Achilles Tendon Augmented Repair Using Human Acellular Dermal Matrix: A Case Series

Acellular dermal matrices in reconstructive surgery; history, current implications and future perspectives for surgeons

Large-scale defects of body in the reconstructive surgical practice, and the helplessness of their repair with autologous tissues, have been an important factor in the development of artificial biological products for the temporary, definitive, or staged repair of these defects. A major advance in the field of plastic and other reconstructive surgery in this regard has been the introduction and successful use of acellular dermal matrices (ADMs). In recent years, not only the type of tissue from which ADMs are produced, product range, diversity and areas of use have increased, but their use in reconstructive fields, especially in post oncologic breast surgery, has become highly regarded and this has favored ADMs to be a potential cornerstone in specific and well-defined surgical fields in future. It is essential that reconstructive surgeons become familiar with some of the ADM's as well as the advantages and limitations to their use. This review not only provides basic science and clinical evidence of the current use of ADMs in wide range of surgical fields but also targets to keep them as an important backdrop in the armamentarium of reconstructive surgeons. Brief considerations of possible future directions for ADMs are also conducted in the end.

Surgical Treatment of Insertional Achilles Tendinopathy Augmented With Human Acellular Dermal Matrix: A Retrospective Case Series

Background

Insertional Achilles tendinopathy (IAT) is often surgically treated with Achilles tendon partial or total detachment, debridement and repair of the Achilles tendon, excision of retrocalcaneal exostosis, and suture anchor reattachment. To date, there is no report that examines the use of acellular dermal matrix (ADM) augmentation in this procedure without the use of suture anchor reattachment.

Methods

Thirty-two female and 10 male patients (mean age 52 years) with IAT underwent surgical treatment including partial detachment of the Achilles tendon, excision of the retrocalcaneal exostosis, debridement and repair of the Achilles tendon, and augmentation with human acellular dermal matrix allograft. Outcomes measured were the visual analog scale (VAS) score, time to weightbearing, major and minor complications.

Results

Forty-two patients were followed for a mean of 20.8 months. The VAS score improved from a mean of 5.1 to 1.9 at final follow-up. The mean time to weightbearing was 4.4 weeks. Eleven patients (26.2%) experienced complications. One patient (2.4%) suffered a rupture of the Achilles in the early postoperative period. Three patients (7.1%) had delayed wound healing, with 1 (2.4%) requiring surgical debridement. Two (4.8%) experienced continued pain requiring further surgical treatment.

Conclusion

This protocol for surgical treatment of IAT with the use of human ADM allograft augmentation resulted in improved VAS scores and was associated with a low risk of postoperative infection without a prolonged nonweightbearing period.

Level of Evidence

Level IV, retrospective case series.

Clinical study on the role of platelet-rich plasma in human acellular dermal matrix with razor autologous skin graft repair of giant congenital pigmented nevus in children

BACKGROUND

NA OBJECTIVE: Evaluate the safety and feasibility of platelet-rich plasma (PRP) in the treatment of giant congenital melanocytic nevi (GCMN) in children with human acellular dermal matrix (HADM) transplantation.

PATIENTS AND METHODS

A total of 22 children with GCMN were included in the study. They were divided into an experimental and a control group. The experimental group used the method of HADM with Razor Autologous Skin Graft combined with PRP to repair skin and soft tissue defects after giant nevus resection (Group A, n = 11). The control group was treated with HADM with Razor Autologous Skin Graft (Group B, n = 11) only. To compare the survival rate of skin grafts, we used the Vancouver Scar Scale (VSS) for the postoperative skin graft area and the Patient and Observer Scar Assessment Scale (POSAS) to compare the two groups of patients.

RESULTS

There was no statistically significant difference in age, gender, location of giant nevi, and pathological classification between Group A and Group (P > 0.05). The survival rate of skin grafting and the VSS and POSAS scores of scar tissue in group A were superior to those of group B (P < 0.05).

CONCLUSIONS

PRP has improved the survival rate of composite skin grafting in children with GCMN, and long-term satisfactory prognosis of scar healing. Therefore, we consider this treatment method a valuable contribution to clinical practice.

