Difficult wounds: pressure ulcerations and leg ulcers.
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The authors' philosophy and regimen of treatment, based on experience with 103 pressure ulcers in 75 patients, are presented. This experience illustrates that the problem of pressure ulcers can be managed well by the application of sound surgical principles in a community hospital with a rehabilitation unit. With some simplification, the standard treatment procedures can be applied easily in this setting.
Four patients with paraplegia at levels T3 or below were required to remain in the prone position for periods of 3 to 5 weeks following plastic surgical repair of their pressure ulcers. Serial nerve conduction studies permitted early identification of compromise of ulnar nerve function prior to onset of symptoms. These objective findings are helpful in encouraging patients to protect the nerve, thus preventing palsy.
Ischial pressure sores can be repaired with gracilis myocutaneous island flaps, and this technique offers numerous advantages over the use of posterior thigh flaps. Several illustrative cases are described.
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Debrisan (Dextranomer) was subjected to a simple open assessment in the treatment of fifty-three chronic leg ulcers and thirty pressure sores in eight hospitals. It was found that 70% of leg ulcers and 76% of pressure sores improved, with a noticeable cleansing effect being evident in 79% and 83% respectively. No side-effects were recorded.
Pressure is a crucial factor in the formation of decubitus ulcers. To elucidate the effect of imposed skin pressure, a new cutaneous oxygen sensor was used to measure the skin oxygen tension under increasing pressure upon skin tissue at "hard sites" (bony prominences) and at "soft sites" (muscle-padded areas). At hard sites the skin oxygen tension fell rapidly under increasing pressure (y = 90.9--0.39. X; r = 0.98) from an initial value of 86.4 +/- 10.6 to 20.2 +/- 12.1 mm Hg under an imposed skin pressure load of 175 gm/cm 2. At soft sites a pressure load of 175 gm/cm 2 decreased the skin oxygen tension only from 82.9 +/- 5.8 to 71.4 +/- 10.0 mm Hg. These results may explain why hard sites (bony prominences) are preferential areas for decubitus ulcer formation.
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Fifty-one patients (55 limbs) who had had deep venous thrombosis (DVT) extending into the femoral or iliofemoral segment three to five years earlier and ten limbs of ten healthy volunteers were studied. The ambulatory venous pressure (AVP) was measured by inserting a needle in a vein on the foot; the presence of reflux in the popliteal vein was determined by a directional Doppler ultrasonic blood velocity detector. All patients had ascending venography. The results suggest that the most important factor in determining the AVP and ulceration in postthrombotic limbs is the condition of the popliteal valves. Ulceration does not occur even in the presence of occlusion if the popliteal valves are competent. The extent of DVT and recanalization or the failure of recanalization is of secondary importance.
In spite of prophylactic treatment pressure sores in para- and tetraplegics often occur. The pressure ulcers are mostly found in certain places. Surgical intervention will be eventually necessary in most cases. Surgery should include the radical excision of the ulcer, the removal of prominent bone areas and the closure of the defect. In order to avoid large scars the surgical procedure should not exceed a certain extent. We feel that the slide and swing method after Schrudde is the most efficacious because by means of this technique large scars and free transplants which are very sensitive postoperatively can be avoided. We report on a total of 128 patients with 169 pressure sores.