Question: Preventing many complications and problems of graft fixation on hand.
Findings: Sufficient fixation was obtained in skin grafts on hand, and there were no complications.
Meaning: Our technique of NPWT is useful for skin graft fixation in the hand.
To improve skin grafting results, immobilization and precise contact of the skin graft is important. A bolster dressing is the gold standard technique to stabilize skin grafts. However, skin grafts on the fingers and hands remain challenging.1–3 Occasionally, joint fixation with Kirschner wire and casting is required for patients with extensive burn injury and pediatric patients who are unable to remain at rest. However, joint fixation can disturb finger growth and cause joint contracture.4
Graft fixation with negative pressure wound therapy (NPWT) has recently become popular.1–3,5–8 However, using NPWT for hands, its complex shape can cause air leaks.1–3 This article describes the application of a glove-shaped foam for effective skin graft immobilization with NPWT on the hand.
PATIENTS AND METHODS
This report includes four patients who required skin grafting on their hand. All patients received skin grafts in the affected area (See table, Supplemental Digital Content 1, which shows the statistics of the cases. https://links.lww.com/PRSGO/C357). Graft fixation was performed using NPWT (RENASYS wound treatment system, Smith and Nephew Wound Management Inc., UK).
At first, two pieces of foam cut to the shape of the patient’s hand were prepared. Then fradiomycin sulfates (Sofratulle Gauze Dressing, Teika Pharmaceutical Company., Ltd.) were placed onto the skin graft. The hand was encased by the foam on the ventral and dorsal sides, and small pieces of foam were also placed between the fingers. The fingertips were left uncovered to allow for observation of skin color. The hand and foam were covered from the palmar and dorsal sides with the attached drape, and a suction pad was placed on the dorsal side (Fig. 1). Fixation was maintained for 7 days postoperatively at a pressure of −50 to −80 mm Hg.
After removal of the NPWT, the graft was treated with ointment and gauze dressing. Fourteen days after the operation, active joint movement was allowed.
Case 1 was a postburn scar contracture. The affected areas were middle and ring fingers. Each size of skin graft measured 1.2 × 3.5 cm and 1.0 × 3.2 cm, respectively. Case 2 was a syndactyly. The affected areas were the interdigital spaces (2nd/3rd, 4th/5th). All the size graft measured 1.5 × 2.0 cm. Case 3 was a pigmented nevus, and the affected area was the palm. The graft measured 1.5 × 1.0 cm. Case 4 was a burn injury. The affected area was almost the entire extent of the dorsal of the hand. The grafted area measured 6.0 × 6.0 cm (dorsal) and 1.5 × 4.0 cm (all fingers). (See Video [online], which demonstrates our technique for skin graft fixation with NPWT for case 4.)
There were no cases of air leak requiring reattachment of the system, and graft take was full in all cases. There was no joint contracture in either case.
The patient was 1-year-old male child with post-burn scar contracture of the fingers on the right hand (proximal interphalangeal and metacarpophalangeal joints of the middle and ring fingers).
Double-Y incisions were made over the proximal interphalangeal and metacarpophalangeal joints of the middle and ring fingers to release the contracture. Full-thickness skin grafts were obtained from the lateral malleoli of the left and right ankles. Glove-shaped foam was applied with the distal interphalangeal and metacarpophalangeal joints in extension. The fingertips were left uncovered to allow observation of skin color (Fig. 2). Fixation was achieved with NPWT (−50 mm Hg) for 7 days (Fig. 3). After NPWT removal, the graft was treated with ointment and gauze dressing. The graft take was complete, with no joint contracture (Fig. 4).
In 2010, Kasukurthi and Borschel described a NPWT mitten technique for skin graft immobilization on the hand.3 In their technique, a large piece of foam was placed on the volar aspect of the hand and small pieces of foam were placed in each web space. However, their cases required K-wire joint fixation. Skin grafting on the fingers and surrounding area often requires joint fixation with K-wire and casting. In pediatric patients, insertion of K-wire through growing cartilage may disturb finger growth; injure tendons, vasculature, and nerves; and cause joint contracture.4 Furthermore, radiation exposure due to X-ray examination to verify wire placement and the fear of wire fixation and removal are a concern.
In our technique, a hand-shaped form was designed. The affected hand was encased on the ventral and dorsal sides, and small pieces of foam were placed between the fingers. With this design, it was possible to reduce movement of the finger joints and keep the joints in the moderate rest position.
In general, the pressure of conventional tie-over bolster technique for skin graft fixation has been determined on the basis of the peripheral blood pressure. In 1984, Sakurai et al analyzed the effect of bolster fixation on graft engraftment and peripheral blood flow.9 They concluded that pressure exceeding the blood pressure of peripheral arteries (about 32 mm Hg) might inhibit the blood supply to the grafts.
In previous reports of NPWT skin graft fixation, the pressure was as much as −80 to −125 mm Hg, well below peripheral blood pressure.1–3,6,7 However, application of NPWT with excessive pressure to the hand and fingers can affect finger blood flow.10 We performed NPWT skin graft fixation on the hand with a lower pressure of −50 to −80 mm Hg. Furthermore, the dressing was designed to allow observation of fingertip color so that blood flow at the end of the finger could be monitored. The complex shape of the hand can cause air leaks of NPWT fixation. Our technique may help improve the graft fixation with NPWT.
In this report, we have not yet treated an adequate number of patients. Therefore, additional case experience is required to clarify its indication.
In conclusion, the NPWT “glove-shape” technique enabled maintenance of average negative pressure for all skin grafts on the hand. This technique does not require joint fixation and may help to prevent growth disturbance and joint contracture.
Continuous suction and compression of the wound bed ensures fluid removal (exudate, hematoma, and waste products) and stabilizes the graft by maintaining a constant level of pressure. These things are large advantages to skin graft take.
In previous reports of NPWT skin graft fixation, the pressure was as much as −80 to −125 mm Hg. However, application of NPWT with excessive pressure to the hand and fingers can affect finger blood flow. We performed NPWT skin graft fixation on the hand with a lower pressure of −50 to −80 mm Hg. In all cases, the graft taking was successful. We thought the excessive pressure is not necessary for skin grafting.
This technique does not require joint fixation and may help prevent growth disturbance and joint contracture. So, especially in pediatric cases, our technique has some advantages.
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