Reoperative Aesthetic & Reconstructive Plastic Surgery

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PART V
R EOPERATIVE SURGERY OF THE TRUNK
wound dehiscence (31%);recurrence or occurrence of a pressure sore secondary to
bony imbalance, ap necrosis, hematomas, and infection; and heterotopic ossi ca-
tion.4
PATIENT EVALUATION
To ensure the success of reoperation, it is important to evaluate and correct factors
that contribute to recurrence. Simply repeating the same procedure that was per-
formed the rst time is likely doomed to failure the second time. Factors that con-
tribute to recurrence, such as debilitation of the patient, poor nutrition, psychoso-
cial complications, poor wound bed with recalcitrant deep infection, and paucity of
surrounding healthy tissue for aps, must be recognized. Psychologic evaluation
may be helpful. Preoperative planning for postoperative support services and fam-
ily support at home is important. Studies that may be bene cial in the evaluation
of the patient undergoing reoperation are nutritional assessment, including mea-
surement of albumin and transferrin levels, and, if necessary, determination of nitro-
gen balance. A complete blood cell count may indicate an elevated white blood cell
count, ongoing infection or anemia, and other nutritional disturbances. Hyper-
glycemia should be detected and controlled. In a quadriplegic patient it may be
necessary to obtain a set of pulmonary function test results to predict the need for
perioperative intubation and ventilatory assistance. A radiograph of the chest may
identify unsuspected pneumonia.With respect to evaluation of the affected area, a
CT scan can be helpful to examine the pelvis. It may indicate soft tissue in amma-
tion or bone erosion caused by osteomyelitis or heterotopic ossi cation. In addition,
associated intrapelvic or ischiorectal abscesses may be identi ed;these defects must
be addressed at the time of pressure sore treatment.Three-phase bone scans may be
helpful in evaluating osteomyelitis.5 MRI is gaining increasing acceptance as a
means to diagnose osteomyelitis;however, the bone biopsy is still the most speci c
test.6
Urologic evaluation may be necessary. Many ischial and perineal pressure sores de-
velop urethrocutaneous stulas. Patients with such defects may require urinary di-
version. In addition, incontinence, which is frequently present in patients with
spinal cord injuries, has been shown to increase the propensity toward skin exco-
riation and ultimate pressure sore damage. Skeletal alignment needs to be evaluated
preoperatively. As a result of having had a radical ischiectomy, some patients have a
bony imbalance with increased pressure on the side contralateral to the ischiec-
tomy. Differential pressure–measuring devices are used to detect this condition.
Some patients with spinal cord injuries may have spastic scoliosis or lordosis
demonstrated on plain radiographs. The patient who has been quadriplegic since
childhood is particularly prone to lordosis because of the shifting of weight to ab-
normal pressure points. Skeletal realignment may be desirable. Often this treatment
is deferred until soft tissue wound coverage is obtained.

1827
Chapter 45
Treatment of Recurrent Pressure Sores
TREATMENT OF R ECURRENT PRESSURE SORES
In the preoperative evaluation, it is important for the surgeon to understand when
to operate, when to delay, and when to recommend against surgery. In an elderly
patient who has dementia or is very debilitated with severe contractures, it is un-
likely that the conditions that caused the pressure sore can be improved;for this rea-
son, surgery is rarely recommended. It is appropriate to delay surgical repair until
the patient has an improved state of mind and is willing to participate in perioper-
ative care. Depression should be treated preoperatively. In patients who have mul-
tiple recurrent pressure sores, we often nd that they are not willing or are unable
to comply with preventive measures against recurrence of pressure sores. Patient
motivation to avoid recurrence is extremely important. It is clinically evident that
psychological counseling, social setting adjustment, and reeducation about self-care
may decrease the incidence of recurrence. No amount of surgical perfection can
prevent recurrence of pressure sores if the patient reverts to previous behavioral
patterns and repeats the pattern of injury.
With a refractory patient, it is helpful to estimate how willing or able the patient is
to cooperate. An outpatient test of compliance can be performed preoperatively.
Initial debridement and wound care are administered. The patient is asked to re-
main on bed rest long enough for the wound to improve and is instructed that bed
rest will need to be maintained for a signi cant period postoperatively. If the patient
is not able to maintain the preoperative bed rest necessary for the wound to im-
prove, it is unlikely that he or she will be able to maintain the postoperative bed rest
required for the wound to heal. In such a case, delay and reassessment are in the best
interest of the patient and the health care system.
COMPLICATIONS
The most common problems requiring reoperation are recurrence of the wound,
dehiscence of the wound, development of pressure sores in other locations, het-
erotopic ossi cation, ap loss, and infected recurrent bursa.
R ECURRENCE
Recurrence of the pressure sore is the most disappointing problem for both the pa-
tient and the physician. A deep sense of loss and waste are felt by the patient who
has invested weeks of bed rest, curtailment of activities, and time away from friends,
family, and familiar surroundings.The major causes of recurrent pressure sores are
dehiscence of the wound postoperatively, residual osteomyelitis, inadequate cover-
age over the prominence, and poor patient compliance with resultant repeated rein-
jury. Contributing causes are obesity, malnutrition, smoking, urinary incontinence,
diabetes mellitus, poor bedding or wheelchair support and cushioning, spasticity,

1828
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R EOPERATIVE SURGERY OF THE TRUNK
scoliosis, rigidity, heterotopic ossi cation, and irritation by garment seams. Some re-
current sores may not be pressure sores (for example, ischemic gluteal slough or
factitious ulcers). Recurrence of a pressure sore years later may indicate Marjolin’s
ulcer.7 Recurrence can occur through a ap or through the scar at the edge of a
ap. Uneven bony prominences, poor posture in a wheelchair, return to a behav-
ioral pattern that causes damaging pressure, contractures, and scoliosis contribute to
recurrence through a ap. Contributing factors in recurrence through the scar at
the edge of a ap include insuf cient excision of scar tissue, tension that causes lo-
cal ischemia in the cicatrices, and inappropriate placement of the scar over a bony
prominence.
Initial care involves resolving infection or sepsis, debriding necrotic tissue, and im-
proving wound hygiene. Much of this process can be accomplished on an outpa-
tient basis. A thorough evaluation with an examination for all of the potential con-
tributing factors must be performed. With the recognition and treatment of as
many of these factors as possible, the odds of success are greater.
A well-conceived plan of ap coverage is essential. A good plan requires (1) patient
positioning with adequate exposure and visualization of the wounds, flaps, and
changes brought on by debridement such as communication of ischial and
trochanteric defects or compromise of blood supply to potential aps, (2) for each
sore, the presence of at least one reliable ap and an alternative ap of adequate di-
mensions for stable, lax coverage when the hips are fully exed, (3) recognition of
the importance of not uncovering bony prominences in ap donor sites, and (4) an
understanding of how, in multiple-sore coverage, each ap closure affects other re-
lated flap closures. Intraoperatively, a thorough debridement of the wound and
complete excision of osteomyelitis must be obtained. However, the surgeon must
keep in mind the need to maintain as much skeletal stability as possible.
DEHISCENCE
Dehiscence of a wound generally occurs before postoperative week 3. Dehiscence
at 3 to 6 weeks is usually a result of burrowing infection from a deep plane or ex-
treme traction across wound edges. Most cases of dehiscence tend to re-create a
wound similar to the original pressure sore. Although the recurrent wound may be
smaller and the tissue fresher, the wound may take just as long to close by second-
ary intention as any other pressure sore.The causes of dehiscence are accumulation
of serous uid or hematoma, infection, ap edge necrosis, motion or movement
across the lines of tension secondary to spasticity or noncompliance, and the most
important factor, tension on closure. Fluid accumulation causing dehiscence is gen-
erally a technical problem attributed to inadequate hemostasis, inadequate drainage
ports, or premature removal of the drains. Drainage from the operative site of pres-
sure sores can be quite heavy because of the large surface areas and the potential

1829
Chapter 45
Treatment of Recurrent Pressure Sores
dead space and leakage from synovial spaces. It is best to leave drains in place until
drainage is minimal or the wounds are securely sealed. Infection is an early cause of
dehiscence and is evident by breakdown of the wound edges and purulent exudate.
Infection is usually secondary to incomplete excision of the contaminated granu-
lation tissue in the bursa, residual osteomyelitis, or primary coverage of an infected
wound that would have been better treated by staged procedures.When purulence
and extensive necrosis are present, the pressure sore is drained and aggressively de-
brided of all infected and necrotic tissue.Then, in a second-stage procedure, when
no further purulent drainage exists, excision and ap coverage are performed. Some
lesser infections may be treated by debridement and healing by secondary inten-
tion. Tension across the operative site may pull the wound apart. Tension may be
caused by spasms, sitting too soon after surgery, and inappropriate positioning or
moving of the patient. The single greatest contributor to dehiscence is tension
across the wound.
Closure of pressure sores demands the strictest application of the prin-
ciple of closure without tension.
Adequate ap coverage must offset a negative balance of soft tissue around the sore.
This negative balance exists for three reasons: (1) tissue loss in all planes as a result
of pressure necrosis that is frequently wider at deeper levels, (2) tissue loss second-
ary to one or multiple debridements, and (3) closure performed with the patient’s
trunk in an extended position so that even the slightest trunk exion causes tension
across the wound.
Dehiscence of a ap donor site is another matter. Donor sites are generally planned
so that they do not cross or uncover other bony prominences or pressure points. If
the donor site wounds open, they generally heal by secondary intention. Alterna-
tively, healing of a dehiscence can be expedited by a vacuum-assisted closure (VAC)
device. Donor site dehiscence can be prevented by skin grafting potential areas of
tension instead of attempting closure.
OCCURRENCE AT OTHER SITES
Another complication encountered after the original surgery for pressure sores is
the occurrence of pressure sores at other sites during convalescence. Often
trochanteric sores develop while the patient is trying to avoid the supine position
to take pressure off sacral sores. In addition, trochanteric and sacral sores develop
while the patient is on bed rest to heal ischial sores. Frequent turning and prone po-
sitioning on a good bed with a water-bed or air-cushioning device can prevent
this complication. Air- uidized beds have provided a major breakthrough in the
immediate postoperative period when the patient’s mobility is severely restricted.
These beds are recommended for the rst 3 weeks after surgery to prevent new

