Surgical Therapy for Complex Pelvic Pressure Injuries

In This Article

Abstract and Introduction
Methods
Results
Discussion
Limitations
Conclusion
References

Abstract and Introduction

Abstract

Introduction: An advanced pelvic PI is a challenging problem that requires care from multiple disciplines.

Objective: This study is a critical evaluation of wound recurrences after surgical repair, and an analysis of factors that may contribute to surgical failures. This study also provides a literature review of pelvic PIs and proposes how a navigator embedded in the wound care department could play a role in decreasing surgical failures.

Methods: A retrospective cohort study of 33 consecutive surgeries for closure of complex pelvic PIs in 22 patients was conducted.

Results: Recurrences developed in 17 of 33 surgeries (52%). Recurrences were seen most frequently in those undergoing simultaneous repair of 2 sites and those who had undergone prior surgeries.

Conclusions: Long-term healing after repair of complex pelvic PIs remains a challenge, especially in certain high-risk populations. A significant portion of recurrences develop after a period of healing, so identifying and addressing factors that lead to wound breakdown following hospital discharge is a critical area of care improvement. A navigator care coordinator within the wound care department may play an important role in preventing wound recurrences.

Introduction

Individuals with chronic or acute mobility impairment are at risk for development of PIs in regions where bony prominences may be exposed to prolonged contact with firm surfaces. When a pelvic PI develops and progresses to stage 3 or 4, a patient is set on a lengthy, complicated, and expensive path of treatment that may require therapy from multiple specialties including wound care, surgery, and rehabilitation. Treatment usually begins with intensive wound care, offloading, and physiologic optimization, but in situations where the wound fails to improve or deteriorates, surgical repair of the wound is often the next consideration. There is an expansive body of literature describing various surgical methods and strategies, but despite decades of surgical experience, postoperative complications and long-term failures remain common. Estimates for recurrence of PIs mostly range between 20% to 40%, but in some studies the long-term failure rate is as high as 80%.^[1–8]

The purpose of this study is to report the experience of surgical management of complex pelvic PIs within a multispecialty practice from 2015 to 2019, with an analysis of wound recurrences and whether other measures may help reduce the frustrations that patients and caregivers experience in trying to achieve sustained healing.

Table 1. Patient Demographics
CHARACTERISTIC	NO. (%)
Sex
Male	19 (57)
Female	14 (43)
Etiology of wound
Spinal cord injury	17 (52)
Multiple sclerosis	7 (21)
Spina bifida	3 (9)
Medical deconditioning	3 (9)
Parkinson's disease	1 (3)
Transverse myelitis	1 (3)
Spinal cord embolus	1 (3)
Level of paralysis
Paraplegia	28 (85)
Quadriplegia	3 (9)
Ambulatory	2 (6)
Location of wound
Ischial tuberosity	18 (55)
Sacral	11 (33)
Greater trochanter tuberosity	4 (12)
Osteomyelitis diagnosed prior to surgery	21 (64)
Prior surgery at the same site	14 (42)
Average duration of wound prior to surgery
(excluding 3 patients whose wounds were present for >4 years)	12 months (range, 1–48)
Comorbidities
Diabetes	4 (12)
Smoking	0

Table 2. Recurrence of Wounds After Surgical Closure
LOCATION	LONG-TERM CLOSURE	RECURRENCE (%)
Ischium (N=17)	7	10 (59)
Sacrum (N=12)	8	4 (33)
Trochanter (N=4)	1	3 (75)

Table 3. Subgroup Analysis of Wound Recurrences
	RECURRENCE RATE (%)	SIGNIFICANCE
First-time surgery at the wound	8/19 (42)
vs		χ²= 1.59 P =.21
Prior surgery at the wound	9/14 (64)
One site repaired	9/23 (39)
vs		χ²=4.66 P =.03
Two sites repaired simultaneously	8/10 (80)
Receiving "redo" surgery in this series	4/7 (57)
vs		χ²=0.11 P =.74
Not undergoing "redo" surgery	13/26 (50)

Table 4. Wound Navigator Preoperative Checklist
1. Document and photograph size of the wound.
2. Order baseline labs to check for systemic disease, infection, and nutritional status (eg, CBC, HbA1c, albumin, prealbumin, ESR, CRP, nicotine level).
3. Manage nicotine cessation; counsel patient on nicotine cessation and provide a referral as necessary.
4. Manage nutritional optimization and refer to dietician if necessary; aim for albumin levels >3.0 g/dL.
5. Evaluate for and seek to control diabetes (HbA1c should be <8 mg/dL for optimal wound healing).
6. Refer to PCP if not seen within the last 3 months to establish general medical health.
6. Review medications that might have an immunosuppressive impact on healing (eg, steroids).
7. Assess for coagulopathies that may impact surgery.
8. Coordinate with physical medicine and rehabilitation departments to order wheelchair mapping, if not done previously, and assess if patient has appropriate pressure offloading bed.
9. If fecal/urinary diversion is necessary, refer to general surgery and urology departments.
10. If contracture is contributing to the wound, refer to physical therapy or orthopaedic surgery department.
11. Review importance of optimization list with patient and family, and then assess for their ability to assist patient with postoperative recovery needs. If appropriate, schedule a social work consult for concerns with food, transportation, or housing insecurity.
12. Consult with surgeon and infectious diseases department for heavily draining or poorly drained wound; order MRI for concerns of osteomyelitis.

Abbreviations: CBC, complete blood count; CRP, c-reactive protein; ESR, erythrocyte sedimentation rate; Hb, hemoglobin; MRI, magnetic resonance imaging; PCP, primary care physician.