Skin Graft Coverage Research Articles

Study of the Influencing Factors and their Predictive Value of Skin Graft Take in Early Excision and Grafting in Severe Burns: A Prospective Study

Abstract Background Burn injury is one of the most life-threatening traumas worldwide especially in developing countries. After severe burns, the patients suffer from loss of multiple functions of skin, such as fluid loss, and high infection rate with burn sepsis and septic shock. Objective To investigate the various factors that affect the survival rate of skin grafts in early excision and grafting procedures (from 3rd to 7th day after burn) in patients with severe burns. Patients and Methods This Prospective cohort study was done in Ain Shams University Burn Center attached to Plastic, burn and maxillofacial department during the period from May 2021 to May 2022. Results Analysis was performed on 75 individuals who had early burnt skin excised and early skin graft coverage. Two patient groups were analyzed, in the form of good skin graft take >70% in 45 patients, and poor skin graft take < 70% in 30 cases, based on the survival rate of the skin graft post operatively. Conclusion The univariate analysis and repeated measurement showed that burn intensity, the post-operative sepsis, the neutrophil lymphocytic ratio on day 3 (NLR3) in the poor skin graft take group were significantly higher than those in the good skin graft take group, while the estimated albumin levels in perioperative period and the estimated pre-albumin levels in perioperative period were higher in the good skin graft take group. Receiver operating characteristic curve showed that NLR3, the estimated albumin levels and pre-albumin levels in perioperative period had a good predictive value for the survival of skin grafts. The estimated albumin levels ≤3.18 gm/dl, estimated pre-albumin ≤23.9 mg/dl, and NLR3 ≥ 12 were independent risk factors for graft take in perioperative period.

Flexor Digitorum Superficialis to Flexor Digitorum Profundus Tendon Transfer after Wide Excision of Myxoinflammatory Fibroblastic Sarcoma: A Case Report

Myxoinflammatory fibroblastic sarcoma (MIFS) is a rare, low-grade soft tissue neoplasm that typically arises in the extremities. A 72-yearold woman presented with recurrent masses on her left forearm. Four years prior, she underwent an excisional biopsy, diagnosed as MIFS, followed by wide excision and split-thickness skin graft coverage. Preoperative magnetic resonance imaging was conducted for the recurrent mass, revealing multiple tumors invading the flexor digitorum profundus (FDP) muscle and fascia. The tumors including most of the FDP muscle were therefore excised. The third flexor digitorum superficialis (FDS) tendon was harvested, divided in half, and connected to the second and fifth FDP tendons. The same procedure was performed for the third and fourth FDP tendons with fourth FDS tendon. An anterolateral thigh free flap was used to reconstruct the skin and soft tissue defect of the left forearm. Adjuvant radiation therapy was performed. At 12 weeks postoperatively, the patient exhibited no wound complications and achieved spontaneous partial flexion of the metacarpophalangeal and proximal interphalangeal joints.

Role of autologous platelet-rich plasma with collagen in storage of skin graft

Skin grafting remains the ideal method for the treatment of majority of wounds. Raw area following burns may require a lot of skin graft coverage. Grafting and regrafting may also be required subsequently. We treated a post-electric burn patient with skin grafting for the raw area over both hands and abdomen, and the excess graft was stored and reapplied. This article discusses the method of preservation of skin grafts and their usage in further grafting.

Role of Plastic Surgery in the Management of Diabetic Foot Ulcer

This article introduces plastic surgeons' various roles in managing diabetic foot ulcers. The role of plastic surgeons is multidimensional and, of course, challenging. Sometimes, the healing process of diabetic ulcer is as simple as only adequate wound care. Sometimes, the ulcer needs reconstruction through a skin graft or flap coverage. Unfortunately, some patients need amputation or disarticulation. Again, plastic surgeons are maximizing patients' future movement ability in the case of amputation. Thus, an experienced plastic surgeon can provide an optimum lifestyle to the diabetic patient.
 TAJ 2022; 36: No-1: 55-61

