Research Articles

Open Soft Tissue Degloving Injuries of Lower Limbs Managed by a Staged Protocol Using Preserved Autologous Skin Graft

Abstract

Background: Degloving soft tissue injuries (DSTIs) are defined as detachment of skin and its appendages from underlying muscle fascia. The present study aimed to assess the outcome of open circumferential DSTIs of lower limbs using a staged protocol by utilizing the stored skin graft harvested from degloved skin flaps.
Methods: This retrospective study included 12 patients with open circumferential lower limb degloving injuries (Arnez types three and four), with a minimum final follow-up of two years. All the patients were treated using a staged protocol, which included harvesting skin grafts from the degloved skin flaps, followed by refrigerator storage of the graft and stay sutures for the flap. The refrigerator-stored graft was then used to cover the raw areas left after secondary debridement.

Results: The mean wound area per patient that required skin grafting was 1082.9 ± 679.0 cm2, and mean area of the wound covered 2 by refrigerator-preserved skin graft per patient was 798.7 ± 350.0 cm . One patient needed a latissimus dorsi flap, and three patients with whole limb degloving had to undergo skin grafting for the remnant raw area harvested from the contralateral thigh. None of the patients ended up with amputation.
Conclusion: Despite being rare, open DSTIs are very complex injuries with no definitive guidelines for management, especially Arnez type three and four injuries. The staged protocol presented in the present series potentially answers the dilemma. However, larger multi-centric trials are needed to study the outcome of the discussed staged protocol.

1. Wójcicki P, Wojtkiewicz W, Drozdowski P. Severe lower extremities degloving injuries--medical problems and treatment results. Pol Przegl Chir. 2011;83:276-82.
2. Innis CO. Treatment of skin avulsion injures of the extremities. Br J Plast Surg. 1957;10:122-40.
3. Antoniou D, Kyriakidis A, Zaharopoulos A, Moskoklaidis S. Degloving Injury. Eur J Trauma. 2005;31:593–6.
4. Krishnamoorthy R, Karthikeyan G. Degloving injuries of the hand. Indian J Plast Surg. 2011;44:227-36.
5. Mello DF, Assef JC, Soldá SC, Helene A Jr. Degloving injuries of trunk and limbs: comparison of outcomes of early versus delayed assessment by the plastic surgery team. Rev Col Bras Cir. 2015; 42: 143-8.
6. Guo J, Li J, Lu KH. Observation of microvascular casting of avulsion injured skin flap under electron microscope. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 1999;13:119-21.
7. Arnez ZM, Khan U, Tyler MP. Classification of soft-tissue degloving in limb trauma. J Plast Reconstr Aesthet Surg. 2010;63:1865-9.
8. Hakim S, Ahmed K, El-Menyar A, Jabbour G, Peralta R, Nabir S, et al. Patterns and management of degloving injuries: a single national level 1 trauma center experience. World J Emerg Surg. 2016;11:35. doi:10.1186/s13017-016-0093-2
9.Powers ML, Hatem SF, Sundaram M. Morel-Lavallee lesion. Orthopedics. 2007;30:250-323.
10. Latifi R, El-Hennawy H, El-Menyar A, Peralta R, Asim M, Consunji R et al. The therapeutic challenges of degloving soft-tissue injuries. J Emerg Trauma Shock. 2014;7:228-32.
11.Cohen SR, LaRossa D, Ross AJ 3rd, Christofersen M, Lau HT. A trilaminar skin coverage technique for treatment of severe degloving injuries of the extremities and torso. Plast Reconstr Surg. 1990;86:780-4.
12. Kudsk KA, Sheldon GF, Walton RL. Degloving injuries of the extremities and torso. J Trauma. 1981;21:835-9.
13. Nogueira A, Martínez MJ, Arriaga MJ, Pérez A, Tévar aF. Delayed full-thickness autografting of cryopreserved avulsed skin in degloving injuries of the extremities. Plast Reconstr Surg. 2001;107:1009-13.
14. Edlich RF, Rodeheaver GT, Thacker JG, Lin KY, Drake DB, Masonet SS, et al. Revolutionary advances in the management of traumatic wounds in the emergency department during the last 40 years: part I. J Emerg Med. 2010;38:40-50.
15. Bianchi J. The cleansing of superficial traumatic wounds. Br J Nurs 2000; 9:S28–38.
16. Farmer AW. Treatment of avulsed skin flaps. Ann Surg. 1939;110:951-9.
17. Prendiville JB, Lewis E. The pneumatic-tyre torsion avulsion injury. Br J Surg. 1955;42:582-7.
18. Jeng SF, Wei FC. Technical refinement in the management of circumferentially avulsed skin of the leg. Plast Reconstr Surg. 1997;100:1434-41.
19. Zwillinger N, Carette S, Lorenceau B. Salvage of a leg avulsion injury by vacuum negative pressure therapy: a case report. Ann Chir Plast Esthet. 2008;53:74-8. In French]. doi: 10.1016/j.anplas.2006.08.006. [PubMed: 17030389].
20. Tian L, Ji X, Chen T, Qi F, Tian F, Yao Q, et al. Deep hypothermic preservation of autologous skin in the treatment of large-area circumferential multi-plane degloving trauma: a pilot study of 2 cases. Cell Tissue Bank. 2019;20(1):109-15. doi: 10.1007/s10561-018-09745-4. [PubMed: 30637555]. [PubMed Central: PMC6469666].
21. Barendse-Hofmann MG, van Doorn L, Steenvoorde P. Circumferential application of VAC on a large degloving injury on the lower extremity. J Wound Care. 2009;18:79-82. doi: 10.12968/jowc.2009.18.2.38747. [PubMed: 19418786].
Files
IssueVol 10 No 2 (2024) QRcode
SectionResearch Articles
DOI https://doi.org/10.18502/jost.v10i2.15515
Keywords
Degloving Injuries Free Tissue Flaps Skin Transplantation

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
1.
Mohd J, Bhat N, Lone Z, Bhat T, Butt M, Ghani A, Dev B, Gupta S. Open Soft Tissue Degloving Injuries of Lower Limbs Managed by a Staged Protocol Using Preserved Autologous Skin Graft. J Orthop Spine Trauma. 2024;10(2):71-7.