1830
PART V
R EOPERATIVE SURGERY OF THE TRUNK
sores from forming while ensuring optimal pressure relief for the operative site. If
pressure sores at a different site are noted early, pressure relief measures can be taken,
allowing the wound to reepithelialize and heal. However, if the damage goes unno-
ticed for a suf cient period of time, a new deep pressure sore may occur.
POSTOPERATIVE HETEROTOPIC O SSIFICATION
Heterotopic ossi cation occurs in 75% of patients with spinal cord injuries.8 Oc-
casionally, the dif cult situation arises in which heterotopic ossi cation develops
around a pressure point that has been subjected to surgery or repeated trauma.The
result is joint immobility.When ankylosis of the hip joints occurs, the patient may
be unable to sit in a wheelchair or lie at in bed. Heterotopic ossi cation has also
been shown to extend from the pressure sore areas up along the spine, exacerbat-
ing spine in exibility and thus increasing the problems of positioning the patient.
As it extends into the soft tissue, heterotopic ossi cation also decreases tissue pli-
ability and padding over prominent points. In addition, it creates a susceptible nidus
for infection. If there is a break in the skin, infection can develop in the area. Het-
erotopic ossi cation typically increases when there is further trauma or surgery.
Treatment may include resection of the heterotopic ossi cation or coverage of the
affected site with a soft tissue ap. Protocols have been developed to prevent exten-
sion or recurrence. Administration of low-dose radiation immediately after surgery
has been shown to decrease the incidence of heterotopic ossi cation.9 Etidronate
disodium (Didronel) 20 mg/ kg/day for the rst 2 weeks, with the dosage decreased
to 10 mg/ kg/day for the next 10 weeks, and indomethacin (Indocin) 25 mg three
times a day for at least 3 weeks have also been shown to decrease the occurrence
and severity of heterotopic ossi cation.10 These regimens should be used in a pa-
tient with known heterotopic ossi cation who is prone to increased ossi cation,
particularly in pressure sore areas.
R ECURRENCE SECONDARY TO BONY IMBALANCE
When a prominent pressure point is removed, increased pressure may be shifted to
other areas that were previously uninjured. Skeletal imbalance is most notably a re-
sult of radical ischiectomy, which causes pressure shifts to the pubic symphysis with
consequent urethral cutaneous stula. A Girdlestone resection of the proximal fe-
mur shifts pressure to the ipsilateral ischium. Although it is clearly necessary to re-
move osteomyelitic bone, it has become evident that it is necessary to retain as
much healthy bone as possible for skeletal balance. If imbalance is present, seating
devices such as specialized molded cushions or pressure-differentiated cushions can
be provided.

1831
Chapter 45
Treatment of Recurrent Pressure Sores
HEMATOMA
Hematoma may be present underneath the ap, requiring reoperation in the early
postoperative period. Hematoma may lead to ap necrosis, wound dehiscence, or
infection. When hematoma is recognized, appropriate treatment includes prompt
evacuation, hemostasis, and reclosure of the wound. If hematoma is noted late, de-
bridement of the ap may be necessary, and recoverage with another ap is often
required.
FLAP NECROSIS
Flap necrosis, when minor, may be treated conservatively and may not pose a risk
of wound breakdown. However, because of the tension across the prominent areas
of pressure sores, and the subsequent shearing forces, even minor ap necrosis may
be signi cant and cause wound dehiscence, leading to sinus tract formation or re-
current pressure sores. A large area of necrosis may progress to immediate wound
breakdown and infection. Flap necrosis is most often caused by undue tension
across the wound. It may be secondary to an inappropriate attempt to close the
donor site completely when a skin graft would have suf ced and created less ten-
sion across the wound.
As mentioned previously, hematoma may cause necrosis of the ap.Venous conges-
tion of the ap from torsion or compression of the pedicle is the most likely vas-
cular cause of ap compromise.Vascular compromise may also result from injury to
the pedicle. Some of the anatomic pitfalls in common aps of the trunk may be
avoided by attention to detail. For the sliding gluteus maximus ap, the superior and
inferior gluteal vessels must be identi ed. These vessels are most easily and safely
found by dissecting in the lateral avascular plane between the gluteus medius and
the gluteus maximus muscles. It is easier to identify the vessels using this technique
than with a medial approach. In the posterior thigh ap the pedicle is maintained
with the ap by identifying the descending branch of the inferior gluteal artery in
the popliteal fossa at the distal tip of the ap, and dissecting from distal to proximal.
In one study the descending inferior gluteal artery was found to be patent for the
full length of the posterior thigh in only 25% of the anatomic dissections.11 The
tensor fascia lata pedicle may have been divided by anterior hip surgery or by pres-
sure sore injury in that region.The VY biceps femoris myocutaneous advancement
may be compromised by inadequate segmental perforators into the biceps femoris
muscle, caused by division of too many perforators. Other problems with flap
necrosis are incorrect territory over the pedicle. Examples include a tensor fascia
lata ap extended more than two thirds of the length of the thigh, a ap designed
off the central axis, and failure to maintain the fasciocutaneous plexus, as in the
posterior thigh ap when the pedicle is separated from the ap.

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PART V
R EOPERATIVE SURGERY OF THE TRUNK
INFECTED R ETAINED R ECURRENT BURSA
Deep-seated infection or uid accumulation caused by retained synovial uid may
result in a recurrent sore. Painting the interior of the bursa sac with methylene blue
and then excising all of the blue-painted tissue helps to ensure total bursal removal.
However, because of dif cult exposure, portions of the bursa may be retained and
may cause a recurrent sore.
TREATMENT OF SPECIFIC DEFORMITIES
CHRONIC WOUND
The pressure sore is treated as a chronic wound. Treatment requires complete ex-
cision of scar, reduction of dead space, transfer of vascularized tissue into the space,
and protection of that vascularized tissue. Improved wound perfusion, oxygenation,
nutrition, and reduced contamination create a milieu for wound healing. Sclerotic
or necrotic bone is excised if it is in proximity to the base of the wound.
R ECURRENT SACRAL PRESSURE SORES
Recurrent sacral pressure sores most commonly occur in the quadriplegic patient.
The recumbent position predisposes the patient to the sacral pressure sore. It may
also be found in patients with multiple recurrent pressure sores and may in fact re-
sult when tissue is borrowed from the gluteal areas to repair ischial or trochanteric
regions. This tissue transfer causes increased tension across the sacral region in an
area that is already scarred. Common causative factors of recurrent sacral sores are
predisposition to osteomyelitis, poor bedding with the absence of appropriate pres-
sure relief measures, spinal deformity that causes slumping in the chair, kyphosis, and
recurrent osteomyelitis. If the quadriplegic patient remains in the recumbent posi-
tion on inadequate bedding for long periods of time, the sacrum is under great
pressure.This situation is aggravated by hip contractures, which increase the weight
on the pelvis.The semireclining position that causes shear forces adds to the tissue
damage in this area. Recurrent osteomyelitis in this area is a dif cult problem. Ex-
tensive debridement of sacral bone may cause instability of the pelvis, exposure of
the spinal cord, and signi cant bleeding.
Assessment of patients with this type of recurrent sore includes evaluation of their
bedding, their seated position in the wheelchair, and their daily habits. Evaluation
of the pelvic bones may be necessary with plain films, CT scan, MRI, or bone
biopsy. It is important to recognize the aps that were previously used, the scars
that exist on the posterior region, and the potential areas of tension on the skin. It
is also essential to ascertain the surgical technique used for the rotation ap, the

1833
Chapter 45
Treatment of Recurrent Pressure Sores
previous elevation of which may have divided some of the perforators from the
gluteus maximus muscle to the overlying fasciocutaneous ap or overlying skin ap.
The surgeon must understand the technique of the gluteus maximus VY musculo-
cutaneous advancement ap, because this ap frequently maintains all of the perfo-
rator supply of the muscle into the fasciocutaneous ap.When aps are planned, the
design of aps over the posterior iliac crest, superior iliac spine, posterior trochanter,
or ischium is avoided. Other aps that may be necessary to close possible recurrent
ischial or trochanteric sores in the future should be taken into account.
Options for closure include the following:
1. Readvancement of a skin or a fasciocutaneous rotation ap
2. Readvancement of a skin or fasciocutaneous rotation ap and creation of a
contralateral rotation ap
3. Readvancement of a VY gluteus maximus musculocutaneous ap or division
of one pedicle of this ap to allow advancement and rotation of the ap
4. Contralateral VY musculocutaneous ap
5. Transverse back fasciocutaneous ap based on its ipsilateral paraspinal perfo-
rators
6. Long posterior thigh ap based on the descending branch of the inferior
gluteal artery
7. Superior gluteal artery perforator ap
8. Free tissue transfer
Experience with these aps dictates speci c indications and disadvantages of each.
Readvancement of the rotation ap is indicated if the perforators from the muscle
are still intact. Inclusion of fascia in the ap improves the vascularity;however, some
extensibility is lost. Skin grafting of the donor site from which the rotation ap is
moved is nearly always necessary with a readvancement of this ap. If the rst op-
eration was a VY musculocutaneous gluteus maximus flap, a readvancement of
this ap can be considered. In fact, the gluteus maximus musculocutaneous ap
can be made to cover a greater area by dividing either the superior or the inferior
pedicle, which allows a 90- to 120-degree rotation of the ap into the area. This
maneuver can be helpful when covering extensive recurrent sores. Again, the sur-
geon must recognize the potential need for a skin graft in the donor area once this
ap is readvanced. If previous rotation fasciocutaneous aps have been harvested
from the gluteus maximus muscle, the musculocutaneous perforators may be dis-
rupted in the normal territory of the VY advancement ap. Before either of the
pedicles is divided, good pulsatile blood ow should be veri ed in both pedicles.
Exposure of both pedicles is easily obtained by dissecting from the lateral superior
edge of the gluteus maximus muscle medially and inferiorly to the superior and in-
ferior gluteal vessels.

