Jordan, S. W., De la Garza, M., & Lewis, V. L. (2017). Two-stage treatment of ischial pressure ulcers in spinal cord injury patients: Technique and outcomes over 8 years. Journal of Plastic, Reconstructive & Aesthetic Surgery, 70(7), 959–966.

Pressure ulcers in patients with SCI pose a significant physical and financial burden and lead to a large number of hospitalizations. Pressure sores in SCI represent a large number of readmissions to hospitals, second only to UTI. Studies have found that more than one-third of SCI patients have a pressure ulcer at any point in time, with the vast majority having more than one ulcer. Despite the use of pressure-relief adjuncts such as wheelchair cushions, air mattresses, and frequent positional changes, pressure ulcers are still a large complication for SCI patients and often require operative repair complicated by high recurrence rates.

This study analyzed the outcomes of a technique for repair of ischial pressure ulcers using two stages. The first stage involved operative debridement and bone biopsy, allowing for treatment of osteomyelitis if present. The second stage involved excision of margins of ulcer and reconstruction using plane-by-plane dissection of muscle and skin flaps, particularly using the gluteus maximus muscle, creating a flap over the ischium. The study is a retrospective chart review of 65 SCI patients treated for stage IV ischial pressure ulcers. Post-operative outcomes included breakdown, superficial dehiscence, deep dehiscence (prior to 1-year post-op), and late recurrence of ulcers (after 1-year post-op). Follow-up time ranged from 148 days to 5.4 years, with a median time of 622 days.

Post-operative care included supine bed rest on air-fluidized beds for 13 days, administration of anti-spasm agents such as diazepam and baclofen, and wound care. Patients were then transitioned to limited sitting and underwent further physical rehab.

Superficial dehiscence rate was 16.2% with all cases subsequently healing by secondary intention. Deep dehiscence rate was 23% and was most commonly associated with wound infection, with the majority occurring within one-month post-op. Late recurrence developed in 20% of patients. Overall, 67% of the flaps were healed at time of last follow-up.

This approach to ischial ulcer treatment in SCI patients was shown to be advantageous due to the ability to identify and treat issues such as osteomyelitis prior to surgical repair. The muscle flap is optimal as it provides a bulky cushion for sitting and eliminates dead space and has lower recurrence rates than other procedures and techniques previously studied.