Management of recurrent ischial pressure sore with gracilis muscle flap and V-Y profunda femoris artery perforator-based flap.
Lee Su-Shin,Huang Shu-Hung,Chen Meng-Chum,Chang Kao-Ping,Lai Chung-Sheng,Lin Sin-Daw
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
BACKGROUND:Inappropriate seating has been implicated as a major contributing factor in ischial pressure-sore recurrence. During their lifetime, paraplegic patients may require several flaps for closure of the same or some other adjacent pressure sore. Despite a wide variety of flap reconstruction options being described, the ischium remains the most difficult pressure-sore site to treat. METHODS:From June 1998 to July 2006, there were 253 pressure-sore patients operated upon at Kaohsiung Medical University Hospital. Ten patients (eight men and two women) suffered from recurrent ischial pressure sores, and all of them received more than one flap reconstruction for the ischial defect. For the treatment of the recurrent ischial pressure sore, gracilis muscle flap and readvancement of the V-Y profunda femoris artery perforator-based flap were used to fill the dead space as well as cover the defect. RESULTS:Among these 10 recurrent ischial pressure-sore patients, six of them had suffered bilateral ischial ulcers. Eight of them had previous sacral pressure sores. In all, 32 flap reconstruction procedures were performed on these 10 patients. Unfortunately, one patient had recurrent grade II bilateral ischial pressure sores after 11 months of ulcer-free period. The other nine patients had no recurrence noted, and enjoyed their lives with an average 27.2 months ulcer-free period (range 9-53 months). CONCLUSIONS:The fasciocutaneous flap provides a higher mechanical resistance than the detached and transposed muscle. However, for the recurrent ischial ulcer patients, readvancement of the perforator-based fasciocutaneous flap alone cannot provide adequate bulk to obliterate the 'dead space' after debridement of the bursa and the surrounding necrotic tissue. By combining the readvancement of V-Y profunda femoris artery perforator-based fasciocutaneous flap and gracilis muscle flap, these recurrent ischial ulcers will heal without complication. Recurrence of ulceration often develops despite successful flap closure. Patients and their relatives have to be educated regarding pressure relief, personal skin, and self-care. Surgeons must collaborate with the rehabilitation department, nursing staffs, and social workers to improve long-term results.
[Clinical strategy on repair of pressure injury on ischial tuberosity based on the histopathological type].
Zhang X H,Gao X X,Chen X X,Yu J A
Zhonghua shao shang za zhi = Zhonghua shaoshang zazhi = Chinese journal of burns
To investigate effects of clinical strategy on repair of pressure injury on ischial tuberosity based on the histopathological type. From January 2014 to January 2018, 33 patients with 33 pressure injuries on ischial tuberosity were admitted to our department. There were 25 males and 8 females aged 35 to 87 years. Pressure injuries on ischial tuberosity were repaired with different methods according to pathological types of denatured tissue on basal parts of wounds and tissue defect volumes. Areas of wounds after thorough debridement ranged from 2.0 cm×1.0 cm to 14.0 cm×12.0 cm. Pressure injuries of necrosis type with tissue defect volumes of 6.5-9.5 cm(3) were sutured directly after debridement at the first stage. Tissue defect volumes of 3 patients with pressure injuries of granulation type ranged from 56.0 to 102.5 cm(3). According to situation around wounds, the above mentioned 3 patients were respectively repaired with posterior femoral Z-shaped reconstruction, posterior femoral advanced V-Y flap, and posterior femoral propeller flap. Tissue defect volumes of 5 patients with pressure injuries of infection type ranged from 67.5 to 111.0 cm(3). Among the patients, 2 patients were repaired with posterior femoral propeller flaps, 2 patients were repaired with posterior femoral advanced V-Y flaps, and 1 patient was repaired with posterior