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Objective: To assess pressure ulcer (PU) risk in persons with mobility impairments using a large data set to identify demographic, laboratory, hemodynamic, and pharmacologic risk factors., Methods: The cohort of interest was persons with disabilities who have mobility impairments and are diagnostically at risk of PUs. To define this cohort, diagnoses that qualify patients for skin protection wheelchair cushions were used. Data were obtained from the Cerner Health Facts data warehouse. Two cohorts were defined: persons with and without a history of PUs. Analysis included descriptive statistics and multivariate logistic regression modeling. Variables retained in the model were identified using LASSO, gradient boosting, and Bayesian model averaging., Main Results: The resulting cohorts included more than 87,000 persons with a history of PUs and more than 1.1 million persons who did not have a PU. The data revealed seven disability groups with the greatest prevalence of PUs: those with Alzheimer disease, cerebral palsy, hemiplegia, multiple sclerosis, paraplegia/quadriplegia, Parkinson disease, and spina bifida. Ulcers in the pelvic region accounted for 82% of PUs. Persons with disabilities who were male or black had a greater prevalence of PUs. Physiologic risk factors included the presence of kidney or renal disease, decreased serum albumin, and increased serum C-reactive protein., Conclusions: The results indicate that, although persons with disabilities can exhibit a wide functional range, they remain at risk of PUs and should be evaluated for proper preventive measures, including support surfaces and wheelchair cushions.

Introduction: The reconstruction of extensive soft tissue defects from pressure ulcers is a great challenge. Resurfacing such defects with like tissues and minimizing morbidities are important. Here we present our surgical experience using a novel modified keystone flap for pressure ulcer patients., Methods: We retrospectively reviewed the data of 13 consecutive cases reconstructed with the modified keystone flaps between March and December, 2017. The mean dimensions of the reconstructed defect were 7.7 × 6.5 cm, while the mean dimensions of the flap were 12.1 × 8.3 cm., Results: Time efficient reconstructions with the modified keystone flap were performed without any following major complications. Minor wound dehiscence occurred in only one case, which soon healed with conservative management., Conclusions: Considering its simple design, reliable flap survival, minimal donor-site morbidity, optimal flap thickness, and evenly distributed surgical tension, our novel technique of the modified keystone flap is as an excellent surgical option for the reconstruction of pressure ulcers in the gluteal region.

Objective: To identify the long-term clinical, individual, and social risk factors for the development of pressure ulcers (PUs) in traumatic spinal cord-injured persons with tetraplegia (TSCIt)., Design: Cohort survey with self-applied questionnaires in 1995 and 2006., Setting: Thirty-five French-speaking European physical medicine and rehabilitation centers participating in the Tetrafigap surveys., Participants: Tetraplegic adults (N=1641) were surveyed after an initial posttraumatic period of at least 2 years. Eleven years later, a follow-up was done for 1327 TSCIt, among whom 221 had died and 547 could be surveyed again., Interventions: Not applicable., Main Outcome Measures: The proportion of PUs documented at the various defined time points, relative to the medical and social situations of the TSCIt, by using univariate analyses followed by logistic regression., Results: Of the participants, 73.4% presented with a PU during at least 1 period after their injury. Four factors had an effect on the occurrence of PUs in the long-term. Protective features for this population were incomplete motor impairment (odds ratio, 0.5) and the ability to walk (odds ratio, 0.2), whereas a strong predictive factor was the development of a PU during the initial posttrauma phase (odds ratio, 2.7). Finally, a significant situational factor was the lack of a social network (odds ratio, 3.1)., Conclusions: We believe that the highlighting of a motor incomplete feature of SCI (protective against the development of a PU) and of a medical risk factor, an early PU (which served as a definitive marker of the trajectory of TSCIt), together with a social situational factor, indicates the crucial role of initial management and long-term follow-up., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The aim of this study was to analyse the effectiveness of an interdisciplinary cooperation between conservative and surgical disciplines for the treatment of pressure sores (PS). From January 2004 to December 2005, a single-centre study was performed with paraplegic and tetraplegic patients presenting with PS grades III-V. Outcome measures were defect size, grade, method of reconstruction, complication and recurrence rate as well as average length of hospitalisation. A total of 119 patients aged 22-84 years with totally 170 PS were included. The most common PS were located in the ischial region (47%), followed by the sacral (18%), trochanteric (11%), foot (9%) and the malleolar (8%) regions. Defect sizes ranged between 4 and 255 cm(2) . Grade IV was the most common PS (68%), followed by grade III (30%) and grade V (2%) PS. For wound closure, fasciocutaneous flaps were used most frequently (71%), followed by skin grafts (10%) and myocutaneous flaps (7%). Postoperative follow-up ranged between 6 and 38 months. The overall complication and recurrence rate was 26% and 11%, respectively. If no complication occurred, the average duration of hospitalisation stay after the first debridement was 98 ± 62 days. In conclusion, our treatment concept is reliable, effective and results in a low recurrence rate. The complication rate, even though favourable when compared with the literature, still needs to be improved., (© 2013 The Authors. International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

