Fall from Tree Resulting in a Gustilo IIIA Fracture Complicated with a Limb-Threatening Chronic Wound Requiring a Unique Approach to Closure

Introduction: Past analyses of U.S. databases have illustrated increased morbidity and mortality experienced by patients with surgical wound dehiscence (SWD). The following case demonstrates a unique approach to lower extremity salvage in a sub-acute compound fracture surgical site infection using a limited reconstructive ladder.

Summary: A 68-year-old diabetic man fell approximately 10 feet out of a tree, resulting in a Gustilo IIIA distal 1/3 tibia fracture. An intramedullary nail was placed after I&D and wound closure on day of injury. Unfortunately, his rehabilitation course was complicated with SWD and purulent drainage. The wound was cultured, ID consulted, PICC line placed for IV antibiotics, and plastic surgery evaluation scheduled.

Method: Further workup revealed 70% occlusion of the tibioperoneal artery, thus eliminating the option of a free muscle flap transfer. Plastics prepared the wound in the OR, placed dehydrated human umbilical cord (dHUC) over exposed bone, then bolstered the dHUC with a negative pressure wound therapy (NPWT) device. Additionally, micronized dehydrated human amnion chorion membrane (mdHACM) suspended in sterile NS was injected into the peri-wound tissue. This procedure was repeated every two weeks x 3. The wound responded well with robust granulation tissue forming over the denuded bone. Once wound preparation was complete without evidence of infection recurrence after antibiotic completion, a full-thickness skin graft (FTSG) was applied over decellularized human collagen matrix (dHCM) and then bolstered with a NPWT device. Again, mdHACM was concomitantly injected into the peri-wound tissue.

Results: The FTSG took 100%, resulting in complete wound closure. The impact of the combined use of dHUC over exposed fracture and injectable mdHACM appeared to be favorable in this limb salvage case. The application of skin grafts over dHCM in a prepared wound bed is a novel approach with the potential to positively affect the incidence of lower limb skin graft failure.