Abstract
Background:
The management of Gustilo-Anderson type IIIB open fractures with extensive soft-tissue loss remains a notable challenge, particularly in resource-limited settings where advanced microsurgical reconstruction techniques are often unavailable. Negative pressure wound therapy (NPWT), combined with the use of an artificial dermis and split-thickness skin grafts, represents a promising alternative in such contexts.
Methods:
We present a case series of two patients treated in Haiti after high-energy trauma resulting in lower limb open fractures associated with large soft-tissue defects. Initial management included serial débridement, administration of broad-spectrum antibiotics, and the use of NPWT to promote granulation tissue formation. Once the wound bed was optimized, an artificial dermal matrix was applied, followed by delayed split-thickness skin grafting.
Results:
Both patients achieved complete wound healing and satisfactory functional outcomes at one-year follow-up, despite delays in definitive coverage due to limited operating room availability and lack of vascular imaging. The integration of NPWT and artificial dermis allowed for successful reconstruction without the need for free flap transfer. Notably, the use of artificial dermis was made possible through humanitarian donation, highlighting challenges related to access and sustainability of advanced wound care products in low-resource environments.
Conclusion:
NPWT combined with artificial dermis and skin grafting offers an effective limb salvage option in low-resource settings. Despite constraints, staged care and rigorous protocols can yield favorable outcomes. Wider access and additional research are needed to validate this approach.
Healthcare systems in developing countries often operate under precarious conditions, where multiple interrelated challenges—including limited financial and material resources, low socioeconomic status, poor health literacy, and the disruptive effect of natural disasters—markedly hinder the delivery of quality medical care. These constraints are further compounded by a critical shortage of trained healthcare personnel, particularly in specialized fields such as reconstructive surgery, thereby impeding the provision of comprehensive treatment for complex injuries.
A stark illustration of the challenges faced by healthcare systems in low-resource settings is provided by the major earthquakes that struck Haiti in January 2010 and August 2021. Both events caused extensive loss of life, large numbers of injuries, and widespread displacement, overwhelming an already fragile healthcare infrastructure.1,2 The massive influx of trauma patients during these periods severely strained our department, necessitating rapid discharge of stabilized cases and making continuity of specialized care a daily challenge. This context highlighted the urgent need for adaptable, resource-efficient strategies for managing complex musculoskeletal and extremity injuries, where timely intervention is essential to prevent infection, preserve function, and avoid limb loss. For logistical reasons, the two patients described here were operated on at a smaller peripheral facility because our plastic surgeon was based there at the time.
Open fractures of the lower extremities, especially Gustilo-Anderson type IIIB injuries, represent a notable surgical challenge due to their extensive soft-tissue loss, high risk of infection, and complex reconstructive demands. In such cases, timely and effective soft-tissue coverage is essential to prevent chronic infection, facilitate fracture healing, and preserve limb function. Negative pressure wound therapy (NPWT) has emerged as a valuable tool in this context. By removing exudate, reducing local inflammation, and promoting granulation tissue formation, NPWT supports the wound environment conducive to secondary healing.3,4
When combined with a synthetic dermal substitute—typically composed of cross-linked collagen, glycosaminoglycan, and a silicone outer layer—this approach can further enhance outcomes. The bilayer design of artificial dermis provides a scaffold for neovascularization, reduces graft rejection, offers antibacterial properties, facilitates exudate drainage, and promotes cellular infiltration and organized tissue regeneration.5-7 In the context of humanitarian aid, such materials were made available in our institution after the 2021 earthquake, enabling their integration into surgical protocols.
In this case series, we report on the management of two patients with Gustilo IIIB open fractures of the lower extremity, both complicated by extensive soft-tissue defects. Each case was treated with a combination of NPWT, artificial dermis, and delayed split-thickness skin grafting. These cases illustrate the potential of this strategy to achieve satisfactory functional and aesthetic outcomes, even in severely resource-limited settings.
Case 1
A 23-year-old woman with no notable medical history was admitted to our orthopaedic surgery department after a high-energy crush injury to the left foot. The patient vital signs were stable; clinically, she had a degloving injury of the left distal tibia and of the dorsum of the left foot, with a large skin defect (Figure 1), the peripheral capillary oxygen saturation was 98%, and no Doppler was available at our institution. Radiographs demonstrate a fracture of the neck of the first metatarsal, associated with fracture-dislocations of the necks of the second through fifth metatarsals and a nondisplaced fracture of the posterior aspect of the calcaneus (Figures 2 and 3).
Figure 1.
Image demonstrating the wound of Case 1 on the day of admission.
Figure 2.
AP radiograph of the left foot of Case 1.
Figure 3.
Lateral radiograph of the left foot of Case 1.
