J Korean Foot Ankle Soc.  2022 Jun;26(2):78-83. 10.14193/jkfas.2022.26.2.78.

Skin Graft Remains a Clinically Good Treatment Strategy for Chronic Diabetic Wounds of the Foot and Ankle

• Kim YC
• Kim BS
• Jeong H
• Ahn JH

• KMID: 2530487
• DOI: http://doi.org/10.14193/jkfas.2022.26.2.78

Abstract

Purpose
The purpose of this study was to evaluate the surgical outcome of split-thickness skin graft (STSG) for chronic diabetic wounds of the foot and ankle.
Materials and Methods
The medical records of 20 patients who underwent surgery for chronic diabetic wounds of the foot and ankle between October 2013 and May 2018 were reviewed. Surgical management consisted of consecutive debridement, followed by negativepressure wound therapy and STSG. We used an acellular dermal matrix between the wound and the overlying STSG in some patients with wide or uneven wounds. Patient satisfaction, comorbidities, wound size and location, length of hospital stay, wound healing time, and complications were investigated.
Results
Of 20 patients, 17 (85.0%) were satisfied with the surgical outcome. Eight patients had diabetic wounds associated with peripheral vascular disease (PVD), 7 patients had diabetic wounds without PVD, and 5 patients had acute infection superimposed with necrotizing abscesses. The mean size of the wound was 49.6 cm 2 . The mean length of hospital stay was 33.3 days. The mean time to wound healing was 7.9 weeks. The mean follow-up period was 25.9 months. Complications included delayed wound healing (4 cases) and recurrence of the diabetic wounds (2 cases), which were resolved by meticulous wound dressing.
Conclusion
STSG remains a good treatment strategy for chronic diabetic wounds of the foot and ankle.

Keyword

Chronic diabetic wound; Skin graft; Negative-pressure wound therapy; Acellular dermal matrix

Figure

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  Figure. 1 (A) A 68-year-old female patient with diabetes mellitus and lymphangitis presented blood-containing blisters on her left foot without a history of trauma. (B) After consecutive debridement for devitalized tissue, healthy granulation tissue growth was confirmed.

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  Figure. 2 (A) A paste-type acellular dermal matrix (ADM) (solid lined arrow) was applied to a bed of granulation tissue followed by an overlying split-thickness skin graft (STSG) (dotted lined arrow). (B) Gauze coated with Vaseline® was used for a skin graft wound dressing and overlying negative-pressure wound therapy (NPWT) was applied. (C) At postoperative 9 months, a patient was satisfied with the surgical outcome and had no discomfort in her daily life.

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  Figure. 3 (A) A 42-year-old male diabetic patient with peripheral angiopathy was well treated with a combination of ADM and STSG with NPWT for a 7x7 cm2 diabetic ulcer of his left ankle. (B) A 73-year-old male patient with a chronic diabetic wound with an acute abscess was also treated with the same protocol for the 8×18 cm2 wound on his right lower leg.

Reference

1. Morton LM, Phillips TJ. 2016; Wound healing and treating wounds: differential diagnosis and evaluation of chronic wounds. J Am Acad Dermatol. 74:589–605. quiz 605–6. doi: 10.1016/j.jaad.2015.08.068. DOI: 10.1016/j.jaad.2015.08.068. PMID: 26979352.

2. Shaw JE, Sicree RA, Zimmet PZ. 2010; Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 87:4–14. doi: 10.1016/j.diabres.2009.10.007. DOI: 10.1016/j.diabres.2009.10.007. PMID: 19896746.

3. Brownrigg JR, Schaper NC, Hinchliffe RJ. 2015; Diagnosis and assessment of peripheral arterial disease in the diabetic foot. Diabet Med. 32:738–47. doi: 10.1111/dme.12749. DOI: 10.1111/dme.12749. PMID: 25764390.

4. Singh N, Armstrong DG, Lipsky BA. 2005; Preventing foot ulcers in patients with diabetes. JAMA. 293:217–28. doi: 10.1001/jama.293.2.217. DOI: 10.1001/jama.293.2.217. PMID: 15644549.

