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Table 1.  
Determinants of Flap-Related Complications Among Patients With Pressure Ulcers Undergoing Pedicled Flap Reconstructiona
Determinants of Flap-Related Complications Among Patients With Pressure Ulcers Undergoing Pedicled Flap Reconstructiona
Table 2.  
Determinants of Resource Utilization for Patients With Pressure Ulcers Undergoing Pedicled Flap Reconstructiona
Determinants of Resource Utilization for Patients With Pressure Ulcers Undergoing Pedicled Flap Reconstructiona
1.
Blocksma  R, Kostrubala  JG, Greeley  PW.  The surgical repair of decubitus ulcer in paraplegics; further observations. Plast Reconstr Surg (1946). 1949;4(2):123-132. PubMedArticle
2.
Chang  SH.  Anterolateral thigh island pedicled flap in trochanteric pressure sore reconstruction. J Plast Reconstr Aesthet Surg. 2007;60(9):1074-1075.PubMedArticle
3.
Lin  H, Hou  C, Chen  A, Xu  Z.  Long-term outcome of using posterior-thigh fasciocutaneous flaps for the treatment of ischial pressure sores. J Reconstr Microsurg. 2010;26(6):355-358.PubMedArticle
4.
Hsu  H, Chien  SH, Wang  CH,  et al.  Expanding the applications of the pedicled anterolateral thigh and vastus lateralis myocutaneous flaps. Ann Plast Surg. 2012;69(6):643-649.PubMedArticle
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Research Letter
Association of VA Surgeons
January 2016

Pedicled Flap Reconstruction for Patients With Pressure UlcersComplications and Resource Utilization by Ulcer Site

Author Affiliations
  • 1Division of Plastic, Aesthetic, and Reconstructive Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
JAMA Surg. 2016;151(1):93-94. doi:10.1001/jamasurg.2015.3228

Pressure ulcers are pervasive and pose a unique burden on the current health care system owing to their association with prolonged hospitalizations and increased costs for patients with chronic medical conditions. These wounds occur frequently in patients with neurological conditions causing immobility and are a significant and common source of patient morbidity. Blocksma et al1 initially described muscle flap coverage for paraplegic patients in 1949. Pedicled flap reconstructions, such as the posterior and anterolateral thigh flaps and, more recently, the vastus lateralis myocutaneous flap, have been used in advanced cases with extensive loss of soft tissue or exposed bony structures.24

Successful pedicled flap coverage of pressure ulcers, defined as flap survival without flap-related complications during hospital admission (with a survival rate of 87% in this analysis), is determined by several factors, including patient characteristics and comorbidities. To date, there have been no investigations of these determinants using a large, population-based database. We sought to identify factors associated with flap-related complications and increased resource utilization using risk-adjusted, multivariate analysis.

Methods

We searched the National Inpatient Sample (2006-2011) for patients with pressure ulcers (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] diagnosis codes 707.03-707.05) undergoing pedicled flap reconstruction (ICD-9-CM procedure codes 86.70-86.72) as a primary procedure. Flap-related complications were defined as flap loss, hematoma, seroma, wound infection, or dehiscence, which occurred at a rate of 13% in our cohort. Binary logistic regression models were constructed using the backward stepwise method (initially 69 covariates) to identify predictors for cases associated with complications vs no complications and above vs below median length of stay and total charges. Comorbid diagnoses were defined using ICD-9-CM codes. Cases were weighted to project national estimates. The analyses presented in this study were based on deidentified admission data. The institutional review board at the University of Miami Miller School of Medicine exempted this retrospective database study from full review. Significance for all analyses were set at P < .05.

Results

Overall, 2749 cases were identified. Locations included the sacrococcygeal (63%), trochanteric (22%), and gluteal (14%) regions. The median age of patients at hospital admission was 56 years (interquartile range, 27 years). The mean (SD) length of stay was 14 (19) days. The mean (SD) total charge was $60 032 ($88 645). Patients were most frequently male (61%), white (68%), with Medicare (58%), and in the lowest income quartile (32%).

