Experience of Surgical Treatment of Pressure Ulcers in Patients with Traumatic Spinal Cord Disease: Effectiveness and Risk of Complications

RELEVANCE One of the urgent issues in the complex treatment of patients with traumatic spinal cord disease is the treatment of pressure wounds. Despite the large number of suggested and applied methods, the results of surgical closure of pressure wounds remain unsatisfactory. The risks of developing purulent-septic wound complications and local circulatory disorders after surgery are high. The correct choice of the method of plastic surgery of bedsores can be made on the basis of a thorough analysis of the advantages and disadvantages of the main surgical methods.

AIM OF THE STUDY To study the spectrum of complications after the use of various types of pressure ulcer plastic surgery in patients with traumatic spinal cord disease and to determine, based on the data obtained, the indications for their implementation.

MATERIAL AND METHODS An analysis of surgical treatment of 151 patients was conducted, who underwent 215 planned surgeries for bedsores of various localizations. The surgical treatment included: plastic surgery using local skin-fat, skin-fascial and skin-muscle flaps. The frequency and spectrum of complications characteristic of each type of plastic surgery were analyzed.

RESULTS Among all operated patients, the most frequent complications in the postoperative period were: partial or complete suture failure, wound infection, flap ischemia, lymphorrhea. In total, wound process complications were recorded in 39 cases (18%) out of 215 reconstructive plastic surgeries performed.

The frequency of ischemic and infectious complications leading to complete or partial loss of flaps after the use of cutaneous-fascial flaps was 4.1%. In patients operated using skin-fat and skin-muscle flaps, relapses did not develop.

CONCLUSION The method of choice for treating patients with extensive bedsores is reconstructive plastic surgery, which is based on the formation of skin-fat, rotational skin-fascial flaps with the provision of principles of tension-free plastics. At the same time, the issue of complications such as suture failure, wound infection, flap ischemia and lymphorrhea remains unresolved, which requires further scientific and practical research.

1. Yakovleva AV, Yakovlev AA, Petrova MV, Krylov KYu. Complex Decubitus Ulcer Therapy in a Patient in Chronic Critical Condition: a Case Report. Bulletin of RSMU. 2019;(3):13–21. https://doi.org/10.24075/vrgmu.2019.035 (In Russ.)

2. Mervis JS. Pressure ulcers: Prevention and management. J Am Acad Dermatol. 2019;81(4):893–902. PMID: 30664906 https://doi.org/10.1016/j.jaad.2018.12.068

3. Khirurgicheskie infektsii kozhi i myagkikh tkaney. Rossiyskie natsional’nye rekomendatsii. 2nd ed., rev. and add. Moscow;2015. (In Russ.)

4. Shlyapnikov SA, Naser NR, Borodina МA, Batyrshin IМ, Sklizkov DS, Mikhelson EP, et al. Modern Bedsore Treatment Approaches. Zhurnal MediAl’. 2019;1(23):40–41. (In Russ.)

5. Mirzaeva LM, Lobzin SV, Chistova IV, Rizahanova OA, Dulaev AA. Predictors of Complications and Mortality in Traumatic Spinal Cord Injuries. Kuban Scientific Medical Bulletin. 2020;27(1):59–71. (In Russ.) https://doi.org/10.25207/1608-6228-2020-27-1-59-71

6. Lobzin SV, Mirzaeva LM. Complications of Acute Traumatic Spinal Injuries in Saint Petersburg. Marine Medicine. 2020;6(1):33–42. (In Russ.). https://doi.org/10.22328/2413-5747-2020-6-1-33-42

7. Achkasov EE, Yaroslavskaya MA, Mashkovsky EE, Puzin SN, Goncharova OV, Burdukov AA. Clinical and psychological aspects of rehabilitation in patients with vertebral and spinal cord injury. Neurology, Neuropsychiatry, Psychosomatics. 2017;9(2):4–9. (In Russ.). https://doi.org/10.14412/2074-2711-2017-2-4-9

