International Wound Journal ISSN 1742-4801
ORIGINAL ARTICLE
Comparison of fasciocutaneous V-Y and rotational flaps for defect coverage of sacral pressure sores: a critical single-centre appraisal Gabriel Djedovic1,2 , Julia Metzler1 , Evi M Morandi1 , Tanja Wachter1 , Shafreena Kühn2 , Gerhard Pierer1 & Ulrich M Rieger2 1 Department of Plastic, Reconstructive and Aesthetic Surgery, Innsbruck Medical University, Innsbruck, Austria 2 Department of Plastic & Aesthetic, Reconstructive & Hand Surgery, AGAPLESION Markus Hospital, Johann Wolfgang von Goethe University, Frankfurt am Main, Germany
Key words Fasciocutaneous flap; Rotational flap; Sacral pressure sore; V-Y flap
Djedovic G, Metzler J, Morandi EM, Wachter T, Kühn S, Pierer G, Rieger UM. Comparison of fasciocutaneous V-Y and rotational flaps for defect coverage of sacral pressure sores: a critical single-centre appraisal. Int Wound J 2017; doi: 10.1111/iwj.12736
Correspondence to Dr. G Djedovic Department of Plastic, Reconstructive and Aesthetic Surgery Innsbruck Medical University Anichstraße 35 6020 Innsbruck Austria E-mail: [email protected]
Abstract Pressure sore rates remain high in both nursing homes as well as in hospitals. Numerous surgical options are available for defect coverage in the sacral region. However, objective data is scarce as to whether a specific flap design is superior to another. Here, we aim to compare two fasciocutaneous flap designs for sacral defect coverage: the gluteal rotation flap and the gluteal V-Y flap. All primary sacral pressure sores of grades III–IV that were being covered with gluteal fasciocutaneous rotational or V-Y flaps between January 2008 and December 2014 at our institution were analysed. A total of 41 patients received a total of 52 flaps. Of these, 18 patients received 20 gluteal rotational flaps, and 23 patients received 32 V-Y flaps. Both groups were comparable with regards to demographics, comorbidities and complications. Significantly more V-Y flaps were needed to cover smaller defects. Mean length of hospital stay was significantly prolonged when surgical revision had to be carried out. Both flap designs have proven safe and reliable for defect coverage after sacral pressure sores. Gluteal rotational flaps appear to be more useful for larger defects. Both flap designs facilitate their reuse in case of pressure sore recurrence. Complication rates appear to be comparable in both designs and to the current literature.
Introduction
In Germany, about 10% of immobile patients develop pressure sores in nursing homes and 27% during their hospital stay (1), all together accounting for more than 400 000 new pressure sores per year requiring further medical care (2). Based on these data, it becomes evident that the development of pressure sores in bedridden and immobile patients is still not only an enormous economic burden but also a great medical challenge. Besides the elderly, paraplegic and tetraplegic patients are especially at great risk of developing pressure sores, with a higher incidence in tetraplegic patients (3,4). There are numerous risk factors that combine to promote pressure sore development, for example moisture, malnutrition, comorbidities or hypoperfusion. However, lack of sensitivity and immobility together with shearing forces and maximum pressure over bony © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd doi: 10.1111/iwj.12736
prominences are the most important factors (5). Therefore, the most endangered regions for developing pressure sores consist of the sacrum and the greater trochanter in bedridden patients
Key Messages • the development of pressure sores in bedridden and immobile patients is still not only an enormous economic burden but also a great medical challenge • the purpose of our study was to analyse and compare the effectiveness and complication rates of the fasciocutaneous V-Y and the fasciocutaneous gluteal rotational flap for defect coverage of sacral pressure sores • a total of 41 consecutive patients underwent defect coverage of a sacral pressure sore; 18 (n = 18) patients received