The bispectral (BIS) monitor uses brain electroencephalographic data to measure the depth of sedation and pharmacological response during anaesthetic procedures. In this case, the BIS monitor was used for another purpose, to demonstrate postoperatively to the nursing staff that a patient with history of locked-in syndrome (LIS), who underwent pressure ulcer debridement, had periods of wakefulness and apparent sensation, even with his eyes closed. Furthermore, as patients with LIS can feel pain, despite being unable to move, local block or general anaesthesia should be provided for sharp surgical debridement and other painful procedures. This use of the BIS has shown that as a general rule, the staff should treat the patient as though he might be awake and sensate even if he does not open his eyes or move his limbs. The goal of this study was to continuously monitor pain level and communicate these findings to the entire wound team, i.e. anaesthesiologists, surgeons and nurses., (© 2012 The Authors. International Wound Journal © 2012 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Pressure ulcers and autonomic dysreflexia (AD) are common complications that may affect individuals with spinal cord injury (SCI). Negative-pressure wound therapy (NPWT) is a frequently used modality to aid in wound healing in the treatment of pressures ulcers in patients with SCI. Although the common triggers of AD have been well described in the literature, there have been no formal reports of NPWT itself as a cause of AD. We detail 2 cases of patients with SCI and with AD thought to be secondary to NPWT and discuss modifications made to allow for continued treatment with NPWT while minimizing further episodes of AD. We propose that NPWT should be considered as a potential source of AD in patients with SCI undergoing this therapy., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

 The cost of pressure ulcers, especially Stage III and Stage IV ulcers, is substantial. A 27-year-old man with a 6-year history of quadriplegia developed an ischial pressure ulcer. Twelve months of treatment with wet-to-dry dressings were followed by admission to several facilities and 15 months of care with biological dressings and negative pressure wound therapy (NPWT). When admitted to the authors' wound care center, the wound measured 4.5 cm x 3.2 cm with exposed bone. A review of his insurance records showed that paid claims totaled $242,350, including $52,992 for NPWT rental costs. The patient was considered a good candidate for minimally invasive surgical intervention with external tissue expanders. Following a 14-day course of antibiotics to treat his infection, the wound was debrided and the tissue expanders applied. After 16 days, the wound was closed. The patient returned to work 6 weeks after the procedure. At the 23-month follow-up, the wound remained closed. Insurance payments for the care that resulted in wound closure totaled $43,814. This case study illustrates the potential of the external tissue expansion technique to close deep pressure ulcers within a relatively short amount of time at comparatively lower cost. Studies including control treatments are needed to confirm these conclusions.

The distally extended tensor fascia lata flap is a good choice to provide sufficient tissue bulk for a deep trochanteric sore defect. However, this flap can result in necrosis of the distal skin due to inadequate blood supply, failure of primary closure at the donor site or suture separation at the proximal donor site. The viability of the distal flap depends on the longitudinal subcutaneous plexi of the perforators anastomosing through multiple small-calibre vessels. If the subcutaneous and fasciocutaneous plexi are maximally preserved, the distal flap may be viable. It may also allow the flap to be narrower at the proximal portion, allowing the donor site to be primarily closed without tension. We performed a V-shaped, distally de-epithelialised, extended tensor fascia lata flap with a wide base of the iliotibial tract. The de-epithelialised distal flap was double-folded to fill the dead space of the defect. A key surgical tip to improve blood supply to the distal flap was to preserve the iliotibial tract 1.5 cm beyond both borders of the V-shaped skin incision. A total of 14 trochanteric wounds were successfully covered in 11 patients without complication. This flap had the advantages of having soft-tissue bulk, a reliable blood supply and primary donor-site closure. This flap may provide a good option for the reconstruction of deep trochanteric pressure sores., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Study Design: Retrospective chart review., Objective: The aim of this study was to analyze the correlation between necrotizing fasciitis (NF) and pressure ulcers, as well as the mortality, and complication rate, in patients with spinal cord injury (SCI)., Summary of Background Data: Pressure ulcers represent a challenging problem, especially in immobilized patients. Necrotizing soft tissue infections arising from decubitus ulcers in patients with SCIs have been reported., Methods: Twenty-five SCI patients with NF treated between April 2000 and December 2009 were included in the study. All patients were analyzed in regard to the number of surgical debridements, length of hospital stay, and laboratory, microbiological, and histological assessments. Information about age, sex, preexisting conditions, anatomical localization, and etiology of the NF were acquired from the patients' medical records., Results: There were 19 paraplegic and 6 tetraplegic patients with a median age of 47 years. In 18 cases, NF developed in the setting of pressure sores. Grade 4 pressure sores were identified in 15 cases and grade 3 pressure sores in 3 cases. The incidence of developing NF is significantly higher in patients with fourth-grade pressure sores than in those with a lower-grade lesion (odds ratio = 2.91; 95% confidence interval, 1.29-6.56). The mean laboratory risk indicator for NF score was 6.6 upon admission. The most common bacteria were streptococci. During the hospital stay, six patients developed sepsis and two died because of septic multiorgan failure., Conclusion: Patients with grade 3 and 4 pressure sores had a significantly increased risk of developing NF. The current investigators recommend that close clinical and laboratory monitoring of all patients with grade 3 or 4 pressure sores is appropriate so that any early clinical signs of NF can be recognized and evaluated for early and aggressive treatment.

