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Maximizing The Efficacy Of Split Thickness Skin Grafts On DFUs
The split thickness skin graft (STSG) is likely the most useful yet underutilized tool in the arsenal of the podiatric surgeon. Prevailing wisdom has traditionally told us that the STSG on the high-risk extremity was verboten — particularly for people with diabetes and in the diabetic foot. Our experience and the experience of colleagues of ours has suggested otherwise.
For many years, we at the Southern Arizona Limb Salvage Alliance (SALSA) and other colleagues, particularly at Yale/New Haven and San Antonio, have discussed the use of STSG in a more consistent manner as a go-to tool to get toward wound simplification and ultimate closure.1,2
We have a “vertical and horizontal strategy” for the management of complex wounds. For a deep wound with exposed structures, we will often vertically reduce the volume of the wound with negative pressure wound therapy (NPWT) before using STSG.3 This is what my coauthors Eric Lew, DPM, and Vlad Saucic, MS, and I explored in our recent study review the Journal of Wound Technology.4
The next thing we do is think about our “horizontal strategy”. For relatively small wounds one generally does not need STSG. This is also true for those in a weightbearing area where the stress is not addressed. However, for very large defects, including (and especially) defects on the plantar aspect of the foot, we frequently use STSG as our primary mechanism to facilitate wound closure. For wounds over a high-use weightbearing surface, we can then either externally offload these wounds with shoes and insoles, or internally offload with osteotomies, tendon transfers, ostectomies or a combination.5
One might argue that STSGs are directly competitive with many of our most frequently used biologics like Dermagraft (Organogenesis), Apligraf (Organogenesis) and some of the amnion-based biologic alterative tissues. While this is likely the case, I do not believe they are always mutually exclusive. I think there may be a way forward where we can use some of them together. Many of my colleagues frequently use something like Integra (Integra LifeSciences) along with STSG in a single- or multiple-stage procedure. Over the years, we have done this less and less frequently but we believe some technologies may be coming in the future that may enable us to “spike” these skin grafts and matrices with other advanced modalities to further assist our way forward.
Another little trick we frequently employ is Platelet rich plasma (PRP). We use this not just on the skin graft itself but on the donor site as well. In our experience, we have found that it appears to have a dramatic effect on post-op pain when we use PRP on the donor site.6
References
1. Belczyk R, Stapleton JJ, Blume PA, Zgonis T. Plantar foot donor sites as a harvest of a split-thickness skin graft. Clin Podiatr Med Surg. 2009; 26(3):493-7.
2. Ramanujam CL, Zgonis T. An overview of autologous skin grafts and advanced biologics for the diabetic foot. Clin Podiatr Med Surg. 2012; 29(3):435-41.
3. Isaac AL, Armstrong DG. Negative pressure wound therapy and other new therapies for diabetic foot ulceration: the current state of play. Med Clin North Am. 2013; 97(5):899-909.
4. Lew EJ, Sauciuc V, Armstrong DG. Pearls and pitfalls of split thickness skin grafting and the diabetic foot ulceration. J Wound Technol. 2014; 26(10):16-21.
5. Rose JF, Giovinco N, Mills JL, et al. Split-thickness skin grafting the high-risk diabetic foot. J Vasc Surg. 2014; 59(6):1657-63.
6. Miller JD, Rankin TM, Hua NT, et al. Reduction of pain via platelet-rich plasma in split-thickness skin graft donor sites: a series of matched pairs. Diabet Foot Ankle. 2015; 6:24972.