1834
PART V
R EOPERATIVE SURGERY OF THE TRUNK
It is important to realize that a single gluteus maximus ap can cover a large defect
of 8 to 12 cm.The prominences are marked so that the design of the ap will avoid
uncovering the posterior iliac crest, posterior iliac spine, trochanter, and superior
lateral sacrum.The V point of the ap should not lie over the trochanter.
Sacral
resection
Posterior
superior
iliac spine
Inferior gluteal
neurovascular
pedicle
Superior gluteal
vascular pedicle
Superior gluteal
vascular pedicle
(tied off)
Inferior gluteal
neurovascular
pedicle
Maximum transposition is obtained by creating an island pedicle ap.This maneu-
ver involves wide exposure and elevation of the ap from the sacrotuberous liga-
ment, division of one of the pedicles (inferior or superior), and complete lateral
and medial elevation of the ap on either side of the pedicles. In the ambulatory pa-
tient the inferior pedicle should not be ligated because it contains the inferior
gluteal nerve to the gluteus maximus muscle.

1835
Chapter 45
Treatment of Recurrent Pressure Sores
With full mobilization of the ap, the gluteus maximus muscle and fascia are ap-
proximated to the contralateral muscle and fascia, and the ap is tailored to t the
defect.
Inferior gluteal
neurovascular
pedicle
The donor site is closed as a VY ap or skin grafted as necessary to avoid tension.
The transverse back ap is an often-forgotten but useful ap for the upper portion
of the sacrum.This fasciocutaneous ap is based on paraspinal perforators on the ip-
silateral side of the midline. A back cut at the midline or on the contralateral side
of the midline can be made as long as the ipsilateral paraspinal perforators are main-
tained intact.The length of this ap can be extended to the midlateral line, and its
width can vary from 8 to 15 cm as long as it is recognized that wider aps increase
the likelihood that a skin graft will be necessary for donor site coverage. It is impor-
tant to design these aps so as not to uncover bony prominences. After the safe
area of the transverse back ap is outlined and the perforators are marked 4 cm
from the midline, the ap is incised through the fat to the fascial layer. The fascial
layer can be more easily found superomedially on the ap, and dissection proceeds

1836
PART V
R EOPERATIVE SURGERY OF THE TRUNK
laterally. A thick area of subcutaneous fat is often found in the ank area;all of this
fat need not be elevated with the flap. The flap is elevated more at the level of
Scarpa’s fascia. The appropriate dissection plane is developed laterally. The dissec-
tion then proceeds from the lateral edge of the ap and around inferiorly, up to
where the perforators are located at a point approximately 4 cm from the midline.
A back cut can be made along the midline of the ap medial to the perforators to
allow full inferior rotation of the ap down to the central sacrum.The back cut is
made in much the same way as the back cut is performed for the deltopectoral
ap, but the perforators are still preserved. Depending on the width of the ap and
evidence of previous scarring, the donor site may be closed primarily or a skin
graft may be required. It is important to obtain coverage of the posterior iliac crest.
Patient Examples
An example of the use of this ap is seen in this patient, who had an L5 to S4 frac-
ture and nonunion with osteomyelitis. Treatment of the recurrent sacral sore re-
quired extensive, wide bony debridement, rerotation of a gluteus maximus muscu-
locutaneous ap, and transfer of bilateral transverse back aps to cover this extensive
area. Because of the inability to obtain complete margins of all potential os-
teomyelitic bone, the patient was continued on long-term intravenous antibiotics
for 6 weeks. At 18 months postoperatively, the patient had no recurrent signs of in-
fection or wound breakdown in this area.
The extended posterior thigh ap based on the descending branch of the inferior
gluteal artery has been described as an elegant way to cover both the ischial and
sacral pressure sores simultaneously. The tip of the ap that is needed to cover the
sacral area may be compromised for two reasons:(1) the extended length necessary
for the ap to reach the sacrum and (2) the relay system of vessels that extends
down the midline of the posterior thigh fasciocutaneous area is incomplete in 50%
to 75% of anatomic specimens.11

1837
Chapter 45
Treatment of Recurrent Pressure Sores
This patient had a recurrent sacral sore and new bilateral ischial sores. A left poste-
rior thigh ap was designed for the left ischium;a right posterior thigh ap was de-
signed for the right ischial and sacral sores. The skin paddle covering the sacrum
necrosed. A subsequent gluteal rotation ap was performed for closure.
In the sacral area when there is extensive scarring or loss of ap donor tissue, it
may be necessary to cover the sacral area with a free tissue transfer from the upper
trunk or the lower extremities. In patients with paraplegia it is not normally advis-
able to borrow any muscle free aps from the upper trunk; it is desirable to main-
tain as much upper body function as possible. In designing a free ap, one should
simultaneously consider reinnervation of the sacral area, a long nerve ap to the in-
tercostal nerves, or a long nerve graft to the intercostal nerves.
If the superior gluteal artery and perforator are undisturbed, a fasciocutaneous ap
can be designed for sacral coverage.12

1838
PART V
R EOPERATIVE SURGERY OF THE TRUNK
A 62-year-old patient with T9 paraplegia had a large recurrent sacral pressure sore
and had previously undergone multiple attempts at reconstruction with local aps
and gluteus maximus musculocutaneous flaps. The remaining buttock area was
markedly scarred from the previous surgical procedures.
To provide tension-free and extensive coverage, free ap reconstruction was cho-
sen. A two-stage procedure was necessary. In the rst stage, infected soft tissue and
bone were debrided and the right inferior gluteal artery and vein were identi ed
as recipient vessels. Two days later, with the patient in the prone position, a lateral
thigh ap 9 cm wide by 20 cm long was dissected from the right thigh based on the
rst and third cutaneous branches of the deep femoral vessels. The ap was trans-
ferred to cover the ulcer, and standard end-to-end arterial and venous vascular anas-
tomoses were performed to the right inferior gluteal artery.

1839
Chapter 45
Treatment of Recurrent Pressure Sores
Postoperatively the flap became infected and the distal 5 cm became partially
necrotic. Correction was obtained with the advancement of the remaining gluteus
maximus musculocutaneous ap. Subsequent healing was uneventful.
Speci c considerations for postoperative care of the patient with a recurrent sacral
sore include reassessment and reeducation regarding (1) the prevention of the recur-
rent sore and (2) pressure relief beds—in particular, the air- uidized bed. A patient
who has undergone repair of a single sacral pressure sore may begin sitting 2 to 3
weeks postoperatively because, when the patient is in the upright sitting position,
the direct pressure of sitting is not on the sacrum. As previously mentioned, long-
term antibiotic therapy is indicated if there is a positive result to bone culture or
bone biopsy, or if there is potential osteomyelitis that could not be resected in the
sacral bone.
R ECURRENT TROCHANTERIC PRESSURE SORES
Factors associated with recurrent trochanteric sores can be divided into two cate-
gories:early postoperative problems and delayed problems. Examples of early post-
operative problems are ap necrosis, ap tension, hematoma, and infection. The
delayed factors specific to recurrent trochanteric pressure sores are (1) retained
trochanteric bursa with subsequent infection;(2) osteomyelitis of the trochanter or
the femoral head; (3) pyarthrosis of the hip secondary to sinuses tracking down
from the open wound to the hip joint; and (3) protruding femoral hardware.
Malalignment of the sitting posture in the wheelchair may cause the side bars to
press against the trochanter.
When this wound is excised, there is usually extensive undermining in the bursal
plane that can be 15 cm from the edge of the pressure sore down along the femur,
and superior posterolaterally along the hip. Sometimes undermining can reach all
the way over to the ischial pressure sore, with continuity of the ischial pressure sore
cavity or a small skin bridge between the sores. Osteomyelitis of the trochanter re-
quires wide debridement, including excision of the entire bursal cavity. Unfortu-
nately, osteomyelitis may communicate by means of the sinus tracts to the hip joint,
and may extend through the femoral head. Infection of the femoral head with
pyarthrosis in the patient with a trochanteric pressure sore generally requires a
Girdlestone procedure and ap closure of the large acetabular defect and proximal
femur stump. This large cavity is dif cult to close because the femur tends to ride
up and down during spasms in a pistonlike motion, increasing the chance of wound
breakdown and recurrence.13
Preoperative assessment of the patient with a trochanteric pressure sore involves
(1) evaluation of the cause of the sore; (2) correction of external factors such as
wheelchair posture, cushion, and bedding; and (3) education of the patient about
preventive methods. Plain radiographic lms of the hip joint and trochanter may
identify potential bony problems, indicating the need for orthopedic consultation
regarding the status of the hip joint.The excision of the sore is facilitated by the use