5. El-Shazly M, Yassin O, Kamal A, Makboul M, Gherardini G. 2008; Soft tissue defects of the heel: a surgical reconstruction algorithm based on a retrospective cohort study. J Foot Ankle Surg. 47:145–52. doi: 10.1053/j.jfas.2007.12.010. DOI: 10.1053/j.jfas.2007.12.010. PMID: 18312922.

6. Oh TS, Lee HS, Hong JP. 2013; Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg. 66:243–50. doi: 10.1016/j.bjps.2012.09.024. DOI: 10.1016/j.bjps.2012.09.024. PMID: 23098584.

7. Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS, Germann GK. 2003; A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg. 112:129–40. discussion 141–2. doi: 10.1097/01.PRS.0000066167.68966.66. DOI: 10.1097/01.PRS.0000066167.68966.66. PMID: 12832886.

8. Chick LR. 1988; Brief history and biology of skin grafting. Ann Plast Surg. 21:358–65. doi: 10.1097/00000637-198810000-00011. DOI: 10.1097/00000637-198810000-00011. PMID: 3069030.

9. Anderson JJ, Wallin KJ, Spencer L. 2012; Split thickness skin grafts for the treatment of non-healing foot and leg ulcers in patients with diabetes: a retrospective review. Diabet Foot Ankle. 3:10204. doi: 10.3402/dfa.v3i0.10204. DOI: 10.3402/dfa.v3i0.10204. PMID: 22403742. PMCID: PMC3297411.

10. Sanniec K, Nguyen T, van Asten S, Fontaine J, Lavery LA. 2017; Split-thickness skin grafts to the foot and ankle of diabetic patients. J Am Podiatr Med Assoc. 107:365–68. doi: 10.7547/15-200. DOI: 10.7547/15-200. PMID: 29077498.

11. Rose JF, Giovinco N, Mills JL, Najafi B, Pappalardo J, Armstrong DG. 2014; Split-thickness skin grafting the high-risk diabetic foot. J Vasc Surg. 59:1657–63. doi: 10.1016/j.jvs.2013.12.046. DOI: 10.1016/j.jvs.2013.12.046. PMID: 24518607.

12. Yammine K, Assi C. 2019; A meta-analysis of the outcomes of split-thickness skin graft on diabetic leg and foot ulcers. Int J Low Extrem Wounds. 18:23–30. doi: 10.1177/1534734619832123. DOI: 10.1177/1534734619832123. PMID: 30841767.

13. Donegan RJ, Schmidt BM, Blume PA. 2014; An overview of factors maximizing successful split-thickness skin grafting in diabetic wounds. Diabet Foot Ankle. 5:24769. doi: 10.3402/dfa.v5.24769. DOI: 10.3402/dfa.v5.24769. PMCID: PMC4216388.

14. Aerden D, Bosmans I, Vanmierlo B, Spinnael J, Keymeule B, Van den Brande P. 2013; Skin grafting the contaminated wound bed: reassessing the role of the preoperative swab. J Wound Care. 22:85–9. doi: 10.12968/jowc.2013.22.2.85. DOI: 10.12968/jowc.2013.22.2.85. PMID: 23665663.

15. Battiston B, Ciclamini D, Tang JB. 2017; Compound or specially designed flaps in the lower extremities. Clin Plast Surg. 44:287–97. doi: 10.1016/j.cps.2016.11.006. DOI: 10.1016/j.cps.2016.11.006. PMID: 28340663.

16. Hong JP, Oh TS. 2012; An algorithm for limb salvage for diabetic foot ulcers. Clin Plast Surg. 39:341–52. doi: 10.1016/j.cps.2012.05.004. DOI: 10.1016/j.cps.2012.05.004. PMID: 22732380.

17. Sommerlad BC, McGrouther DA. 1978; Resurfacing the sole: long-term follow-up and comparison of techniques. Br J Plast Surg. 31:107–16. doi: 10.1016/s0007-1226(78)90057-7. DOI: 10.1016/S0007-1226(78)90057-7. PMID: 638300.

18. Akhtar S, Ahmad I, Khan AH, Khurram MF. 2015; Modalities of soft-tissue coverage in diabetic foot ulcers. Adv Skin Wound Care. 28:157–62. doi: 10.1097/01.ASW.0000460889.44609.0c. DOI: 10.1097/01.ASW.0000460889.44609.0c. PMID: 25775199.

