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- 1.1. Forty-seven ischial ulcers are presented in forty-one patients.
- 2.2. The “sore-free” interval from the time of injury to the onset of the ulcer ranged from three months to thirteen years.
- 3.3. There were two cervical, sixteen upper dorsal, seventeen lower dorsal, and six lumbar lesions. Secondary bone changes were present in thirty-five cases but no relationship between level of injury and secondary bone changes could be established.
- 4.4. Local trauma plays the major role in the etiology of the ischial ulcer. It is believed that the skin circulation is unimpaired but that the neurogenic disuse atrophy of the underlying structures is a contributory factor. This “late” ulcer might develop in the absence of protein disturbances, anemia, or infection.
- 5.5. The tendency of the infection to spread to deeper tissues is favored by the presence of poorly vascularized bursae and the proximity of the anus. True metaplastic ossification and cartilage formation is found on histologic examination. The bacterial flora is similar to that encountered in the concurrent urinary infection. Conservative treatment of a fully developed ulcer is unsuccessful.
- 6.6. The local preoperative treatment consists in débridement. The general preoperative treatment should correct hypoproteinemia, avitaminosis, and anemia. Multiple blood transfusions are beneficial even in the absence of hypoproteinemia or anemia. Sulfonamides and penicillin are used systemically. Postoperatively a similar regime is carried out as preoperatively. Sutures are removed at a late date.
- 7.7. Two methods of surgical treatment are presented. Both remove the ulcer en bloc, including the bone. The “primary method” uses the redundant gluteal musculature for the covering of the bone defect by an inverting stitch of stainless steel wire. The “secondary method” uses a pedicled gluteal flap for the padding of the bone. Stainless steel is used for skin closure. Drainage is important.
- 8.8. The total number of cures was 85.1 per cent, the total number of failures, 15 per cent; 66 per cent healed after one intervention, 19 per cent needed more than one operation. The number of cures with one intervention and the number of recurrences is in favor of the “secondary method.” The causes of failure were faulty interpretation of x-rays, technical errors, lack of immobilization, and lack of cooperation of the patient.
- 9.9. The results presented and the technique are discussed in the light of the recent literature.
- 10.10. Early use of braces and medical instruction of the patients are recommended for the prevention of ulcers.
- 11.11. A simple ulcer with bursa formation is excised. A primary ulcer with redundant muscle and bone involvement is treated by the primary method, and all other conditions by the secondary method.
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Received: December 1, 1947
☆Published with permission of Chief, Medical Director, Department of Medicine and Surgery, Veterans Administration, who assumes no responsibility for the opinion expressed or conclusions drawn by the authors.
© 1948 Published by Elsevier Inc.