ORIGINAL ARTICLE

The Impact of Time of Mobilization After Split

Thickness Skin Graft on Lower Extremity Wound
Healing—Systematic Review and Meta-analysis
Helene Retrouvey, MDCM*,†, Annie Wang, BSc‡,
Joseph Corkum, MD||,$, and Shahriar Shahrokhi, MD, FRCSC, FACS*,†

Following split-thickness skin grafting (STSG), surgeons have used different postoperative
care protocols. One area of contention is the timing of mobilization of the grafted area after
STSG. The aim of this systematic review and meta-analysis is to summarize the evidence for
timing of mobilization in the extremities after STSG. MedLine, Embase, and the Cochrane
Library were searched to conduct a systematic review and meta-analysis evaluating the
impact of early versus late mobilization after STSG in adult patients with wounds in the
upper extremity (UE) or lower extremity (LE). Outcomes evaluated were graft healing,
postoperative morbidity, and length of stay in hospital. A fixed-effect model was used to
calculate pooled odds ratio and mean difference with 95% confidence intervals (CI). A total
of seven full texts (five randomized trials and two observational studies) were included
in the analysis. All wounds were in the LE. Odds of graft loss, infection, and hematoma
were 0.55 (CI: 0.12–2.54), 1.66 (CI: 0.54–5.10), and 0.98 (CI: 0.25–3.85), respectively,
for early versus late mobilization (n = 2). Deconditioning was more common in the late
mobilization group (n = 3). Hospital length of stay was shorter in the early mobilization
group (n = 3). We conclude that early mobilization may be the preferred strategy for
patients treated with STSG to the LE as it provides good graft healing and prevents
morbidity. High-quality studies are needed to provide more robust recommendations
on mobilization in the LE. Studies are needed to provide evidence in the UE.

Systematic Review registration: Prospero CRD42017070990.

Different postoperative care protocols have been
proposed to optimize the take of split-thickness skin
grafting (STSG) and to minimize complications. One
area of contention is the timing of mobilization of the
newly grafted area. In 1971, Bodenham et  al ques-
tioned the tradition of prolonged bed rest following
STSG and found that while early mobilization did not
facilitate “quicker” or “better” graft healing, avoiding
prolonged confinement in bed did prevent “lowering
of morale.”1 This article led to subsequent studies that
From the *Division of Plastic and Reconstructive Surgery, †Ross
Tilley Burn Centre, Sunnybrook Health Sciences Centre, and
‡
Faculty of Medicine, University of Toronto, Ontario, Canada;
||
Division of Plastic and Reconstructive Surgery and $Queen
Elizabeth II Health Sciences Centre, Halifax Infirmary Site,
Dalhousie University, Halifax, Nova Scotia, Canada
Address correspondence to Helene Retrouvey, MDCM, Division of
Plastic and Reconstructive Surgery, University of Toronto, 149
College Street, Suite 508, ON M5T 1P5, Canada. Email: helene.
retrouvey@mail.utoronto.ca
© American Burn Association 2018. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com
doi:10.1093/jbcr/iry003
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Downloaded from https://academic.oup.com/jbcr/advance-article-abstract/doi/10.1093/jbcr/iry003/4843983
by University of New England user
on 30 April 2018
found results favoring early mobilization, suggesting
that prolonged bed rest may increase postoperative
risks related to patient immobility and contribute to
higher healthcare costs associated with prolonged hos-
pitalization.2–5 Despite these findings, the traditional
approach of bed rest after STSG remains popular, as
this strategy is thought to optimize wound healing.2–8
The aim of this systematic review and meta-analysis
was to summarize the evidence for early versus late
mobilization of adult patients after STSG of the upper
extremities (UEs) and lower extremities (LEs). We
hypothesized that early mobilization results in similar
wound healing outcomes but decreased morbidity.
METHODS
This review followed guidance published by
the Centre for Reviews and Dissemination and
the Cochrane Collaboration  and  the Preferred
Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines.9–11 A  protocol
1