Hyalomatrix coverage in scalp wounds with exposed cranium and dura

The armamentarium of options available for soft tissue reconstruction of the scalp spans the reconstructive ladder. The purpose of this paper is to describe a case series of patients with exposed cranium and dura who were successfully reconstructed using esterified hyalomatrix (eHAM, Hyalomatrix, Medline Industries Inc., US). After obtaining Institutional Review Board approval, a retrospective review of the senior author's (ALF) patient database was completed. Patients who underwent scalp reconstruction using eHAM were identified. Each patient's chart was reviewed and data collected on demographics, days to skin graft, duration of follow-up, pathology, comorbidities and complications. This case series consisted of five patients aged ≥18 years, with scalp wounds exposing dura or cranium, who were treated with eHAM as a bridge to definitive coverage with a skin graft. Each wound successfully granulated the exposed critical structure with the use of the eHAM. The mean time to skin graft coverage was 41 days, with a range of 13-79 days. Of the series of five patients, four had a follow-up of ≥12 weeks. The mean defect size was 90.2cm2. Complex scalp reconstruction can be accomplished using healing by secondary intention, skin grafts, local flaps, tissue expansion and free tissue transfer. As shown in this case series, another option available in select patients is using a dermal substitute such as eHAM. This is one treatment option available to reconstructive surgeons in multiple specialties.

Scalp Reconstruction Techniques for the General Surgeon – A Case Report

Scalp injuries are extremely common and although most scalp lacerations/ injuries can be primarily repaired, few require flap coverage. This article discusses the various ways in which we have reconstructed the scalp. This article is a case series of six different cases that required flap reconstruction where six different techniques were used to obtain wound cover with good outcomes. Patients who presented to various smaller hospitals/nursing homes with availability of only a general surgeon and no super specialists in Rural Bangalore with the need for scalp reconstruction were considered for the study. The operative outcome of six different methods of scalp reconstruction/ repair that include four different local flaps, a split skin graft with a wig and a pericranium burr hole drilling followed by split skin graft coverage have been studied.
 All six cases were followed up for a period of one month post intervention and all of them had good functional and cosmetic outcomes with no complications. There was no incidence of surgical site infection, seroma, or flap/graft failure in the 6 cases included in our study. Both grafts and flaps are equally good modalities in scalp reconstruction, but the choice for which to use should be based on the need of the patient and the type of wound. Grafts can be considered in conditions where there is adequate soft tissue cover over the scalp and in wounds with larger surface area. Grafts have the advantage of being technically simpler and are associated with fewer complications/failure but cannot be used in injuries where the bone is exposed. Flaps have better cosmetic outcome but are technically more challenging.

Retrospective comparison of split-thickness skin graft versus local full-thickness skin graft coverage of radial forearm free flap donor site

The study aimed at comparing outcomes between split-thickness skin graft (STSG) and local ipsilateral full-thickness skin graft (FTSG) after radial forearm free flap defect closure.A comprehensive study protocol for objective and subjective assessment was established for this retrospective, single-center study. Clinical examinations were carried out, encompassing measuring wrist and finger range of movement and grip strength, testing skin sensitivity, and evaluating aesthetics using the Patient and Observer Scar Assessment Scale (POSAS). In addition, medical history, and questionnaire, including Cold Intolerance Severity Score (CISS) and 18 items, were used to assess satisfaction, functional limitations, and complaints.44 patients were examined, and 40 patients included, who had received STSG (group 1; n = 19) respectively local FTSG from the ipsilateral forearm (group 2; n = 21) at least three months previously. Significantly lower values for parameters pigmentation, relief (p = 0.015), overall impression (p = 0.044), as well as mean POSAS observer scale total score (p = 0.046) and no complaints wearing a wristwatch (p = 0.012) were shown in group 2 (FTSG).Within the limitations of the study, it seems that FTSG harvested from the forearm should be preferred over STSG to cover RFFF donor site whenever appropriate, because of beneficial outcomes, while providing single intervention closure and avoiding secondary donor site.