1840
PART V
R EOPERATIVE SURGERY OF THE TRUNK
of methylene blue to paint the extensive bursa. Exposure may be obtained by in-
cising the extensive undermined area in a planned line of incision for ap coverage.
The choice of the ap used to cover the trochanteric pressure sore depends on the
size of the defect after excision.The defect shape may range from a super cial at
defect to an extensive one if resection of the femoral head is necessary. Again, the
ap design should avoid bony prominences such as the posterior iliac crest, postero-
superior iliac spine, ischium, and anterosuperior iliac spine.
Patient Example
For small super cial defects, rerotation of the tensor fascia lata ap may suf ce.To
ll the undermined defect, deepithelialization of the distal portion of the tensor
fascia lata ap is helpful. In this patient an extensive area of undermining was nec-
essary; the defect was then covered with a tensor fascia lata ap. Rerotation of the
tensor fascia lata ap often requires a split-thickness skin graft for donor site cov-
erage on the more distal lateral thigh.The posterior thigh ap or the lateral poste-
rior thigh ap may be used on the more distally based trochanteric defects, provided
the ischium is not placed at risk by thin donor site coverage.
The rectus femoris ap is especially suited for coverage of a trochanteric defect
with a point of rotation in proximity but anterior to the trochanter.The donor de-
fect is relatively remote from the posterior weight-bearing surfaces, thus posing lit-
tle risk of exposing other bony prominences or pressure points.The rectus femoris
ap can be used as a muscle ap to ll a deep defect with a lateral or anterior thigh
random skin ap used to close the skin, or it may be transferred as a musculocuta-

neous ap. The rectus femoris musculocutaneous ap offers a great deal of versa-
tility. It can be elevated en bloc and transferred, or the rectus femoris fasciocuta-
neous ap can be elevated from the muscle, and the fasciocutaneous ap and mus-
cle can be transposed individually to ll separate parts of the defect. The blood
supply to the rectus femoris muscle is the transverse and descending branch of the
lateral femoral cutaneous artery and its veins.The point of rotation is just lateral to
the edge of the sartorius muscle approximately 8 to 10 cm below the anterior iliac
spine. An 8 cm width of the skin ap can be harvested and still allow primary clo-
sure. Future skin aps may require a graft in the donor site.The ap is designed to
reach all the way down to the distal three fourths of the thigh. The muscle is di-
vided at the musculotendinous junction, and elevated from distal to proximal and
from lateral to medial. Once the descending branch of lateral femoral cutaneous ar-
tery is identi ed on the deep surface of the rectus femoris muscle, this artery can
be traced up to the pedicle at its point of rotation.The muscle ap is sutured with
heavy absorbable mono lament suture to the depth of the excised wound. The
skin ap may be deepithelialized at its tip to allow further bulk to be inset into the
undermined area. Closed suction drains are placed in the donor site of the anterior
thigh and below the aps across the surface of the debrided bone.
Occasionally an additional muscle ap may be necessary to ll an extensive deep
defect.The vastus lateralis muscle is situated in proximity to the defect with its ori-
gin on the greater trochanter and linea aspera, and insertion on the patellar com-
plex. The blood supply to the vastus lateralis muscle is the lateral femoral circum-
ex vessels.This muscle provides adequate bulk at the point of rotation in proximity
to the trochanteric defect with an easily closed donor site. Numerous vessels en-
countered along the linea aspera and the indistinct plane between the vastus inter-
medius and vastus lateralis muscles cause the dissection to be somewhat bloody.
Other aps available for closure of the trochanteric pressure sore are the distal end
of the gluteus maximus, which requires taking the insertion off the linea aspera
and the trochanter, and random rotation aps of the lateral thigh and hip.When fea-
sible, innervation of the tensor fascia lata by nerve grafts or other innervated free
aps may be considered.
The anterior lateral thigh perforator ap is an extremely useful ap for trochanteric
coverage. The ap provides a large fasciocutaneous area based on the descending
branch of the transverse femoral circumflex artery with good excursion to the
trochanter. Use of this ap saves the vastus lateralis and rectus femoris muscles for
later use, if needed.
1841
Chapter 45
Treatment of Recurrent Pressure Sores

1842
PART V
R EOPERATIVE SURGERY OF THE TRUNK
If a trochanteric sore is one of many sores that needs to be resurfaced at the same
operative setting, consideration should be given to the donor sites available with the
patient in the prone position. These donor sites include the posterior thigh ap
based on the descending branch of the inferior gluteal artery;inferior portion of the
gluteus maximus ap as a musculocutaneous unit; lateral posterior thigh ap; and
extended gluteus maximus ap combined with the posterior thigh ap, as described
by Ramirez et al.14
R ECURRENT ISCHIAL PRESSURE SORES
As with other pressure sores, the recurrent ischial sore may be caused by early post-
operative factors or delayed factors. It is important to recognize the early postop-
erative factors that may have caused the recurrence to avoid repeating the same
mistakes and problems with the second operation. Factors that may cause delayed
recurrence of the ischial pressure sore are insuf cient soft tissue coverage with the
rst operation, which is aggravated by trunk and hip exion that causes tension
across the ischial coverage; rectal or urethral stulas; residual osteomyelitis, which
may extend anteriorly to the pubis;skeletal imbalance caused by overaggressive re-
section of the contralateral ischium, or by scoliosis or kyphosis. It is most important
to reevaluate the wheelchair padding and seating position. Ankylosis of the hip
from heterotopic ossi cation may cause relative immobility in the seated position,
with pressure always occurring in the same spot. Occasionally cushions have de-
ated or become worn out. A serious complication of the ischial pressure sore is the
ischiorectal abscess.This problem may be the result of direct extension of ischial os-
teomyelitis or the infected bursa into the ischiorectal space, or it may be caused by
a rectal stula. A CT scan is helpful in de ning the extent of the abscess and other
possible bony involvement.
When a ap for ischial coverage is designed, the scars and areas of previous ap el-
evation are marked. Bony prominences are marked, and the remaining blood sup-
ply to potential aps is analyzed. Options for ap coverage are (1) readvancement
of the VY biceps femoris musculocutaneous ap as indicated by Tobin et al,15 (2)
lateral posterior thigh ap based on the cutaneous perforators from the rst branch
of the deep femoral artery, (3) inferior gluteal rotation ap based on multiple mus-
cular perforators and broad-based skin blood supply, (4) inferior gluteal artery per-
forator ap, (5) distal gluteus maximus muscle ap with a separate random skin ro-
tation ap, (6) tensor fascia lata fasciocutaneous ap, and (7) readvancement of the
posterior thigh ap based on the descending branch of the inferior gluteal artery.

1843
Chapter 45
Treatment of Recurrent Pressure Sores
Patient Examples
Posterior
descending
branch of
inferior gluteal
artery
Old skin graft
Tensor fascia lata
fasciocutaneous flap
Ischial tuberosity
Soft tissue defect
Gracilis muscle
In this patient a recurrent ischial pressure sore was initially covered by a large rota-
tion ap of the posterior thigh with the ap incised on the medial and distal aspects,
with a superior rotation of the ap into the defect.
The borders of the ap are outlined using lines of the previous incisions.The ap
is incised medially and distally in a plane super cial to the biceps femoris muscles,
but deep to the descending artery branch. Once the vessels are identi ed, the ap
is incised on its lateral edge and elevated from distal to proximal.The septal perfo-
rating vessels that connect into the system of the descending gluteal vessel must be
ligated and divided.The point of rotation of the descending gluteal vessel is at the
inferior edge of the gluteus maximus muscle in the midline of the posterior thigh.
This point is one half of the distance between the trochanter and the ischial
tuberosity.

1844
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The ap is completely elevated on its medial, distal, and lateral aspects on the pedi-
cle of the descending branch of the inferior gluteal artery.The gracilis muscle is el-
evated and draped across the ischium.The posterior thigh ap is inset with the dis-
tal tip deepithelialized to ll the undermined deep space. Drains are placed in the
donor site and deep to the ap over the surface of the ischial bone, and 2-0 ab-
sorbable mono lament sutures are placed to secure the ap down to the periosteum
and brous tissue around the ischium to ensure that the ap is into the deep space
of the defect.The donor defect of the thigh is generally closed by primary approx-
imation of the edges, but sometimes a skin graft is necessary.
Blood supply
Dog ear

This patient presented with a right ischiorectal abscess contiguous with a right is-
chial sore.The wound was cavernous.
1845
Chapter 45
Treatment of Recurrent Pressure Sores
A gracilis muscle was harvested to ll the ischiorectal space, and a posterior thigh
ap was rerotated into the defect.

1846
PART V
R EOPERATIVE SURGERY OF THE TRUNK
For ischial coverage the tensor fascia lata ap should be considered.This ap, taken
down to the distal two thirds of the thigh, can easily be rotated to cover the ischial
defect. However, this approach is recommended only if there is already a scar or de-
fect between the trochanter and ischium that also needs to be covered.
An inferior gluteal artery perforator ap is an excellent choice for ischial tuberos-
ity coverage if the artery and perforator are undisturbed.16 A medial and lateral per-
forator are both present but the lateral perforator yields a greater excursion toward
the tuberosity. The elevated flap is in proximity to the typical ischial tuberosity
wound.
A free medial plantar ap can be used for ischial coverage.17 The patient, with a re-
current right ischial pressure sore, was placed in a supine lithotomy position.
After excision, the right super cial femoral vessel was prepared as a recipient ves-
sel.The medial plantar ap, including the exor digitorum brevis muscle, was har-
vested with a long posterior tibial artery and vein pedicle.

The ap was inset and shown to be well-healed at 2 months.The advantage of this
ap is the long pedicle of the posterior tibial artery and vena comitans.
Postoperative care includes complete pressure relief precluding any sitting for a pe-
riod of 6 weeks. At the end of 6 weeks, if all wounds over the areas of pressure
prominences are healed, a graduated sitting schedule is given to the patient. This
regimen generally begins with 20 minutes three times a day, and is doubled every
2 to 3 days until the patient is able to sit for 3 to 4 hours at the end of a 2-week pe-
riod. The patient is instructed to perform pressure relief while in the sitting posi-
tion and to carefully examine the pressure prominences every evening with direct
visual scrutiny using a mirror. It is at this time that the appropriate wheelchair cush-
ions need to be provided. Cushion design can be simpli ed by computerized pres-
sure point evaluation. Computerized evaluation facilitates the ne-tuning of the
seating cushion to help to correct areas of increased pressure caused by skeletal im-
balance in the sitting posture.
ISCHIAL TROCHANTERIC DEFECTS AFTER GIRDLESTONE
R ESECTION OF THE PROXIMAL FEMUR
Recurrent ischial trochanteric pressure sores may result in osteomyelitis of the prox-
imal femur with pyarthrosis.This condition necessitates a resection of the femoral
head and proximal femur, leaving the acetabular defect and stump of the proximal
femur in the wound. Speci c problems that occur with closing these defects are re-
lated to the mechanics of the pseudarthrosis and the extent of the osteomyelitis
that necessitated the resection. Infected sinus tracts may run from the hip joint an-
teriorly around the anterior lip of the iliac rim and in front of the pubis, and then
extend posteriorly across the superior and inferior rami of the pubis. Osteomyelitis
of the acetabular cup may be present. The most effective treatment involves exci-
sion of all sinus tracts and all osteomyelitic bone.The wound is unstable and dif -
cult to cover because the proximal edge of the resected femur tends to ride up and
down within the acetabular space. Optimal management of this problem involves
extensive coverage of the defect with well-vascularized bulky tissue, which usually
requires more than one muscle ap and a skin or fasciocutaneous ap.
1847
Chapter 45
Treatment of Recurrent Pressure Sores