19. Attinger CE, Ducic I, Hess CL, Basil A, Abbruzzesse M, Cooper P. 2006; Outcome of skin graft versus flap surgery in the salvage of the exposed achilles tendon in diabetics versus nondiabetics. Plast Reconstr Surg. 117:2460–7. doi: 10.1097/01.prs.0000219345.73727.f5. DOI: 10.1097/01.prs.0000219345.73727.f5. PMID: 16772957.

20. Bingol UA, Cinar C, Arslan H, Altındas M. 2015; A novel and alternative treatment method for diabetic heel ulceration exposing the calcaneus which is not suitable for flap surgery: vacuum assisted sandwich dermal matrix. Biomed Res Int. 2015:785819. doi: 10.1155/2015/785819. DOI: 10.1155/2015/785819. PMID: 26516626. PMCID: PMC4592884.

21. Llanos S, Danilla S, Barraza C, Armijo E, Piñeros JL, Quintas M, et al. 2006; Effectiveness of negative pressure closure in the integration of split thickness skin grafts: a randomized, double-masked, controlled trial. Ann Surg. 244:700–5. doi: 10.1097/01.sla.0000217745.56657.e5. DOI: 10.1097/01.sla.0000217745.56657.e5. PMID: 17060762. PMCID: PMC1856589.

22. Nakamura Y, Fujisawa Y, Ishitsuka Y, Tanaka R, Maruyama H, Okiyama N, et al. 2018; Negative-pressure closure was superior to tie-over technique for stabilization of split-thickness skin graft in large or muscle-exposing defects: a retrospective study. J Dermatol. 45:1207–10. doi: 10.1111/1346-8138.14536. DOI: 10.1111/1346-8138.14536. PMID: 30010206.

23. Yin Y, Zhang R, Li S, Guo J, Hou Z, Zhang Y. 2018; Negative-pressure therapy versus conventional therapy on split-thickness skin graft: a systematic review and meta-analysis. Int J Surg. 50:43–8. doi: 10.1016/j.ijsu.2017.12.020. DOI: 10.1016/j.ijsu.2017.12.020. PMID: 29292216.

24. Wainwright DJ. 1995; Use of an acellular allograft dermal matrix (AlloDerm) in the management of full-thickness burns. Burns. 21:243–8. doi: 10.1016/0305-4179(95)93866-i. DOI: 10.1016/0305-4179(95)93866-I. PMID: 7662122.

25. Zelen CM, Orgill DP, Serena T, Galiano R, Carter MJ, DiDomenico LA, et al. 2017; A prospective, randomised, controlled, multicentre clinical trial examining healing rates, safety and cost to closure of an acellular reticular allogenic human dermis versus standard of care in the treatment of chronic diabetic foot ulcers. Int Wound J. 14:307–15. doi: 10.1111/iwj.12600. DOI: 10.1111/iwj.12600. PMID: 27073000. PMCID: PMC7949710.

26. Shin SH, Kim C, Lee YS, Kang JW, Chung YG. 2017; Feasibility and advantages of full thickness skin graft from the anterolateral thigh. J Hand Surg Asian Pac Vol. 22:497–502. doi: 10.1142/S0218810417500563. DOI: 10.1142/S0218810417500563. PMID: 29117823.

27. Shim HS, Choi JS, Kim SW. 2018; A role for postoperative negative pressure wound therapy in multitissue hand injuries. Biomed Res Int. 2018:3629643. doi: 10.1155/2018/3629643. DOI: 10.1155/2018/3629643. PMID: 29780821. PMCID: PMC5892250.

28. Kim YH, Hwang KT, Kim KH, Sung IH, Kim SW. 2019; Application of acellular human dermis and skin grafts for lower extremity reconstruction. J Wound Care. 28(Sup4):S12–7. doi: 10.12968/jowc.2019.28.Sup4.S12. DOI: 10.12968/jowc.2019.28.Sup4.S12. PMID: 30975064.

29. Tchero H, Herlin C, Bekara F, Kangambega P, Sergiu F, Teot L. 2017; Failure rates of artificial dermis products in treatment of diabetic foot ulcer: a systematic review and network meta-analysis. Wound Repair Regen. 25:691–6. doi: 10.1111/wrr.12554. DOI: 10.1111/wrr.12554. PMID: 28597935.