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Using full-thickness skin graft from amputated foot can provide a stump with durable skin
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e667ee669
CORRESPONDENCE AND COMMUNICATION
Using full-thickness skin graft from amputated foot can provide a stump with durable skin Management of an open fracture of the tibia and fibula with massive skin damage and chronic infection is difficult. Despite modern reconstructive technique, amputation is sometimes required. The most important desire of a lower-limb amputee is acquisition of ambulation with a prosthesis. Transtibial amputation is the most proximal level in the lower extremity at which near-normal function is available to a wide spectrum of lower-limb amputees. On the other hand, the skin at the end of stump should be of good texture, mobile and normally sensate1 so that a prosthesis can be worn safely. However, when we try to preserve sufficient limb length for the function of walking with a prosthesis, it is often difficult to fulfil these requirements for an amputee after trauma. In such a case, surgeons are presented with the alternative as to whether to amputate above the knee even if the ambulatory ability with the artificial limb would be decreased or to amputate below the knee and risk future skin trouble. We report a case of skin grafted from an amputated foot sole to damaged stump at the same time as transtibial amputation after open fracture of the tibia and fibula with massive soft-tissue damage.
Case report A 57-year-old woman was run over by a truck while riding a scooter. She sustained an open tibial and fibular fracture with massive soft-tissue avulsion of the right leg. As an initial effort to salvage the leg, the broken tibia was fixed with an external fixator after irrigation and debridement. Skin defect was covered with reticulated skin harvested from degloved soft tissue of the right leg and inguinal lesion. Although a partial open wound persisted, adding a split-skin mesh graft completely closed the wound at 85 days after the primary trauma. Shortly thereafter, osteomyelitis of the tibia was detected. The patient selected amputation rather than reconstruction by vascularised bone grafting. In the surgery, transtibial cutting at 12 cm
distal to the line of the knee joint was performed in order to preserve the knee-joint function. We denuded the stump which was fragile mesh skin (Figure 1a) and grafted the fullthickness skin harvested from the sole of the amputated foot (Figure 1bed). The grafted skin almost took, and sutures were removed by 2 weeks after the surgery. Two years after the last surgery, she is now fully mobile on the prosthesis (Figure 2).
Discussion In this case, when deciding on the level of amputation, it was agonising as to whether to select a transfemoral amputation by which the stump was covered with usual skin or a transtibial amputation by which the stump was covered with transplanted skin. Of course, successful ambulation with a prosthesis is more likely if the amputation is transtibial rather than through the knee joint or at a transfemoral level.1Although we selected transtibial amputation, the stump was covered with grafted mesh skin. This would be unsuitable for artificial limb attachment in this patient because after mesh skin grafting the stump would be very fragile. In order to solve these problems, we felt that a fillet flap must be the best choice.2 Although using a fillet flap is very feasible, the surgical procedure is not easy for every surgeon, especially tracking on the neurovascular bundle through the injured region. On the other hand, skin grafting is a fundamental technique for plastic surgeons, and for almost all surgeons who routinely perform amputations, it would be easier to perform skin grafts than fillet flaps. Skin grafts of various thicknesses from various regions also have been reported to be used in the coverage for amputation stumps.3e5 Many reports emphasised that even split-thickness skin grafts were durable for wearing a prosthesis. Furthermore, Anderson et al.5 reported six cases in which skin grafts were used to salvage a degloved transtibial amputation stump, and in two of these cases fullthickness grafts were harvested from the amputated part. It would seem logical to use the amputated part as a donor site for our case. In our case, plantar skin was harvested because the skin structure below the ankle joint of the amputated limb was kept normal and full-thickness skin grafting was done. Plantar skin has a thicker dermis and a more horny layer
1748-6815/$ - see front matter Crown Copyright ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. doi:10.1016/j.bjps.2008.11.110
e668
Correspondence and communication
Figure 1 (a) After transtibial amputation, stump has been covered with grafted mesh skin. (b) Stump has been prepared with the mesh skin denuded. (c) Plantar skin has been harvested from the amputated foot. (d) Plantar full-thickness skin has been graft to the denuded stump.
