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A Logical and Straight Forward Component Separation Technique for Ischial Pressure Sore Reconstruction
Mauricio De la Garza, MD1, Victor L. Lewis, Jr., M.D.2.
1University of Massachusetts, Berkshire Medical Center, Pittsfield, MA, USA, 2Northwestern University, Northwestern Memorial Hospital, Chicago, IL, USA.

Background: Pressure sores represent a significant source of physical and financial burden to patients with spinal cord injury (SCI). Successful flap transfer or advancement has had no significant translation into improved outcome. The rate of failure of primary healing after operative treatment has continued to be reported dauntingly high, with rates ranging from 19% to 80%.
Methods: A non-selective group of seventy five SCI patients with ischial pressure sores were equally treated with bone biopsy, histologic evaluation, best choice antibiotics, and a component separation reconstructive technique. All patients were operated by the senior author at Northwestern Memorial Hospital, Chicago, IL.
Results: All SCI patients who underwent operative reconstruction had either a stage III (7%) or IV (93%) ischial pressure sore. Follow up ranges from 3 months to 78 months, with an average of 35 months. The length of the operation averaged 74 minutes. The gluteus maximus and hamstring muscle flaps remain intact over the ischial tuberosity and thus far none (0%) of the operatively treated SCI patients has had stage III or IV pressure sore recurrence. Only eight patients have dehisced (10.6%) at the subcutaneous level and sixty seven patients remain with an intact healed reconstruction (89.4%).
Conclusion: Our study reports the improved outcome and technical ease of a logical and straight forward component separation technique for ischial pressure sore reconstruction. Demonstrable successful repair for most patients prevents the prolonged need for dressing changes and use of vacuum assisted closure therapy, and increases the level of patient function in the shortest possible time frame. We are convinced that successful and reproducible plane by plane tissue closure of grade III and IV ischial pressure sores is achievable, and within the competence of plastic surgeons, trauma surgeons and general surgeons.

Figure 1 Component Separation Technique for Ischial Pressure Sore Reconstruction. (A) Preoperative appearance on day of component separation technique reconstruction. Depicted patient is postoperative day 14 from the first stage treatment of a referred recurrent ischial pressure sore. (B) Bursectomy and ostectomy of ischial prominence is performed and surrounding muscles identified. (C) Gluteus maximus and hamstring muscles flaps are freed from adjacent subcutaneous tissues and fascial planes to allow advancement. (D) Mobilized ischial origin of hamstring muscles is sutured to the advanced gluteus maximus muscle to provide a cushioned tensionless muscular repair over the ischial tuberosity. (E) Subcutaneous tissue and (F) skin are simply primarily approximated.

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