy for 6 months or more;
• the need for urgent surgical interventions requiring the treatment of foci of infection (orthopedic surgeries, interventions on the heart and blood vessels);
• the need to fill the skin defect with vascularized tissues to prevent the development of recurrent bedsores (applicable to spinal and other sedentary and immobilized patients).

Skin plastic interventions are possible if the following conditions are met:

• stable general condition of the patient;
• persistent transition of the wound process to phase II;
• the ability to close a pressure ulcer without excessive tissue tension;
• the possibility of providing adequate postoperative treatment and care for the patient.

Contraindications to skin grafting are closely related to the characteristics of the local wound process, the general condition of the patient, and the lack of preparation of personnel for such interventions:

• pressure ulcer in phase I of the wound healing process;
• lack of sufficient plastic material to allow the pressure sore to be closed without obstruction;
• the presence of diseases and conditions with a predicted life expectancy of less than 1 year (oncological diseases, severe strokes);
• unstable mental state of the patient, accompanied by periods of agitation, inappropriate behavior, frequent seizures, stupor and coma;
• rapid progression of the underlying disease (multiple sclerosis, repeated strokes), decompensation of concomitant diseases (severe circulatory failure, respiratory failure);
• occlusive diseases of the vessels of the lower extremities (if the bedsore is located below the waist);
• lack of skills and special training of surgeons to perform the required skin-plastic interventions.

PM Linder in 1990 formulated the basic surgical treatment of pressure ulcers:

• absence of signs of infection and inflammation in the area of the pressure ulcer and surrounding tissues;
• During surgery, the patient is positioned in such a way as to ensure maximum tissue tension when suturing the wound;
• all infected, contaminated and scar tissue in the area of the pressure ulcer should be removed;
• in case of osteomyelitis or the need to reduce underlying bone protrusions, an osteotomy is performed;
• the line of skin incision or suture formation should not pass over a bony protrusion;
• the defect formed after excision of the pressure ulcer is filled with well-vascularized tissue;
• to eliminate dead space and prevent the formation of seroma, the wound is drained using a closed vacuum system;
• after the operation, the patient is placed in a position that eliminates pressure on the wound area;
• After the operation, the patient is prescribed targeted antibacterial therapy.

To eliminate decubital ulcers, various surgical treatment methods can be used. The arsenal of plastic interventions is currently quite wide and diverse and allows for the closure of bedsores of virtually any size and location in stable patients. Types of skin-plastic interventions for bedsores:

• autodermoplasty;
• plastic surgery with local tissues using: - simple displacement and suturing of tissues;
• dosed tissue stretching;
• VY plastic surgery with sliding skin-muscle flaps;
• combined methods of skin plastic surgery;
• free transplantation of tissue complexes on microvascular anastomoses. Such interventions as isolated autodermoplasty are currently
• time are of historical interest only. In some cases, it is advisable to use it for temporary closure of a pressure sore defect as a stage of patient preparation. Plastic surgery with a split skin flap is also possible when closing extensive superficial defects that do not carry a supporting function and are not subject to constant load (chest, scalp, shin). The use of autodermoplasty in other situations is unjustified, since it leads to the formation of an unstable scar and relapse of the pressure sore.

Local tissue plastic surgery by excising the pressure ulcer and simply suturing the wound defect is possible for small pressure ulcers without osteomyelitis of the underlying bone and when the wound can be closed with tension-free sutures. With a high risk of pressure ulcer recurrence, plastic surgery by simply shifting flaps and suturing tissues is inappropriate.

In case of excessive tissue tension, the method of dosed tissue stretching is used. For this purpose, after excision of the bedsore, a wide mobilization of skin-fat or skin-fascial flaps is performed, the wound is drained, frequent sutures are applied to it, they are tightened with safe tension and tied with a "bow". The remaining diastasis of the wound is subsequently eliminated by systematic daily (or less often) traction of the flaps using ligatures. When the flaps touch, the threads are finally tied and cut off.

The presence of extensive and recurrent bedsores and the lack of local plastic material force the widespread use of the tissue balloon dilation method. The tissues are dilated both in the immediate vicinity of the wound defect and at some distance from it. To do this, a silicone balloon dilator is inserted through separate incisions under the fascia or muscle, which is slowly filled with sterile saline over 6-8 weeks. Upon reaching the required tissue dilation, the dilator is removed, a flap is formed and moved to the bedsore defect.

In most cases of pressure ulcers, preference is given to the use of skin-fascial or skin-muscle flaps located in the immediate vicinity of the defect or at a distance from it. The advantage of such flaps is that they are used to replace the previously ischemic area with well-perfused tissues. The displaced skin-muscle flap serves as a soft pad on the area subject to constant pressure. It participates in the uniform distribution of pressure, cushioning and helps to avoid recurrence of the pressure ulcer.

