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A successful result with the Proxiderm procedure is contingent upon two criteria, good wound care practices and physician technique. - 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 therefore can 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 In many chronic trochanteric pressure sores the marginal skin is adherent to the underlying granulation tissue in an effort to close the defect. Undermining is necessary when the edges of the ulcer are depressed, adherent to underlying structures or infolded. Initially a scalpel is used, after which finger mobilization renders the tissue mobile enough to slide to a modest degree. Undermining of wound margins is at a supra-fascial or deep subcutaneous level approximately 1 to 2 cm. from the wound edges. Wound margins are also freshened prior to closure of the wound. - 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 - Evaluation of wound For relatively clean trochanteric pressure sores, the Proxiderms are left in place and the wound is evaluated on 2 to 3 days intervals. At evaluation the wound is irrigated, cleansed and debrided, the Proxiderms are replaced and the above process repeated Significantly contaminated wounds are evaluated daily. 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 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 7 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 Trochanteric Pressure Sores The Proxiderm procedure is carried out at the bedside. Most patients are managed by the administration of analgesic and sedative drugs with, if necessary, the infiltration of a local anesthetic agent. In instances where debridement or removal of bone necessitates the use of an ambulatory surgery center a short acting drug that produces deeper sedation may be required.
Figure 1 An 89 year old patient with a trochanteric pressure sore of nine months duration. The pressure ulcer measured 9.2 cm by 12.5 cm. Figure 2 Necrotic tissue is removed by careful wound cleansing or sharp debridement. Wound margins are undermined for 2 cm to 3 cm and at a deep subcutaneous/supra fascial level which avoids damage to cutaneous blood vessels. Wound edges are also freshened. Prior to application of Proxiderms, #2/0 nylon sutures were placed and tied 1-2 cm from the wound margins at 2 cm intervals to approximate the wound margins. The ends of the tied sutures are left long, later they will be looped around the Proxiderms for increased stabilization. Additional #2/0 nylon sutures are placed between the tied sutures, and the ends are secured by steristrips; these sutures will be tied after 2-3 days of tissue expansion by the Proxiderms.
Figure 3 Proxiderms are applied at bedside. Initially Proxiderm model PS 460 are selected. As the wound closes a combination of PS 460 and D 460 are used. 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 1 cm to 2 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. Figure 4 Four by four dressings and combines are placed beneath the ends, between and over the Proxiderms to assist in stabilization and minimize external pressure.
Figure 5 The Proxiderms and padding are secured to the patient by Elastoplast or adhesive tape. Patients are recommended to be placed on specialized supporting surfaces such as fluidized beds. A note is usually placed on the dressings to alert the staff that movements should be carefully carried out so as not to dislodge the devices. The wound is evaluated at 2 to 3 day intervals and the process repeated until the wound is closed. Figure 6 After 4 applications of Proxiderms the pressure ulcer was closed by suture in 12 days. Appearance at 19 days shows a well healed wound. In many elderly patients it is recommended that the sutures remain in place for 21 days. This patient deceased 18 months later with no recurrence of the pressure sore. 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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