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Three Part Question

In [patients with pretibial flap lacerations] is [a primary skin graft or simple wound edge approximation] better at [reducing the time to healing]?

Clinical Scenario

A 69 year old woman has slipped and caught her leg on a chair. She attends your A&E department with a large flap laceration to the anterior aspect of her right leg. She has no other injuries, no other significant past medical history and has good social support. you want her wound to heal quickly so that she may get back to her normal activities as soon as possible. You wonder whether a primary split skin graft or a simpler procedure using the existing flap would be best to achieve this.

Search Strategy

Medline 1966- week 4 March 2005
Embase 1980- week 13 2005
Cochrane Issue 1 2005
Medline: [pre-tibia$.mp OR pretibia$.mp] AND [exp wounds and injuries/ OR lacerat$.mp. OR injur$.mp OR exp skin flaps/ OR exp skin transplantation] limit to human and English language. 64 articles found
Embase: [pre-tibia$.mp. OR pretibia$.mp.] AND [exp injury/ OR lacerat$.mp OR exp skin transplantation/ or exp skin graft/ or skin flap/] limit to human and English language 54 articles found
Cochrane: Pretibial [all fields] 23 records found

Search Outcome

72 papers found of which only one was relevant and of sufficient quality for inclusion. This paper is shown below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Haiart DC et al, 1990, UK	25 patients with pretibial lacerations Primary excision under local anaesthetic and split skin graft versus defatting of flap and steristrips	Prospective randomised controlled trial	Duration of hospitalisation	11.0 v 16.1 days	Small numbers No independent assessment of wounds
			Further operative treatment	0 v 4 patients
			Proportion of defect not covered at 10 days	0 v 26.9%
			Time to complete healing	13.2 v 40.7 days

Comment(s)

Earlier studies only compared primary split skin grafting with grafting after failed conservative management or studied conservative management alone. This study shows that primary split skin grafting under local anaesthetic shortens the time to full healing of pretibial flap lacerations by nearly four weeks though a larger prospective randomised controlled trial would be needed to confirm this. Early mobilisation has been shown to be beneficial in the elderly after such a procedure which makes management as an out-patient the preferred option.

Clinical Bottom Line

A primary split skin graft performed under local anaesthetic significantly reduces the healing time for pretibial flap lacerations and can be done successfully as an out-patient procedure.

References

1. Haiart DC, Paul AB Chalmers R et al. Pretibial lacerations: a comparison of primary excision and grafting with "defatting the flap". British Journal of Plastic Surgery 1990;43:312-14.