The potential for skin breakdown presents significant challenges to the healthcare providers of physically compromised children. Pressure ulcers (PUs) can lead to grave and costly problems in the care of immobile children, contributing to hospital admissions solely for the treatment of skin breakdown and related complications; infection, septicemia, and potential death. Skin breakdown and the development of PUs in children is often overlooked as pediatric healthcare providers do not fully understand or realize the risks. Although there is little written related to skin breakdown and the risk of PU development in children, it is important for nurses who work with children to be fully aware of the factors that place a child at increased risk.

Background/objectives: Chronic pressure ulcers affect patient health, emotional state, and quality of life, causing considerable morbidity and mortality in addition to contributing to significant health care costs from lengthy hospitalizations to advanced home care and surgical care costs. The conventional treatment of these wounds can be slow due to their chronic inflammatory state and the senescence of local reparative cells. Platelet-rich plasma (PRP) therapy has been growing as a viable treatment alternative for a number of clinical applications and has potential benefit for use in chronic wounds. The sustained release of large quantities of autologous growth factors, cytokines, and other mediators found in PRP plus the favorable mononuclear cell profile of PRP may help us to stimulate wound healing and resolve chronic inflammation., Methods: Three veterans with spinal cord injury (SCI), presenting with chronic stage IV pressure ulcers, were treated with a sustained release PRP therapy to stimulate wound healing., Results: PRP treatment consistently resulted in the formation of granulation tissue and improved vascularity for each of the three patients treated, while reducing the overall ulcer area and volume., Conclusion: The controlled release of growth factors from PRP demonstrated a positive stimulatory effect on the healing rate of chronic pressure ulcers in individuals with SCI.

Background: The new design of the gluteus maximus perforator-based island flap for coverage of gluteal defects has the distinct advantage of being able to use customizable tissue components for coverage and at the same time sparing the source vessel. This adds a further option for use in reconstruction., Methods: After excisional débridement of the lesion, a perforator adjacent to the defect is selected. The tissue of the donor region is pinched to simulate closure. The change in shape of the recipient defect is noted and the dimensions of this new shape are measured. This will serve as the new dimensions of the donor tissue. The tissue components required to fill the defect are then analyzed and the flap is raised. It can be either muscle-sparing, muscle-splitting, or muscle-inclusive. A 1- to 2-cm diameter of soft tissue around the perforator is preserved. The flap is islanded and transposed, and the donor site is closed primarily, acting as a "locking barrier" to the flap. Tension-free closure of the recipient flap is then carried out. Seventy-five patients underwent closure of varying defects of the gluteal region using this technique., Results: The authors had a total of three minor complications. The rest of the patients healed well, with no recurrence at a mean follow-up of 15 months., Conclusions: The flap design for coverage of gluteal defects has a great impact on recurrence and complications. This design is novel and the flap is simple to elevate. This is an ideal flap in any high-risk patient in whom the risk of recurrence is high.

Pressure sores can be defined as lesions caused by unrelieved pressure resulting in damage of the underlying tissue. They represent a common problem in the pathology of plegic patients and, plastic surgery has a significant role in their treatment. Pressure sores occur over bony prominences and so, they are most commonly seen at the sacrum and trochanters in paralyzed patients and at ischium for the patients who sit in a wheelchair for a long time. For these patients, surgical treatment is very important because on one hand, it stops the loss of nutrients and proteins at the site of the pressure sore, and on the other hand, it permits the initiation of neuromuscular recuperation treatment much faster.

