The Use of Acellular Dermal Matrix in Release of Burn Contracture Scars in the Hand:

Management of Scar Contractures of the Hand-Our Therapeutic Strategy and Challenges

The essence of treating scar contractures lies in covering the skin deficit after releasing the contractures, typically using flaps or skin grafts. However, the specific characteristics of scar contractures, such as their location, shape, and size, vary among patients, which makes surgical planning challenging. To achieve excellent outcomes in the treatment of scar contractures, we have developed a dimensional classification system for these contractures. This system categorizes them into four types: type 1 (superficial linear), type 2-d (deep linear), type 2-s (planar scar contractures confined to the superficial layer), and type 3 (planar scar contractures that reach the deep layer, i.e., three-dimensional scar contractures). Additionally, three factors should be considered when determining surgical approaches: the size of the defect, the availability of healthy skin around the defect, and the blood circulation in the defect bed. Type 1 and type 2-d are linear scars; thus, the scar is excised and sutured in a straight line, and the contracture is released using z-plasty or its modified methods. For type 2-s, after releasing the scar contracture band, local flaps are indicated for small defects, pedicled perforator flaps for medium defects, and free flaps and distant flaps for large defects. Type 2-s has good blood circulation in the defect bed, so full-thickness skin grafting is also a suitable option regardless of the defect's size. In type 3, releasing the deep scar contracture will expose important structures with poor blood circulation, such as tendons, joints, and bones. Thus, a surgical plan using flaps, rather than skin grafts, is recommended. A severity classification and treatment strategy for scar contractures have not yet been established. By objectively classifying and quantifying scar contractures, we believe that better treatment outcomes can be achieved.

Basic and clinical study of the effect of exogenous hyaluronic acid on the quality of acellular dermal matrix combined with thin intermediate split thickness skin graft

BACKGROUND

To promote wound recovery in the recipient region, we studied the impact of exogenous hyaluronic acid (HA) on acellular dermal matrix (ADM) paired with thin intermediate-thickness skin transplant.

METHODS

This study contains animal and clinical experiments. 50 Japanese big ear rabbits were separated into HA1, HA2, PADM, TS, and NS groups. Clinical part included 50 scar patients dividing into 5 groups (TS + HA + ADM 1, TS + ADM2, TS, TS + ADM and normal skin (NS)).

RESULTS

In the animal trial, after 56 days, the grafts contracted least in the HA2 group; HA2 had the highest microvascular density (MVD), HA concentration, and collagen I and III expression. In clinical work, ADM > HA + ADM2 > HA + ADM1 > TS > NS; Type I and III collagen: HA + ADM1 and HA + ADM2 were higher than ADM; HA content: TS > HA + ADM1 > HA + ADM 2 > ADM.

CONCLUSIONS

ADM, exogenous hyaluronic acid mixed with thin skin autograft has better biomechanical qualities and therapeutic impact than acellular dermal matrix alone, and the reconstructive result is near to self-thick skin autograft in all indexes.

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.

Concepts in soft-tissue reconstruction of the contracted hand and upper extremity after burn injury

Burns and their subsequent contracture result in devastating functional and aesthetic consequences which disproportionally affect the upper extremity. By focusing on reconstruction with analogous tissue and utilizing the reconstructive elevator, function can be restored concomitantly with form and aesthetic appearance. General concepts for soft-tissue reconstruction after burn contracture are presented for different sub-units and joints.

Clinical Applications of Allograft Skin in Burn Care

Allograft skin has been widely used for wound management in burn centers. Functional as biologic dressing, it can not only provide ideal temporary wound coverage in extensive burns when autograft is not immediately available but also prepare the wound bed for definitive autografting. In this article, the up-to-date clinical application of allograft in burn care was reviewed, including coverage of extensive burn wounds, combined use with meshed autograft, template for delayed application of cultured epidermal autografts, and the use of human acellular dermal matrix. Although it has potential disadvantages of rejection and disease transmission, allograft skin remains a workhorse in treatment of severe burn wounds.

Acellular dermal matrix in skin wound healing in rabbits - histological and histomorphometric analyses

OBJECTIVES

To analyze the histology and histomorphometry of healing associated with acellular dermal matrix in skin wounds in rabbits.