Surgical Correction of Ectropion: Comparison Between Full Thickness Skin Grafts and Local Flaps

Objective: To compare the effectiveness of two reconstruction techniques, i.e., full-thickness skin graft and local flap, for patients undergoing reconstructive surgery for ectropion repair.
 Study Design: Prospective comparative study.
 Place and Duration of Study: Department of Plastic & Reconstructive Surgery, Dr Ruth K.M. Pfau Civil Hospital Karachi, from Feb to Aug 2020.
 Methodology: The study was conducted after acquiring approval from the Institutional Review Board of Dow University of Health Sciences. Patients advised repairing ectropion were admitted to the ward prior to a day or night of the procedure. The consultant surgeon decided on the operative management, either using a full-thickness skin graft or a local flap, depending on the type of ectropion.
 Results: 60 patients were recruited for the study, with 30 patients in each group. At follow-up of two weeks, one month, and three months’ skin colour match and pliability were significantly better in patients who received local flap than those treated with a full-thickness skin graft. Out of 30, 2 (6.7%) patients developed ectropion recurrence when they received full-thickness skin graft coverage, whereas ectropion recurrence was not observed in patients managed with local flap.
 Conclusion: Local flap appears to be more effective than full-thickness skin graft in achieving excellent aesthetic effects in patients who underwent correction of ectropion.

Evolution of a concept with enzymatic debridement and autologous in situ cell and platelet-rich fibrin therapy (BroKerF).

BackgroundDeep partial-thickness burns are traditionally treated by tangential excision and split thickness skin graft (STSG) coverage. STSGs create donor site morbidity and increase the wound surface in burn patients. Herein, we present a novel concept consisting of enzymatic debridement of deep partial-thickness burns followed by co-delivery of autologous keratinocyte suspension and plated-rich fibrin (PRF) or fibrin glue.Material and methodsIn a retrospective case study, patients with deep partial-thickness burns treated with enzymatic debridement and autologous cell therapy combined with PRF or fibrin glue (BroKerF) between 2017 and 2018 were analysed. BroKerF was applied to up to 15% total body surface area (TBSA); larger injuries were combined with surgical excision and skin grafting. Exclusion criteria were age <18 or >70 years, I°, IIa°-only, III° burns and loss of follow-up.ResultsA total of 20 patients with burn injuries of 16.8% ± 10.3% TBSA and mean Abbreviated Burn Severity Score 5.45 ± 1.8 were identified. Of the patients, 65% (n = 13) were treated with PRF, while 35% (n = 7) were treated with fibrin glue. The mean area treated with BroKerF was 7.5% ± 0.05% TBSA, mean time to full epithelialization was 21.06 ± 9.2 days and mean hospitalization time was 24.7 ± 14.4 days. Of the patients, 35% (n = 7) needed additional STSG, 43% (n = 3) of whom had biopsy-proven wound infections.ConclusionBroKerF is an innovative treatment strategy, which, in our opinion, will show its efficacy when higher standardization is achieved. The combination of selective debridement and autologous skin cells in a fibrin matrix combines regenerative measures for burn treatment.Lay SummaryPatients suffering from large burn wounds often require the use of large skin grafts to bring burned areas to heal. Before the application of skin grafts, the burned skin must be removed either by surgery or using enzymatic agents. In this article, we describe a method where small areas of skin are taken and skin cells are extracted and sprayed on wound areas that were treated with an enzymatic agent. The cells are held in place by a substance extracted from patients’ blood (PRF) that is sprayed on the wound together with the skin cells. We believe this technique can be helpful to reduce the need of skin grafts in burned patients and improve the healing process.

