Degloving Injuries of the Extremity: A Systematic Approach to Reconstruction

BACKGROUND: Degloving soft tissue injuries (DSTIs) of the extremities are avulsion-type injuries.  These injuries leave significant soft tissue defects which compromise the integrity of the extremity.  Reconstruction of DSTIs is challenging due to their variable extent.  A systematic approach to the reconstruction of DSTIs is not established.  We propose a comprehensive protocol for the reconstructive management of extremity DSTIs.

METHODS: A review of the literature regarding DSTIs was completed.  In addition, a retrospective study was conducted including all patients who sustained DSTIs of the extremity requiring reconstruction over a 6 year period. 

RESULTS: A total of 36 extremity DSTIs were identified.  Mean patient age at the time of injury was 45 and patients required an average of 5 operations.  All injuries underwent debridement and 83% underwent skin grafting.  A dermal regeneration template (DRT) was used in 42% of patients.  Ninety-two percent of patients had negative pressure wound therapy (NPWT) utilized in their DSTI care.  Twenty-eight percent of patients required flap reconstruction.  Four patients required amputation.

CONCLUSIONS: DSTIs are complex injuries that frequently require multiple operations and the application of a variety of techniques for reconstruction.  In contrast to previous management descriptions, NPWT and DRTs are commonly used in the management of these injuries.  NPWT is frequently employed as a wound dressing with goal options of achieving a wound bed adequate for supporting a skin graft, temporizing until definitive surgical management, or bolstering a DRT or skin graft.  Dermal regeneration templates are commonly utilized to reconstruct injuries involving tendons to aid in future tendon gliding.  Based on the available literature and our experience with these difficult injuries, we propose a reconstructive algorithm based on three factors: the anatomic extent of injury with respect to the extremity’s deep fascia, the “usability” of degloved tissues, and the status of underlying critical structures including tendon/ paratenon and bone/ periosteum.  Superficial DSTIs involve structures superficial to the extremity’s deep fascia therefore management includes debridement and defatting of usable degloved tissues to produce a full thickness skin graft (FTSG).  If the degloved tissue is inadequate for use, split thickness skin grafting (STSG) is completed.  Deep DSTIs involve tissues deep to the extremity’s deep fascia and therefore may involve critical structures such as tendons and bone.  Deep DSTIs with viable paratenon and/ or periosteum and usable degloved tissues are reconstructed with appropriate tendon/ bone intervention followed by application of the degloved soft tissues as a FTSG.  Dermal regeneration templates should be considered in the DSTI with tendon/ paratenon injury to improve future tendon motion.  If the coverings of bone or tendon are injured and lack adequate vascularity to support any form of graft/ DRT, reconstruction will require flap reconstruction (local/ regional/ free tissue).