METHODS

Twelve male rabbits were divided into two groups: the control group (CG) and the matrix group (MG). Three skin wounds with a total area of 20 × 20 mm were created on the dorsal region of each animal. Photographic records of the lesions taken over a 21-day period and use of the ImageJ program allowed calculation of the wound contraction rate. The lesions were biopsied on days 3, 14 and 21 for histomorphometric analysis to define the thicknesses of the dermis and epidermis (hematoxylin-eosin) and calculate the densities of type I and type III collagen (picrosirius).

RESULTS

No significant difference in the healing rate was found between the groups (p>0.05). The MG presented greater epidermal thickness on day 3 (p<0.05) and on days 14 and 21 (p<0.001). The MG presented greater dermal thickness throughout the study period (p<0.05). The type I collagen density was higher in the MG throughout the study period (p<0.05), and the type III collagen density was higher in the MG on days 3 and 14 (p<0.05) and on day 21 (p<0.001).

CONCLUSION

The use of acellular dermal matrix increased the thickness of the dermal and epidermal layers and the amount of type I and III collagen during skin wound healing and did not alter the rate of wound contraction.

Recent strategic approach in postburn extremity scars and contractures

This study aims to present the outcomes from current alternative treatment modalities combined with the conventional techniques used in the treatment of burn contractures. Twenty-nine patients were included in the study. Patients were divided into three groups according to the severity of contractures: 1- mild, 2- moderate, and 3- severe. Skin defects that occurred following the incision and scar contracture release were closed with a collagen-elastin acellular dermal matrix (ADM). The split-thickness skin graft was evenly placed on the ADM and fixed with absorbable sutures. The grafts were closed with NPWT (negative pressure wound therapy system) dressings. In platelet-rich plasma (PRP) mild cases as well as moderate and severe PRP cases, stem cell and fat injection were applied. PRP injection was applied to the scar base before the contracture; fat injection and stem cells were applied at the 3rd and 6th months. Preoperative and postoperative range of motion (ROM), Patient and Observer Scars Evaluation Scale (POSAS), and histopathological scores were evaluated. There was a statistically significant decrease in postoperative POSAS scores (p < .05) and a significant increase in the ROM score (p < .05). Histopathological examination revealed an increased postoperative collagen accumulation and organization, increased vascularization, decreased scar tissue thickness and increased subcutaneous tissue thickness. There was no difference in treatment outcomes between the groups.Based on the current findings, we conclude that ADM, stem cell-rich fat grafting, and PRP therapies combined with conventional methods could satisfactorily improve functional outcomes in the repair of burn contractures.

What happens to an acellular scar matrix after implantation in vivo? A histological and related molecular biology study

It has been established that scar acellular matrices (AMs), which allow cell proliferation, have similar characteristics. The aim of this study was to investigate the repair effect of scar AMs on animals, thus providing a reference for clinical application. Selected mature and immature scar AMs were implanted into animals, and then a negative control group was set for comparison. The effect of scar AMs on wound healing was observed through tissue staining, RT-qPCR, and immunohistochemistry. The materials showed milder inflammation and faster extracellular matrix (ECM) deposition than the negative control group. The ECM deposition and new vessels increased over time. However, the arrangement of ECM in mature scar AM was more regular than in immature scar AM and the negative control group, and more new vessels grew in the mature scar AM group than in the immature scar AM group and negative control group over the same period. The transforming growth factor-β level was elevated at one month, two months, and six months. COLA1 and vimentin levels all peaked at six months. Matrix metalloproteinase and TIMP1 were also elevated at different months. Collectively, scar AMs can effectively promote wound healing and vascularization. Mature scar AMs have a better regeneration effect.