Reconstruction of a soft tissue defect of the thumb using a modified dorsal metacarpal artery flap: A case report study

Finger injuries to the hand with extensive soft tissue defects might be challenging to treat. Typically, the first dorsal metacarpal artery (DMA) flap is used for reconstruction, whereas closure of the donor site is routinely performed with a split-thickness skin graft. The aim of the current study is to present a surgical technique that reports a modified incision, which allows elevation of the first DMA flap for the management of the soft tissue defects of the thumb without requiring a skin graft for coverage of the donor site. A 65-year-old man presented to the emergency department with a crush injury to the thumb. The patient had an extensive skin defect on the dorsal side of the thumb extending circumferentially to the ipsilateral thenar without tendon damages, whereas sensation of the finger was found intact. Surgical intervention was performed within six hours and involved DMA flap transfer through a modified skin incision, which allowed coverage of the donor defect in the index finger with a second DMA perforator flap. 3 months postoperatively, patient’s satisfaction, sensation and range of motion (ROM) of the fingers were assessed using The Michigan Hand Outcomes Questionnaire (MHQ) and the 2-point discrimination (2-PD) test. The patient regained active ROM of the thumb and index along with complete preservation of sensation, while the final cosmetic outcome was satisfactory. The application of this technique allows coverage of both trauma defect and donor site with a single skin incision, providing a successful clinical outcome.

Matriderm dermal substitute in the treatment of post traumatic hand's fingertip tissue loss.

Treatment of fingers tissue loss is particularly challenging as it often necessitates advanced reconstructive techniques such as flaps or grafts, with esthetic and functional results that are not always as good as hoped for, with long healing times. Recently, along with tissue engineering development, numerous types of dermal substitute have been commercialized, with promising possibilities of treatment in finger tissue loss. In the author's unit, Matriderm® is the most commonly used dermal substitute. As described by the manufacturer, this scaffold is designed to be covered with a split-thickness skin graft. In using a two-step procedure, the authors realized that in most cases of fingertips injuries, at three weeks follow-up, the wound appeared in an advanced state of healing, which permitted to avoid grafting. Between October 2017 and October 2018, 27 fingers have been included in this study. Patients have been divided in two groups: those treated with Matriderm® alone (15 fingers) and those who had a skin graft three weeks after the first surgery (12 fingers). At the 6-month follow-up, authors evaluated the esthetic results with the Vancouver Scar Scale (VSS), the functional results with Quick Disability of the Arm, Shoulder and Hand (qDASH) score, and sensibility by the mean of two-point discrimination test (2-PD). All outcomes were overlapping in patients treated with or without skin graft: mean VSS was 2.3, mean qDASH was 13.3, and mean 2-PD was 7.7mm. The results obtained allow to consider Matriderm® , used also without skin graft coverage, as a valid solution for treatment of fingertip tissue loss.

Treatment and Outcomes of Women With Large Locally Advanced Breast Cancer.

Advances in breast cancer research have made breast cancer a treatable disease. However, there is a population of women who present with large, advanced, or sometimes neglected breast cancers who can prove difficult to treat. These women often require multiple modality treatment including chemotherapy, surgery, and radiation. The purpose of our study is to examine the treatment and outcomes on women with large, locally advanced breast cancers (LABCs). We identified 8 individuals who presented with LABCs requiring extensive treatment. Patients with inflammatory or metastatic cancer at the time of presentation were excluded. These patients’ charts were reviewed and analyzed. Patient demographics, hormone receptor status, stage, types of treatment, presence of metastasis, survival, and presence of barriers for seeking treatment sooner were identified. The median age at presentation was 65 years old. The patients were equally African American and Caucasian. All patients presented with T4 or stage 3 tumors involving the skin and/or pectoralis muscle. Half of the patients were found to have triple-negative (estrogen receptor, progesterone receptor, Her-2/neu negative) tumors. 87% of the patients received chemotherapy; 1 refused. All 8 patients, either neoadjuvantly or adjuvantly, underwent a modified radical or radical mastectomy. Skin graft or flap coverage was necessary in half of the patients. Postmastectomy radiation was received in 87% of the patients; 1 patient refused the treatment. Half of the patients developed metastatic disease. Thirty-seven percent of the patients have since died with a median survival of 44 months. Reasons for delay in seeking care were monetary or social barriers. Many of the patients finally sought care via the emergency room due to symptoms they could no longer ignore. Women who present with LABC require complex multidisciplinary treatment consisting of chemotherapy, surgery, and radiation treatments. Many of these patients faced economic and social challenges to accessing care. Better access to care and more prompt connection to breast surgeons are required to assist this patient population.

