Primary reattachment of avulsed skin flaps with negative pressure wound therapy in degloving injuries of the lower extremity

Artificial dermis combined with negative pressure wound therapy and platelet-rich plasma to treat traumatic wounds: a retrospective study

OBJECTIVE

The reconstruction of complex soft tissue defects with exposure of bones and tendons represents an increasing challenge in wound care, especially in large extremity wounds. The aim of this study was to detect the clinical efficacy of combined use of negative pressure wound therapy (NPWT), artificial dermis (ADM), platelet-rich plasma (PRP) and split-thickness skin grafting (STSG) in the reconstruction of large traumatic extremity skin defects.

METHOD

In this study, eight cases were treated with combined therapies for repairing complex extremity wounds and the results were reviewed retrospectively. After surgical debridement, all wounds received ADM, PRP and delayed STSG, which were all aided with NPWT.

RESULTS

The patients consisted of five males and three females, with a mean age of 44 years. A total of six lower extremity wounds were located at the foot/ankle, with exposed tendon in five, bone exposure in three and both in two. Of the group, two patients had exposed tendon on arm/hand wounds. The size of wounds and ADM averaged 126cm2 and 42.3cm2, respectively. ADM was used to cover the exposed bone or tendon, the granulation and muscular tissue were covered with vacuum sealing drainage (VSD) directly, for NPWT. The survival rate of ADM averaged 98.9%. The average time for survival of ADM was 12.8 days and the mean uptake of autologous skin graft was 93.5%. Only one patient received repeated skin grafts. All patients achieved successful healing and reported no complications. The mean length of hospital stay was 36.1 days.

CONCLUSION

Our study revealed that ADM in conjunction with NPWT, PRP and STSG could be used for repairing large traumatic extremity wounds. Wound closure was achieved without flaps, the aesthetic and functional outcomes were acceptable, and only one patient developed a 35% loss of skin graft.

DECLARATION OF INTEREST

This work was supported by grants from the Natural Science Foundation of Hubei Province (grant no. 2020CFB464) and Youth Foundation of Wuhan Municipal Health Commission (grant no. WX20Q15). The authors have no conflicts of interest to declare.

Effect of ethanolic extracts from Piperaceae leaves on the reduction of skin necrosis and wound healing in an animal model of degloving injuries

PURPOSE

To assess the effect of the ethanolic extract of the leaves of three species of plants from the Piperaceae family on reducing necrosis and enhancing wound healing in an animal model of degloving injuries.

METHODS

The animals were divided into six groups, each consisting of six animals: sham, negative control, EEPA (Piper amalago ethanolic extract), EEPG (Piper glabratum ethanolic extract), EEPV (Piper vicosanum ethanolic extract), and positive control receiving hyperbaric oxygenation. The animals underwent surgery to induce excision wounds, and the extent of cutaneous necrosis was evaluated using graphic software, while wound healing was assessed through histopathology.

RESULTS

Skin necrosis percentage area was: sham group = 62.84% 6.38; negative control group = 63.03% 4.11; P. vicosanum = 40.80% 4.76 p < 0.05; P. glabratum 32.97% 4.01 p < 0.01; P. amalago = 32.40% 4.61 p < 0.01; hyperbaric oxygenation = 33.21% 4.29 p < 0.01. All treated groups showed higher collagen deposition and less intense, plus predominantly mononuclear inflammatory infiltrate, suggesting improved healing process.

CONCLUSIONS

The three tested extracts demonstrated efficacy in reducing the extent of cutaneous necrosis caused by degloving injuries and also showed evidence of improvement in the wound healing process.

The Bridging Effect of Artificial Dermis on Reconstruction of Skin Avulsion Injury

Skin avulsion wounds are expected to be swollen and tense after trauma, and skin perfusion can be compromised after primary closure, resulting in wound dehiscence and poor healing. The artificial dermis (AD) serves as a dermal regeneration template that is used to heal skin defects with secondary intention. Therefore, the aim of this study is to evaluate the effect of AD application on traumatic skin avulsion injuries compared to conventional primary closure. A retrospective cohort of 20 patients with skin avulsion injuries were included the study: ten patients were treated with AD and ten patients were managed with primary closure. When compared to the primary closure group, AD group had a shorter average healing time (58.40 ± 26.94 days V 65.50 ± 46.45 days) and significantly higher flap viability (92.00 ± 13.17% V 78.00 ± 13.98%; p = .03). In conclusion, AD is a promising material for the treatment of skin avulsion injury and produces better clinical results.

