Title: Combination application of ultrasonic debridement, methylene blue staining, and negative pressure wound therapy for severe pressure ulcers
Abstract: Though common, the treatment of pressure ulcer is still a great challenge for clinical surgeons. The mainstays of pressure ulcer treatment include offloading the offending pressure source, control of remaining infection with antibiotics, debridement of devitalized tissues, medical and nutritional patient optimization, appropriate dressing selection, and regular wound care to support the healing process. However, the optimal therapeutic approach of pressure ulcer remains controversial. Debridement of devitalized tissues and biofilm is essential for the treatment of pressure ulcer.1 Ultrasonic debridement (UD) is a superior choice for the primary management of pressure ulcer. With the ultrasonic technique, the fine scaler tip with its ultrasonic vibration makes it ideal for efficient, rapid, precise, and thorough removal of ingrained dirt and grit from contaminated facial wounds without injuring or sacrificing adjacent normal skin.2 Coincidentally, negative pressure wound therapy (NPWT) is another excellent alternative adjunct to surgical debridement. NPWT is a non-invasive adjunctive therapy that applies controlled negative pressure using vacuum sealing drainage (VSD) or vacuum-assisted closure device to help promote wound healing by removing fluid from open wounds through a sealed dressing and tubing which is connected to a collection container.3 However, by the aid of radical debridement, the damaged tissues still cannot be totally removed, just because the damaged tissues cannot be visually identified on the surface of pressure ulcers. In our previous study, we created the first paradigm for using methylene blue staining (MBS) as an aid to identify the dead tissue layer before and during surgery upon the pressure ulcers.4 Herein, for the second time, we created another successful case. However, distinguishing from the previous paradigm, the patient in this report is treated by a conservative combination therapy instead of reconstructive surgery. We present the case of a 28-year-old male to our department with two grade IV pressure ulcers on the sacrococcygeal region after fall injury on his thoracic vertebrae over 6 years. The lesion was induced by a long-term sitting or prone position. On physical examination, his bilateral ischium area showed two deep pressure sores involving approximately 7 × 8 × 6 cm3 on the left and 5 × 6 × 3 cm3 on the right, respectively (Figure 1A). Laboratory and physical examination, chest radiography, and CT scan of the head did not show any signs of neurological, respiratory, and cardiovascular abnormalities. To control the remaining infection, antibiotics and UD were first applied (Figure 1B). Following appropriate surgical debridement, NPWT is cautiously performed by the aid of VSD (Figure 1C). After 2-month treatment, the size and depth of both soles were obviously shrunk. To further identify the damaged tissues on the surface of pressure ulcers, MBS was applied topically on the dermal pressure ulcers. Within 24 hours, an acceptable colour change had been produced in what was considered to be non-viable tissues (Figure 1D). By the aid of MBS and surgical debridement, the dead and damaged tissues were completely removed. To accelerate epithelial proliferation and promote wound healing, inorganic induced active elements (Dermlin) were applied every 2 days in later stage (Figure 1E). At a 4-month follow-up visit, the pressure ulcer was completely healed without complications (Figure 1F). To the best of our knowledge, no case has previously been reported of combination application of UD, MBS, and NPWT upon the pressure ulcers. In our study, for the first time, combined with UD, MBS, and NPWT, a successful paradigm is created for the treatment of severe pressure ulcers. Furthermore, by the aid of this novel combination therapy, the patient in our report achieved a favourable restoration without complications.