2  Retrouvey et al XXXX/XXXX 2018
for this systematic review was registered using the
International Prospective Register of Systematic
Reviews (PROSPERO CRD42017070990).
Study Eligibility Criteria
The study population was defined as adults
(>18 years old) with wounds in the UE or LE from
any etiology treated with STSG. The intervention
and comparator were early versus late mobilization
after STSG. Early mobilization was defined as mo-
bilization prior to postoperative day (POD) 3, while
late mobilization was defined as postoperative bed
rest or immobilization until at least POD 4. The pri-
mary outcome evaluated was graft healing from 5
to 7 days postoperatively. The secondary outcomes
were graft site pain, postoperative complications,
and length of stay in hospital. Included study designs
consisted of randomized control trials (RCTs) or
observational studies, whereas editorials, commen-
taries, letters, conference abstracts, dissertations,
reviews, case reports, and case series were excluded.
Search Strategy
A comprehensive, electronic search strategy was
used to identify studies indexed in MedLine, Embase,
and Cochrane databases. The search strategy was
developed by a medical librarian in collaboration
with the first author (H.R.) and peer reviewed by a
second medical librarian. Articles were not restricted
based on language or year of publication. The search
strategy focused on 1)  skin grafts, 2)  mobilization,
and  3)  adult patients (search strategy in Appendix
1). Citations from key papers were hand searched
and added if relevant. The first 200 citations output-
ted by Google Scholar were reviewed and included
if appropriate. All articles retrieved were independ-
ently assessed by two reviewers (H.R. and A.W.): first
through title and abstract screen and then through
full-text review. Disagreements were resolved through
consensus or discussion with the senior author (S.S.).
Quality Assessment
The quality of the included studies was independ-
ently evaluated by two authors (H.R. and A.W.). The
two reviewers were not blinded to study authors,
institution, or journal when performing quality
assessment.
Bias was evaluated using the Cochrane Effective
Practice and Organisation of Care (EPOC) RoB Tool
for randomized studies and the New Castle Ottawa
Scale for observational studies.12,13 The EPOC RoB
tool is used to assess seven domains: 1)  random
sequence generation, 2)  allocation concealment,
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Downloaded from https://academic.oup.com/jbcr/advance-article-abstract/doi/10.1093/jbcr/iry003/4843983
by University of New England user
on 30 April 2018
Journal of Burn Care & Research
3) blinding of participants and personnel, 4) blind-
ing of outcome assessment, 5) incomplete outcome
data, 6) selective reporting, and 7) other biases. Each
domain was assessed as having a “low,” “unclear,” or
“high” risk of bias. For our study, the EPOC RoB
tool was modified by removing the domain of blind-
ing of participants, as blinding of participants was not
possible due to the nature of the intervention. On
the other hand, the New Castle Ottawa Scale is used
to evaluate three domains in observational studies:
1) the selection of the study groups (maximum four
stars), 2) the comparability of the groups (maximum
two stars), and 3) the ascertainment of either the ex-
posure or outcome (maximum three stars). Each do-
main is scored using a star system, with a maximum
of nine stars possible, which represents the lowest
risk of bias in an observational study. Publication bias
using a funnel plot could not be evaluated due to the
small number of studies but is hypothesized to be
low or absent.
The Grades of Recommendation, Assessment,
Development and Evaluation (GRADE) approach
was used to score the quality of the evidence for each
outcome.14–23 For the assessments of outcomes from
pooled RCT data, evidence was downgraded from
“high quality” if serious study limitations, indirect-
ness of evidence, serious inconsistency, imprecision of
effect estimates, or publication biases were present.
Data from the observational studies started at “low
quality” and could be upgraded if appropriate.
Data Extraction
Data extraction was performed using Microsoft
Excel (Office 2010; Microsoft Corporation,
Redmond, Washington, United States). The data ex-
traction form was created by the first author (H.R.)
with guidance from the Cochrane Data Collection
Form.12 It was pilot tested with the first two stud-
ies and modified based on identified discrepancies.
The key data extracted included study characteristics
(year of publication, study design, country of publi-
cation, and sample size), study population character-
istics, wound characteristics (etiology of wound and
location of wound), and outcomes of the study (graft
healing, postoperative complications, and length of
stay in hospital). The number of events per group was
extracted for binary outcomes. For continuous out-
comes, raw data for each group (mean and standard
deviation or median and range) were extracted.
Data Synthesis
The extracted data were analyzed in a qualita-
tive fashion for all studies. The RCTs were further
 Journal of Burn Care & Research
Volume XX, Number XX Retrouvey et al  3

