Negative Pressure Wound Therapy Versus Traditional Bolster for Securing Split Thickness Skin Grafts in Chronic Lower Extremity Wounds
Elliot Walters, MD1, Tara Chadab, BS2, Iram Naz, MD3, Tammer Elmarsafi, DPM1, Jon Turissini, BS2, John Steinberg, DPM1, Karen K. Evans, MD1, Christopher E. Attinger, MD1, Paul J. Kim, DPM1.
1Georgetown University Hospital, Washington, DC, USA, 2Georgetown University School of Medicine, Washington, DC, USA, 3MedStar Georgetown University Hospital, Washington, DC, USA.
Negative Pressure Wound Therapy Versus Traditional Bolster for Securing Split Thickness Skin Grafts in Chronic Lower Extremity Wounds
Background
NPWT has become an increasingly popular alternative due to its perceived advantages sponge bolsters to secure split thickness skin grafts (STSG) to wound beds. However, these advantages come at an increased cost and complexity of skin graft care. Many studies have compared these two dressing methods but have not described when NPWT is more advantageous for STSGs over chronic wounds. This study compares these dressing methods for healing STSGs in the setting of predominantly lower extremity wounds.
Methods
This is a retrospective study of all patients who received STSGs at MedStar Georgetown University Hospital from 2014-2016. During this time period 177 patients received a total of 200 skin grafts which met inclusion criteria. Two grafts were excluded due to exceptionally large size. We compare NPWT to traditional sponge bolster on the healing outcomes of STSG. Successful skin grafting was defined as ≥99.5% wound epithelialization at 30 days of follow up. Measurements of wound length and width were taken during grafting and at follow up appointments and used to determine graft healing.
Results
Baseline characteristics of patients were not significantly different. Patients with bolster were more likely to have venous stasis (p=0.0166) and patients with NPWT were more likely to have hyperlipidemia (p=0.0129). Average initial wound size between the traditional bolster (54.4cm2) and NPWT (70.6cm2) groups were not statistically significant (p=0.0882) but did become significant when compared as subgroups of initial wound size (p=<0.0001): <20cm2 (bolster 34 (38.2%) vs NPWT 13 (11.9%)), 20-80cm2 (bolster 33 (37.1%) vs NPWT 61 (56.0%)), >80cm2 (bolster 22 (24.7%) vs NPWT 35 (32.1%)). No significant difference was found in graft success at 30 days (bolster 20 (23.8%) vs NPWT 31 (30.7%), p=0.2969) or in median time to complete healing (12 weeks vs 11 weeks, p=0.4139). Percent epithelialization at 30 days was significant for NPWT (mean 92% vs 70% for bolster (p<0.001)). Bolster trended toward better healing for smaller wounds while NPWT trended toward better healing for larger wounds. These trends crossed at 11.77cm2 suggesting STSG healing favors NPWT for wounds larger than this threshold.
Conclusions
Split thickness skin grafting is an effective coverage technique for chronic lower extremity wounds. For wounds over 11.77cm2 NPWT trends toward faster and more complete wound healing. We recommend using NPWT as a dressing for STSGs in wounds larger than 11.77cm2.
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