Immediate Versus Staged Soft Tissue Reconstruction After Soft Tissue Sarcoma Resection Has Similar Wound and Oncologic Outcomes.

The aim of this study was to compare the wound complication rate and oncologic outcome in patients undergoing immediate versus staged soft tissue reconstruction after soft tissue sarcoma (STS) resection. This is a retrospective analysis of a single sarcoma referral center between 2006 and 2016 which identified a cohort that underwent resection of an extremity or trunk STS with reconstruction surgery (split thickness skin graft or flap coverage). Patients were divided into 2 groups based on the reconstruction timing: immediate (same day) versus staged (later date). Demographic characteristics, wound complications, and oncologic outcomes were compared. Of the 491 patients who underwent resection of an extremity or trunk STS, 81 (16%) received reconstructive surgery, with 26 patients undergoing immediate reconstruction and 55 patients undergoing staged reconstruction. Overall wound complication (58% vs 45%, P = 0.347) and infection rates (35% vs 25%, P = 0.602) were similar between immediate and staged groups, respectively. Likewise, local recurrence (8% vs 7%, P = 1.000), metastasis (19% vs 20%, P = 0.755), and all-cause mortality (27% vs 27%, P = 1.000) rates after reconstruction was similar. Patients in the staged group with positive margins after resection were re-excised before definitive reconstruction, whereas those in the immediate group were not. The staged group required fewer surgical intensive care unit stays after resection surgery (22% vs 58%, P = 0.006). The mean ± SD final follow-up was 38 ± 33 months. Wound complication rates and oncologic outcomes remain similar, regardless of timing for reconstruction. Staged reconstructions were associated with fewer surgical intensive care unit stays, while also affording opportunity for reintervention after positive margins with little additional morbidity.

Reverse-Flow Versus Perforator Propeller Lateral Arm Flap for Elbow Reconstruction.

The lateral arm flap (LAF) represents an attractive option for elbow reconstruction, due to low donor site morbidity and a consistent surgical anatomy. It has been described as reverse-flow and as perforator propeller flap (radial collateral artery perforator [RCAP]). We compared the 2 techniques in terms of immediate- and long-term outcomes, together with functional and aesthetic evaluation. We retrospectively reviewed 15 patients, 9 males and 6 females, according to the department prospectively maintained database. Ethiology of the defects and patient comorbidities were listed together with flap and clinical data (operative time, time to healing, hospital stay, etc). Functional outcomes were measured according to Quick Disability of Arm Shoulder and Hand score at the time of the last follow-up. Seven LAF flaps were raised in a reverse-flow fashion, whereas 8 were RCAP flaps. No patients described any major elbow functional limitations, and they were generally satisfied with the aesthetic appearance. When comparing the 2 groups of reconstruction, harvest of RCAP flap resulted significantly faster and patients needed less hospitalization days (*P < 0.05). Aesthetic scores were lower where a cutaneous bridge was left intact during rotation (leading to a dogear), which was always the case in reverse-flow flap. Among complications, a partial RCAP flap necrosis occurred in a highly comorbid patient and required a skin graft coverage, whereas 4 reverse-flow flaps presented distal venous congestion which, in 1 patient, led to a secondary flap procedure. In our practice, elbow reconstruction using the RCAP flap required less hospital stay and operative time. Being less prone to venous congestion, in presence of sizeable perforators, it should be preferred to the reverse-flow LAF flap.

Full-thickness skin grafting for coverage of dorsal hand defect

Full-thickness skin grafting for coverage of dorsal hand defect

Firework Injuries of the Hand: An Analysis of Treatment and Health Care Utilization.