analyzed quantitatively through meta-analysis if het- Study Characteristics

erogeneity was low. The clinical assessment and I2
statistic were reviewed to determine study hetero-
geneity. Fixed effects model were generated using
Review Manager 5.3 (Version 5.3.5; Copenhagen:
The Nordic Cochrane Centre, The Cochrane
Collaboration, 2014)  to statistically compare out-
comes, with odds ratios presented for binary out-
comes and mean differences for continuous data.
Forrest plots were computed to present the results.
RESULTS
The literature review process is shown in Figure 1 in
a Prisma diagram. The searches identified 4172 articles
of which 1108 duplicates were removed. The title and
abstract of the remaining 3064 articles were screened,
and 42 articles were deemed to be potentially relevant.
A full-text review based on study design, study popu-
lation, and selection of comparator and intervention
groups further eliminated 35 articles. The resulting
seven articles were included in the quantitative analysis.
The seven eligible studies (five RCTs and two ob-
servational studies) were published between 1979 and
2014 (Table 1). Studies were published in Australia
(n  =  1), England (n  =  3), New Zealand (n  =  1),
Sweden (n = 1), and the United States (n = 1). All
studies evaluated outcomes after mobilization in
patients with LE STSG.7,8,24–28 The specific location
of the wound was defined as LE (n  =  3), pretibial
(n = 2), shin (n = 1), and area below the inguinal lig-
ament (n = 1). Wound size varied between each study
and is presented in Table 1. There were no included
studies that evaluated UE wounds. In all studies, the
grafted site was dressed using a conventional dressing
with splinting as needed if the graft crossed a joint.
None of the included patients received negative pres-
sure wound therapy dressings. Early mobilization was
defined as mobilization on the day of the operation or
the first day postoperatively (n = 5), the second POD
(n = 1), and prior to POD 3 (n = 1). Late mobiliza-
tion was defined as mobilization postoperatively after
4 days of bed rest (n = 2), on POD 5 (n = 1), POD

Figure 1. Prisma diagram.

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

Downloaded from https://academic.oup.com/jbcr/advance-article-abstract/doi/10.1093/jbcr/iry003/4843983
by University of New England user
on 30 April 2018
on 30 April 2018

Table 1. Included study characteristics

Year of Country of Location of
Author publication Study design publication Patient age (y) wound Wound etiology Wound size

 Budny24 1993 RCT EnglandEM: 77.5 (47–93) pretibial – EM: 28.5 (6–99) cm3
LM: 74.2 (50–92) LM: 38.8 (2–99) cm3

by University of New England user

4  Retrouvey et al

 Gaze25 1979 Retrospective cohort England 55–89 shin – 3 × 4 cm to 10 × 16 cm

EM: 35.4 (SD: 16.4) EM: 3.56 (SD: 2.06) % TBSA
 Lorello26 2014 RCT United States LM: 43.6 (SD: 14.8) lower extremity Burn LM: 4.07 (SD: 4.18) % TBSA
Sharp trauma, blunt trauma, infection,
 Luczak8 2012 Retrospective cohort Australia EM: 42 LM: 55.7 lower limb burn, excision of lesion –
EM: 915 (210–2025) mm2
 Tallon27 2009 RCT New Zealand EM: 78.3 LM: 78.0 lower leg – LM: 716 (180–2250) mm2
Skin cancer, trauma, venous wound,
area below the arterial wound, diabetic wound,
 Wallenberg28 1999 RCT Sweden 69 (20–85) inguinal ligament erysipelas, unspecified –
 Wood7 1994 RCT England EM: 74.3 (SD: 14.2) pretibial — EM: 48.4 (SD: 40.8) cm2
LM: 73.3 (SD: 12.9) LM: 51.7 (SD: 37.5) cm2

Wound healing Wound evaluation

Author EM definition LM definition Dressing Sample size evaluation timing Other outcomes

 Budny POD 0–1 POD7 Conventional with below knee 61 Percent skin graft POD7 and 21 Any complication
plaster backslab in LM group EM: 21 take
LM: 40
30
EM: 16
 Gaze POD1 – Conventional LM: 14 – POD7 –
31

Downloaded from https://academic.oup.com/jbcr/advance-article-abstract/doi/10.1093/jbcr/iry003/4843983

Conventional with immobilization EM: 17
 Lorello POD1 POD5 splint for grafts crossing joints LM: 14 Percent graft loss POD5 –
48
Conventional with plaster of Paris EM: 25 Hematoma, infection,
 Luczak <POD3 POD4 backslab in 35 patients for 5 d LM: 23 Percent graft take POD5 deconditioning
42
EM: 18 Number of grafts
 Tallon POD2 POD7 Conventional LM: 24 loss POD7 Any complication
50 Healing of graft
EM: 25 using four
 Wallenberg POD1 POD4 Conventional LM: 25 codes POD14 –
 Wood POD1 POD10 Conventional 75 Percent graft take POD 7, 10, and 14 Date discharge,
EM: 36 complications
LM: 39
XXXX/XXXX 2018
Journal of Burn Care & Research

RCT, randomized controlled trials; EM, early mobilization; LM, late mobilization; %TBSA, percent total body surface area; POD, postoperative day.