1848
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Patient Example
One of the most effective surgical treatments for this type of defect involves recon-
struction with the vastus lateralis muscle ap and an overlying fasciocutaneous ap
from the anterior lateral thigh. This technique is demonstrated in a patient with a
Girdlestone wound.
The vastus lateralis vascular pedicle is in proximity to the defect just anterior to
the acetabulum and 8 to 10 cm below the anterior spine. It is mobilized from the
femur and carefully separated from the vastus intermedius and rectus femoris mus-
cles, and posteriorly from the biceps femoris muscle. It is important to identify the
pedicle (arrow) as it comes into the deep surface of the muscle 8 to 10 cm inferior
to the anterior iliac spine.The pedicle is best located by re ecting the rectus femoris
muscle away from the vastus lateralis muscle and visualizing the pedicle as it enters
into the medial edge of the deep surface of the vastus lateralis muscle. Usually a por-
tion of the origin of the vastus lateralis muscle has been previously elevated when
the Girdlestone procedure was performed.

After the muscle is elevated, it is carefully and securely sutured into the acetabular
defect and draped over the stump of the femur. Outer coverage is provided by a ro-
tation fasciocutaneous ap from the anterior lateral thigh. An extremely large de-
fect may require the transfer of a second muscle.The rectus femoris muscle is avail-
able on the same pedicle for rotation into the defect.
A recurrence of the pressure sore after a Girdlestone procedure or a dehiscence of
the wound after a Girdlestone procedure commonly necessitates a disarticulation
amputation of that extremity with a total thigh ap then used to cover the area. An
alternative to amputation is a free ap transfer.
EXTENSIVE R ECURRENT PUBORECTAL ISCHIAL
PRESSURE SORES
1849
Chapter 45
Treatment of Recurrent Pressure Sores
A frequent sequela of bilateral disarticulation amputation is extensive puborectois-
chial sores that develop because of direct pressure on the pubic rami, rectal tissue,
and ischial bones. Generally patients with this problem have already undergone dis-
articulation amputations, and consideration can be given to readvancing the total
thigh ap over the area. A signi cant amount of redundant tissue is usually available
after disarticulation amputation. For example, in this patient a recurrent ischial sore
was covered by advancement of the right total thigh ap.

1850
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Consideration is given to the rectus abdominis myocutaneous ap brought down
on its pedicle of the inferior deep epigastric vessels. This ap provides a large area
of skin with abundant bulk to cover these extensive defects. Frequently patients
who have reached this stage of recurrent pressure sore reconstruction will already
have had urinary diversion and/or colostomies, which preclude a rectus abdominis
ap. Consideration can be given to a free tissue transfer from the upper torso. In
these advanced cases in which all other alternatives have been exhausted, consider-
ation should be given to a total fecal and urinary diversion with colostomy and
suprapubic catheter.
R ECURRENT OLECRANON BURSA PRESSURE SORES
The elbow bursa pressure sore has the greatest potential to cause loss of function for
the quadriplegic patient.These sores frequently occur because patients are propping
the upper body on their elbows to eat, read, or watch TV. Although they have
enough motor function to prop themselves up on their elbows, they may not have
enough sensation to provide protection of the skin over the olecranon bursa, and
a pressure sore subsequently develops. It is necessary to rule out a pyarthrosis of
the elbow, which can be done by careful physical examination and radiologic eval-
uation, with consideration of injection of the joint to see whether any extravasation
occurs.
Radial
recurrent
artery
Defect
C
Muscular
perforators
Radial
recurrent
artery
Defect
A
B
Options for coverage include the lateral arm ap distally based on the radial re-
current artery (A), fasciocutaneous ap based on muscle perforators from the mo-
bile wad muscles (B), and an antebrachial fasciocutaneous ap based on the radial
recurrent artery (C).The donor sites can be closed primarily.

One ap that works well is the antebrachial fasciocutaneous ap elevated in the
same line of axis as the lateral arm ap rotated posteriorly, with the back cut made
as necessary.The donor site is closed by primary closure, and closed suction drains
are placed in the donor site and beneath the ap. Postoperatively it is important to
provide immobilization with the use of a well-padded plaster splint, compression,
and suction drains to allow closure. Nonsteroidal antiin ammatory drugs are help-
ful in reducing bursitis in the area;if not treated, bursitis and development of a bur-
sal space may recur.
1851
Chapter 45
Treatment of Recurrent Pressure Sores
Muscular
perforators

Olecranon
Radial
recurrent
artery

1852
PART V
R EOPERATIVE SURGERY OF THE TRUNK
CONCOMITANT R ECURRENT SORES
Ipsilateral Ischial and Trochanteric Pressure Sores
When ischial and trochanteric pressure sores exist on the same side, the descending
branch of the inferior gluteal vessel may have been eroded by either one or both of
the pressure sores.The sores may interconnect beneath a skin bridge. Depending on
the existing scars and previous ap elevations, aps are designed to cover both sores
at the same operative setting. Options that can be considered are (1) a tensor fascia
lata ap designed long enough to cover both sores; (2) a gluteus maximus rotation
ap to cover both sores as an extended ap; and (3) a tensor fascia lata ap with a
posterior thigh ap.
Patient Example
In this patient with ipsilateral trochanteric and ischial sores, the base of each sore
was 10 cm in diameter. A posterior thigh ap based on the descending branch of
the gluteal artery was elevated and used to cover the ischial and trochanteric sores.
In this case a good skin bridge was present between the trochanter and the ischium,
with a robust descending branch of the inferior gluteal artery to supply the poste-
rior thigh ap. An island pedicled ap based on the descending branch was inset
into both defects. In this situation it would not have been advantageous to divide
this skin bridge to bring a long tensor fascia lata ap across to cover both sores.
Ischial and Sacral Pressure Sores
An ischial sore coexisting with a sacral sore can be covered with an extended glu-
teus maximus ap as described by Ramirez et al.14 If necessary, an added transverse
back fasciocutaneous ap can be used to ll and cover the upper portion of the
sacral defect.This type of ap is useful if the defects tend to be at and super cial
although broad.

Patient Example
1853
Chapter 45
Treatment of Recurrent Pressure Sores
This patient had communicating sacral and ischial sores. An extended gluteus max-
imus musculocutaneous ap was designed based on the right inferior gluteal artery,
including its descending branch.
The ap was elevated by identifying the gluteal pedicle as for a VY gluteal ap.
The ap was inset and the donor sites were closed in a VY fashion and skin grafted.
The area is healed 12 weeks postoperatively.

1854
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Sacral, Bilateral Ischial, and Bilateral Trochanteric Pressure Sores
Occasionally, desperate situations may arise in patients who have multiple sores that
require closure. Preoperative evaluation includes the same examination for each
pressure sore as if it were an individual pressure sore to rule out possible factors
causing recurrence, osteomyelitis, and sinus tracts. Multiple pressure sores can be
treated at one operative setting, which is usually completely performed with the pa-
tient in the prone position.
The patient is positioned in a slightly jack-knifed fashion. In atable beanbag sup-
port is helpful because it allows support of the thoracic cage and also can be built
up under the pelvis to allow exposure of the trochanteric areas and the tensor fas-
cia lata aps. An alternative method of positioning is the use of thick chest rolls,
which lift the pelvis off the table to allow adequate lateral exposure of the tensor
fascia lata regions.The patient is prepared from the midback down to the popliteal
fossa and nearly circumferentially on each thigh, including the entire perineal re-
gion. All existing scars are marked, and an estimation of scarring caused by the el-
evation of previous aps is made. A two-team approach is helpful in reducing op-
erative time. Both teams work simultaneously to excise the sores, irrigate the
wounds, obtain hemostasis, and develop ap coverage. Donor sites should be de-
signed to avoid any bony prominence, and they should have a good soft tissue base.
The surgeon must maintain a high index of suspicion of osteomyelitis because pa-
tients in this type of predicament frequently have had a long course with exposed
bone for a number of months.Therefore adequate bony debridement is most im-
portant.This requires excising down to healthy bleeding bone that is nonsclerotic.
In addition, bone biopsy specimens are taken from all excised areas for examination
to help to determine the need for postoperative, long-term antibiotic therapy,
which may be helpful.Then the aps are designed.The goal should be tension-free
coverage of all sites with viable aps, avoiding potential compromise of previously
unexposed bony prominences or other pressure points. In addition, it is important
to realize that borrowing tissue from one region compromises another region.

