The use of Integra™ in necrotizing fasciitis

Use of a bilayer biodegradable synthetic dermal matrix for the management of defects arising from necrotising fasciitis

The aim of this article is to provide a brief overview of necrotising fasciitis, including causative factors, incidence, diagnosis and clinical outcomes. Various surgical treatment options are outlined, including methods of soft tissue reconstruction after wide excision of infected and necrotic tissues. The role of dermal matrices, including a synthetic biodegradable temporising matrix made of polyurethane, are described in terms of wound bed preparation, surgical application and clinical outcomes.

Survival of an 80-Year-Old Male With a Successful Split-Thickness Skin Graft for End-Stage Necrotizing Fasciitis: A Case Report

Herein, we report a case of an 80-year-old male who was diagnosed with a fatal condition known as necrotizing fasciitis. This devastating soft tissue infection can cause profound damage to multiple tissue planes. Despite its etiology being multifactorial, impaired immunity with increasing age weighs in as the most significant. We intend to shed light on its detrimental clinical features and how we managed to treat the patient both conservatively and surgically. Through our case findings and management plan, we hope this case to be of clinical value and knowledge to clinicians to better diagnose and treat the deleterious condition.

Indications and functional outcome of the use of integra® dermal regeneration template for the management of traumatic soft tissue defects on dorsal hand, fingers and thumb

INTRODUCTION

Few studies have been conducted to explore the utility of the Integra^® dermal regeneration template (IDRT) combined with a delayed split-thickness skin graft (STSG) for reconstructing complex dorsal hand, digit, and thumb injuries. This study reports the indications and outcomes for 14 patients treated with this technique via a two-stage process.

MATERIALS AND METHODS

We retrospectively reviewed all patients treated by IDRT combined with STSG from May 2015 to October 2018. The inclusion criterion was traumatic or post-infectious soft tissue defects (STDs) of the dorsal hand, fingers, and thumb, not suitable for direct wound closure and requiring local, pedicle, or free flap reconstruction. After debridement, a two-stage procedure was applied, namely IDRT followed by STSG. Indications, functional outcomes, aesthetic results, complications, patient satisfaction, and the STSG take rate were evaluated over a 36-month follow-up using standardised instruments.

RESULTS

A total of 14 patients with 15 reconstructions (average age = 48 years) were included. The dominant hand was involved in 50% of cases. Dorsal STDs involved the hand, fingers, thumb, and hand and thumb in 7, 3, 2 and 2 cases, respectively. The mean STD size was 35 cm² (range: 3-150 cm²). The wound was associated with exposed tendons (without peritenon), bone (without periosteum), and joints (without a capsule) in eight cases (57%). The IDRT/STSG take rate was 97%. The average Vancouver Scar Scale score was 2 (1-4).

CONCLUSION

The 36-month follow-up demonstrated that IDRT is a safe and reliable technique that can be considered a viable alternative to flap reconstruction for the management of traumatic STDs in selected patients. The aesthetic outcomes are acceptable, functional recovery of the fingers is excellent, patient satisfaction is very high and the rate of complications is very low.

Immune Cell Therapies to Improve Regeneration and Revascularization of Non-Healing Wounds

With the increased prevalence of chronic diseases, non-healing wounds place a significant burden on the health system and the quality of life of affected patients. Non-healing wounds are full-thickness skin lesions that persist for months or years. While several factors contribute to their pathogenesis, all non-healing wounds consistently demonstrate inadequate vascularization, resulting in the poor supply of oxygen, nutrients, and growth factors at the level of the lesion. Most existing therapies rely on the use of dermal substitutes, which help the re-epithelialization of the lesion by mimicking a pro-regenerative extracellular matrix. However, in most patients, this approach is not efficient, as non-healing wounds principally affect individuals afflicted with vascular disorders, such as peripheral artery disease and/or diabetes. Over the last 25 years, innovative therapies have been proposed with the aim of fostering the regenerative potential of multiple immune cell types. This can be achieved by promoting cell mobilization into the circulation, their recruitment to the wound site, modulation of their local activity, or their direct injection into the wound. In this review, we summarize preclinical and clinical studies that have explored the potential of various populations of immune cells to promote skin regeneration in non-healing wounds and critically discuss the current limitations that prevent the adoption of these therapies in the clinics.