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

 Journal of Burn Care & Research
Volume XX, Number XX Retrouvey et al  5
7 (n = 2), POD 10 (n = 1), or unspecified (n = 1).
Graft healing was evaluated at POD 5 (n = 2), POD
7 (n = 4), POD 10 (n = 1), POD 14 (n = 2), or 3
weeks postoperatively (n = 1). The total study sample
size varied between 30 and 75 patients, with 16 to 36
patients in the early mobilization group and 14 to 39
in the late mobilization group.
Study quality as evaluated by the modified
Cochrane EPOC RoB Tool for RCTs and the New
Castle Ottawa Scale for observational studies is
presented in Tables 2 and 3.  All RCTs had bias,
with random sequence generation, allocation con-
cealment, and blinding of outcome being the most
common sources of bias identified.7,24,26–28 The
quality of included observational studies was vari-
able; Gaze et al scored three out of nine stars due
to poor selection, comparability and outcome re-
porting, whereas Luczak et  al scored nine out of
nine stars.8,25
Primary Outcome
Graft Healing. There was no statistically signifi-
cant difference in percent graft take between early
mobilization and late mobilization (2 RCTs7,24, 136
participants, mean difference −2.16%; 95% con-
fidence intervals [CI]: −9.05–4.72%; I2  =  0 and
P  =  0.56; Table  4 and Figure  2). An observational
study by Wallenberg et  al reported no difference
at POD 14, with 80% in the early group and 88%
in the late group with primary healing of the graft
(P = 0.7).28 Quality of the RCT evidence was down-
graded to “moderate” due to the presence of bias
(poor random sequence generation and the possi-
bility of allocation concealment bias).
In addition, there was no statistically significant
difference in number of grafts lost (2 RCTs26,27, 73
participants, OR: 0.55, 95% CI: 0.12–2.54; I2 = 0%
and P  =  0.86; Table  4 and Figure  3). Two obser-
vational studies also evaluated this outcome and
found no difference between the comparator groups
(Figure 3).8,28 The quality of the RCT evidence was
graded as “moderate” due to sparce data.
Table 2. Modified Cochrane Effective Practice and Organisation of Care (EPOC) RoB Tool assessing bias for the five ran-
domized clinical trials
Adequate
sequence Allocation
generation concealment
Budny24 High High
Lorello26 Unknown Unknown
Tallon27 Unknown Unknown
Wallenberg28 Low High
Wood7 Unknown Unknown
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Downloaded from https://academic.oup.com/jbcr/advance-article-abstract/doi/10.1093/jbcr/iry003/4843983
by University of New England user
on 30 April 2018
Secondary Outcomes
Graft Pain. Graft pain was evaluated by one RCT
(Lorello et al).26 At rest, pain rated on a scale of 1
to 10 was 1.3 (SD: 2.0) for the early group and 3.5
(SD: 3.1) for the late group (P = 0.02). With ambula-
tion, pain rating was 1.8 (SD: 2.3) in the early group
versus 3.5 (SD: 2.9) in the late group (P = 0.08).26
Local Complications. Infection and hematoma
were the two local complications reported. There
was no statistically significant difference in infection
rate between early mobilization and late mobiliza-
tion (2 RCTs24,27, 103 participants; OR: 1.66, 95%
CI: 0.54–5.10; I2 = 0% and P = 0.61; Table 4 and
Figure 4). One observational study also reported this
outcome and found no difference between groups
(P = 0.22; Figure 4).8
There was no statistically significant difference in
hematoma rate between early mobilization and late
mobilization (2 RCTs24,27, 103 participants; OR:
0.98, 95% CI: 0.25–3.85; I2  =  0% and P  =  0.97;
Table 4 and Figure 4). One observational study by
Luczak et  al reported no difference between these
comparator groups (P = 1; Figure 4).8 Quality of the
evidence presented in these RCTs was downgraded
to “low” due to bias and inconsistencies in outcome
reporting.
Systemic Complications. Deconditioning defined
by decreased ease of mobilization was reported by
two studies, including one observational study and
one RCT. Luczak et  al defined deconditioning as
“delay of discharge after the immobilization period
secondary to poor mobility, requiring rehabilita-
tion.” Budny et al defined it as “diminished ease of
activity.”8,24 Quantitative analysis reveals lower rates
of deconditioning in patients treated with early mo-
bilization (Figure 5).8,24
Three studies reported other systemic complica-
tions in a heterogenous manner that did not allow for
quantitative assessments, hence only qualitative anal-
ysis is performed for this outcome. Budny et  al re-
ported no systemic complications in the early group
and one severe complication related to the heparin
Incomplete Free of selective
Blinding of outcome outcome Free of other
outcome assessment reporting bias
High Low Low Low
Low Low Low Low
Unknown Low Low Low
Low Low Low Low
High Unknown Low Low
 Journal of Burn Care & Research
6  Retrouvey et al XXXX/XXXX 2018