1855
Chapter 45
Treatment of Recurrent Pressure Sores
Guidelines used for ap coverage for this patient were as follows:(1) all scars and ar-
eas of potential scar resulting from ap elevation were mapped;(2) the extent of un-
dermining of the excised pressure sores was mapped; and (3) the aps for sacral
coverage were designed and elevated first. Superomedial rotation of the gluteus
maximus fasciocutaneous ap (A) and inferomedial rotation of the gluteus maximus
fasciocutaneous ap (B) covered the sacrum.The right ischial and trochanteric ar-
eas were covered with an extended tensor fascia lata flap (D), which was taken
down to two thirds of the lateral thigh. On the left side a tensor fascia lata ap (E)
was used to cover the trochanteric sore, and a transverse gracilis ap (C) based on
the main pedicle of the gracilis muscle 10 cm below the pubis was designed for the
left ischial sore. As each ap was designed, its effect on the tension and donor sites
of the other aps was considered.
C
A
B
Muscular
perforators
Midline of
posterior thigh
C
Iliotibial
tract
D
C
A
B
D
E

1856
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The step-by-step approach provided a tension-free closure of all areas.The patient
achieved complete healing of all of these extensive pressure sores without further
dif culty.
TREATMENT WITH THE VACUUM-ASSISTED
CLOSURE DEVICE
Successful closure of 10% of full-thickness ulcers will occur in 6 weeks with the use
of the VAC device. Additionally, the device will decrease the in ammatory in ltrate,
increase the capillary density, and improve mild osteomyelitis in pressure ulcers.18

CONCLUSION
Successful reoperative surgery in the patient with pressure sores requires evalua-
tion and correction of factors that contribute to reoperative problems. Factors that
should be examined are debilitation of the patient, poor nutrition, psychosocial
complications, poor wound bed with recalcitrant deep infection, and surrounding
damage from previous surgery or pressure injury. Appropriate studies should be
performed to evaluate the condition of the underlying bone. A careful plan should
be developed to treat reoperative problems.This plan should include analysis of the
failure of the rst operation, a plan for operative positioning, selection of alternate
aps, and postoperative care. With careful evaluation, correction of contributing
factors to reoperative problems, and planning of intraoperative and postoperative
care, success can be obtained.
References—With Key Annotated References
1. Stover SL, ed. Spinal Cord Injury:The Facts and Figures. Birmingham, AL:The University of
Alabama at Birmingham, 1986.
2. Hentz UR. Management of pressure sores in a specialty center. Plast Reconstr Surg 64:683-
691, 1979.
3. Relander M, Palmer B. Recurrence of surgically treated pressure sores. Scand J Plast Reconstr
Surg 22:89-92, 1988.
4. Schryvers O, Stranc M, Nance P. Surgical treatment of pressure ulcers: 20-year experience.
Arch Phys Med Rehabil 81:1556-1562, 2000.
A retrospective medical record review of the outcomes of surgical management of patients with spinal
cord injury and severe pressure ulcers.The authors examine likely risk factors for recurrence of pressure
ulcers for patients admitted to the spinal cord injury unit for grade 4 pressure ulcers between 1976 and
1996. Complications and recurrence rates are examined, along with conditions that appear to increase
the risk for pressure ulcer development.
5. Deloach ED, Check WE, Long R. Diagnosing osteomyelitis underlying pressure sores. Con-
temp Orthop 27:240-246, 1993.
6. Lewis VL Jr, Bailey MH, Pulawski G, et al.The diagnosis of osteomyelitis in patients with pres-
sure sores. Plast Reconstr Surg 81:229-232, 1988.
7. Mustoe T, Upton J, Marcellino V, et al. Carcinoma in chronic pressure sores: A fulminant dis-
ease process. Plast Reconstr Surg 77:116-121, 1986.
8. Stover SL. Heterotopic ossi cation after spinal cord injuries. In Bloch RF, ed. Management of
Spinal Cord Injuries. Baltimore:Williams & Wilkins, 1986, pp 284-301.
9. Ayers DC, Rellegrini VD, Evarts CM. Prevention of heterotopic ossi cation in high-risk pa-
tients by radiation therapy. Clin Orthop Rel Res 263:87-93, 1991.
10. Kjaersgaard-Andersen P, Schmidt SA. Total hip arthroplasty: The role of anti-in ammatory
medication in the prevention of heterotopic ossification. Clin Orthop Rel Res 263:78-86,
1991.
11. Maruyama Y, Iwahir Y. Popliteo-posterior thigh fasciocutaneous island ap for closure around
the knee. Br J Plast Surg 42:140-143, 1989.
12. Verpaele A, Blondeel P,Van Landuyt K, et al.The superior gluteal artery perforator ap:An ad-
ditional tool in the treatment of sacral pressure sores. Br J Plast Surg 52:385-391 1999.
The authors describe the use of a large skin-subcutaneous tissue ap based on one perforator of the
superior gluteal artery (SGA) to reconstruct large midline posterior defects in one stage.The authors
discuss the bene ts of using this ap in the treatment of pressure sores.
1857
Chapter 45
Treatment of Recurrent Pressure Sores

13. Evans GRD, Lewis VL Jr, Manson PN, et al. Hip joint communication with pressure sore:The
refractory wound and the role of Girdlestone arthroplasty. Plast Reconstr Surg 91:288-294,
1993.
Girdlestone arthroplasty with soft tissue coverage is mandatory for successful treatment of pressure sores
with hip joint involvement. Fifteen patients who underwent Girdlestone arthroplasty (proximal
femoral head resection) were reviewed at The Johns Hopkins Hospital and Northwestern Memorial
Hospital. Patients were either paraplegics or quadriplegics (C7-L3) and presented with signs of sep-
sis and evidence of osteomyelitis.The recurrence of ulcers at the site of the Girdlestone arthroplasty, and
pressure sores occurring at nonsurgical sites are discussed.
14. Ramirez OM, Orlando JC, Hurwitz DJ. The sliding gluteus maximus myocutaneous ap: Its
relevance in ambulatory patients. Plast Reconstr Surg 74:68-75, 1984.
15. Tobin GR, Brown GL, Derr JW, et al.V-Y advancement aps: Reusable aps for pressure ul-
cer repair. Clin Plast Surg 17:727-732, 1990.
16. Higgins J, Orlando G, Blondeel P. Ischial pressure sore reconstruction using an inferior gluteal
artery perforator (IGAP) ap. Br J Plast Surg 55:83-85, 2002.
The inferior gluteal artery perforator ap may provide a muscle-sparing alternative for ischial recon-
struction. A case report of the successful use of an inferior gluteal artery perforator ap for ischial pres-
sure sore reconstruction is described, including the surgical technique used for ap harvest, and 2-year
follow-up results.
17. Yamamoto Y, Nohira K, Shintomi Y, et al. Reconstruction of recurrent pressure sores using
free aps. J Reconstr Miscrosurg 8:433-436, 1992.
The authors describe two successful reconstructions of recurrent pressure sores with free fasciocutaneous
aps. In Case 1, a free lateral thigh ap pedicled on the rst and third direct cutaneous branches of
the deep femoral vessels was used to cover a large recurrent sacral pressure sore. In Case 2, a free me-
dial plantar ap was transferred to a recurrent ischial pressure sore.The authors advocate the use of
free tissue transfer for recurrent pressure sore reconstruction.
18. Ford C, Reinhard E, Syrek D, et al. Interim analysis of a prospective, randomized trial of vac-
uum-assisted closure versus the Healthpoint system in the management of pressure ulcers. Ann
Plast Surg 49:55-61, 2002.
Twenty-eight patients with 41 full-thickness decubitus ulcers were randomized to compare the VAC
device with the Healthpoint (HP) System of wound gel products in promoting ulcer healing.The au-
thors found that VAC promotes an increased rate of wound healing and favorable histologic changes
in soft tissue and bone compared with HP.
1858
PART V
R EOPERATIVE SURGERY OF THE TRUNK

1859
Chapter 45
Treatment of Recurrent Pressure Sores
1. Which of the following is the most speci c test for osteomyelitis?
a. Sed rate elevation
b. Culture of the wound
c. Bone biopsy
d. Bone scan
2. Which of the following should be checked for in a pathologic exam for an ex-
cised pressure sore?
a. Necrotic bone
b. Bacteria in viable tissue
c. Squamous cell cancer
d. All of the above
3. Which of the following cause a de cit of soft tissue around pressure sores?
a. Tissue loss in all planes caused by pressure necrosis at deeper levels
b. Tissue loss resulting from debridement
c. Flexion of the trunk
d. All of the above
4. On which vessel is the gluteus maximus ap rotated?
a. Superior gluteal artery
b. Lumbar perforators
c. Internal pudendal artery
d. None of the above
5. Which of the following is not a ap used for ischial coverage?
a. Biceps femoris myocutaneous ap
b. IGAP ap
c. Free ap
d. Lumbar perforator ap
R EVIEW QUESTIONS

(Trang không có chữ)

REOPERATIVE SURGERY
OF THE EXTREMITIES
P a r t V I

(Trang không có chữ)

1863
Reoperative Hand Surgery
Wyndell H. Merritt and Victoria R. Masear
C ha pter 4 6
Reoperative Problems
Biologic principles
Recurrent giant cell tumor
Dupuytren fasciitis
Recurrent ganglion cyst
Rheumatoid arthritis
Carpal boss syndrome
Scleroderma digital necrosis
Flexor tendon injury
The human hand is a miracle which we completely take for granted.
The work of our hands, in their eloguence, silence, restlessness,
creativity, and violence, have made human history and continue
to shape the present and future.
Tamas Wormser
BIOLOGIC PRINCIPLES IMPORTANT
TO HAND REOPERATION
The inherent wound-healing differences in dense connective tissue (types II, III,
and IV collagen) and skin (largely type I collagen) is an important consideration in
hand injury and repair.Three important principles explain why there is frequent inci-
dence of hand reoperation and can help develop strategies to reduce this incidence.
1. The hand is an organ. Any injury promotes response in the entire
organ.

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PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Following emergency or elective hand surgery, the necessity for reoperation is fre-
quently caused by biologic changes in adjacent, not directly injured structures.
There is a popular misconception that dense connective tissue, such as fascia, joint
capsule, and ligament, is biologically inert and inactive.This misconception results
in surgeons and emergency personnel having false confidence that when these
structures are not directly injured, they can be expected to remain biologically in-
active, and will maintain their motion and function after being placed at rest until
the adjacent injured part heals. In fact, nothing could be further from the truth. In-
jured dense connective tissue actually has a greater acceleration of collagen syn-
thesis than skin wounds and continues at an accelerated rate of collagen turnover
for months after injury, long after a similar skin injury has decreased its rate.1
Macrophages activated in an injured digit do not discriminate between the unin-
jured volar plate, innocent collateral ligament, and an intact joint capsule adjacent
to the injury.These innocent adjacent intact structures will undergo broplasia and
may remodel so that even digits remote from the site of injury will undergo in-
creased collagen turnover, remodeling, and loss of function.
An example is this patient, who had an avulsed index digit that became the primary
focus of attention, while exion was lost in the remote little nger metacarpopha-
langeal (MP) joint as a result of collateral ligament shortening. At the time of in-
dex ray amputation revision, capsulotomy of the little nger MP joint became nec-
essary, a complication that would have been prevented by early mobilization of the
uninjured digits. It is a reality that the entire hand responds to injury, with the
structures nearest the site of injury usually sustaining the greatest response. As a re-
sult, the second principle postulates the following.

