Pretibial injuries in the elderly: a prospective trial of early mobilisation versus bed rest following surgical treatment

Extremity Mobilization After Split-Thickness Skin Graft Application: A Survey of Current Burn Surgeon Practices

PURPOSE

To determine the current postoperative mobilization care practice patterns of burn surgeons after split-thickness skin grafting and to assess potential inconsistencies in management strategies.

METHODS

A cross-sectional study of active burn surgeons was conducted with an online questionnaire (SurveyMonkey) comprising 7 demographic and 22 mobilization-related questions.

RESULTS

Seventy-three (22%) of the 337 members of the American Burn Association mailing list consented to participate in the study, of whom 71 completed the demographic questions and 59 completed the mobilization-related questions. The majority of respondents had more than 10 years of burn care experience (68%) and practiced in an American Burn Association-verified center (70%). Standardized postoperative autograft mobilization protocols were used by 68% of respondents. Most (66%) never or rarely immobilized the upper extremity without joint involvement. When the elbow or wrist was involved, 73% always or very often immobilized. Similarly, 63% never or rarely immobilized the lower extremity without joint involvement. Most immobilized when the knee (70%) or ankle (63%) was involved. Immobilization duration was most commonly 3 or 5 days. Most respondents (71%) reported following Nedelec and colleagues' recommendation that "early postoperative ambulation protocol should be initiated immediately after lower extremity grafting," although there was practice variability.

CONCLUSIONS

Our findings reveal that the majority of survey respondents do not immobilize the extremities after autograft without joint involvement. When grafts cross major joints, most surgeons immobilize for 3 or 5 days. Despite some practice variability, surveyed burn surgeons' current lower extremity ambulation practices generally align with the 2012 guidelines of Nedelec et al.

Tension subcutaneous haematomas associated with anticoagulants in the elderly: Do they have earlier morbidity and mortality than hip fractures?

INTRODUCTION

Complications related to anticoagulant therapy have been widely described, although tension haematomas in the extremities are frequently undervalued, and commonly considered banal pathologies.

MATERIAL AND METHOD

Retrospective descriptive study between 2014 and 2017, including patients with limb haematomas after minimal trauma related with anticoagulant therapy, and surgically treated by Traumatology.

RESULTS

32 cases were eventually included, 81% were women, average age of 83.56 years, and a mean aCCI of 5.97. Anatomical location of haematomas was 65.6% in leg/foot, 15.6% in thigh/buttock, and 18.8% in the upper limb. Seventy-eight point thirteen percent received acenocoumarol, 15.63% LMWH, and 3.13% NOACs. Of the cases, 59.38% were due to AF, 15.63% to valvular heart disease/valve prosthesis, and 12.5% to PE/DVT. The mean time from diagnosis to surgical drainage was 2.66 days, mainly as a result of alterations in coagulation parameters. Forty-six point eighty-eight percent were reoperated for new drainage, cure or skin defect coverage, and 3 patients required embolisation. Of the patients, 78% needed consultation with other specialties. The average length of stay was 22.34 days, and the in-hospital mortality rate was 9.38%.

CONCLUSION

Tension haematomas in the extremities associated with anticoagulants occur in patients with multiple comorbidities that make them vulnerable. Surgical drainage is usually delayed by numerous factors which lead to skin defects that require further surgical operations, and prolonged hospital stays that are associated with medical complications. In our study, the average length of stay and in-hospital mortality rate were higher than those for hip fractures, so we should not underestimate this pathology.

The Impact of Time of Mobilization After Split Thickness Skin Graft on Lower Extremity Wound Healing-Systematic Review and Meta-analysis

Systematic Review registration

: Prospero CRD42017070990.

The management of pretibial lacerations

Introduction Pretibial lacerations are common injuries, often presenting in the elderly and infirm. Unclear management pathways often result in inappropriate care. We identify patient demographics, morbidity risk factors, injury severity and management options. Materials and methods This retrospective study involved analysing databases and hardcopy notes for patients admitted with pretibial lacerations to Addenbrooke's Hospital, January to December 2012. Microsoft Excel and Fishers exact test were used to analyse the data with a P-value of less than 0.05 representative of statistical significance. Information on patient demographics, site of lesion, preoperative symptoms, management, operative details and clinical outcomes were collected. Results A total of 36 patients were identified; the mean age was 79 years (± 16 years, 1 standard deviation) with a three to two female to male preponderance; 57% of injuries were caused by mechanical fall, 33% traumatic blunt impact and 7% road traffic accidents. American Society of Anesthesiologists physical status classification was 43% level III, 40% II, 9% I and 9% IV. Dunkin classification of severity was 33% grade III, 30% grade I, 24% grade IV and 12% grade II. Median inpatient duration was 11 days for surgically managed compared with 15 days for conservatively managed patients. Discussion Pretibial lacerations tend to affect the elderly. Management is compounded by polypharmacy and comorbidities. If inadequately managed, such injuries can adopt characteristics of chronic wounds, with lengthy inpatient stays. Surgical intervention may be appropriate where injuries are severe and the patient stable enough for theatre. Conclusions We believe that surgical management with autologous tissue repair, with minimal delay between presentation and theatre, is warranted for extensive injuries wherever possible, with conservative management used for predominantly less extensive pretibial lacerations.