Background: Firework injuries to the hand can be devastating due to the explosive and ballistic nature of these devices. The aim of this study was to describe the injury and treatment characteristics of patients requiring surgery for firework-related hand injuries and to investigate which factors are associated with an increased utilization of health care resources. Methods: A retrospective chart review of patients undergoing surgery for firework-related hand injuries at two American College of Surgeons level I trauma centers between 2005 and 2016 was performed. Twenty cases were identified. These patients were evaluated for demographics, injury characteristics, number and types of surgical interventions, length of stay, and utilization of health care resources. Bivariate analyses were performed to investigate which factors were associated with increased consumption of health care resources. Results: Injuries ranged from digital nerve injuries to traumatic amputation. Patients underwent a median of 3 surgical operations. More than half the patients underwent flap or skin graft coverage of a soft tissue defect. The median length of hospital stay was 7 days. Factors found to be associated with an increased utilization of surgical and hospital resources included a first web space injury, thumb fracture, and traumatic amputation of any digit. Conclusions: The morbidity inflicted by firework injuries to individual patients is substantial. Patients with severe injuries undergo a median of three surgical operations and have a long duration of initial hospital stay. Knowing which factors are associated with an increased utilization of resources can help prognosticate these preventable injuries.

Abstract: Outcomes of Reconstructive Limb-Salvage Surgery in Lower Extremity Soft Tissue Sarcomas: A 20-Year Experience

INTRODUCTION: Extremity sarcoma management follows a multidisciplinary approach involving orthopedic oncologists, plastic surgeons, medical oncologists, and radiation oncologists. Surgical resection of lower extremity soft tissue sarcomas often leads to large, complex defects with exposure of underlying neurovascular structures, tendons, and/or bone. Subsequent reconstructive surgery is often required in order to provide adequate soft tissue coverage and allow for functional preservation of the limb. We report our 20-year experience with limb-salvage surgery following lower extremity soft tissue sarcoma resection. METHODS: We performed a retrospective review on all patients 18 years or older at the time of operation that underwent soft tissue reconstructive surgery following resection of lower extremity soft tissue sarcomas between 1996 and 2016 at our institution. Medical records were reviewed for patient demographics, tumor characteristics, details of tumor resection and plastic surgery reconstruction, administration and timing of chemo/radiation therapy, and postoperative outcomes. RESULTS: 136 patients underwent plastic surgery reconstruction following tumor resection. The average age was 55.7 years. The majority of tumors were high grade (47.1%), greater than 5 cm (66.9%), AJCC stage 3 (38.2%) and located in the proximal thigh (41.2%). 93.4% of reconstructive procedures were performed in the same operative setting as the oncologic resection. Approximately 90% of the advanced plastic surgery reconstructions involved a flap for coverage. Local flap reconstruction was most common for proximal thigh wounds (69.6%) and microvascular free flap reconstruction was most common for distal leg wounds (60.9%) (p=0.013). Skin grafts alone were most common for tumors ≤5cm (p=0.043), superficial wounds (p=0.001), and re-excisions (p=0.029) due to incomplete margins or recurrent disease. In conjunction with surgery, seventy-two patients (52.9%) received neoadjuvant radiation and twenty-six patients (19.1%) received neoadjuvant chemotherapy. The utilization of neoadjuvant radiation or neoadjuvant chemotherapy was not associated with the type of reconstruction utilized following tumor resection. Wound complications occurred within 6-months postoperatively in 52.9% of patients. The most common complication was wound dehiscence (26.4%), followed by infection (18.4%), and seroma (15.4%). Thirty-two patients (23.5%) required a re-operation for wound complications. Average time to healing was 13.0 weeks. Limb survival was 94.9%. There was no significant difference in the incidence of overall wound complications, re-operations, time to heal, or limb survival, between patients receiving local flap, free flap, or skin graft coverage. 16.9% and 36.8% of patients had evidence of local recurrence or metastatic disease through last known follow up, respectively. There was no significant difference in local recurrence or metastatic disease between the different reconstructive techniques. CONCLUSION: Patients with extensive lower extremity soft tissue defects often require plastic surgery soft tissue reconstruction after sarcoma resection. Based on our results, in patients that cannot undergo primary closure, local flaps can effectively reconstruct the majority of lower extremity sarcoma defects. However, microvascular free tissue transfer may be warranted for large wounds, areas of previous irradiation damage, or in the distal lower extremity. The post-operative management of sarcoma patients remains challenging due to high rates of wound complications. Local recurrence and metastatic disease confer additional morbidity and mortality in this patient population.

