EARLY AMBULATION AFTER-GRAFTING

OF LOWER EXTREMITY BURNS

J.P. Gawaziuk a, B. Peters b, S. Logsetty
ABSTRACT
 Objective

Purpose
May help to avoid some of
the complications associated to retrospectively assess the
with immobilization outcomes of lower extremity
skin graft cases dressed
with a multi-layer
compression bandage who
were ambulated in the
immediate post-operative
period.
ABSTRACT (CONTINUED)
 Methods
 This single centre observational study examined
patients with a lower extremity burn that received a
compressive dressing (ProforeTM) application
immediately after surgical grafting and were
ambulated no later than 1day post-operatively.
ABSTRACT (CONTINUED)
 Results

Forty-two burn patients (47 25 patients were operated on as

limbs) met inclusion criteria for an inpatient. 17 patients were
this study. done on an outpatient basis

Mean patient age was 48.2

Mean TBSA affected was 5.3%
years and 34 (81.0%) of patients
(792cm²).
were male.

Mean number of procedures was The graft take rate across all
1 and mean graft take was 98. cases was 98.92.3%.

No patients failed early

ambulation with their
compressive dressings, were
readmitted or underwent
repeated skin grafting.
ABSTRACT (CONTINUED)
 Conclusions
 This study demonstrates the excellent graft take
rates that can be achieved with immediate
ambulation following lower extremity skin grafting
and challenges the conventional teaching of post-
operative bed rest following lower extremity skin
grafting procedures.
1. INTRODUCTION

A survey by Nedelec et al found that 50% of burn centres

did not routinely practice early ambulation after lower
extremity skin grafting

Hematoma formation and shearing  a lack of graft

adherence

Immobilization  decreased range of motion, physical de-

conditioning, lack of independence in activities of daily
living, an increased risk of deep vein thrombosis and
pulmonary embolism.

Early ambulation may also reduce the risk of thrombo-

embolism
2. OBJECTIVE
 To examine if it is possible to safely and
effectively treat lower extremity burns with early
ambulation after debridement and grafting.
 The use of a compressive dressing as a tool
facilitates outpatient surgery for these
procedures without significant graft loss.
3. METHODS
3.1. Patient population

We reviewed patients ≥17 year old

admitted to our regional burn
centre from July 2007 to June
2013 who underwent skin grafting
for a lower extremity burn.

This study incorporated patients

with burns of the lower leg that
received Profore compressive Fig. 1
dressing for the below-knee portion Foot with Profore in place
3. METHODS (CONTINUED)
 One patient with an injury due to necrotizing fasciitis
affecting a single limb was included.
 Patients with a history of lower extremity vascular
disease, previous injury to the lower extremity or
burns greater than 30% TBSA were excluded from
the study.
3. METHODS (CONTINUED)
The following de-identified patient data was recorded:
Demographic: Injury-specific: Outcomes:
gender, age. total body days from
surface area surgical
(TBSA) coverage to
affected (% and discharge, days
cm2), to ambulation,
anatomical days to
location of discharge from
injury, whether hospital, graft
or not the graft take rate (%).
crossed a joint
surface (ankle).
3. METHODS (CONTINUED)
3.2. Surgical methods and dressing protocol
• Standard : to do a one stage excision and grafting as
soon as the wound depth has declared
• For smaller burns (<10% TBSA) the majority of distal
lower extremity surgery is done on an outpatient
basis.
• The patients are treated as outpatients while waiting
for the depth to declare, unless there are extenuating
circumstances.
3. METHODS (CONTINUED)

The wound bed was prepped with tangential

debridement prior to coverage with a meshed split
thickness skin graft.

The grafts were harvested using a Zimmer

dermatome at 10–12/1000in. and meshed at a 1.5:1
ratio.

The grafts were held in place using staples or sterile

surgical tape, and dressed with silver nanocrystalline
impregnated gauze followed by the compressive dressing.
3. METHODS (CONTINUED)

•For the compressive dressing we used

ProforeTM dressing
•ProforeTM is a multilayer compression
bandage system that is otherwise
used for venous stasis ulcers.
•It is clean not sterile, inexpensive,
and is easy to apply.
•The dressing is placed at the time of
surgery and left intact for 5 to 7 days.
3. METHODS (CONTINUED)
• Analgesic is given in the form or oral narcotics,
supplemented with an NSAID.
• The same burn surgeon evaluated the percentage of
graft take on the initial dressing change and any
subsequent clinic visits.
3. METHODS (CONTINUED)
3.2. Data management and statistical analysis

Patient information was Descriptive statistics

entered into a database were obtained for all
created using FileMaker variables and are
Pro 12 software (Apple, presented as mean
Cupertino, CA, USA) and standard deviation and
statistical analysis was range or N (%).
performed using SPSS
version 22 software (IBM,
Chicago, IL, USA).
3. METHODS (CONTINUED)
4. Results
• Forty-two patients (47 limbs) met inclusion criteria
for this study (Table 1).
3. METHODS (CONTINUED)

25 were operated on as an inpatient basis

whereas 17 were done as outpatients and
were discharged the same day of surgery.
All patients had no activity restrictions post-
operatively and were able to weight bear as
tolerated with their dressing intact.

