Bedsores over Seat Bone (Ischium)

Bedsore Development

Bedsores, or pressure ulcers, can develop when a person is seated in the same position for an extended period on a bed or wheelchair. These bedsores usually develop on one or both sides of the ischial bone. Typically, one side of the sore is deep, while the other side is superficial. The location of bedsores depends on the patient’s position:

• Prolonged seated position can result in ischial (seat bone) bedsores.
• Prolonged lying-down position can lead to sacral (lower back) bedsores.
• Prolonged side position can cause trochanter (side bone/hip) bedsores.

Other common areas for bedsores include the heel, elbow, malleolus (ankle), knee, scapula (shoulder blade), and occiput (back of the head).

Development of Ischial Bed Sores

Ischial bed sores typically occur in individuals with paraplegia due to spine injuries that affect the lower half of the body, leading to a lack of mobility. People who are very sick and unable to move due to primary ailments like paralysis, trauma, fractures, or old age are also at risk. These conditions confine the patient to a bed or wheelchair in an upright or sitting position for an extended period, making them susceptible to developing bedsores.

Categories of Ischial Bed Sores

Bedsores are categorized based on the extent of damage:

• Category I: Generalized redness over the pressure areas.
• Category II: Partial loss of skin, similar to an injury caused by rubbing forcefully against an object.
• Category III and IV: Full-thickness loss of skin and muscle in category III, with exposed bone in category IV.

Regardless of the stage, relatives or attendants are advised to consult a plastic surgeon immediately to prevent further progression.

Treatment at Kayakriti

For Categories I and II:

Patients with Category I or II ischial bed sores may not require admission if other comorbidities and factors are well controlled. They are educated about wound management, and specific dressings are advised. Follow-up is typically scheduled every week initially, and later, once or twice a month for three months after complete healing.

For Categories III and IV:

Patients with Category III or IV ischial bed sores require hospital admission. A comprehensive evaluation of their nutritional status and surgical fitness is conducted. After admission, a pre-anesthetic checkup is performed. Clearances from specialists, such as neurologists, cardiologists, and physicians, are obtained to ensure surgical fitness. Once the patient is vitally stable and medically cleared, surgical correction is planned.

• Single-Stage Surgery: In most cases, a single-stage surgery is performed, involving proper debridement. The procedure includes the total excision of the bedsore , removal of the infected ischial bone, and closure of the defect with a flap in the same sitting.
• Local Flap Closure: Closure of the wound is typically achieved with local flaps, using the skin and soft tissue from the surrounding normal area. Common flaps used for closure include the banner flap, posterior thigh flap, gluteus maximus muscle flap with overlying skin, and rotation flap. Dr. Amit Agarwal offers a variety of flap options for the coverage of ischial pressure sores.

In cases where the wound is severely infected and requires further debridement or the patient is too ill to undergo flap coverage in the same sitting, two-stage surgery may be considered. In the first stage, debridement is performed, and Negative Pressure Wound Therapy (VAC) is applied for 5-7 days. After approximately a week, the VAC is removed. If there are no signs of active infection and the patient’s condition has improved, a flap cover surgery is planned for the second stage.

Recovery After Surgery

• The patient is nursed in a prone, side lateral position.
• An air mattress is used,
• Proper Hygiene has to be maintained,
• Foley’s catheterization is done and
• Flap is being monitored regularly for any color changes, or any infection.
• The patient is kept on a soft diet for a few days, to decrease the frequency of stools.
• Dressing is done every alternate day.
• The patient is kept in the hospital for at least 10-14 days.
• Suction is removed once the amount is less than 10-15 ml in 24 hours.
• Sutures are removed after 2 weeks.
• Once the flap is settled and the patient is vitally stable, discharge is planned.

Patients receive instructions for home care, including the use of an air mattress, hygiene practices, and regular side-to-side turning. Follow-up visits are scheduled after one week and later once or twice a month as needed.