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Debridement to Negative Qualitative Cultures: Does it Matter for Lower Extremity Split-Thickness Skin Grafts?
Rachel N. Rohrich
*1, Karen Li
1, Christian X. Lava
1, Sami Alahmadi
2, Henry L. Stanton
2, Karen K. Evans
1, John Steinberg
3, Jayson Atves
3, Christopher E. Attinger
1, Stephen Baker
11Department of Plastic and Reconstructive Surgery, Medstar Georgetown University Hospital, Washington, ; 2Georgetown University School of Medicine, Washington, ; 3Department of Podiatric Surgery, Medstar Georgetown University Hospital, Washington,
Background: Serial debridement to achieve a negative culture is standard protocol before closure of chronic, lower extremity (LE) wounds. However, achieving sterility is often not feasible. This study aims to evaluate the impact of the qualitative debridement cultures obtained immediately before STSG placement on outcomes.
Methods: A retrospective review of patients receiving STSG for chronic LE wounds from 2014 to 2022 was conducted. Microbiological data included pathogen type and bacterial load. Wounds that had a preoperative positive culture (PC) on the day of STSG were compared to those that had a negative culture (NC).
Results: Overall, 114 patients underwent STSG for 164 chronic LE wounds. Most wounds had PC (n=128, 78.1%) while 36 wounds (22.0%) had NC. The cohort had a median age of 63 (IQR: 19.5) years.Charlson Comorbidity Index for the PC group was 5 (IQR: 3) and 4 (IQR: 3.5) for the NC group (p=0.212). Median wound sizes for the PC wounds were larger than NC groups (23.3, IQR: 48.3 cm
2 vs. 38, IQR: 109.5 cm
2, p=0.204). Of the PC wounds, 63.3% (n=81/128) were polymicrobial, and the majority (51.2%) were quantified as "light" volume of growth. There were no differences in graft failure (18.8% vs. 19.4%, p=0.925) or reintervention (38.4% vs. 22.2%, p=0.073) between the PC and NC groups. However, PC wounds demonstrated a significantly higher rate of infection (17.2% vs. 2.8%, p=0.028) compared to NC wounds. Sub-analysis of PC wounds demonstrated that wounds with heavy bacterial loads (p=0.035) and were polymicrobial (p=0.024) had significantly higher rates of graft failure.
Conclusions: Our findings suggest that the presence of a PC prior to STSG placement for chronic LE wounds does not adversely affect outcomes compared to NC wounds. Rather, it is the quality of the PC, specifically polymicrobial presence and heavy growth, that significantly influences the graft success. This challenges the conventional emphasis on achieving negative cultures before proceeding with STSG. We show that a positive culture result alone does not impact outcomes.
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