Currently, transplantation of tissue complexes on microvascular anastomoses in the treatment of bedsores is used less frequently compared to methods of local skin grafting. This is due to the technical difficulties of the intervention, which requires special surgical preparation and equipment, and frequent postoperative complications. In addition, local plastic resources are in most cases sufficient for adequate replenishment of bedsore defects, and the interventions are technically simpler, give fewer complications and are easier for patients to tolerate.

Skin plastic interventions for pressure ulcers have their own characteristics. Stopping bleeding even from the smallest vessels in patients with paraplegia presents significant difficulties due to the inability of the vessels to vasoconstrict, which is why the wound must be drained for a long time with one or more catheters followed by vacuum aspiration. In case of osteomyelitis of the underlying bone, it is removed within the bleeding bone tissue. In spinal patients, even in the absence of osteomyelitis, resection of bone protrusions (ischial tuberosity, greater trochanter) is necessary to prevent recurrence of decubital ulcers. When adapting skin flaps to the bottom, edges of the wound and to each other, absorbable sutures on an atraumatic needle should be used. It is advisable to eliminate all residual cavities by layer-by-layer tissue suturing in several levels.

Treatment of bedsores of the sacral region

Sacral bedsores are usually large in size with overhanging skin edges. The sacrum and coccyx are located directly under the skin. The vascularization of this area is good, carried out from the system of the superior and inferior gluteal arteries, which provide multiple anastomoses. The intervention begins with complete excision of the bedsores and surrounding scar tissue. If necessary, protruding parts of the sacrum and coccyx are removed.

Rotational gluteal fasciocutaneous flap has proven itself well in the plastic surgery of small and medium sacral bedsores. The flap is cut out in the lower part of the gluteal region. The skin incision is made from the lower lateral edge of the bedsore defect strictly downwards, parallel to the intergluteal fold, then the incision line is turned at an angle of 70-80° and led to the outer surface of the buttock. The size of the formed flap should slightly exceed the size of the bedsore. The flap is cut out together with the gluteal fascia, rotated to the area of the bedsore defect, and sutured to the bottom and edges of the wound. The donor defect is closed by moving and suturing skin and fat flaps according to the VY-plasty type.

Plastic surgery with an island upper gluteal skin-muscle flap according to S. Dumurgier (1990) is mainly used to close medium-sized pressure ulcers. For this purpose, a skin flap of the required shape and size is cut above the greater trochanter. Without breaking the connection with the large gluteal muscle, the latter is cut off from the greater trochanter. The skin-muscle flap is mobilized and passed through a subcutaneous tunnel to the pressure ulcer defect, where it is fixed with sutures.

For plastic surgery of large pressure ulcers, two skin-fascial or skin-muscle flaps are usually used. The flaps are formed from the lower or upper parts of the gluteal region, or one upper and one lower gluteal flap are used. In plastic surgery according to Zoltan (1984), two upper skin-muscle flaps are cut out. Skin incisions are made from the upper lateral edge of the pressure ulcer to the posterior superior iliac spine, then they are rounded and drawn down to the level of an imaginary line passing through the lower edge of the pressure ulcer defect. The formed flaps include the large gluteal muscles, which are cut off from the surrounding tissues without breaking their connection with the skin flap. The formed flaps are rotated to the area of the pressure ulcer, fixed without tension with sutures to the bottom, the edges of the wound defect and to each other. Donor wounds are closed by moving the tissues and suturing them according to the VY-plasty type.

The island sliding skin-muscle VY flap according to Haywood and Quabb (1989) is widely used for plastic surgery of large pressure ulcers. Two large triangular flaps are formed along the edges of the excised pressure ulcer in the shape of the letter V, with the tip of the angle directed towards the greater trochanters and the base towards the pressure ulcer. The incisions are continued deeper with dissection of the gluteal fascia. The gluteus maximus muscle is mobilized by cutting it off from the sacrum, and if it is insufficiently mobile, from the greater trochanter and ilium. The blood supply to the skin flaps is good, and is carried out by means of numerous perforating gluteal arteries. After sufficient mobility appears, the flaps are shifted medially towards each other and sutured together in layers without tension. The lateral areas of the donor wound are closed in such a way that the suture line takes a Y-shape.

Treatment of pressure ulcers of the greater trochanter area

Pressure ulcers of the greater trochanter area are usually accompanied by the development of a small skin defect and extensive damage to the underlying tissues. The greater trochanter serves as the bottom of the pressure ulcer. Excision of the decubital ulcer is performed widely, together with cicatricial tissues and the bursa of the greater trochanter. Resection of the greater trochanter is performed. For plastic surgery of the resulting defect, a skin-muscle flap from the m. tenzor fasciae latae no F. Nahai (1978) is most often used. The flap has a good axial blood supply from the branches of the lateral circumflex femoral artery. The length of the flap can be 30 cm or more. In the distal part, the flap is skin-fascial, in the proximal part - skin-muscle. After rotation of the flap by 90 °, its skin-muscle part lies on the area of the resected greater trochanter. The distal skin-fascial part of the flap fills the remaining part of the pressure sore defect without much tension. In the presence of large subcutaneous pockets, the distal part of the flap is de-epithelialized, invaginated into the pocket area and fixed with sutures, thereby eliminating the residual cavity. The donor wound is easily closed by shifting additionally mobilized skin flaps and applying vertical U-shaped sutures.