One Step Double Augmentation with Human Dermis Allograft and Homologous PRP in Misdiagnosed and or Chronic Achilles Tendon Ruptures

OBJECTIVE

Misdiagnosed/chronic Achilles tendon injuries are rare and disabling for patients. The surgical treatment of these rare injuries aims to ensure the tendon heals mechanically and biologically. This is the prerequisite for a good clinical and functional outcome and reduces recurrences. The main aim of the study is to present a surgical technique that has proven to be original, reproducible, and capable of guaranteeing solid tendon repair and optimal tissue regeneration.

METHODS

We treated five patients, four males and one female, with the one-step double augmentation technique. All patients of this study complained of pain, but above all severe functional limitation that Achilles tendon injury had been causing for more than a month. In this study, we widely described the surgical technique, original and not found in the literature, which provides a biological graft (allograft of decellularized dermis) and homologous, thrombin-activated, platelet-rich plasma (H-PRP) in a single step. Surgical approach, always used by the first author, respected predefined steps: careful dissection and preparation of the peritendinous tissues from suture to the end of the procedure, tenorrhaphy, and augmentation with allopatch to obtain a mechanically effective repair to avoid recurrences, and finally "biological" augmentation with a unit of homologous, thrombin activated, PRP. We offered to all patients a regenerative rehabilitation program post-operatively.

RESULTS

All patients were evaluated clinically (functional clinical tests and questionnaires) and instrumentally (elastic-sonography and perfusion MRI). The obtained results have been evaluated at a minimum follow-up of 18 months and a maximum of 24 months. In all patients pain was resolved, and district function and kinetic chains improved with resumption of daily activities, work, and sports.

CONCLUSION

The present study confirmed the regenerative potential of decellularized dermis allograft and PRP (homologous and thrombin-activated). The same approach can also be exploited in cases of severe tendon destructuring and limited "intrinsic" regenerative potential at any age. The proposed one-step surgical technique of a double augmentation therefore appears useful, safe, reproducible, and applicable in all chronic tendon lesions with low regenerative potential.

Comparative proteomic analysis of regenerative acellular matrices: The effects of tissue source and processing method

Acellular tissue matrices are used in regenerative medicine from weak tissue re-enforcement to cosmetic augmentation. However, proteomic signatures leading to different clinical outcomes among matrices are not well understood. In an attempt to investigate the effects of tissue source and processing method, we examined by liquid chromatography tandem mass spectrometry (LC-MS/MS) the proteomic profiles of 12 regulatory agency-approved acellular matrices (AlloMax, AlloDerm, CollaMend, Heal-All, JayyaLife, ReGen, Renov, Strattice, SurgiMend, Surgisis, UniTrump and Vidasis). The compositions of acellular matrices varied greatly with the number of identified proteins ranging from 7 to 106. The content of individual proteins was between 0.0001% and 95.8% according to their abundances measured by the M/Z signal intensities. Most acellular matrices still contained numerous cellular proteins. AlloMax, AlloDerm, ReGen, Strattice, SurgiMend and Surgisis retained necessary structural and functional proteins to form the extracellular protein-protein interaction networks for cell adhesion, proliferation and tissue regeneration, whereas CollaMend, Heal-All, JayyaLife, Renov, UniTrump and Vidasis had only retained certain structural collagens. Principal component analysis showed that proteomic variations among acellular matrices were largely attributed to tissue source and processing method. Differences in proteomic profiles among acellular matrices offers insights into molecular interpretation for different clinical outcomes, and can serve as useful references for rational design of regenerative bio-scaffolds.

