Jordan Sumanas W, De la Garza Mauricio, Lewis Victor L
Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
Institute for Plastic Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA.
J Plast Reconstr Aesthet Surg. 2017 Jul;70(7):959-966. doi: 10.1016/j.bjps.2017.01.004. Epub 2017 Jan 23.
Despite newly introduced techniques, reconstruction of ischial pressure ulcers remains a difficult problem with high-reported failure rates.
A retrospective chart review was performed on all spinal cord injury patients who underwent ischial pressure ulcer reconstruction by the senior author (V.L.) between 2004 and 2012. The two-stage procedure consisted of debridement and bone biopsy, followed by bursectomy, partial ischiectomy, fascial release, and gluteus maximus and hamstring advancement flaps. Postoperative care included 2-week supine bed rest on an air-fluidized bed, sitting tolerance rehabilitation, and thorough behavioral training.
Sixty-five patients (74 flaps) were identified. A 45.9% had a previous attempt at reconstruction. The median follow-up period was 622 days. Overall, 67.6% of flaps were intact at the last follow-up. Superficial and deep dehiscence rates were 16.2 and 28.4%, respectively. Seven out of 35 flaps suffered late recurrence after being well healed for more than 1 year. History of previous reconstruction was found to be associated with increased odds of superficial (OR 6.02, 95% CI 1.55-23.3) and deep dehiscence (OR 12.3, 95% CI 1.99-76.9).
The evolution of the senior author's decades of practice has led to the development of a simpler repair, which relies on plane-by-plane release of scarred tissues to improve the mobility of muscle and skin flaps without large tissue movements, even in the setting of apparent extensive tissue loss. This technique is a reliable option, particularly for the primary ischial pressure ulcer.
尽管引入了新的技术，但坐骨压力性溃疡的重建仍然是一个难题，报告的失败率很高。
对2004年至2012年间由资深作者（V.L.）进行坐骨压力性溃疡重建的所有脊髓损伤患者进行回顾性图表审查。两阶段手术包括清创和骨活检，随后是滑囊切除术、部分坐骨切除术、筋膜松解以及臀大肌和腘绳肌推进皮瓣。术后护理包括在气悬浮床上仰卧卧床休息2周、坐位耐受康复以及全面的行为训练。
共确定了65例患者（74个皮瓣）。45.9%的患者曾尝试过重建。中位随访期为622天。总体而言，在最后一次随访时，67.6%的皮瓣完好无损。浅表和深部裂开率分别为16.2%和28.4%。35个皮瓣中有7个在愈合超过1年后出现晚期复发。发现既往重建史与浅表裂开（比值比6.02，95%置信区间1.55 - 23.3）和深部裂开（比值比12.3，95%置信区间1.99 - 76.9）的几率增加有关。
资深作者数十年实践的演变促成了一种更简单修复方法的发展，该方法依靠逐层松解瘢痕组织来提高肌肉和皮瓣的活动度，而无需进行大幅度的组织移动，即使在明显存在广泛组织缺损的情况下也是如此。这项技术是一种可靠的选择，尤其适用于原发性坐骨压力性溃疡。