Purpose: Pressure sores are a significant source of physical and financial burden for debilitated patients. When conservative measures fail, surgical reconstruction with myocutaneous flaps may be the last hope for cure and/or improved quality of life in these patients. Adequate haemostasis is an integral component of these reconstructive procedures, as bleeding and haematoma formation can lead to increased morbidity. This study was designed to investigate the use of argon beam coagulation in patients undergoing bony debridement and subsequent pressure sore reconstruction with myocutaneous flaps., Methods: The clinical records of 34 patients undergoing pressure sore reconstruction with the use of argon beam coagulation from 2004 to 2006 at an academic institution were reviewed and outcomes were assessed., Results: Reconstruction was performed by a single surgeon on 34 patients (31 men, three women; mean age 41+/-15 years), with a total of 41 pressure sores. Thirteen (32.5%) patients had evidence of osteomyelitis preoperatively and five (12.5%) had previous coccygectomies secondary to infection. Twenty-six (65%) of the pressure sores were treated with hamstring V-Y musculocutaneous flaps, 10 (25%) with gluteal flaps, and four (10%) with tensor fascia lata flaps. Overall, suture line dehiscence occurred in six (15%) cases, flap failure and pressure sore recurrence occurred in six (15%) cases, an abscess developed in one (2.5%) case, and a sinus tract with a superficial wound developed in one (2.5%) case. There were no complications related to haemostasis, including excessive bleeding or haematoma formation., Conclusions: Argon beam coagulation is an efficacious tool for achieving adequate haemostasis during pressure sore reconstruction, particularly when significant bony debridement is involved. The use of argon beam coagulation does not result in an increased complication or recurrence rate when compared with conventional electrocautery methods.

Objective: To evaluate whether an individualized cyclic pressure-relief protocol accelerates wound healing in wheelchair users with established pressure ulcers (PrUs)., Design: Randomized controlled study., Setting: Spinal cord injury clinics., Participants: Forty-four subjects, aged 18-79 years, with a Stage II or Stage III PrU, were randomly assigned to the control (n = 22) or treatment (n = 22) groups., Interventions: Subjects in the treatment group used wheelchairs equipped with an individually adjusted automated seat that provided cyclic pressure relief, and those in the control group used a standard wheelchair. All subjects sat in wheelchairs for a minimum of 4 hours per day for 30 days during their PrU treatment., Main Outcome Measures: Wound characteristics were assessed using the Pressure Ulcer Scale for Healing (PUSH) tool and wound dimensions recorded with digital photographs twice a week. Median healing time for a 30% healing relative to initial measurements, the percentage reduction in wound area, and the percentage improvement in PUSH score achieved at the end of the trial were compared between groups., Results: At the end of 30 days, both groups demonstrated a general trend of healing. However, the treatment group was found to take significantly less time to achieve 30% healing for the wound measurement compared with the control group. The percentage improvement of the wound area and PUSH scores were greater in using cyclic seating (45.0 +/- 21.0, P < .003; 29.9 +/- 24. 6, P < .003) compared with standard seating (10.2 +/- 34.9, 5.8 +/- 9.2)., Conclusions: The authors' findings show that cyclically relieving pressure in the area of a wound for seated individuals can greatly aid wound healing. The current study provides evidence that the individualized cyclic pressure-relief protocol helps promote pressure wound healing in a clinical setting. The authors concluded that the individualized cyclic pressure relief may have substantial benefits in accelerating the healing process in wheelchair users with existing PrUs, while maintaining the mobility of individuals with SCI during the PrU treatment.

Background/objective: To study the effect on tissue perfusion of relieving interface pressure using standard wheelchair pushups compared with a mechanical automated dynamic pressure relief system., Design: Repeated measures in 2 protocols on 3 groups of subjects., Participants: Twenty individuals with motor-complete paraplegia below T4, 20 with motor-complete tetraplegia, and 20 able-bodied subjects., Methods: Two 1-hour sitting protocols: dynamic protocol, sitting configuration alternated every 10 minutes between a normal sitting configuration and an off-loading configuration; wheelchair pushup protocol, normal sitting configuration with standard wheelchair pushup once every 20 minutes., Main Outcome Measures: Transcutaneous partial pressures of oxygen and carbon dioxide measured from buttock overlying the ischial tuberosity and interface pressure measured at the seat back and buttocks. Perfusion deterioration and recovery times were calculated during changes in interface pressures., Results: In the off-loading configuration, concentrated interface pressure during the normal sitting configuration was significantly diminished, and tissue perfusion was significantly improved. Wheelchair pushups showed complete relief of interface pressure but incomplete recovery of tissue perfusion., Conclusions: Interface pressure analysis does not provide complete information about the effectiveness of pressure relief maneuvers. Measures of tissue perfusion may help establish more effective strategies. Relief achieved by standard wheelchair pushups may not be sufficient to recover tissue perfusion compromised during sitting; alternate maneuvers may be necessary. The dynamic seating system provided effective pressure relief with sustained reduction in interface pressure adequate for complete recovery of tissue perfusion. Differences in perfusion recovery times between subjects with spinal cord injury (SCI) and controls raise questions about the importance of changes in vascular responses to pressure after SCI.