Lower Extremity Orthopedic Augmentation Utilizing a Synthetic Hybrid-Scale Fiber Matrix

Introduction Lower extremity injuries represent about 15% of all emergency room visits in the United States, with ankle injuries accounting for 20% of these. Surgical site infections resulting from ankle reconstructive surgery can result in severe complications, including amputation. Depending on the procedure performed, surgical site infections of ankle reconstructive surgery can occur at a rate as high as 14%. A synthetic hybrid-scale fiber matrix with an engineered design resembling a native human extracellular matrix could be utilized to augment these difficult surgical procedures. Materials and methods A retrospective review of 10 patients who underwent orthopedic reconstructive surgeries of lower extremity injuries that were augmented with the synthetic hybrid-scale fiber matrix between October 2021 and February 2022 was conducted. Results Injuries included Achilles ruptures, bimalleolar and trimalleolar ankle fractures, ankle arthrodesis, and injuries of various other etiologies. All surgical wounds achieved complete closure and patients went on to fully recover. The average time to wound closure was 12.6 days after an average of 1.2 applications of the synthetic hybrid-scale fiber matrix. Post-reconstruction, two patients went on to have complications unrelated to the synthetic hybrid-scale fiber matrix, which then went on to heal uneventfully. Conclusions The positive results seen with the retrospective case series indicated that the synthetic hybrid-scale fiber matrix can promote healing and should be considered as an option in at-risk lower extremity reconstructive procedures.

Development of a full-thickness acellular dermal graft from human skin: Case report of first patient rotator cuff patch augmentation repair

The processing and initial testing of a new human tissue preparation is described. Full-thickness Acellular Dermal Matrix (ftADM) is the extracellular matrix (ECM) obtained by decellularization of full-thickness human skin from cadaveric donors. The safety, stability and usability of the graft are discussed with respect to the results of the residual cellular content, maintenance of ECM components, and biomechanical properties. Quantitative and qualitative analysis of the ECM demonstrated the absence of cell debris, while the native structure of human dermis was maintained. Biomechanical testing showed stiffness values comparable to other commercial products used for tendon reinforcement, suggesting that our ftADM could be successfully used not only in soft tissue regeneration surgeries, but also in tendon reinforcement. First case of ftADM in rotator cuff augmentation is described. Technical management of the patch during surgery and clinical outcomes are discussed.

Acellular dermal matrix in reconstructive surgery: Applications, benefits, and cost

Modern tissue engineering has made substantial advancements that have revolutionized plastic surgery. Acellular dermal matrix (ADM) is an example that has gained considerable attention recently. ADM can be made from humans, bovines, or porcine tissues. ADM acts as a scaffold that incorporates into the recipient tissue. It is gradually infiltrated by fibroblasts and vascularized. Fortunately, many techniques have been used to remove cellular and antigenic components from ADM to minimize immune system rejection. ADM is made of collagen, fibronectin, elastin, laminin, glycosaminoglycans, and hyaluronic acid. It is used in critical wounds (e.g., diabetic wounds) to protect soft tissue and accelerate wound healing. It is also used in implant-based breast reconstruction surgery to improve aesthetic outcomes and reduce capsule contracture risk. ADM has also gained attention in abdominal and chest wall defects. Some studies have shown that ADM is associated with less erosion and infection in abdominal hernias than synthetic meshes. However, its higher cost prevents it from being commonly used in hernia repair. Also, using ADM in tendon repair (e.g., Achilles tendon) has been associated with increased stability and reduced rejection rate. Despite its advantages, ADM might result in complications such as hematoma, seroma, necrosis, and infection. Moreover, ADM is expensive, making it an unsuitable option for many patients. Finally, the literature on ADM is insufficient, and more research on the results of ADM usage in surgeries is needed. This article aims to review the literature regarding the application, Benefits, and costs of ADM in reconstructive surgery.

Reconstruction of chronic distal biceps ruptures by dermal matrix

OBJECTIVES

Distal biceps tear is uncommon, with well-recognized risk factors and typical clinical presentation. Delays in surgical treatment lead to several challenges, such as tendon retraction and tendon degeneration. We present a surgical technique using a sterilized acellular dermal matrix, which provides a solution for a challenging pathology.

MATERIAL AND METHODS

We present a detailed surgical technique of distal biceps reconstruction with acellular dermal matrix, performed in 4 patients, with an average time to diagnosis of 36 days (range, 28-45 days). Demographics, clinical data, range of motion and subjective satisfaction were collected.

