From the Guidelines
For an open below-knee amputation (BKA) wound that has been debrided, treated with wound VAC therapy, and has progressed to a superficial, granulating wound, continued wound care alone may be sufficient for complete healing without requiring a skin graft before prosthetic placement, as long as the wound is small and the patient has good circulation and nutritional status. The decision to proceed with or without a skin graft depends on several factors including the size of the remaining wound, the quality of the granulation tissue, and the patient's overall health status 1. If the wound is small (less than 2 cm²), has healthy granulation tissue, shows progressive healing, and the patient has good circulation and nutritional status, continued local wound care with appropriate dressings may allow complete epithelialization within 2-4 weeks.
Some key considerations in wound care include:
- The use of negative-pressure wound therapy, which has been shown to be especially useful in wound preparation for skin grafts and flaps and assists in the closure of deep, large wounds 1.
- The application of topical oxygen therapy, which has been supported by several high-quality RCTs and systematic reviews as an effective treatment for healing chronic diabetic foot ulcers at 12 weeks 1.
- The importance of a multidisciplinary approach to wound care, including the collaboration of surgeons, wound care specialists, and prosthetists to determine the best course of treatment for each patient 1.
However, if the wound is larger, healing has plateaued, or the patient has factors that impair wound healing (such as diabetes, vascular disease, or malnutrition), a skin graft would likely accelerate closure and provide more durable coverage before prosthetic fitting. The timing of prosthetic placement typically requires complete wound healing or stable coverage to prevent breakdown from pressure and shear forces. Without adequate healing or coverage, prosthetic use could cause wound deterioration, infection, and potentially require surgical revision.
Key factors to consider when deciding between continued wound care and skin grafting include:
- Wound size and depth
- Quality of granulation tissue
- Patient's overall health status, including circulation and nutritional status
- Presence of factors that impair wound healing, such as diabetes or vascular disease
- Patient's functional goals and prognosis for rehabilitation with a prosthesis.
From the Research
Wound Healing with Debridement and Wound Vac Placement
- The use of vacuum-assisted closure (VAC) therapy, also known as wound vac, has been shown to be effective in promoting wound healing, even in complex cases with exposed prosthetic vascular grafts 2, 3.
- Debridement, the removal of dead or unhealthy tissue from a wound, is a crucial step in preparing the wound bed for healing 4, 5.
- The application of VAC therapy after debridement can help to enhance wound healing by promoting granulation tissue formation and reducing bacterial load 2, 6.
Skin Grafting and Prosthetic Placement
- While skin grafting may be necessary in some cases to achieve complete wound closure, it is not always required prior to prosthetic placement 6, 3.
- The decision to perform a skin graft should be based on the individual patient's wound characteristics and healing potential, as well as the presence of any underlying conditions that may affect wound healing 4, 5.
- In some cases, continued wound care and VAC therapy may be sufficient to promote wound healing and prepare the wound bed for prosthetic placement 2, 3.
Key Considerations
- The bacterial load of the wound bed can affect the success of skin grafting and wound healing 6.
- The use of VAC therapy and debridement can help to reduce bacterial load and promote a healthy wound environment 2, 3.
- A comprehensive and holistic approach to wound care, including regular debridement, VAC therapy, and wound dressing changes, can help to promote wound healing and prepare the wound bed for prosthetic placement 4, 5.