Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 49

CLINICAL PRACTICE GUIDELINE

may be treated with a lesser duration of
antibiotics (Marriott, 2008). Appropriate
antibiotic selection requires the identification of
the causative organism from bone culture.
Successful treatment of osteomyelitis is based
on a combination of medical and surgical
modalities, the balance determined by the extent
of disease. Debridement is the basis of surgical
treatment, and should be direct and atraumatic
with the ultimate goal of reconstruction. All
necrotic (de-vascularized) and infected bone
should be removed, unless the goal of treatment is
non-curative. Osteomyelitis of the greater
trochanter of the femur associated with
trochanteric pressure ulcers represents a special
case. Significant disease or communication with
the hip joint requires a Girdlestone Procedure or
resection arthroplasty of the hip (popularized by
British surgeon Gathorne Robert Girdlestone in
the early 20th century for the treatment of late
septic arthritis of the hip) to eradicate the
infection. The resulting wound is typically repaired
with soft tissue coverage using a vastus lateralis
muscle flap and is considered essential to
successful management of those cases (Evans et
al., 1993). Girdlestone surgeries present unique,
seating challenges due to the sitting surface being
reduced to a smaller area. When a girdlestone
procedure is performed, the thigh/femur is no
longer a viable load bearing surface. It is no
longer connected to the body by a bony structure,
therefore, it cannot offer support. A referral to a
specialized seating clinic is recommended
following this procedure so that the most
appropriate seating system accommodations can
be prescribed for maximal sitting stability and skin
protection over the weight bearing pelvic surface.
Myocutaneous flaps have been long
established as the preferred method of
reconstructing wounds in the presence of infected
bone including pelvic pressure ulcers (Bruck et
al., 1991). Well-vascularized muscle tissue
increases the antimicrobial potential of the wound
by supplying oxygen, nutrients, and antibiotics to
a previously hypoxic wound bed. There is some
controversy over the timing of reconstructive
surgery, with some advocating for treatment and
complete resolution of osteomyelitis prior to flap
coverage (Han et al., 2002), presumably to
reduce infectious complications following
reconstruction. This requires either a preoperative core needle bone biopsy and culture or
a two-stage reconstruction with operative
debridement and bone biopsy as a first stage,
followed by 4-6 weeks of parenteral antibiotics.
Clearly, cases of acute suppurative infections

should be debrided and drained, but the
overwhelmingly more common chronic superficial
osteomyelitis found with pressure ulcers can be
successfully treated as a one-stage surgical
procedure by adequate debridement of diseased
bone with biopsy of the remaining healthy bone
surface (to determine any residual bacterial
contamination and to direct post-operative
antibiotic therapy) and immediate flap
reconstruction. (Larson et al., 2011; Marriott,
2008; Darouishe et al., 1994). In fact, a recent
published case series of 101 patients over a span
of five years found no correlation between
positive bone cultures and surgical complications
or ulcer recurrence (Larson et al., 2012).
WOUND BI OBURDEN

The bioburden of a wound refers to the
absolute number of microorganisms with which it
is contaminated. Bacteria in a wound may
originate from normal body flora, enteric sources,
or from the environment. There is a wide
spectrum of bacterial activity level in wounds,
ranging from contamination or colonization
(proliferating colonies without host response) to
overt suppurative infection (bacterial invasion of
healthy tissue) or cellulitis. Colonization generally
does not impact wound healing, however, at a
certain point critical colonization occurs based on
bacterial number or virulence, with the beginning
of a host inflammatory response and impaired
wound healing. Clearly, purulent wounds must be
drained. All non-viable and necrotic tissue must
be debrided and removed as a nutrient source for
bacteria.
The administration of systemic antibiotics
(oral or parenteral) should be reserved for cases
of objective findings of infection (or for persons
with immunodeficiency). Swab biopsy of a wound
is of no value in the diagnosis of wound infection
and antibiotic selection since these cultures are
invariably polymicrobial and reflective only of
surface contamination and do not isolate the
invasive bacteria causing the infection. (Levi,
2007; Bauer, 2008). To diagnose infection of the
tissue below the wound surface, a quantitative
culture is taken.
Prior to definitive flap closure, the wound
bioburden should be reduced as much as
possible. This involves wound debridement as
discussed earlier, which is further performed in
the operating room with copious irrigation
immediately prior to flap insetting. Additionally,
the bioburden can be controlled using topical
antimicrobials (not systemic antibiotics) such as
sodium hypochlorite (Dakin's solution), and

Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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