OBJECTIVE: Pressure injury is a gradually increasing disease in the aging society. The reconstruction of a pressure ulcer requires a patient and surgical technique. The patients were exposed to the radiation risk under other ways of detection of perforators such as computed tomographic angiography and magnetic resonance angiography. Here, we compared two radiation-free methods of a superior gluteal artery perforator (SGAP), flap harvesting and anchoring. One is the traditional method of detecting only handheld acoustic Doppler sonography (ADS) (Group 1). The other involves the assistance of intraoperative indocyanine green fluorescent near-infrared angiography (ICGFA) and handheld ADS (Group 2).
METHODS: This is a single-center, retrospective, observational study that included patients with sacral pressure injury grades III and IV, who had undergone reconstructive surgery with an SGAP flap between January 2019 and January 2021. Two detection methods were used intraoperatively. The main outcome measures included the operative time, estimated blood loss, major perforator detection numbers, wound condition, and incidence of complications.
RESULTS: Sixteen patients underwent an SGAP flap reconstruction. All patients were diagnosed with grade III to IV sacral pressure injury after a series of examinations. Group 1 included 8 patients with a mean operative time of 91 min, and the mean estimated blood loss was 50 mL. The mean number of perforators was 4. Postoperative complications included one wound infection in one case and wound edge dehiscence in one case. No mortality was associated with this procedure. The mean total hospital stay was 16 days. Group 2 included 8 patients with a mean operative time of 107.5 min, and the mean estimated blood loss was 50 mL. The mean number of perforators was 5. Postoperative complications included one wound infection. No mortality was associated with this procedure. The mean total hospital stay was 13 days.
CONCLUSIONS: The combination of detection of the SGAP by ICGFA and handheld ADS for the reconstruction of a sacral pressure injury provides a more accurate method and provides the advantage of being radiation-free.

Pressure ulcers are caused by sustained pressure, friction, or shear on the skin which limits blood flow to the dermis and surrounding tissue. Symptoms include redness and ulceration and may result in a chronic wound. This ailment affects three million adults in the United States, and is a major burden to the healthcare system. Pressure ulcers are associated with pain and immobility that substantially lower the patient\'s quality of life, resulting in longer and more frequent hospitalization and a higher risk of mortality. As the severity of the pressure ulcer increases, it becomes more challenging for clinicians to successfully treat the wound and achieve healing objectives. Treatment of a pressure ulcer is more challenging when the wound is associated with infection, heavy exudate, inflammation, high enzymatic activity, and exposed bone and/or muscle. An advanced technology that may provide a new solution for the treatment of pressure ulcers is the use of a biodegradable synthetic hybrid-scale fiber matrix. The synthetic hybrid-scale fiber matrix provides a porous scaffold for cellular infiltration and vascularization that leads to granulation tissue formation and re-epithelialization, before completely resorbing via hydrolysis. In this case report, a patient who had a large sacral pressure ulcer present for over 16 years with two exposed spinal segments and exposed peritoneum was treated with the hybrid-scale fiber matrix. A total of nine applications of the material were applied over 11 weeks. The wound demonstrated significant healing, wound exudate was notably reduced, and no complications were observed. New epithelial tissue formation, tissue coverage over the exposed bone, infection management, and wound exudate reduction were observed to the extent that the patient was discharged from the hospital. Overall, the excellent healing response achieved on this 16-year-old chronic wound suggests that the synthetic hybrid-scale fiber matrix may be a good treatment option for difficult-to-heal pressure ulcers.