1
G. Djedovic et al.
Fasciocutaneous gluteal rotational and V-Y flaps for sacral pressure sore coverage
a gluteal rotational flap, and in 23 (n = 23) patients, V-Y flaps were performed • gluteal rotational flaps appear to be more useful for larger defects when used unilaterally than V-Y flaps • in case of complications, a significantly longer duration of hospitalisation has to be taken into account
and the ischial tuberosity in wheelchair-mobilised paraplegic patients (6,7). Besides pressure sores of grade I and II, which usually heal conservatively after pressure relief, surgeons are mostly presented with pressure ulcers of grade III and IV, which require surgical management (8). After debridement and wound conditioning, defect coverage with local flaps is still considered the ‘gold standard’ (8,9). Nevertheless, especially in bedridden and plegic patients, pressure sores tend to recur despite adequate debridement and subsequent defect closure with vascularised tissue being performed successfully. Therefore, these patients may require several flap surgeries during their lifetime, and local flaps should be used with the forethought of subsequent flap procedures (10,11). In case of sacral pressure sores, numerous local myocutaneous, fasciocutaneous and perforator flaps have been described (10,12–15). For a long period, myocutaneous flaps were thought to be superior to fasciocutaneous flaps with regards to their vascularity and bulk of available tissue, especially for deep defects. However, more recent studies have shown the equality or even superiority of fasciocutaneous flaps with regards to their resistance to pressure compared to the underlying detached muscle of myocutaneous flaps (16,17). The advantages of the fasciocutaneous V-Y or the gluteal rotational flap for defect closure in this region are their reliability, easiness to harvest and the possibility for multiple re-mobilisations if required (15,18,19). However, despite their frequent use and their given benefits, no literature could be found that has compared these particular ‘work-horse flaps’ in sacral pressure sore coverage so far. Thus, the purpose of our study was to analyse and compare the effectiveness and complication rates of the fasciocutaneous V-Y and the fasciocutaneous gluteal rotational flap for defect coverage of sacral pressure sores in a critical single-centre appraisal. Materials and methods
A retrospective analysis was conducted of all primary sacral pressure sores of grades III–IV, according to Daniel and Seiler (20,21), that were covered with gluteal fasciocutaneous rotational or V-Y advancement flaps and operated on between January 2008 and December 2014 at our institution. Treatment protocol
All patients were treated according to the six principles as described by Seiler: (i) Pressure relief and placing the patients on a low-air-loss bed, (ii) operative debridement of the pressure sore and systemic or local infection treatment (if required), (iii) wound conditioning with moist or vacuum-assisted wound 2
Figure 1 (A) Representative image of an 84-year-old female patient after debridement of a sacral pressure sore of grade III. (B) Postoperative result after defect coverage of the sacral pressure sore with a gluteal fasciocutaneous rotational flap.
Figure 2 (A) Representative image of a 70-year-old female patient after debridement of a sacral pressure sore of grade III. (B) Postoperative result after defect coverage of the sacral pressure sore with a gluteal fasciocutaneous V-Y advancement flap.
dressings, (iv) optimising of risk factors and malnutrition, (v) defect closure of the pressure sore and (vi) postoperative pressure sore prophylaxis (8). Blood samples analyses were performed routinely to detect signs of infection, and if bone was exposed, biopsies were taken during surgery for histological and bacteriological analyses to diagnose possible osteomyelitis. Pre-operative x-ray imaging of the pressure sore-underlying bone was routinely performed to detect signs of osteitis. An ultrasound examination of the pelvic vessels was performed prior to flap surgery for exclusion of vascular stenosis or obliteration. Surgical procedure
Under general anaesthesia, the patients were placed in a prone position. The flaps were planned and designed to maintain the pressure zone in the sacral region without scars. Afterwards, the fasciocutaneous rotational (Figure 1) or V-Y advancement flap (Figure 2) was elevated, preserving as many perforating vessels as possible. If necessary, the flaps were partially de-epithelialised at their tip and buried to allow full contact © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd
G. Djedovic et al.
Fasciocutaneous gluteal rotational and V-Y flaps for sacral pressure sore coverage
of the flap with the underlying defect zone or the exposed bone. For layered wound closure, intradermal progressive tension sutures with 2–0 and 3–0 Vicryl® (Ethicon, Cincinnati, OH), ranging from the flap base to the defect-covering part, were performed to avoid tension and, hence, partial flap necrosis at the flap tip. Definitive skin closure was performed with 2–0 Prolene® (Ethicon) Donati-type stitches. Intraoperatively, two Charrière 12 suction drains were routinely inserted and removed when the output was less than 30 ml/24 hours postoperatively. All patients were strictly immobilised with permitted maximum passive hip flexion of 30∘ , without tension exposure to the flap for a maximum of 30 minutes, for a period of 3 weeks. After 3 weeks, mobilisation was increased gradually without tension exposure to the flap until full hip flexion of 90∘ was achieved. Sutures were removed 3 weeks postoperatively. Analysed parameters