1865
Chapter 46
Reoperative Hand Surgery
2. The greatest challenge in hand injury is to preserve function in all
of the structures not directly injured.
Because the hand is an organ and uninjured stabilizing structures will remodel in
response to adjacent in ammation, it becomes important to develop management
strategies that will allow the uninjured structures to be protected.These are gener-
ally measures that permit early mobility of the structures that are not directly
injured, when possible without disruption of repairs or displacement of fractures.
Examples include such measures as plate xation of fractures, dynamic traction mo-
bility of exor tendon repairs, and use of a splint that will permit immediate active
motion following long extensor repair or sagittal band rupture.2,3
On the left, the normal areolar covering over fascia is seen before injury. On the
right, the areolar covering over fascia is seen 5 days after injury;a thick coat of col-
lagen is present. (Tissues were stained for collagen with trichrome blue.)
Clinically, we see uctuations in stiffness and mobility long after skin wounds are
maturing because of the prolonged increased collagen turnover and remodeling in
dense connective tissue. Studies show this collagen response to be greatest at the
surface level of dense connective tissue rather than deep within the substance of
tendon, capsule, fascia, or ligament adjacent to the injury.4 As much as a 20-fold in-
crease in collagen proliferation and deposition into the thin areolar surface of fas-
cia occurs within 5 days after simple laceration, as illustrated above.The surface ac-
tivity forms a disorganized “coat” of collagen that may adhere to skin and remodel
to restrict the mobility of collateral ligament, capsule, or tendon.

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PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
This patient had a simple laceration and infection on the back of his hand that was
skin grafted (left). He developed MP and IP joint stiffness during immobilization
that required tenolysis and capsulotomy (right).
There is a dense collagen coating over this patient’s extensor mechanism between
the skin and MP joint capsule (left); further dissection reveals the surface of the joint
capsule (right). Note that in amed dense connective tissue affects the entire hand in
this case, causing remodeling of the collateral ligaments and joint capsules to pro-
duce nger stiffness after injury to the back of the hand.The only practical method
of modifying this collagen response is by early judicious application of stress. Arem
and Madden5 demonstrated that while stress will not modify collagen strength or
deposition, it clearly modi es the shape and potential mobility when applied before
cross-linking occurs (usually before 1 to 3 months).Thus it is imperative to recog-
nize that dense connective tissue in ammation throughout the hand after injury or
surgery may cause remodeling of adjacent uninjured hand organ structures, and to
provide early motion to preserve these previously normal and uninjured structures.
If that is not possible, they should be positioned in a posture that will promote the
best opportunity to recover from stiffness after immobilization;generally with MP
joints exed, interphalangeal (IP) joints extended, the thumb abducted, and the
wrist in slight extension. In hand management, the therapist and surgeon should be
proud if all uninjured parts of the injured hand retain their function.

1867
Chapter 46
Reoperative Hand Surgery
As noted, morbidity leading to reoperation of the hand is usually caused by changes
in these normal adjacent structures. For example, repaired immobilized long exten-
sor tendons most frequently have disability from a loss of exion rather than exten-
sion after immobilization, according to a review by Blair et al.6 This is as a result of
remodeling of the uninjured dorsal joint capsule and collateral ligaments and is
prevented by early passive motion using dynamic splinting or early active motion
using relative motion splinting.2,7
This gure demonstrates a splinting method permitting immediate active motion
following long extensor repair in the middle digit.The wrist is splinted for the rst
3 to 4 weeks; the ngers are splinted for 6 weeks.2,3
The role of the knowledgeable hand therapist cannot be overemphasized in the
importance of preserving function in the uninjured digits that are undergoing
change; there is also great value in a prolonged course of hand therapy during the
months that dense connective tissue has accelerated turnover and remodels.
An example of the importance of preserving uninjured structures by splinting was
one author’s (W.H.M.) first hand replantation case in 1976. Wrist stabilization,
blood flow, and tendon, nerve, and skin repair were excitedly managed while
preservation of the normal thumb web was neglected. As illustrated in the gure
above, within 3 weeks after replantation, the thumb web had contracted, probably
urinated away as hydroxyproline!

1868
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
The specialized, accordion-like thumb web could have easily been preserved by
splinting, but instead required reoperation and reconstruction using a Brand trans-
position ap and skin graft.
3. Scar will most simulate the tissue to which it is juxtaposed (Pea-
cock’s “one wound/one scar” concept).
Peacock8 pointed out that a single viscous uniform scar develops between complex
structures such as bone, tendon, paratenon, tendon sheaths, nerve, and skin. The
ability of this scar to differentiate into replacement structures is severely limited, but
nonetheless exists, and it will structurally most simulate the adjacent tissue.There-
fore eyelid scar will be different to a limited but important functional degree from
chest skin or dense connective tissue scar like tendon. Thus rough handling of
epitenon (the important gliding tendon surface) causing exposure of the deep raw
tendon will result in a tendonlike scar (or adhesion), whereas careful handling and
preservation of the epitenon tendon surface is more likely to produce scar that will
permit gliding.This is what is often described as “favorable scar.” A complex crush
injury with raw bone surface and much-denuded dense connective tissue can
therefore be anticipated to form “unfavorable scar” for gliding and produce a likely
candidate for reoperation. It is especially important to preserve function of the un-
injured structures in these cases.
DUPUYTREN FASCIITIS
The greatest challenge in Dupuytren disease is management and reoperation for re-
current proximal interphalangeal (PIP) joint contracture.The most important mea-
sure to avoid ultimate functional loss is a clear understanding between the patient
and surgeon of indications for early repeat interventions. Some surgeons believe
that recurrence is caused by inadequate removal of diseased tissue at the primary
operation.9

1869
Chapter 46
Reoperative Hand Surgery
Actually, recurrence and reoperation for Dupuytren fasciitis is common, with most
reports averaging 34%10 to 68%11 However, the true incidence of recurrence re-
mains obscure, because while all reports agree that recurrence increases with time,
they vary in the follow-up interval as well as their criteria for de ning recurrence,
and there is marked variation in individual patient response. McGrouther’s study12,13
of 100 postoperative patients revealed all to show some recurrence or extension of
Dupuytren disease within 10 years, and González14 found a 96% recurrence or ex-
tension within 5 years among 531 patients. In this series, 36% of patients lacked 30
degrees or more of extension, placing them in a reoperative status. It must be ac-
cepted and explained to patients that recurrence is common, regardless of who
does the surgery.
There has been a popular misconception that recurrent Dupuytren contracture
represents a failure to adequately remove the involved fascia at the primary opera-
tion.15 At surgery there is no obvious margin for clearance of the diseased fascia, and
it is often impossible to distinguish between actual recurrence (diseased fascia in the
previous operative eld) and extension (new nodules and cords in the previously
uninvolved fascia).16 In hopes of preventing recurrence, radical palmar fasciectomy
became popular 40 or 50 years ago17 and is still advocated by some.The increased
incidence of wound-healing problems and the fact that typical recurrences are in
the digits led most surgeons to abandon this concept. However, debate continues
regarding operative techniques that might diminish recurrence, with dermatofas-
ciectomy (resecting the overlying skin with the diseased fascia) and full-thickness
skin grafting believed to result in a lower incidence of recurrence, varying from
zero15 to 33%.18 In reality, there is no operative technique that will de nitively pre-
vent recurrence or extension of this disorder, so the most important issue becomes
individualization of management for each speci c patient, because they certainly
vary in their response to this disorder.
ETIOLOGIC FACTORS
The peculiar cellular response leading to contracting fibromatosis between skin and
deep structures of the hand remains a mystery. Although there is better understand-
ing of the cellular biologic changes, this has not led to any comprehensive expla-
nation of the cause or any improved method for treatment. However, clinical trial
has been underway for experimental collagenase injection of Dupuytren bands by
Hurst et al,19 with promising early results.
The initial proliferative process is dominated by immature fibroblasts, many of
which are myofibroblasts, which produce types I, III, and IV collagen, multiple
growth factors, bronectin, laminin, and cellular response similar to wound healing,
mainly found in the proliferative nodules.20-25 The later changes were character-
ized by McGrouther13 as a mechanotransduction phase, in which broblasts align along
known paths of tension and may proliferate and contract. These characteristically
follow normal anatomic brous bands that have been well described by McFar-

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PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
lane26 and McGrouther27 and will determine the route of an individual Dupuytren’s
cord in the nger, whether central (pretendinous), spiral (encircling the neurovas-
cular bundle), lateral (attached to Grayson’s ligament), or retrovascular (longitudi-
nal fascia dorsal to the neurovascular bundle).28
Primary PIP contracture can be caused by four types of Dupuytren cords: central
(pretendinous), spiral, lateral, and retrovascular.The retrovascular cord is a longitu-
dinally oriented fascia that lies dorsal to the neurovascular bundle. The most fre-
quent cause of recurrent contracture is probably a retrovascular cord that either
was not adequately excised or became active after the initial procedure.
Cellular and molecular biologic studies do not reveal what initiates this process,
but epidemiologic studies show a predisposition in populations of Northern Euro-
pean origin. For example, Dupuytren disease is ve times more common in whites
than in blacks, and 10 times more common in whites than in Asians29 and has its
highest incidence in Iceland with 39.5% prevalence at age 70 to 74.30 Given that
genetic predisposition seems to be the most important known etiologic factor, the
clinician should identify the level of predisposition in each individual patient.This
will prove the most important factor to predict need for reoperation. Findings that
predispose for contracture recurrence include early onset (less than 40 years of age)
strong family history of Dupuytren disease, bilateral involvement of the hands, and
ectopic deposits of Dupuytren bromatosis on the dorsum of the proximal inter-
phalangeal joints (knuckle pads), plantar surface of the feet (plantar bromatosis) or
base of the penis (Peyronie disease). When all four of these factors were present,
McFarlane noted a 78% incidence of recurrence or extension, and when all four
were absent only a 17% recurrence rate was noted.31 Hueston9 characterized this
predisposition as a Dupuytren diathesis.
Neurovascular
bundle
Retrovascular
cord
Grayson’s
ligament
Lateral cord
Neurovascular
bundle
Spinal cord
Pretendinous
cord

