Pressure sores are localized areas of tissue breakdown in skin and/or underlying tissues that develop when persistent pressure between a bony site and underlying surface obstructs healthy capillary flow. Constant external pressure over 70 mm Hg for 2 hours produces irreversible ischemic changes. Synonyms : Pressure ulcer, Decubitus ulcer, Bed sore.

1. SURGICAL INTERVERNTIONS
IN PRESSURE SORE
MANAGEMENT AT CRP
Presented by : Dr. Shamim Khan
RMO, Medical Care
Services
CRP, SAVAR

2. PRESSURE SORE
 Pressure sores are localized areas of
tissue breakdown in skin and/or underlying
tissues that develop when persistent
pressure between a bony site and
underlying surface obstructs healthy
capillary flow.
 Constant external pressure over 70 mm
Hg for 2 hours produces irreversible
ischemic changes.
 Synonyms : Pressure ulcer, Decubitus
ulcer,

3. Patient Populations at High Risk
 Paraplegic or tetraplegic patients
 Patients with decreased sensation due to neurologic
disorders, e.g. stroke.
 Patients with impaired mental capacity.
 Seriously ill patients in an intensive care unit.
Additional Risk Factors
 Malnutrition
 Incontinence
 Tobacco use.

4. Areas Prone to the Development of
Pressure Sores
 More common
• Scrum
• Trochanter
• Ischial tuberosity
 Less common
• Calcaneum
• Malleolus
• Scapula
• Elbow
• Knee

5. Patients Admitted with Pressure
Sore at CRP on 2007
 Total patients : 415
 Total patients with pressure sore : 173 (30% of
total)
 Male patients with pressure sore : 157 (27%)
 Female patients with pressure sore : 16 (3%)
Sex distribution among pressure sore
patients on 2007
Female
3%
Male
27%
Total
70%

6. Pressure Sore Staging System
 Stage I : Redness of intact skin that does not
blanch.
 Stage II : Partial-thickness skin loss involving the
epidermis and dermis.
 Stage III : Full-thickness skin loss involving the
underlying subcutaneous fat but not the
muscle.
 Stage IV : Full-thickness skin loss with extensive
destruction, tissue necrosis, or damage in
muscle, bone, or supporting structures.

7. Treatment of STAGE I and II
Pressure Sore
 Keep the affected tissue clean and the
surrounding area dry by regular daily
dressing.
 Apply antibiotic ointment (e.g., Bacitracin,
silver sulfadiazine) daily to areas that have
blistered.

8. Treatment of STAGE III and IV
Pressure Sore
 If the wound has a red, granulating base :
Apply saline dressing daily.
 If the wound contains necrotic tissue :
- Surgical debridement is necessary.
- Follow with daily dressings, using saline or EUSOL
solution.
 If the wound is infected :
- Treat the patient with a course of antibiotics.
- Twice daily dressing with Betadine solution.

9. Dressing Materials
 Normal Saline
 Betadine solution
 EUSOL solution
 Spirit
 Betadine ointment

10. Out come of Regular
Wound Dressing
On Admission Two months later

11. Surgical Intervention
 Wound Debridement
 Skin Grafting
 Plastic surgery

12. Wound Debridement
 When a wound is covered with black, dead
tissue or thick gray/green exudates, surgical
removal of necrotic tissue is needed.
 Dead bone or tendon in the wound must be
removed.
 Bleeding tissue is a good sign healthy tissue.
Dead tissue does not bleed.
 Once the necrotic tissue has been removed,
regular Wet-to-dry dressing should be started.

13. Out Come of Debridement and Dressing
Before After

14. Skin Grafting
 Cross-section of human skin showing the
epidermis, dermis and subcutaneous tissue.
 The relative thickness of skin grafts is shown.

15. Split-thickness Skin Graft
 Indications :
• Large wound (> 5–6 cm in diameter) that
would take many weeks to heal secondarily.
• Wounds that cannot be closed primarily.
• Wounds that require more stable coverage
than scar.
 Contraindications :
• Malnourished patient.
• Necrotic tissue or signs of infection at the
wound
• A wound that has exposed tendon or bone.

