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An Evidence-Based Approach to the Surgical Management of Pressure Ulcers

Steven M. Levine, MD, Sammy Sinno, MD, Jamie P. Levine, MD, and Pierre B. Saadeh, MD

Objective: This study aims to use the evidenced-based approach to better understand the surgical management and treatment of pressure ulcers.

Summary of Background Data: Pressure sores are a cause of significant morbidity in the medical community. Although there are a multitude of preventative and treatment options, there remains some degree of uncertainty in the literature in defining the best way to treat and manage pressure sores.

Methods: An exhaustive literature search was performed using several electronic databases. The search revealed several identified modalities for treatment of pressure ulcers. We then assessed each modality individually for the level of evidence that exists in the most current literature, with preference given to more recent studies (2005-present).

Results: Here, we reviewed the most relevant, high-level evidence that exists for the following modalities for managing pressure ulcers from a surgical perspective: wound cleansers, repositioning, negative pressure therapy, enteral and parenteral feeding, vitamin and mineral supplementation, specialized mattresses, ultrasound therapy, honey, cellular therapy, debridement, ostectomy,and musculocutaneous and fasciocutaneous flap closure.

Conclusions: Although many of the previously mentioned modalities are used,we encourage clinicians and health care providers to consider the evidence- based data when deciding how to most appropriately manage their patient’s pressure sores.

Key Words: pressure ulcers, prevention of prevention ulcers, decubitus ulcers,evidence-based

Pressure ulcers, also known as decubitus ulcers, are a significant cause of morbidity. It has been reported that anywhere from 2% to 28% of nursing home residents suffer from pressure ulcers. These wounds result from sustained pressure against skin and cause a local inflammatory reaction, potentially leading to bacterial contamination or systemic disease. The severity of pressure ulcers varies according to the amount and quality of tissue involved. The grading system used to classify these wounds is shown in Table 1.

Certain identifiable risk factors have been shown to be associated with the development of pressure ulcers. One study showed that incontinence, smoking, hypoalbuminemia, alcoholism, and diabetes were all associated with pressure ulcer formation. Pressure and friction have both been shown experimentally to increase sus-ceptibility to decubitus ulcer formation.

Although there are a variety of treatment modalities available for pressure ulcers, there is no widely accepted algorithm for treatment. Consequently, there is some confusion in appropriately understanding and treating these most effectively. the purpose of this article is to review current modalities in the surgical management of pressure ulcers.

METHODS

Electronic searches were performed using the following data-bases: the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (1950-August 2011), Ovid EMBASE (1980-August 2011), Ovid CINAHL (1982-August 2011), and Google Scholar. The following keywords were then searched in each of the databases: ‘‘pressure sores,’’ ‘‘pressure ulcers,’’ ‘‘decubitus ulcers,’’ ‘‘treatment of pressure sores,’’ ‘‘treatment of pressure ulcers,’’ ‘‘treatment of decubitus ulcers,’’ ‘‘surgery for pressure sores,’’ ‘‘surgery for pressure ulcers,’’ and ‘‘surgery for decubitus ulcers.’’ The titles and abstracts from the initial literature search were appraised to identify articles for full review,and the references sections from each article were searched manually for relevant publications. Several non-English articles of interest were reviewed if English translations were available.

The search revealed several identified modalities for surgical treatment and management of pressure ulcers. We then assessed each modality individually for the level of evidence that exists in the most current literature, with preference given to more recent studies (2005-present). Table 2 gives a summary of the levels of evidence for the reviewed literature.

RESULTS
Modalities for Preoperative Care of Pressure Sores

Wound Cleansers (Level II) Topical therapies in the form of wound cleansers have long been believed to play a role in ulcer healing. By removing dead tissue and foreign bodies from the wound, wound cleansers prepare the wound bed for dressing application. Although most of the data that exist for wound cleansers is largely anecdotal, double-blinded randomized controlled trials have demonstrated the efficacy of saline spray containing aloe, silver chloride, and decyl glucoside in im- proving ulcer healing when compared to saline alone.

Repositioning (Level V)
Although repositioning is commonly used to prevent pressure ulcer formation, to date there are no randomized controlled trials that support this intervention. Several studies have examined the frequency of positioning or optimal position for patients with pressure ulcers, yet the evidence is insufficient to suggest optimal protocols. Nevertheless, repositioning is considered a practice with good face value, as added pressure to an area of vascular compromise will undoubtedly lead to a decrease in capillary blood flow.

Negative Pressure Therapy (Level I) Negative pressure devices have revolutionized wound healing in many respects. By reducing wound edema, decreasing the wound bioburden, and increasing local blood supply, these devices can help overcome traditional obstacles to ideal wound healing. However, the literature is inconclusive as to whether negative pressure therapy has an advantage for healing of pressure ulcers. Specifically, 2 randomized controlled studies examined negative pressure devices for pressure ulcers. One showed a reduction of ulcer volume using vacuum-assisted wound closure, whereas another showed equivocal results when compared to traditional dressings. More studies are clearly needed to define the role of this therapy in the temporizing treatment of pressure ulcers.

Enteral and Parental Feeding (Levels II and III) There is some evidence to support nutritional intervention in the form of enteral or parental feeding in aiding in pressure ulcer formation healing. A multicenter trial examining the effects of 2 daily oral supplemental drinks showed this intervention to significantly lower the incidence of pressure ulcers and identified low serum albumin and lower limb fracture as independent risk factors. Another more recent paired cohort study examined serum markers for metabolism in spinal cord patients with pressure sores and noted that the surgical correction of sores resolved the serologic abnormalities, such as in hemoglobin and serum protein.Therefore, it is reasonable to conclude that nutritional optimization has a beneficial effect on pressure sore healing.