8. Stillman MD, Barber J, Burns S, Williams S, Hoffman JM. Complications of Spinal Cord Injury Over the First Year After Discharge from Inpatient Rehabilitation. Arch Phys Med Rehabil. 2017;98(9):1800–1805. PMID: 28115072 https://doi.org/10.1016/j.apmr.2016.12.011

9. Christodoulou VN, Varvarousis D, Theodorou A, Voulgaris S, Beris A, Doulgeri S, et al. Rehabilitation of the multiple injured patient with spinal cord injury: A systematic review of the literature. Injury. 2019;50(11):1847–1852. PMID: 31409453 https://doi.org/10.1016/j.injury.2019.07.035

10. Paker N, Buğdaycı D, Gökşenoğlu G, Akbaş D, Korkut T. Recurrence rate after pressure ulcer reconstruction in patients with spinal cord injury in patients under control by a plastic surgery and physical medicine and rehabilitation team. Turk J Phys Med Rehabil. 2018;64(4):322–327. PMID: 31453529 https://doi.org/10.5606/tftrd.2018.2175 eCollection 2018 Dec.

11. Papp A. Incisional negative pressure therapy reduces complications and costs in pressure ulcer reconstruction. Int. Wound J. 2019;16(2):394–400. PMID: 30548531 https://doi.org/10.1111/iwj.13045

12. Lim NK, Goo H, Yoon SR, Ahn JC, Hong N, Choi YH, et al. The validity and safety of multispectral light emitting diode (LED) treatment on grade 2 pressure ulcer: Double-blinded, randomized controlled clinical trial. PLoS One. 2024;19(8):123–132. PMID: 39178286 https://doi.org/10.1371/journal.pone.0305616

13. Walter GP, Seidel W, Giustina RD, Bins-Ely J, Maurici R, Narciso-Schiavon JL. Prognostic factors in patients with pressure sores in a university hospital in Southern Brazil. Acta Ortop Bras. 2017;25(6):243–247. PMID: 29375252 https://doi.org/10.1590/1413-785220172506169042

14. Chen C, Chiang IH, Ou KL, Chiu YL, Liu HH, Chang CK, et al. Surgical treatment and strategy in patients with pressure sores: A singlesurgeon experience. Medicine (Baltimore). 2020;99(44):e23022. PMID: 33126386 https://doi.org/10.1097/MD.0000000000023022

15. Erçöçen AR, Yilmaz S, Can Z, Emiroglu M, Yormuk E. Bası yaralarının cerrahi tedavisi: 108 Olgunun değerlendirilmesi. Turk Plast Cer Dcrg. 2000;8(2):82–89.

16. Bamba R, Madden JJ, Hoffman AN, Kim JS, Thayer WP, Nanney LB, et al. Flap Reconstruction for Pressure Ulcers: An Outcomes Analysis. Plast Reconstr Surg Glob Open. 2017;5(1):e1187. PMID: 28203494 https://doi.org/10.1097/GOX.0000000000001187 eCollection 2017 Jan.

17. Irmak F, Baş S, Sızmaz M, Akbulut HA, Karşıdağ SH. Management and Treatment of Pressure Ulcers: Clinical Experience. Sisli Etfal Hastan Tip Bul. 2019;53(1):37–41. PMID: 33536824 https://doi.org/10.14744/SEMB.2018.70973 eCollection 2019.

18. Khrupkin VI, Lipatov KV, Komarova EA, Asatrian AG, Borodin AV. Plastic Surgery in Patients with Soft-tissue Infection. Journal of Experimental and Clinical Surgery. 2013;6(2):131–139. (In Russ.)

19. Pyatakov SN, Zavrazhnov AA, Lebedev IO, Zimin VA, Morozov VV, Ralko SN. Modern Concepts of Opportunities in the Treatment of Extensive Dermotension Soft Tissue Defects. Infektsii v khirurgii. 2014;12(2):7–12. (In Russ.)