Full-thickness skin grafts for lower leg defects coverage: Interest of postoperative immobilization

INTRODUCTION

Full-thickness skin graft is an effective reconstruction method after excision of skin lesions on the lower limb that are not amenable to primary closure. The randomness of graft take is the major drawback of this procedure.

OBJECTIVE

The objective of the study was to evaluate the outcome of full-thickness skin grafts (FTSG), used to repair lower leg defects after excision of skin lesions, after a 5-day immobilization period.

MATERIAL AND METHODS

All consecutive patients who underwent FTSG to cover defects below the knee between November 2011 and January 2016 were retrospective reviewed. Graft take was assessed and defined as good (>90% graft take), moderate (between 50% and 90% graft take), or poor (<50% graft take).

RESULTS

Seventy patients were included. Median age was 70 years (range, 18-92 years). The median area of the defect was 12cm². Graft take was good in 64 patients (91.4%), moderate in 3 patients (4.3%), and poor in 3 patients (4.3%) at Day 5. Complications included hematoma (11%), infection (14%) and venous thrombosis (3%).

CONCLUSION

Full-thickness skin graft is a reliable method to repair defects on the lower leg after removal of skin lesions. A 5-day immobilization period can improve the graft take. The authors have indicated no significant interest with commercial supporters.

Early ambulation after-grafting of lower extremity burns

OBJECTIVE

Early ambulation of lower extremity burns that undergo a skin graft may help to avoid some of the complications associated with immobilization. Despite recent evidence supporting early ambulation, post-operative immobilization following lower extremity skin grafting is still a common practice. The purpose of this study was to retrospectively assess the outcomes of lower extremity skin graft cases dressed with a multi-layer compression bandage who were ambulated in the immediate post-operative period.

METHODS

This single centre observational study examined patients with a lower extremity burn that received a compressive dressing (Profore™) application immediately after surgical grafting and were ambulated no later than 1day post-operatively.

RESULTS

Forty-two burn patients (47 limbs) met inclusion criteria for this study. Of these 42 patients, 25 were operated on as an inpatient. The remaining 17 patients were done on an outpatient basis and discharged the same day of surgery. Mean patient age was 48.2 years and 34 (81.0%) of patients were male. Mean TBSA affected was 5.3% (792cm²). Mean number of procedures was 1 and mean graft take was 98.9%. Nearly all patients were ambulated within 1day of surgery. The graft take rate across all cases was 98.9±2.3%. No patients failed early ambulation with their compressive dressings, were readmitted or underwent repeated skin grafting.

CONCLUSIONS

This study demonstrates the excellent graft take rates that can be achieved with immediate ambulation following lower extremity skin grafting and challenges the conventional teaching of post-operative bed rest following lower extremity skin grafting procedures.

Clinical analysis of 54 cases of large area soft tissue avulsion in the lower limb

OBJECTIVE

To assess the clinical curative effect of different treatment methods for large area avulsion injury in the lower limb.

METHODS

Between January 2010 and December 2013, 54 patients with large area avulsion injury in the lower limb were treated in the trauma center of our hospital, including 34 males and 20 females with a mean age of 35.7 years (range, 16-65 years). The injury mechanism was traffic accident in 44 cases, hitting by heavy objects in 8 cases, and fall from height in 2 cases, involving 31 thighs, 19 legs and 4 feet involved. The sizes of the avulsed wounds ranged from 10 cm ×15 cm to 50 cm ×30 cm. There were 16 cases combined with hemorrhagic shock, 5 with femoral fractures, and 7 with tibiofibula fractures. Averagely the patients were sent to our hospital within 3.5 h (range, 1.5-10 h) after injury. For the 54 patients, three different surgical strategies were performed based on the wound area and condition of the avulsed skin: in Group A, 24 patients were treated by debridement and preservation of subcutaneous vascular network ⁺ vertical mattress suture of full thickness skin flap ⁺ tube drainage; in Group B, 25 patients were treated by split-thickness skin flap meshing and grafting ⁺ vacuum sealing drainage (VSD); and in Group C, the other 5 patients were treated by debridement and VSD at stage I ⁺ reattachment of autologous reserved frozen split-thickness skin graft at stage II.

