Surgical Therapy for Complex Pelvic Pressure Injuries: A Review of Outcomes for Five Consecutive Years and a Proposal for a Navigator in the Care Pathway

Individuals with chronic or acute mobility impairment are at risk for development of PIs in regions where bony prominences may be exposed to prolonged contact with firm surfaces. When a pelvic PI develops and progresses to stage 3 or 4, a patient is set on a lengthy, complicated, and expensive path of treatment that may require therapy from multiple specialties including wound care, surgery, and rehabilitation. Treatment usually begins with intensive wound care, offloading, and physiologic optimization, but in situations where the wound fails to improve or deteriorates, surgical repair of the wound is often the next consideration. There is an expansive body of literature describing various surgical methods and strategies, but despite decades of surgical experience, postoperative complications and long-term failures remain common. Estimates for recurrence of PIs mostly range between 20% to 40%, but in some studies the long-term failure rate is as high as 80%.^1-8     

The purpose of this study is to report the experience of surgical management of complex pelvic PIs within a multispecialty practice from 2015 to 2019, with an analysis of wound recurrences and whether other measures may help reduce the frustrations that patients and caregivers experience in trying to achieve sustained healing.

From 2015 to 2019, 22 patients with 33 pelvic PIs underwent surgical repair. Patient demographics and wound characteristics are depicted in Table 1. The patients were typically referred to the advanced wound care department with advanced pelvic PIs. These wounds were located in the sacrum, ischial tuberosity, and trochanter tuberosity regions. After a period of time of trying to heal the PI with dressing changes and other non-surgical methods, usually lasting several months, the patient would be referred to 2 surgeons (P.T. and G.H.) if the wound failed to improve. Occasionally, the route for referral would be a patient who presented acutely with an infected abscess to the hospital for debridement. In all cases except 1, the PIs were stage 4 at the time of consideration for surgical management. Preoperatively, patients underwent imaging to identify signs of osteomyelitis; in most cases, the modality was MRI, but occasionally CT was used. After the patient was felt to be medically optimized, the most common surgical method was wound debridement, with bone biopsy and debridement of bone if imaging or clinical findings showed signs of osteomyelitis. Patients with non-infected wounds then underwent a concurrent modified tissue advancement closure involving wide mobilization of healthy soft tissue, re-approximation with heavy permanent sutures, and drain placement. They were then immediately transferred to an LTACH for an offloading protocol. If the wound was infected, patients underwent debridement first, and then were transferred to the LTACH for antibiotics and ongoing topical wound care. When the infection resolved, the wound was surgically closed at the bedside.

At the LTACH, the protocol started with bedrest in an air-fluidized bed for 2 weeks, and then the patient progressed to a sitting protocol. Typically, patients were discharged in approximately 6 weeks, with sutures removed after discharge (Figure 1). The drain was usually removed at 3 to 4 weeks after surgery, depending on output. An advantage for the patients in this study was that the medical director of the LTACH (G.H.) was available to follow the wound during hospitalization and repair wound dehiscence at the bedside if it occurred. As most of the patients had limited sensation below the waist, wound repair and revision could be performed with local anesthesia and minor instrumentation at the bedside.

Postoperatively, these patients were seen in the advanced wound care department shortly after discharge. If there were no surgical complications, they were seen approximately every 3 months for a year, and then as needed.

The first patient in this series underwent surgery in 2015, and outcomes for all patients were most recently reviewed in January 2021. Four patients died during this period (2015-2021) of causes not directly related to their PIs. Of the 33 wounds that underwent surgical repair, 17 (52%) had either short or long-term recurrence (Table 2). Immediate postoperative wound dehiscence occurred in 2 cases (6%), and there were no postoperative deaths. The average duration to recurrence was 13 months (range, 2-51 months), and of those who experienced long-term healing, the average duration of healing was 38.5 months (range, 9-68 months).

The site with the highest rate of failure was the trochanter (75%), followed by the ischium (59%), and then sacrum (33%).

The factor associated with a higher risk of failure that achieved statistical significance was undergoing repair of 2 wounds concurrently (80% vs 39% for undergoing a single site repair; P =.03). There was a trend towards higher recurrence in patients who had undergone prior surgery in the same wound site (64% vs 42% for first-time surgery; P =.21). Seven “redo” surgeries were performed in which a recurrence was repaired at a subsequent time in this series, and 4 of those achieved long-term healing (Table 3).

