Bed sores ; Role of plastic surgery
Although the scientists have been searching for more and more advance methods of treating III and IV degree pressure ulcers, the fastest and more effective method of treating pressure ulcers is surgery with the application of pedicled flaps: fasciocutaneous flaps and musculocutaneous flaps. The selection of the applied flap depends on the location and depth of the pressure ulcer to be treated.
Treatments involving direct closure of the wound margins after its surgical excision (debridement) and cutting out the bursa usually fail. The tension at the suture line is too high and, consequently, the edges of the skin do not have sufficient blood supply. Reconstructive surgery consists of the following key elements: radical resection of bone prominences as well as dead bone, filling dead spaces using pedicled flap, well-vascularized tissue and the simultaneous application of large pedicled flaps. It is significant to stitch the edges of the wound without causing the tension. It is obtained by using reliable drainage of the post-operative wound .
Non-treatment of pressure ulcers can result in cancer transformation of an ulcer called Marjolin’s ulcer. The discussed types of cancer (well-differentiated “squamous cell carcinoma”) are more malignant compared to the cancer changes observed in case of burns and osteomylitis. Professional literature suggests that 12 out of 18 patients diagnosed with a pressure ulcer related cancer die within 12 years.
Therefore, surgical treatment of deep pressure ulcers and cancer changes originating from pressure ulcers should be indeed radical. Adverse consequences of a chronic pressure ulcer include renal failure and amyloidosis . The highest mortality rate was discovered among patients with a new pressure ulcer appearing after a therapeutic failure. In recent years much attention has been devoted to the treatment of deep wounds using vacuum-assisted closure therapy (V.A.C.) .
In some cases this type of therapy can replace surgical treatment of pressure ulcers involving pedicled flaps. However, one should bear in mind that there are contraindications for applying V.A.C. therapy such as: cancerous transformation of pressure ulcer, untreated bone infection, surgically untreated fistula located in the wound, pressure ulcer covered with dead tissue, sometimes with dry scab, presence of large blood vessels or internal organs walls at the place where V.A.C. is to be applied . Naturally, anaerobic colony infections also constitute contraindications to using V.A.C. V.A.C. therapy is more frequently applied in general surgery as well as at vascular surgery departments. Treatment of deep ulcers using pedicled flaps is still a less known method of treatment of deep ulcers among general surgeons. Plastic surgery departments in Poland are usually not interested in treating patients suffering from deep, extensive pressure ulcers. In most cases these patients are sent to surgical wards. It is advisable to educate the surgeons not only as regards the currently popular V.A.C. therapy but also as regards methods of covering extensive pressure ulcer tissue defects with pedicled flaps as this technique has been proven successful in the faster proper surgical treatment of deep pressure ulcers for many years now