RESULTS

All the 54 patients recovered and were discharged eventually, without any deaths or amputees. In each group, there were no statistical differences (all p > 0.05) among different injury sites in terms of survival rate and length of hospital stay, except for the infection rate, which was much higher (p =0.000) at the leg area than that at the thigh (32.54% ± 2.97% vs. 2.32% ± 2.34% in Group A and 50.00% ± 0.00% vs. 0 in Group C) or the foot (50.00% ± 0.00% vs. 0 in Group C). Moreover comparison of the three surgical methods showed a significant different (all p < 0.05) between each other for all the three assessed parameters, i.e. flap survival rate, length of hospital stay, and infection rate.

CONCLUSION

Treatment choices for skin avulsion on the lower limb should be based on the viability of the avulsed skin flap and the location of the wound. Proper choice can not only reduce the economic burden caused by using VSD, but also shorten the long hospital stay due to repeated wound dressing change or second stage surgery.

Pretibial wounds: a review of current practice

Pretibial wounds are often associated with prolonged wound healing, particularly in the elderly female population. The wounds characteristically have either a proximally or distally based flap. Delayed wound healing has been attributed to flap necrosis and poor blood supply to this area. The aim of this review article is to examine the vascular anatomy, pathology and management options of patients with pretibial wounds.

Pretibial lacerations: experience from a lower limb trauma centre and systematic review

BACKGROUND

Pretibial lacerations are an important and neglected problem among the elderly. Poor management leads to prolonged hospitalisation and terminal decline. This study summarises our experience and evidence from the literature to ascertain an evidence-based rationale for referral and management.

METHODS

Our data were obtained from review of a prospectively gathered database. Additionally, Pubmed, Embase, Medline, and the Cochrane Database of Systematic Reviews were searched through July 2013, with eligible studies evaluated using standard methodology.

RESULTS

Seventy-three pretibial lacerations in 73 patients (63 females) were identified. Mean age was 78 ± 14, 1SD. Sixty patients were managed operatively with a mean length of stay of 11 ± 7 days, 1SD when uncomplicated by medical co-morbidity. Seven deaths occurred (4 in-hospital; 2 treated surgically and 2 treated conservatively) and 3 deaths occurred within 3 months of discharge; a death rate more than twice that of matched controls. Donor site "over-grafting" was performed in 19 cases and resulted in accelerated donor site healing (11 ± 9 days, 1SD vs. 29 ± 42 days, 1SD; P < 0.001). Negative pressure wound therapy delayed discharge (21 ± 23 days, 1SD vs. 15 ± 14 days, 1SD; P = 0.028). Microbiological sampling is unhelpful. Bed rest is unnecessary. "De-fatting" the flap is unproven.

CONCLUSION

Admissions expose the elderly to physical/functional decline and death. Our findings support a change of practice, minimising admissions for minor (Dunkin type I/II) injuries and rapid, protocol-driven surgical intervention and discharge for Dunkin type III/IV injuries with avoidance of negative pressure wound therapy in all but selected cases.

A kick in the shins: the financial impact of uncontrolled warfarin use in pre-tibial haematomas

Warfarin is increasingly prescribed in the elderly population for a number of medical conditions. Pre-tibial haematomas are a common cause of morbidity in this group. The aim of the study was to identify the proficiency of INR monitoring at a primary care level in correlation with their recommended INR range and to study the treatment outcome in this group. A retrospective single-centre study of patients diagnosed with pre-tibial haematomas was conducted over a two-year period. Length of hospital stay, time delay until operative intervention, blood transfusion and warfarin reversal requirements, social care input and cost to the NHS were considered. A total of 62 patients were admitted with pre-tibial haematomas of which 20 were on Warfarin. Females were predominantly more affected (5.6:1). The mechanism of injury was as a result of minor trauma. The mean INR level was 3.8 with a standard deviation of 3.1. Mean length of hospital stay was 11 days with a standard deviation of 13.6. Nine patients required skin grafting. Average cost for the acute episode was £3500 per patient. INR levels were significantly outwith the target range causing substantial patient morbidity and imposing a significant financial burden on the NHS. Tighter regulation at a primary care level should help reduce this risk.