She was given triple antibiotic therapy consisting of cefazolin, gentamicin, and metronidazole. She underwent three surgical débridements and irrigations at 48-hour intervals over a 6-day period. Negative pressure wound therapy (NPWT) was initiated on day 6, with dressing changes every 72 hours.
The clinical course was favorable, with progressive granulation tissue formation. By day 21, the wound bed exhibited healthy, red, bleeding tissue, with no clinical signs of necrosis or infection. However, owing to a high caseload limiting availability for elective procedures, definitive wound coverage was deferred until day 25 after injury. A synthetic dermal substitute was applied. The wound was first irrigated with an isotonic saline solution, the allograft was then secured with skin staples, and the dressing consisted of nonadherent petrolatum gauze (Vaseline gauze) overlaid with sterile dry gauze.
The postoperative protocol was structured as follows: a dual antibiotic regimen consisting of cefazolin and gentamicin was administered. The first postoperative dressing change was performed on postoperative day 5, followed by changes every 48 hours thereafter. The dressing procedure was standardized as follows: with the initial dressing still in place, the limb was immersed in saline solution for approximately 30 minutes to facilitate atraumatic removal. The area was then gently cleansed with a saline solution mixed with gentamicin. An antibiotic ointment, such as bacitracin, was applied evenly over the entire wound surface, followed by a layer of nonadherent petrolatum gauze (Vaseline gauze) and sterile dry gauze.
On day 33 after injury, the wound evolution was satisfactory (Figure 4). Owing to the high surgical demand associated with emergency cases, definitive skin grafting was deferred until day 48 after injury.
Figure 4.
Image demonstrating the wound of Case 1 after four dressing changes.
The split-thickness skin grafts were taken from her thighs and stapled in place after fenestration; the dressing consisted of petrolatum jelly gauze impregnated with antibiotic ointment. Ceftriaxone and gentamicin were given to the patient. The dressings were first changed on postoperative day 5 and subsequently every 48 hours (Figure 5). Beginning with the sixth dressing change, the protocol was modified to include the application of methylene blue (Figure 6), followed by petroleum jelly gauze and a sterile gauze bandage.
Figure 5.
Image demonstrating the wound of Case 1 at 15 days after skin grafting.
Figure 6.
Image demonstrating the wound of Case 1 at 1 month.
By 12 months after injury, complete soft-tissue regeneration was observed (Figure 7). Owing to financial constraints, the patient was unable to undergo radiographic imaging to assess the underlying orthopaedic injuries. However, she reported no pain during ambulation and exhibited functional mobility with few limitations (Video 1).
Figure 7.
Image demonstrating the wound of Case 1 at 12 months.
Case 2
The second patient was a 42-year-old man with a known history of hypertension, admitted to our orthopaedic department after a crush injury to the right foot. On admission, there was a notable soft-tissue defect over the dorsal aspect of the foot (Figure 8); the peripheral oxygen saturation was 82%; unfortunately, no Doppler was available at the time. Radiographic evaluation revealed a Gustilo-Anderson type IIIB open fracture-dislocation involving the bases of the first to fifth metatarsals, as well as fractures of the necks of the second to fourth metatarsals (Figures 9 and 10). Emergent surgical débridement was performed on the day of admission, and the patient was started on our triple antibiotic therapy protocol. Seventy-two hours later, soft-tissue coverage was attempted using a serratus anterior muscle free flap (Figure 11). However, on postoperative day 3, the flap had failed, exhibiting complete necrosis along with necrosis of the underlying plantar soft tissues of the foot, most likely due to vascular thrombosis. A Lisfranc-level amputation was performed by day 5; given this evolution, a VAC was installed during the surgery, in the operation theater, and changed every 3 days.
Figure 8.
Image demonstrating the wound of Case 2 on the day of admission.
Figure 9.
AP radiograph of the right foot of Case 2.
Figure 10.
Lateral radiograph of the right foot of Case 2.
Figure 11.
Image demonstrating Case 2 serratus anterior donor-site dressing.
The clinical course was favorable, with progressive granulation tissue formation. By day 26, the wound bed exhibited healthy tissue, with no clinical signs of necrosis or infection. As for the previous case, due to limited operating room availability secondary to high surgical demand, the synthetic graft was applied on day 33. The wound was first irrigated with a normal saline solution, and the synthetic graft was also secured with staples; again, the dressing consisted of nonadherent petrolatum gauze (Vaseline gauze) overlaid with a secondary layer of sterile dry gauze.