Figure 2 Two years postoperatively, the full-thickness skin graft from the amputated foot provide durable coverage (a) anteroposterior view, (b) lateral view and (c) the patient is independently mobile on her prosthesis.
Correspondence and communication than other skin, and it is most suitable to get a firm skin structure. Additionally, the skin harvested at this time is destined to be discarded in usual course, and it can be said that there is no loss at the donor site. Because of a decline in sensory perception, full-thickness skin grafting is not always useful for all cases, but it may be considered aggressively in the case of stump with hypaesthesia as in this case.
Conflict of interest No authors have conflict of interest.
References 1. Tooms RE. General principle of amputations. In: Canale ST, editor. Campbell’s Operative Orthopaedocs. 9th ed. Memphis, Tennessee: Mosby; 1998. p. 521e31. 2. Hamm JC, Stevenson TR, Mathes SJ. Knee joint salvage utilising a plantar musculocutaneous island pedicle flap. Br J Plast Surg 1986;39:249e54. 3. Ascott JR. Skin transfer to amputation stumps. Br J Plast Surg 1953;6:115e22. 4. Henman PD, Jain AS. Skin grafting an amputation stump: considerations for the choice of donor site. Br J Plast Surg 2000; 53:357.
e669 5. Anderson WD, Stewart KJ, Wilson Y. Skin graft for the salvage below-knee amputation stump. Br J Plast Surg 2002;55:320e3.
Kazunori Yokota Misa Nakanishi Department of Orthopedic Surgery, Division of Plastic Surgery, Graduate School of Biochemical Science, Hiroshima University, Hiroshima, Japan E-mail address: [email protected] Toru Sunagawa Department of Locomotor System Dysfunction, Graduate School of Health Science, Hiroshima University, Hiroshima, Japan Hiroaki Kimura Department of Rehabilitation, Hiroshima University Hospital, Hiroshima, Japan Takeshi Hiramatsu Osami Suzuki Mitsuo Ochi Department of Orthopedic Surgery, Graduate School of Biochemical Science, Hiroshima University, Hiroshima, Japan
CORRESPONDENCE AND COMMUNICATION
Using full-thickness skin graft from amputated foot can provide a stump with durable skin Management of an open fracture of the tibia and fibula with massive skin damage and chronic infection is difficult. Despite modern reconstructive technique, amputation is sometimes required. The most important desire of a lower-limb amputee is acquisition of ambulation with a prosthesis. Transtibial amputation is the most proximal level in the lower extremity at which near-normal function is available to a wide spectrum of lower-limb amputees. On the other hand, the skin at the end of stump should be of good texture, mobile and normally sensate1 so that a prosthesis can be worn safely. However, when we try to preserve sufficient limb length for the function of walking with a prosthesis, it is often difficult to fulfil these requirements for an amputee after trauma. In such a case, surgeons are presented with the alternative as to whether to amputate above the knee even if the ambulatory ability with the artificial limb would be decreased or to amputate below the knee and risk future skin trouble. We report a case of skin grafted from an amputated foot sole to damaged stump at the same time as transtibial amputation after open fracture of the tibia and fibula with massive soft-tissue damage.
Case report A 57-year-old woman was run over by a truck while riding a scooter. She sustained an open tibial and fibular fracture with massive soft-tissue avulsion of the right leg. As an initial effort to salvage the leg, the broken tibia was fixed with an external fixator after irrigation and debridement. Skin defect was covered with reticulated skin harvested from degloved soft tissue of the right leg and inguinal lesion. Although a partial open wound persisted, adding a split-skin mesh graft completely closed the wound at 85 days after the primary trauma. Shortly thereafter, osteomyelitis of the tibia was detected. The patient selected amputation rather than reconstruction by vascularised bone grafting. In the surgery, transtibial cutting at 12 cm
distal to the line of the knee joint was performed in order to preserve the knee-joint function. We denuded the stump which was fragile mesh skin (Figure 1a) and grafted the fullthickness skin harvested from the sole of the amputated foot (Figure 1bed). The grafted skin almost took, and sutures were removed by 2 weeks after the surgery. Two years after the last surgery, she is now fully mobile on the prosthesis (Figure 2).
