Journal of Tissue Viability (2015) 24, 35e40

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Case report

Wound fixation for pressure ulcers: A new therapeutic concept based on the physical properties of wounds Fumihiro Mizokami a, Yoshiko Takahashi b, Tetsuya Nemoto c, Yayoi Nagai d, Makiko Tanaka e, Atsushi Utani f, Katsunori Furuta a,g, Zenzo Isogai h,* a

Department of Pharmacy, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan b Department of Nursing & Health, School of Nursing & Health, Aichi Prefectural University, Nagoya, Aichi, Japan c Department of Gerontechnology, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan d Department of Dermatology, Gunma University School of Medicine, Maebashi, Gunma, Japan e Graduate Division of Health and Welfare, Department of Nursing and Human Nutrition, Yamaguchi Prefectural University, Yamaguchi, Japan f Department of Dermatology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan g Department of Clinical Research and Development, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan h Division of Dermatology and Connective Tissue Medicine, Department of Advanced Medicine, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan

KEYWORDS Pressure ulcer; Undermining formation; Wound deformity; Wound fixation

Abstract A pressure ulcer is defined as damage to skin and other tissues over a bony prominence caused by excess pressure. Deep pressure ulcers that develop over specific bony prominences often exhibit wound deformity, defined as a change in the 3-dimensional shape of the wound. Subsequently, the wound deformity can result in undermining formation, which is a characteristic of deep pressure ulcers. However, to date, a concept with respect to alleviating wound deformity has yet to be defined and described.

* Corresponding author. 35 Gengo, Morioka-cho, Obu, Aichi 474-8511, Japan. Tel.: þ81 562 46 2311x7156; fax: þ81 562 48 2373. E-mail address: [email protected] (Z. Isogai). http://dx.doi.org/10.1016/j.jtv.2015.01.002 0965-206X/ª 2015 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

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F. Mizokami et al. To clarify the issue, we propose a new concept called “wound fixation” based on the physical properties of deep pressure ulcers with wound deformity. Wound fixation is defined here as the alleviation of wound deformity by exogenous materials. The wound fixation methods are classified as traction, anchor, and insertion based on the relation between the wound and action point by the exogenous materials. A retrospective survey of a case series showed that wound fixation was preferentially used for deep pressure ulcers at specific locations such as the sacrum, coccyx, and greater trochanter. Moreover, the methods of wound fixation were dependent on the pressure ulcer location. In conclusion, our new concept of wound fixation will be useful for the practical treatment and care of pressure ulcers. Further discussion and validation by other experts will be required to establish this concept. ª 2015 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction

2. Concepts and case series

A pressure ulcer develops due to the application of excess pressure over bony prominences. Despite recent research developments in the process of wound healing, treatment strategies for pressure ulcers are still inconclusive [1]. An important factor in the resistance to treatment is undermining formation, which is often observed in deep pressure ulcers [2]. We recently proposed a concept involving wound physical properties for defining wound mobility and deformity [3]. In our previous paper, wound mobility was defined as movement using the bony prominence as a predefined specific marker, and wound deformity as a change in the 3dimensional shape of the wound [3]. Wound deformity is preferentially observed in pressure ulcers of the sacrum owing to the physical properties of the surrounding tissue [3]. The physical properties of the wound may be related to the high incidence of undermining formation of pressure ulcers over the sacrum, coccyx, and greater trochanter [4]. We have previously reported a case of sacral pressure ulcer treated with traction by bandage [5]. In addition, we have performed several procedures using bandages and sponges for refractory pressure ulcers exhibiting marked wound deformity. Although these procedures seemed clinically effective in most cases, the underlying concept has not been systemically theorized. In the present report, we propose a concept for wound fixation. Further, we retrospectively analyze a case series to clarify the characteristics of the procedures and to support the theoretical background. Wound fixation may be a useful concept for the treatment of pressure ulcers that exhibit marked wound deformity.

We previously defined wound deformity as a change in the shape of the wound caused by external force (Fig. 1A and B). In several meetings involving pressure ulcer experts, we held several consensus discussions about the concept of “wound fixation.” We defined wound fixation as an alleviation of wound deformity by exogenous materials. The concept and classification of wound fixation are schematically shown to aid reader understanding; the classification is based on an action point applied to an individual wound (Fig. 1CeE). In wound fixation by traction, the force is applied in the direction indicated by the dotted arrow (Fig. 1C). The procedure alleviates wound deformity against the applied force indicated by the arrow. Wound fixation by anchor theoretically maintains the distance indicated by the broken line (Fig. 1D). Wound fixation by insertion (Fig. 1E) is defined as the alleviation of wound deformity by filling of material into an individual wound. In wound fixation by insertion (Fig. 1E), the space indicated by the broken line is theoretically maintained. The method is useful for deeper pressure ulcers exhibiting a cylindrical shape. In practice, wound fixation by traction was conventionally performed using an elastic bandage as shown in Fig. 2A and B. Through traction, wound deformity is alleviated from the specific directional force. As a result, the area of the undermining lesion is decreased by the traction (Fig. 1C, and Fig. 2A, B). The traction procedure was preferentially used in pressure ulcers over the sacrum, greater trochanter, and coccyx (Table 1). Wound fixation by anchor is shown in Fig. 2C and D. This procedure is usually performed with the commercially available sponge, Reston (Sumi