A multidisciplinary approach to early mobilization of patients with burns

Mobilizing patients with burns can be challenging due to their unique characteristics. Many times, common practice is to elevate and immobilize the burned extremity after debridement and grafting. On the contrary, mobility is imperative for patients with burns, as patients can lose function and flexibility quickly. The objective of this article was to review the current evidence related to early ambulation in patients with burns as well as barriers to mobilization within a burn intensive care unit. It also provides a demonstration of how a nurse at the bedside in collaboration with a physical therapist can implement these interventions and assist with early ambulation in patients with burns.

Physical rehabilitation of the critically ill trauma patient in the ICU

OBJECTIVES

To 1) review the existing evidence for early mobilization of the critically ill patients in the ICU with polytrauma; 2) provide intensivists with an introduction to the biomechanics, physiology, and nomenclature of injuries; 3) summarize the evidence for early mobilization in each anatomic area; and 4) provide recommendations for the mobilization of these patients.

DATA SOURCES

A literature search of the MEDLINE and EMBASE databases for articles published in English between 1980 and 2011.

STUDY SELECTION

Studies pertaining to physical therapy and rehabilitation in trauma patients were selected. Articles were excluded if they dealt with pediatrics, geriatrics, burn injuries, isolated hand injuries, chronic (i.e., not acute) injuries, nontraumatic conditions, and pressure/decubitus ulcers, were in a language other than English, were published only in abstract form, were letters to the editor, were case reports, or were published prior to 1980.

DATA EXTRACTION

Reviewers extracted data and summarized results according to anatomical areas.

DATA SYNTHESIS

Of 1,411 titles and abstracts, 103 met inclusion criteria. We found no articles specifically addressing the rehabilitation of polytrauma patients in the ICU setting or patients with polytrauma in general. We summarized the articles addressing the role of mobilization for specific injuries and treatments. We used this evidence, in combination with biologic rationale and physician and surgeon experience and expertise, to summarize the important considerations when providing physical therapy to these patients in the ICU setting.

CONCLUSIONS

There is a paucity of evidence addressing the role of early mobilization of ICU patients with polytrauma and patients with polytrauma in general. Evidence for the beneficial role of early mobilization of specific injuries exists. Important considerations when applying a strategy of early physical therapy and mobilization to this distinctive patient group are summarized.

Practice guidelines for early ambulation of burn survivors after lower extremity grafts

The objective of this review was to systematically evaluate the available clinical evidence for early ambulation of burn survivors after lower extremity skin grafting procedures so that practice guidelines could be proposed. It provides evidence-based recommendations, specifically for the rehabilitation interventions required for early ambulation of burn survivors. These guidelines are designed to assist all healthcare providers who are responsible for initiating and supporting the ambulation and rehabilitation of burn survivors after lower extremity grafting. Summary recommendations were made after the literature, retrieved by systematic review, was critically appraised and the level of evidence determined according to Oxford Centre for Evidence-Based Medicine criteria. A formal consensus exercise was performed to address some of the identified gaps in the literature which were believed to be critical building blocks of clinical practice.

Mobilisation versus Bed Rest after Skin Grafting Pretibial Lacerations: A Meta-Analysis

Pretibial lacerations are problematic and best managed by surgical debridement, then skin grafting. Traditional postoperative care involves bed rest to optimise graft survival. This meta-analysis assesses early mobilisation versus bed rest for skin graft healing of these wounds. Medline, Embase, Cochrane, Cinahl, and Google Scholar databases were searched. Analyses were performed on appropriate clinical trials. Four trials met with the inclusion criteria. No difference was demonstrated in split skin graft healing between patients mobilised early compared to patients admitted to hospital for postoperative bed rest at either 7 (OR 0.86 CI 0.29-2.56) or 14 days (OR 0.74 CI 0.31-1.79). There was a statistically significant delay in healing in patients treated with systemic corticosteroids (OR 8.20 CI 0.99-15.41). There was no difference in postoperative haematoma, bleeding, graft infection, or donor site healing between the comparison groups. In the available literature, there is no difference between early mobilisation and bed rest for the healing of skin grafts to pretibial wounds. Corticosteroids exert a negative effect on skin graft healing unlike early mobilisation, which does not cause increased haematoma, bleeding, infection, or delayed donor site healing. Modality of anaesthesia does not affect skin graft healing.