RESULTS

At a mean follow-up of 18 months, all 4 patients showed full range of motion and strength, complete recovery and previous work resumed without pain. No complications appeared during this time.

CONCLUSIONS

Delayed distal biceps tear reconstruction by acellular dermal matrix showed promising results. Meticulous surgical technique using this matrix provided excellent reconstruction, with very solid anatomical repair and exceptionally good fixation, good clinical outcome and satisfied patients.

LEVEL OF EVIDENCE

IV.

Peroneal Stabilization Via Tightening of the Peroneal Tendon Sheath

Peroneal subluxation is a rare but debilitating pathology that can be the result of a superior peroneal retinaculum tear or intrasheath laxity. On clinical examination of both cases, the pathology is observed when the ankle is circumducted in eversion and dorsiflexion. With a superior peroneal retinaculum tear, the tendons dislocate from the peroneal groove, whereas with intrasheath laxity the tendons remain in the groove. In the present case series, peroneal stabilization was performed for both superior peroneal retinaculum tear and intrasheath laxity. With our technique, the fibro-osseous connections of the peroneal tendon sheath are detached from the distal one third of the fibula. Drill holes are made through the fibula for suture to be passed through and the peroneal tendon sheath is reattached to the fibula through horizontal mattress sutures via pants over vest technique to restore tension to the sheath. A total of 5 patients underwent peroneal stabilization, 100% (5/5) of which had preoperative pain with palpation along the peroneal tendons and a palpable click with range of motion of the ankle joint. Postoperatively, 100% (5/5) of the patients were fully weight-bearing, compared to 60% (3/5) preoperatively. No patients had residual subluxation of the peroneal tendons postoperatively or a need for revisional surgery. Residual peroneal tendonitis was present in 20% (1/5) of patients and sural neuritis occurred in 20% (1/5) of patients. The peroneal tendons are physiologically tightened within the peroneal tendon sheath to mitigate the pathologic subluxation, without sacrificing tendons for transfer or using allograft material.Clinical Level of Evidence: Therapeutic, Case Series, Level 4.

Microfragmented Adipose Tissue (M-FATS) for Improved Healing of Surgically Repaired Achilles Tendon Tears: A Preliminary Study

INTRODUCTION

Tendon healing is a complicated process that results in inferior structural and functional properties when compared with healthy tendon; the purpose of this study was to assess the effects of the adjunct of microfragmented adipose tissue (M-FATS) after the suture of a series of Achilles tendons.

METHODS

After complete Achilles tendon tear, 8 patients underwent open suture repair in conjunction with perilesional application of a preparation of M-FATS rich in mesenchymal stem cells. Results were compared with a similar group of patients treated with conventional open suture. Outcomes were evaluated based on range of motion, functional recovery, and complications according to the American Orthopedic Foot and Ankle Society (AOFAS) score and Foot and Ankle Disability Index (FADI). Achilles tendons were examined by ultrasound (US) at 3 months.

RESULTS

The AOFAS and FADI scores showed no differences between the 2 groups. US evaluation showed quicker tendon remodeling in the M-FATS group. Adverse events were not documented for both procedures.

CONCLUSIONS

The combined application of derived M-FATS for tendon rupture is safe and presents new possibilities for enhanced healing.

LEVELS OF EVIDENCE

Level IIIb: Case control study.

Prevention of postoperative adhesions after flexor tendon repair with acellular dermal matrix in Zones III, IV, and V of the hand: A randomized controlled (CONSORT-compliant) trial

BACKGROUND

Various techniques have been attempted for preventing postoperative flexor tendon adhesion, such as modification of suture technique, pharmacological agents, and mechanical barriers. However, there is no evidence of the efficacy of these methods in clinical settings. In this study, we present the long-term outcomes of a randomized prospective study in which acellular dermal matrix (ADM) was used to prevent postoperative adhesions after tendon injury in the hand.