femoral Z-shaped reconstruction. Among patients with pressure injuries of synovium type, wounds of 14 patients with tissue defect volumes 6.4-9.5 cm(3) were sutured directly after debridement, and tissue defect volumes of another 8 patients were 97.0-862.5 cm(3). Among the 8 patients, 7 patients were repaired with gluteus maximus myocutaneous flaps and continued vacuum sealing drainage was performed for 7 to 14 days according to volume of drainage, and 1 patient was repaired with posterior femoral propeller flap. Areas of flaps or myocutaneous flaps ranged from 3.5 cm× 2.5 cm to 14.0 cm×12.0 cm. The donor sites of flaps were sutured directly. Operative areas after operation and healing of wounds during follow-up were observed. The sutured sites of 33 patients connected tightly, with normal skin temperature, color, and reflux. During follow-up of 12 months, wounds of 25 patients healed well with no local ulceration, and 8 patients were admitted to our department again due to recurrence of pressure injuries on or near the primary sites. Pathological types of pressure injuries of the 8 patients were synovium types. After complete debridement, the tissue defect volumes were 336.8-969.5 cm(3,) wounds with areas ranged from 8.0 cm×7.0 cm to 14.0 cm×12.0 cm were repaired with gluteus maximus myocutaneous flaps or posterior femoral propeller flaps which ranged from 8.0 cm×7.0 cm to 14.0 cm×12.0 cm. Eight patients were discharged after wound healing completely. During follow-up of 12 months, operative sites of the patients healed well, with no recurrence. Appropriate and targeted methods should be chosen to repair pressure injuries on ischial tuberosity based on the pathological types. Direct suture after debridement is the first choice to repair pressure injury of necrosis type. Pressure injuries of granulation type and infection type can be repaired with posterior femoral propeller flap, Z-shaped reconstruction, or advanced V-Y flap according to situation around wounds. Gluteus maximus myocutaneous flap is the first choice to repair pressure injury of synovium type. In addition, recurrence-prone characteristics of pressure injury of synovium type should be taken into consideration, plan should be made previously, and resources should be reserved.
Orthotic-Style Off-Loading Wheelchair Seat Cushion Reduces Interface Pressure Under Ischial Tuberosities and Sacrococcygeal Regions.
Crane Barbara,Wininger Michael,Call Evan
Archives of physical medicine and rehabilitation
OBJECTIVE:To assess the efficacy of an off-loading wheelchair seat cushion in removing pressure from high-risk ischial tuberosities and the coccyx/sacrum in wheelchair sitting. DESIGN:Repeated-measures design. SETTING:Private research laboratory. PARTICIPANTS:Manual wheelchair users with chronic spinal cord injuries (N=10). INTERVENTIONS:Three configurations of an off-loading wheelchair seat cushion compared with a flotation style (10-cm air inflation) wheelchair seat cushion. MAIN OUTCOME MEASURES:Outcome measures included peak pressure index (PPI), ischial tuberosity peak pressures, and the dispersion index or ratio of pressures under the ischial and sacral regions to the total of all pressures recorded. RESULTS:PPI and ischial tuberosities peak pressure ranged from a low of 39±18 and 68±46mmHg in the fully off-loaded cushion to a high of 97±30 and 106±34mmHg, respectively, for the flotation style cushion (2-way analysis of variance main effect across 4 conditions, P<.001). Dispersion index ranged from a low of 8%±3% in the fully off-loaded cushion to a high of 16%±3% in the flotation style cushion. Pairwise comparisons yielded significance in all cushion-pair analyses (P<.05 after multiple corrections). CONCLUSIONS:The force-removal approach of this orthotic off-loading cushion design effectively reduces a known extrinsic risk factor for pressure ulcers-interface pressure-in the high-risk ischial tuberosity and sacral/coccygeal regions of the buttocks.
[Effects of perforator flaps combined with muscle flaps for repairing grade Ⅳ pressure ulcers in ischial tuberosity of elderly patients].