The postoperative protocol was structured as follows: a dual antibiotic regimen consisting of cefazolin and gentamicin was administered. The first postoperative dressing change was performed on postoperative day 5, followed by changes every 48 hours thereafter. The dressing procedure was standardized as follows: with the initial dressing still in place, the limb was immersed in saline solution for approximately 30 minutes to facilitate atraumatic removal. The area was then gently cleansed with a saline solution mixed with gentamicin. An antibiotic ointment, such as bacitracin, was applied evenly over the entire wound surface, followed by a layer of nonadherent petrolatum gauze (Vaseline gauze) and sterile dry gauze. On day 48, the evolution of the wound was satisfactory with no sign of necrosis (Figure 12). Again, owing to surgical constraints as for the first case, the surgery was delayed to day 54.
Figure 12.
Image demonstrating the wound of Case 2 after five dressing changes.
A split-thickness skin graft was taken from his thigh, fenestrated, and stapled on site; the dressing consisted of petrolatum jelly gauze impregnated with antibiotic ointment. The patient was placed on ceftriaxone and gentamicin, and the dressings were first changed on postoperative day 5 and subsequently every 48 hours.
On day 65, the patient exhibited a satisfactory clinical course and was subsequently managed on an outpatient basis (Figure 13). However, owing to clinical signs of graft infection (Figure 14), he required readmission and was placed on intravenous antibiotic therapy. He remained hospitalized until day 76 after injury, at which point he was discharged. At the one-year follow-up, the patient demonstrated complete wound healing (Figure 15), reported no concerns, and was able to ambulate independently while wearing regular footwear, without the need for a prosthesis (Video 2).
Figure 13.
Image demonstrating the wound of Case 2 at 14 days after skin grafting.
Figure 14.
Image demonstrating the wound of Case 2 at 20 days.
Figure 15.
Image demonstrating the wound of Case 2 at 12 months.
Discussion
The use of artificial dermis associated with split-thickness skin graft is a well-documented approach for the treatment of large soft-tissue defects.8,9 However, reliable fixation to the wound bed, a factor of paramount importance for successful application, is often hard to achieve. The vacuum-assisted closure system, a well-established subatmospheric pressure device, might be of interest to overcome these problems because of its ability to conform to almost any surface.10 This combination is an effective means for repairing refractory wounds.11
Open fractures are injuries in which skin and soft tissue are disrupted and the underlying bone is exposed to the external environment. This leads to contamination by microorganisms that can cause deep and superficial infection. The management of severe open fractures of the lower limb remains a major challenge in surgery, and adequate treatment of the concomitant soft-tissue injury is of the highest priority because it determines the fate and outcome of the bone and the extremity.12 Impaired vascularity, devitalized tissue, and loss of skeletal stability are all factors leading to increased susceptibility to infection after an open fracture.13 The VAC therapy may avoid the need for free tissue transfer in some patients, but it does not eliminate the need for formal surgical débridement.14 In type III open fractures, it can decrease the need for flap coverage and for major soft-tissue coverage in acute type III lower leg fractures by decreasing interstitial edema and increasing capillary blood flow,15 thus reducing the rate of infections.16 It also serves as an effective adjunct in the management of both acute and chronic wounds,4,17 even in limited-resource settings.18,19 In diabetic patients with postamputation wounds, using NPWT resulted in lower resource utilization and a greater proportion of patients obtaining wound healing at a lower overall cost of care.20
The utilization of artificial dermis in the management of soft-tissue defects is well established and has demonstrated notable efficacy in treating extremities with exposed bones and tendons.21 Although the literature concerning its application in cases involving exposed fractured bones remains limited, artificial dermis has been used successfully and is considered a cost-effective alternative to free flap reconstruction in select cases.22 However, its use in resurfacing bone-exposing wounds associated with Gustilo type III fractures remains controversial, as some studies have reported limited effectiveness in such scenarios.23
In both reported cases, the assessment of vascular inflow to the injured extremities was limited by the unavailability of Doppler ultrasonography, a common constraint in low-resource settings. As such, we adopted a “wait-and-see” approach, relying on serial clinical evaluations and the use of negative pressure wound therapy (NPWT) to promote granulation tissue formation and monitor tissue viability. An important question is whether prolonged NPWT alone, without artificial dermis and subsequent split-thickness skin grafting, might have been sufficient to achieve wound closure. NPWT can, in some situations, be used as a standalone modality to promote granulation and allow closure by secondary intention. However, our patients had large, deep defects in weight-bearing, high-mobility regions with exposed bone and tendon and, in Case 2, a Lisfranc-level amputation stump that would need to tolerate shoe wear and ambulation. In this context and given the limited reliability of NPWT access in our institution, we used it primarily as a bridge to a clean, vascular wound bed rather than as definitive treatment. The application of the artificial dermis aimed to facilitate definitive wound closure, as its collagen sponge layer provides a scaffold for the infiltration of recipient fibroblasts. This structure serves as a template for the formation of a neodermis that is histologically comparable to normal dermis, thereby supporting the integration of split-thickness skin grafts and promoting organized scar formation.24 Although we cannot completely exclude the possibility that NPWT alone might ultimately have led to wound closure, we believe that this would have required a much longer open-wound period and more intensive wound care, and carried a higher risk of breakdown and contracture in these functionally critical areas.
