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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 7  |  Issue : 4  |  Page : 141-142

Successful autologous skin grafting in a patient of severe Haemophilia


Department of Burns, Plastic and Reconstructive Surgery, Christian Medical College Hospital, Vellore, Tamil Nadu, India

Date of Web Publication18-Jan-2017

Correspondence Address:
Dr. Rahul Gorka
Senior PG Registrar, Department of Burns, Plastic and Reconstructive Surgery, Christian Medical College Hospital, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-5127.198511

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  Abstract 

In haemophilia-A patients, if the plasma concentration of factor VIII could be maintained at an optimum level, an open wound can be easily covered with split-thickness skin grafting without any significant bleeding or complication. Removing a split-thickness layer of skin should cause no more difficulty than in a normal individual. This can be attributed to normal bleeding time, prothrombin time, clot retraction and platelet count found in such patients. Skin grafting over non-healing raw areas in haemophiliac patients can significantly decrease the morbidity and length of hospitalization required, thereby, decreasing health expenditure. We present a case report of a haemophilia-A patient having raw area over lower limb, which was managed successfully by skin grafting.

Keywords: Factor VIII, haemophilia, skin grafting


How to cite this article:
Gorka R, Barreto E, Ete G. Successful autologous skin grafting in a patient of severe Haemophilia. J Appl Hematol 2016;7:141-2

How to cite this URL:
Gorka R, Barreto E, Ete G. Successful autologous skin grafting in a patient of severe Haemophilia. J Appl Hematol [serial online] 2016 [cited 2020 Jan 20];7:141-2. Available from: http://www.jahjournal.org/text.asp?2016/7/4/141/198511


  Introduction Top


It is a great challenge to achieve haemostasis in a severe haemophiliac patient, even with a small open wound.[1] There are only a few cases published in literature where autologous or homologous split-thickness skin grafts were used to cover open wounds in haemophiliac patients. This may be attributed to the lack of sufficient replacement factor VIII concentrate, the risk of haemolytic complications associated with use of the relatively impure concentrates available, uncontrolled bleeding, transmission of blood-borne infectious agents, postoperative infections and problems with wound healing. Today, substitution factor concentrates are abundantly available and are characterized by high purity, few or no red cell allo-agglutinin antibodies, and a high degree of viral safety.[2]

Davidson and Levenson[3] were the first to use a split-thickness autograft (STSG) for successfully covering a small slowly healing ulcer in a haemophiliac patient in 1945.


  Case History Top


We present a case of 36-year-old gentleman from Jharkhand state, a diagnosed case of severe haemophilia-A for 2 years who presented with complaints of prolonged bleeding from an ulcer over right lower limb for 2 months, following minor trauma when he was hit by a two wheeler while crossing road [Figure 1] and [Figure 2]. There was no bone exposure or fracture in the involved leg. He was initially managed at local hospital where primary suturing of laceration right leg was done. Despite suturing, there was continuous bleeding from the wound which did not stop for 2 days. Thereafter, the patient was shifted to another hospital where he received factor VIII transfusion, and bleeding stopped. The patient was on daily dressings with non-adherent paraffin gauze since then but the ulcer did not heal.
Figure 1: Raw area over middle of right leg, anteromedial aspect

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Figure 2: Raw area right leg (close up view)

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The patient also had a past history of recurrent episodes of haemarthrosis involving elbows and knees since childhood. There was a family history of his two brothers having similar symptoms, and one of them had succumbed to a fatal episode of prolonged bleeding in an accident 15 years ago. The patient then reported to our hospital, where he was evaluated. The investigations revealed that the haemoglobin level was 12 g%, with a normal platelet count, morphology and bleeding time; normal prothrombin time, fibrinogen. Activated partial thromboplastin time was prolonged with reduced level of factor VIII (<1%). Inhibitors were not detected. He was diagnosed as having severe haemophilia-A with no inhibitors. Target trough levels were above 30% and target peak level about 60%. The correction was initiated by infusing pooled normal plasma and recombinant factor VIII rich plasma pre-operatively otherwise, uncontrollable bleeding may arise during surgery.[4] The factor VIII target levels thus achieved were 60%. He underwent debridement and STSG of right leg ulcer under spinal anaesthesia [Figure 3]. Post-operatively, he was infused with 40% factor VIII twice daily for next 2 days. In total, 5700 units of factor VIII were administered during the course duration of 3 days. Laboratory monitoring was done using factor VIII assay. The graft healed well with 100% take. There was no haematoma or excess bleeding from grafted site. The patient was discharged on 7th post-operative day with closed dressing and crepe bandage.
Figure 3: Raw area covered by autologous split-thickness skin graft

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  Discussion Top


We here by conclude that if the plasma concentration of factor VIII could be maintained at an optimum level, an open wound can easily be covered with split-thickness skin graft without any significant bleeding or complication. Removing a split-thickness layer of skin should cause no more difficulty than in a normal individual.[5] This can be attributed to normal bleeding time, prothrombin time, clot retraction and platelet count found in such patients. Skin grafting over non-healing raw areas in haemophiliac patients can significantly decrease the morbidity and length of hospitalization required, thereby, decreasing health expenditure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
McKittrick JE. Control of hemophilic bleeding: A report of two cases utilizing autogenous skin grafts. Ann Surg 1961;154:48-52.  Back to cited text no. 1
    
2.
Ingerslev J, Hvid I. Surgery in hemophilia. The general view: Patient selection, timing, and preoperative assessment. Semin Hematol 2006;43(1 Suppl 1):S23-6.  Back to cited text no. 2
    
3.
Davidson CS, Levenson SM. Skin grafting in hemophilia with a preparation of thrombin and sulfanilamide. JAMA 1945;128:656-7.  Back to cited text no. 3
    
4.
Jentzsch T, Brand-Staufer B, Schäfer FP, Wanner GA, Simmen HP. Illustrated operative management of spontaneous bleeding and compartment syndrome of the lower extremity in a patient with acquired hemophilia A: A case report. J Med Case Rep 2014;8:132.  Back to cited text no. 4
    
5.
Zaroff LI, Linder WR, Moncrief JA. Successful autografting in a burned hemophiliac without systemic or local hemostatic agents. Plast Reconstr Surg 1965;35:271-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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