From the Guidelines
The next step in managing a decubitus ulcer with sacral bone exposure is surgical debridement followed by advanced wound care, as recommended by the most recent and highest quality study 1.
Key Considerations
- The exposed bone requires immediate surgical intervention to remove necrotic tissue, infected bone (if present), and create a clean wound bed.
- Following debridement, the wound should be managed with negative pressure wound therapy (wound VAC) at 125 mmHg continuous pressure, changed every 48-72 hours.
- Nutritional support is critical, with protein intake of 1.2-1.5 g/kg/day and supplementation of vitamins A, C, and zinc to promote healing, as suggested by previous studies 1.
- Pressure must be completely eliminated from the area using a specialized air-fluidized bed or frequent repositioning every 1-2 hours.
- Infection control with appropriate antibiotics based on wound culture results is essential, typically involving broad-spectrum coverage until culture-specific therapy can be initiated, as outlined in guidelines for managing diabetic foot infections 1.
- Once the wound bed is adequately prepared with healthy granulation tissue, surgical reconstruction with myocutaneous flaps or other advanced techniques will likely be necessary to achieve wound closure.
Additional Recommendations
- Patients with suspected chronic osteomyelitis and an adjacent extensive necrotic decubitus ulcer should be referred for surgical debridement and intraoperative cultures, as recommended by recent consensus guidelines 1.
- The use of antimicrobial dressings, growth factors, bioengineered skin products, and other adjunctive therapies should be approached with caution and considered on a case-by-case basis, as their effectiveness and potential harms are still being studied 1.
From the Research
Management of Decubitus Ulcer with Sacral Bone Exposure
The next step in managing a decubitus ulcer with sacral bone exposure involves a comprehensive approach, including:
- Aggressive debridement to remove dead tissue and promote healing 2
- Use of negative-pressure wound therapy (NPWT) to accelerate wound healing 3, 4
- Antibiotic therapy to prevent or treat infections 4
- Surgical interventions, such as flap coverage or hip disarticulation, may be necessary in severe cases 2
Treatment Options
Treatment options for decubitus ulcers with sacral bone exposure include:
- Negative-pressure wound therapy with instillation and dwelling (NPWTi-d) 4
- Use of myocutaneous flaps to provide soft tissue coverage 2
- Debridement and antibiotic therapy to prevent or treat osteomyelitis 4, 5
- A multidisciplinary approach, including prevention and education, is essential for effective management 6
Importance of Histopathologic Assessment
Histopathologic assessment of bone biopsies may not be necessary in all cases of grade IV decubitus ulcers, as the extent of osseous involvement may be overestimated by macroscopic aspect and clinical imaging techniques 5
- However, in cases with suspected osteomyelitis or sepsis, histopathologic assessment can provide valuable information for establishing a therapeutic approach 5