On risk-adjusted multivariate analysis, flap-related complications increased for women (odds ratio [OR], 1.64 [95% CI, 1.10-2.44]), patients with renal failure (OR, 4.99 [95% CI, 2.23-11.16]), and obese patients (OR, 1.90 [95% CI, 1.02-3.55]) (Table 1). Trochanteric (OR, 4.54 [95% CI, 2.38-8.33]) and sacrococcygeal (OR, 1.72 [95% CI, 1.02-2.86]) ulcers had more flap-related complications. Length of stay increased for women (OR, 1.69 [95% CI, 1.05-2.78]), patients on Medicaid (OR, 10.4 [95% CI, 4.45-24.47]), patients in the lowest income quartile (OR, 20.0 [95% CI, 8.11-48.31]), patients with wound dehiscence (OR, 7.43 [95% CI, 2.68-20.62]), and patients with renal failure (OR, 7.04 [95% CI, 2.30-21.53]) (Table 2). Sacrococcygeal ulcers portended a longer length of stay (OR, 2.56 [95% CI, 1.33-4.92]). Total charges increased for men (OR, 2.02 [95% CI, 1.32-3.08]), patients on Medicaid (OR, 2.03 [95% CI, 1.04-3.96]), patients in the highest income quartile (OR, 5.88 [3.23-10.0]), patients with pneumonia (OR, 28.0 [95% CI, 4.29-182.90]), and patients with flap loss (OR, 7.53 [95% CI, 1.39-40.71]). Trochanteric ulcers had higher total charges (OR, 3.47 [95% CI, 1.80-6.68]).

Discussion

Pressure ulcers involving the gluteal region, while least common among the sites analyzed, were associated with the lowest resource utilization and complication rates. In addition, demographic factors, such as sex, race, and socioeconomic status, affected complication rates and resource utilization in our analysis. Renal failure was associated with higher complication rates and longer lengths of stay. Pneumonia was associated with higher cost. Owing to the retrospective nature of the National Inpatient Sample database, however, chronological or causal relationships between diagnoses cannot be concluded.

As health care resource allocations continue to be a challenge, our findings may assist plastic surgeons by defining groups of patients at high risk for complications or higher resource utilization related to pedicled flap reconstruction, such as comorbid diagnoses or variation by ulcer site. Other adjunctive management options, such as the use of a vacuum-assisted closure device or skin grafting, may be more appropriate therapeutic approaches. Future research should focus on subpopulations of patients at high risk for postoperative complications that are directly associated with resource utilization.

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Article Information

Corresponding Author: Seth R. Thaller, MD, DMD, Division of Plastic, Aesthetic, and Reconstructive Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th St, Ste 410, Miami, FL 33136 (sthaller@med.miami.edu).

Published Online: October 14, 2015. doi:10.1001/jamasurg.2015.3228.

Author Contributions: Drs Thaller and Tashiro had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Tashiro.

Drafting of the manuscript: Tashiro.

Critical revision of the manuscript for important intellectual content: Gerth, Thaller.

Statistical analysis: Tashiro, Gerth.

Administrative, technical, or material support: Thaller.

Study supervision: Thaller.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This paper was presented at the 39th Annual Meeting of the Association of VA Surgeons; May 4, 2015; Miami Beach, Florida.

References
1.
Blocksma  R, Kostrubala  JG, Greeley  PW.  The surgical repair of decubitus ulcer in paraplegics; further observations. Plast Reconstr Surg (1946). 1949;4(2):123-132. PubMedArticle
2.
Chang  SH.  Anterolateral thigh island pedicled flap in trochanteric pressure sore reconstruction. J Plast Reconstr Aesthet Surg. 2007;60(9):1074-1075.PubMedArticle
3.
Lin  H, Hou  C, Chen  A, Xu  Z.  Long-term outcome of using posterior-thigh fasciocutaneous flaps for the treatment of ischial pressure sores. J Reconstr Microsurg. 2010;26(6):355-358.PubMedArticle
4.
Hsu  H, Chien  SH, Wang  CH,  et al.  Expanding the applications of the pedicled anterolateral thigh and vastus lateralis myocutaneous flaps. Ann Plast Surg. 2012;69(6):643-649.PubMedArticle
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