METHODS

From January 2017 to January 2020, all patients with an acute single flexor tendon injury in hand Zones III, IV, or V were candidates. A single-digit, total tendon rupture repaired within 48 hours, from the index finger to the little finger, was included in the study. Patients were randomly allocated to either a control or ADM group. Complications and the range of movements were recorded. Functional outcomes and a patient satisfaction questionnaire were evaluated after 12 months following the tendon repair surgery. The present study is adhered to the CONSORT guidelines.

RESULTS

A total of 25 patients was enrolled in the study: 13 patients in the ADM group and 12 in the control group. According to Buck-Gramcko II criteria, the postoperative functional outcome score was 14.38 ± 1.71 in the ADM group and 13.08 ± 1.82 in the control group (P value = .0485). Patient satisfaction was recorded at 8.38 ± 1.44 in the ADM group and 7.08 ± 1.58 in the control group (P value = .0309), a significant difference. There were no differences in complications between the 2 groups.

CONCLUSION

The beneficial effects of ADM after tendon repair were confirmed by improved postoperative functional outcome at flexor Zones III, IV, and V, preventing peritendinous adhesions and acting effectively as an anti-adhesive barrier.

Clinical applications of acellular dermal matrices: A review

INTRODUCTION

The extracellular matrix (ECM) plays an integral role in wound healing. It provides both structure and growth factors that allow for the organised cell proliferation. Large or complex tissue defects may compromise host ECM, creating an environment that is unfavourable for the recovery of anatomical function and appearance. Acellular dermal matrices (ADMs) have been developed from a variety of sources, including human (HADM), porcine (PADM) and bovine (BADM), with multiple different processing protocols. The objective of this report is to provide an overview of current literature assessing the clinical utility of ADMs across a broad spectrum of applications.

METHODS

PubMed, MEDLINE, EMBASE, Scopus, Cochrane and Web of Science were searched using keywords 'acellular dermal matrix', 'acellular dermal matrices' and brand names for commercially available ADMs. Our search was limited to English language articles published from 1999 to 2020 and focused on clinical data.

RESULTS

A total of 2443 records underwent screening. After removing non-clinical studies and correspondence, 222 were assessed for eligibility. Of these, 170 were included in our synthesis of the literature. While the earliest ADMs were used in severe burn injuries, usage has expanded to a number of surgical subspecialties and procedures, including orthopaedic surgery (e.g. tendon and ligament reconstructions), otolaryngology, oral surgery (e.g. treating gingival recession), abdominal wall surgery (e.g. hernia repair), plastic surgery (e.g. breast reconstruction and penile augmentation), and chronic wounds (e.g. diabetic ulcers).

CONCLUSION

Our understanding of ADM's clinical utility continues to evolve. More research is needed to determine which ADM has the best outcomes for each clinical scenario.

LAY SUMMARY

Large or complex wounds present unique reconstructive and healing challenges. In normal healing, the extracellular matrix (ECM) provides both structural and growth factors that allow tissue to regenerate in an organised fashion to close the wound. In difficult or large soft-tissue defects, however, the ECM is often compromised. Acellular dermal matrix (ADM) products have been developed to mimic the benefits of host ECM, allowing for improved outcomes in a variety of clinical scenarios. This review summarises the current clinical evidence regarding commercially available ADMs in a wide variety of clinical contexts.

Reconstruction of Achilles region defects: A single-centre experience

BACKGROUND

Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to the use of free flaps. The aim of this study was to discuss reconstruction options and to help the surgeon to select reliable approach to achieve favourable outcomes.

METHOD

In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single centre.

RESULTS

Reconstructions were performed with secondary healing (n = 2), negative pressure wound therapy and skin grafting (n = 2), free flaps (n = 6) and local and distant flaps (n = 4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting.

CONCLUSION

Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. The use of special digital imaging techniques facilitates flap surgery and helps minimise the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Super-thin free flaps offer a distinct advantage in skillful hands. The use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favourable outcomes.