The classification and principles of management of wounds in trauma

The correct assessment and early management of wounds is vital in achieving a good outcome in both the acute and chronic setting. A robust management plan for the trauma patient depends upon accurate and timely assessment of all injuries and evaluation of key features such as mechanism of injury, pre-hospital findings and intervention, zone of injury, patient characteristics and structures damaged. This article describes the general principles of wound assessment and management, discussing mechanism and zone of injury, debridement techniques, types of irrigation and the use of antibiotic prophylaxis. Particular attention is given to the management of open tibial fractures, fasciotomy wounds, pretibial lacerations and haematomas and bite wounds.

Keystone flap reconstruction of primary melanoma excision defects of the leg-the end of the skin graft?

BACKGROUND

During the last 4 years, the keystone-design fasciocutaneous island flap has become the principal form of reconstruction in our unit for primary melanoma defects of the leg distal to the knee where primary closure is not possible.

METHODS

Data describing the primary tumor, surgical management, and outcome were collected prospectively for consecutive keystone flap cases. The study's primary end points were complication rates and length of hospital stay.

RESULTS

A total of 176 patients with new primary melanomas of the lower limb were treated over 4 years. The average Breslow thickness was 1.33 mm (range, in situ to 9.0 mm), and the average width of the defect was 3 cm. The reconstructions comprised 106 standard, 65 modified, and 5 double-opposing keystone type flaps performed from the knee to the dorsum of the foot. Complications that required further therapeutic intervention were seen in eight patients (4.6%), with only one partial flap necrosis (.6%) and one total flap loss (.6%). In this series, modification of the flap design significantly decreased the complication rate (Fisher's exact test, P = .033). There was no increase in complications in the distal third of the leg. The procedure was performed in day-only surgery setting in almost a quarter of patients.

CONCLUSION

We present the largest series of flap reconstructions for melanoma of the leg. The keystone flap is extremely reliable, affords excellent cosmesis, and is technically straightforward to perform. At the Sydney Melanoma Unit, reconstruction after primary melanoma excision on the leg has been transformed so that skin grafts are now rarely performed.

Long term outcomes following pretibial injury: mortality and effects on social care

INTRODUCTION

Pretibial injuries are common, and those patients requiring hospital admission are often elderly with significant comorbidity. The long term impact on social care and associated mortality seen in this patient group has not been reported previously. It was our impression that pretibial injury is often a marker of increasing social and/or medical needs of the patient, and that a significant proportion of these patients underwent long term changes in social circumstances following injury.

METHODS

A review of 109 patients with pretibial injuries over a 3-year period admitted to the Plastic Surgery Unit at Derriford Hospital, Plymouth, UK. Overall mortality and changes in social circumstances within a 6-month period following discharge from hospital were recorded.

RESULTS

The overall mortality was 11%. Twenty-five percent of patients underwent an escalation of their social care requirements immediately on discharge from hospital. At 6 months only 78% of patients who were living independently at home prior to admission had returned home. Increasing age, cardiovascular comorbidities, length of time to operation were significantly associated with deterioration in social circumstances and death.

CONCLUSIONS

Mortality following pretibial injury is higher than that expected for the population. A sizeable proportion of patients with pretibial injuries can be expected to need significant long term changes in social input after injury. Whether this change is directly due to injury, or is a reflection of underlying medical and social deterioration identified by the hospital admission process is unclear. In either respect, close liaison with medical and social care teams is essential to facilitate optimum care in this patient group.

Comparison of inpatient bed rest and home convalescence following split thickness skin grafting to the lower leg

There has been a substantial move towards care of patients in an outpatient setting. This study was performed to determine if discharge home following split thickness skin grafting to the lower leg compromised graft results or morbidity compared with admission to hospital. Cases were reviewed retrospectively from the dermatology department's surgical records. All split thickness skin grafts to the lower legs over a 12-month period were included. All clinical notes were reviewed and phone calls made to patients and relatives. A total of 61 cases were included: 31 admitted as inpatients, 30 discharged home. There was no significant difference between the two groups' age, sex or comorbidities. A trend was seen in inpatients towards increased infection (P = 0.19) and venous thrombosis (P = 0.34). There is a lack of significant difference between admitted and discharged patients in all outcomes including bleeding, number of dressing clinic follow ups and graft loss. These results suggest that home convalescence after split thickness skin grafting to the lower legs compares favourably with inpatient care.

A step-by-step guide to classifying and managing pretibial injuries

Even in cases of relatively minor trauma, pretibial injuries to older patients can cause significant damage as a result of poor blood supply to the skin. This paper offers a classification of pretibial injuries and an algorithm for their management.

Pretibial lacerations in older patients: the treatment options

Skin grafts and compression may be more effective than traditional sutures and dressings in speeding healing of pretibial lacerations in older patients. This review looks at the evidence.