- Surgery can play an important role in the management of pressure injuries (for example stage 3 or 4, DTI) that are non-responsive to other management strategies. There are a range of surgical interventions possible, such as surgical debridement, direct wound closure, skin grafting, and skin, fasciocutaneous or myocutaneous flap repairs. Advantages may include definitive wound debridement with skin and soft tissue coverage, improved vascularity, healing from underlying osteomyelitis, and so on -allowing the person to regain function and independence more efficiently.
- Complications can occur and an extended period of hospitalisation followed by a graduated and significantly limited sitting time is required following the surgery.
- Post-surgical skin may be more vulnerable to re-injury. Equipment, weight shifting strategies, transfers, nutrition, general health and knowledge of PI prevention will need to be optimised and any lifestyle factors addressed to prevent a new PI or recurrence.
- Complex surgical management of a PI in a person with SCI or SB , involving a flap repair or other major reconstructive surgery, such as a flap in combination with proximal femoral osteotomy (Girdlestone procedure) or end-stage lower extremity disarticulation and total thigh flap, should only be done in a specialist centre (see Referral).
The wound being clean and having a granulating wound bed; as well as the person being:
- Able to keep the surgical site free from pressure for the post-operative period.
- Motivated and knowledgeable about pressure injury prevention and making changes to address both the cause of the PI and contributing factors.
- Supported with adequate psychosocial support, resources and knowledge to sustain the changes they have made to prevent future PIs.
In general, flap surgery involves11:
- Infected tissue and scar tissue debridement (usually prior to the flap surgery) to produce a clean wound. In some cases debridement may result in a larger wound area due to removal of infected or necrotic tissue.
- During flap surgery, infected bone and irregular bone that would cause a point of pressure are removed.
- A well-vascularised flap is freed from an adjacent part of the body and moved or rotated and then reconstructed over the defect. The flap covers and protects the affected bony prominence with healthy tissue.
The cause and contributing factors must be addressed prior to surgery. The tertiary SCI or SB service will assess and provide pre-operative recommendations specific to each individual person with a PI.
Assess, treat and optimise:
Post-operative care usually involves the following:
- Period of inpatient care usually in a spinal cord injury unit on complete bed rest.
- Positioning to keep direct pressure off the surgical site.
- Use of optimal support surfaces. For example, an alternating air mattress replacement is usually required.
- Frequent repositioning to reduce risk of skin breakdown of other sites – use of a slide-sheet and correct manual handling techniques to minimise shear and friction.
- Specialised seating assessment and regular evaluation.
- Progressive sitting, once the surgical site has healed, over 4-8 weeks using a gradual return to sitting protocol.
- Evaluation and optimisation of wheelchair seating and other support surfaces such as the commode and mattress (only those support surfaces that have been assessed and optimised will be introduced into the protocol).
- Gradual introduction of new potential mechanical stressors and evaluation of their effect on the skin (including transfers, commode use, downgrading of the mattress).
- Provision of pressure management and skin checking education tailored to the individual to reduce future PI risk.
- Provision of psychological support, counselling and monitoring of mood and quality of life.
- Family and/or social support is important during this period.
The post-operative protocol is different for every individual and should be closely monitored.