The range of time PIs were present prior to surgery was from 1 month to approximately 10 years. Those who lived with PIs for a year or longer often were either treated in a different health care system prior to entering the authors’ institution, or for some reason were not referred to the authors for surgical treatment. Thirteen of the 33 wounds in this series were “long-term PIs,” defined as a PI that had been present for more than a year prior to surgery; these had a recurrence rate of 6/13 (46%). Recurrence rates for wounds present for under a year were 10/20 (50%). Average preoperative albumin for the healed group was 3.23 g/dL, and it was 3.15 g/dL for the recurrence group.

Studies in the United States indicate prevalence rates of PIs of up to 15% in the acute care setting, 8% to 32% in the long-term care setting, and 3% to 19% in home care settings⁹; approximately 2.5 million patients are treated in the acute care setting annually for PIs.⁹ The worldwide prevalence of PIs in patients with spinal cord injuries was found to be 32% in a study by Shiferaw et al.¹⁰ In this population, the development of a PI is an ongoing risk for the life of the patient,¹¹ with 17% of these individuals hospitalized for a PI in the first year after injury and 37% hospitalized at 20 years.¹² The medical costs associated with PIs of all types is challenging to calculate. Inpatient costs are estimated to be 11 billion to 18 billion dollars annually in the United States,^1,13 and the Agency for Healthcare Research and Quality estimates a cost of $20 900 to $151 700 to treat a PI.¹⁴ For advanced PIs, a 2010 review of 19 PIs indicated inpatient costs of stage 4 PIs averaged $129 248 for hospital-acquired wounds and $124 327 for community-acquired wounds.¹⁵ However, that article analyzed direct medical costs, which is a limited representation of the true costs as these patients are often treated for months—if not years—in an outpatient setting, utilizing services that include home health care, office visits, and dressing supplies. In terms of indirect costs—eg, lost opportunities in employment, social interactions, etc.—the cost is likely incalculable.

Early-stage PIs often heal with prompt attention and reversal of factors that may have caused the wound. Therapy includes debridement, an appropriate dressing regimen, and compulsive offloading, which help restore the wound environment to a state where granulation and epithelialization can occur in a progressive fashion. However, when the wound presents at or advances to a stage 3 or 4 PI, studies following such wounds indicate that more than 50% remain unhealed or deteriorate when followed for 6 months.^16,17 A 2018 analysis of patients with PIs in the United Kingdom showed a 21% healing rate for stage 4 PIs after a year.¹⁸ These poor healing rates come as no surprise to wound care providers, and are the impetus to refer such patients for surgical repair of the wounds.

Postoperative complications and recurrence rates of a PI after surgical repair are significant. Immediate postoperative complications, including dehiscence of the surgical site, range from 25% to 50%.^4,5,19,20 Reported long-term durability of surgical repair ranges from 0% to 100%,^1,2 with such vast disparities likely in part due to variation in how long patients are followed. In more recent studies, recurrence rates range from 20% to 50%.^2-5 Selection criteria for patients were not clear in those studies, which could account for additional variation in outcomes, with better outcomes expected for lower-risk patients. Predictors of recurrence include surgery on an ischial site,^3,4 previous surgical failure at the same site,⁵ hypoalbuminemia,^4,5,6 poor diabetes control,⁵ and smoking.^4,20

In this current series, a long-term durable surgical repair was achieved in 16 (48%) of the wounds repaired. The long-term failure rate of 52% is higher than that of more recent series,^4-6,8 but not an outlier. The most significant predictor for a poor outcome was performing surgery on 2 sites simultaneously. It may be that the existence of multiple pelvic PIs is a proxy for poor medical adherence or failure of other wound-protective habits, which may jeopardize the longevity of a surgical repair. It is difficult to draw conclusions due to the limited size of the current study, but the authors feel that patients presenting with more than 1 pelvic PI should be treated with especially careful consideration prior to undergoing surgery, in order to identify and remedy medical or social conditions that may jeopardize long-term success.

Although there was a trend in this current series for higher recurrence in patients who have undergone prior surgeries, it did not achieve statistical significance, with 36% of such patients achieving long-term healing. Some surgeons may be reluctant to consider “redo” surgery under the impression that this is destined to fail, but the authors of the current study believe that giving such patients another chance at healing through surgery may be reasonable.

For this series, the surgery method used was a modified tissue advancement technique, whereas most other series cited herein used rotational and advancement flaps. This technique was chosen in part due to its simpler nature and ability to be performed at the bedside within an integrated wound care program. It is possible that better results might have been achieved using flap techniques, although in 2 series, direct wound closure techniques yielded similar results to flaps.^21,22

If outcomes from “high-risk” patients from this series were excluded—which would be those having 2 sites repaired simultaneously and those with prior surgery at the same site—then the failure rate fell to 33%, more in line with the results of recently published series.