Adipose-Derived Stromal Cells Seeded on Integra® Dermal Regeneration Template Improve Post-Burn Wound Reconstruction

Fibrosis of burn-related wounds remains an unresolved clinical issue that leads to patient disability. The aim of this study was to assess the efficacy of the transplantation of adipose-derived stromal cells seeded onto a collagen-based matrix in the reconstruction of burn-related scars. Here, we characterized an in vitro interaction between adipose-derived stromal cells and a collagen-based matrix, Integra^®DRT. Our results show that transcription of pro-angiogenic, remodeling, and immunomodulatory factors was more significant in adipose-derived stromal cells than in fibroblasts. Transcription of metalloproteinases 2 and 9 is positively correlated with the collagenolytic activity of the adipose-derived stromal cells seeded onto Integra^®DRT. The increase in the enzymatic activity corresponds to the decrease in the elasticity of the whole construct. Finally, we validated the treatment of a post-excision wound using adipose-derived stromal cells and an Integra^®DRT construct in a 25-year-old woman suffering from burn-related scars. Scarless healing was observed in the area treated by adipose-derived stromal cells and the Integra^®DRT construct but not in the reference area where Integra^®DRT was applied without cells. This clinical observation may be explained by in vitro findings: Enhanced transcription of the vascular endothelial growth factor as well as remodeling of the collagen-based matrix decreased mechanical stress. Our experimental treatment demonstrated that the adipose-derived stromal cells seeded onto Integra^®DRT exhibit valuable properties that may improve post-excision wound healing and facilitate skin regeneration without scars.

Comparison of xenogeneic acellular dermal matrix and skin grafts in reconstruction of postoperative defects of hypopharyngeal cancer: A retrospective cohort study

Successful reconstruction after tumor resection facilitates rapid recovery and retention of good quality of life, and this is important for a successful operation. This study aimed to analyze and compare the application and efficacy of xenogeneic acellular dermal matrix (xeno-ADM) and abdominal skin graft in hypopharynx reconstruction.This is a retrospective cohort study that included 25 patients with posterior hypopharyngeal wall cancer who underwent partial hypopharyngectomy with laryngeal preservation. The patients were divided into 2 groups according to the repair materials used. Eleven patients were treated with xeno-ADM, and 14 patients with abdominal skin grafts for repairing hypopharyngeal mucosal defects. The intraoperative data, postoperative recovery time of eating function, graft contraction, infection and pharyngeal fistula rate, and 1-year survival rate of the 2 groups were analyzed and compared.Compared with skin grafts group (23.1 ± 5.8 days), the recovery time of eating function in xeno-ADM group was shorter (17.3 ± 6.4 days), (P = .026). Also the number of postoperative hospitalization days were less in the xeno-ADM group (18.5 ± 6.7 days) than in the skin grafts group (24.1 ± 5.6 days) (P = .035). Besides, no significant differences were observed in other comparisons between the 2 groups. Also no obvious rejection and severe graft contraction were observed in both the groups. All patients were successfully decannulated.Both xeno-ADM and abdominal skin grafts demonstrated good effects in the reconstruction of hypopharynx, but the recovery time of eating function in patients with xeno-ADM was faster, which may be due to rapid epithelialization. In addition, it avoids trauma of donor sites.

A New Human-Derived Acellular Dermal Matrix for 1-Stage Coverage of Exposed Tendons in the Foot

The closure of wounds associated with soft tissue defects is surgically challenging, frequently requiring extensive plastic surgery and free flaps. The combination of ADM and STSG is an innovative method used to cover such wounds. The human-derived ADMs (H-ADMs) are the most described in the literature but according to European legislations, Companies H-ADMs outside the EC are not allowed to commercialize them in Europe, H-ADMs being “human products” and not “medical devices”, so being ruled by European legislations on transplants. The Skin Bank of the Bufalini Hospital (Cesena, Italy) obtained in 2009 the approval for the production and distribution of the first human cadaver-donor derived ADM from the Italian National Transplant Center and National Health Institute, we called with the Italian acronym M.O.D.A. (Matrice Omologa Dermica Acellulata). We present here the first use of a new H-ADM for treatment of distal lower extremity wounds with exposed tendons managed in one-stage pocedure with STSG. The excellent performance suggests that in cases where autologous tissue is unavailable or undesirable, the use of M.O.D.A. in one-stage procedure represents a promising alternative for covering wounds associated with tendons exposition.

