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The most difficult pressure sores to close are those of the sacral areas. The lesions tend to be deep and contamination by bladder and rectal contents is common. Particularly difficult situations occur in patients with lesions abutting the anal canal or with persistent diarrhea. A successful result with the Proxiderm procedure is contingent upon two criteria, good wound care practices and physician technique. Patient selection is critical.
- Criteria for starting Proxiderm procedure While it is common to culture a variety of organisms, the knowledge that many organisms are merely contaminants is well known and contaminated wounds can therefore be approximated with the Proxiderm. There are also times where a dominant organism is present which would require coverage, such as a methicillin resistant staphylococcus aureus and some species of streptococci. Prior to commencing with the Proxiderm procedure, good wound care practices dictate the following;
- Debridement Lesions are rendered as clean as possible by a combination of local cleansing , sharp debridement, the latter often required on repeated occasions, and the use of antimicrobial agents. In the presence of inflammatory changes (as evidenced by erythema, edema, increased heat) or of a persistent discharge, the cause must be ascertained and treated prior to application of Proxiderms. For example the inflammation may be due to necrotic material with the organisms playing a secondary role. If the inflammation is due to the pathogenic presence of bacteria, antibiotic treatment is indicated and identification of the responsible organism/s may be helpful; in these circumstances a tissue biopsy is desirable. After the inflammation or discharge has been effectively controlled the Proxiderms may be applied. - Undermining of wound margins Undermining of the wound margins is minimal or avoided, especially when the ulcer is near the anus. In many sacral ulcers the skin is rather elastic and undermining is unnecessary and only required when skin edges are adherent to the underlying tissues - Suture of wound margins prior to application of Proxiderms Prior to application of Proxiderms, wound margins are approximated by #2/0 sutures which are placed 1 to 2 cm from the wound edges at 2 cm intervals. The ends of the tied sutures are left long, later they will be looped around the Proxiderms for increased stabilization. In patients with fragile skin the sutures are passed through "rubber booties" to diminish pressure on the skin. The wound is then lightly packed with dressings impregnated with anti-microbial medication of the physicians choice. - Proxiderm tissue hook insertion
The placement of tissue hooks of the Proxiderm are critical
Upon application of Proxiderms the long ends of the previously placed sutures are looped around the Proxiderms and tied. - Wound dressing Four by four dressings and combines are placed beneath the ends, between and over the Proxiderms to assist in stabilization and minimize external pressure. The Proxiderms and padding are secured to the patient by Elastoplast and/or adhesive tape. ; if the former is used a Tincture of Benzoin is applied to the skin to encourage a good seal, especially near the anus. Adhesive tape is then applied around the periphery of the Elastoplast/adhesive dressing - Evaluation of wound For sacral pressure sores, the Proxiderms are left in place and the wound is evaluated daily to remove any fecal contamination and prevent infective episodes. At evaluation the wound is irrigated, cleansed and debrided, the Proxiderms are replaced and the above process repeated. This process of wound evaluation and Proxiderm application is continued until the wound is closed. - Intermittent use of Proxiderms During the procedure, if there are signs of ischemia of the wound edges, the onset of edema, maceration or inflammation, a temporary discontinuation of the application of the devices is required, and the devices should be removed and the situation reassessed. When these conditions are controlled the Proxiderms may be reapplied. There are also instances where good wound care practices indicate that Proxiderm tissue expansion should be discontinued for a few days to allow for intensive irrigation and wound cleansing. During this time period the expansion achieved is retained by the previously placed sutures. - Wound Closure and Healing. The Proxiderm tissue hooks are sufficiently long to oppose the superficial subcutaneous tissue (approximately 3 cm), the deeper tissue layers being opposed by number 2 sutures prior to final closure of the wound by suture. Upon apposition of the wound margins it is recommended that the Proxiderms be applied for an additional 2-3 days to allow to wound edges to form a strong resilient bond in a tension free environment. Premature removal of the Proxiderms can result in regression of the wound closure. Most wounds are closed in 4 to 14 days, but the principles of wound healing are still basic to achieving the ultimate goal, namely a well healed wound. Final healing is related to the patients general condition. - Pain Management The tissue hook insertion of the Proxiderm is uncomfortable and performed under local anesthesia thereafter discomfort is minimal. Some patients may be require local anesthesia supplemented by a longer acting anesthetic agent. Thereafter oral medications of different strengths can be employed. Sacral Pressure Sores
Figure 1 A 77 year old patient with a necrotic sacral pressure sore measuring 14.2 cm by 11.9 cm by 4.5 cm deep. Figure 2 The patient underwent surgery under local anesthesia, where the skin edges and necrotic tissue were debrided and the wound extensively irrigated.
Figure 3 The wound is lightly packed with dressings impregnated with anti-microbial medication of the physicians choice. #2/0 nylon sutures were placed and tied 1-2 cm from the wound margins at 2 cm intervals. The ends of the tied sutures are left long, later they will be looped around the Proxiderms for increased stabilization. The use of rubber "booties" to diminish pressure on the skin by the tied sutures is optional. Additional #2/0 nylon sutures are placed between the tied sutures, and the ends are secured by steristrips; these sutures will be tied at the next application of Proxiderms. (See right center arrow). Proxiderm models (PS 460) are selected. When multiple devices are used, the spacing between the Proxiderms should be 2 cm. The Proxiderm has two tissue hooks that are manually separated. One tissue hook is placed through the skin into the subcutaneous tissue approximately 2 to 3 cm from the wound margins. The second tissue hook is inserted into the opposing side of the wound in a similar fashion. The long ends of the previously tied sutures are looped around the Proxiderm device and tied.(See long arrow)
Figure 4 Thick pads (combines) are placed beneath the ends, between, and over the devices. Figure 5 The Proxiderms and padding were secured to the patient by elastoplast or adhesive tape; if the former is used a Tincture of Benzoin is applied to the skin to encourage a good seal, especially near the anus. Adhesive tape was then applied around the periphery of the Elastoplast/adhesive dressing. The patient was placed on a flotation bed to reduce the weight on the expanders. A note was placed on the dressings to alert the staff that movements should be carefully carried out so as not to dislodge the devices.
Figure 6 In all sacral wounds, the dressing changes are carried out daily. At the first dressing change the previously untied sutures were tied so as to maintain the expansion of the tissues. The above process was repeated and the Proxiderms replaced as needed. There were 2 daily applications of Proxiderms followed by 4 days of extensive irrigation, debridement and wound cleansing and 5 hours of Proxiderm tissue expansion. On the sixth day the wound was closed by suture. Because of the depth of this wound the deeper tissue layers are opposed by number 2 sutures prior to closure of the wound. The Proxiderm tissue hooks are sufficiently long to oppose the superficial subcutaneous tissue (approximately 3 cm) . The Proxiderms are placed over the suture line for an additional 24 hours to allow the suture line to heal in a tension free environment. Sutures were removed only when the wound edges were completely adherent. Appearance at 13 days.
Figure 7 Appearance at 6 months. The wound reopened at the nursing home at 4 weeks and 12 weeks, both small wounds were closed by suture. Figure 8 Appearance at one year. While the Proxiderm device and procedure closes the pressure sore relatively quickly, final healing is dependent upon the patients general health. Patients in poor general health may require a longer time to achieve the final results and may experience some wound breakdown a week or two after closure. In these instances the wound is usually sutured closed or another application of Proxiderms may be indicated. |
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