The average time to recurrence of PIs was 13 months, which is consistent with studies that have shown that a large percentage of recurrences develop between the first and second years after surgery, with recurrence rates plateauing after 4 years.^5,8.23 Recurrences within the first year may be due to factors associated with poor surgical wound healing, such as a wound infection disrupting the reapproximated soft tissue, poor nutrition, and mechanical dehiscence prior to full healing. However, the recurrences between the first and fourth years develop in patients who have completely healed, but then experience something that leads to breakdown of the previously healed wound. In this series, recurrences have been associated with a patient taking a road or airplane trip without an adequate cushion, or other situations representing breaks in offloading adherence routines. The authors of the current study believe that long-term success after wound repair surgery is significantly dependent on adherence with offloading, which coincides with other opinions.^21,24

Benefits of a wound care navigator

Use of health care navigators have become increasingly popular and necessary to help patients understand the complex nature of multidisciplinary medical therapies. They are used commonly for treatment of breast cancer,²⁵ but also are used by medical systems for treating colorectal cancer,²⁵ inflammatory bowel disease,²⁶ and primary care patients.²⁷ Treating an individual with a complex pelvic PI is arguably as challenging as these medical conditions, with multiple providers engaged through the surgical and aftercare processes. In addition, patients with a pelvic PI often face a host of competing medical and socioeconomic challenges, and difficulty of just “getting through the day” may understandably make adherence to wound-preserving activities a secondary priority. Just a single moment of oversight or indiscretion can lead to development of a recurrent wound.

The authors of the current study believe that a wound care navigator may be a cost-effective way to identify and intervene on modifiable factors that can lead to a wound recurrence. The navigator would be an RN or midlevel position within the wound care department who would help coordinate care as the individual progressed from initial evaluation and treatment of the wound, to surgical optimization, to surgery, and then the transition home from rehabilitation. The navigator would then remain in contact with the patient for the years after surgery, performing in-person visits regularly and conducting phone calls to maintain discussions about offloading, smoking cessation, quality nutrition, etc. Figure 2 diagrams where a navigator would fit into a treatment protocol for patients with a pelvic PI. Table 4 represents issues that should be addressed prior to scheduling surgery. In addition to these duties, the navigator would be able to refer patients to social services and other similar resources, as studies have shown a correlation of wound recurrences with socioeconomic factors.^4,21 In the authors’ own practice, it has been observed that those who tend to fare the best are those who have robust family participation in wound care and other active social support systems. There are precedents for a wound care navigator system. In a small study based at Veterans Administration Medical Centers, navigator-like elements were incorporated in postsurgical flap patients, and during a 2-year follow-up, there was a decreased rate of recurrence and time to recurrence in patients undergoing their first operation.²⁸ If a mature navigator system can prevent just 1 or 2 recurrences per year, the cost savings alone would likely exceed the partial or full full-time equivalent salary of the navigator.

Finally, a crucial duty of a navigator would be to gather and organize data pertaining to these patients. The several dozen publications regarding surgical repair of pelvic PIs have been retrospective case series, with high-quality data from randomized controlled studies absent in this body of literature.²⁹ Understandably, a study randomizing patients to surgery versus a control such as optimal wound care will be expensive and difficult to recruit for given that the current paradigm is to operate on these wounds, but the first step of moving towards a high-quality study is the meticulous collection of data.

A significant barrier to development of a navigator system may involve how to charge for these services. Much of the work would be in the postoperative global period, and it may be challenging to convince private insurance payors to approve coverage for extended phone calls and care coordination. Within an integrated payor and provider system, a navigator position could be deployed more seamlessly. In the future, management of pelvic PIs potentially could be included in a CMS merit-based incentive payment system. The financial added value of a navigator would manifest by helping a practice participate in quality improvement activities, which may then result in positive payment adjustments by CMS.

The limitations in this series include the relatively small sample size and the retrospective nature of the analysis. In addition, there was no active wound care navigator position within the authors’ organization during the study time; if there was, the authors could have compared outcomes before and after implementation of the navigator.

Based on the outcomes of the current study, it seems indicated to move patients with stage 3 or 4 pelvic PIs onto a treatment track that may ultimately culminate in surgical repair of the wound. The best chance for success would seem to be in patients who have experienced their first single PI. Undergoing such an operation is an immense investment by the patient and medical system, and when a wound fails, it is a significant loss. The factors responsible for recurrence of a wound are complicated, but the authors believe some may be identified and remedied, although it takes effort and resources that may not be available to a surgeon or wound care practitioner. A wound care navigator may be a cost-effective way to follow these complicated patients and provide interventions that may allow for such patients to enjoy a wound-free life.