Complex Wound Closure Following Mysterious and Vicious Animal Attack

Animal attacks are a worrisome and dangerous entity that occur at high volumes and are evaluated frequently by ER physicians, primary care physicians, trauma teams, acute care surgeons, and plastic surgeons. The severity of animal attacks can range from a small insect sting to mauling by large animal, and even death. With animal attacks of high intensity, there is often significant scratching, tearing, shearing, with destruction of the skin, subcutaneous tissues, muscles, and bone. Serious attacks frequently lead to infection, sepsis, pain, loss of sensation or mobility, operative interventions, and amputations of affected limbs. We report herein the traumatic mauling of a woman by a reported unknown animal. Though the entity of animal attacks has been reported in the past, this case dictates presentation given the suspicious circumstances surrounding the attack, the involvement of her care requiring a multidisciplinary surgical approach via trauma surgery and plastic surgery, multiple extensive interventions, and the excellent take of the split thickness skin graft (STSG) after the use of a dermal regeneration template (DRT).

Novel Scrotal Reconstruction after Fournier's Gangrene Using the Integra™ Dermal Regeneration Template

We report a novel use of the Integra™ dermal regeneration template to facilitate a functional recovery in a young male with Fournier's gangrene. After multiple debridements he had a large soft tissue defect and local flaps were not possible for reconstruction. Integra™ facilitated reconstruction of a neo-scrotum to allow a good cosmetic outcome.

Successful Use of Negative-pressure Wound Therapy and Dermal Substitute in the Treatment of Gluteal Ecthyma Gangrenosum in a 2-year-old Girl

Ecthyma Gangrenosum is a manifestation of Pseudomonas Aeruginosa infection, usually occurring in immunocompromised patients, which can be associated with Pseudomonas Aeruginosa bacteremia with potentially lethal outcome. The clinical appearance is of an inflammatory cutaneous lesion with a central necrotic spot; the lesion then rapidly progresses to a gangrenous ulcer with a gray-black eschar extending in the deep soft tissues. Treatment of Ecthyma Gangrenosum includes both aggressive systemic antibiotic therapy and surgical procedures. A 2-year-old girl affected by B-cell precursor acute lymphoblastic leukemia was admitted to our hospital for suspected sepsis; the diagnosis was later confirmed by blood cultures positive for Pseudomonas Aeruginosa. In the days following the diagnosis, the patient developed a necrotic lesion of the right gluteal area consistent with Ecthyma Gangrenosum. Aggressive surgical debridement was then performed, followed by negative-pressure wound therapy and reconstruction with dermal substitute and autologous skin graft, which were successful. Ecthyma Gangrenosum is a potentially lethal condition affecting especially immunocompromised patients; aggressive medical treatment with combination antibiotic therapy is warranted and multiple surgical procedures, including extensive surgical debridement and diverting colostomy, are needed. Various reconstructive techniques have been reported in the literature, although no gold-standard can be established to date. Since Ecthyma Gangrenosum lesions are characterized by the presence of both high inflammatory activity due Pseudomonas infection and extensive tissue loss, the association of negative-pressure therapy and dermal substitutes implant seem to have a rationale in the surgical treatment of Ecthyma Gangrenosum and should therefore be considered.

Physiology, not modern operative approach, predicts mortality in extremity necrotizing soft tissue infections at a high-volume center

BACKGROUND

Multiple factors are associated with mortality in necrotizing soft tissue infection, such as organ dysfunction and underlying medical comorbidities, but are not often modifiable. Operative interventions are an attractive modifiable variable in modern management of extremity necrotizing soft tissue infection, but the influence of amputation and advanced wound management techniques on mortality is unknown.

METHODS

A single-institution review was performed of extremity necrotizing soft tissue infection . Admission demographics, organ dysfunction, and operative interventions were investigated. The primary outcome was mortality. Advanced wound management techniques were considered flap creation or use of a dermal matrix substitute for coverage of neurovascular structures, tendon, or bone.

RESULTS

Overall, 124 patients with extremity necrotizing soft tissue infection were included, with 112 of 124 (90.3%) patients living and 12 of 124 (9.7%) patients dying. Patients who lived had a lower Sequential Organ Failure Assessment score (1.00 [interquartile range, 5] vs 10.50 [interquartile range, 11], P < .001), but no difference in use of amputation (11.6% vs 25.0%, P = .19) or advanced wound management techniques (12.5% vs 0%, P = 0.36), respectively. Indications for amputation in the 16 patients who underwent amputation included nonsalvageable limb in 13 of 16 (81.3%), medical comorbidity in 2 of 16 (12.5%), and a nonsalvageable limb and medical comorbidity in 1 of 16 (6.3%) patients. In multivariate analysis, only the Sequential Organ Failure Assessment score remained associated with mortality (odds ratio 1.315, 95% confidence interval 1.146-1.509, P < .001) CONCLUSION: Use of amputation or advanced wound management techniques was not associated with mortality in patients with extremity necrotizing soft tissue infection. At centers able to provide the critical care support, aggressive use of limb salvage may not affect mortality.