Paraplegic and quadriplegic patients particularly those suffering from spinal cord injuries are at a high risk of developing pressure ulcerations. Unlike pressure ulcers in geriatric patients, which usually can be controlled with pressure relieving devices and local wound care, pressure ulceration complicating spinal cord injuries should be viewed from another perspective. Clinical management is also more complex because of the associated spasticity. Although it is now recognised that spasticity control is critical for management of patients with cerebral or spinal cord diseases or injuries, published risk assessment studies and risk assessment pressure sore scales fail to recognise spasticity as a major risk factor. Identification of spasticity should heighten the awareness of medical and paramedical personnel and have a positive impact on prevention as well as on treatment of pressure sores in this particularly difficult group of patients. We present our experience with a young quadriplegic patient with severe spasticity presenting with a large infected ischial pressure sore. All surgical as well as conservative attempts to achieve healing failed because of our failure to recognise the importance of spasticity control in the overall treatment scheme. Spasticity control should be included as a prerequisite for any treatment protocol of such patients.

Objective: To evaluate the internal consistency and sensitivity to change of the Skin Management needs assessment checklist (SMnac), a measure specifically developed for the spinal cord injury (SCI) population to assess skin management ability and equip individuals with the skills they need to prevent pressure ulcer development., Study Design: Consecutive series, psychometric evaluation study., Setting: Spinal Cord Injuries Rehabilitation Unit, United Kingdom., Participants: 317 participants with traumatic or nontraumatic SCI., Measure: This study used the SMnac, which assesses the ability to perform skin checking, pressure relief, and the prevention of skin insults based on the individual's perception of his or her ability to independently undertake skin management activities., Results: Assessment of internal consistency produced a Cronbach's alpha for this scale of 0.85. A paired-samples t test was used to evaluate the SMnac's sensitivity to change. There was a significant difference between the first and second SMnac scores (t = - 24.38, df = 186, P < 0.001)., Conclusion: The SMnac has high internal consistency and sensitivity to change. The SMnac provides constructive assessment of skin management, specifying problems for individuals with SCI, standardizing the critical inputs required to meet rehabilitation targets, and measuring the effects of those inputs and their relationship to other mediating variables and expected outcome.

Background: Individuals with spinal cord injury (SCI) are at an increased risk of pressure ulcer development. Electrical stimulation of adjacent muscles may be underutilized as a tool for pressure ulcer healing in individuals with SCI., Method: Single case study., Summary: A 27-year-old man with C4 tetraplegia developed a left ischial pressure ulcer that for 23 months responded slowly and inconsistently to conventional treatment. Electrically induced lower extremity ergometry (EILEE) was introduced to facilitate wound healing. The pressure ulcer healed completely in 6.5 months., Conclusion: This case illustrates the potential important contribution of EILEE in the healing of an ischial pressure ulcer in individuals with SCI.

Objectives: To estimate the point prevalence of pressure sores in a community sample of spinal cord injured patients who were followed up by a spinal injuries unit and to evaluate whether self-management strategies were associated with decreased risk of pressure sores., Setting: A regional spinal injuries unit, UK., Design: Postal questionnaire survey., Main Outcome Measure: Presence of pressure sores., Subjects: All patients who were being followed up on a regular basis by the unit., Results: Out of 760, 520 replied to the questionnaire; 472 were eligible for analysis. Point prevalence of pressure sores was 23% (99). Failure to inspect the skin daily for pressure damage was associated with decreased prevalence of pressure sores (odds ratio (OR) 0.5; 95% confidence interval (CI) 0.2-0.83). Those who inspected their skin daily, however, had a higher proportion of stage I pressure sores, but this was not statistically significant. Smoking (OR 1.8; 95% CI 1-3.3) and pre-existing medical problems (OR 1.8; 95% CI 1-3) were associated with increased prevalence of pressure sores. Regular lifting of weight at least once in an hour while seated, age, gender, neurological level, employment status, living alone and faecal and urinary incontinence were not significant predictors of pressure sores., Conclusions: Nearly one-quarter of participants had pressure sores at the time of the survey. Periodic weight lifts and daily inspection of skin for pressure damage were not associated with decreased prevalence of pressure sores in this sample. However, those who inspected skin daily tended to detect pressure damage early.

