Some wounds do not follow a healing trajectory. They stay open for months, sometimes years, and the patients living with them require a level of care and coordination that even the most well-resourced clinical teams struggle to provide. Chronic pelvic pressure wounds, particularly those involving exposed bone and underlying osteomyelitis, represent one of the most complex and understudied problems in wound care today.
In a WHS Education Committee webinar on chronic pelvic wounds and osteomyelitis, two clinicians with deep experience in this population, Dr. Lisa Gould, a reconstructive plastic surgeon and past president of the Wound Healing Society, and Dr. Christina Megal, nurse practitioner and medical director of a wound care program at the Medical College of Wisconsin, offered an honest and clinically detailed look at the problem: what we know, what we do not know, and where the field needs to go.
A Population That Slips Through the Data
One of the first things Dr. Megal made clear is that we do not have a reliable picture of how many people are living with chronic pelvic pressure wounds. The incidence and prevalence of this condition are not well defined in the literature, and many patients never reach a facility that can capture data in a meaningful way. What clinicians do know from experience is that these wounds can remain open for years. Dr. Megal shared that some of her patients have lived with chronic pelvic pressure injuries for twelve to fifteen years.
The population most affected includes people with spinal cord injury, older adults with frailty and limited mobility, and patients who develop hospital-acquired pressure injuries during serious illness and are left managing them long after discharge. In a retrospective review of traumatic spinal cord injury patients seen at a Level 1 trauma center, the mean time from injury to pressure injury development was 3.7 years, with a range extending out to fifteen years. Significant predictors included complete spinal cord injury, violent mechanism of injury, male sex, unmarried status, and increasing age. These are not abstract risk factors. They describe a specific, underserved, and under-researched group of people.
The Reality of Caring for These Patients
Dr. Megal described what it actually takes to manage this population in an outpatient wound clinic, and the picture is one of extraordinary resource intensity. Moving a patient with a spinal cord injury from a wheelchair to an exam table for assessment may require one or two technicians, nursing staff, and provider involvement, often with social work as well. Transportation barriers can also prevent patients from consistently keeping appointments, further delaying care and treatment.
Stage four pressure injuries with exposed bone are particularly challenging to treat, and some simply do not progress toward healing regardless of the interventions applied. In response to this reality, Dr. Megal’s team developed a palliative wound care program specifically for patients whose wounds are not on a healing trajectory. The word palliative is used deliberately and carefully here, grounded in its true meaning: to relieve suffering, manage symptoms, and support quality of life. The program is not about giving up; it’s about being honest with patients and families about what is achievable, while still doing everything possible to limit tissue loss, control infection, manage drainage and pain, and keep patients supplied with what they need to care for their wounds at home.
As of 2025, their facility is tracking 81 patients with chronic pelvic pressure injuries that are not healing. Those 81 patients carry 130 pressure injuries between them, and 62 have an additional diagnosis of underlying osteomyelitis. Palliative wound care visits now account for 13 percent of total clinic volume, averaging 68 visits per month. That data matters not only clinically but operationally, allowing the team to predict staffing needs and manage resources around a population that would otherwise be invisible in traditional volume metrics.
Why Osteomyelitis Makes Everything Harder
Dr. Gould used the second half of the webinar to address the osteomyelitis component, emphasizing the complexity of the problem. Pelvic osteomyelitis, she argued, is a neglected disease. The literature is thin, the diagnostic tools are unreliable, and clinical practice varies enormously.
The challenge begins with diagnosis. Unlike long bone osteomyelitis, where MRI is the gold standard and clinical findings are more consistent, pelvic osteomyelitis is notoriously difficult to confirm through imaging. MRI is highly sensitive (around 94 percent) but not specific (as low as 22 percent) in this context, as there are many reasons for bone marrow edema in the pelvis other than bone infection.. Hardware artifacts, prior surgical changes, patient spasticity, positioning difficulties, and osteopenia all further compromise what imaging can tell you. The gold standard is bone biopsy for culture and histopathology, but even that comes with limitations. There is no universally agreed-upon pathologic definition of osteomyelitis. Pathologists may see bone remodeling and acute and chronic inflammation and call it osteomyelitis, but the grading is not standardized, and sampling error is a real risk, particularly with small or percutaneous biopsies.
Compounding all of this is the fact that many patients with pelvic pressure wounds have concurrent medical conditions that elevate inflammatory markers regardless of whether bone infection is present. A urinary tract infection, for example, will raise CRP and produce leukocytosis, and in the emergency department, the wound is often blamed first. Albumin and pre-albumin, already poor markers for nutritional status in a hospitalized patient, become even less useful in the setting of active infection.
What the Guidelines Say and Where Practice Diverges
The WHS pressure ulcer guidelines do address osteomyelitis directly. Bone biopsy for culture and histopathology is supported at Level I evidence, and the guidelines recommend adequate debridement of confirmed osteomyelitis followed by culture-guided antibiotic therapy. When the patient is an appropriate surgical candidate, flap reconstruction with well-vascularized tissue is recommended to facilitate healing.