Su W G,Li D P,Xing P P,Xu L G,Shi F C,Wen B,Niu X H
Zhonghua shao shang za zhi = Zhonghua shaoshang zazhi = Chinese journal of burns
To explore effects of perforator flaps combined with muscle flaps for repairing grade Ⅳ pressure ulcers in ischial tuberosity of elderly patients. Nine elderly patients with grade Ⅳ pressure ulcers in ischial tuberosity were hospitalized in our burn ward from April 2014 to April 2017. Size of wounds ranged from 5 cm×3 cm to 12 cm×7 cm, and depth of sinus ranged from 6 to 22 cm. After admission, emergency debridement or debridement in selective time was performed. After debridement, the wounds were treated with continuous vacuum assisted closure therapy. After the treatment for 1 to 2 weeks, tissue flaps repair operations were performed. Four patients were repaired with inferior gluteal artery perforator flaps combined with long head of biceps femoris muscle flaps. Three patients were repaired with inferior gluteal artery perforator flaps combined with semimembranous muscle flaps. One patient was repaired with inferior gluteal artery perforator flap combined with gracilis muscle flap. One patient was repaired with femoral profound artery perforator flap combined with gluteus maximus muscle flap, and the distal area of femoral profound artery perforator flap of the patient which showed intraoperative cyanosis of 6 cm×4 cm was thinned to medium thickness skin to cover the muscle flap. The other eight patients showed no abnormality during operation. Size of perforator flaps ranged from 7 cm×5 cm to 14 cm×12 cm, and size of muscle flaps ranged from 11 cm×4 cm to 24 cm×6 cm. The donor sites of flaps were all sutured directly. The tissue flaps and skin graft of all patients survived well after operation. During follow-up of 8 to 35 weeks, operative area of all patients showed good shape and texture, with no local diabrosis or recurrence of pressure ulcers. The combination of perforator flaps and muscle flaps is effective in repairing and reducing recurrence of grade Ⅳ pressure ulcers in ischial tuberosity of elderly patients.
[Repair of pressure ulcers in ischial tuberosity of 15 patients by partially de-epithelialized posterior femoral bilobed flaps].
Chu G P,Lyu G Z,Zhu Y G,Yang M L,Qin H B,Cheng J
Zhonghua shao shang za zhi = Zhonghua shaoshang zazhi = Chinese journal of burns
Fifteen patients with sinus-type pressure ulcer in ischial tuberosity were admitted to our unit from April 2013 to April 2017, including 12 patients of unilateral pressure ulcer and 3 patients of bilateral pressure ulcer. The wounds were with infection of different degrees. The outer wound area of pressure ulcer before debridement ranged from 1.5 cm×1.0 cm to 6.0 cm×5.0 cm. Fifteen patients with 15 pressure ulcers were treated with vacuum sealing drainage for 3 to 13 days after debridement and sinus wall resection. Unilateral pressure ulcer was repaired with posterior femoral bilobed flap. One side of bilateral pressure ulcer was repaired with posterior femoral bilobed flap, and the other side was repaired with gluteus maximus muscle flap combined with local flap. The size of flaps ranged from 11.0 cm×7.5 cm to 15.0 cm×10.0 cm. Epidermis of the distal part and edge of the main flap was removed to make complex dermal tissue flap to fill the deep cavity. The other part of the main flap was applied to cover wound, and another flap of the bilobed flap was applied to cover the donor site where main flap was resected. The donor sites were sutured directly. The posterior femoral bilobed flaps in 15 patients survived after operation. Pressure ulcers of 12 patients were healed well. Incision of 2 patients ruptured and healed 15 days after second sewing. One pressure ulcer with infection under the flap healed on 16 days post second completely debridement. During follow-up of 3 to 18 months, flaps were with soft texture, good appearance, and no recurrence.
Infragluteal fasciocutaneous flap for management of recurrent ischial pressure sore.
Kumar Umesh,Jain Pradeep
Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India
Objective:The objective of the study was to determine the feasibility of infragluteal fasciocutaneous flap in recurrent ischial pressure sore. Materials and Methods:In our study, from 2015 to 2017, nine patients suffering from recurrent ischial sore with scars of previous surgery were managed with infragluteal fasciocutaneous flap. Wound bed was prepared by surgical debridement and negative pressure wound therapy in each case. In two cases, gracilis muscle flap was used as adjuvant to fill up the residual cavity. Donor area of flap was primarily closed. Results:Infragluteal fasciocutaneous flap was used in all nine cases. Superficial distal congestion was present in two cases. Haematoma (1) and infection (1) at flap donor site occurred. Recurrence of ulcer was observed in two cases which were managed by bursectomy and advancement of the bridge segment of the original infragluteal fasciocutaneous flap. All flaps survived without any major complication. Discussion:Ischial pressure sores have a tendency of recurrence after conservative or flap surgery. Scars due to previous surgeries adjacent to the pressure sore preclude the use of local skin or muscle flap. Infragluteal fasciocutaneous flap is a thick reliable fasciocutaneous flap that can be used for resurfacing recurrent ischial pressure sore. This flap has an axial pattern blood supply along with rich subfascial and fascial plexus supplied by various perforators. Conclusion:Infragluteal fasciocutaneous flap is reliable option for managing recurrent ischial sore as it transposes well-vascularised thick fasciocutaneous flap from adjacent posterior thigh and its bridge segment can be further used in case of recurrence.