The following parameters were collected from the medical records and analysed: gender, age, level of plegia, complications after surgery, defect size and grade, flap design, number of flaps, average length of hospital stay, follow-up time and comorbidities. Statistical analysis
Data are presented as mean and standard deviation if not indicated otherwise. For normal distributed data, the Student-t-test, otherwise the non-parametric Mann–Whitney U test, was applied to compare continuous variables between resulting independent sub-group pairs. Pearson’s Chi-square test was applied to compare categorised data of independent sub-groups. In cases where requirements for Pearson’s Chi-square test were not met, Fisher’s exact test was applied. Correlations between continuous variables were calculated using Spearman’s rho. A P-value of
ORIGINAL ARTICLE
Comparison of fasciocutaneous V-Y and rotational flaps for defect coverage of sacral pressure sores: a critical single-centre appraisal Gabriel Djedovic1,2 , Julia Metzler1 , Evi M Morandi1 , Tanja Wachter1 , Shafreena Kühn2 , Gerhard Pierer1 & Ulrich M Rieger2 1 Department of Plastic, Reconstructive and Aesthetic Surgery, Innsbruck Medical University, Innsbruck, Austria 2 Department of Plastic & Aesthetic, Reconstructive & Hand Surgery, AGAPLESION Markus Hospital, Johann Wolfgang von Goethe University, Frankfurt am Main, Germany
Key words Fasciocutaneous flap; Rotational flap; Sacral pressure sore; V-Y flap
Djedovic G, Metzler J, Morandi EM, Wachter T, Kühn S, Pierer G, Rieger UM. Comparison of fasciocutaneous V-Y and rotational flaps for defect coverage of sacral pressure sores: a critical single-centre appraisal. Int Wound J 2017; doi: 10.1111/iwj.12736
Correspondence to Dr. G Djedovic Department of Plastic, Reconstructive and Aesthetic Surgery Innsbruck Medical University Anichstraße 35 6020 Innsbruck Austria E-mail: [email protected]
Abstract Pressure sore rates remain high in both nursing homes as well as in hospitals. Numerous surgical options are available for defect coverage in the sacral region. However, objective data is scarce as to whether a specific flap design is superior to another. Here, we aim to compare two fasciocutaneous flap designs for sacral defect coverage: the gluteal rotation flap and the gluteal V-Y flap. All primary sacral pressure sores of grades III–IV that were being covered with gluteal fasciocutaneous rotational or V-Y flaps between January 2008 and December 2014 at our institution were analysed. A total of 41 patients received a total of 52 flaps. Of these, 18 patients received 20 gluteal rotational flaps, and 23 patients received 32 V-Y flaps. Both groups were comparable with regards to demographics, comorbidities and complications. Significantly more V-Y flaps were needed to cover smaller defects. Mean length of hospital stay was significantly prolonged when surgical revision had to be carried out. Both flap designs have proven safe and reliable for defect coverage after sacral pressure sores. Gluteal rotational flaps appear to be more useful for larger defects. Both flap designs facilitate their reuse in case of pressure sore recurrence. Complication rates appear to be comparable in both designs and to the current literature.
Introduction
In Germany, about 10% of immobile patients develop pressure sores in nursing homes and 27% during their hospital stay (1), all together accounting for more than 400 000 new pressure sores per year requiring further medical care (2). Based on these data, it becomes evident that the development of pressure sores in bedridden and immobile patients is still not only an enormous economic burden but also a great medical challenge. Besides the elderly, paraplegic and tetraplegic patients are especially at great risk of developing pressure sores, with a higher incidence in tetraplegic patients (3,4). There are numerous risk factors that combine to promote pressure sore development, for example moisture, malnutrition, comorbidities or hypoperfusion. However, lack of sensitivity and immobility together with shearing forces and maximum pressure over bony © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd doi: 10.1111/iwj.12736
prominences are the most important factors (5). Therefore, the most endangered regions for developing pressure sores consist of the sacrum and the greater trochanter in bedridden patients
Key Messages • the development of pressure sores in bedridden and immobile patients is still not only an enormous economic burden but also a great medical challenge • the purpose of our study was to analyse and compare the effectiveness and complication rates of the fasciocutaneous V-Y and the fasciocutaneous gluteal rotational flap for defect coverage of sacral pressure sores • a total of 41 consecutive patients underwent defect coverage of a sacral pressure sore; 18 (n = 18) patients received
