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CHAPTER 30
may lead to breakdown, especially in the centre of the scar where the blood circulation is
particularly delicate and can easily be damaged by pressure or shear stress. This is also
a very important pre-operative measure if plastic repair is contemplated, as the more
pliable the surrounding skin has become the easier will be the approximation of the skin
flaps following excision of the scar. We have always preferred to wait with closing skin
defects with flaps until the sore is healed or at least in the last stage of epithelialization,
because the size of the defect is greatly diminished by cicatrization.
Rotation and transposition flaps
A great variety of rotation and transposition flaps containing whole thickness of the skin
and varying amount of subcutaneous tissue with or without addition of split skin grafts
have been advocated for the surgical repair of large scars or sores, especially over the
sacrum and trochanters (Barker, 1945,1946; Conray
et
a/., 1947; Osborne, 1955; Conray
& Griffith, 1956; Blocksam, Kostrubala & Greeley, 1947; Bors & Comarr, 1948; Comarr,
1964; Bailey, 1967; Griffith, 1969). At the Stoke Mandeville Spinal Centre, the technique
of glutaeal rotation flaps, as practised by Kilner and his school, has been adopted and
carried out for many years successfully by my colleague JJ.Walsh (Fig. 201). This
technique allows good approximation of the rotation flaps with the least amount of
tension, and thus the whole scar is completely covered without forming a new open area
which has to be covered with sliding grafts, as is often necessary following transposition
flaps such as large thoraco-abdominal tubed pedicles as described by Conray & Griffith
(1956), Bailey (1967) and others.
Trochanteric scars and ischial sores of smaller size are excised including removal of
the osteomyelitic bone and closure by primary sutures can be accomplished in the majority
of cases. The same applies to small sores over the buttocks.
Special mention may be made of two methods which I introduced some years ago for
the surgical repair of special types of sores in the ischial area:
(i) 'Pseudo-tumor' technique for the removal of sinus sores
As already mentioned, the visible skin lesion in this type of sore is, as a rule, small and
innocent in appearance, but it leads into a greater or lesser cavity adherent to the bone,
and unless the wall of the cavity is excised
in toto
with the infected bone, such a sore will
not heal. In order to facilitate the tedious dissection of such a flaccid bursa, the wall of
which is often difficult to define, thus necessitating continuous working in a highly
contaminated area, the cavity is first packed as tightly as possible with narrow ribbon
gauze soaked in a brightly coloured antiseptic, usually flavine or flavazole, whereby the
cavity is distended as much as possible and has the appearance of a tumour. The narrow
opening in the skin is then closed with one or two sutures, and, through an elliptical
incision, the whole mass of pseudo-tumour is dissected out of the surrounding tissues
(Fig. 214). Contamination of the operation field is thus avoided. The pseudo-tumour
adherent to the bone is then removed with the infected part of the bone (Guttmann,
1953). Onty i*1 selected cases has it been necessary to perform a complete ischiectomy—
