Background: Investigators have recommended aggressive use of
skin-grafting in order to preserve length and proximal joint function
following an acquired amputation in children. However, there is little
objective evidence to either support or refute that recommendation.
Methods: We performed a retrospective review of the cases of all
children for whom a skin graft had been applied to the residual limb following
an acquired lower-extremity amputation at our Limb Deficiency Clinic between
1984 and 2002. Skin graft dysfunction, defined as breakdown, contracture,
and/or pain, was considered to be clinically relevant if it required the child
to discontinue use of the prosthesis for any period of time or if it required
revision surgery to facilitate continued prosthetic fitting.
Results: Twenty-three children (mean age at amputation, 4.4 years)
with a total of thirty-one acquired lower-extremity amputations had been
treated with skin-grafting. At a mean of 6.3 years after the operation,
sixteen (52%) of the thirty-one extremities had had no episodes of skin graft
dysfunction. The remaining fifteen extremities (48%) had had clinically
relevant skin graft dysfunction (breakdown in thirteen and contracture and
pain in one extremity each). Nine of the ten extensive skin grafts underwent
clinically relevant breakdown, as did thirteen of the twenty-four grafts that
were located distally on the residual limb. Subsequent surgical revision of
the residual limb because of inadequate function of the skin graft was
performed on seven extremities (23%), with revision to a more proximal
limb-segment level required in five.
Conclusions: Focal skin-grafting (involving =25% of the surface
area) of partial-thickness soft-tissue defects in order to optimize the length
of the residual limb at the time of an amputation is an effective option for
children with an acquired lower-extremity amputation. Limited skin-grafting
(involving 26% to 50% of the surface area) is more likely to result in skin
graft breakdown, particularly when it is done distally. Extensive
skin-grafting, while technically possible, frequently requires revision and
rarely results in an optimally functioning limb. Alternative treatment
strategies should be considered for extremities that would require extensive,
distal skin-grafting.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.