Pressure ulcers: surgical intervention

Abstract

Pressure ulcers are tissue damage, mainly over a bony prominence, occurring in critically ill, paraplegic, bedbound and elderly patients. They are classified from stage 1-4, and the most common sites are around the pelvic area (sacral, trochanteric and ischial). Stages 1 and 2 usually heal with non-surgical, conservative management, while stages 3 and 4 require a surgical approach. Preoperative, intraoperative and postoperative measures are paramount for the successful operative repair of pressure ulcers, together with proper patient selection and adequate support from the patient’s circle of care. Surgical choice is based on principles, surgeon experience and preference, subject to individual and patient choice. Reconstructive options are based on the complexity of the repair, the type of tissue used to close the ulcer, and specific flap design chosen by the trained reconstructive surgeon. The procedures, in ascending level of complexity, are direct (primary) closure; skin grafts; and local, fasciocutaneous, muscular, myocutaneous, perforator and free flaps. A high recurrence rate, associated complications and costs remain a challenge with regard to the surgical management of these chronic wounds, and this remains common worldwide. Prevalence studies are lacking in South Africa, and preclude estimates of associated costs relating to the clinical and surgical treatment of pressure ulcers in the country. Prevention is still the best management strategy to avoid litigation and the elevated costs of pressure ulcer management.