How to manage a sloughy skin graft on the midthigh of a patient with a history of midshaft fracture treated with a long intramedullary (IM) nail, distal femur fracture, and rhabdomyosarcoma treated with radiotherapy?

From the Guidelines

I would manage the sloughy skin graft on the midthigh with a multidisciplinary approach focusing on wound care and addressing underlying factors, prioritizing gentle debridement, antimicrobial dressings, and nutritional optimization. The patient's history of radiation therapy for rhabdomyosarcoma and multiple surgeries, including a long intramedullary nail for a midshaft fracture and treatment for a distal femur fracture, suggests a complex wound with potential radiation-induced tissue damage. According to the guidelines for managing radiation dermatitis 1, gentle cleaning and drying of the skin, as well as the use of topical moisturizers, are recommended. However, in the case of a sloughy skin graft, more aggressive management may be necessary.

Wound Care Approach

• Gentle debridement of the sloughy tissue using enzymatic agents like collagenase or mechanical debridement during dressing changes
• Antimicrobial dressings such as silver-impregnated products or polyhexamethylene biguanide (PHMB) foam dressings, changed every 2-3 days depending on exudate levels
• Consider negative pressure wound therapy at 75-125 mmHg continuous pressure if there is significant exudate or to promote granulation tissue

Addressing Underlying Factors

• Evaluate the patient for vascular compromise with an ankle-brachial index and possible vascular imaging, as radiation-induced vasculopathy may be contributing to poor healing 1
• Nutritional optimization is essential, with protein intake of 1.2-1.5 g/kg/day and vitamin supplementation including vitamin C (500 mg daily) and zinc (220 mg daily for 2-3 weeks) 1
• The sloughing is likely due to radiation-induced tissue damage, which causes microvascular changes, fibrosis, and impaired tissue oxygenation

Additional Considerations

• If conservative measures fail after 4-6 weeks, surgical revision of the graft or flap reconstruction may be necessary, though this should be approached cautiously given the patient's complex history of radiation and multiple surgeries
• The management team should include a wound specialist, radiation oncologist, medical oncologist, dermatologist, and nurse, as required 1

From the Research

Managing a Sloughy Skin Graft

To manage a sloughy skin graft on the midthigh of a patient with a history of midshaft fracture treated with a long intramedullary (IM) nail, distal femur fracture, and rhabdomyosarcoma treated with radiotherapy, consider the following:

• Immobilization and adequate surface contact to wounds are critical for skin graft take 2
• Techniques such as the tie-over dressing, cotton bolster, and vacuum-assisted closure can be used to address this, but each has its limitations 2
• Antimicrobial-impregnated dressing combined with negative-pressure wound therapy (NPWT) can increase split-thickness skin graft engraftment 2
• NPWT can improve the take rate of skin grafts in irregular, high-mobility areas and shorten the dressing time 3

Considerations for Skin Graft Care

When caring for a skin graft, consider the following:

• The reasons for grafting, type of graft used, preoperative and postoperative care of the recipient and donor sites, and the provision of general measures required to promote wound healing and successful graft take 4
• The use of NPWT as a postoperative dressing for skin grafts can be effective, but conventional dressing may not be inferior and can be easier to use and less expensive 5
• Intermediate skin substitutes may be unnecessary in small burns and can add complexity and cost to patient care 6

Potential Complications

Potential complications to consider when managing a sloughy skin graft include:

• Infection, inadequate immobilization, hematoma, seroma, displacement, and necrosis 2, 3, 5
• Graft failure, which can be caused by infection or inadequate debridement 6