Microvascular “on-top-plasty”: An Alternative for Thumb Reconstruction in Constriction Band Syndrome

Constriction band syndrome affecting the hand and importantly the thumb may require reconstruction to improve function. This case report presents a patient with auto-amputation through the proximal phalanx of the middle, index, and thumb. Microvascular reconstruction was used to perform an on-top-plasty with the remaining index finger to the thumb. The case also involved skin graft coverage, venous grafting, and tendon reconstruction. The patient presents with 12 months follow up after index procedure and 3 months after revision. She has the ability to grasp large objects. Sensation remains present in pulp of new thumb. Cosmesis subjectively improved per patient’s family and physician. Strength continued to improve and reached 2 Kg of grip strength by 12 months. Microvascular on-top-plasty is a possible option for improving function in constriction hand syndrome affecting multiple digits.

Clinical management of Gustilo IIIB and IIIC type open fractures of forearm

Objective To evaluate the clinical effects of different methods in the treatment of GustiloⅢB andⅢC type open fractures of forearm. Methods From December 2006 to June 2014, 28 cases of forearm open fractures with severe soft tissue injuries were treated in our department. According to Gustilo open fracture classification, 10 cases were typeⅢB and 18 cases were typeⅢC. Fractures were treated by plate fixation at first stage in 9 cases, external fixation at first stage in 4 cases, external fixation at first stage and plate fixation at second stage in 15 cases. The wounds of 7 cases were closed at first stage, and the rest 21 cases were treated by wound open with VSD coverage at first stage and free skin graft or flap coverage at second stage. Results All the patients were follow-up for 12 to 24 months with an average of 17.5 months. Postoperative osteomyelitis and bone nonunion occurred in one case which was healed 12 months after the second operation of plate fixation after complete debridement and simultaneous shortening of the radius and ulna. The healing time of other 27 cases ranged from 8 to 14 months with an average of 9.3 months. According to Anderson's forearm fracture evaluation standard, the results were excellent in 16 cases, good in 8 cases, and fair in 4 cases. Conclusion Complete debridement, reasonable fixation and one or two stage wound closure for the treatment of GustiloⅢtype forearm fracture accompanied with different degree of soft tissue injury can maximally achieve limb salvage and reduce the occurrence of postoperative infection, osteomyelitis and bone exposure. Key words: Forearm; Fractures,open; GustiloⅢtype; Severe soft tissue injury

Staged management of open Lisfranc injury: Experience from 14 patients.

There are still controversies on the management and outcome of open Lisfranc injury in available studies. This study evaluates the staged management of Lisfranc injury and its complications.Patients who received a staged strategy for open Lisfranc injury were reviewed.One patient with degloving injury suffered from partial skin and hallux necrosis which was treated by debridement, hallux amputation, definitive internal fixation, and local flap transfer on the 12th day after first stage management. A definitive internal fixation and simultaneous skin graft or flap coverage were performed in another 3 patients with soft tissue defects. Other patients without soft tissue problems underwent a second stage of definitive internal fixation. Bone union was observed on the 12.5th week after definitive surgery. The median AOFAS midfoot score at the last follow-up was 74.4 ± 8.7, while the average VAS score was 2.2 ± 1.8. The average return-to-work time was 8th months postoperatively in 9 patients. Flap necrosis, infection, implant failure, nonunion, and osteomyelitis were not observed during the follow-up. Two patients received Lisfranc arthrodesis for persistent pain due to posttraumatic arthritis.In the management of open Lisfranc injury, surgeons must consider soft tissue condition. Staged strategy is a rational protocol for this severe injury. Temporary K-wire fixation after early radical debridement and realignment will facilitate the definitive internal fixation until soft tissue condition improves, which also can decrease the soft tissue complication.