Wound fixation for pressure ulcers

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Fig. 1 Schematic presentation of wound fixation. (AeF) The direction of the external force is indicated by an arrow. (A, B) A cross-sectional model of wound deformity. Wound deformity is defined as a change in the shape of the wound. External force is a primary cause of wound deformity. (C) A cross-sectional model of wound fixation by traction. Traction force is applied in the direction indicated by the dotted arrow. The procedure alleviates wound deformity against the force indicated by the arrow. (D) A cross-sectional model of wound fixation by anchor is shown. The distance indicated by the broken line is theoretically maintained by this fixation. (E) A cross-sectional model of wound fixation by insertion is shown. The space indicated by the broken line is theoretically maintained by the fixation.

tomo 3M, Tokyo, Japan) or Prosoft (Nichiban, Tokyo, Japan). This method also alleviates the direct pressure force onto the wound. Anchor fixation was exclusively used in sacral pressure ulcers because of the available space around individual wounds (Table 1). Because sacral pressure ulcers often deform in multiple directions, anchor fixation may be a feasible method to alleviate wound deformity in such cases. In practice, this method was not used for pressure ulcers over the greater trochanter because of the limited space around individual wounds (Table 1). Wound fixation by insertion is usually performed using materials with appropriate hardness and absorbability, such as chitin cotton and alginate foam (Fig. 2E and F). Although these materials have been used for the regulation of wound exudate, they could also reduce the external force exerted on the inner surface of the wound through alleviation of the wound deformity. Theoretically, this method is more feasible for deeper wounds

with smaller diameters. Because wound deformity at deeper lesions is not alleviated by traction and anchor fixation, deep and smaller pressure ulcers are good candidates for this treatment. However, an appropriate amount of the filler materials should be considered, as an inappropriate insertion can possibly damage the granulation tissue within a wound. In some pressure ulcers located on the sacrum and coccyx, combined fixation procedures were used (Table 1). In addition, multiple procedures were used in some cases of sacral pressure ulcer to combine the characteristics of each procedure.

3. Discussion Undermining formation is a characteristic phenomenon observed in pressure ulcers. External forces applied to individual wounds are important factors in undermining formation [2]. We recently

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F. Mizokami et al.

Fig. 2 Representative cases of wound fixation. (A, C, and E) Pressure ulcers exhibiting marked wound deformity are shown. Wound deformity appears to be dependent on age and location. (A, B) A clinical case of fixation by traction is shown. Traction by bandage toward the left side of the patient alleviates wound deformity of a sacral pressure ulcer. (C, D) A case of fixation by anchor is shown. This fixation maintains the shape of the wound as illustrated in Fig. 1. (E, F) A case of fixation by insertion is shown. Beschitin W-A (Unitika, Osaka, Japan) is inserted into the wound to alleviate wound deformity.

reported that the pressure ulcer location is an important factor for undermining formation, suggesting that the external forces, physical properties of the connective tissue, and characteristics of the bony prominences are critical factors in undermining formation [4]. Indeed, external forces and bony prominences are dependent on the pressure ulcer locations. For instance, external forces over the sacrum are usually multidirectional and different from those over the ilium. Moreover, the deformability of pressure ulcers is affected by aging, because a decrease in collagen fibers, in addition to other aspects of aging, may impair the physical properties of the connective tissue around the wound [3]. Based on the concept of wound fixation, we reported that bandage traction improved sacral [5] and ilium

pressure ulcers [6] through possible alleviation of wound deformity. However, to date, these procedures have not been theoretically classified. Reducing external forces on each pressure ulcer is the most important strategy to alleviate wound deformity. However, as reported previously, a direct pressure or a shear force is not the only force exerted on an existing pressure ulcer [3]. Moreover, such forces are often difficult to eliminate completely because of the impaired mobility of the patient. Therefore, it is important to develop new strategies to reduce wound deformity. In addition to a new concept of wound fixation, we have classified the wound fixation methods as traction, anchor, and insertion. Each procedure reduces wound deformity, but the effect is