Short-term changes of human acellular dermal matrix (Megaderm) in a mouse model

BACKGROUND

Physicians tend to overcorrect when applying the acellular dermal matrix for reconstructive option because of volume decrement problem after absorption comparing with initial volume. However, there are no studies on the exact volume decrement and absorption rate with commercial products in South Korea. To figure out absorption rate of acellular dermal matrix product in South Korea (Megaderm), authors designed this experiment.

METHODS

Nine mice were used and randomly divided into three groups by the time with sacrificing. The implant (Megaderm) was tailored to fit a cuboid form (1.0 cm× 1.0 cm in length and width and 2.0 mm in thickness). A skin incision was made at anterior chest with blade #15 scalpel with exposing the pectoralis major muscle. As hydrated Megaderm was located upon the pectoralis major muscle, the skin was sutured with Ethilon #5-0. After the surgical procedure, each animal group was sacrificed at 4, 8, and 12 weeks, respectively, for biopsies and histological analysis of the implants. All samples were stained with routine hematoxylin and eosin staining and Masson's trichrome staining and the thickness were measured. A measurements were analyzed using Friedman test. Statistically, the correlation between thicknesses of Megaderm before and after implantation was analyzed.

RESULTS

After sacrificing the animal groups at postoperative 4, 8, 12 weeks, the mean tissue thickness values were 2.10± 1.03 mm, 2.17± 0.21 mm, and 2.40± 0.20 mm (p= 0.368), respectively. The remaining ratios after absorption comparing with after initial hydrated Megaderm were 82.7%, 85.4%, and 94.5%, respectively. In histopathological findings, neovascularization and density of collagenous fiber was increased with time.

CONCLUSION

Author's hypothesis was absorption rate of implant would be increased over time. But in this experiment, there is no statistical significance between mean absorption thickness of implant and the time (p= 0.368). Also it can be affected by graft site, blood supply, and animals that were used in the experiment.

Use of Acellular Dermal Matrix in Treatment of Congenital Muscular Torticollis in Patients Over Eight Years of Age

BACKGROUND

Treatment for neglected or recurred congenital muscular torticollis should be differentiated from primary patients due to the long-standing adjacent tissue contracture. The aim of this study was to evaluate the effect of acellular dermal matrix (ADM) on surgery of recurred and neglected patients of congenital muscular torticollis.

METHODS

Forty-nine patients were included in the study. All patients underwent resection at the distal end of the sternocleidomastoid muscle. In the study group of 18 patients (ADM group), the defect caused by myectomy and scar tissue removal was covered with ADM. Passive range of neck motion, head tilt, cosmetic and functional satisfaction, and scar was evaluated and compared with the control group of 31 patients (non-ADM group) during follow-up. Logistic and linear regression analyses with adjustment by propensity score were performed to determine the association between ADM implantation and postoperative variables.

RESULTS

The mean follow-up period was 18.8 months. No patient required further operation for recurrence during follow-up. The improvement of neck motion in ADM group was significantly superior to non-ADM group at the 1-year follow-up, and the overall assessment score was significantly higher in the ADM group. Acellular dermal matrix implantation was not associated with increased discharge of total drain.

CONCLUSIONS

In patients over 8 years of age with recurred or neglected congenital muscular torticollis, use of dermal substitute to fill the defect caused by torticollis release is effective in achieving satisfactory neck motion. Surgical sectioning of the sternocleidomastoid muscle and ADM graft should be considered in recurred and neglected torticollis.

Is there any place for spontaneous healing in deep palmar burn of the child?

Child palm burns arise by contact and are often deep. The singular difficulty of such a disease comes from the necessity of the child growth and from the potential occurrence of constricted scars. In order to avoid sequelae, the actual gold standard is to practice an early excision of the burn, followed by a skin graft. The aim of this study is to evaluate the results of spontaneous healing combined with rehabilitation versus early skin grafting and rehabilitation concerning the apparition of sequelae. We performed a retrospective study in two burn centers and one rehabilitation hospital between 1995 and 2010. Eighty-seven hands have been included in two groups: one group for spontaneous healing and the other group for excision and skin grafting. Every child benefited from a specific rehabilitation protocol. The two main evaluation criteria were the duration of permanent splint wearing and the number of reconstructive surgery for each child. The median follow-up duration is about four years. The two groups were comparable. For the early skin grafting group, the splint wearing duration was 1/3 longer than for the spontaneous healing group. Concerning the reconstructive surgery, half of the grafted hands needed at least one procedure versus 1/5 of spontaneous healing hands. Our results show the interest of spontaneous healing in palmar burn in child, this observation requires a specific and intense rehabilitation protocol.

