Postoperative management of lower limb split-thickness skin grafts in Australia

Lisa Ellis,Miguel Cabalag,Patricia Terrill,George Miller,Kin Seng Tong

doi:10.34239/ajops.v3n2.232

Abstract

Background: Evidence for postoperative management of split-thickness skin grafts (SSGs) to lower leg wounds has shown early mobilisation has no adverse effects on graft take, while improving patient outcomes and significantly reducing hospitalisation costs. The development of negative-pressure wound therapy (NPWT) for SSGs led to new options for bolster dressings. This study aimed to determine the current postoperative mobilisation and dressing choices of Australian plastic surgeons. Methods: Australian plastic surgeons were invited electronically to participate in a questionnaire regarding their postoperative regimens for lower limb SSG in 2013, and again in 2018. A literature review was performed to establish whether surgeon-reported practice was in line with current evidence for early mobilisation of lower limb SSGs and also for NPWT on SSGs. Results: In 2013, 119 responses were received and in 2018, 110 responses were received. Survey responses showed significant reductions in the numbers of patients kept immobilised for more than five days (30% to 9%, p = 0.001) between 2013 and 2018. Surgeons reported immobilising their patients longer with standard dressings than with NPWT dressings (p = 0.003 by multinomial logistic regression). More than two-thirds of surgeons reported NPWT use in both 2013 (66%) and 2018 (70%). Conclusion: Between 2013 and 2018, NPWT use increased slightly and the percentage of surgeons mobilising their patients early significantly increased, in accordance with evidence in the literature. A link was noted between NPWT use and an increased tendency to early mobilisation. However, a large proportion of surgeons continued to prescribe bed rest postoperatively.

Highlights

Postoperative management of lower leg splitthickness skin grafts (SSGs) has traditionally involved the use of bolster-style dressings and immobilisation of the patient for five to 10 days before the patient resumes ambulation. Evidence suggests that such prolonged bed rest provides no significant improvement in graft take or overall patient outcomes and increases the risk of venous thromboembolism (VTE),[1,2,3] as well as reducing mobility[4,5] and increasing the risk of deconditioning
The aim of this study was to evaluate the practice preferences of Australian plastic surgeons for dressings and postoperative protocols after lower limb SSGs, and to evaluate whether these practices have changed over a five-year period and whether their practice was in line with current evidence recommendations
The percentage area of graft take was not statistically significantly different at one week (93.7% with bed rest compared with 88.7% having early mobilisation, p = 0.29) or at three weeks post-surgery (92.8% having bed rest compared with 89.7% having early mobilisation, p=0.55)

Summary

Introduction

Postoperative management of lower leg splitthickness skin grafts (SSGs) has traditionally involved the use of bolster-style dressings and immobilisation of the patient for five to 10 days before the patient resumes ambulation. Evidence suggests that such prolonged bed rest provides no significant improvement in graft take or overall patient outcomes and increases the risk of venous thromboembolism (VTE),[1,2,3] as well as reducing mobility[4,5] and increasing the risk of deconditioning. This adversely affects patients and generates a significant burden from the health costs associated with prolonged hospitalisation.[4] Despite this evidence showing advantages in early mobilisation, in the literature there is a paucity of information as to whether early mobilisation is implemented in practice. This study aimed to determine the current postoperative mobilisation and dressing choices of Australian plastic surgeons and to assess whether the evidence has induced change in clinical practice

Objectives

Discussion

Conclusion