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Page 4 of 14 Evans et al. Plast Aesthet Res 2022;9:34 https://dx.doi.org/10.20517/2347-9264.2021.134

WOUND TEMPORIZATION - DEVELOPMENTS IN SUBACUTE THERAPY UNTIL
DEFINITIVE RECONSTRUCTION
Reconstructive efforts in unstable patients with traumatic lower extremity injuries are contraindicated until
cleared by Advanced Trauma Life Support practice management. In these patients, wounds can be
temporized with devices such as negative pressure wound therapy (NPWT), dermal matrices, and external
delayed primary closure devices (e.g., DermaClose, Jacob’s Ladder, Shoe-String Method) [50,52-60] .

NPWT was introduced in 1996 as a method for delayed wound closure, in which an open-cell polymer
foam is placed within a wound bed and subjected to negative pressure to promote wound contracture and
[61]
granulation tissue formation . Since its introduction, evidence has shown that NPWT can effectively
temporize and shrinks wounds, as well as assist in converting full-thickness wounds with exposed bone or
tendon into a granulated wound bed for skin grafting [18,53,62,63] . However, in the contaminated field or areas of
severe soft tissue defects, indications are limited. While NPWT has been shown to improve overall wound
hygiene, it does not definitively decrease bioburden or infection rates, and is not a substitute for early
operative debridement when able [22,64,65] . Newer versions of NPWT include the instillation of irrigation to
continually cleanse contaminated wounds [56-58,66-68] . Instillation solutions vary widely, with studies
demonstrating comparable efficacy amongst solutions, suggesting a utility in the process of irrigation rather
than the solution itself . Overall, the adjuvant of an instilling NPWT can help change a static wound to a
[67]
variable environment, which may ultimately help cleanse contaminated wound beds.

In addition to NPWT, the utilization of acellular dermal regenerative templates, such as Integra, has
provided surgeons with an additional tool to temporize and close wounds secondarily. These dermal
matrices are composed of a bilaminate sheet of cross-linked bovine tendon collagen and shark
glycosaminoglycans, which serve as a collagen scaffolding for the growth of a neodermis [50,55,69] . Wounds of
the lower extremity that would previously be treated with free flap reconstruction can now potentially be
closed with Integra application and skin grafting following 3-4 weeks of neodermis development. While
dermal matrices can be a useful tool in soft tissue reconstruction, their overall efficacy remains poor in
contaminated wound beds .
[69]

ORTHOPEDIC ADVANCEMENTS IN SKELETAL STABILIZATION AND BONEY DEFECTS
Traumatic lower extremity wounds are inherently contaminated. Open fractures should be managed with
the initiation of intravenous antibiotics and washout within 6 hours. Severe open fractures such as Gustilo
IIIB or IIIC injuries, may result in large bony defects or a grossly contaminated wound in which immediate
internal fixation with hardware is contraindicated. In these injuries, antibiotic-impregnated cement is
commonly used as temporization [70-73] . While first described in the 1970s, antibiotic-impregnated cement
continues to be routinely used to eliminate dead space and elute antibiotics at high local concentrations to
decrease bacterial burden in contaminated wound beds [71,74] . Prior to definitive skeletal fixation, or flap
coverage, the beads are removed.

Skeletal defects of the lower extremity offer a unique challenge. Autologous bone grafting can provide
structural cortical bone and osteogenic potential to fill smaller defects. For larger defects, modalities such as
limb shortening and distraction osteogenesis are effective but morbid and inherently complex . By
[75]
convention, bony defects greater than 6cm are largely reconstructed with vascularized bone graft. While this
[76]
convention has been largely adopted, Allsopp et al. , determined that this indication is not evidence-based.
Today, a variety of techniques have gained traction in reconstructing complex boney defects of the lower
extremity.