Here again is the wound after debridement has been done. There is no dead tissue, no important structure exposed, and no obvious signs of infection. The wound seems to have a healthy, granulating base.
What to do now?????
A wound with exposed bone/tendon/hardware is more challenging- because a skin graft or scar tissue will usually not provide long-term, stable coverage. These types of wounds require some type of flap coverage. This current patient has a less challenging problem- the wound can either be left open to heal on it’s own, or a split thickness skin graft (STSG) can be done.
Healing secondarily vs. STSG: which to choose?
Because the wound is so large, several months of regular dressing changes will be required before it completely heals. This can be quite burdensome. Another consideration is the location of the wound- the medial lower leg and ankle area. Allowing the wound to heal secondarily will lead to tightness and scar contracture, which can cause significant limitation of motion at the ankle. In addition, the bones are already healing slower than desired, in part because of the open wound. All of these factors make allowing the wound to heal secondarily an unattractive choice for the patient. A STSG is the best option because it will result in faster wound healing and stabilization of the soft tissue. And this will in turn, promote bone healing.
The STSG was not done at the first operation due to the significant amount of necrotic tissue in the wound with concomitant bacterial colonization. For a STSG to be successful, it’s critical to have a very clean bed. So in this patient, dressings were done for several days, to be sure the wound was clean and ready for grafting.
Here is the wound 1 week after debridement- somewhat smaller than at initial presentation, with a healthy granulating base. It is now ready for STSG.
Corresponding chapters for further information:
Chapter 10: Secondary wound closure
Chapter 12: Skin grafts