The pedicled internal pudendal artery perforator (PIPAP) flap for ischial pressure sore reconstruction: Technique and long-term outcome of a cohort study.
Legemate Catherine M,van der Kwaak Monique,Gobets David,Huikeshoven Menno,van Zuijlen Paul P M
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
BACKGROUND:The ischial region is the site most affected by pressure sores and has the highest recurrence and complication rates compared to other affected sites. We developed a practical and safe pedicled flap for reconstruction of ischial pressure sores based on the rich available perforators from the internal pudendal artery and the surplus of skin at the infragluteal fold. METHODS:A retrospective cohort study was conducted in all patients who underwent ischial pressure ulcer reconstruction using the PIPAP flap between March 2010 and March 2017. The skin flap was designed along the gluteal fold. The skin perforators of the pudendal artery were marked with a Doppler probe in the medial region of the gluteal fold. Surgery was performed in the jackknife position, and flaps were elevated in the suprafascial plane. Patients were assessed for minor (requiring no additional surgery) and major complications (requiring additional surgery). RESULTS:Twenty-seven patients (34 flaps) were identified. The median follow-up period was 38 months (IQR 37). Primary closure of the donor-site was achieved in all procedures, only one flap required muscle flap transposition in order to fill the dead space. The mean operating time was 60 ± 21 minutes. In six flaps (9%) wound healing problems were noted that did not require an additional operative procedure. Among the nine flaps (27%) that required a second procedure, 3 (9%) were necessary due to recurrent ulcers. CONCLUSIONS:The PIPAP flap is a safe and reliable alternative for ischial pressure sore reconstruction, certainly when compared to available techniques. Moreover, it has significant advantages over other techniques including minimal donor-site morbidity, preservation of posterior thigh skin, buttock-line integrity and reliable vascularity.
A Descriptive, Retrospective Study of Using an Oblique Downward-design Gluteus Maximus Myocutaneous Flap for Reconstruction of Ischial Pressure Ulcers.
Chou Chang-Yi,Sun Yu-Shan,Shih Yu-Jen,Tzeng Yuan-Sheng,Chang Shun-Cheng,Dai Niann-Tzyy,Lin Chin-Ta
Despite advances in reconstruction techniques, ischial pressure ulcers continue to present a challenge for the plastic surgeon. The purpose of this retrospective study was to evaluate outcomes of using an oblique downward gluteus maximus myocutaneous (GMM) flap for coverage of grade IV ischial ulcers. Data regarding defect size, flap size, operation time, duration of wound healing, and surgical outcome were abstracted from the medical records of patients whose ischial pressure ulcers had been reconstructed using GMM island flaps between January 2010 and December 2015. The 22 patients comprised 15 men and 7 women with a mean age of 52 (range 16-81) years. Twenty (20) had paraplegia, 6 had a recurrent ischial ulcer, 2 were bedridden following a cerebrovascular accident, 1 had a myelomeningocele status post operation, and 19 were spinal cord injury patients. Follow-up time ranged from 6 to 40 months. Pressure ulcer size ranged from 3 cm x 2 cm to 10 cm x 5 cm (average 22.3 cm2). The average flap size was 158 cm2 (15.9 cm x 9.7 cm); the largest was 286 cm2 (22 cm x 13 cm). The operating time ranged from 52 minutes to 110 minutes (average, 80 minutes). In 2 cases, wound dehiscence occurred but completely healed after resuturing. One (1) ischial pressure ulcer recurred 6 months following surgery and was successfully covered with a pedicled anterolateral thigh flap. No recurrences or problems were observed in the remaining 20 patients. Time to complete wound healing ranged from 14 to 24 days (average 17.8 days). Treatment of ischial pressure ulcers with GMM flaps allowed for an easy, simple procedure that provided the adequate thickness of soft tissue needed to cover the bony prominence, fill dead space, and cover the lesion. This technique was a reliable and safe reconstructive modality for the management of ischial pressure ulcers, even in recurrent cases.
A dual padding method for ischial pressure sore reconstruction with an inferior gluteal artery perforator fasciocutaneous flap and a split inferior gluteus maximus muscle flap.