Figure 2. Forrest plot of results of meta-analysis of percent graft healed at POD7.

Figure 3. Forrest plot of quantitative analysis of graft loss at POD5-14.

Figure 4. Forrest plot of results of the quantitative analysis for local complications including infections and hematomas.

Figure 5. Forrest plot of the quantitative analysis for deconditioning.

Figure 6. Forrest plot of the quantitative analysis for length of stay in hospital.

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

Downloaded from https://academic.oup.com/jbcr/advance-article-abstract/doi/10.1093/jbcr/iry003/4843983
by University of New England user
on 30 April 2018
 Journal of Burn Care & Research
Volume XX, Number XX Retrouvey et al  7

Table 3. New Castle Ottawa Scale for bias assessment for included in the review. The percent graft take and
the two observational studies the number of grafts lost were not statistically dif-
Selection Comparability Outcome Total ferent between the early and late groups in the LE
based on moderate-quality evidence.7,24,26,27 Graft
Gaze 25
** * 3/9
pain, both at rest and with ambulation, was improved
Luczak8 **** ** *** 9/9
in the early mobilization group, although this was
reported in only one study.26 The pooled odds for
local complications (infection or hematoma) demon-
administration (hematuria with diffuse intravascular
strated no statistical difference between early and late
coagulopathy) in the late group.24 Tallon et  al and
mobilization groups.24,27 No systemic complications
Wood et  al reported no systemic complications (ve-
related to the graft procedure were reported in either
nous thromboembolism or chest infections) in either
group.7,24,27 Deconditioning was more severe in the
group.7,27
late group as compared with the early mobilization
Length of Stay in Hospital. Four of the included
group. Lastly, length of stay tended to be lower in
studies discussed length of stay. These were not
the early mobilization group.7,24–26
meta-analyzed because of high clinical heterogeneity
Our findings are mostly consistent with the ex-
between studies, specifically different discharge proto-
isting literature. In fact, a meta-analysis published
cols and variable reporting of the length of stay out-
in 2012 evaluated graft take after STSG for pretibial
come. Lorello et al’s criteria for discharge consisted of
lacerations and found no difference in skin graft heal-
independent ambulation and ability to change dress-
ing between early mobilization and bed rest (OR:
ings at home.26 Budny et al and Wood et al allowed
0.74, 95% CI: 0.31–1.79).2 Since the publication of
patients in the early group to be discharged on the day
this 2012 meta-analysis, Lorello et  al published an
of the operation, whereas patients in the late group
RCT that found statistically significant lower rates
were hospitalized for the duration of their immobili-
of graft loss in the early mobilization group.26 Our
zation.7,24 Although Budney et al and Wood et al had
meta-analysis pooled this new data with the previous
similar discharge protocols, they had different mea-
literature, confirming the 2012 findings that no dif-
surements of the length of stay outcome. Budny et al
ference between the groups existed with regard to
captured overall length of stay, whereas Wood et al de-
wound healing and more comprehensively assessed
fined length of stay as the period following initiation
patient outcomes such as graft site pain, local, and
of mobilization.4,29
systemic complications as well as length of stay in
Quantitative analysis of these three RCTs suggests
hospital.
that length of stay is equivalent or shorter in patients
Our findings support the assertion that early mo-
treated with early mobilization (Figure  6).7,24,26
bilization of the LE does not impact wound healing
Gaze reported a shorter length of stay in the early
if appropriate wound bed preparation, proper sur-
mobilization group but did not specify the number
gical technique, and adequate wound dressing are
of days in each group.25 Quality of the evidence in
performed. Furthermore, as expected, confinement
these RCTs is “low” due to high heterogeneity and
of a patient to bed rest may lead to increased mor-
the presence of biases (poor allocation concealment
bidity, including deconditioning, systemic complica-
and poor blinding of outcome).
tions, and prolonged length of stay in hospital.
DISCUSSION This review is significant as it highlights a gap
in evidence with regard to the optimal postopera-
Seven articles describing LE STSG procedures and tive mobilization protocol for patients with UE
no articles describing UE STSG procedures were STSG, as no UE studies have been conducted to
date. Although some authors suggest that early UE