Skin grafting treatment of adolescent lower limb avulsion injury

Background

Under the influence of various factors, the number of lower extremity avulsion injuries in adolescents is increasing year by year. The main modality of treatment is skin grafting. There are many types of skin grafting. Although many studies on skin grafting after avulsion injuries have been published in the past few decades, there are differences in the treatment options for adolescents with post avulsion injuries.

Main body

Thorough debridement and appropriate skin grafts are essential for the surgical management of avulsion injuries for optimal prognosis. In the acquisition of grafts, progress has been made in equipment for how to obtain different depths of skin. The severity of the avulsion injury varies among patients on admission, and therefore the manner and type of skin grafting will vary. Especially in adolescents, graft survival and functional recovery are of great concern to both patients and physicians. Therefore, many efforts have been made to improve survival rate and activity.

Conclusion

This review summarizes the principles of treatment of avulsion injuries, the historical development of skin grafts, and the selection of skin grafts, hoping to be helpful for future research.

Regionalized coverage of the totally degloved foot by a combination of "Boat sock" style free flap and skin graft

INTRODUCTION

To maximize the morpho-functional recovery on the totally degloved foot while not excessively introducing the technical complexity of microsurgery, we present a regionalized reconstruction, in which the highly functional subunit (weight-bearing area and ankle-around area) is covered by free skin flaps, and the less functional subunit (dorsum) by skin graft.

METHODS

From June 2011 to December 2017, 10 patients who had total degloving injury on foot underwent reconstruction based on regionalized coverage. As the shape of combined flaps resemble a boat sock in high-heeled shoe, we name it as "Boat Sock" flaps. Complication like vascular compromise, partial or total flap loss, Equinus deformity and delayed plantar ulceration were documented elaborately. Secondary surgeries were also recorded. Foot function was evaluated by Maryland foot score at the last follow up.

RESULTS

Twenty-one free skin flaps were used for "Boat sock" coverage on highly functional subunits. Flap dimension ranged from 19×5cm² to 28×8cm² (mean 151cm²). Among these flaps, one experienced partial necrosis which was treated conservatively, one experienced burn due to lack of protective sensation. Complication like Equinus deformity or delayed plantar ulceration did not occur. Secondary surgery included debulking on two cases. Mean Maryland foot score was 90.4.

CONCLUSION

This regionalized coverage by "Boat Sock" flaps and skin graft could serve as a standard procedure for reconstruction of the totally degloved foot, by offering the benefits of multi-plane coverage, a well-contoured ankle, an abrasion-tolerant planta, and eclectic surgical complexities.

[Initial and surgical care of foot ailments]

A rare lesion, limb dislocation, particularly of the foot, is extremely serious. Its initial mortality is related to hemorrhage. Its morbidity is major due to lack of skin coverage of the bones and infection with functional issues. Management remains poorly codified and unknown, and requires a multidisciplinary medical and paramedical team from pre-hospital to rehabilitation. The initial surgery is ideally conservative to control the infection and cover the persistent skin flaps. An unfavorable evolution imposes amputation, sometimes early.

Photoacoustic Microscopy Provides Early Prediction of Tissue Necrosis in Skin Avulsion Injuries

BACKGROUND

Skin avulsion injuries caused by high-energy traffic and machinery accidents are important topics in the field of repair and reconstruction. The injury generates a skin flap with uncertain vascular basis resulting in ischemic necrosis of the distal portion of the flap. Yet there is lack of reliable way for estimating the extent of blood supply in damaged tissue, which has limited the possibility of prompt surgical intervention. Recent studies have confirmed that photoacoustic microscopy imaging has a wide range of applications in the biomedical field owing to its good performance in angiography.

METHODS

In our study, we successfully surgically induced skin avulsion injury on mice hindlimbs. Then, we used this novel approach to image skin microcirculation and predict skin necrosis with impaired blood supply after injury in live mice.

