Factors influenc­­ing recur­rence of the pres­sureulcers after plastic surgery –  retrospective analysis

Summary

Aim:

The aim of the study was to evaluate the ther­apy process in patients with pres­sure ulcers indicated for plastic surgery intervention and to determine the factors influenc­­ing recur­rence of pres­sure ulcers.

Methods:

Retrospective analysis of patients’ documentation indicated for plastic surgery performed in a plastic surgery unit.

Results:

Body mass index (BMI) and body site of the pres­sure ulcers were identified as the significant factors influenc­­ing the rate of the recur­rence of the lesion in the analyses of 46 patients with 55 pres­sure ulcers.

Conclusion:

In the monitored patients’ population, BMI and the site of pres­sure ulcers were identified as statistical­ly significant parameters responsible for the recur­rence of the lesions. The higher the BMI, the more frequent recur­rence had occur­red. The presence of pres­sure ulcers in the ischiatic area was related to the increased recur­rence rate, regardless of the average size of the lesion.

Introduction

Pres­sure ulcers (PUs) and their occur­rence, especial­ly in patients with neurological dis­ease and with permanently limited mobility (para- or tetraplegic), are chal­leng­­ing is­sues for health care systems. The lesions occur more frequently in patients with spinal cord injury [1]. These patients suf­fer from the PUs predominantly localized at the ischiatic, sacral and trochanteric areas which do not al­low appropriate conservative treatment typical for the I. and II. category PUs, and therefore patients are indicated for mostly two-stage surgical intervention [2]. With respect to the over­all condition of patients, there is a high risk of recur­rence of PUs that we tried to identify.

Aim

The aim of this study was to analyse the process of the treatment in patients with PUs indicated for the plastic surgery intervention and to determine the factors influenc­­ing recur­rence of PUs.

Methods

Data col­lection was performed by retro­spective record analysis of patients hos­pitalized at the Clinic of Burns and Plastic Surgery of one of the university hospitals in the Czech Republic, in one-year time interval (from January 2016 to January 2017).

Patients enrol­led in the study were hospitalized with the main dia­gnosis of L89 accord­­ing to the International Clas­sification of Dis­eases (ICD)-10 and were also indicated for plastic surgical treatment.

The fol­low­­ing parameters were observed: patient‘s demographic data (age, gender, and occupation), general patient status (mobility, Norton Scale Pres­sure Ulcers RiskAs­ses­sment), local finding, PUs character­istics (localization, categorization based on EPUAP/NPUAP), type, time and number of surgical interventions and the PUs recur­rence. Statistical analysis of the data was performed with the software for analysis and statistics SPSS version 20.0 (IBM Corp., Armonk, NY, USA) us­­ing the Kruskal Wal­lis test and multilinear regres­sion analysis at a significance level of 0.05.

Characteristics of the monitored population

In period of 12 months, 48 patients were sur­gical­ly treated. The total number of patients enrol­led in this analysis was 43. Five patients were admitted to different department so they were excluded due to lack of follow up data. Three patients underwent an independent fol­low-up on another site that was not considered as a recur­rence and therefore the total number of cases under review was 46, i.e. 100% with a total of 55 PUs. For a more detailed description of the examined population, see Tab. 1.

Results and discus­sion

Of the total number of 46 cases, 41 (89.1%) males and 5 (10.9%) females were included. Us­­ing the descriptive statistics, general population characteristics (age, body mass index [BMI], number of days in hospital, Norton Scale) were also evaluated (Tab. 1).

The mean age in our population seems to be not as high as expected; on the other hand, the most com­mon comorbidity of paraplegia (N = 31; 72%) was the most frequent risk factor for the formation of PU, but the aetiology of paraplegia was not documented, or it was impos­sible to determine the time of its onset. Spinal cord lesions also occur in patients of younger age, most often due to traumatic etiology [3,4].

With a higher age, the risk of PUs as well as the mobility limitation and length of hospitalization are increasing [1]. Most of the patients had significantly limited mobility - wheelchair mobility (23; 50%); total im­mobility on the bed (6; 13%) and a minimum of patients were able to use crutches or walk­­ing sticks (2; 4.4%). In 15 (32.6%) patients, mobility was not recorded nor rated by any scale (e. g. Activity of Daily Liv­­ing Scale [ADL]). Similarly, the study presented by Hoff et al., shows that patients with reduced activity/ im­mobility due to spinal cord injury are more at risk with the occur­rence of PUs [5].

Another important observed parameter was body weight and nutritional status. In our population, mean BMI was 25.9 kg/  m² (min. 14.7 kg/ m²; max. 43.1 kg/ m²). Greater weight of the patient is as­sociated with a higher risk of PU lesions and complicates the position­­ing of the patient by healthcare staf­f [6]. Equal­ly important is the fact that obesity is directly as­sociated with numerous health problems such as stroke, heart dis­ease or diabetes, and these comorbidities can also indirectly influence the development and course of treatment of PUs [7]. This was also verified in our retrospective study.

