INTRODUCTION
Pressure injuries (PI) are defined by the National Pressure Sore Advisory Panel (NPUAP)
as tissue damage to the skin and/or adjacent soft tissues induced by increased external
pressure and usually appear at sites of bony prominences. Thus, they result from prolonged
exposure without pressure relief on the tissues, generating tissue ischemia and necrosis.
PIs are a significant problem for health services, as they often require prolonged
treatments, with high costs and the involvement of multidisciplinary teams that require
specific training1, 2, 3, 4.
PIs have a high prevalence in hospitalized and institutionalized patients who have
an acute injury that leads to prolonged immobilization or in patients with exacerbation
of disabling chronic diseases. In general, they are more common in the elderly, men,
patients with sensory alterations, and immobilized and malnourished patients5. It is estimated that the incidence of pressure injuries in trauma victims varies
from 0.4% to 30.6% for patients requiring hospitalization for more than 48 hours6, 7, 8, 9.
The diagnosis is clinical and made through physical examination. The PIs are then
classified in order to define the therapeutic strategy. One of the most used classifications
worldwide is the NPUAP, which classifies PIs in four stages according to the severity
of the wound:
Stage I - Intact skin, but with persistent and non-blanching erythema even after pressure
relief;
Stage II - Partial skin lesion, affecting the epidermis and dermis, with blisters;
Stage III - Deep lesion, reaching all layers of skin and subcutaneous tissue, but
still not showing tendon, bone or muscle exposure;
Stage IV - Total tissue injury, with slough and exposure of structures such as tendon,
joint, bone or muscle, necrotic tissue and the presence of infection1, 2.
The treatment of PI is complex. Conservative management includes measures that promote
pressure relief at the wound site, nutritional optimization and dressings. Topical
agents can be used (enzymatic, antimicrobial, growth factors, etc.), semi-occlusive
coatings and negative pressure dressings, among others. Conservative management is
indicated in PI grades I and II and preparation for surgical treatment5. Surgical treatment is mostly indicated in grade III and IV PI cases, which did not
respond to conservative treatment. This treatment modality has as its fundamental
principle the debridement of the wound, with the removal of necrotic and devitalized
tissues, which may include partial bone removal. Wound closure depends on the location,
size and extent of the PI. It encompasses several methods, such as primary closure,
grafts and flaps. Recurrence or occurrence of a new lesion is not infrequent5, 10.
OBJECTIVE
To describe the epidemiology of pressure injuries surgically treated by the Plastic
Surgery team of the Hospital do Trabalhador, analyzing the characteristics of patients
and injuries, the surgical technique used and the evolution of the cases.
METHODS
From June 2012 to March 2020 (94 months), a retrospective observational study was
carried out through the analysis of medical records of patients diagnosed with pressure
injuries and submitted to surgical treatment by the Plastic Surgery team, in a trauma
referral center - Hospital do Trabalhador, in Curitiba - PR. The project was analyzed
and accepted by the Research Ethics Committee of the Hospital do Trabalhador (CAAE:
38454520.4.0000.5225).
The following data were collected and analyzed: sex, age, presence of spinal cord
injury and plegia, smoking, location and degree of injury classification, surgical
procedures performed, recurrences and postoperative complications. The initial sample
of the study was 42 patients, four patients were excluded from the analysis because
they had incomplete medical records or developed other skin wounds that were not classified
as pressure injuries, leaving 38 patients in the research sample.
For assessing risk factors in the development of PI, age and occurrence of spinal
cord injury were considered predominant. The PIs were evaluated in terms of location,
which could be in the sacrum, ischium, trochanter, calcaneus, ankle, popliteal fossa
and gluteus. All patients underwent the most appropriate surgical correction for each
case - exclusive debridement, primary closure, fasciocutaneous or myocutaneous flaps
or skin grafts.
Regarding postoperative complications, the occurrence of surgical site infection,
osteomyelitis, hematoma and suture dehiscence were evaluated.
RESULTS
Thirty-eight patients met the inclusion criteria, 32 males and six females, aged between
6 and 75 years (mean age 35.4 years). In 33 cases (86.84%), the patient had a single
lesion, while another five patients (13.15%) had multiple PIs. In all, 45 pressure
injuries were surgically treated.
Concerning risk factors, 22 patients had spinal cord injury (57.8%) resulting from
spinal trauma or transverse myelitis sequelae, 17 of whom were paraplegic (44.7%),
and five were quadriplegic (13.1%). The mean time of evolution of the pressure injury
since the trauma was 6.2 months.