RESULTS AND CONCLUSION

All skin tissues in the avulsed hindlimb flap group show different levels of necrosis at the end of the observation period. The "dark zone" with impaired microcirculation in PAM images, which continuously extends over time, was seen as a prediction of necrosis of skin tissue and at 60 min after surgery was similar to the area of clinical necrosis on postoperative day 7. All these indicate that photoacoustic microscopy imaging is a feasible, precise, high-resolution, non-invasive technique for early prediction of necrosis in skin avulsion injury, providing a promising tool for surgeons to manage the injury.

Fluorescence angiography-assisted debridement of critically perfused glabrous skin in degloving foot injuries: Two case reports

RATIONALE

Degloving foot injuries are challenging to treat and associated with life-long sequelae for patients. An appropriate debridement of ischemic soft tissues with maximal preservation of glabrous skin is key during the reconstruction of these injuries. Indocyanine green (ICG) fluorescence angiography is an established technique for the intraoperative evaluation of tissue perfusion.

PATIENT CONCERNS

Two patients sustained complex foot injuries in traffic accidents, including multiple fracture dislocations and extensive degloving of the plantar skin.

DIAGNOSIS

Clinical inspection revealed significant degloving of the glabrous skin in both patients.

INTERVENTIONS

After fracture fixation, ICG fluorescence angiography-assisted debridement with immediate latissimus dorsi free flap reconstruction was performed.

OUTCOMES

In both cases, this technique allowed a precise debridement with maximal preservation of the glabrous skin. The healing of the remaining glabrous skin was uneventful and the 6-month follow-up was characterized by stable soft tissues and satisfying ambulation.

LESSONS

ICG fluorescence angiography is a safe, user-friendly, and quick procedure with minimal risks, expanding the armamentarium of the reconstructive surgeon. It is highly useful for the debridement of extensive plantar degloving injuries and may also help to minimize the number of procedures and the risk of infection.

Management of lower extremity traumatic injuries with negative pressure wound therapy: Experience of a pediatric plastic surgery department

INTRODUCTION

Extensive lower limb traumatic injuries are particularly challenging when they associate skin and soft tissue defects, moreover when the patient is a child. In view of more frequent recommendations and reports of negative pressure wound therapy (NPWT) use for severe trauma and extensive soft tissue defects of the lower extremity, we aimed at reviewing the indications and outcomes of this technique in our pediatric plastic surgery department.

METHOD

We performed a retrospective study for the period 2016-2019, in order to identify patients having suffered injuries of the ankle and foot, for who NPWT was used in the therapeutic protocol.

RESULTS

For the study period we identified a total of 9 children with ankle and foot injuries who had NPWT in their therapeutic protocol. The average age was 10 years (range 3 years 5 months to 14 years 4 months) and 8 of them were pedestrians, victims of traffic accidents. Five patients presented with associated injuries and fractures in other anatomic locations. NPWT was started 1-3 days after admission and it was used in average for 21.77 days, with good results in all cases. For 8 patients NPWT was sufficient to contract the wound and cover exposed bone and tendons before closing with split thickness skin graft (STSG). One patient needed also a free muscular flap transfer before grafting. All patients achieved complete healing and started physical therapy before discharging.

CONCLUSION

NPWT has proven to be an easy to use, safe and effective therapeutic tool for pediatric patients, with considerable improvement for healing in case of traumatic injuries of foot and ankle, presenting extensive skin and soft tissue defects and bone exposure in children. NPWT is also suitable for children since its use implies less frequent dressing changes, and decreases the level of pain and anxiety, and spares donor areas needed for more complicated procedures and, by creating an optimal grafting bed, it ensures good outcomes, in the short term and long term as well.

NIR-II Fluorescence Imaging of Skin Avulsion and Necrosis

Skin avulsion is commonly seen in individuals exposed to heavy shearing forces. Subcutaneous tissue detachment and bone fractures usually accompany skin avulsion. Thus, the estimation of the extent of damaged tissue is very important. Currently, the viability of skin and subcutaneous tissue is determined by clinical observations, and these observations always underestimate the true extent of the avulsed skin. Herein, we synthesized an innovative probe, CH1055-GRRRDEVDK (CH1055-GK), which can specifically bind to caspase-3 so as to image skin avulsion and define necrotic regions. Our uptake and binding affinity tests in apoptotic cells and evaluation of the probe ex vivo and in vivo showed that the probe has a strong ability to bind caspase-3 in skin avulsion models and that it vividly detected the necrotic area in avulsed skins. Furthermore, the increased fluorescence intensity of the probe in the avulsed skin showed a larger affected area than that determined by clinical observations in live mice. Consequently, our results indicated that observation of the caspase-3-targeted probe CH1055-GK via NIR-II imaging allowed the clear detection of skin avulsion in subjects, indicating its potential as an imaging tool for the early diagnosis of skin avulsion and the determination of necrotic margins.