Table 4. Summary of meta-analysis findings

Number of Mean difference
Outcome studies I2 P-value (95% CI) Odds ratio (95% CI) P-value GRADE

Graft take 2 7,24

0 0.56 −2.16% (−9.05–4.72) 0.54 Moderate
Graft loss 226,27 0 0.86 0.55 (0.12–2.54) 0.44 Moderate
Infection 224,27 0 0.61 1.66 (0.54–5.10) 0.37 Low
Hematoma 224,27 0 0.97 0.98 (0.25–3.85) 0.98 Low

GRADE, Grades of Recommendation, Assessment, Development and Evaluation.

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

Downloaded from https://academic.oup.com/jbcr/advance-article-abstract/doi/10.1093/jbcr/iry003/4843983
by University of New England user
on 30 April 2018

8  Retrouvey et al XXXX/XXXX 2018
motion is safe and prevents stiffness and contracture,
no observational study or RCT has been performed
to validate these claims.30,31 Furthermore, this meta-
analysis underscores the paucity of high-quality stud-
ies evaluating mobilization protocols in the LE.
This review has a number of limitations. First,
studies included in the qualitative and the quantita-
tive analysis have small sample sizes ranging between
30 and 75 patients. Therefore, despite pooling of
the study results, our conclusions are based on small
sample sizes. Larger RCTs are needed to further con-
firm our conclusions. The estimates presented in our
meta-analysis can serve as a guide for sample size cal-
culations during the design of these future studies.
Second, the studies included were published over a
long period, between 1979 and 2014. Care provided
to patients during this long time period is likely to
have changed over time. Third, wound evaluation
was performed in a heterogenous manner, with dif-
ferent metrics for wound evaluation conducted at
varying time points. In fact, the included studies
evaluated wounds with criteria ranging from percent
graft take, percent graft loss, number of grafts lost to
categorizing wounds into four levels of healing. The
timing of these wound evaluations was even more
diverse, being performed at POD 5, POD 7, POD
10, 2 weeks postoperatively, or 3 weeks postopera-
tively. This heterogeneity allowed for pooling of only
two studies for percent graft take and two studies
for number of grafts lost. Furthermore, heteroge-
neity was noted in the postoperative splinting proto-
cols used by authors. Budny et al, Luczak et al, and
Lorello et al described using splints postoperatively
to immobilize the grafts, whereas Wallenberg et al,
Gaze et al, Tallon et al, and Wood et al did not dis-
cuss splinting. A consensus on the optimal reporting
strategy and timing for wound healing as well as im-
mobilization protocols would allow for inclusion of
a greater number of studies in future meta-analyses,
leading to more robust conclusions. Fourth, the ma-
jority of studies included in the analysis had high or
unknown bias with regard to random sequence gen-
eration, allocation concealment, and blinding of the
outcome, leading to significant sources of bias. The
presence of these biases led to lower GRADE score
for each outcome reported. Future studies should
favor rigourous study design and should report this
in detail in the study methodology. Lastly, the anal-
ysis followed an intention to treat approach, as stud-
ies included only described mobilization protocols,
with no description of protocol deviation by health
care workers or due to patients’ inability to tolerate
ambulation.32 Information on workload of health
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Downloaded from https://academic.oup.com/jbcr/advance-article-abstract/doi/10.1093/jbcr/iry003/4843983
by University of New England user
on 30 April 2018
Journal of Burn Care & Research
care workers and tolerance of early mobilization by
patients would provide useful information prior to
making recommendations on the use of this strategy.
CONCLUSION
This comprehensive summary combines the ev-
idence for early versus late mobilization of adult
patients after STSG in the LEs. Graft healing was
found to be similar between interventions in the LE
based on moderate-quality evidence. Local complica-
tions were also similar based on low-quality evidence.
Graft pain was decreased, deconditioning was pre-
vented, and length of stay was shortened in the early
mobilization group, based on low-quality evidence
and heterogenous study results. No studies evaluated
the effect of mobilization in UE STSG. We conclude
that early mobilization may be the preferred strategy
for patients treated with STSG to the LE, as it pro-
vides similar graft healing compared with late mobi-
lization but prevents morbidity. High-quality studies
are needed to evaluate the impact of mobilization on
UE STSG and to make stronger recommendations for
LE STSG.
REFERENCES
1. Bodenham DC, Watson R. The early ambulation of patients
with lower limb grafts. Br J Plast Surg 1971;24:20–2.
2. Southwell-Keely J, Vandervord J. Mobilisation versus bed
rest after skin grafting pretibial lacerations: a meta-analysis.
Plast Surg Int 2012;2012:207452.
3. Smith TO. When should patients begin ambulating follow-
ing lower limb split skin graft surgery? A systematic review.
Physiotherapy 2006;92:135–45.
