Reconstruction of a Complex Pretibial Wound Using Dermal Regeneration Template and Split-Thickness Skin Graft

The reconstruction of the distal leg is challenging due to watershed vascularity and scarce soft-tissue bulk. While traditional reconstruction guidelines rely on vascularized flap coverage, such interventions are higher-risk options in certain patients with significant medical co-morbidities. This case report describes non-microsurgical reconstruction of a distal-third pre-tibial wound in a patient with a history of renal transplant, type 2 diabetes, coronary artery disease, and peripheral vascular disease. In this patient, chronic immunosuppression induced blunt wound healing, while concurrent peripheral artery disease made microsurgery unreliable. We navigated this challenge by "engineering" a wound bed using a dermal regeneration template (DRT) in conjunction with antimicrobial negative pressure wound therapy (NPWT). Within four weeks, the wound showed robust granulation, with complete coverage of previously exposed tendon. The wound was then covered with a split-thickness skin graft (STSG) eight weeks after the initial application of DRT. The patient returned to his pre-injury functional status within five months. This staged strategy offers a lower-risk alternative to traditional flap-based protocols for patients with significant co-morbidities, including transplant immunosuppression and peripheral arterial disease.