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Title: [Clinical strategy on repair of pressure injury on ischial tuberosity based on the histopathological type].
Author: Zhang XH, Gao XX, Chen XX, Yu JA.
Journal: Zhonghua Shao Shang Za Zhi; 2019 Apr 20; 35(4):261-265. PubMed ID: 31060173.
Abstract:
Objective: To investigate effects of clinical strategy on repair of pressure injury on ischial tuberosity based on the histopathological type. Methods: From January 2014 to January 2018, 33 patients with 33 pressure injuries on ischial tuberosity were admitted to our department. There were 25 males and 8 females aged 35 to 87 years. Pressure injuries on ischial tuberosity were repaired with different methods according to pathological types of denatured tissue on basal parts of wounds and tissue defect volumes. Areas of wounds after thorough debridement ranged from 2.0 cm×1.0 cm to 14.0 cm×12.0 cm. Pressure injuries of necrosis type with tissue defect volumes of 6.5-9.5 cm(3) were sutured directly after debridement at the first stage. Tissue defect volumes of 3 patients with pressure injuries of granulation type ranged from 56.0 to 102.5 cm(3). According to situation around wounds, the above mentioned 3 patients were respectively repaired with posterior femoral Z-shaped reconstruction, posterior femoral advanced V-Y flap, and posterior femoral propeller flap. Tissue defect volumes of 5 patients with pressure injuries of infection type ranged from 67.5 to 111.0 cm(3). Among the patients, 2 patients were repaired with posterior femoral propeller flaps, 2 patients were repaired with posterior femoral advanced V-Y flaps, and 1 patient was repaired with posterior femoral Z-shaped reconstruction. Among patients with pressure injuries of synovium type, wounds of 14 patients with tissue defect volumes 6.4-9.5 cm(3) were sutured directly after debridement, and tissue defect volumes of another 8 patients were 97.0-862.5 cm(3). Among the 8 patients, 7 patients were repaired with gluteus maximus myocutaneous flaps and continued vacuum sealing drainage was performed for 7 to 14 days according to volume of drainage, and 1 patient was repaired with posterior femoral propeller flap. Areas of flaps or myocutaneous flaps ranged from 3.5 cm× 2.5 cm to 14.0 cm×12.0 cm. The donor sites of flaps were sutured directly. Operative areas after operation and healing of wounds during follow-up were observed. Results: The sutured sites of 33 patients connected tightly, with normal skin temperature, color, and reflux. During follow-up of 12 months, wounds of 25 patients healed well with no local ulceration, and 8 patients were admitted to our department again due to recurrence of pressure injuries on or near the primary sites. Pathological types of pressure injuries of the 8 patients were synovium types. After complete debridement, the tissue defect volumes were 336.8-969.5 cm(3,) wounds with areas ranged from 8.0 cm×7.0 cm to 14.0 cm×12.0 cm were repaired with gluteus maximus myocutaneous flaps or posterior femoral propeller flaps which ranged from 8.0 cm×7.0 cm to 14.0 cm×12.0 cm. Eight patients were discharged after wound healing completely. During follow-up of 12 months, operative sites of the patients healed well, with no recurrence. Conclusions: Appropriate and targeted methods should be chosen to repair pressure injuries on ischial tuberosity based on the pathological types. Direct suture after debridement is the first choice to repair pressure injury of necrosis type. Pressure injuries of granulation type and infection type can be repaired with posterior femoral propeller flap, Z-shaped reconstruction, or advanced V-Y flap according to situation around wounds. Gluteus maximus myocutaneous flap is the first choice to repair pressure injury of synovium type. In addition, recurrence-prone characteristics of pressure injury of synovium type should be taken into consideration, plan should be made previously, and resources should be reserved. 目的：探讨基于组织病理类型的坐骨结节压力性损伤临床修复策略。 方法：2014年1月—2018年1月，笔者科室收治33例共33处坐骨结节压力性损伤患者，其中男25例、女8例，年龄35～87岁，根据创面基底部变性组织病理类型及组织缺损量采用不同修复方法。彻底清创后创面面积为2.0 cm×1.0 cm～14.0 cm×12.0 cm。坏死型压力性损伤患者组织缺损量为6.5～9.5 cm(3)，扩创后皆Ⅰ期直接缝合。肉芽型压力性损伤患者组织缺损量为56.0～102.5 cm(3)，依据创周情况分别采用股后侧Z字改形术修复1例，股后侧V－Y皮瓣推进术修复1例，股后侧螺旋桨皮瓣修复1例。感染型压力性损伤患者组织缺损量为67.5～111.0 cm(3)，应用股后侧螺旋桨皮瓣修复2例，股后侧V－Y皮瓣推进术修复2例，股后侧Z字改形术修复1例。滑膜型压力性损伤患者中14例组织缺损量为6.4～9.5 cm(3)，采用扩创后直接缝合；8例组织缺损量为97.0～862.5 cm(3)，采用臀大肌肌皮瓣修复7例，并根据引流量行持续负压封闭引流治疗7～14 d，采用股后侧螺旋桨皮瓣修复1例。本组患者皮瓣或肌皮瓣面积为3.5 cm×2.5 cm～14.0 cm×12.0 cm。供瓣区直接拉拢缝合。观察术后术区情况及随访创面愈合情况。 结果：33例患者术后缝合部位对接紧密，皮温、皮色及反流正常。随访12个月，25例患者创面愈合良好，未见局部破溃；8例患者因原发部位或邻近部位出现压力性损伤而再次入院，病理类型均为滑膜型，经彻底清创后，组织缺损量为336.8～969.5 cm(3)，创面面积为8.0 cm×7.0 cm～14.0 cm×12.0 cm，采用臀大肌肌皮瓣或股后侧螺旋桨皮瓣进行修复，皮瓣或肌皮瓣面积为8.0 cm×7.0 cm～14.0 cm×12.0 cm。8例患者创面完全愈合后出院。随访12个月，术区愈合良好，未见复发。 结论：坐骨结节压力性损伤的修复，应结合其病理类型选择针对性的修复方式，坏死型首选扩创后直接缝合，肉芽型及感染型可根据创周情况选择股后侧螺旋桨皮瓣、Z字改形术或V－Y皮瓣推进术进行修复，滑膜型首选臀大肌肌皮瓣进行修复。此外，还应考虑滑膜型压力性损伤易复发的特点，为复发预设修复方案、预留修复资源。.

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