Background & Objective: The depression-style raise maneuver is commonly performed by persons with spinal cord injury (SCI) to relieve skin pressures and avoid skin ulceration. The demands of this critical activity, however, are not fully documented for individuals with higher spinal cord lesions. The purpose of this investigation was to determine the influence of SCI lesion level on shoulder muscle activity during a depression raise maneuver., Experimental Design: Sample of convenience, group comparison., Methods: Fine-wire intramuscular electrodes recorded electromyographic (EMG) activity from 12 shoulder muscles in 57 men with SCI while they performed depression raises (C6 tetraplegia, n = 10; C7 tetraplegia, n = 18; high paraplegia, n = 16; low paraplegia, n = 13). EMG intensity was normalized to a manual muscle test (MMT) effort., Results: For persons with paraplegia and C7 tetraplegia, dominant EMG activity was recorded from latissimus dorsi, sternal pectoralis major, and triceps muscles (31%-69% MMT). Tetraplegic groups had significantly greater anterior deltoid activity (C6 = 53%, C7 = 22% MMT) than that recorded in paraplegic groups (high paraplegia = 10%, low paraplegia = 3% MMT). Participants with tetraplegia also had increased infraspinatus activity (C6 = 50%, C7 = 32% MMT) compared with participants with low paraplegia (7% MMT). All other muscles had low or very low EMG activity during the depression raise., Conclusions: Persons with tetraplegia lack normal strength of the primary muscles used by participants with paraplegia for the depression raise (ie, latissimus dorsi, sternal pectoralis major, and triceps muscles). Although increased anterior deltoid activation assisted with elbow extension, it potentially contributes to glenohumeral joint impingement. Alternate methods of pressure relief should be considered for persons with tetraplegia.

This study compared transcutaneous oxygen tension (TcpO2) in subjects with paraplegia and pressure ulcers (PU), those with paraplegia and no pressure ulcer (NPU), and ambulatory controls. TcpO2 was measured using a surface-electrode monitoring system, recorded at 1-min intervals for 5 min and averaged. Mean TcpO2 was significantly lower in the PU than the NPU and control groups (23.53+/-1.83 vs. 58.93+/-2.53 and 79.70+/-6.77 mmHg, respectively, p<0.05). In a PU subgroup (n=4) mean TcpO2 of the pressure ulcer and nonpressure ulcer sides (trochanter or ischium) were significantly different (21.05+/-2.98 vs. 67.65+/-2.11 mmHg, respectively, p<0.001). Additionally, the NPU group demonstrated significantly lower TcpO2 than the controls. PUs had a greater reduction in TcpO2 levels relative to controls than NPUs. No association was found between TcpO2 and duration of injury, completeness of lesion, or smoking history. Thus, TcpO2 may be an effective method to identify individuals who are susceptible to pressure ulcers. The further attenuation of TcpO2 observed in the PU group may be useful to help predict whether ulcers will heal with local care or will require additional treatment.

Decubitus ulcers remain a significant healthcare concern today, especially in the elderly and immobile population. Following the observation of three Stage IV decubitus ulcers refractory to standard medical and surgical therapy for 10 months, a new vacuum-assisted closure device (V.A.C.) was initiated to speed wound healing. The V.A.C. was initiated in August 1996. The three Stage IV ulcers were located on the patient's right ischium, left ischium, and sacrum. On initiation, they measured 7 1/2 cm x 2 1/2 cm x 2 1/2 cm, 8 cm x 3 1/2 cm x 2 1/2 cm, and 3 1/2 cm x 2 cm x 2 cm respectively. The treatment consisted of insertion of sterile sponge into the wound bed connected to the negative pressure device by suction hose. The device operated at a negative pressure of 125 mm Hg with a 5-minute-on 2-minute-off-cycle. Dressing changes were performed every 48 hours during the treatment period. Successful closure of the sacral ulcer occurred in October 1996. The ischial ulcers were small enough to be taken off V.A.C. therapy in early November 1996. While we are encouraged by the results of this study, further additional clinical studies are warranted.

Pressure ulcers are an important complication of spinal cord injury which place an enormous burden on society due to their financial, psychosocial, and vocational implications. Although they are now rarely fatal, they can still have devastating consequences, often needing prolonged hospitalisation to be properly managed. This study reviews the use of electrical stimulation to overcome increasing debility due to sacral pressure ulcers and saddle soreness in a man with tetraplegia. After 24 months of regular cyclic stimulation he had increased circumferential dimensions across his buttocks by up to 21%, and increased his sitting tolerance.

