Early and Sequential Punch Grafting in the Spectrum of Arteriolopathy Ulcers in the Elderly

Elena Conde-Montero, PhD, MD; Laura Pérez Jerónimo, RN; Alicia Peral Vázquez, RN; Lorena Recarte Marín, RN; Pablo Ernesto Sanabria Villarpando, MD; Pablo de la Cueva Dobao, PhD, MD


Wounds. 2020;32(8):E38-E41. 

In This Article

Abstract and Introduction


Introduction: Posttraumatic ulcers secondary to age-related arteriolosclerosis may be included in the clinic-histopathological spectrum of the Martorell hypertensive ischemic ulcer. Histologically, they both present occlusive subcutaneous arteriolosclerosis. Considering these similarities, they could benefit from the same treatment.

Case Report: The authors present an 84-year-old white female who had a painful 9-cm x 4-cm ulcer of the central inner aspect of her left leg. The ulcer had developed 2 months prior after mild trauma, with good response to early and sequential punch grafting, combined with single-use negative pressure wound therapy and compression therapy. Pain reduction was obtained from the first punch grafting session. To achieve complete epithelialization 16 weeks after the first punch grafting procedure, 2 more sessions were necessary.

Conclusions: Early punch grafting is an effective technique for pain control and healing promotion in Martorell ulcers. Punch grafting, which may be performed in an outpatient setting, is well tolerated by patients and may be repeated several times if necessary.


Secondary to mild trauma, large wounds in the elderly are a frequent reason for consultation. If the elderly hit their legs on household items (eg, furniture or open dishwasher door), they are susceptible to injuries, including wounds. Normally, these wounds have an insignificant clinical aspect at first and progressively acquire a purplish or blackish color and, in a few days, become extensive, deep, and painful wounds. In addition to age, these patients often have comorbidities such as hypertension or diabetes.

This clinical description is similar to Martorell hypertensive ischemic ulcer. In fact, some of these posttraumatic lesions may be considered Martorell ulcers, because they have characteristics traditionally associated with this entity (typical lateral and posterior location on the leg, bilaterality, hypertension, or diabetes mellitus).[1] The rest of the wounds that do not meet the criteria included in the traditional Martorell definition could be called posttraumatic ulcers due to age-associated arteriolopathy. Skin biopsy does not assist in differentiating them because, histopathologically, both types of wounds present occlusive subcutaneous arteriolosclerosis. The results of a retrospective study comparing leg biopsy findings of patients with and without Martorell ulcers concluded that arteriolosclerosis, which is present in both groups, was associated with age.[1] Consequently, biopsy of these ulcers is only needed when other entities are suspected, such as pyoderma gangrenosum or vasculitis.[1]

Punch grafting is a traditional method to obtain thin split-thickness skin grafts containing epidermis and papillary dermis. Grafts are obtained under a local anesthetic with a punch, curette, or surgical blade and are placed directly on the wound bed. The donor site is normally the thigh, which heals by secondary intention. The procedure can be performed in an outpatient setting.[2–6]

Early punch grafting is considered the first-line treatment for Martorell leg ulcers in France, mainly for its benefit in pain reduction and limitation of wound progression.[4] Even if the conditions for grafting are not ideal, the punch graft releases growth factors and cells that promote epithelialization and pain reduction.[2,5,6] In these cases, clinicians have to perform several sessions of punch grafting to obtain complete epithelialization, which has been well-tolerated by the patient.[2,6]

Several studies support the interest of this technique in this wound type.[2,4–6] However, thus far, to the authors' knowledge, no case reports have been published regarding punch grafting in posttraumatic leg wounds in the elderly. The case of an elderly female with a posttraumatic ulcer that was successfully managed with sequential punch grafting is presented herein.