1
G. Djedovic et al.
Fasciocutaneous gluteal rotational and V-Y flaps for sacral pressure sore coverage
a gluteal rotational flap, and in 23 (n = 23) patients, V-Y flaps were performed • gluteal rotational flaps appear to be more useful for larger defects when used unilaterally than V-Y flaps • in case of complications, a significantly longer duration of hospitalisation has to be taken into account
and the ischial tuberosity in wheelchair-mobilised paraplegic patients (6,7). Besides pressure sores of grade I and II, which usually heal conservatively after pressure relief, surgeons are mostly presented with pressure ulcers of grade III and IV, which require surgical management (8). After debridement and wound conditioning, defect coverage with local flaps is still considered the ‘gold standard’ (8,9). Nevertheless, especially in bedridden and plegic patients, pressure sores tend to recur despite adequate debridement and subsequent defect closure with vascularised tissue being performed successfully. Therefore, these patients may require several flap surgeries during their lifetime, and local flaps should be used with the forethought of subsequent flap procedures (10,11). In case of sacral pressure sores, numerous local myocutaneous, fasciocutaneous and perforator flaps have been described (10,12–15). For a long period, myocutaneous flaps were thought to be superior to fasciocutaneous flaps with regards to their vascularity and bulk of available tissue, especially for deep defects. However, more recent studies have shown the equality or even superiority of fasciocutaneous flaps with regards to their resistance to pressure compared to the underlying detached muscle of myocutaneous flaps (16,17). The advantages of the fasciocutaneous V-Y or the gluteal rotational flap for defect closure in this region are their reliability, easiness to harvest and the possibility for multiple re-mobilisations if required (15,18,19). However, despite their frequent use and their given benefits, no literature could be found that has compared these particular ‘work-horse flaps’ in sacral pressure sore coverage so far. Thus, the purpose of our study was to analyse and compare the effectiveness and complication rates of the fasciocutaneous V-Y and the fasciocutaneous gluteal rotational flap for defect coverage of sacral pressure sores in a critical single-centre appraisal. Materials and methods
A retrospective analysis was conducted of all primary sacral pressure sores of grades III–IV, according to Daniel and Seiler (20,21), that were covered with gluteal fasciocutaneous rotational or V-Y advancement flaps and operated on between January 2008 and December 2014 at our institution. Treatment protocol
All patients were treated according to the six principles as described by Seiler: (i) Pressure relief and placing the patients on a low-air-loss bed, (ii) operative debridement of the pressure sore and systemic or local infection treatment (if required), (iii) wound conditioning with moist or vacuum-assisted wound 2
Figure 1 (A) Representative image of an 84-year-old female patient after debridement of a sacral pressure sore of grade III. (B) Postoperative result after defect coverage of the sacral pressure sore with a gluteal fasciocutaneous rotational flap.
Figure 2 (A) Representative image of a 70-year-old female patient after debridement of a sacral pressure sore of grade III. (B) Postoperative result after defect coverage of the sacral pressure sore with a gluteal fasciocutaneous V-Y advancement flap.
dressings, (iv) optimising of risk factors and malnutrition, (v) defect closure of the pressure sore and (vi) postoperative pressure sore prophylaxis (8). Blood samples analyses were performed routinely to detect signs of infection, and if bone was exposed, biopsies were taken during surgery for histological and bacteriological analyses to diagnose possible osteomyelitis. Pre-operative x-ray imaging of the pressure sore-underlying bone was routinely performed to detect signs of osteitis. An ultrasound examination of the pelvic vessels was performed prior to flap surgery for exclusion of vascular stenosis or obliteration. Surgical procedure
Under general anaesthesia, the patients were placed in a prone position. The flaps were planned and designed to maintain the pressure zone in the sacral region without scars. Afterwards, the fasciocutaneous rotational (Figure 1) or V-Y advancement flap (Figure 2) was elevated, preserving as many perforating vessels as possible. If necessary, the flaps were partially de-epithelialised at their tip and buried to allow full contact © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd
G. Djedovic et al.
Fasciocutaneous gluteal rotational and V-Y flaps for sacral pressure sore coverage
of the flap with the underlying defect zone or the exposed bone. For layered wound closure, intradermal progressive tension sutures with 2–0 and 3–0 Vicryl® (Ethicon, Cincinnati, OH), ranging from the flap base to the defect-covering part, were performed to avoid tension and, hence, partial flap necrosis at the flap tip. Definitive skin closure was performed with 2–0 Prolene® (Ethicon) Donati-type stitches. Intraoperatively, two Charrière 12 suction drains were routinely inserted and removed when the output was less than 30 ml/24 hours postoperatively. All patients were strictly immobilised with permitted maximum passive hip flexion of 30∘ , without tension exposure to the flap for a maximum of 30 minutes, for a period of 3 weeks. After 3 weeks, mobilisation was increased gradually without tension exposure to the flap until full hip flexion of 90∘ was achieved. Sutures were removed 3 weeks postoperatively. Analysed parameters
The following parameters were collected from the medical records and analysed: gender, age, level of plegia, complications after surgery, defect size and grade, flap design, number of flaps, average length of hospital stay, follow-up time and comorbidities. Statistical analysis
Data are presented as mean and standard deviation if not indicated otherwise. For normal distributed data, the Student-t-test, otherwise the non-parametric Mann–Whitney U test, was applied to compare continuous variables between resulting independent sub-group pairs. Pearson’s Chi-square test was applied to compare categorised data of independent sub-groups. In cases where requirements for Pearson’s Chi-square test were not met, Fisher’s exact test was applied. Correlations between continuous variables were calculated using Spearman’s rho. A P-value of