Discussion In this case, when deciding on the level of amputation, it was agonising as to whether to select a transfemoral amputation by which the stump was covered with usual skin or a transtibial amputation by which the stump was covered with transplanted skin. Of course, successful ambulation with a prosthesis is more likely if the amputation is transtibial rather than through the knee joint or at a transfemoral level.1Although we selected transtibial amputation, the stump was covered with grafted mesh skin. This would be unsuitable for artificial limb attachment in this patient because after mesh skin grafting the stump would be very fragile. In order to solve these problems, we felt that a fillet flap must be the best choice.2 Although using a fillet flap is very feasible, the surgical procedure is not easy for every surgeon, especially tracking on the neurovascular bundle through the injured region. On the other hand, skin grafting is a fundamental technique for plastic surgeons, and for almost all surgeons who routinely perform amputations, it would be easier to perform skin grafts than fillet flaps. Skin grafts of various thicknesses from various regions also have been reported to be used in the coverage for amputation stumps.3e5 Many reports emphasised that even split-thickness skin grafts were durable for wearing a prosthesis. Furthermore, Anderson et al.5 reported six cases in which skin grafts were used to salvage a degloved transtibial amputation stump, and in two of these cases fullthickness grafts were harvested from the amputated part. It would seem logical to use the amputated part as a donor site for our case. In our case, plantar skin was harvested because the skin structure below the ankle joint of the amputated limb was kept normal and full-thickness skin grafting was done. Plantar skin has a thicker dermis and a more horny layer
1748-6815/$ - see front matter Crown Copyright ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. doi:10.1016/j.bjps.2008.11.110
e668
Correspondence and communication
Figure 1 (a) After transtibial amputation, stump has been covered with grafted mesh skin. (b) Stump has been prepared with the mesh skin denuded. (c) Plantar skin has been harvested from the amputated foot. (d) Plantar full-thickness skin has been graft to the denuded stump.
Figure 2 Two years postoperatively, the full-thickness skin graft from the amputated foot provide durable coverage (a) anteroposterior view, (b) lateral view and (c) the patient is independently mobile on her prosthesis.
Correspondence and communication than other skin, and it is most suitable to get a firm skin structure. Additionally, the skin harvested at this time is destined to be discarded in usual course, and it can be said that there is no loss at the donor site. Because of a decline in sensory perception, full-thickness skin grafting is not always useful for all cases, but it may be considered aggressively in the case of stump with hypaesthesia as in this case.
Conflict of interest No authors have conflict of interest.
References 1. Tooms RE. General principle of amputations. In: Canale ST, editor. Campbell’s Operative Orthopaedocs. 9th ed. Memphis, Tennessee: Mosby; 1998. p. 521e31. 2. Hamm JC, Stevenson TR, Mathes SJ. Knee joint salvage utilising a plantar musculocutaneous island pedicle flap. Br J Plast Surg 1986;39:249e54. 3. Ascott JR. Skin transfer to amputation stumps. Br J Plast Surg 1953;6:115e22. 4. Henman PD, Jain AS. Skin grafting an amputation stump: considerations for the choice of donor site. Br J Plast Surg 2000; 53:357.
e669 5. Anderson WD, Stewart KJ, Wilson Y. Skin graft for the salvage below-knee amputation stump. Br J Plast Surg 2002;55:320e3.
Kazunori Yokota Misa Nakanishi Department of Orthopedic Surgery, Division of Plastic Surgery, Graduate School of Biochemical Science, Hiroshima University, Hiroshima, Japan E-mail address: [email protected] Toru Sunagawa Department of Locomotor System Dysfunction, Graduate School of Health Science, Hiroshima University, Hiroshima, Japan Hiroaki Kimura Department of Rehabilitation, Hiroshima University Hospital, Hiroshima, Japan Takeshi Hiramatsu Osami Suzuki Mitsuo Ochi Department of Orthopedic Surgery, Graduate School of Biochemical Science, Hiroshima University, Hiroshima, Japan