Retrospective study of the application of acellular dermis in reconstructing full-thickness skin defects

The purpose of the article is to evaluate the acellular dermis' utility in reconstructing full-thickness defects after scar contracture releasing and giant nevus resection. From the year 2012 to 2014, 18 consecutive patients underwent composite graft (thin autograft and alloderma) transplantation. Among these patients, 16 patients suffered from burned scar contracture in the upper extremities, and two young cases were met with giant nevus on the upper extremity. Ten of 13 adult cases with upper extremity scar affection were chosen for a comparative study. Twenty hands were randomly allocated into group A and group B. The thick autograft was used to repair one upper extremity in group B, and the composite grafts were used to cover the other upper extremity in group A. Besides appraisal of the recipient sites' function and aesthetics, donor sites were also estimated after a mean of 12 months' follow-up through the Vancouver Scar Score Scale. After evaluation in the above comparative study through the Vancouver Score Scale, in the recipient evaluation, no statistical difference was found in the pigmentation score between two groups, while statistical difference was achieved in other aspects (vascularity, pliability, height). In the donor site's evaluation, statistical difference was established between the two groups in all facets. One adult patient was dissatisfied with the hypertrophic scar on the donor site, and about almost a half of the area became a hypertrophic scar in the recipient site. No atrophic change occurred; one little girl, suffering from large nevus, was operated on by removing nearly the whole giant nevus on the upper limb. Unfortunately, she presented with finger tip necrosis occurring. The finger tip was not ultimately preserved and was repaired with an abdomen flap. Acellular dermal matrix is an excellent option and a useful tool for reconstructing large full-thickness skin defects after releasing burned scar contracture and removing giant nevus. With thin-skin graft meshed, a donor site's presentation brings courage to patients, while recipient sites can reach nearly the same elasticity and function compared to thick-grafted skin.

A Meta-analysis of Postoperative Complications of Tissue Expander/Implant Breast Reconstruction Using Acellular Dermal Matrix

BACKGROUND

Acellular dermal matrix (ADM) is commonly used for tissue expander/implant breast (TE/I-based) reconstruction. But the relation between ADM and postoperative complications remains controversial. A few meta-analyses were conducted in 2011-2012 and the result revealed that ADM can increase the risk of complications. The purpose of our study is to offer updated evidence for ADM clinical application by analyzing the effect of ADM on complications of TE/I-based breast reconstruction.

METHODS

The literature published from January 2010 to February 2015 was searched in EMbase, Medline, Science Direct, the Cochrane Central Register of Controlled Trials (CENTRAL), CBMdisc, CNKI, VIP, and the references of those included studies were also searched by hand. According to inclusive criteria, 11 studies were selected and the values were extracted from the included literature. Complications with four different categories assigned for overall complications, infection, hematoma/seroma, and explantation were collected. RevMan 5.1 was used for meta-analysis. The evidence level was assessed by using the GRADE system.

RESULTS

Eleven published studies were included. The results showed that compared to the control group, the ADM group increased the rate of overall complications (OR = 1.33, 95% CI 1.03-1.70, p = 0.03), infection (OR = 1.47, 95% CI 1.04-2.06, p = 0.03), hematoma/seroma (OR = 1.66, 95% CI 1.13-2.44, p = 0.01), but there was no significant difference in explantation (OR = 1.37, 95% CI 0.89-2.11, p = 0.15). Based on the GRADE system, all the evidence was at level C and weak recommendation.

