Laboratory Studies

A complete blood count (CBC) with differential may show an elevated white blood cell (WBC) count indicative of inflammation or invasive infection. The erythrocyte sedimentation rate (ESR) should be determined. An ESR higher than 120 mm/hr and a WBC count greater than 15,000/µL suggest osteomyelitis.

Nutritional parameters should be evaluated to assess adequate nutritional stores needed for adequate wound healing. Useful tests include the following:

Albumin level - This should be optimized to at least 3.5 g/mL before flap reconstruction
Prealbumin level
Transferrin level
Serum protein level

When indicated by the specific clinical situation, the following laboratory studies should be obtained:

Urinalysis and culture in the presence of urinary incontinence
Stool examination for fecal WBCs and Clostridium difficile toxin when pseudomembranous colitis may be the cause of fecal incontinence
Blood cultures if bacteremia or sepsis is suggested

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 higher than 12 g/dL.

Imaging Studies

A diagnosis of underlying osteomyelitis can be evaluated first with plain films. Osteomyelitis may also be suggested by positive bone scan findings. A negative bone scan finding generally excludes osteomyelitis; however, patients with an open wound, such as a pressure injury, can often have a falsely positive bone scan. A positive bone scan finding can be evaluated further by means of magnetic resonance imaging (MRI) or bone biopsy (see below).

Biopsy

A tissue biopsy should be performed for wounds that do not demonstrate clinical improvement despite adequate care and for wounds in which tissue invasion by bacteria is suggested. This allows quantification and identification of bacterial species and their antibiotic susceptibilities. Biopsy also enables the clinician to distinguish between simple contamination and tissue invasion, an important distinction that is not revealed by the common practice of swabbing the wound surface for culture.

Tissue biopsy of chronic wounds is indicated to rule out the presence of an underlying malignancy (ie, Marjolin ulceration). Whenever a chronic pressure injury has been stable for months or years but has recently deteriorated, a biopsy should be performed. Scar carcinoma is uncommon and typically occurs in wounds that have been open for many years.

Bone biopsy is the criterion standard for the diagnosis of osteomyelitis within a pressure injury.^[66]It should be considered in patients with an elevated ESR, an elevated WBC count, and or abnormal pelvic films suggestive of osteomyelitis, as well as in cases of stage 4 pressure injury with exposed bone. If osteomyelitis is confirmed, treatment with a prolonged course of antibiotic therapy may be indicated.

Histologic Findings

A concept that has been developed with regard to wound healing has to do with the presence of bacterial biofilms within a wound. Biofilms are structured communities of bacteria that may exist on a wound surface. A microscopic analysis of chronic wound specimens revealed the presence of densely aggregated bacterial colonies, often within their own extracellular matrix; however, these microscopic findings were not seen in acute wounds.^[67]

Multiple in vivo studies have shown that wound healing is delayed when these biofilms are present in the wound.^{[68, 69]}The biofilms seem to protect the underlying bacteria and provide resistance to antibiotic treatment and the body’s own immune system. Discussions among expert panels on wound healing have concluded that the most effective means of managing biofilms within wounds is to remove the biofilm; however, optimal methods of removal have yet to be clearly defined.^[70]

