Over 3 million patients in the US are diagnosed annually with a pressure ulcer. Deep tissue infection, such as osteomyelitis may develop within weeks of pressure ulcer formation. This video highlights the technique and pathological findings in two pressure ulcers on the same patient.

We review of operative notes on 431 consecutive pressure ulcer debridements. This video details how to diagnose and treat osteomyelitis associated with pressure ulcers in the operating room. Select specimens of the non-healing edge of stage IV pressure ulcers were also immunostained with a molecular marker for non-healing. Cellular apoptosis was evaluated using a TUNEL assay.

Steps in Deep Ulcer Debridement:

1. Assess for undermining in the wound and excision of the overlying skin to expose the wound bed and bone. Place emphasis on minimizing new skin loss.
2. Remove all non-viable skin edges. Normal skin should not have signs of hyperkeratosis and parakeratosis.
3. Remove deep wound bed tissue, with radical excision of all infected muscle and bone. Healthy remaining tissue is characterized by absence of fat necrosis and fibrosis. Bone should be free of osteomyelitis and fibrosis.
4. Perfect hemostasis is emphasized using combination of suture and topical hemostatics.

Operative debridement of pressure ulcers involves removing cells that have an impaired ability to heal, as defined by pathology. Rapid, detailed and sequential operative technique is needed in order to ensure patient safety and stimulation of healing in patients who have multiple co-morbidities.