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Thread: Ischial Flap Surgery Success Rate

  1. #1

    Ischial Flap Surgery Success Rate

    I realize this is going to vary considerably between individuals and circumstances, but one item in JakeHalsted's recent Stage 4 Pressure Sore post has me somewhat concerned... he states that about 60% of ischial flap surgeries on SCIs are successful. Is this figure correct and if so, where does it come from?

    My situation... 60 years old, 23+ years post injury, pretty healthy until 18 months ago when everything took the express south... Stage 4 pressure sore on the right ischial approx. 6cm diameter and 3.75cm deep, severe hip flexion/contracture (45 degrees when lying down... can't even clear the opening on a cat scan machine anymore), scheduled for flap surgery on April 18. They are going to try snipping mucsle/tendon in the right leg beforehand to lessen the amount of contracture. It's not like there's any alternative to having the flap (wound vac, leaking dressings and nurse visits were old a long time ago, but I'm starting to wonder just what kind of quality of life there's going to be when I come out on the other side of all this.

  2. #2
    I have not seen this figure, but it is probably about right. An important aspect of this is the condition of the patient pre-op, the surgeon's skills and experience, post-op care, and the sitting program following the flap.

    If you have had previous flaps or pressure ulcers in the same area, the failure rate is higher.

    If you are not nutritionally ready for surgery (no anemia, good protein stores as identified by pre-albumin, albumin and transferrin levels in the blood), failure rate is higher. If you don't eat right during your recovery period and for at least the first year post-op, the failure rate is higher.

    If you smoke (or use any other tobacoo products) and don't quit at least 4 weeks prior to surgery, the failure rare is much higher. If you start smoking again within 3 months after surgery, your failure rate will be higher.

    If you have peripheral vascular disease or diabetes (esp. if poorly controlled), your failure rate will be much higher.

    If your surgeon is not very experienced in doing flaps, is not a board certified plastic surgeon, your failure rate will be higher.

    If you have an untreated UTI prior to surgery, failure rate is higher.

    If you have untreated osteomyelitis pre-op, the failure rate is very high.

    If you have uncontrolled spasticity pre-op your failure rate is higher.

    If your drains or staples are removed too early, the failure rate is higher.

    If you don't stay on 6 weeks of total bedrest post op (usually at least 5 on an air-fluidized bed like a Clinitron), the failure rate will be higher. We use a low air loss (LAL) bed for at least another 3 months after this.

    If you push your seating program too fast, do slide board transfers right away, don't religiously do weight shifts when sitting, or are not sitting on the right cushion, the failure rate is higher.

    Keep in mind that after the flap, your skin in that area will never be as tolerant of abuse again. You may need to decrease your uptime, do more frequent weight shifts, change cushions or chairs, change transfer techniques, and be that much more meticulous about doing skin inspection and taking immediate action while still a stage I or II to avoid further breakdown.

    (KLD)

  3. #3
    Wow! I'll chime in because I had a right ischial wound with osteo. in 2003. I had the wound for a couple years-- woundvac, home health nurse, etc. Everyone always told me how clean and great my wound looked. I went to my ortho MD and he said my body had started to lay down bone in that area due to the wound. It wasn't HO, but some other name. He told me to get it flapped. I got a premiere wound surgeon; his waiting room was always full of unhealthy looking people. I saw some of the wounds on these people and they looked hideous. They just lay the people on carts in the hall and their feet sometimes looked like death. He free flapped mine and it has healed without any reoccurence. He did shave some of my ischium, though, due to osteo. My MD at the LTAC where I recovered told me most patients are not healthy enough or are noncompliant and do have failures. It takes a long time, but I followed the schedule and I'm good.

    I think KLD is saying to get your ducks in a row and do everything you can to help your chances.

  4. #4
    Senior Member reedyd's Avatar
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    Quote Originally Posted by kwip
    I realize this is going to vary considerably between individuals and circumstances, but one item in JakeHalsted's recent Stage 4 Pressure Sore post has me somewhat concerned... he states that about 60% of ischial flap surgeries on SCIs are successful. Is this figure correct and if so, where does it come from?

    My situation... 60 years old, 23+ years post injury, pretty healthy until 18 months ago when everything took the express south... Stage 4 pressure sore on the right ischial approx. 6cm diameter and 3.75cm deep, severe hip flexion/contracture (45 degrees when lying down... can't even clear the opening on a cat scan machine anymore), scheduled for flap surgery on April 18. They are going to try snipping mucsle/tendon in the right leg beforehand to lessen the amount of contracture. It's not like there's any alternative to having the flap (wound vac, leaking dressings and nurse visits were old a long time ago, but I'm starting to wonder just what kind of quality of life there's going to be when I come out on the other side of all this.

    you did ok 23 years you will make it
    Good luck keep us posted

  5. #5
    Quote Originally Posted by kwip
    JakeHalsted's recent Stage 4 Pressure Sore post has me somewhat concerned... he states that about 60% of ischial flap surgeries on SCIs are successful. Is this figure correct and if so, where does it come from?
    My surgeon told me that the failure rate is closer to 50% in the first year. How depressing is that?

    I'm starting to wonder just what kind of quality of life there's going to be when I come out on the other side of all this.
    Your age is catching up with you. Can't get by on youth and good looks anymore. If you weren't absolutely diligent in pressure relief before this, now's the time to repent and do it right. That's the case for me. I had flap surgery just over a year ago and I've done everything (OK, almost everything) my surgeon has told me to do since then. So far, so good when it comes to the wound staying closed and the skin looking good. One complication that you may want to ask your doctor about before hand concerns your lymphatic system. Good luck.

    C.

  6. #6
    Moderator Obieone's Avatar
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    Bill is in hosp having his sore treated .. its a stage 3-4 on his right ischium where he had a flap done about 2 years ago so I guess that confirms the stats mentioned above ... he had a good plastics guy do the surgery so I don't think its his fault .... but reading everything in this forum absolutely confirms a number of things ... the age thing is true (Bill is pushing 60) he isn't doing his transfers as clean as he used to (shears are common and of course that skin is even more vulnerable as has been stated) .... nutrition is vital (he hasn't been eating great this winter sick with the flu and he has this gas issue) and because he has lost weight there isn't as much padding there ... he needs to be reevaluated for his cushion.

    When he gets home we need to figure out what kind of mattress to get for the bed .. he's good for sleeping on his side when he needs to but he loves his back the best he can't sleep on his belly because of his ileostomy !
    It'd be awesome if someone could come up with a spray you could use to toughen up and protect the skin making it shear,scrape and puncture proof .... seems simple enough .. maybe I'll just get on that right now ...

    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
    HI, Obi - This is the mattress we got last year for Matt, and it's been working great for him; it's the alternating low air loss:

    http://healthproductsforyou.com/list...9&sscid=0&id=0

    The above company also has the best prices if you're going to be putting out for it yourselves.

    You can go to spanamerica.com for more info on the mattress itself.

    Know what you mean about the skin tougheners - Matt wants to know when they're going to come up with a 'Rhino' skin transplant!
    _____________

  8. #8
    Senior Member smokey's Avatar
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    "If you have an untreated UTI prior to surgery, failure rate is higher." - KLD.

    Why does a pre-op UTI increase the rate of failure for surgery on an ischial ulcer?

  9. #9
    you have ti have treated uti treated before ANY surgery. The stress can make i t turn into sepsis. Also might increase tempwerature and don't want to trying to figure out is it the uti or surgical area.
    cwo

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