4. Budny PG, Lavelle J, Regan PJ, Roberts AH. Pretibial inju-
ries in the elderly: a prospective trial of early mobilisation
versus bed rest following surgical treatment. Br J Plast Surg
1993;46:594–8.
5. Tallon B, Lamb S, Patel D. Randomized nonblinded
comparison of convalescence for 2 and 7  days after split-
thickness skin grafting to the lower legs. Dermatol Surg
2009;35:634–7.
6. Reddy S, El-Haddawi F, Fancourt M, et al. The incidence
and risk factors for lower limb skin graft failure. Dermatol
Res Pract 2014;2014:582080.
7. Wood SH, Lees VC. A prospective investigation of the heal-
ing of grafted pretibial wounds with early and late mobilisa-
tion. Br J Plast Surg 1994;47:127–31.
8. Luczak B, Ha J, Gurfinkel R. Effect of early and late mobili-
sation on split skin graft outcome. Australas J Dermatol
2012;53:19–21.
9. Systematic reviews: CRD’s guidance for undertaking reviews
in health care 2009. York, UK: Centre for Reviews and
Dissemination (CRD), University of York; https://www.
york.ac.uk/media/crd/Systematic_Reviews.pdf; accessed 6
March 2018.
10. Higgins JPT, Green S. Cochrane handbook for system-
atic reviews of interventions. Version 5.1.0 [updated
March 2011]. 2011; available from http://handbook-5-1.
cochrane.org/; accessed 6 March 2018.
 Journal of Burn Care & Research
Volume XX, Number XX Retrouvey et al  9
11. Moher D, Liberati A, Tetzlaff J, Altman DG; The PRISMA
Group. Preferred reporting items for systematic reviews
and metaanalyses: The PRISMA statement. PLoS Med
2009;6(6):e1000097.
12. Data collection form. EPOC resources for review authors
2013; available from http://epoc.cochrane.org/epoc-spe-
cific-resources-review-authors; accessed 25 May 2017.
13. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa
Scale (NOS) for assessing the quality of nonrandomised studies
in meta-analyses; available from http://www.ohri.ca/programs/
clinical_epidemiology/nosgen.pdf; accessed 26 May 2017.
14. Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P,
Knottnerus A. GRADE guidelines: a new series of articles
in the journal of clinical epidemiology. J Clin Epidemiol
2011;64:380–2.
15. Guyatt GH, Oxman AD, Sultan S, et al.; GRADE Working
Group. GRADE guidelines: 9. Rating up the quality of evi-
dence. J Clin Epidemiol 2011;64:1311–6.
16. Guyatt GH, Oxman AD, Kunz R, et al.; GRADE Working
Group. GRADE guidelines: 8.  Rating the quality of evi-
dence—indirectness. J Clin Epidemiol 2011;64:1303–0.
17. Guyatt GH, Oxman AD, Kunz R, et  al.; GRADE
Working Group. GRADE guidelines: 7.  Rating the
quality of evidence—inconsistency. J Clin Epidemiol
2011;64:1294–302.
18. Guyatt GH, Oxman AD, Montori V, et al. GRADE guide-
lines: 5. Rating the quality of evidence—publication bias. J
Clin Epidemiol 2011;64:1277–82.
19. Guyatt GH, Oxman AD, Vist G, et al. GRADE guidelines:
4. Rating the quality of evidence—study limitations (risk of
bias). J Clin Epidemiol 2011;64:407–15.
20. Balshem H, Helfand M, Schünemann HJ, et  al. GRADE
guidelines: 3.  Rating the quality of evidence. J Clin
Epidemiol 2011;64:401–6.
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Downloaded from https://academic.oup.com/jbcr/advance-article-abstract/doi/10.1093/jbcr/iry003/4843983
by University of New England user
on 30 April 2018
21. Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines:
2.  Framing the question and deciding on important out-
comes. J Clin Epidemiol 2011;64:395–400.
22. Guyatt G, Oxman AD, Akl EA, et  al. GRADE guidelines:
1. Introduction-GRADE evidence profiles and summary of
findings tables. J Clin Epidemiol 2011;64:383–94.
23. Guyatt GH, Oxman AD, Kunz R, et  al. GRADE guide-
lines 6. Rating the quality of evidence—imprecision. J Clin
Epidemiol 2011;64:1283–93.
24. Budny PG, Lavelle J, Regan PJ, Roberts AH. Pretibial injuries in
the elderly: a prospective trial of early mobilisation versus bed rest
following surgical treatment. Br J Plast Surg 1993;46:594–8.
25. Gaze NR. Early mobilization in the treatment of shin inju-
ries. Injury 1979;10:209–10.
26. Lorello DJ, Peck M, Albrecht M, Richey KJ, Pressman MA.
Results of a prospective randomized controlled trial of early
ambulation for patients with lower extremity autografts. J
Burn Care Res 2014;35:431–6.
27. Tallon B, Lamb S, Patel D. Randomized nonblinded compar-
ison of convalescence for 2 and 7 days after split-thickness skin
grafting to the lower legs. Dermatol Surg 2009;35:634–7.
28. Wallenberg L. Effect of early mobilisation after skin graft-
ing to lower limbs. Scand J Plast Reconstr Surg Hand Surg
1999;33:411–3.
29. Wood SH, Lees VC. A prospective investigation of the heal-
ing of grafted pretibial wounds with early and late mobilisa-
tion. Br J Plast Surg 1994;47:127–31.
30. McKee DM. Acute management of burn injuries to the hand
and upper extremity. J Hand Surg Am 2010;35:1542–4.
31. Cox GW, Griswold JA. Outpatient skin grafting of extremity
burn wounds with the use of Unna Boot compression dress-
ings. J Burn Care Rehabil 1993;14:455–7.
32. Gupta SK. Intention-to-treat concept: a review. Perspect
Clin Res 2011;2:109–12.
 Journal of Burn Care & Research
10  Retrouvey et al XXXX/XXXX 2018