CONCLUSIONS

In TE/I-based breast reconstruction, ADM increased the incidence of overall complications, infection, and hematoma/seroma; the incidence of explantation remains unknown. For the poor quality of the original studies, a prudent choice is suggested; and more high-quality, large-sample studies are needed.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Foot web free flaps for single-stage reconstruction of hand webs

PURPOSE

To present a method for reconstructing the digital web in posttraumatic defects using a free tissue transfer of the web from the foot and to present the functional and aesthetic results.

METHODS

Nine web free flaps were performed; 8 were used to reconstruct posttraumatic web losses and 1 was used to reconstruct a defect resulting from to infection. All cases involved the first (3) or second (6) webs of the hand. Web flaps were taken from the foot first web (2 patients), from the second (6 cases), and from the third (1 case) in a patient with congenital syndactyly of second foot web space. The donor site was managed by skin grafting from the instep (1 case), creation of a syndactyly (7 cases), or both (1 case).

RESULTS

All flaps survived without complications. Finger abduction and flexion-extension were similar to the contralateral side. No functional limitations, pain, or contracture were reported. One donor site healed with hypertrophic scars; otherwise, no donor site complications occurred. On a visual analog scale (0-10), the patient assessed appearance of the hand and the donor foot as 9.0 and 9.0, respectively, on average. One web was not well-positioned in the first operation and required revision.

CONCLUSIONS

The foot web free flap reconstructs the hand web by replacing it with a similar functional subunit rather than attempting to recreate the complex geometry, and allows for full function and excellent appearance of the hand.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Acellular Dermal Matrix in Reconstructive Breast Surgery: Survey of Current Practice among Plastic Surgeons

Background:

Acellular dermal matrices (ADMs) in plastic surgery have become increasingly popular particularly for breast reconstruction. Despite their advantages, questions exist regarding their association with a possible increased incidence of complications. We describe a collective experience of plastic surgeons’ use of ADMs in reconstructive breast surgery using an internet-based survey.

Methods:

Members of the American Society of Plastic Surgeons were recruited through voluntary, anonymous participation in an online survey. The web-based survey garnered information about participant demographics and their experience with ADM use in breast reconstruction procedures. After responses were collected, all data were anonymously processed.

Results:

Data were ascertained through 365 physician responses of which 99% (n = 361) completed the survey. The majority of participants were men (84.5%) between 51 and 60 years (37.4%); 84.2% used ADM in breast reconstruction, including radiated patients (79.7%). ADM use was not favored for nipple reconstruction (81.5%); 94.6% of participants used drains, and 87.8% administered antibiotics postoperatively. The most common complications were seroma (70.9%) and infection (16%), although 57.4% claimed anecdotally that overall complication rate was unchanged after incorporating ADM into their practice. High cost was a deterrent for ADM use (37.5%).

Conclusions:

Plastic surgeons currently use ADM in breast reconstruction for both immediate and staged procedures. Of those responding, a majority of plastic surgeons will incorporate drains and use postoperative antibiotics for more than 48 hours.

Postburn contractures of the hand

Several functionally limiting sequelae can follow deep thermal injury to the hand. Despite appropriate initial management, contractures are common. Whereas acute burn care is often managed by multidisciplinary, specialized burn units, postburn contractures may be referred to hand surgeons, who should be familiar with the patterns of burn contracture and nonsurgical and operative options to improve function and expected outcomes. The most common and functionally limiting sequelae are contractures of the webspace, hand, and digits. Webspace contractures and postburn syndactyly are managed with scar excision and local soft tissue rearrangement or skin grafting. The burn claw hand presents as extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstays of management of these contractures include complete surgical excision of scar tissue and resurfacing of the resultant soft tissue defect, most commonly with full-thickness skin grafts. If scar contracture release results in major exposure of the tendons or joints, distant tissue transfer may be required. Early motion and rehabilitative modalities are essential to prevent initial contracture formation and recontracture after surgical release.

Porcine bladder extracellular matrix for closure of a large defect in a burn contracture release

Porcine bladder extracellular matrix (PBEM) is an innovative wound healing alternative to traditional wound closure and reconstruction. By stimulating blood vessel formation and chemotaxis of progenitor cells to the site of injury, it promotes a unique healing environment favouring regeneration of native tissue over scar formation. This is the first clinical report describing the novel use of PBEM scaffold material to close a large defect resulting from a burn contracture release. The benefits of this method are the improved functional and cosmetic result. PBEM-moderated tissue regeneration may serve a valuable role in burn reconstruction.