Wound fixation for pressure ulcers

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Table 1 Location-dependent application of wound fixation for deep pressure ulcers. The application of wound fixation was retrospectively examined in the database at the National Center for Geriatrics and Gerontology, a specialized hospital for elderly patients. Some of the cases in the database were reported in our previous studies [3,4,6]; however, we used the newest database from August 2011 to July 2013. This survey complied with the ethical tenets for human experimentation outlined in the 1975 Declaration of Helsinki. With the exception of the details regarding the pressure ulcers, the patient information has been maintained in anonymity. The pressure ulcer sites are described according to the bony prominences. The application of wound fixation for deep pressure ulcers was retrospectively examined for stage III or IV [National Pressure Ulcer Advisory Panel (NPUAP) criteria] pressure ulcers, because most stage II pressure ulcers do not exhibit wound deformity [3]. The number of wounds and percentage of each fixation procedure are indicated in the table. Location

All fixation

Traction

Anchor

Insertion

Combination

Sacrum (n ¼ 29) Coccyx (n ¼ 22) Greater trochanter (n ¼ 9)

26 (90%) 6 (27%) 7 (86%)

14 (54%) 2 (33%) 6 (86%)

5 (19%) 1 (16%) 0

2 (8%) 1 (16%) 1 (14%)

5 (19%) 2 (33%) 0

dependent on the external forces and physical properties of the wounds. If the external forces are beyond the effect of wound fixation, wound deformity could still occur. Soft tissues are usually movable from the predefined bony prominences because of tissue deformability [3]. Thus, the physical differences in soft tissues facilitate an understanding of the wound character and were remarkably different between the various locations of the pressure ulcers. For instance, deep pressure ulcers over the toe do not deform, while those over the great trochanter are usually affected by a single directional force. Therefore, the observed locationdependent frequency of wound fixation may account for the physical properties of pressure ulcers. In terms of the wound fixation concept, bony prominences located beneath a pressure ulcer may be useful as wound fixer. In ilium pressure ulcers, external force can cause complicated wound deformity, which we have characterized as the “cliff phenomenon” [6]. Modification of the relative location of the wound by traction can possibly alleviate wound deformity [6]. At present, the mechanism of wound fixation is not completely clear. However, we speculate the following mechanisms: First, the alleviation of wound deformity reduces the friction in the undermining lesions [5]. Second, wound fixation theoretically improves the retention of topical agents within an individual ulcer. Severe wound deformity can inhibit the retention of topical agents in an individual wound. Third, wound deformity may lead to blood vessel occlusion around the ulcer. Therefore, the mechanism of wound fixation should be investigated using appropriate experimental approaches in the near future.

As we have only newly introduced the concept of wound fixation, it will require more discussion to be widely accepted. Moreover, the material, direction, position, and strength of wound fixation should be discussed based on the proposed concept. Future prospective studies are required to facilitate wound fixation procedures, such as the treatment of bone fractures.

Conflicts of interest The authors declare that they have no conflicts of interest.

Acknowledgements Funding for this study was provided by Research Funding for Longevity Sciences (23-13) (to ZI, TN, and KF) from the National Center for Geriatrics and Gerontology (NCGG), Japan.

References [1] Smith ME, Totten A, Hickam DH, Fu R, Wasson N, Rahman B, et al. Pressure ulcer treatment strategies: a systematic comparative effectiveness review. Ann Intern Med 2013;159:39e50. [2] Ohura T, Ohura N. Pathogenetic mechanisms and classification of undermining in pressure ulcers elucidation of relationship with deep tissue injuries. Wounds 2006;18: 329e39. [3] Mizokami F, Furuta K, Utani A, Isogai Z. Definitions of the physical properties of pressure ulcers and characterisation of their regional variance. Int Wound J 2013;10:606e11. [4] Takahashi Y, Isogai Z, Mizokami F, Furuta K, Nemoto T, Kanoh H, et al. Location-dependent depth and undermining formation of pressure ulcers. J Tissue Viability 2013;22:63e7.

40 [5] Mizokami F, Furuta K, Matsumoto H, Utani A, Isogai Z. Letter: sacral pressure ulcer successfully treated with traction, resulting in a reduction of wound deformity. Int Wound J 2014;11:106e7.

F. Mizokami et al. [6] Takahashi Y, Yoneda M, Tanaka M, Katsunori F, Isogai Z. Ilium pressure ulcer with pathognomonic wound deformity: the “cliff phenomenon.” Int J Dermatol 2014 (in press).

Wound fixation for pressure ulcers: a new therapeutic concept based on the physical properties of wounds.

A pressure ulcer is defined as damage to skin and other tissues over a bony prominence caused by excess pressure. Deep pressure ulcers that develop ov...
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