Surgical Intervention for Necrotic Deep Tissue Injury of the Buttock
Surgical debridement should only be performed if the necrotic DTI has evolved to full-thickness tissue loss with visible necrotic tissue requiring removal; otherwise, aggressive pressure offloading is the primary treatment strategy. 1
Initial Assessment and Decision Algorithm
The critical decision point is determining whether you are dealing with:
- Intact DTI (no open wound): Pressure offloading is the cornerstone, NOT surgical intervention 1
- DTI evolved to full-thickness loss with necrotic tissue: Surgical debridement is indicated 1
- Infected necrotic DTI: Emergent surgical debridement is mandatory 2, 1
When Surgical Debridement IS Indicated
Timing of Surgery
Perform surgical debridement as soon as possible, ideally within 12 hours of diagnosis, when necrotic tissue is present and infection is suspected. 3 Delayed surgical debridement beyond 12 hours is associated with significantly higher mortality, increased septic shock, acute renal failure, and requirement for more debridement procedures. 3
Surgical Technique
- Remove all necrotic tissue completely until healthy, viable, bleeding tissue is encountered 3
- Extend incisions along involved tissue planes and continue debridement into healthy-looking tissue 3
- Spare normally perfused skin—if skin viability is questionable, preserve it and reassess at the second operation 3
- Leave the wound open; never perform primary closure 3
- Obtain deep tissue cultures before starting antibiotics to guide definitive antimicrobial therapy 2
Repeat Surgical Revisions
Plan the first re-exploration within 12-24 hours and repeat serial debridements until the patient is completely free of necrotic tissue. 3 Delayed re-debridement after initial source control results in worse survival and increased acute kidney injury. 3
When Surgical Debridement IS NOT Indicated
Primary Management for Intact DTI
The cornerstone of DTI management is aggressive pressure offloading, not debridement. 1 This includes:
- Turning schedule every 2-3 hours to eliminate pressure on the affected area 1
- Specialized pressure-relieving mattresses to redistribute pressure 1
- Specialized cushions when sitting is necessary 1
- Maintain moist wound environment with appropriate dressings 1
Critical pitfall: Inadequate pressure offloading will prevent healing regardless of any other interventions, including surgical debridement. 1
Adjunctive Therapies Post-Debridement
Negative Pressure Wound Therapy (NPWT)
Consider NPWT only after complete removal of all necrotic tissue. 3, 1 NPWT should never be applied to infected wounds until complete surgical removal of necrosis has been accomplished. 1 It promotes granulation tissue formation, increases blood supply, removes exudate and bacteria, and accelerates wound healing. 3
Hyperbaric Oxygen Therapy
Consider adjuvant hyperbaric oxygen therapy after prompt debridement, as it reduces mortality (RR = 0.47; 95% CI, 0.30-0.74) despite higher costs and longer hospital stays. 3 However, HBO should not delay standard surgical care or require patient transfer. 3
Fecal Diversion Considerations
For buttock wounds with fecal contamination risk, consider rectal diversion devices or fecal management systems before resorting to colostomy. 3 Temporary stoma formation significantly increases healthcare costs without affecting mortality rates or hospital length of stay. 3
Systemic Optimization
Concurrent with local wound management, optimize: 1
- Tight glycemic control if diabetic
- Smoking cessation
- Cardiovascular risk factors
- Adequate nutrition with appropriate protein intake
- Edema control
- Adequate pain control
Common Pitfalls to Avoid
- Delaying surgical debridement when necrotic tissue is present leads to treatment failure even with appropriate antibiotics 2
- Performing debridement on intact DTI without necrotic tissue when pressure offloading is the appropriate intervention 1
- Applying NPWT before complete necrotic tissue removal 1
- Inadequate pressure offloading will prevent healing regardless of surgical intervention 1
- Removing viable skin at initial operation—preserve questionable skin for reassessment 3