16. Skin-graft (Humby) knife
Harvesting a split-thickness
graft with the Humby knife.
Wound covered with a split-thickness skin graft.

17. Skin Grafting at Sacral Pressure
Sore
Preoperative Postoperative
Two months
before surgery

18. Plastic Surgery
 End to end closure
 Flaps
Pre requisites of plastic surgery :
 Excellent nutritional status.
 Albumin > 3.5 gm/dl,
 Prealbumin > 20mg/dl,
 Transferrin > 250 mg/dl (2.5 gm/L).
 The patient must not smoke.
 Patients should be motivated enough to change
positions regularly.

19. End to End Closure
Preoperative Postoperative

20. End to End Closure
Preoperative
Postoperative

21. FLAP
 A flap is a piece of tissue with a blood supply
that can be used to cover an open wound.
 A flap can be created from skin with its
underlying subcutaneous tissue, fascia, or
muscle. Flap
Local Flap Distant Flap
Skin Flap Muscle Flap
Axial Flap Random Flap

22. Random Flaps
 Circulation to a
random flap is
provided in a diffuse
fashion through tiny
vascular connections
from the pedicle into
the flap.
 The pedicle must be
bulky to increase the
number of vascular
connections.
 The flap should not
be longer than 3
times its width.
Random skin flap. The blood supply
comes diffusely from the remaining skin
attachment, which serves as the
pedicle.

23. Different Types of Random
Flaps
 Rhomboid flap
 Rotation flap
 Tensor fascia lata (TFL) flap
 V-Y advancement flap.
 Rectangular advancement flap.

24. Rhomboid Flaps
 Rhomboid flaps
are useful for
wounds up to 6
to 8cm in
diameter on the
trunk or
extremity.
 Useful in
pressure sores
with less
surrounding
tissue laxity.

25. Rhomboid Flaps
Preoperative
5th Postoperative day 15th Postoperative day

26. Rhomboid Flaps
Pre-operative Pre-operative
10th Post-operative day15th Post-operative day

27. Rhomboid Flaps
Pre-operative
7th Post-operative day One month later

28. Rhomboid Flaps
Per-operative pictures

29. Buttocks Rotation Flap
 Most
commonly
used for sacral
pressure
sore.
 Useful for
sacral wounds
about 10 to
12cm in
diameter.

30. Bilateral Rotation Flap
Pre-operative
Per-operative

31. Bilateral Rotation Flap
Per-operative pictures

32. Tensor Fascia Lata (TFL) Flap
 TFL flap is the
most commonly
used for closure
of trochanteric
pressure sore.
 The flap is
composed of the
skin and fascial
extension from
the TFL muscle.

33. Tensor Fascia Lata (TFL) Flap
Pre-operative
Post-operative

34. Tensor Fascia Lata (TFL) Flap
Pre-operative
Per-operative

35. Tensor Fascia Lata (TFL) Flap
Per-operative pictures

36. General Post Operative Care
 Cleanse and apply antibiotic ointment to the
suture lines daily.
 If a suction drain was used, it should stay in
place at least 1 week.
 The patient should apply no pressure to the
surgical site until the suture line has healed
(usually 2–3 weeks).
 Leave the skin sutures in place for at least
14 days unless there are signs of irritation
from the sutures.

37. Failure of Flap surgery
 Ischemic flap necrosis.
 Infection.
 Haematoma.
 Recurrence of pressure sore at
surgical site.

38. Graphical Presentation of
Pressure Sore surgeries from
Jan’07 to Apr’08
 Skin Grafting
 Plastic Surger
1
9
5
13
5 5
8
20
0
2
4
6
8
10
12
14
16
18
20
Jan'07 - Apr'07 May'07 - Aug'07 Sep'07- Dec'07 Jan'08- Apr'08