Once a healthy granulation or neodermal bed is established, epithelialization from the wound margins by secondary intention is a recognized pathway to closure. However, in the large defects described here, this would likely have been very prolonged and associated with intensive wound care, extended vulnerability to infection, and a higher risk of scarring and contracture, especially in weight-bearing areas. In addition, in our setting, prolonged persistence of a large open wound is often a major source of anxiety for patients and families who may equate visible closure with successful treatment and remain fearful of eventual amputation or permanent disability, particularly loss of walking ability and capacity to work. Earlier provision of definitive-appearing coverage with skin graft helped reduce this psychological burden and improved acceptance of the limb-salvage strategy, which was particularly important, given the limited reliability of outpatient follow-up and the financial hardship associated with repeated long-distance travel for wound care. Although the timing of grafting in our series was influenced by psychosocial and logistical factors, our indication for split-thickness skin grafting was mainly to accelerate wound closure once an adequate vascular bed had been obtained, reduce the duration and frequency of dressings, and limit soft-tissue contraction and deformity. These goals were particularly important for preserving foot contour, facilitating shoe wear, and maintaining functional gait. In this sense, artificial dermis and STSG were integral components of our reconstructive strategy rather than optional adjuncts.
The “turtle” VAC system used at our institution effectively restores function by ensuring complete soft-tissue coverage and aiding in infection control. In a setting with limited healthcare personnel, it allowed for optimized wound management with minimal resource utilization. Compared with standard dressing methods, it offers a cost-effective and practical alternative, with a manufacturing cost of approximately 60 USD.18 Nevertheless, its implementation in our setting was met with several logistical challenges, including the inability to adjust suction pressure in the event of air leaks, fluctuations in electrical voltage, and frequent power outages. The artificial dermis used in both cases cost approximately 17.96 USD/cm225 but was obtained through humanitarian aid after the 2021 earthquake and was, therefore, available at no cost to the patients. This highlights a critical limitation: such biomaterials are not routinely accessible in our institution because of financial and supply constraints. Furthermore, the use of artificial dermis necessitates a two-stage surgical approach and requires multiple dressing changes, which can be demanding for both medical staff and institutional resources. Although hospital stays were prolonged for both patients, the cost was minimal—approximately 10 USD for the entire duration—due to the communal ward system. Their extended hospitalization was also necessitated by the long distance from their homes and ongoing national security concerns, which rendered outpatient follow-up both difficult and unsafe. These contextual factors underscore the importance of adapting treatment protocols to the realities of low-resource environments while striving to maintain high standards of care.
In summary, while the combined use of vacuum-assisted closure (VAC) therapy and artificial dermis has been extensively reported in the literature, its application in resource-limited settings remains poorly documented. Our experience highlights that, despite constraints such as limited access to synthetic dermal substitutes, absence of advanced vascular imaging, and unpredictable surgical delays, this approach can be successfully implemented with rigorous wound care protocols. The favorable outcomes observed in both cases underscore the potential of this technique as a viable alternative to microsurgical reconstruction in low-income environments. However, the limited number of cases and challenges in material accessibility represent notable limitations. These findings reinforce the need to establish long-term partnerships with international institutions to improve the availability of advanced wound care materials such as artificial dermis. Expanding access to such technologies could markedly improve outcomes in patients with severe open fractures and extensive soft-tissue defects in low-resource healthcare settings.
Conclusion
The successful management of complex Gustilo IIIB open fractures with large soft-tissue defects in our setting demonstrates that the combined use of negative pressure wound therapy (NPWT), artificial dermis, and split-thickness skin grafts can offer a viable, effective, and affordable reconstructive option in resource-limited environments. While the individual efficacy of these techniques is well established, their integrated application in low-income settings remains underreported. Our experience suggests that, even in the absence of advanced infrastructure—as is the case in our country, Haiti, and within our hospital system—favorable outcomes can be achieved through a staged surgical approach, rigorous wound management protocols, and sustained clinical vigilance. However, the limited availability of artificial dermis and the dependence on donated materials represent notable barriers to reproducibility. Strengthening supply chains and fostering international collaborations to ensure access to essential wound care biomaterials are critical steps toward improving the treatment of severe open fractures in low-resource settings. Furthermore, studies involving larger patient cohorts are warranted to validate the clinical effectiveness and generalizability of this treatment protocol.
Footnotes
None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Michel, Dr. Degand, Dr. Petit and Dr. Woolley.
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