Lessons Learned From Two Survivors of Greater Than 90% TBSA Full-Thickness Burn Injuries Using NovoSorb Biodegradable Temporizing Matrix™ and Autologous Skin Cell Suspension, RECELL™: A Case Series

Optimizing Outcomes in the Management of the Burned Hand

Burns of the hand are prevalent and must be managed aggressively in the acute phase to prevent deformity and disability. Proper early wound management, achieving durable soft tissue coverage, and appropriate positioning in the acute period offer substantial benefits to patients long-term. When contractures occur, secondary procedures are often indicated, and they range from laser therapy to local/regional flap coverage; rarely free flaps are used. Boutonniere deformities are common, and unfortunately, at times finger amputation renders the hand more functional than further efforts at reconstruction.

Benefits of Aerosolized, Point-of-care, Autologous Skin Cell Suspension (ASCS) for the Closure of Full-thickness Wounds From Thermal and Nonthermal Causes: Learning Curves From the First 50 Consecutive Cases at an Urban, Level 1 Trauma Center

OBJECTIVE

To determine the utility of Autologous Skin Cell Suspension (ASCS) in closing full-thickness (FT) defects from injury and infection.

BACKGROUND

Although ASCS has documented success in closing partial-thickness burns, far less is known about the efficacy of ASCS in FT defects.

METHODS

Fifty consecutive patients with FT defects (burn 17, necrotizing infection 13, crush 7, degloving 5, and other 8) underwent closure with the bilayer technique of 3:1 widely meshed, thin, split-thickness skin graft and 80:1 expanded ASCS. End points were limb salvage rate, donor site reduction, operative and hospital throughput, incidence of complications, and re-epithelialization by 4, 8, and 12 weeks.

RESULTS

Definitive wound closure was achieved in 76%, 94%, and 98% of patients, at 4, 8, and 12 weeks, respectively. Limb salvage occurred in 42/43 patients (10 upper and 33 lower extremities). The mean area grafted was 435 cm 2 ; donor site size was 212 cm 2 , representing a potential reduction of 50%. The mean surgical time was 71 minutes; the total operating room time was 124 minutes. The mean length of stay was 26.4 days; the time from grafting to discharge was 11.2 days. Four out of 50 patients (8%) required 6 reoperations for bleeding (1), breakdown (4), and amputation (1). Four out of 50 patients (8%) developed hypertrophic scarring, which responded to silicone sheeting (2) and laser resurfacing (2). The mean follow-up was 92.7 days.

CONCLUSIONS

When used for the closure of FT wounds, point-of-care ASCS is effective and safe. Benefits include rapid re-epithelialization, high rate of limb salvage, reduction of donor site size and morbidity, and low incidence of hypertrophic scarring.

Development of Early Abdominal Compartment Syndrome Leading to Emergent Decompressive Laparotomy in Full-Thickness Burn Injury

Burn injuries carry an increased risk of intra-abdominal hypertension and are an independent risk factor for abdominal compartment syndrome (ACS). ACS is most commonly due to large volume resuscitation. The added concern of ACS can complicate resuscitative efforts. Early monitoring for ACS (intra-abdominal pressure > 20 mm Hg with associated new-onset organ dysfunction) and performing prudent decompressive laparotomies are important factors to keep in mind when treating large surface area burn patients. This case report describes the hospitalization of a 60-year-old male who presented with 45% full-thickness (FT) total body surface area (TBSA) and inhalation injury. On arrival to the emergency department (ED), he had received a total of 6 L of intravenous lactate Ringers, and vasopressors were initiated due to hypotension. During the tertiary examination it was noted that there was increased difficulty ventilating the patient, and his abdomen was becoming increasingly distended and tense. His intra-abdominal pressure was measured in the ED and found to be elevated at 32 mm Hg. The findings were suggestive of ACS and a decompressive laparotomy was performed in the ED. Upon entering the abdominal cavity, the abdominal contents extruded through the incision and diffuse venous congestion and gastric distention were noted. Items commonly found in operating rooms (Top-Draper® warmer drape, Kerlix rolls, Jackson-Pratt suction drains, and 3M® Ioban sterile antimicrobial incise drape) were utilized to maintain an open abdomen where abdominal contents could easily be observed and to prevent delay in performing a decompressive laparotomy. Here we describe a patient with 45% FT TBSA and inhalation injuries requiring an emergent decompressive laparotomy for ACS after only 6 L of lactate Ringers were administered. This highlights the importance of early monitoring for ACS and the ease of performing a decompressive laparotomy with commonly found items in the ED and operating rooms.

Biodegradable polyurethane scaffolds in regenerative medicine: Clinical translation review

Early explorations of tissue engineering and regenerative medicine concepts commonly utilized simple polyesters such as polyglycolide, polylactide, and their copolymers as scaffolds. These biomaterials were deemed clinically acceptable, readily accessible, and provided processability and a generally known biological response. With experience and refinement of approaches, greater control of material properties and integrated bioactivity has received emphasis and a broadened palette of synthetic biomaterials has been employed. Biodegradable polyurethanes (PUs) have emerged as an attractive option for synthetic scaffolds in a variety of tissue applications because of their flexibility in molecular design and ability to fulfill mechanical property objectives, particularly in soft tissue applications. Biodegradable PUs are highly customizable based on their composition and processability to impart tailored mechanical and degradation behavior. Additionally, bioactive agents can be readily incorporated into these scaffolds to drive a desired biological response. Enthusiasm for biodegradable PU scaffolds has soared in recent years, leading to rapid growth in the literature documenting novel PU chemistries, scaffold designs, mechanical properties, and aspects of biocompatibility. Despite the enthusiasm in the field, there are still few examples of biodegradable PU scaffolds that have achieved regulatory approval and routine clinical use. However, there is a growing literature where biodegradable PU scaffolds are being specifically developed for a wide range of pathologies and where relevant pre-clinical models are being employed. The purpose of this review is first to highlight examples of clinically used biodegradable PU scaffolds, and then to summarize the growing body of reports on pre-clinical applications of biodegradable PU scaffolds.

The Current Challenges on Spray-Based Cell Delivery to the Skin Wounds

Cell delivery through spray instruments is a promising and effective method in tissue engineering and regenerative medicine. It is used for treating different acute and chronic wounds, including burns with different etiologies, chronic diabetic or venous wounds, postcancer surgery, and hypopigmentation disorders. Cell spray can decrease the needed donor site area compared with conventional autologous skin grafting. Keratinocytes, fibroblasts, melanocytes, and mesenchymal stem cells are promising cell sources for cell spray procedures. Different spray instruments are designed and utilized to deliver the cells to the intended skin area. In an efficient spray instrument, cell viability and wound coverage are two determining parameters influenced by various physical and biological factors such as air pressure, spraying distance, viscosity of suspension, stiffness of the wound surface, and velocity of impact. Besides, to improve cell delivery by spray instruments, some matrices and growth factors can be added to cell suspensions. This review focuses on the different types of cells and spray instruments used in cell delivery procedures. It also discusses physical and biological parameters associated with cell viability and wound coverage in spray instruments. Moreover, the recent advances in codelivery of cells with biological glues and growth factors, as well as clinical translation of cell spraying, have been reviewed. Impact statement Skin wounds are a group of prevalent injuries that can lead to life-threatening complexities. As a focus of interest, stem cell therapy and spray-based cell delivery have effectively decreased associated morbidity and mortality. This review summarizes a broad scope of recent evidence related to spray-based cell therapy, instruments, and approaches adopted to make the process more efficient in treating skin wounds. An overview including utilized cell types, clinical cases, and current challenges is also provided.