The Japanese registry for surgery of ischial pressure ulcers: STANDARDS-I.

OBJECTIVE: To clarify the surgical indications and the appropriate perioperative management of ischial pressure ulcers (PUs). METHOD: A two-year prospective, nationwide registry study was carried out across 26 medical institutions in Japan. All participating institutions managed ischial PUs according to the standardisation of total management and surgical application for the refractory decubitus (STANDARDS-I) perioperative protocol. Analysis was conducted on a range of clinically or statistically important variables for the achievement of primary or secondary endpoints: complete wound healing and hospital discharge at three months, and complete wound healing at one month after surgery, respectively. RESULTS: A total of 59 patients took part in the study. All patients underwent surgery for ischial PUs during the study period. Patients who had achieved the primary endpoint had a higer preoperative functional independence measurement (FIM score), a higher 'G' score in the DESIGN-R scale and were more likely to have healed by primary intention. Patients who had achieved the secondary endpoint were more likely to have spastic paralysis, preoperative physiotherapy and localised infection of the wound, among other variables. CONCLUSION: This survey suggests that preoperative physiotherapy increases the speed of wound healing, and good granulation of the wound bed preoperatively increases the likelihood of woundless discharge from hospital, whereas the existence of comorbidities negatively influences the likelihood of woundless discharge from hospital. The study also suggests that the existence of spastic paralysis, preoperative infection of the wound, or surgical reduction of the ischial tubercle speeds up the healing of the wound. However, the wound failed to heal significantly more often in patients with increasing white blood cell count after surgery.

Versatility of the Limberg flap and the V-Y flap (based on a distal perforator) for covering sacral ulcers.

Our simple criteria for selection of two efficient flaps achieves consistently good results for most sacral ulcers. One hundred and ten patients had their sacral ulcers reconstructed with the Limberg flap (n = 48) or the distal-perforator-based V-Y (DPVY) flap (n = 62). The criteria for selection were based on pinching of the donor skin to estimate the feasibility of the Limberg flap. Overall, 101/110 (92%) of the flaps healed primarily, 43/48 (90%) in the Limberg flap group, and 58/62 (94%) in the DPVY flap group. The advantages of reconstruction using our two flaps include simple and consistent design of, and procedure for, both flaps, wide excursion of the DPVY flap, and consistency of the surgeons' skill because they used only two flaps.

Triple coverage of ischial ulcers with adipofascial turnover and fasciocutaneous flaps.

Despite a wide variety of flap options, ischial ulcers remain the most difficult pressure ulcers to treat. This article describes the authors' successful surgical procedure for coverage of ischial ulcers using adipofascial turnover flaps combined with a local fasciocutaneous flap. After debridement, the adipofascial flaps are harvested both cephalad and caudal to the defect. The flaps are then turned over to cover the exposed bone in a manner so as to overlap the two flaps. A local fasciocutaneous flap (Limberg flap) is applied to the raw surface of the turnover flaps. Twenty-two patients with ischial ulcers were treated using this surgical procedure. Overall, 86.4 percent of the flaps (19 of 22) healed primarily. Triple coverage with the combination of double adipofascial turnover flaps and a local fasciocutaneous flap allows for an easily performed and minimally invasive procedure, preservation of future flap options, and a soft-tissue supply sufficient for covering the prominence and bony prominence and filling dead space. This technique provides successful soft-tissue reconstruction for minor to moderate-size ischial pressure ulcers.

Distal perforator-based fasciocutaneous V-Y flap for treatment of sacral pressure ulcers.

Although the gluteal V-Y advancement flap has been recognized as the most reliable method for management of sacral pressure ulcers, its limited mobility has been a challenging problem. The authors present a new modification of the V-Y advancement flap to overcome the problem. After débridement, a large triangle is designed to create a V-Yadvancement flap on the unilateral buttock and the medial half is elevated as a fasciocutaneous flap, preserving the distal perforators in the muscular attachment. Then an arc-shaped incision is made in the gluteus maximus muscle along with the lateral edge of the triangular flap. The split muscle is elevated at a depth above the deeper fascia until sufficient advancement of the flap is obtained. This full-thickness elevation of the gluteus maximus muscle from the distal (lateral) side avoids the impairment of perforators or their mother vessels and achieves great advancement. Thirty-one patients with sacral pressure defects larger than 8 cm in diameter were treated using this surgical procedure. Overall, 93.5 percent of the flaps (29 of 31) healed primarily. The largest defect that was closed with a unilateral flap was 16 cm in diameter. The present technique accomplishes remarkable excursion of the unilateral V-Y fasciocutaneous flap, with high flap reliability and preservation of the contralateral buttock as well as gluteus maximus muscle function.