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Clinical Case of the Month Pressure Ulcer Treatment Spinal Cord (1997) 35, 641 ± 646 1997 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/97 $12.00 Clinical Case of the Month Pressure ulcer treatment F Biering-Sùrensen1, JL Sùrensen2, TEP Barros3, AA Monteiro3, I Nuseibeh4, SM Shenaq5 and K Shibasaki6 1Centre for Spinal Cord Injured, the Neuroscience Centre, and 2Department of Plastic Surgery, Rigshospitalet, Copenhagen University Hospital, Denmark; 3Spinal Injury Unit, Department of Orthopaedics, University of Sao Paulo, Brazil; 4National Spinal Injuries Centre, Stoke Mandeville, England; 5Department of Surgery, Baylor College of Medicine, The Methodist Hospital, Houston, Texas, USA; 6Spinal Cord Division, Department of Orthopedic Surgery, National Murayama Hospital, Japan Keywords: spinal cord injury; paraplegia; pressure ulcer; management; treatment; surgery Introduction The complicated case story below was presented to and found. Over the sacrum there was an ulcer measuring discussed by senior colleagues from Brazil, England, 2.561.5 cm with bone at the base. The plastic surgeon Japan and USA. None of the the responders knew that concluded, not least because of the patient's mental the patient had sustained his injury in 1981, and the habitus, not to operate, but to try conservative initial report stopped at the New Year 1986/87. A treatment. X-ray gave no indication of osteitis. Three review of the patient's medical history for the following weeks later the left trochanteric ulcer measured 3.5 cm years up to date is presented. Finally a short discussion in diameter and 3.5 cm in depth with necrosis and an of the possibilities of treatment is given. iliotibial tract at the base. Over the right trochanter an area of 1.5 cm62.5 cm had defective epithelium. The Case story sacral ulcer was undermined 3 cm in a proximal direction. Again he was strenuously informed of the The patient, a man aged 18 years, sustained a spinal seriousness of the condition and of the importance of cord injury (SCI) in a motorcycle accident. Spinal X- total pressure relief. Despite this he used his wheelchair rays showed a fracture dislocation of 1 cm at vertebrae several times. Due to his lack of cooperation and Th6/7, with a complete spinal cord lesion at Th6. The motivation, he was 8 months after injury, ®nally fracture was stabilised in a neurosurgical department transferred from the Centre for Spinal Cord Injured to with Harrington rods. Before being transferred for a local general hospital. At this time his indwelling rehabilitation he developed a small super®cial sacral catheter had to be changed each week because of pressure ulcer, which healed by conservative means encrustations. He was treated with baclofen 20 mg qid during the primary rehabilitation. During the initial for spasticity and spasms. weeks he was treated for pneumonia and urinary tract In the local hospital he accepted the total pressure infection. During the rehabilitation he was generally relief regime, and the sacral and the right trochanteric dicult regarding cooperation, but he obtained ulcers healed. The plastic surgeon then, approximately independence in a wheelchair and was going to 10 months after injury, performed a resection of the proceed with the use of long leg calipers. After a left greater trochanter and a musculocutaneous prolonged weekend visit at his home he returned with transposition of the left tensor fascia lata muscle. A super®cial pressure ulcers over the sacrum, both small secondary defect healed within two months. trochanteric regions, and both lateral malleoli. They Because of various social, psychological, as well as all healed within a couple of weeks. Continuously the somatic reasons, he came to live in a nursing home. A patient did not want to follow the directions given by few months later he again had bilateral trochanteric the sta, and he ended up with a urethral catheter for ulcers. He continued with the indwelling catheter, and bladder drainage and he had bilateral trochanteric and 17 months post-injury cystoscopy and cystolithotripsy sacral pressure ulcers 7 months after injury. At the left of 20 ± 25 urinary calculi was performed. Eight months trochanter a 1.5 cm large necrotic ulcer and at the later additional urinary calculi were removed via a right trochanter a 565 mm super®cial ulcer were cystotomy. The patient still had the bilateral trochanteric ulcers, each now measuring 669cm.In addition subluxation of the left hip had developed resulting from contracture of the iliopsoas muscle and Correspondence: F Biering-Sùrensen spasticity of the adductor muscles. Clinical case of the month: pressure ulcer treatment F Biering-Sorensen et al 642 Two years and three months after the SCI, From this stage in this patient what would your orthopaedic surgeons performed tenotomies of the management be? adductor and psoas muscles bilaterally. At the operation the left hip