As for smoking, seven patients (18.4%) were smokers. However, it was not possible
to establish a statistically significant relationship between smoking and postoperative
complications.
The proposed surgical treatment was based on the classification of the lesion, the
site of involvement, the patient’s general condition, conditions of care and support
in the postoperative period, and the availability of a tissue donor area. The size
of the defects varied between 2 and 30 centimeters in the largest diameter (average
of 5.8 cm), being classified mostly in grades III and IV of the NPUAP (97.7%).
Among the affected regions, the ischial had the highest occurrence (46.6%), followed
by lesions located in the sacrum and trochanter. In smaller numbers, PI in the calcaneus,
popliteal fossa, gluteus and ankle were treated (Figure 1).
Figure 1 - Regions affected by pressure injuries.
Figure 1 - Regions affected by pressure injuries.
All cases underwent debridement of devitalized tissues. In only one case, wound debridement
was performed exclusively. In 44 cases, the lesions were treated with tissue coverage.
Because some injuries were confluent and close together, some cases of multiple injuries
were treated with the same coverage.
Considering the surgical techniques used for tissue coverage, 39 procedures were performed:
in three cases, primary wound closure was possible (7.7%), in six cases, skin grafts
were performed (15.4%), and in 30 cases, flaps (76.9%).
Regarding the skin grafts, three were full-thickness, taken from the inguinal region,
and three were partial-thickness, taken from the lower third of the leg.
Among the types of flap, the gluteus maximus VY advancement fasciocutaneous flap was
the most used (Figures 2 and 3), followed by the gluteus maximus island myocutaneous flap (Figures 4 and 5). The anterolateral fasciocutaneous flap of the thigh was used mainly in defects
in the trochanteric region (Figures 6 and 7).
Figure 2 - Pressure injury in the sacral region.
Figure 2 - Pressure injury in the sacral region.
Figure 3 - Bilateral gluteus maximus flap in VY to correct pressure injury in the sacral region.
Figure 3 - Bilateral gluteus maximus flap in VY to correct pressure injury in the sacral region.
Figure 4 - Gluteus maximus island flap for correction of pressure injury in the ischial region.
Figure 4 - Gluteus maximus island flap for correction of pressure injury in the ischial region.
Figure 5 - Late postoperative period of the flap.
Figure 5 - Late postoperative period of the flap.
Figure 6 - Anterolateral thigh island flap to correct a pressure injury in the trochanteric region.
Figure 6 - Anterolateral thigh island flap to correct a pressure injury in the trochanteric region.
Figure 7 - Distribution of flaps performed.
Figure 7 - Distribution of flaps performed.
Among the 45 lesions treated in total, 44.4% had postoperative complications, namely:
flap suture dehiscence (20%), surgical site infection (11.1%), osteomyelitis (8.8%),
hematoma (2.2%) and flap necrosis (2.2%).
There was a need for reoperation in ten cases, including resuture of the flap in eight
cases and making a new flap in two cases.
It was not possible to establish the mean follow-up time of patients at the end of
the study due to the high rate of absences from scheduled outpatient consultations.
DISCUSSION
Pressure injuries currently represent one of the main complications in debilitated
and chronically hospitalized and/or bedridden patients, especially the elderly or
those with neurological disorders resulting from trauma. Most of these are preventable
injuries and, in addition to prolonging hospital stays and increasing the risk of
developing other complications, they contribute to greater physical and emotional
suffering for these patients. Therefore, frequent and rigorous clinical evaluations
are essential, paying special attention to changes in the skin color and appearance
that is not intact, in addition to periodic changes in the decubitus position in patients
at risk11.
The prevalence of pressure injuries was higher in young men, with a mean age of 35.4
years and an incidence of 84.2% in males. All patients were victims of accidents causing
spinal cord injury or major fractures, with consequent limitation of movement and
ambulation, predisposing to the emergence of PI.
In general, the global prevalence of PI is higher in elderly patients, with a significant
increase in risk in patients over 75 years of age, as evidenced by Fogerty et al.12. This is due to the comorbidities associated with PI, which are more frequent in
the elderly population. Regarding gender, the literature has not shown a significant
difference in the prevalence of PI between men and women3, 11, 13.
However, the trauma victim population is composed of younger and male patients. Young
men have a higher prevalence of spinal cord injuries, an important risk factor for
PI in patients without other comorbidities, as demonstrated in the study by Ham et
al. 8. In addition, medical devices are also associated with the emergence of pressure
injuries in trauma patients8, 9. This explains the demographic data present in this study.