Vitamins and Minerals (Level I) Although correcting vitamin deficiency was initially the focus of the role of vitamins in wound healing, recent research has shown that supplementation either orally or topically with vitamins has a positive effect on healing. Of the many vitamins and minerals implicated in wound healing, ascorbic acid (vitamin C) and zinc have been studied specifically for pressure sore healing. One double-blind randomized controlled trial of 88 patients with pressure sores showed a reduction in pressure sore area with 500 mg of ascorbic acid twice daily for 4 weeks. Another multicenter study showed 500 mg of ascorbic acid twice daily for 12 weeks improved healing velocity. A double-blind randomized controlled trial studied the administration 200 mg of zinc sulfate 3 times daily for 24 weeks; this intervention failed to show any statistically significant effects in ulcer healing. Therefore, it can be reasonably concluded that vitamin C, but not zinc, supplementation may have a positive effect on pressure ulcer healing.

Ultrasound Therapy (Level I) Ultrasound therapy has been proposed to have a therapeutic effect on wound healing. The literature suggests, however, that ultrasound therapy does not improve pressure ulcer healing. No significant differences in healing were seen in 2 randomized controlled trials that compared ultrasound therapy with sham ultrasound. Another study failed to show statistically significant differences in healing between ultrasound/ultraviolet treatment and standard of care.

Honey (Level II) Honey has been used for centuries as a wound healing adjuvant. The mechanisms of action of honey in wound healing include antimicrobial activity, immunologic modulation, and physiologic mediation. Of the multitude of studies examining the use of honey in various wounds, 1 trial randomly assigned patient with pressure ulcers to receive either honey or saline-soaked dressings. This study found that the overall time to healing in days was less in the honey-treated group.

Cellular Therapy (Level IV) Apligraf is an FDA-approved living bilayered cell therapy that has been shown to be efficacious in a case study of patients with heel pressure ulcers (Level IV).In this study, 10 patients were treated with Apligraf and pressure offloading. The patients in this study had ulcers for an average of 161.3 days before using Apligraf and sub-sequently achieved a mean time to complete ulcer healing of 44 days with therapy.

Modalities for Surgical Treatment of Pressure Sores

Debridement (Levels III and IV) There is much debate in the surgical literature as to which method of debridement is best. Typically, clinical experience andpractice determine which forms of debridement are used. Debridement options for pressure ulcers can include biologic, autolytic, chemical, mechanical, and enzymatic debridement. Biologic debridement involves application of sterile larvae, or maggots to the wound bed, which then remove devitalized tissue. Autolytic debridement uses naturally occurring enzymes that dissolve sloughed tissue. Chemical debridement uses chemical compounds, such as sodium hypochlorite (Dakin solution) to enhance wound debridement. Mechanical debridement can encompass a variety of debridement techniques, including wet to dry dressings, wound cleansing, and whirlpool debridement. Enzymatic debridement uses preparations such as collagenase, papain,or urea over devitalized wound tissue. Unfortunately, although many studies have examined the efficacy of one type of debridement over another, a recent Cochrane Review demonstrated that there are no randomized controlled trials to support any one method of debridement over another.

Ostectomy (Levels IV and V) Removal of any bony prominence is often viewed as a necessary step in the treatment of pressure ulcers. Ostectomy was shown in 1 small study to be an effective strategy to reduce the recurrence of pressure sores.It is generally accepted that removing as little bone as necessary is optimal in the planned treatment of pressure ulcers.

Musculocutaneous and Fasciocutaneous Flap Closure (Levels III, IV, and V) The application of various flaps to close debrided pressure ulcers has been studied in a number of case reports and series. Musculocutaneous and fasciocutaneous flaps have been well described for reconstruction of pressure sores, as these flaps provide vascularized tissue. Tangentially split gluteus maximus myocutaneous flaps have been used to reconstruct pressure sores while minimizing functional loss. A study of 30 patients showed excellent reconstructive outcomes with tangentially split myocutaneous gluteusperforator flaps for pressure sore management without flap loss and few complications.To further preserve the gluteal muscle, the superior gluteal artery perforator flap and inferior gluteal artery perforator flap have also been described and used with success for sacral, trochanteric, and ischial reconstruction.Local fasciocutaneous gluteal flaps have also been used to reconstruct parapelvic pressure sores. The posterior-lateral thigh V-Y flap has been shown to be a very efficacious option. Posterior thigh island flaps have been used for trochanteric pressure sores and perforator flaps have been used for perineal reconstruction.

Interestingly, a recent review of the literature of all of the previously mentioned flaps performed for ischial pressure sores found an overall complication rate ranging from 0% to 80% and arecurrenceratefrom0%to33.3%. Unfortunately, given the uniqueness of each case including etiology, age, and risk factors, it has been impossible to determine a hierarchy for flap selection. Furthermore, there has been no study that has been able to compare the effectiveness of musculocutaneous and fasciocutaneous flaps. It is important to note that given the likelihood of recurrence, careful attention to patient selection and surgical planning is absolutely necessary.

CONCLUSIONS

The surgical treatment of pressure sores begins with preoperative care, including the optimization of nutrition, eradication of infection, and relief of pressure. During surgical planning, consideration must be paid to the location of the wound, as well as size and depth. Musculocutaneous and fasciocutaneous flaps provide unique advantages and disadvantages, and each option as well as the flap closure strategy for ischial, sacral, or trochanteric defects must be appropriately chosen.

Although many of the previously mentioned modalities are used, we encourage clinicians and health care providers to consider the evidence based data when deciding how to most appropriately manage their patient’s pressure sores.