According to federal regulations for nursing homes, all pressure ulcers must be assessed for undermining. However, there is no standard technique for surgical treatment of pressure ulcers with undermining. The video highlights surgical techniques for the initial debridement of a stage IV pressure ulcer.

Operative notes on 431 consecutive pressure ulcer debridements over a four year period is reviewed. Routine histology of each layer of tissue was examined & discussed.

Surgical Technique:

1. Assess for undermining of the wound.
2. Plan a triangular incision with the base formed by the wound edge and the apex extended into normal skin.
3. Remove all underlying non-viable tissue and send to pathology. H&E sections illustrate the difference between normal representative tissue histology and stage IV pressure ulcer pathology. Pathological analysis showed hyperkeratosis of the skin edge, fat necrosis and fibrosis in the subcutaneous tissue, and osteomyelitis at the deepest level.
4. Presence of granulation tissue with endothelial tissue and inflammatory cells should indicate adequate depth of debridement.

431 consecutive operative debridements were completed without any mortality or return to the operating room. Pressure ulcer debridement involves removing cells that have an impaired ability to heal. Initial debridement must expose the entire wound bed, including surgical removal of undermined tissue to allowing healing from the base upwards. By removing infection, fibrosis and scar as defined by pathology, the patient may then be a candidate for soft tissue closure with a myocutaneous flap or other treatment.