Considering the possibilities of treatment, the role of the plastic surgeon was essential
in cases refractory to conservative treatment or deeper lesions, justifying the indication
of surgical treatment mainly for the management of PI grades III and I V. Likewise,
the choice of reconstruction procedure was based on individual factors of each patient,
including the level of spinal cord injury and its repercussion on the body (plegias,
bed restriction or need to use a wheelchair), location, extent and severity of the
injury, history of injuries or previous surgeries, habits and daily care, nutritional
status and previous comorbidities.
Surgical debridement was performed in 100% of the cases. Debridement is always the
initial step in the surgical treatment of pressure injuries, as removing devitalized
tissue is essential for tissue healing5, 14.
We opted for exclusive debridement in only one patient because it was the only case
treated surgically classified in grade II of the NPUAP classification, with a small
diameter and good healing conditions by secondary intention.
Studies indicate that 95% of patients with spinal cord injuries will present PI throughout
their lives15. The correlation between pressure injuries and spinal cord injuries
was 57.8% in this study, with 44.7% of the patients having paraplegia and 13.1% quadriplegic.
Sciatic injuries arise in patients who remain sitting for long periods5, a fact that explains this high incidence observed. In general, injuries in this
location are treated with myocutaneous or purely muscular flaps, the most used being
the gluteus maximus, gracilis, medial thigh and posterior thigh. Fasciocutaneous flaps
are less used due to the need for greater thickness for satisfactory wound coverage5. Gluteus maximus flaps were the choice for 76% of ischial PI coverage.
Pressure injuries in the distal regions of the lower limbs had an incidence of 15.6%
in this study. This is justified by the fact that the hospital where the study was
conducted is a state reference for trauma, with a high number of car accidents and
falls, causing complex fractures, use of medical devices and long immobilization time
of lower limbs.
In 57.1% of the cases, closure was possible only with a skin graft, due to the earlier
approach and less local tissue loss, without bone exposure. Grafts tend to have limited
use in the treatment of PI, due to their thin thickness and low resistance in areas
of friction, with recurrence rates close to 70%, which is contraindicated in areas
of bony prominences5.
In the two cases of lesions in the popliteal fossa, a reverse anterolateral thigh
flap was chosen in one case and total skin graft in the other. The flap evolved with
hematoma, infection and dehiscence, culminating in total necrosis of the flap and
the need for a new surgical correction. The two PIs in the gluteal region were closed
primarily as they were not very extensive and had adjacent tissue available, preserving
a possible skin donor area.
The coverage of PIs is mostly performed with the manufacture of flaps. Fasciocutaneous
flaps are an excellent option, as they are well vascularized, provide good coverage
of bony prominences and cause little damage to the donor area5, 16, 17. On the other hand, myocutaneous flaps also have good vascularization and excellent
coverage, indicated in deeper wounds and needing thicker coverage. They have the disadvantage
of generating more damage in the donor area5.
The gluteus maximus fasciocutaneous flap in VY advancement was the most used, representing
33.3% of the procedures. Calil et al.10 justify the wide use of this flap in the treatment of PI due to the easy mobilization
of the tissue when performed unilaterally, allowing good reach and satisfactorily
covering the lesion area. In lesions in the sacral region, this flap is safe and allows
further advancement if necessary, justifying the majority use of the gluteus maximus
flap in VY for the treatment of sacral PI5.
Trochanteric lesions occur more frequently in patients who remain in lateral recumbency
for prolonged periods. For the treatment of pressure injuries in this region, the
anterolateral thigh and gluteus maximus flaps were the most used. The fascia lata
myocutaneous flap is the method of choice for coverage of trochanteric PI 5, 18, 19, but studies show a recurrence rate of 80% using this technique, especially in patients
with spinal cord injuries19. In patients with the ability to walk, this flap is associated with the risk of destabilization
of the quadriceps femoris muscle and functional deficit. Anterolateral thigh and gluteus
maximus flaps have been described as good options for correcting trochanteric PI,
preserving local muscles without important functional sequelae19.
In 47.5% of the treated cases, there were postoperative complications. Of this total,
72.7% were PI in the sacral and/or ischial regions. The high incidence of complications
in these regions is related to the difficult healing control due to the need for an
environment with minimal pressure on the lesion and other mechanisms of tissue stress,
a fact that is complex, as most patients are bedridden and/or bedridden. or spinal
cord injuries2. Furthermore, these are lesions whose surgical scars are susceptible to contamination,
as they are close to areas of contact with urine and feces20, generating moisture, contamination and infection that are difficult to control.