20. Norman G, Wong JK, Amin K, Dumville JC, Pramod S. Reconstructive surgery for treating pressure ulcers. Cochrane Database Syst Rev. 2022;10(10):CD012032. PMID: 36228111 https://doi.org/10.1002/14651858.CD012032.pub3

21. Awad SS, Stern JD, Milne CT, Dowling SG, Sotomayor R, Ayello EA, et al. Surgical Reconstruction of Stage 3 and 4 Pressure Injuries: A Literature Review and Proposed Algorithm from an Interprofessional Working Group. Adv Skin Wound Care. 2023;36(5):249–258. PMID: 37079788 https://doi.org/10.1097/01.ASW.0000922708.95424.88

22. Lindqvist EK, Sommar P, Stenius M, Lagergren JF. Complications after pressure ulcer surgery a study of 118 operations in spinal cord injured patients. J Plast Surg Hand Surg. 2020;54(3):145–150. PMID: 32003279 https://doi.org/10.1080/2000656X.2020.1720700

23. Beschastnov VV, Ryabkov MG, Leontiev AE, Tulupov AA, Yudanova TN, Shirokova IYu. Viability of Bacteriophages in the Complex Hydrogel Wound Dressings in Vitro. Modern Technologies in Medicine. 2021;13(2):32–39. (In Russ.). https://doi.org/10.17691/stm2021.13.2.03

24. Dibirov MD. Decubitus: prevention and treatment. Ambulatory Surgery (Russia). 2016;(1–2):55–63. (In Russ.)

25. Sun JL, Guo PF, Cui ZJ, Meng QN, Wei AZ, Zhou J. Clinical effects of superior gluteal artery perforator “buddy flap” in repairing pressure ulcer in sacrococcygeal region. Zhonghua Shao Shang Za Zhi. 2020;36(8):726–729. PMID: 32829613 https://doi.org/10.3760/cma.j.cn501120-20190607-00265

26. Sinnott CJ, Stavrides S, Boutros C, Kuruvilla A, Glickman LT. Dual-Plane Gluteal Myocutaneous Flap for Reconstruction of Ischial Tuberosity Pressure Wounds. Ann Plast Surg. 2020;85(1):S23–S27. PMID: 32530847 https://doi.org/10.1097/SAP.0000000000002331

27. Zwanenburg PR, Verdijk RWA, Lapid O, Obdeijn MC, Gans SL, Boermeester MA. Systematic review and meta-analysis of sensate versus non-sensate flaps for the prevention of pressure ulcer recurrence among individuals with spinal cord disease. Spinal Cord. 2021;59(5):463-473. PMID: 33727678 https://doi.org/10.1038/s41393-020-00590-5

28. Wurzer P, Winter R, Stemmer SO, Ivancic J, Lebo PB, Hundeshagen G, et al. Risk factors for recurrence of pressure ulcers after defect reconstruction. Wound Repair Regen. 2018;26(1):64-68. PMID: 29381242 https://doi.org/10.1111/wrr.12613

29. Huiming G, Yuming W, Mingliang Y, Changbin L, Qiuchen H, Jianjun L. Study on the characteristics of microcirculation in the site of pressure ulcer in patients with spinal cord injury. Sci Prog. 2021;104(3):368504211028726. PMID: 34495784 https://doi.org/10.1177/00368504211028726

30. Beschastnov VV, Ryabkov МG, Pavlenko IV, Bagryantsev МV, Dezortsev IL, Kichin VV, et al. Current Methods for the Assessment of Oxygen Status and Biotissue Microcirculation Condition: Diffuse Optical Spectroscopy (Review). Modern Technologies in Medicine. 2018;10(4):183–195. (In Russ.) https://doi.org/10.17691/stm2018.10.4.22