Open fractures of the hand with soft tissue loss

The evaluation, initial treatment, and definitive reconstruction of open fractures of the hand with associated soft tissue loss are reviewed. Specific attention is given to the literature on open fracture antibiotic prophylaxis in the hand; the timing of bone and soft tissue reconstruction; and options for soft tissue coverage, including local, regional, and distant tissue transfer. Factors that have shown association with outcomes in these injuries are also discussed, and the authors' preferred management is summarized.

Experimental assessment of the neo-vascularisation of acellular dermal matrix in the wound bed pretreated with mesenchymal stem cell under subatmospheric pressure

Neo-vascularisation of the acellular dermal matrix (ADM) is an essential procedure if a full-thickness wound is closed with ADM and skin is grafted over the ADM. In this study, we aimed to improve the neo-vascularisation of ADM by combining the effects of negative pressure wound therapy (NPWT) and mesenchymal stem cells (MSCs) on angiogenesis. In this study, 28 female Sprague-Dawley rats were used and divided into four groups. Full-thickness dorsal skin defects were created in 2 × 2 cm dimensions. The wounds were treated with only the ADM in group 1, the ADM and NPWT in group 2, the ADM and MSCs in group 3 and the ADM, NPWT and MSCs in group 4. By the ninth day of surgery, the excisional biopsy samples were histologically examined to identify the rates of ADM adherence to the recipient bed; the newly formed blood vessels which penetrate the ADM vertically and vascularisation were evaluated by immunohistochemical staining. The graft adherence rates were higher in group 4 than in the other groups statistically, p = 0.003. The numbers of cluster of differentiation 31 (CD31)-stained newly formed microvessels were higher in group 4 than in the other groups statistically, p < 0.05. All subjects in group 4 had the vertical vessels in normal calibration with open lumen vessels which penetrate the ADM. These findings suggest that MSC transplantation induces angiogenesis more efficiently than NPWT. The combination of the NPWT with MSC in this study has shown a synergistic effect on angiogenesis and has affected the neo-vascularisation of the ADM significantly.

One-stage Integra coverage for fingertip injuries

BACKGROUND

We hypothesize that one-stage Integra skin coverage is an effective treatment modality for the treatment of fingertip defects.

METHODS

Nine patients who sustained fingertip injuries were treated with one-stage Integra coverage. In all cases, Integra was placed directly on bone. Static two-point discrimination and the Semmes-Weinstein Monofilament Test (SWMFT) were used to determine the sensations of the affected and opposite unaffected digit. The QuickDASH, Cold Intolerance Symptom Severity (CISS), visual analog scale (VAS), and a 0-10-point pain scale were administered to assess patient function, satisfaction, and pain levels.

RESULTS

The mean age was 53.1 years (39-61). There were 8 males and 1 female. The average area covered was 2.3 cm(2) (1.0-3.2). The mean follow-up duration was 16 months (8-46). The median QuickDASH, CISS score, VAS patient satisfaction, and 0-10 pain score were 9.1 (2.3-40.9), 18 (4-30), 10 (most satisfied) (7-10), and 0 (0-3), respectively. Five patients were evaluated for their digital sensory perception. The mean static two-point discrimination was 9.6 mm for the affected digit and 4.6 mm for the opposite unaffected digit. The median SWMFT was 4.31 for the affected digit and 3.61 for the opposite unaffected digit.

CONCLUSION

For small soft tissue and bone defects involving the fingertip, the use of Integra without further skin grafting appears to be effective, avoids the morbidity of the donor site, and avoids a second surgery. Despite mild sensory deficits, patients were satisfied with the results and fully functional during short-term follow-up.