Patients were ambulated within 1day of

surgery (mean days 0.40.6).

The graft take rate across all inpatient and

outpatient cases was 98.92.3% (range 90–
100%)

Fig. 2
Foot after grafting on initial
dressing removal
3. METHODS (CONTINUED)
No patients underwent regrafting, readmissio
or failed to ambulate with compressive
dressings.

We also compared the proportion of patients

who were operated on during the study as an
inpatient versus outpatient

Table 2
Proportion of surgeries performed as inpatient versus outpatient during study period.
3. METHODS (CONTINUED)
• In the first half of the study, 51.7% of these surgeries
were done on an outpatient basis compared to 77.9%
in the second half.
• There was no difference in the graft take between
these two periods.
3. METHODS (CONTINUED)
5. Discussion
a high success rate with immediate ambulation following lower
extremity skin grafting.

the average number of days of bed rest traditionally prescribed

for these cases being 5–7 days, the potential cost savings are
extremely large when using this technique  early ambulation
takes an inpatient procedure to an outpatient setting.

use the compression dressing technique on patients with

bilaterallowerleg burns ofsmalltomoderate size asoutpatients
with success.

a shift from inpatient to outpatient surgery for lower extremity

burn may also result in cost savings.

Previous studies show that the use of compression dressings

can shorten the time to ambulation and length of hospital stay
while maintaining high graft take rates above 95%
3. METHODS (CONTINUED)

Wells et al. Schmitt and et al. Tallon and Oliver Luczak et al.

•investigated the •have shown that •no difference in • found there was
effects of Unna mobilization at graft loss, no statistically
(zinc, gelatin and post-operative day infection, and significant
gauze strip) paste 6 after skin bleeding between difference in the
semi-rigid grafting a lower patients rates of graft loss,
bandage system extremity for a randomized to 2 infection,
applied after skin burn was not or 7days of hematoma and
grafting after associated with bedrest after- hypergranulation
burn on the lower worse outcomes grafting of a lower when lower
limb; patients than waiting until extremity burn extremity skin
were discharged day 8 or day 10. graft patients
home with were ambulated
instructions to at postoperative
‘move freely’. day 3 or earlier
compared to
patients who
started
ambulation
postoperative day
4 or later.
3. METHODS (CONTINUED)
• Awareness has been increasing regarding the effect of
bedrest on patient deconditioning and bedrest as a risk
factor for venous thromboembolic disease

• Lower extremity burns also can have negative functional

consequences that effect patients long-term, such as a
decreased likelihood of return to work at 6 months

• Exercise has been shown to counteract the muscle-

wasting effects of age and inactivity

• Aerobic conditioning in combination with standard

functional restoration therapy has been shown to be
superior to standard functional restoration alone
3. METHODS (CONTINUED)
Luczak Baker et al Lorello et al.

• an increased rate • determined that • no difference in

of deconditioning patients with an graft take
in the group of increased length between early
patients in their of stay reported a ambulation
study who were decreased compared to
put on bedrest functional status standard
post-operatively on the Burn treatment
Specific Health • The TBSA in
Scale, a Lorello’s study
questionnaire was only 3.6%,
completed by the there was a mean
patient. of 2.1 operations
and a hospital
length of stay of
16 days
3. METHODS (CONTINUED)
• Surgery is one stage (excision and grafting) and early
ambulation includes weight bearing as tolerated by
the patient, even if the graft crosses the ankle joint,
using a soft compressive dressing, and the majority of
these procedures are done as day surgery with no
readmission to hospital  an outpatient (no inpatient
stay)
3. METHODS (CONTINUED)
6. Limitations

This study is not a

randomized controlled trial
and is retrospective in
nature.

We were unable to make

comparisons of outcomes
between outpatients and
inpatients within this study
due to relatively low number
of study participants.
3. METHODS (CONTINUED)
7. Future directions

We have grafted up to
10% TBSA as
The knee joint has yet to
outpatients, with the
be assessed in this
limiting factor being
regard at our centre
donor site pain
management.
3. METHODS (CONTINUED)
8. Conclusions

This study demonstrates

the excellent graft take
rates that can be
achieved with Additionally, it shows
immediate ambulation the feasibility of doing
following lower these procedures as a
extremity skin grafting day surgery which may
procedures and also result in cost
challenges the savings to the
conventional teaching of healthcare system
post-operative bed rest
following lower
extremity skin grafting.
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