PI recurrence rates range from 3% to 82%, averaging around 70%. Complication rates
are around 36%5, 21, 22. In our study, the complication rate was 44.4%, with suture dehiscence predominating
(20%), requiring resuture or a new correction in 22.2% of these cases. In our study,
the recurrence rate was 7.9%. This fact can be explained by the large number of injuries
reported in different locations in the lower limbs, as these have a lower recurrence
rate23, 24.
CONCLUSION
Most of the population affected by pressure injuries treated surgically by the Plastic
Surgery team in public service in Curitiba developed only one injury. Young male patients
predominated, with a mean age of 35.4 years, and 57.8% had spinal cord injury. Considering
the classification used, 97.7% of the injuries were classified in severe stages, with
the highest incidence in the ischial region. Considering the treatment choice, 100%
of cases underwent debridement, and only patients without clinical conditions did
not receive surgical tissue coverage, mostly fasciocutaneous flaps, with a complication
rate of 44.4%.
REFERENCES
1. Pressure ulcers prevalence, cost and risk assessment: consensus development conference
statement--The National Pressure Ulcer Advisory Panel. Decubitus. 1989;2(2):24-8.
2. European Pressure Ulcer Advisory Panel; National Pressure Injury Advisory Panel; Pan
Pacific Pressure Injury Alliance; Haesler E, ed. Prevention and Treatment of Pressure
Ulcers/ Injuries: Clinical Practice Guide. EPUAP/NPIAP/PPPIA; 2019.
3. Santos LLR, Ferreira LM, Sabino Neto MS. Úlcera por pressão. In: Ferreira LM, ed.
Manual de Cirurgia Plástica. São Paulo; 1995. p. 214-7.
4. Ferreira LM, Calil JA. Etiopatogenia e tratamento das úlceras por pressão. Diagn Trat.
2001;(6):36-40.
5. Cushing CA, Phillips LG. Evidence-based medicine: pressure sores. Plast Reconstr Surg.
2013;132(6):1720-32. PMID: 24281597 DOI: https://doi.org/10.1097/PRS.0b013e3182a808ba
6. Watts D, Abrahams E, MacMillan C, Sanat J, Silver R, VanGorder S, et al. Insult after
injury: pressure ulcers in trauma patients. Orthop Nurs. 17(4):84-91. PMID: 9814340
DOI: https://doi.org/10.1097/00006416-199807000-00012
7. O’Sullivan KL, Engrav LH, Maier R V, Pilcher SL, Isik F F, Copass MK. Pressure sores
in the acute trauma patient: incidence and causes. J Trauma. 1997;42(2):276-8. PMID:
9042881 DOI: https://doi.org/10.1097/00005373-199702000-00016
8. Ham HW, Schoonhoven LL, Galer AA, Shortridge-Baggett LL. Cervical collar-related pressure
ulcers in trauma patients in intensive care unit. J Trauma Nurs. 2014;21(3):94-102.
PMID: 24828769 DOI: https://doi.org/10.1097/JTN.0000000000000046
9. Grigorian A, Sugimoto M, Joe V, Schubl S, Lekawa M, Dolich M, et al. Pressure Ulcer
in Trauma Patients: A Higher Spinal Cord Injury Level Leads to Higher Risk. J Am Coll
Clin Wound Spec. 2018;9(1-3):24-31.e1. DOI: https://doi.org/10.1016/j.jccw.2018.06.001
10. Calil JA, Ferreira LM, Sabino Neto S, Castilho HT, Garcia EB. Aplicação clínica do
retalho fáscio-cutâneo da região posterior da coxa em V-Y. Rev Assoc Med Bras. 2001;47(4):311-9.
DOI: https://doi.org/10.1590/S0104-42302001000400033
11. Blanes L, Duarte I da S, Calil JA, Ferreira LM. Avaliação clínica e epidemiológica
das úlceras por pressão em pacientes internados no Hospital São Paulo. Rev Assoc Med
Bras. 2004;50(2):182-7. DOI: https://doi.org/10.1590/S0104-42302004000200036
12. Fogerty MD, Abumrad NN, Nanney L, Arbogast PG, Poulose B, Barbul A. Risk factors for
pressure ulcers in acute care hospitals. Wound Repair Regen. 2008;16(1):11-8. PMID:
18211574 DOI: https://doi.org/10.1111/j.1524-475X.2007.00327.x
13. Bryant RA, Shannon ML, Pieper B, Braden BJ, Morris DJ. Pressure ulcers. In: Bryant
RA, ed. Acute and chronic wounds: nursing management. St Louis: Mosby; 1992. p. 105-63.
