Surgical Treatment of Pressure Ulcers Workup

  • Author: Bradon J Wilhelmi, MD; Chief Editor: Lars M Vistnes, MD, FRCSC, FACS   more...
 
Updated: Jan 29, 2010
 

Laboratory Studies

  • Osteomyelitis is suggested by an erythrocyte sedimentation rate (ESR) greater than 120 mm/h and a WBC count greater than 15,000/µL.
  • Preoperative nutritional status can be determined by obtaining the patient's albumin level, which should be optimized to at least 3.5 g/mL prior to flap reconstruction. These patients often have anemia of chronic disease, suggested by a low mean corpuscular volume, and can be considered for a transfusion in order to achieve a preoperative hemoglobin level greater than 12 g.
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Imaging Studies

  • Diagnosis of underlying osteomyelitis can be evaluated first with plain films. Osteomyelitis can also suggested by positive bone scan findings. A negative bone scan finding generally excludes osteomyelitis. However, patients with an open wound such as a pressure sore can often have a falsely positive bone scan. A positive bone scan finding can be evaluated further with an MRI or bone biopsy.
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Diagnostic Procedures

  • Bone biopsy is the criterion standard for the diagnosis of osteomyelitis within a pressure sore.[14] Bone biopsy should be considered in patients with elevated ESR, elevated WBC, and or abnormal pelvic films suggestive of osteomyelitis.
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Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Bradon J Wilhelmi, MD  Professor and Endowed Leonard J Weiner, MD, Chair of Plastic Surgery, Residency Program Director, University of Louisville School of Medicine

Bradon J Wilhelmi, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Hand Surgery, American Association of Clinical Anatomists, American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Association for Surgical Education, Plastic Surgery Research Council, and Wound Healing Society

Disclosure: Nothing to disclose.

Coauthor(s)

Michael Neumeister, MD, FRCSC, FRCSC, FACS  Chairman, Professor, Division of Plastic Surgery, Director of Hand/Microsurgery Fellowship Program, Chief of Microsurgery and Research, Institute of Plastic and Reconstructive Surgery, Southern Illinois University School of Medicine

Michael Neumeister, MD, FRCSC, FRCSC, FACS is a member of the following medical societies: American Association for Hand Surgery, American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Association of Academic Chairmen of Plastic Surgery, Canadian Society of Plastic Surgeons, Illinois State Medical Society, Illinois State Medical Society, Ontario Medical Association, Plastic Surgery Research Council, Royal College of Physicians and Surgeons of Canada, and Society of University Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Albert E Cram, MD, FACS  Professor Emeritus, Departments of Surgery, Otolaryngology Head & Neck Surgery and Orthopedic Surgery, University of Iowa College of Medicine; Consulting Staff, Iowa City Plastic Surgery

Albert E Cram, MD, FACS is a member of the following medical societies: American Association of Tissue Banks, American Burn Association, American College of Surgeons, American Heart Association, American Society for Aesthetic Plastic Surgery, and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

Wayne Karl Stadelmann, MD  Stadelmann Plastic Surgery, PC

Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Nicolas (Nick) G Slenkovich, MD  Director, Colorado Plastic Surgery Center

Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Lars M Vistnes, MD, FRCSC, FACS  Professor of Surgery, Emeritus, Stanford University Medical Center

Lars M Vistnes, MD, FRCSC, FACS is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

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Heaps of verrucous white tissue around the ulcer suggest malignant transformation as observed with Marjolin ulcers.
Pressure ulcers. Close-up view of area with heaps of verrucous white tissue around the ulcer, the presence of which suggests malignant transformation as observed with Marjolin ulcers.
Pressure ulcers. Radical bursectomy is performed by placing a methylene blue–moistened sponge in the bursa and excising the pressure sore circumferentially, removing all granulation tissue, even from the wound base.
Pressure ulcers. With the gluteal thigh flap, a superiorly based flap is elevated, with the inferior gluteal artery located between the greater trochanter and the ischial tuberosity as its axis.
Pressure ulcers. The gluteal thigh rotation flap is raised as a fasciocutaneous flap superiorly to the gluteal crease.
Pressure ulcers. The gluteal thigh flap may be raised to include the inferior portion of the gluteus maximus muscle, which increases the arc of rotation to allow this flap to also be used to reconstruct sacral defects.
Pressure ulcers. Small sacral pressure sores can be reconstructed with the inferior-based skin rotation flap with or without the superior gluteus maximus myocutaneous flap.
Pressure ulcers. Small sacral pressure sores can be reconstructed with the inferior-based skin rotation flap with or without the superior gluteus maximus myocutaneous flap.
Pressure ulcers. Small sacral pressure sores can be reconstructed with the inferior-based skin rotation flap with or without the superior gluteus maximus myocutaneous flap.
Pressure ulcers. The landmarks for the superior gluteal artery, on which the superior gluteus maximus muscle flap is based, include the posterior superior iliac spine and the ischial tuberosity. The superior and inferior gluteal arteries branch from the internal iliac superior and inferior arteries to the piriformis muscle approximately 5 cm from the medial edge of the origin of the gluteus maximus muscle from the sacrococcygeal line.
Pressure ulcers. In using the superior portion of the gluteus maximus muscle as a flap, it is elevated in a lateral-to-medial direction to avoid injury to the superior gluteal artery, which can be difficult to identify from the medial direction because of the inflammation and scarring from the sacral pressure sore. The insertion of the superior portion of gluteus maximus muscle is the iliotibial. This insertion is released. The superior gluteal artery is only 4 cm long, which limits the rotation of the muscle. Thus, harvesting the entire length of the muscle may be necessary to allow for rotation or turnover into the defect without tension.
Pressure ulcers. In using the superior portion of the gluteus maximus muscle as a flap, it is elevated in a lateral-to-medial direction to avoid injury to the superior gluteal artery, which can be difficult to identify from the medial direction because of the inflammation and scarring from the sacral pressure sore. The insertion of the superior portion of gluteus maximus muscle is the iliotibial. This insertion is released. The superior gluteal artery is only 4 cm long, which limits the rotation of the muscle. Thus, harvesting the entire length of the muscle may be necessary to allow for rotation or turnover into the defect without tension.
Pressure ulcers. The V-Y flaps can be based superiorly or inferiorly or on the whole gluteus maximus muscle.
Pressure ulcers. Larger sacral ulcers require the use of bilateral flaps such as bilateral V-Y advancement flaps.
Pressure ulcers. The skin paddle is harvested 10 cm in width and designed over the muscle along an axis from the anterior superior iliac spine to the lateral tibial condyle.
Pressure ulcers. The inferior limit of the cutaneous territory can be extended to 6 cm above the knee and 25-35 cm in length. The lateral femoral circumflex artery can be found approximately 6-8 cm inferior to the anterior superior iliac spine.
Pressure ulcers. This patient required reconstruction of an extremely large pressure sore flap with a fillet total thigh flap procedure.
Pressure ulcers. This picture demonstrates the Girdlestone arthroplasty procedure for femoral head osteomyelitis pyarthrosis of the hip joint. The femur head is removed, and the hip joint space is reconstructed with the vastus lateralis muscle flap.
Pressure ulcers. This patient has a urethral fistula within his pressure ulcer. When he performs the Valsalva maneuver, he leaks urine through this opening.
Pressure ulcers. Closer view of the image above. A patient with a urethral fistula within his pressure ulcer. When he performs the Valsalva maneuver, he leaks urine through this opening.
 
 
 
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