Extensive Sacral Pressure Sore Reconstructed with Staged Negative Pressure Wound Therapy Dermatotraction and Superior Gluteal Artery Perforator Flap Reconstruction -- A Case Report

階段性負壓傷口治療皮膚牽引和併臀上動脈穿通支皮瓣重建大面積薦部壓瘡－個案報告

徐國峰(Kuo-Feng Hsu) ； 陳俊宇(Chun-Yu Chen) ； 王志信(Chih-Hsin Wang) ； 戴念梓(Niann-Tzyy Dai) ； 陳錫根(Shyi-gen Chen) ； 陳天牧(Tim-Mo Chen) ； 曾元生(Yuan-Sheng Tzeng)

《臺灣整形外科醫學會雜誌》 30卷1期 (2021/03) Pp. 39-47

摘要

Background: A sacral pressure sore is associated with pressure in the lying down position, most frequently as a result of paraplegia or a long-term bedridden condition. The roles of surgical debridement and flap reconstruction are well-established. However, reconstructing an extensive sacral wound is still challenging even with the use of a bilateral gluteus maximus myocutaneous V-Y advancement flap. Negative pressure wound therapy (NPWT) became a gold standard treatment for difficult wounds in recent years. Many studies showed that NPWT could decrease the tension across the suture site. Aim and Objectives: NPWT facilitates granulation of wound, promotes marginal apposition of the wound edge, increased tissue perfusion, and therefore increased the successful rate of wound healing with direct closure. Several studies have applied this method to limbs with fasciotomy and laparotomy wounds sutured under tension, but to our knowledge, no studies have reported using this method for pressure ulcer reconstruction. Here, we report a case with an extensive sacral pressure ulcer in which we successfully achieved wound healing with staged NPWT-assisted dermatotraction and superior gluteal artery perforator flap (SGAP) reconstruction. Materials and Methods: A 65-year-old male, bedridden due to lumbar spondylosis with severe spinal stenosis status post operation with failed back surgery syndrome and paraplegia, presented with two ulcers over the right and left posterior superior iliac spine (PSIS) areas. After conservative management, debridement, and NPWT failed to resolve the ulcers, the ulcers worsened to an extensive grade IV ulcer, and surgical reconstruction was necessary. 21 weeks after first debridement, we closed the wound edge with primary suture and simultaneous NPWT dermatotraction, which successfully decreased the wound area. Finally, 30 weeks after first debridement, we performed reconstruction surgery with a rotation SGAP flap. Results: The wound healed well, and the hospital course was uneventful. The patient returned to a rehabilitation program 2 months later, and the ulcer had not recurred within the 2-year follow-up period. Conclusion: Based on these results and experiences, our case indicates that closing wound edges with local advanced skin flap with simultaneous NPWT dermatotraction to decrease wound surface may be an alternative option for reconstruction of sacral pressure sores which are extensive and difficult to reconstruct. This technique provides an alternative reconstruction option for large sacral pressure ulcers that avoids the double myocutaneous flap reconstruction, thereby preserving the one side gluteus maximus myocutaneous flap and minimizing the functional damage to the muscle.

關鍵字

sacral pressure ulcer ； surgical reconstruction ； negative pressure wound therapy ； vacuum-assisted closure ； superior gluteal artery perforator flap

並列摘要

背景：薦骨部壓瘡與臥位壓力有關，最常見的原因是截癱或長期臥床。外科手術清創和皮瓣重建仍是目前主要治療方式。然而，即使使用雙側臀大肌皮瓣重建，重建大面積薦骨部傷口仍然具有挑戰性。近年來，負壓傷口治療已成為治療困難傷口之主流療法。目的及目標：許多研究發現，負壓傷口治療可以降低縫合部位的張力。另外，負壓傷口治療可以減少縫合傷口的空腔，促進傷口邊緣對靠，增加組織灌注，並因此增加傷口癒合的成功率。目前有幾篇文章將這種方法應用於在張力下縫合筋膜切開術傷口以及張力下縫合剖腹手術的傷口，但沒有研究將此方法應用於壓迫性潰瘍的重建。在此，我們報導一例伴有大面積薦骨部壓瘡的病例，我們成功地通過階段性負壓傷口治療輔助皮膚牽引術和臀上動脈穿通支皮瓣手術成功重建了大面積薦骨部傷口。材料及方法：一名65歲男性因腰椎關節病變併椎管狹窄，接受腰椎手術後併發脊椎手術後疼痛症候群以及雙下肢癱瘓處於長期臥床狀態，在左右後上髂棘區域出現兩個潰瘍。在經過保守治療，清創手術和負壓傷口療法後，患者的壓迫性潰瘍惡化為大面積的第四級潰瘍，因此必須進行手術重建。在距離第一次清創21週後，我們通過縫合兩側傷口邊緣並同時進行負壓傷口治療皮膚牽引術，成功減少了傷口面積。最後，離第一次清創30週後我們使用臀上動脈穿通支皮瓣進行了重建手術。結果：傷口癒合良好，患者在皮瓣手術後2個月後開始復健計劃，且在2年的術後追蹤中並無復發。結論：根據這些結果和經驗，我們的案例說明，對於重建困難的大面積薦骨部壓瘡，「縫合傷口邊緣並同時進行負壓傷口治療皮膚牽引，以減少了傷口面積」可能是種替代的重建方法。該技術為大面積薦骨部壓瘡提供了另一種重建選擇，避免了雙側臀大肌皮瓣重建，從而保留了臀大肌皮瓣並將對肌肉的功能性損害降至最低。