From the Guidelines
For large below-knee amputation (BKA) wounds, skin grafting is generally preferred over leaving the wound to epithelialize on its own for long-term prosthetic use, as it provides more durable coverage and reduces healing time. This is because split-thickness skin grafts can better withstand the pressure and friction from a prosthetic device, whereas wounds that heal by secondary intention typically develop thin, fragile skin that is prone to breakdown. The use of negative pressure wound therapy (NPWT) can enhance split skin graft take, as shown in a systematic review and evidence-based recommendations for the use of NPWT in the open abdomen 1. Although this study focused on abdominal wounds, the principles can be applied to BKA wounds, particularly in the context of promoting graft take and reducing healing time.
In the context of BKA wounds, the guidelines on the use of interventions to enhance healing of chronic foot ulcers in diabetes suggest that NPWT can be used to reduce wound size, in addition to best standard of care, in patients with post-operative wounds on the foot 1. However, the evidence for NPWT in BKA wounds is limited, and the decision to use skin grafting or continued wound care should be based on individual patient factors, such as wound size, depth, and location.
Some key considerations for skin grafting in BKA wounds include:
- Harvesting a thin layer of skin from a donor site, often the thigh
- Securing the graft to the prepared wound bed
- Post-grafting care, including immobilization for 5-7 days, followed by gradual activity increase
- The potential benefits of reduced healing time and improved functional outcomes with earlier prosthetic fitting and rehabilitation.
Overall, the decision to use skin grafting or continued wound care in BKA wounds should be based on a comprehensive assessment of the patient's individual needs and the potential benefits and risks of each approach.
From the Research
Wound Healing and Skin Grafting
- The decision to perform a skin graft on a wound prior to prosthetic placement depends on various factors, including the size and depth of the wound, as well as the patient's overall health and prognosis for healing 2, 3.
- For large wounds, skin grafting may be preferred over allowing the wound to epithelialize on its own, as it can provide a more stable and durable covering for the wound, which is essential for long-term prosthetic use 2.
- However, the use of vacuum-assisted closure (VAC) therapy has been shown to be effective in promoting wound healing and may be used as an alternative to skin grafting in some cases 3, 4.
- Aggressive debridement and wound care are critical components of promoting optimal wound healing, regardless of whether skin grafting is performed or not 5, 6.
Considerations for Prosthetic Placement
- The goal of wound care and skin grafting is to create a stable and durable wound bed that can support prosthetic placement and use 2, 4.
- The use of VAC therapy and other wound-healing adjuncts can help to promote wound healing and prepare the wound bed for prosthetic placement 3, 6.
- However, the decision to perform a skin graft or allow the wound to epithelialize on its own should be made on a case-by-case basis, taking into account the individual patient's needs and prognosis for healing 2, 3.
Wound Debridement and Care
- Wound debridement is a critical component of promoting optimal wound healing, as it helps to remove necrotic tissue and promote the growth of healthy tissue 5, 6.
- Aggressive debridement and wound care are essential for promoting wound healing and preparing the wound bed for skin grafting or prosthetic placement 5, 6.
- The use of VAC therapy and other wound-healing adjuncts can help to promote wound healing and support the growth of healthy tissue 3, 6.