APPENDIX 1.  MEDLINE SEARCH STRATEGY (PERFORMED ON MAY 23, 2017)

# Searches Results

1 Skin transplantation/and graft*.af. 16,898

2 (skin* adj6 graft*).mp. 17,187
3 “split thickness”.mp. 2929
4 split skin graft.mp. 378
5 stsg.mp. 189
6 (skin* adj6 autograft*).mp. 524
7 1 or 2 or 3 or 4 or 5 or 6 24,483
8 Early ambulation/ 2487
9 ambulat*.mp. 149,346
10 (mobilis* or mobiliz*).mp. 68,444
11 exp Immobilization/ 25,674
12 immobili*.mp. 103,546
13 splint*.mp. 17,002
14 cast*.mp. 101,129
15 bed rest/ 3787
16 bed rest*.mp. 890
17 rest/ 15,668
18 rest???.mp. 269,961
19 exp walking/ 44,313
20 walk*.mp. 89,304
21 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 786,150
22 7 and 21 1302
23 exp animals/not (exp humans/ and exp animals/) 4,399,007
24 22 not 23 1146
limit 24 to (“all adult (19 plus years)” or “young adult (19 to 24 years)” or “adult (19 to 44 years)” or “young adult
and adult (19–24 and 19–44)” or “middle age (45 to 64 years)” or “middle aged (45 plus years)” or “all aged (65
25 and over)” or “aged (80 and over)”) 710
limit 24 to (“all infant (birth to 23 months)” or “all child (0 to 18 years)” or “newborn infant (birth to 1 month)”
or “infant (1 to 23 months)” or “preschool child (2 to 5 years)” or “child (6 to 12 years)” or “adolescent (13 to
26 18 years)”) 400
27 24 not 26 746
28 25 or 27 1012
29 remove duplicates from 28 998

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

Downloaded from https://academic.oup.com/jbcr/advance-article-abstract/doi/10.1093/jbcr/iry003/4843983
by University of New England user
on 30 April 2018