Fast protocol for the processing of split-thickness skin into decellularized human dermal matrix

BACKGROUND

Dermal scaffolds for tissue regeneration are nowadays an effective alternative in not only wound healing surgeries but also breast reconstruction, abdominal wall reconstruction and tendon reinforcement. The present study describes the development of a decellularization protocol applied to human split-thickness skin from cadaveric donors to obtain dermal matrix using an easy and quick procedure.

METHODS

Complete split-thickness donor was decellularized through the combination of hypertonic and enzymatic methods. To evaluate the absence of epidermis and dermal cells, and ensure the integrity of the extracellular matrix (ECM) structure, histological analysis was performed. Residual genetic content and ECM biomolecules (collagen, elastin, and glycosaminoglycan) were quantified and tensile strength was tested to measure the effect of the decellularization technique on the mechanical properties of the tissue.

RESULTS

Biomolecules quantification, residual genetic content (below 50 ng/mg dry tissue) and histological structure assessment showed the efficacy of the decellularization process and the preservation of the ECM. The biomechanical tests confirmed the preservation of native properties in the acellular tissue.

CONCLUSIONS

The acellular dermal matrix obtained from whole split-thickness skin donor with the newly developed decellualrization protocol, maintains the desired biomechanical and structural properties and represents a viable treatment option for patients.

A Suture Anchor-Based Repair Plus Reconstruction Using Acellular Human Dermal Allograft for Recurrent Sports-Related Patellar Tendon Rupture

Recurrent traumatic patellar tendon rupture following early repair of a primary rupture is exceedingly rare; there is little technical literature on how to manage this potentially devastating injury. We describe here a suture anchor-based technique for revision repair augmented with an extensor reconstruction using acellular human dermal allograft.

The Role of Scaffolds in Tendon Tissue Engineering

Tendons are unique forms of connective tissue aiming to transmit the mechanical force of muscle contraction to the bones. Tendon injury may be due to direct trauma or might be secondary to overuse injury and age-related degeneration, leading to inflammation, weakening and subsequent rupture. Current traditional treatment strategies focus on pain relief, reduction of the inflammation and functional restoration. Tendon repair surgery can be performed in people with tendon injuries to restore the tendon's function, with re-rupture being the main potential complication. Novel therapeutic approaches that address the underlying pathology of the disease is warranted. Scaffolds represent a promising solution to the challenges associated with tendon tissue engineering. The ideal scaffold for tendon tissue engineering needs to exhibit physiologically relevant mechanical properties and to facilitate functional graft integration by promoting the regeneration of the native tissue.

Pulley Release and Reconstruction With Acellular Dermal Matrix After Zone 2 Flexor Tendon Injury

Zone 2 flexor tendon repair has been historically associated with poor outcomes, mainly due to stiffness. In an effort to minimize adhesions, accommodate flexor digitorum profundus and flexor digitorum superficialis bulk, and prevent bowstringing, we have developed a novel approach to flexor tendon repair that relies on aggressive flexor tendon pulley release and pulley reconstruction with acellular dermal matrix. This technique leverages the antiadhesive properties and high tensile strength of acellular dermal matrix to maximize gliding and prevent bowstringing. Here we describe the details of our technique and illustrate a case where this technique was employed.

Recent development and biomedical applications of decellularized extracellular matrix biomaterials

Decellularized matrix (dECM) is isolated extracellular matrix of tissues from its original inhabiting cells, which has emerged as a promising natural biomaterial for tissue engineering, aiming at support, replacement or regeneration of damaged tissues. The dECM can be easily obtained from tissues/organs of various species by adequate decellularization methods, and mimics the structure and composition of the native extracellular matrix, providing a favorable cellular environment. In this review, we summarize the recent developments in the preparation of dECM materials, including decellularization, crosslinking and sterilization. Also, we cover the advances in the utilization of dECM biomaterials in regeneration medicine in pre-clinic and clinical trials. Moreover, we highlight those emerging medical benefits of dECM beyond tissue engineering, such as cell transplantation, in vitro/in vivo model and therapeutic cues delivery. With the advances in the preparation and broader application, the dECM biomaterials could become the gold scaffold and pharmaceutical excipients in medical sciences.