[New tendencies in hand surgery]

The author summarizes the new therapeutic tendencies in hand surgery at the past one and a half decade. He discusses the development of hand surgery, as an independent field, in a form of a short historical summary, then he reviews in detail new therapeutic methods considered important such as rehabilitation procedures after tendon injuries, present position of complete hand transplantation, new operations of regeneration of the injured skin and repair of nerve damages, as well as the conservative therapeutic options of Dupuytren's disease. Finally he outlines the modified, new operative procedures in bone and joint injuries of the hand. He concludes that constant development of hand surgical knowledge will likely result in further novel therapeutic methods.

Acellular dermal matrices in hand reconstruction

BACKGROUND

The goal of this article is to review the current literature on the use of acellular dermal matrix in forearm, wrist, and hand reconstruction.

METHODS

A comprehensive literature search was performed using the Cochrane Database of Systematic Reviews, MEDLINE, PubMed, and Web of Knowledge. Articles were categorized as acellular dermal matrix used in soft-tissue repair and in ligament reconstruction. Search terms included "acellular dermal matrix," "biologic dressing," "skin replacement," "dermal allograft," "AlloDerm," "FlexHD," "Permacol," and "Strattice." These were all cross-referenced with "forearm," "wrist," and "hand." Data extraction focused on indications, surgical techniques, clinical outcomes, and complications. Exclusion criteria included regeneration templates, neonatal foreskin, and review articles.

RESULTS

More than 100 articles published between 1994 and 2011 were identified. Upon final review, five prospective case-control studies, three retrospective case-control studies, four case reports, one cross-sectional cohort, one prospective consecutive series, and one study type unknown were evaluated. Matrix was most commonly used in burn reconstruction. It has also been used in ligament and joint reconstruction for first carpometacarpal arthritis. One article illustrated the use of porcine matrix in basal joint arthritis, a practice that was abruptly terminated because of a concern over increased infections.

CONCLUSIONS

The clinical indications for acellular dermal matrix have increased throughout the last 15 years. Hand surgeons have been cautious but diligent in developing alternative treatment options in hand reconstruction, with a focused effort to reduce donor-site morbidity. Although acellular dermal matrices continue to find innovative uses to solve upper extremity surgical problems, more comparative prospective trials are needed.

Advances in treating skin defects of the hand: skin substitutes and negative-pressure wound therapy

Surgeons and scientists have been developing alternative methods of hand reconstruction that may play an adjunctive role to, or completely supplant, more traditional reconstructive modalities. This article provides an overview of these emerging techniques, with an emphasis on skin substitutes and negative-pressure wound therapy as they apply to the treatment of soft tissue defects of the hand. The indications, contraindications, and relative advantages and disadvantages of these techniques are discussed in detail.

Utilizing biologic assimilation of bovine fetal collagen in staged skin grafting

Seven patients underwent 2-stage skin grafting with bovine fetal collagen (BFC) as an initial wound cover. Split-thickness skin grafts were successfully placed on the wounds after completion of interval management. BFC proved to be a resilient acellular dermal matrix that could proceed to assimilation and skin grafting under a variety of wound conditions. BFC may prove to be a valuable material, as the role of acellular dermal matrices in skin grafting becomes better defined.

[Sequelae of hand burns]

INTRODUCTION

Hand burns are common. Aesthetic and functional consequences are mixed together.

ANATOMY

Palmar and dorsal skin are very different. Palmar skin is thick and strong, dedicated to the prehension. Dorsal skin is very thin, creating a mobility plan dedicated to the flexion of the fingers.

AESTHETIC SEQUELAE

They are rarely isolated. Proximal nail retractions can occur after nail burns, with matricial exposition. We remove the scar and a full skin graft is done in order to give a normal proximal nail skin shape.

FUNCTIONAL SEQUELAE

They are fingers and wrist retractions. We often use collagen substitute to cover soft tissue defect after scar excision. Commissure retractions are treated by trident plasty.

PARTICULAR CASES

Electrical burns: we expose the case of a thumb amputation after necrosis by electrical burn, secondary treated by index policization. Children burns: the bridles appear during the growth, so we must follow this patient for a long time.

CONCLUSION

Hand burns are frequent. Functional sequelae are often important: retractions, amputations. The orthopaedic treatment of these retractions is unspecific. We often use collagen substitute in our unit. The patient must be involved in his treatment, because it is very long and difficult.