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Thread: Need Help-Abcess on Ischium/Surgery

  1. #1

    Exclamation Need Help-Abcess on Ischium/Surgery

    My husband is a C5 quad, 50y/o, MVA in 1981. He has been having trouble with an abcess in the area of his ischium for over a year now. It became infected last November and he was treated with IV antibiotics and it got smaller and closed up. There was a fluid pocket about the size of a marble under the skin, but it was tolerable. This week it became very large and infected again. We went to the local ER and he was septic, so emergency surgery was done to remove the abcess. The surgery was done on Wednesday by a general surgeon with no experience with SCI patients. He now has an incision approximately 3 inches long and goes all the way to the bone. They removed about the size of a baseball/grapefruit. They are supposed to put a wound vac on this today. The surgeon has him already sitting in his w/c. The medical dr. says stay off it.

    What should we be doing to get this thing to heal??? They are talking about discharging him on Monday. I cannot take care of him 24 hours a day and we have no outside help. Does anyone know what we can expect?? Can he go to an inpatient rehab?

    The hospital we are in has no clue what to do with him. Very frightening!!!!

    Thanks for any help,
    Rosie
    Rosie, wife to Bobby
    C5 due to MVA in 1981

  2. #2
    He undoubtably has osteomyelitis. This requires bone biopsy and/or MRI to definitely diagnose. We prefer the former as this also allows a good determination of what IV antibiotic (minimum of 6 weeks) is needed to treat it. He must stay off it. A wound VAC should not be used over osteomyelitis unless it is being actively treated with antibiotics. He needs to see a plastic surgeon who is expert in wound management in people with SCI. It is very likely that he will eventually need a myocutaneous flap to close the wound, but this cannot be done until the osteomyelitis has been successfully treated (monitoring WBC, sed rate, and CRP to determine this once the IV course is complete). He should have a PICC line placed to prepare for the IV antibiotics too.

    Some of this can be done at home with appropriate home health assistance (for the IVs). He needs to be on a LAL mattress at least, with no sitting at all either in bed, wheelchair, commode, etc. etc. during this time. Once he has a flap, this will be a minimum of another 6 weeks of bedrest if it is done correctly. Most acute rehab centers will not take someone for acute management of a pressure ulcer, although you may be able to get them to take him for the 3-4 weeks sitting program that should occur after the 6 weeks of post-flap bedrest. Some send people to nursing homes for the post-surgical recovery, which is an option for those who absolutely cannot coordinate managing this at home.

    Where in TX are you? You should be able to get a referral to an appropriate plastic/reconstructive surgeon or wound clinic through a good SCI rehab center, or through his SCI physiatrist.

    (KLD)

  3. #3
    Thanks, KLD. They did an MRI within the past month and said it was not into the bone. The surgeon said that it was enclosed in a capsule that went to the bone, but he also said it did not look like the bone was affected.

    They have already put the wound vac on it today. I think I will not get him up on it this weekend as the dr. wants. They hospital will not get him up on the weekend, as they will not have anyone that knows how to transfer. The surgery was done on Wednesday and they discontinued the IV antibiotics on Thursday and put him on oral antibiotics. Today they were giving him a bag of iron.

    We live about 130 miles North of the DFW area. He was in Baylor Rehab for 4 weeks last winter after a 2 month hospitalization where the local hospital did not get him out of bed at all. The physiatrist there has been following him.

    As for where to go for this recovery, we have a hard time getting any type of assistance and cannot afford to pay for it out of pocket. I work full time 60 miles away from our house, and we have 3 young children. I would prefer him be at home if we could get help, but cannot leave him alone in bed for 10+ hours a day.

    thanks for any more thoughts and advice
    Rosie, wife to Bobby
    C5 due to MVA in 1981

  4. #4
    Senior Member lynnifer's Avatar
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    Just a word of caution that MRI's, xrays and what-have-you are not conclusive enough to determine osteomyelitis. I was told it's one of those things that you don't know until the surgeon is in there or a tissue sample is taken. Rather, a history ... and I agree with KLD that it sounds it ... is taken and considered before surgery. Wish they had 'scraped' the bone area just to be sure! Sounds like they rushed into it ... good and bad. Good and hope they got all the infection out! Bad if they didn't and there was some underlying on the bone because it will come back. I struggled with this for years.