Health individuals with quadriplegia generally have a reduced metabolic rate. However, individuals with quadriplegia who develop pressure ulcers may have an elevated metabolic rate. In this study, energy expenditure in 16 individuals with quadriplegia and pressure ulcers (PU-QUAD) was compared to the energy expenditure in 16 individuals with quadriplegia but no pressure ulcers (NPU-QUAD) and 16 healthy non-spinal cord injured subjects (controls). Resting energy expenditure (REE) was measured by indirect calorimetry. Both measured REE (t(30) = 2.38, p = 0.24) and percent predicted REE (t(30) = 3.23, p = .003) were significantly higher in subjects with quadriplegia and pressure ulcers compared with subjects with quadriplegia but no pressure ulcers. On average, REE in the PU-QUAD subjects was nearly equal to the absolute energy expenditure of healthy non-spinal cord injured controls. To ensure optimal care of patients with quadriplegia and pressure ulcers, quantification of energy expenditure with provision of adequate caloric intake is recommended.

Persons with spinal cord injury above C7 lack the ability to extend their elbows and grip with their hands. Consequently, when seated, they are unable to press down to shift their weight to relieve pressure on the ischial tuberosities. This can ultimately cause serious pressure sores to develop on the buttocks. Those with adequate insurance coverage can eliminate this problem with an electric power recliner wheelchair. With the touch of a button, the backrest will fold down to a laying position, thus relieving the pressure on the ischial tuberosity. Unfortunately, not all individuals with quadriplegia possess this type of coverage. Therefore, the problem requires an alternate design that will utilize mechanical rather than electrical power to produce a cost-effective solution. The purpose of this project was thus to design and build an affordable apparatus adaptable to wheelchairs that allows individuals with quadriplegia to shift their weight from one side to the other thus relieving the pressure on the ischial tuberosities. A pneumatic system that utilizes two inflatable air bladders was employed. One cushion is placed under each buttock and inflated separately to tilt the user from one side to the other. The inflated cushion elevates one side of the buttock, which relieves the pressure from the other side. The power required to operate the system is generated using repetitions of elbow flexion. The system was evaluated on an individual with C6 quadriplegia. The subject demonstrated independent pressure relief without intrusion on cosmesis or independence.

Over a period of 10 years 57 pelvic pressure sores of 47 para- and tetraplegic patients were covered operatively with a muscle flap at the Co-Operative Trade Association Hospital for Accidents, at Tübingen, Germany. 39 patients with 49 muscle flap-covered decubiti were seen in a follow-up examination. Despite many postoperative complications--not uncommon for septic patients--there was a high rate of complete healing (94%) of the pressure sores within a short period of rehabilitation. Indeed one cannot prove the superiority of the muscle flaps over cutaneous and fasciocutaneous flaps because of the missing statistical comparability and correlation capability of the results with other studies. In our opinion muscle flaps in the pelvic area seem to be advantageous to cutaneous and fasciocutaneous flaps.

Authors report their experience with the V-Y advancement flap in the coverage of trochanteric pressure sores. Nine flaps have been performed concerning 7 patients. Trochanteric sores in paraplegia or tetraplegia may lead to suppurative arthritis of the hip, with a risk of anaerobic infection and acute septicaemia. The treatment has to be as complete as possible. The trochanteric sore is debrided, with special attention given to removing all necrotic material, the surrounding bursa, and the bony prominence of the greater trochanter. The debrided trochanteric region is then covered by a well-vascularized and thick tissue. We observed only one complication at the donor site which can be closed primarily by this technique. The V-Y advancement technique is a new, simple and safe design of tensor fasciae latae flap. The defect is covered by the thicker and the best vascularized portion of the musculo-cutaneous flap. It allows preservation of other donor sites of the gluteal region to cover other sores, which are often associated.

This article presents a case that epitomizes the complexity of chronic pressure ulcer care in the home health arena. Proper assessment and care of a wound with appropriate therapy can result in cost savings, ease of application, decreased skilled nursing visits and ultimately, wound healing.

Able-bodied, paraplegic, and quadriplegic subjects sat for 30-minute intervals on various surfaces in a wheelchair with a forceplate mounted on the seat in order to determine factors that could contribute to the formation of decubitus ulcers. All three groups of subjects sat on ROHO and Jay cushions; in addition to sitting on the two cushions, the able-bodied subjects sat on a hard surface. Factors studied were: normal and shear seat forces, the location of the center of mass, and armrest force. The forceplate was under the cushions; therefore, the values reflect average forces over the buttocks and posterior thighs. These factors were compared between disability levels as well as between surface types. Larger, normal, and forward shear forces and a more anterior position of the center of mass were observed with the ROHO cushion. More frequent and larger lateral weight shifts occurred with the Jay cushion. The armrests tended to support from 5 percent of the body weight for quadriplegics to 9 percent for paraplegics. The results suggest that armrests reduce seat forces by carrying some of the body weight.

