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Split-Thickness Skin Graft Outcomes in Nontraumatic Lower Extremity Wounds: Does Location Matter?
Rachel N. Rohrich
*1, Karen Li
1, Christian X. Lava
1, Sami Alahmadi
2, Henry L. Stanton
2, Victoria Kim
2, Karen K. Evans
1, John Steinberg
1, Christopher E. Attinger
1, Stephen Baker
11Department of Plastic and Reconstructive Surgery, Medstar Georgetown University Hospital, Washington, ; 2Georgetown University School of Medicine, Washington,
BACKGROUND Split-thickness skin grafts (STSG) are a mainstay for chronic lower extremity (LE) wound reconstruction. However, LE biomechanics introduces shearing forces and pressure points that lead to STSG failure, deterring surgeons from considering STSG in mobile regions. This study aims to determine if wound location impacts STSG outcomes.
METHODS A retrospective review of patients undergoing LE STSG from 2014 to 2022 was conducted. Wounds pre-treated with synthetic dermal matrix (SDS) were excluded. A sub-analysis of plantar wounds treated with and without SDS was performed.
RESULTS 168 patients with 245 wounds underwent STSG. The cohort was 61.3% male with a median age of 61.9 (IQR: 15.1) years. Median Charlson Comorbidity Index was 4 (IQR: 3), reflecting prevalent rates of diabetes (57.1%), chronic kidney disease (22.6%), and peripheral artery disease (36.9%). Median wound size was 29 (IQR: 71) cm
2. Wounds were located on the forefoot (n=48/245, 19.6%), midfoot (n=20/245, 8.2%), hindfoot (n=36/245, 14.8%), ankle (n=45/245, 18.4%), leg (n=78/245, 31.8%), knee (n=15/245, 6.1%), and transmetatarsal amputation site (n=5/245. 2.0%). Graft failure rate was 18.0% (n=44/245), with no difference between locations (p=0.601). Plantar wounds exhibited significantly higher rates of graft failure (n=11/37, 29.7% vs. n=8/70, 11.4%, p=0.018). Furthermore, plantar wounds were associated with a 3.3-fold increase in the odds of graft failure (OR: 3.3, p=0.022). Sub-analysis of plantar defects treated with and without SDS prior to STSG demonstrated that pre-treatment with SDS decreases failure rates significantly (7.1% vs. 30.8%, p=0.019).
CONCLUSIONS Our results suggest that STSG is a viable tool for LE wounds across multiple locations. However, plantar wounds are more susceptible to graft failure, and the use of SDS preoperatively may improve results. Emphasizing off-loading protocols is critical to improve graft outcomes in high-risk areas in a comorbid patient population.
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