was totally luxated, but was easily repositioned. Response I Nearly 3 years after injury the patient was admitted to the department of plastic surgery. The right K Shibasaki, MD trochanteric ulcer measured 1 cm in diameter with The diculties of treatment relate to his personality; an undermining of 4 ± 5 cm. The left trochanteric ulcer the development of recurrent pressure ulcers with bone measured 767 cm. A right ischial pressure ulcer and joint involvement, and in lack of donor sites of measured 1 cm with 3 ± 4 cm undermining. All the musculocutaneous ¯aps in this special case. ulcers were excised. The right trochanteric ulcer was Treatment should be directed to control the severe coveredwithafasciocutaneoustensorfascialata¯ap. degree of spasticity, to manage the infection of the On the left side the defect was covered after femur and of the hip joint, and to close the skin remobilisation of a tensor fascia lata ¯ap. The defects of the bilateral pressure ulcers. For the secondary defects were covered with meshed split- management of spasticity in paralysed limbs, rhizot- thickness skin graft. The right ischial ulcer was closed omy or myelotomy would be recommended. As far as directly. Afterwards he was transferred to the centre the recurrence of spasticity is concerned, myelotomy for SCI. At discharge he still had a ®stula over the left would be preferable. The problem of myelotomy trochanter. He was now living with his mother in a would be the postoperative change in bladder house, but shortly afterwards he moved into his own function in this patient, but it would not be necessary apartment. to preserve his automatic bladder function, as the During the following year the patient was patient is still using an indwelling catheter. admitted to the local hospital twice because of an Secondly, treatment for the right trochanteric ulcer ulcer on the right heel and the ®stula in the left should be performed. After excision of the pressure trochanter region. ulcer, removal of upper part of the right femur is Four and a half years after the SCI, he was again necessary, including the femoral head and greater admitted to the department of plastic surgery because trochanter. To control the local infection local of super®cial ulceration over the right heel and defects irrigation of sterile normal saline should be continued in the trochanteric regions with a ®stula on the left for at least 2 weeks. Prior to the closure of the skin side. A revision was performed including split-skin defect using a musculocutaneous ¯ap, tubes for transplantation to the heel and the right trochanter irrigation should be placed in the wound. To cover region. The ®stula was excised and closed. the skin defect a musculocutaneous ¯ap of the tensor Six months later he was readmitted because of the fascia lata muscle is no longer useful and V-Y two trochanteric ulcers and a recurrence of a right advancement of the gluteus maximus myocutaneous calcaneal ulcer. Again excision and transplantation was island ¯ap is helpful in this case (Figure 1). The lower carried out in a total of three times, and a transposition part of gluteus maximus muscle is supplied by the of part of the adductor muscles was carried out to ®ll a inferior gluteal artery, and as Sche¯an et al. reported defect in the left inguinal region, which had its origin in 1981,1 downward or outward rotation of this from a ®stula to the trochanteric ulcer. myocutaneous island ¯ap is available to cover a About two months later the patient was admitted pressure ulcer of the ischium or of the greater again with recurrence of both trochanteric ulcers now trochanter. Saline irrigation should be continued for measuring about 10610 cm with trochanteric bone in two or three weeks post-operatively. the central parts. After revision, a free dorsalis pedis The third procedure is the treatment for the island ¯ap was used to cover the right hip defect after pressure ulcer of the left greater trochanter asso- interposition of a free saphenous magna vein to supply ciated with a communication to the hip joint. the ¯ap from the femoral vessels. The ¯ap was torn by Removal of infected bone and cartilage, and spasms and was resutured after 4 days. However, the thorough curettage of infected granulation would be ¯ap was totally necrotic after a week. Bilaterally the necessary around the left hip joint, followed by local femoral bones were luxated proximally out of the hip saline irrigation with medication of appropriate joints. On the right side a defect of 8610 cm with an antibiotics. The advanced V-Y myocutaneous island undermining of 2 cm posteriorly with femoral bone in ¯ap of the gluteus maximus is also available for the central part was found. The proximal femoral bone closure of the skin defect on this side. Generally, showed clinical signs of osteitis and was surrounded by complete healing of joint infections is especially heterotopic ossi®cations.
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