1871
Chapter 46
Reoperative Hand Surgery
PATIENT EVALUATION
Each patient differs from others in the degree of functional impairment imposed by
Dupuytren contracture and in the rate of change occurring, and any individual pa-
tient may well vary the rate at different times in his or her life. The patient there-
fore requires careful education and monitoring of three important features: rst,
whether there is any functional impairment; second, the rate of progression; and
third, whether there is any xed exion contraction developing in the PIP joints.
It is important to document all of the Dupuytren cords in the palm and ngers as
well as the range of motion and sensation. Most reoperation patients seem to have
new cords that are not exactly where the last ones were removed, so whenever
elective surgery is done, it seems advisable to remove all palpable cords, including
those not causing contracture, to reduce the chance of likely extension of disease in
these existing cords. In reoperation patients, preoperative Doppler study of the neu-
rovascular bundles should be done in any operative digit to anticipate possible vas-
cular compromise. Semmes Weinstein mono lament and two-point discrimina-
tion sensory measurements are necessary preoperative parameters to provide a
baseline for postoperative assessment, because dissection of the digital nerves from
previous surgical scar is likely to cause neurapraxia, which will need to be moni-
tored until the objective preoperative sensory measurement is recovered. It is essen-
tial to clearly communicate with the patient so that his or her expectations regard-
ing morbidity and results are realistic. For the patient with no functional dif culty,
early aggressive resection of contracting cords across the PIP joint will seem unduly
morbid unless the patient understands that this is being done to prevent develop-
ment of a shortened volar place and collateral ligaments that can cause xed defor-
mity with loss of passive motion in the PIP joint and less chance for recovery of
normal motion. Patients must understand that reoperation is fraught with greater
risk to the digital nerves, which now have surrounding scar and no clear plane of
dissection, and that there is a greater chance of wound complications and ap loss.
In the initial assessment for reoperation across the PIP joint (the most dif cult and
common recurrent problem) two important issues arise. First is the issue of whether
there has been remodeling of the PIP joint volar plate and collateral ligaments to
form a xed exion contracture (possibly with subsequent extensor hood attenu-
ation in severe deformities).This is simply determined by fully exing the MP joint
and actively and passively extending the PIP joint. Lost passive extension is an in-
dication of volar plate and collateral ligament shortening, and the degree of lost
active extension may represent extensor hood attenuation (if the PIP joint can still
be passively extended). The degree of PIP xed exion contracture directly in-
creases the complexity of surgical correction, and is best avoided by early surgical
intervention, before it occurs. The second issue is whether there is adequate skin
present to close the PIP de cit.While use of skin grafts has become popular in re-
operation, severe contracture of the PIP joint will require release of the tendon
sheath, wide exposure of the digital nerves, and possible volar plate release and col-
lateral ligament release. This results in a poor bed for a skin graft, and one author

1872
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
(W.H.M.) has found that cross- nger aps are preferable. Although this requires
an additional later procedure (to release the ap pedicle), earlier PIP motion is pos-
sible and the transferred dorsal skin ap to the volar PIP area seems no more in-
clined to redevelopment of Dupuytren bands than a skin graft (no recurrence yet
seen in the ap tissue).
The PIP joint is assessed by maximum MP exion and passive PIP extension (top).
This patient has an 85-degree xed contracture with probably extensor attenuation,
so 12-day K-wire xation was done across the PIP joint after capsulotomy (left)
and Z-plasty and extension is maintained at 3 weeks after surgery (right).
Patients with recurrent disease must become partners with the surgeon in recogniz-
ing early change, and be committed to possibly a long hand therapy course after-
ward. Therefore the preoperative assessment by the hand therapist is an essential
part of each patient’s evaluation. Patients must understand that the goal of surgery
and therapy is to maintain at least the preoperative range of motion and sensation
in a better functional position and to stop the progression of contraction.While we
hope to increase the active range of motion that should never be promised beyond
the preoperative passive joint motion.With severe recurrent xed exion contrac-
ture (especially of the fth digit) some very active patients may opt for PIP joint fu-
sion or ray amputation once the therapy requirement is honestly outlined.

1873
Chapter 46
Reoperative Hand Surgery
INDICATIONS FOR SURGERY
Indications for surgery may be fasciectomy to correct functional dif culty caused
by progressive Dupuytren contracture or prophylactic fasciectomy for the proximal
interphalangeal joint to avoid changes that may otherwise become irreversible.The
surgical indications differ for the palm, and MP, PIP, and DIP joints.
Palm
Patients requesting surgery for their palm usually do so for uncomfortable or
painful Dupuytren nodules or because of contracture across the thumb web.There
is no clear evidence that prophylactic nodule excision alters the course of their dis-
ease, which might never progress beyond the nodular phase. Usually the nodular
discomfort subsides with time, and reassurance is all that most patients need, but tri-
amcinolone injection can give relief for those whose symptoms persist. When a
thumb web Dupuytren cord contracts, it can interfere with abduction and function,
or may simply become uncomfortable with grasp. The degree of web shortening
will determine whether a Z-plasty is needed.
Metacarpophalangeal (MP) Joint
Dupuytren cords across the metacarpophalangeal joint usually progress along the
central pretendinous bands, and are the most amenable for successful correction,
even when severe. More than 75% can be fully corrected, and 95% are either im-
proved or corrected.32 The cam shape of the MP joint places collateral ligaments in
a lengthened position while exed, so they do not adversely remodel, and the volar
plate does not seem inclined to shorten, so even prolonged contraction is cor-
rectable without need for capsulotomy. Patients are therefore advised to consider
MP surgery whenever the contracture suf ciently interferes with their function.
Often this is first requested in the right hand because of the need to shake the
hands of friends.
Proximal Interphalangeal (PIP) Joint
The proximal interphalangeal joint (especially of the fth digit) is the most trou-
blesome to completely correct, with primary operation fully correcting only 21%
of the fth digit PIP joints, and 17% reportedly worse after surgery, leaving 62%
with an improved but compromised result.32 However, when passive extension re-
mains intact in the PIP joint, results of surgery can be expected to be good.When
the MP joint is fully exed and the PIP joint cannot be extended (see p. 1872), this
represents changes usually deeper than the Dupuytren’s cord, such as a shortened
exor tendon sheath, proximal volar plate or volar collateral ligaments, and with se-
vere prolonged contracture, attenuation of the extensor mechanism. Surgery now
must include release of each of these restraining structures once the fasciectomy is

1874
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
completed until full passive extension is possible at surgery, and this greatly in-
creases the morbidity. In fact, some surgeons recommend accepting some exion
contracture or proceeding with a PIP joint fusion, replacement arthroplasty or digit
amputation.Therefore patients with no functional dif culty but PIP joint contrac-
ture are carefully monitored and advised to have early surgery if they begin losing
passive extension of the PIP joint. If there is no functional problem and no addi-
tional measurable loss of PIP passive extension, they can await functional dif culty,
which may occur at the MP level. If they begin losing PIP passive extension, how-
ever, correction should be done at the earliest possible time. Patients must be cau-
tioned that postoperative total active motion is unlikely to be much better than
the preoperative passive range of motion, thus surgical intervention is warranted
with any progressive loss of passive amplitude. Sometimes there is a pleasant surprise
at surgery, with full extension achieved after only fasciectomy. However, the greater
the degree of PIP xed contracture and the longer it has remained contracted the
more likely the joint has remodeled. Unfortunately, primary physicians often coun-
sel patients that they do not need surgery for Dupuytren disease until it interferes
with function, without distinguishing the difference between the interphalangeal
and metacarpophalangeal joint. Awaiting xed, exed, functionless PIP contrac-
ture condemns them to decreased amplitude of motion in the future. Many sur-
geons feel that contractures of greater than 30 to 40 degrees at the PIP joint should
be handled by osteotomy, arthrodesis or amputation13; however, others (W.H.M.)
have occasionally seen surprisingly good recovery of motion after aggressive correc-
tion that may include capsulotomy and temporary K-wire xation, and sometimes
cross- nger ap (see p. 1872).Thus fusions and amputations may be reserved for pa-
tients who are postoperative failures or who prefer a more de nitive procedure be-
cause they cannot participate in a prolonged hand therapy program.
Distal Interphalangeal Joint
Distal interphalangeal (DIP) joint Dupuytren contracture is uncommon, but when
seen may have uncomfortable Dupuytren nodules that can cause joint angulation.
Most patients improve DIP range of motion following fasciectomy32 and experi-
ence relief from excision of the thickened nodules and axial alignment of the joint.
Compensatory DIP hyperextension sometimes occurs with long-standing PIP xed
exion contractures, giving a boutonnière posture, which may be caused by ad-
herence or involvement of the oblique retinacular ligament, but usually is corrected
with fasciectomy and full extension of the PIP joint.
The most important consideration in patients after reoperation for Dupuytren’s is
their commitment to recognize early recurrence or extension of disease in their
PIP joint as an indication for surgery. Hand therapy objective measurement is in-
valuable to con rm any subjective change, and frequent surgery with preservation
of early active full motion is preferable to any late extensive procedures with skin
grafts or ap reconstructions and likely loss of motion.These patients learn to rec-
ognize and con rm early changes and to seek surgery.