Dr. Gould was candid about the gap between guideline recommendations and the actual variation in clinical practice. A survey of 558 infectious disease physicians from the Emerging Infections Network found wide disagreement on nearly every aspect of antibiotic management for stage four pressure ulcers: whether to use oral or IV antibiotics, which pathogens warranted which routes, and how long to treat. The consensus, such as it is, includes the observation that osteomyelitis is often treated too broadly and for too long, and that antimicrobial duration does not appear to be strongly associated with treatment success or failure.
On the question of whether to treat pelvic osteomyelitis aggressively at all, the literature itself is divided. Some authors argue that sacral osteomyelitis is overdiagnosed and overtreated, and that most positive cultures represent focal rather than diffuse infection that can be managed with targeted debridement rather than prolonged antibiotics. Others treat aggressively, but there is no consensus on duration. Dr. Gould noted that all the review articles in this space are drawing from the same small pool of literature and interpreting it differently. The research base simply is not large enough to settle the clinical questions.
A Surgical Perspective on Debridement and Flap Reconstruction
Dr. Gould described her own surgical strategy in detail, emphasizing that her goal at the time of operative debridement is to understand what is being left in the patient, not just what is being removed. She debrides to viable tissue, irrigates, and then takes tissue biopsies from what remains, culturing for aerobes, anaerobes, and in long-standing or unusual cases, fungi and atypical mycobacteria. She noted that fungal cultures currently take six weeks to return, making empiric treatment difficult and pointing to a clear need for faster diagnostics.
Regarding flap reconstruction timing, the approach depends on wound condition and patient status. Debridement followed by a period of antibiotic treatment before flap reconstruction allows time to confirm organism clearance or identify new pathogens that may have taken over a wound. In a clean, well-prepared wound with a medically stable patient, immediate flap reconstruction is a reasonable option. What does not work, in her experience, is primary closure or V-Y advancement in most cases. Rotation flaps that keep the incision away from the wound site and bring well-vascularized tissue over the bone give the best long-term results.
She is equally clear about what has to be in place before surgery is offered at all. Patients must be able to comply with offloading requirements postoperatively, which may mean a minimum of six weeks of bed rest in a population already exhausted by immobility. Blood glucose must be controlled, nutrition must be optimized, spasticity must be managed, and both the patient and their support system must genuinely understand and commit to the recovery protocol. Both mental health and social support is critical for the patient’s wellbeing during this time. For patients who cannot meet these criteria, the palliative wound care pathway is not a lesser option, it is the appropriate one.
What the Field Still Does Not Know
Both speakers were open regarding the limits of current knowledge; these gaps can represent a roadmap for future research. For example, we do not know whether sacral osteomyelitis differs from ischial osteomyelitis in diagnosis, prognosis, or treatment response. Neither, do we have a standardized pathological definition of osteomyelitis that wound care providers and pathologists can use consistently. We do not have validated biomarkers for pelvic osteomyelitis or randomized controlled trials examining the impact of bone biopsy on treatment decisions, or establishing optimal antibiotic duration in this population. Finally, we also do not have a clear picture of the national or international prevalence of chronic pelvic pressure wounds or the long-term outcomes of the people living with them.
Currently there is only one multi-center clinical trial registered on clnicaltrials.gov focused on osteomyelitis associated with pressure ulcers (https://clinicaltrials.gov/study/NCT06283979). Funding for this kind of research is difficult to secure, as the patient population is complex to study, and multi-center trials are needed to generate the sample sizes that would make findings meaningful.
Why This Work Matters
The Wound Healing Society exists precisely for problems like this one. Chronic pelvic pressure wounds sit at the intersection of basic science, translational research, and clinical practice, and they affect a population that is already marginalized by disability, poverty, and limited access to care. The WHS pressure ulcer guidelines provide the most rigorous commercially unbiased framework available for clinical decision-making, and the society’s education programming, including the webinar series from which this article draws, works to close the distance between what the literature supports and what happens at the bedside.
The questions raised by Dr. Gould and Dr. Megal in this webinar are invitations to researchers seeking a meaningful, genuinely underserved clinical problem to study.
The content in this article is intended for informational and educational purposes only and does not constitute medical advice. The information presented is based on published scientific research and clinical guidelines and should not be used as a substitute for professional medical judgment, diagnosis, or treatment. Clinicians should apply their own clinical expertise and consider individual patient circumstances when making treatment decisions. Researchers should consult primary sources and exercise independent judgment when interpreting findings. The Wound Healing Society does not endorse any specific product, treatment, or commercial entity referenced in this content.
Connect with WHS
The Wound Healing Society is the premier scientific membership organization for wound healing researchers and clinicians, founded in 1989. WHS publishes Wound Repair and Regeneration and convenes the annual scientific meeting to advance wound healing science from bench to bedside.
Learn more at woundheal.org and follow us on Facebook, Instagram, Linkedin and YouTube.