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Pressure ulcers, or decubitus ulcers (wounds), occur when constant pressure deprives skin overlying bone of blood. They're frequent in people who lie in bed for long periods of time, need to use a wheelchair or have a limited ability to move because of spinal damage, stroke, a long hospital stay, etc.
They're also more serious than they appear. If a mark begins to turn red, and pressure is not alleviated and the cut is not cared for well, it can become bone in days. At stage 4, a bed sore will almost certainly require plastic surgery in order to close it.
Pressure sores develop when there is an excessive amount of pressure on a bony prominence for a prolonged period of time. Most frequently these occur on the sacrum (lower back), hips, heels, ankles, elbows and back of the head. The greatest incidence of their development is from patients sitting for long periods of time, usually on the buttocks and tailbone. Diabetics or those with poor nutrition are at higher risk, as tissues heal slower.
The treatment of Stage 1 and 2 pressure sores is non-surgical, and involves the use of pressure redistribution, advanced wound dressings, infection control, and nutrition support. Conservative care must be taken, but an air alternating mattress or a wheelchair cushion with pressure mapping can help prevent further harm.
Stage 3 and 4 sores are another set of problems. Once the wound has penetrated to deep tissue or bone, dressings will not seal the wound. The surrounding tissue may be poorly nourished and unable to nourish from within the wound. These patients need reconstructive plastic surgery.
The two aims of reconstructive surgery of pressure ulcers are to eliminate all damaged and infected tissue and to close the wound with well-vascularised (well-blooded) tissue that can take the pressure of the wound.
Debridement comes first. Necrotic tissue, dead bone (sequestrum) and infected material are surgically removed. If it is not completely clean, the wound will not heal and if a flap is used over the infected area, it will not survive.
The most common reconstruction of a stage 3 or 4 pressure ulcer is flap surgery. Flaps involve bringing in a whole thickness of tissue (skin, fat and sometimes muscle) from a nearby area with its own blood supply, whereas skin grafts only involve skin. Gluteal muscle flaps are the most common flaps used for sacral sores. The flap of the tensor fasciae latae is a commonly used flap for hip and trochanteric sores. The flap overfills the wound cavity, prevents infection and offers long-lasting cover.
The negative pressure wound therapy (NPWT / VA) is applied before the surgery to prepare the wound and can be applied after the flap closure to assist wound healing.
Surgery may not be suitable for all patients. If the patient is severely medically ill, has uncontrolled infection, or if surgery is unlikely to improve quality of life, then a plan for non-surgical management is needed. This decision must be based on a clear communication between the surgeon, patient and family.
Recurrence rates after pressure ulcer surgery are high in all centres as the underlying causes of pressure ulcers (immobility, poor nutrition, incontinence) persist unless actively managed. Following reconstruction, the following skin care measures are required:
Frequent repositioning every two hours, an appropriate mattress, nutritional optimisation (such as protein supplementation) and skin checks by a nurse at least once a day.
Specialist cushion for the patient if they use a wheelchair will reduce loads on the reconstructed area from an assessment using a pressure mapping device. When patients and caregivers know the cause of the wound, they are not likely to get it again.
Bed sores can be treated by a GP or a wound care nurse using appropriate dressings and a pressure relief plan, if they are in the early stages. If the wound progresses beyond stage 3 or 4, if the bone or tendon is exposed, if the infection penetrates into the surrounding tissues or if a wound has failed to heal after 4 weeks of adequate conservative treatment, a plastic surgeon should be involved.
A plastic surgeon that specializes in reconstructive surgery has the experience and judgment necessary to design a flap to the skin that will last long-term, and not just close the wound on the spot.
Dr. Anup Dhir, Senior Consultant in Plastic and Reconstructive Surgery at Indraprastha Apollo Hospital, New Delhi treats both conservative and surgical treatment of Bed Sores and Pressure Ulcers. He has been at the forefront of plastic and reconstructive surgery for 40 years, treating pressure sores at all stages, with cases that come with bone involvement, and are thus covered using flaps.
Consultations are held at Image Medical Centre, Nehru Place, New Delhi, in person and via video for family members who have to attend to an ill patient who is kept at home.
If the wound of someone in your care is not healing or if there is bone visible or felt in the wound, now is not next week.
Leave a request to connect to Dr. Anup Dhir for an Appointment.