14. Ford CN, Reinhard ER, Yeh D, Syrek D, De Las Morenas A, Bergman SB, et al. Interim
analysis of a prospective, randomized trial of vacuum-assisted closure versus the
healthpoint system in the management of pressure ulcers. Ann Plast Surg. 2002;49(1):55-61:
discussion 61. PMID: 12142596 DOI: https://doi.org/10.1097/00000637-200207000-00009
15. Houghton PE, Campbell KE, CPG Panel. Canadian Best Practice Guidelines for the Prevention
and Management of Pressure Ulcers in People with Spinal Cord Injury. A resource handbook
for Clinicians [Internet]. 2013. p. 1-317. Disponível em: https://onf.org/wp-content/uploads/2019/04/Pressure_Ulcers_Best_Practice_Guideline_Final_web4.pdf
16. Lee SS, Huang SH, Chen MC, Chang K P, Lai CS, Lin SD. Management of recurrent ischial
pressure sore with gracilis muscle flap and V-Y profunda femoris artery perforator-based
flap. J Plast Reconstr Aesthetic Surg. 2009;62(10):1339-46. DOI: https://doi.org/10.1016/j.bjps.2007.12.092
17. Wettstein R, Tremp M, Baumberger M, Schaefer DJ, Kalbermatten DF. Local flap therapy
for the treatment of pressure sore wounds. Int Wound J. 2015;12(5):572-6. PMID: 24131657
DOI: https://doi.org/10.1111/iwj.12166
18. Milcheski DA, Mendes RRS, Freitas FR, Zaninetti G, Moneiro Júnior AA, Gemperli R.
Brief hospitalization protocol for pressure ulcer surgical treatment: outpatient care
and one-stage reconstruction. Rev Col Bras Cir. 2017;44(6):574-81. DOI: https://doi.org/10.1590/0100-69912017006005
19. Ishida LH, Munhoz AM, Montag E, Alves HR, Saito FL, Nakamoto HA, et al. Tensor fasciae
latae perforator flap: minimizing donor-site morbidity in the treatment of trochanteric
pressure sores. Plast Reconstr Surg. 2005;116(5):1346-52. PMID: 16217478 DOI: https://doi.org/10.1097/01.prs.0000182222.66591.06
20. Tang J, Li B, Gong J, Li W, Yang J. Challenges in the management of critical ill COVID-19
patients with pressure ulcer. Int Wound J. 2020;17(5):1523-4. PMID: 32383319 DOI:
https://doi.org/10.1111/iwj.13399
21. Keys KA, Daniali LN, Warner KJ, Mathes DW. Multivariate predictors of failure after
flap coverage of pressure ulcers. Plast Reconstr Surg. 2010;125(6):1725-34. PMID:
20517098 DOI: https://doi.org/10.1097/PRS.0b013e3181d51227
22. Disa JJ, Carlton JM, Goldberg NH. Efficacy of operative cure in pressure sore patients.
Plast Reconstr Surg. 1992;89(2):272-8. PMID: 1732895 DOI: https://doi.org/10.1097/00006534-199202000-00012
23. Relander M, Palmer B. Recurrence of surgically treated pressure sores. Scand J Plast
Reconstr Surg. 1988;22(1):89-92. DOI: https://doi.org/10.3109/02844318809097940
24. Kierney PC, Engrav LH, Isik F F, Esselman PC, Cardenas DD, Rand R P. Results of 268
pressure sores in 158 patients managed jointly by plastic surgery and rehabilitation
medicine. Plast Reconstr Surg. 1998;102(3):765-72. PMID: 9727442 DOI: https://doi.org/10.1097/00006534-199809010-00022
1. Universidade Federal do Paraná, Hospital de Clínicas, Curitiba, PR, Brazil.
2. Hospital do Trabalhador, Serviço de Cirurgia Plástica Reparadora, Curitiba, PR,
Brazil.
3. Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil.
4. Universidade Positivo, Curitiba, PR, Brazil.
Corresponding author: Carolina Peressutti Rua General Carneiro, 181, Alto da Glória, Curitiba, PR, Brazil Zip Code: 80060-900
E-mail: carol.peressutti@gmail.com
Article received: May 28, 2021.
Article accepted: October 15, 2021.
Conflicts of interest: none.
Institution: Hospital do Trabalhador, Curitiba, PR, Brazil.
