Protocol management of late-stage pressure ulcers: a 5-year retrospective study of 101 consecutive patients with 179 ulcers.

BACKGROUND: Despite a 12 to 82 percent pressure ulcer recurrence rate, no standard protocol exists for postoperative management. The authors reviewed a single surgeon's experience using a standard protocol: surgery and immediate reconstruction regardless of nutrition, intraoperative bone culture guiding postoperative antibiotic use, and hospital admission for 3 weeks of flat bedrest before graduated sitting.
METHODS: A 5-year retrospective chart review was performed on consecutive surgically treated pressure ulcers. A search of billing records identified 101 patients with 179 ulcers. Data abstracted included demographics, comorbidities, location and stage of ulcers, treatment history with outcomes, and laboratory data.
RESULTS: Seventy-nine percent of the patients were men with a mean age of 49.4 years. Of 179 ulcers, 49.7 percent were ischial, 26.8 percent were sacral, and 19 percent were trochanteric; 87.7 percent of ulcers were stage 4. Primary closure was performed on 45.8 percent; others underwent flap closure. There was no correlation between positive bone cultures and recurrence or complications. The overall recurrence rate was 16.8 percent at a mean period of 435.9 days. New ulcer occurrence was 14.5 percent and the complication rate was 17.3 percent. Admission prealbumin and albumin did not correlate with recurrence or complication. Mean follow-up was 629 days.
CONCLUSIONS: A standard clinical pathway for pressure ulcer treatment improves long-term outcomes; the authors' protocol's validity is supported by low recurrence and complication rates. Nutritional data do not predict outcome. Intraoperative bone cultures are the most valid method of diagnosing osteomyelitis; results should not delay definitive treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.