    I agree with everything KLD has said. The V.A.C. is contraindicated by infection of any kind. Stay out of the chair, off of it, and give the surgeon's work some time to heal or else it was all for naught.

    It's a good idea for anyone paralyzed to have a back-up plan in case a wound like this occurs ... as in 'what do you do when you're confined to bed' for a certain amount of time.

    I have no immediate family close to me ... but this summer my sister (2hrs away) took two weeks from work and I had an extra week with a niece (she met some jerk and left me hanging!) .. but three weeks was enough time for me to figure out how to slowly get in/out of my bed minimally (for washroom, food, mail) to give healing a chance (I had a left ankle bone not responding to antibiotics removed because of osteo). I am separated and because of shift work, my only close friends were those I work with ... and I wasn't about to ask a co-worker to take care of me! lol
    Roses are red. Tacos are enjoyable. Don't blame immigrants, because you're unemployable.

    T-11 Flaccid Paraplegic due to TM July 1985 @ age 12

  5. #5
    I agree. In addition, even if there is no osteomyelitis (unlikely if the abscess and wound reached the bone) he will need surgery and a flap to successfully close a deep wound like this. Trying to close it only with a VAC and what is called "secondary intention" (the wound just filling in on its own) will be an exercise in futility with a Stage IV pressure ulcer like this. Even if it fills in (with months and months of down time) it will fill in only with scar tissue, not with normal tissue, and if he then attempts to sit on it at all, it will break open. A myocutaneous flap is really the best way to manage this.

    (KLD)

  6. #6
    Moderator Obieone's Avatar
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    Yes yes and yes .... everything KLD and Lynnifer have told you is exactly correct TXrosebud.
    Please don't be intimidated by the team caring for your husband ... I would print this off and give it to one of the nurses ..... most often these situations are a learning opportunity for them as well !! My husband and I are facing very similar circumstances .... we have been trying to heal a stage 4 wound on his ischium for close to 2 years now and are currently waiting for a flap to be done.

    All the best
    Obieone
    ~ Be the change you wish to see in the world ~ Mahatma Gandi


    " calling all Angels ...... calling all Angels ....walk me through this one .. don't leave me alone .... calling all Angels .... calling all Angels .... we're tryin' and we're hopin' cause we're not sure how ....... this .... goes ..."
    Jane Siberry

  7. #7
    Senior Member lynnifer's Avatar
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    Also, the longer you've been paralyzed, the greater your chances of developing a wound. The risk increases as you age. Stay frosty. (Hyper vigilant).

    http://sci.washington.edu/info/newsl...sureulcers.asp

    The Model SCI System Statistical Center recently reported that the risk of getting a pressure ulcer is about 15% in the first year after injury and increases steadily thereafter, to about 27% at 25 years postinjury. The recurrence rate is even higher: between 40% and 80% of patients who have had a pressure ulcer develop another one. At any given time, an estimated 17% to 39% of the SCI population suffers from a pressure ulcer.

    I only know this because I attended a seminar on aging with paralysis a few years back. I was surprised .. but it makes sense. I know there was some research being conducted on why some are prone and other not ... something about interlukin or proteins in the blood ... but I'm not sure what conclusion that research came to as I didn't follow up with it.
    Roses are red. Tacos are enjoyable. Don't blame immigrants, because you're unemployable.

    T-11 Flaccid Paraplegic due to TM July 1985 @ age 12

  8. #8
    Thanks so much for the help. I am going to get this printed so I can share the info. with the dr. At this point he is on the wound vac and I am planning on keeping him off of it. I don't think anything else will happen until Monday.
    Rosie, wife to Bobby
    C5 due to MVA in 1981

  9. #9

    Update

    I got in touch with his physiatrist at Baylor and now the local dr. and the physiatrist are communicating. They are looking at transferring to a Specialty hospital. He is still in the local hospital. I'm just ready for him to be where they know how to take care of him. This is very stressful.

    Thanks again for all your help here. I will keep updating on how things are going.
    Rosie, wife to Bobby
    C5 due to MVA in 1981

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