The management of degloving injuries of the limb with full thickness skin grafting using vacuum sealing drainage or traditional compression dressing: A comparative cohort study

BACKGROUND

Degloving injuries of the limb are severe and frequently underrated. Few researches are available comparing the results of reattachment of the degloved skin grafts with the vacuum sealing drainage technique and the traditional compression dressing method. In this study, we aimed to compare the treatment outcomes of these two approaches.

METHODS

Eighty-three consecutive patients were treated for degloving injury of the limb. Based on the treatment approach, the patients were divided into vacuum sealing drainage group (VSD group, n = 55) and traditional compression dressing group (TCD group, n = 28). After reattachment, the degloved skin was secured with stitches and compressed with VSD or TCD. The outcomes were mainly assessed based on the percentage of skin graft take.

RESULT

In VSD group, there were excellent results in 18, fair in 9 and poor in 28, respectively; In TCD group, there were excellent results in 11, fair in 10 and poor in 7, respectively. Statistically, no significant difference was found between two groups in terms of the category of excellent results. However, significant higher incidence of poor results with necrotic areas exceeding 50% was observed in the VSD group than that in the TCD group. In addition, although the duration of hospitalization in the VSD group was shorter than that in the TCD group, the medical supply costs and total costs were much higher than that of the TCD group.

CONCLUSION

VSD and TCD are equally effective in the management of degloving injuries of the limb; however, VSD technique may potentially have a higher risk of poor results with increased hospital charges. The traditional approach still has its merits in clinical practice, especially in rural hospitals when VSD is not available or unaffordable.

A Synthetic Biodegradable Temporising Matrix in Degloving Lower Extremity Trauma Reconstruction: A Case Report

Supplemental Digital Content is available in the text.

Presented is the case of an obese, 72 year-old diabetic man with a dorsal foot de-gloving injury. Whilst the tendons of extensor hallucis longus, extensor digitorum longus to all digits, and extensor digitorum brevis to hallux and second toe were intact after surgical debridement, none had any covering paratenon. The joint between the medial cuneiform and first metatarsal was open. Reconstructive options were limited by his age and co-morbidities. A novel, completely synthetic dermal matrix (NovoSorb BTM) was applied, after which the patient was discharged home to attend for dressings and review of integration progress as an outpatient. He was allowed to mobilise without limitation. Because of the poor quality of the wound bed (and patient), the material integrated slowly over 9 weeks. Delamination of the matrix, and definitive closure by application of sheet split skin autograft, produced a robust, soft, mobile and excellent aesthetic result, over which he could wear footwear immediately. Clinically, the paratenon-denuded tendons glided under the neo-dermis without tethering to the overlying integrated matrix, allowing a full range of digital movement. This was confirmed on ultrasound examination, which also demonstrated no inflammation or oedema. Already proven in extensive burns, necrotising fasciitis and complex surgical wounds, BTM represents a useful addition to the reconstructive surgeon’s toolbox.

Unified classification of open fractures: Based on Gustilo and OTA classification schemes

BACKGROUND

The Orthopaedic Trauma Association (OTA) classification scheme for open fractures has improved precision, validity and reliability over the modified Gustilo classification system. However, it needs to be modified into a simple and practical classification system to gain widespread acceptance and application.

MATERIAL AND METHODS

We devised a new "unified" classification of open fractures based on the Gustilo and OTA classification systems. The new classification was tested for interobserver reliability on five different fractures classified by 15 surgeons each using the Krippendorff's alpha. Preference of surgeons for the Gustilo, OTA and unified classifications was assessed.

RESULTS

The new classification showed excellent interobserver reliability (α = 0.93). A significantly higher number of surgeons expressed preference for the new over the Gustilo and OTA classifications for routine clinical use.

CONCLUSION

The new "unified" classification of open fractures has good validity, reliability and acceptability, and has the potential to replace all other existing classification systems.