Treatment & Management

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Media Gallery

Advanced sacral pressure ulcer shows effects of pressure, shearing, and moisture.
Heel pressure ulcer.
Small sacral pressure sores can be reconstructed with the inferior-based skin rotation flap, with or without the superior gluteus maximus myocutaneous flap.
Sacral pressure ulcer before and after flap closure.
Heaps of verrucous white tissue around the ulcer suggest malignant transformation, as observed with Marjolin 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 of lateral aspect of right foot.
Radical bursectomy is performed by placing methylene blue–moistened sponge in bursa and excising pressure ulcer circumferentially, removing all granulation tissue, even from wound base.
With gluteal thigh flap, superiorly based flap is elevated, with inferior gluteal artery located between greater trochanter and ischial tuberosity as its axis.
Gluteal thigh rotation flap is raised as fasciocutaneous flap superiorly to gluteal crease.
Gluteal thigh flap may be raised to include inferior portion of gluteus maximus, which increases arc of rotation to allow flap also to be used to reconstruct sacral defects.
Small sacral pressure ulcer reconstructed with inferiorly based skin rotation flap.
Small sacral pressure ulcer reconstructed with inferiorly based skin rotation flap.
Landmarks for superior gluteal artery, on which superior gluteus maximus muscle flap is based, include posterior superior iliac spine and ischial tuberosity.
Superior and inferior gluteal arteries branch from internal iliac superior and inferior arteries to piriformis approximately 5 cm from medial edge of origin of gluteus maximus from sacrococcygeal line.
When superior portion of gluteus maximus is used as flap, it is elevated in lateral-to-medial direction to avoid injury to superior gluteal artery. Insertion of superior portion of gluteus maximus into iliotibial tract is released. Harvesting entire length of muscle may be necessary to allow rotation or turnover into defect without tension.
V-Y flaps can be based superiorly or inferiorly or on entire gluteus maximus.
Larger sacral ulcers require use of bilateral flaps, such as bilateral V-Y advancement flaps.
Skin paddle is harvested 10 cm in width and designed over muscle along axis from anterior superior iliac spine to lateral tibial condyle.
Inferior limit of cutaneous territory can be extended to 6 cm above knee and 25-35 cm in length. Lateral femoral circumflex artery can be found approximately 6-8 cm inferior to anterior superior iliac spine.
Patient required reconstruction of extremely large pressure ulcer with fillet total thigh flap procedure.
Illustrated is Girdlestone arthroplasty for femoral head osteomyelitis pyarthrosis of hip joint. Femoral head is removed, and hip joint space is reconstructed with vastus lateralis muscle flap.
Patient has urethral fistula within his pressure ulcer. When he performs Valsalva maneuver, urine leaks through this opening.
Close-up view in patient who has urethral fistula within his pressure ulcer. When he performs Valsalva maneuver, urine leaks through this opening.

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Table 1. Advantages and Disadvantages of Specialized Support Surfaces

Surface	Advantages	Disadvantages
Air	Low maintenance; inexpensive; multipatient use; durable	Can be punctured; requires proper inflation
Gel	Low maintenance; easy to clean; multipatient use; resists puncture	Heavy; expensive; little research
Foam	Lightweight; resists puncture; no maintenance	Retains heat and moisture; limited life
Water	Readily available in community; easy to clean	Requires heater; transfers are difficult; can leak; heavy; difficult to maintain; procedures difficult
Dynamic overlays	Easy to clean; moisture control; deflates for transfers; reusable pump	Noisy; can be damaged by sharp objects; requires assembly; requires power
Replacement mattresses	Reduced staff time; multipatient use; easy to clean; low maintenance	High initial cost; may not control moisture; loses effectiveness
Low air loss	Head and foot of bed can be raised; less frequent turning required; relieves pressure; reduces shear and friction; moisture control	Noisy; expensive; transfers are difficult; requires energy source; restricts mobility; requires skilled setup; rental charge
Air fluidized	Reduces shear and friction; lowest interface pressure; low moisture; less frequent turning required	Expensive; noisy; heavy; dehydration and electrolyte imbalances can occur; may cause disorientation; transfers are difficult; hot

Table 2. Key Performance Characteristics of Major Wound Dressing Types

Major Dressing Type	Key Performance Characteristics
Alginates (sheets and fillers)	Exudate absorption; obliteration of dead space; autolytic débridement
Foams (sheets and fillers)	Obliteration of dead space; retention of moisture; exudate absorption; mechanical débridement
Gauzes (woven and nonwoven)	Obliteration of dead space; retention of moisture; exudate absorption; mechanical débridement
Hydrocolloids (wafers and fillers)	Occlusion; retention of moisture; obliteration of dead space; autolytic débridement
Hydrogels (sheets and fillers)	Retention of moisture; autolytic débridement
Transparent films	Occlusion; retention of moisture; autolytic débridement
Wound fillers	Obliteration of dead space; exudate absorption; retention of moisture; autolytic débridement
Wound pouches	Exudate control

Table 3. Norton and Braden Scales for Assessing Pressure Ulcer Risk

Area of Comparison	Norton Scale	Braden Scale
Assessment criteria	Physical condition; mental condition; activity; mobility; incontinence (score ≥12 is at risk)	Activity; mobility; sensory perception; moisture; nutrition; friction; shear
Attributes	Tested on elderly persons in hospital settings	Evaluated in diverse sites (eg, medical-surgical, intensive care units, nursing homes)
Replications	Tested extensively	Tested extensively
Reliability	Not available	Good interrater reliability