Current and emerging vascularization strategies in skin tissue engineering

Vascularization is a key process in skin tissue engineering, determining the biological function of artificial skin implants. Hence, efficient vascularization strategies are a major prerequisite for the safe application of these implants in clinical practice. Current approaches include (i) modification of structural and physicochemical properties of dermal scaffolds, (ii) biological scaffold activation with growth factor-releasing systems or gene vectors, and (iii) generation of prevascularized skin substitutes by seeding scaffolds with vessel-forming cells. These conventional approaches may be further supplemented by emerging strategies, such as transplantation of adipose tissue-derived microvascular fragments, 3D bioprinting and microfluidics, miRNA modulation, cell sheet engineering, and fabrication of photosynthetic scaffolds. The successful translation of these vascularization strategies from bench to bedside may pave the way for a broad clinical implementation of skin tissue engineering.

Successful combined approach to a severe Fournier's gangrene

We present a case of a successful reconstruction of a severe Fournier's gangrene (FG) involving the scrotum, the perineum, the right ischial area and extended to the lower abdomen. There are many different surgical techniques to repair and reconstruct the defect following debridement in FG. The authors treated this complex wound using negative pressure wound therapy (NPWT), dermal regeneration template and a split-thickness skin graft. Complete recovery was achieved and no major complications were observed. The patient showed a satisfying functional and aesthetic result.

Necrotizing fasciitis of the extremity caused by Haemophilus influenzae serotype b in a healthy adult

Haemophilus influenzae is a rare cause of necrotizing fasciitis with only a few previously reported cases. We describe the case of a 44-year-old man who had necrotizing fasciitis of the right lower extremity develop after intramuscular injections of paracetamol on his right buttock. The causative organism isolated was Haemophilus influenzae serotype b. This unusual infection was treated with repeated débridement and culture-guided antibiotics. There was no recurrence of infection at last followup 1 year after the initial surgery. Wound coverage was achieved with the use of a full-thickness skin graft after application of platelet-rich plasma and a dermal regeneration template. This resulted in a cosmetically acceptable appearance of the involved extremity for our patient.

Necrotizing fasciitis

Necrotizing fasciitis is a rare but life-threatening soft-tissue infection characterized by rapidly spreading inflammation and subsequent necrosis of the fascial planes and surrounding tissue. Infection typically follows trauma, although the inciting insult may be as minor as a scrape or an insect bite. Often caused by toxin-producing, virulent bacteria such as group A streptococcus and associated with severe systemic toxicity, necrotizing fasciitis is rapidly fatal unless diagnosed promptly and treated aggressively. Necrotizing fasciitis is often initially misdiagnosed as a more benign soft-tissue infection. The single most important variable influencing mortality is time to surgical débridement. Thus, a high degree of clinical suspicion is necessary to avert potentially disastrous consequences. Orthopaedic surgeons are often the first to evaluate patients with necrotizing fasciitis and as such must be aware of the presentation and management of this disease. Timely diagnosis, broad-spectrum antibiotic therapy, and aggressive surgical débridement of affected tissue are keys to the treatment of this serious, often life-threatening infection.

The use of artificial dermis (Integra) and topical negative pressure to achieve limb salvage following soft-tissue loss caused by meningococcal septicaemia

Meningococcal sepsis leading to purpura fulminans leaves survivors with extensive areas of skin and soft-tissue necrosis. Soft-tissue loss in the limbs may result in large areas of exposed bone, leaving a choice between free tissue transfer and amputation. We present a case of meningococcal sepsis where the entire medial and lateral surfaces of the tibiae were exposed with loss of anterior muscle compartments on each side. Faced with the possibility of bilateral above-knee amputation, these were instead covered using the dermal replacement Integra (Integra LifeSciences Corp.), in conjunction with an antimicrobial dressing, topical negative pressure dressing and subsequent skin grafting. This management decision achieved rapid wound closure avoiding amputation. Additional secondary reconstruction with microvascular free flaps was performed to preserve joint function.

Lotus petal flaps for scrotal reconstruction combined with Integra resurfacing of the penis and anterior abdominal wall following necrotising fasciitis

Necrotising fasciitis of the external genitalia following routine circumcision is uncommon. We describe reconstruction of the scrotum with local perforator flaps and a dermal regeneration template (Integra) to cover the penile shaft after debridement. Lotus petal flaps were originally designed to cover vulvo-vaginal defects, but in this instance integrated well with the remaining scrotal sac to produce a good volume neoscrotum for testicular cover. Integra creates an acceptable neodermis usually to cover areas of debrided full thickness burns. In this case, Integra adequately replaced the mobile dermal layer over Bucks fascia over the penis to create a pliable and cosmetically acceptable result with erectile capability.