Ku Inhoe,Lee Gordon K,Yoon Saehoon,Jeong Euicheol
Archives of plastic surgery
BACKGROUND:Various surgical management methods have been proposed for ischial sore reconstruction, yet it has the highest recurrence rate of all pressure ulcer types. A novel approach combining the advantages of a perforator-based fasciocutaneous flap and a muscle flap is expected to resolve the disadvantages of previously introduced surgical methods. METHODS:Fifteen patients with ischial pressure ulcers with chronic osteomyelitis or bursitis, who underwent reconstructive procedures with an inferior gluteal artery perforator (IGAP) fasciocutaneous flap and a split inferior gluteus maximus muscle flap from January 2011 to June 2016, were analyzed retrospectively. The split muscle flap was rotated to obliterate the deep ischial defect, managing the osteomyelitis or bursitis, and the IGAP fasciocutaneous flap was rotated or advanced to cover the superficial layer. The patients' age, sex, presence of bursitis or osteomyelitis, surgical details, complications, follow-up period, and ischial sore recurrence were reviewed. RESULTS:All ischial pressure ulcers were successfully reconstructed without any flap loss. The mean duration of follow-up was 12.9 months (range, 3-35 months). Of 15 patients, one had a recurrent ulcer 10 months postoperatively, which was repaired by re-advancing the previously elevated fasciocutaneous flap. CONCLUSIONS:The dual-flap procedure with an IGAP fasciocutaneous flap and split inferior gluteus maximus muscle flap for ischial pressure ulcer reconstruction is a useful method that combines the useful characteristics of perforator and muscle flaps, providing thick dual padding with sufficient vascularization while minimizing donor morbidity and vascular pedicle injury.
Modification of the Pedicled Anterolateral Thigh Myocutaneous Flap for the Reconstruction of Ischial Pressure Ulcers: A Retrospective Case Study of 21 Patients.
Wang Chi-Yu,Wu Chien-Ju,Shih Yu-Jen,Chu Tzi-Shiang,Liu Hung-Hui,Chen Chun-Yu,Hsu Kuo-Feng,Chen Shyi-Gen,Tzeng Yuan-Sheng
Wounds : a compendium of clinical research and practice
INTRODUCTION:Ischial pressure ulcers are considered the most difficult type of pressure ulcers (PUs) to treat. OBJECTIVE:The authors report the use of a pedicled anterolateral thigh (pALT) myocutaneous ﬂap as an alternative for covering an ischial PU. MATERIALS AND METHODS:The authors retrospectively collected the data of 21 patients with an indurated recurrent ischial ulcer or a fresh ischial ulcer. A pALT myocutaneous ﬂap was harvested without intramuscular dissection and skeletonization of the perforators for the ischial defect reconstruction. Two modiﬁed ﬂap-insetting techniques, an open-route method and a subcutaneous tunnel method, were used for the ischial defect reconstruction. The open-route flap-insetting was used for a recurrent ulcer status after other surgical procedures, and the subcutaneous tunnel method was used for fresh ulcers. RESULTS:The mean follow-up period was 10 months (range, 4-14 months). During the postoperative follow-up, all open-route reconstructions resulted in flap take; however, poor healing with seroma was noted in 2 patients who had undergone pALT reconstruction with subcutaneous tunneling after other previous surgical reconstructions. CONCLUSIONS:In the authors' experience, because of constant blood supply, sufﬁcient bulk, easy elevation, longer pedicle for the arc of rotation, primary closure of the donor site without morbidity, and a non-weightbearing flap donor site, the pALT myocutaneous flap for ischial ulcer reconstruction can serve as a primary treatment and secondary salvage.
Successful Pedicled Anterolateral Thigh Flap Reconstruction for a Recurrent Ischial Pressure Ulcer: A Case With Multiple Recurrences Over a 7-year Follow-up.