The shortest period of hospitalization was 3 days, the longest hospital stay of one patient was 65 days (average hospital stay was 19.4 days). Several authors report that the average time of the hospitalized patients increases the risk of complications, includ­­ing colonization by hospital-acquired pathogens (hospital acquired infections) [8]. Therefore, in addition to practical and economic considerations, the goal is to reduce the number of days of stay at the hospital to the shortest pos­sible time. An interest­­ing study was presented by Milchelski et al., in which, due to the careful and intensive patients’ preparation at the outpatient clinic, hospitalization alone dur­­ing reconstructive surgery lasted in average of 3.6 days. Dur­­ing a relatively short postoperative fol­low-up, only 11.1% of patients experienced a mild wound dehiscence, and no patient underwent reoperation or necrosis of the transmitted lobe [9]. However, this procedure as­sumes an excel­lent level of care after the patient had been dismis­sed from the hospital.

The Norton Scale, used by the clinic‘s nurses to as­sess the risk of PUs at the reported institution, was at least 9 in the observed patients and the highest value was 18 points (12 points mean).

Comorbidities of patients in our popula­tion are involved, in a greater or les­ser extent, in the formation and treatment of PUs. In accordance with the international literature, patients with neurological disorders, especial­ly with spinal cord af­fection, are the most at risk, where accord­­ing to the literature there may be up to 80% risk of recur­rence of PUs [10]. Eslami et al. evaluated that between tetraplegic and paraplegic patients, the prevalence of PUs was 20– 60%, and about 85% of patients with spinal cord injury may experience PUs dur­­ing treatment [11]. In our population, as already mentioned, 31 (72%) patients were dia­gnosed with neurological dis­ease –  paraplegia. Other comorbidities are sum­marized in Fig. 1. In majority of the patients, multiple surgeries were performed (Tab. 2, 3).

The recur­rence of PUs was documented in 28 cases (60,9%). Based on the literature research, follow­­ing parameters: age, gender, BMI, mobility accord­­ing to compensatory aid for locomotion and locality of PUs, were identifies as potential factors of recur­rence of PUs after plastic surgery intervention. The statistical analysis is sum­marized in Tab. 4.

Based on the results, we can state that the age, gender, and patient mobility do not have a significant ef­fect on the prediction of recur­rence of PUs (p > 0.05) in monitored population. On the other hand, BMI and localization (body site) of PU had shown to significantly predict the occur­rence of recur­rence. Thus, we can say that in patients with higher BMI there is a significantly higher risk of recur­rence of PUs. The location of the PU is also a significant factor for the formation of PUs and their recur­rences. Most of the total number of 55 PUs was documented in the ischiatic area, and the average size of the PUs varied at dif­ferent locations (see Tab. 5 for details).

Consider­­ing the location/ body site of the PU as a factor of the recur­rence, the higher risk is in PU localized at the ischiatic area, in which 45.5% of all PUs had documented the recur­rence. This find­­ing is clinical­ly related to the documented size of the decubitus, although this as­sumption has not been confirmed in our statistical analysis.

Conclusion

Pres­sure ulcers in patients with neurological dia­gnosis and dis­eases and impaired mobility indicated for surgical performance is typical for a relatively high risk of recur­rence. From a retrospective analysis of 46 cases of patients with PU lesions, BMI and the localization of the PUs were validated as statistical­ly significant risk factors of PUs recur­rence. Higher BMI and the PUs at the ischiatic region were identified with the higher risk of the recur­rence of PUs.

Limitations of the study

The main limitation was the retrospective nature of the study. Some of the information reviewed were not available in the medical records at all or in the dif­ferent parts of documentations. Thus, there have been identified shortcomings in the management of documentations. By elimination of this limitation in the future, it could result in greater clarity and consequently ef­fectiveness in further proces­s­­ing of data that can be used to improve the care of patients with reduced mobility indicated for plastic surgery. The second main limitation is relatively small number of cases enrol­led in the study (N = 46), which is af­fected by the total number of patients with neurological dis­ease indicated for the plastic surgical treatment of PUs at the given unit. Nonetheles­s, the study‘s advantage is that fol­low-up of 46 cases was complete and all the patients met the inclusion criteria in the one-year period of data col­lection.

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manu­script met the ICMJE “uniform requirements” for biomedical papers.

doc. PhDr. Andrea Pokorná, Ph.D.

Department of Nursing

Faculty of Medicine

Masaryk University

Kamenice 3, 625 00 Brno

Czech Republic

e-mail: apokorna@med.muni.cz

Accepted for review: 13. 6. 2018

Accepted for print: 10. 8. 2018