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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 162-164

Primary Coverage of Donor Site Using Expanded Meshed Skin Graft in a Polytrauma Patient with Degloving Injury of Foot


Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India

Date of Submission25-Nov-2020
Date of Acceptance01-Dec-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Sharath Kowshik
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_84_20

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  Abstract 


It is a known fact that following split thickness skin grafting in post traumatic wounds the donor site heals with re-epithliazation. The skin thus formed initially is fragile and takes a long time to become strong mobile and elastic. However, in some patients, donor site poses risk of nonhealing, delayed healing, hypertrophic scar formation and cosmetic disfigurement, etc., In such patients, it is ideal to identify such risk factors and manage them carefully. We are reporting a case of degloving of the foot in a poly-traumatized patient treated by split thickness skin grafting where to avoid the above problems, the donor site was also skin grafted primarily after meshing the skin and making it large.

Keywords: Degloving wound, meshed skin graft, skin graft


How to cite this article:
Agrawal AC, Kowshik S, Ojha MM, Rakshit J, Choudhary R, Yadav SK. Primary Coverage of Donor Site Using Expanded Meshed Skin Graft in a Polytrauma Patient with Degloving Injury of Foot. J Orthop Traumatol Rehabil 2020;12:162-4

How to cite this URL:
Agrawal AC, Kowshik S, Ojha MM, Rakshit J, Choudhary R, Yadav SK. Primary Coverage of Donor Site Using Expanded Meshed Skin Graft in a Polytrauma Patient with Degloving Injury of Foot. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2021 Jul 25];12:162-4. Available from: https://www.jotr.in/text.asp?2020/12/2/162/305090




  Introduction Top


Management of wounds sustained by patients due to high-velocity injuries such as road traffic accidents and farm injuries takes a very long course. Split-thickness skin grafting is a most often used technique in repairing the degloving wounds.[1] However, harvesting a skin graft creates another wound at the donor area at risk of nonhealing, delayed healing, cosmetic disfigurement, hypertrophic scars, etc. To avoid the abovementioned complications, several kinds of dressings for caring of such wounds are reported.[2] Donor area dressings can be open or semi-open, occlusive or semi-occlusive, and biological. Ideal donor site dressing should be pain free, reduce blood loss, and change after wound healing.[3] The biological way of management of the donor site by primary split-thickness skin graft is an excellent method to overcome these complications. For successful result in this aspect, meshing of the graft can expand the graft area and helps in limiting the area of the donor site. With this background, we report our experience in primary coverage of the donor area in a polytrauma patient degloving ankle injury.


  Case Report Top


A 19-year-old female sustained a high-velocity injury in the form of road traffic accident and presented to our casualty with fracture shaft of femur left side, fracture proximal tibia right side, and medial malleolus fracture with degloving injury over the anteromedial aspect of the distal third of the left leg. After initial stabilization, the patient underwent definitive management for femur shaft fracture. During this surgery, the degloving wound over the left leg was debrided thoroughly and medial malleolus was fixed with k-wires. Following this, negative pressure wound therapy (NPWT) dressing was applied to the wound twice for 7days each. After the development of healthy granulation tissue, as shown in [Figure 1], the patient was planned for split-thickness graft coverage of the wound.
Figure 1: Image of the degloved wound over the ankle with healthy granulation

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The recipient site was measured to be approximately size 15 cm × 10 cm. Split-thickness skin graft of size 15 cm × 10 cm was harvested from the anterolateral aspect of the ipsilateral thigh for sheet graft to wound and 15 cm × 5 cm for mesh graft to donor site. Adequate graft was placed upon the recipient site as a sheet graft, as shown in [Figure 2]. The remaining skin graft was meshed in a 3:1 mesher and used to cover the donor site. Below-knee slab support was given to immobilize the left ankle joint. Upon inspection on the 5th postoperative day, there was a good graft uptake at both recipient and donor sites, as shown in [Figure 3] and [Figure 4]. After 2-week follow-up, the entire wound was epithelialized and the patient was satisfied with the cosmetic appearance.
Figure 2: Immediate postoperative image showing sheet graft for covering degloved wound in the ankle and meshed graft for donor site

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Figure 3: Follow-up images of wound showing complete uptake of graft

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Figure 4: Follow-up image of donor site with meshed graft uptake

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  Discussion Top


Many evidences are available on the complications arising from the donor site following split-thickness skin grafting due to various reasons.[2] Various complications that are reported are nonhealing, delayed healing, hypertrophic scar formation, infection and sloughing, etc., Furthermore, many risk factors are identified for these complications. Age, physical activity, comorbidities, malnutrition, immunocompromised status, alcohol dependence, predisposing factors for keloid, and hypertrophic scars are the main risk factors identified in this regard.[2] The incidence of nonhealing of donor site is more common in elderly and bedridden patients. Hypertrophic scar occurrences are seen in younger population.

To prevent these complications, different types of wound dressing are used, and among them, biological coverages by autologous meshed skin graft have more benefits than artificial dressings.[4] Most of the studies based on burn injuries propose the use of meshed graft both for the wound and the donor site.[5] Meshed graft has an advantage of expanding over larger site, allowing drainage of hematoma, and draping around irregular surfaces, however, because of secondary contracture and poor cosmesis, this is avoided in the face, hands, and over joints. Commonly used meshers for this purpose have an expansion ratio of 1.5:1, 3:1, or 6:1.[6],[7] These ratios indicate the size of donor skin that should be 85%, 60%, and 45% size of the recipient wound, respectively. This helps the operating surgeon to calculate the approximate area of graft requirement to cover both the wound and the donor area.

This method of grafting the donor site primarily reported in this article, with an excellent result with no complications reported in this patient, has a good cosmetic outcome. This technique is ideal to be followed in higher specialty centers for use in patients likely to develop extreme wound healing difficulty. Further studies are required in identifying the patients with risks of such complication

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ratner D. Skin grafting. Semin Cutan Med Surg 2003;22:295-305.  Back to cited text no. 1
    
2.
Lars PK, Giretzlehner M, Trop M, Parvizi D. The properties of the “ideal” donor site dressing: results of a worldwide online survey. Ann Burns Fire Disasters 2013;26:136-41.  Back to cited text no. 2
    
3.
Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res 2010;89:219-29.  Back to cited text no. 3
    
4.
Caliot J, Bodin F, Chiriac S, Correia N, Poli-Mérol ML, François-Fiquet C, et al. Split-thickness skin graft donor site: Which dressing use?. Ann Chir Plast Esthet 2015;60:140-7.  Back to cited text no. 4
    
5.
Bian Y, Sun C, Zhang X, Li Y, Li W, Lv X, et al. Wound-healing improvement by resurfacing split-thickness skin donor sites with thin split-thickness grafting. Burns 2016;42:123-30.  Back to cited text no. 5
    
6.
Lyons JL, Kagan RJ. The true meshing ratio of skin graft meshers. J Burn Care Res 2014;35:257-60.  Back to cited text no. 6
    
7.
Goverman J, Kraft CT, Fagan S, Levi B. Back grafting the split-thickness skin graft donor site. J Burn Care Res 2017;38:e443-9.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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