Poster Presentation New Zealand Association of Plastic Surgeons Annual Scientific Meeting

Neurological pressure ulcers: Our experience with perforator flaps (494)

Daniel NK Yang 1 , Parag J Mahadik 1 , Geoffrey P Curtin 1 , Jake Lim 1
  1. Plastic and Reconstructive Surgery, Westmead Hospital, Sydney, NSW

Title:
Neurological pressure ulcers: Our experience with perforator flaps

Aims:
This is a retrospective study of the efficacy of perforator flaps to reconstruct extensive grade IV pressure ulcers combined with tailored nursing care in paraplegics without a specialised spinal unit. We focused on two key factors; the selection of an appropriate, robust perforator flap for pressure ulcer reconstruction and a standardised post operative positioning and seating protocol.

Methods:
We retrospectively analysed 6 patients who were neurologically compromised from trauma, metastatic malignancy, spina bifida and multiple myeloma. Exclusion criteria were applied. Perforator flaps based on superior gluteal and internal pudendal artery perforators were performed to reconstruct pressure sore defects ranging from 10 by 12 cm to 20 by 21 cm in size. All donor sites were primarily closed. Sound flap healing was achieved in all cases by time of discharge with an average post-operative admission of 28 days. The nursing care protocol involved a rule of two; no pressure bearing on the flap site for two weeks and intermittent two hourly flap offloading for a further two weeks. A seating protocol started two months post-operatively, again with two-hour off-loading periods for every two hours spent sitting.

Discussion:
While the technical aspects in the surgical management of pressure ulcers have been extensively explored; comparatively scant information exists on the complexities of post-operative care1.
The reduction in recurrences and complications in protocol-guided inpatient multidisciplinary spinal units suggests that the paucity of dedicated spinal units, difficulty in reconstruction and post-operative care jeopardised by inconsistent nursing in the community are major contributing factors to post-operative outcomes following pressure sore surgery.2, 3
This integrated approach of carefully designed robust perforator flaps, along with protocol-guided inpatient nursing care can achieve satisfactory outcomes to reduce morbidity, mortality and costs.

  1. Sameem M, Au M, Wood T, Farrokhyar F, Mahoney J. A systematic review of complication and recurrence rates of musculocutaenous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores. Plastic Reconstructive Surgery. 2012;130(1):67-77.
  2. Schryvers O, Stranc M, Nance P. Surgical treatment of pressure ulcers: 20-year experience. Archives of Physical Medicine and Rehabilitation. 2000;81(12):1556-62.
  3. Larson D, Hudak K, Waring W, Orr M, Simonelic K. Protocol management of late-stage pressure ulcers: a 5-year retrospective study of 101 consecutive patients with 179 ulcers. Plastic Reconstructive Surgery. 2012;129(4):897-904.