Split-thickness skin graft together with site-specific offloading: Accelerated and durable option for healing diabetic foot skin defect

Background/purposes
Diabetic foot is a major health problem affecting a large portion of diabetic patients and needs multidisciplinary teamwork to achieve satisfactory results. Revascularization, surgical debridement, and soft tissue reconstruction are essential for complete cure. Split-thickness skin graft (STSG) is a widely accepted method for soft tissue coverage of open wounds; this technique has a significant role in burn wounds and plastic surgery reconstruction. Its use in the treatment of chronic diabetic foot ulcers is challenged by the high failure rates, particularly when used to cover plantar ulcers. Other reconstructive options are costly, demanding, and, therefore, not preferable in the setting of comorbid high-risk patients. This study assesses whether the addition of site-specific offloading would help prevent recurrent ulceration following the application of STSGs for the treatment of diabetic foot plantar ulcers.
Patients and methods
Adult patients with diabetic foot infection who underwent surgical debridement, plantar wound reconstruction with STSG, site-specific offloading, and completed a clinical follow-up of at least 1 year were selected for analysis.
Results
Forty-two patients underwent STSG. Out of them 38 (90.0%) patients had infection and 23 (54.8%) had gangrene. Successful revascularization was done in 27 (64.3%) patients before enrollment. Debridement and toe amputation were done in 16 (38.1%) and 17 (40.5%) patients, respectively. Transmetatarsal amputation was done in nine (21.4%) patients. The average wound size was 21 cm and ranged from 6 to 120 cm. The median time to complete wound healing was 6 weeks. Thirty-four (81.0%) patients had complete healing by 2 months. We found a statistically significant relationship between compliance to offloading and healing at 3, 4, and 5 months of follow-up (=0.001, 0.02, 0.02, respectively). During the 1-year follow-up period, 13 (30.95%) patients experienced ulcer recurrence. Ulcer recurrence was significantly higher among patients who were noncompliant to offloading (58.82 vs. 12%, =0.0021).
Conclusions
STSG together with site-specific offloading can be considered a reliable option for achieving accelerated wound healing and prevention of recurrence in diabetic foot patients after proper wound preparation.