The response of skin blood cell flux (SBF) to locally applied pressure was evaluated by laser Doppler fluxmetry over the sacrum and the gluteus maximus muscle in twenty patients with spinal cord injuries (SCI)-ten with tetraplegia, ten with paraplegia-and ten healthy subjects. The SCI patients were further divided into two subgroups, one with sensation and the other without sensation over the sacrum area. The SBF over the sacrum, without applied pressure, showed somewhat higher values among the patients. The ten paraplegic patients (p less than 0.05) and the subgroup of patients without sensation over the sacrum (p less than 0.05) showed the highest values. Occlusion of the SBF was reached at a lower external skin pressure over the sacrum than over the gluteus maximus muscle in the group with spinal cord injuries (p less than 0.01). During the postocclusive reactive hyperemia we found a much shorter time to peak SBF over the gluteus muscle for the patients compared to the healthy subjects (p less than 0.01). In the subgroup of patients without sensation over the sacrum a prolonged time to peak SBF was found (p less than 0.01) over the sacrum compared to patients with sensation and to healthy subjects. The increase of the SBF during postocclusive hyperemia response was lower over both the sacrum and the gluteus maximus muscle areas in the patients with spinal cord injuries (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Musculo cutaneous flaps help to cover the important tissues defects of the pressure sore. During 1988, two of our patients in general bad conditions, needed a quick simple treatment for bed sores involving joints. The patients, one who was paraplegic, the other tetraplegic, were suffering from joint lesions in the elbow and both knees. We carried out a musculo cutaneous flap of the brachio radialis and two of the gastrocnemius medialis, once septic conditions had improved. The simple procedure by transfer assured the cover of the skin defect. The results of the treatment being successful allow us to suggest this type of treatment being used in general traumatologic lesions affecting the elbow and knee joints.

The authors' philosophy and regimen of treatment, based on experience with 103 pressure ulcers in 75 patients, are presented. This experience illustrates that the problem of pressure ulcers can be managed well by the application of sound surgical principles in a community hospital with a rehabilitation unit. With some simplification, the standard treatment procedures can be applied easily in this setting.

This case reports the use of a tissue expander to facilitate the surgical closure of a decubitus ulcer in a spinal cord injured quadriplegic. The patient is a 42-year-old man with chronic nonhealing of a right ischial pressure ulcer. It had required a flap rotation and partial ischiectomy in the remote past that had been problem-free for many years. The patient subsequently required the placement of a new flap, but insufficient tissue was available to close the wound with the hip in 90 degrees of flexion. Closing the wound with the hip in extension merely led to breakdown when the hip was put in the 90 degrees of flexion required for the sitting position. The problem was solved by using a tissue expander to increase the available soft tissue. A tissue expander was inserted and gradually expanded over a period of weeks by injecting it with fluid. It was then removed, and the expanded tissue that had grown over it allowed closure of the wound without tension on the tissues with the hip in flexion. The patient subsequently returned to the sitting position and his work as a computer programmer. Tissue expanders are commonly used in breast reconstruction, but have found many other uses in plastic surgery over the last decade. It is felt that tissue expansion techniques should not be the primary surgery treatment of decubitus ulcers, but can be used in difficult cases like this one to provide additional tissue.

Twenty-three paralyzed patients admitted for treatment of recurrent pressure sores were evaluated by computed tomography, bone scanning, gallium scanning, and sonography. Computed tomography was helpful in detecting associated peripelvic and pelvic abscesses and pelvic osteomyelitis, which were undiagnosed by all other modalities combined in more than half of the patients. Computed tomography was also useful in preoperative planning by revealing the extent of the undermining of the pressure sore, the thickness of the fibrous scar at its base, and the size and status of the adjacent muscles.

Due to the loss of topesthesia and to the impairment of the vasomotorium in the paralyzed area, patients suffering from tetraplegia have a high risk from pressure sores. Bed sores respond successfully to therapy if, on observing the relevant basic nursing procedure--requiring in particular that the damaged areas of skin be consistently relieved from pressure by means of special positioning of the patient--the sores are subjected to intensive cleansing via surgical and/or enzymatic débridement, and are conditioned with the synthetic skin substitute Epigard. This is achieved as a result of therapeutic procedure followed in a series of methodical steps. Specific treatment with antibiotics before conditioning the wounds supplements these measures and facilitates the spontaneous healing of the lesions or, in the case of larger bed sores, the optimal preparation of the wound bed prior to skin grafting and plastic surgery.