Wang Chi-Yu,Shih Yu-Jen,Chou Chang-Yi,Chen Tim-Mo,Chen Shyi-Gen,Tzeng Yuan-Sheng
Wounds : a compendium of clinical research and practice
Ischial pressure ulcers are difficult ulcers to treat and have a low treatment success rate compared to sacral and trochanteric ulcers; regional flap failure further complicates the treatment. Reported here is a case of a 65-year-old man who experienced a spinal injury with paraplegia due to trauma 20 years ago. The patient experienced a recurrent ischial ulcer since 2007, and underwent several types of flap reconstruction with poor outcomes over a 7-year period. Therefore, the chosen intervention was a pedicled anterolateral thigh (pALT) fasciocutaneous flap reconstruction for the ischial ulcer via a subcutaneous route. Over the 10-month follow-up, the recurrent ischial ulcer healed without wound dehiscence. Island pALT reconstruction appears to be an alternative technique for treating recurrent ischial pressure ulcers. Though reconstruction of ischial ulcers via the pALT technique has been described previously, this may be the first case report to describe pALT flap in a patient with recurrent ischial ulcers after failed reconstructions using a gluteus maximus flap, V-Y advancement flap, and hatchet flap.Ischial pressure ulcers are difficult to treat and have a low treatment success rate1 compared to sacral and trochanteric ulcers. In addition, there are many different techniques that can be used to treat ischial pressure ulcers, including primary wound closure, gluteus maximus flaps, V-Y advancement flaps, or inferior gluteal artery perforator flaps. However, several experts have recently described using the pedicled anterolateral thigh (pALT) flap for reconstruction of recurrent ischial pressure ulcers.1,2 In the presented case, the authors followed a single patient with paraplegia with a recurrent ischial ulcer who had undergone several types of wound treatment over a 7-year period. The indurated ulcer was ultimately resolved by pALT reconstruction.
Usefulness of Simple-Designed Bilobed Flap for Reconstruction of Ischial Decubitus Ulcer.
Iida Naoshige,Watanabe Ayako
Plastic and reconstructive surgery. Global open
The pressure ulcer of the ischial region is often accompanied by complete paraplegia in patients with spinal cord injury and is attributable to the compression and breakdown of tissue arising from constant sitting. Characteristically, a pressure ulcer of this region is circular and deep. We recently reconstructed ischial decubitus ulcer of 8 patients using simple-designed bilobed flap. In all cases, the flap survived completely without any complication. Moreover, none of the patients in this group experienced any pressure ulcer relapse during the postoperative follow-up from 1 year 1 month to 9 years. In the vicinity of the ischial region, the buttock contains the most abundant amount of fatty tissue. Therefore, for our technique, we create the first flap in the buttock neighboring the defect and the second flap on the posterior thigh. Using this approach, it is possible to cover the skin or soft tissue defect of the ischial region with the flap from the buttock having a thickness large enough to bear the patient's weight during sitting. The first flap is arranged parallel to the gluteal sulcus, and the second flap from the thigh is moved to the first-flap donation site. This technique allows closure of the wound without producing tension along the suture line. The bilobed flap, which does not require the artery to be included in the flap, is applicable for patients with relapsing pressure ulcer having a history of surgery. Our flap operative procedure is particularly useful in the reconstruction of ischial decubitus ulcer.
Sacral and Ischial Pressure Ulcer Management With Negative-Pressure Wound Therapy With Instillation and Dwell.
Arowojolu Omotayo A,Wirth Garrett A
Plastic and reconstructive surgery
BACKGROUND:The addition of topical fluid instillation, a programmable "dwell" time and a novel foam-wound interface to the established wound healing benefits of negative-pressure wound therapy (NPWT) works synergistically to benefit patients with complex wounds. This engineering breakthrough for wound care has been termed NPWT with instillation and dwell (NPWTi-d), and the new foam dressings are reticulated open cell foam dressings specifically designed for use with NPWTi-d. This combined technology has shown promise in chronic, complex wounds and has potential for the management of sacral and ischial pressure wounds. METHODS:A qualitative comprehensive review was performed analyzing articles from PubMed and Medline that reported on the use of NPWTi-d in sacral or ischial pressure ulcers. Case series and case reports were predominant, and results of cases specific to sacral and ischial pressure wounds were extracted from larger studies and summarized for presentation. RESULTS:Compared with conventional NPWT alone, NPWTi-d has been shown to help irrigate the wound, remove fibrinous debris, and promote granulation tissue formation. This is associated with a decreased number of operative debridements and decreased hospital length of stay. CONCLUSIONS:This technology is rapidly demonstrating expanded utilization in hospitalized patients with chronic sacral and ischial pressure ulcers. When used correctly, NPWTi-d serves as an effective "bridge to defined endpoint": whether that is a flap reconstruction, skin grafting, or discharge home with a stable chronic wound and simplified wound care.