In VY plasty according to Paletta (1989), a large triangular flap with a wide base extending beyond the edges of the pressure ulcer is cut distally to the pressure ulcer. The broad fascia of the thigh is dissected, the flap is displaced proximally and the wound defect is completely covered with it. The donor wound is closed with local tissues, forming a Y-shaped suture line.

Much less frequently used are other types of plastic surgery using island skin-muscle flaps cut from the rectus femoris and vastus lateralis muscles.

Treatment of pressure ulcers of the sciatic region

In cases of pressure ulcers in the area of the ischial tuberosities, the skin defect is usually small, but extensive cavities-bursae are revealed underneath it. Osteomyelitis of the ischial tuberosity is often observed. Additional difficulties arise during surgical treatment due to the close location of blood vessels and nerves, as well as the rectum, urethra and cavernous bodies of the penis. Total removal of the ischial tuberosity is fraught with pressure ulcers and diverticula of the perineum, urethral strictures, rapid development of a similar pressure ulcer in the area of the ischial tuberosity on the opposite side, in connection with which it is more advisable to perform only partial resection of the bone protrusions.

For plastic surgery of pressure ulcers of the sciatic region, the rotational inferior gluteal skin-muscle flap according to Minami (1977) is most widely used. The flap is abundantly supplied with blood by branches of the inferior gluteal artery. It is cut out in the lower part of the gluteal region, the muscle is cut off from the femur. The flap is rotated to the area of the pressure ulcer and fixed with sutures. The donor wound is closed after additional tissue mobilization.

For plastic surgery of sciatic pressure ulcers, it is also possible to use the rotational gluteal-femoral skin-muscle flap according to Hurwitz (1981), and the sliding skin-muscle VY flaps of the biceps femoris according to Tobin (1981).

In the development of extensive pressure ulcers of the ischial tuberosity in combination with perineal ulcers, an island skin-muscle flap on the gracilis m. has proven itself well. The flap is fed by branches of the internal circumflex femoral artery. A skin flap of the required shape and size is formed along the posteromedial surface of the middle third of the thigh. The delicate muscle is cut off in the distal part. The island skin-muscle flap is rotated by 180° and brought through a subcutaneous tunnel to the area of the pressure ulcer defect, where it is fixed with sutures.

Treatment of pressure ulcers of the heel area

The most common location of pressure ulcers is the posterior part of the heel area. Skin defects are usually small. The incidence of osteomyelitis of the calcaneal tuberosity is about 10%. Treatment of pressure ulcers of this localization is a significant problem due to the lack of a sufficient amount of local plastic material and the frequent development of pressure ulcers against the background of occlusive diseases of the vessels of the lower extremities. The ulcer is excised within the bleeding tissues. In case of osteomyelitis, the calcaneal tuberosity is resected. For small ulcers, plastic surgery is used with sliding skin-fascial VY flaps according to Dieffenbach. Proximal and distal to the pressure ulcer, two triangular flaps are formed with a base in the defect area. They are mobilized from three sides, shifted towards the ulcer until they are completely converged without tissue tension. The flaps are sutured together. The donor wound is closed with a Y-shaped suture. The foot is fixed with a dorsal plaster cast in the equinus position. For medium-sized bedsores, Italian skin grafting is used. The best results are achieved with a medial gastrocnemius skin-fascial flap of the contralateral limb.

The need for skin grafting of bedsores of other localizations is encountered much less frequently. The choice of the method of plastic closure of the defect can be very diverse and depends on the localization and area of the chronic wound.

Postoperative treatment of bedsores

In the postoperative period, it is necessary to exclude pressure on the area of the surgical wound for 4-6 weeks. Drains are left in the wound for at least 7 days. They are removed after the discharge from the wound has decreased to 10-15 ml. Targeted antibacterial therapy is canceled the next day after the removal of the drainage system. Sutures are removed on the 10th-14th day. If suppuration develops in the area of several sutures, they are partially removed, the edges of the wound are sparingly spread with daily sanitation of the purulent focus and the application of a dressing with a water-soluble ointment or alginates. Antibacterial therapy is continued in case of massive wound suppuration or flap necrosis, accompanied by a systemic inflammatory reaction. If marginal skin necrosis develops, it is delimited using dressings with antiseptic solutions (iodopyrone, povidone-iodine, dioxidine, lavasept). After demarcation of necrosis, its excision is performed. When the wound passes into stage II, dressings intended for the treatment of wounds of this stage are used.