Tendon coverage using an artificial skin substitute

Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 1544e1550

Tendon coverage using an artificial skin substitute* Jaimie T. Shores a, Matthew Hiersche b,*, Allen Gabriel b, Subhas Gupta b a b

Johns Hopkins University School of Medicine, Department of Plastic and Reconstructive Surgery, Baltimore, MD, USA Loma Linda University Medical Center, Department of Plastic and Reconstructive Surgery, Loma Linda, CA, USA

Received 17 October 2011; accepted 26 May 2012

KEYWORDS Integra; Tendon; Reconstruction; Soft tissue; Trauma

Summary Background: Soft tissue deficits associated with exposed tendon and absent paratenon pose difficult reconstructive problems due to tendon adhesions, poor range of motion, poor cosmesis, and donor site morbidity. Integra Bilayer Matrix Wound Dressing (Integra Lifesciences Corp Plainsboro, NJ) is a skin substitute widely used in reconstructive surgery, including the incidental coverage of tendons. However, Integra’s post-operative functionality of the tendons has not been well documented. We report the results of using Integra for soft tissue reconstruction overlying tendons with loss of paratenon in upper and lower extremity soft tissue defects. Methods: Forty-two patients (35 men and 7 women) with exposed tendons due to trauma (37), cancer excision (2) or chronic wounds (3) were reconstructed using Integra. Results were compiled in a prospective manner, including age, gender, wound location, wound size, time to final closure, operative time, follow-up length, split-thickness skin graft percentage take and active post-operative range of motion. Likewise using Medline, a literature search of current surgical techniques for the treatment of exposed tendons and the results from the literature were compared with these study results. Results: All patients healed with an average split-thickness skin graft take rate of 92.5%
6.1 (range, 80e100%). The thirty-two patients not lost to follow-up achieved an average range of motion of 91.2%
6.5 (range, 80e100%). Conclusion: Integra offers a convenient, efficient operative procedure with minimal morbidity, demonstrating good cosmesis and tendon function. Thus, Integra may offer an alternative option for immediate tendon coverage in both the upper and lower extremities. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

* The content of this paper has been presented at the California Society of Plastic Surgeons, 2008; American College of Surgeons Southern California Chapter, 2007; Annual Post-Graduate Convention Loma Linda University Medical School, 2007. * Corresponding author. Tel.: þ1 909 558 8085; fax: þ1 909 558 4175. E-mail address: [email protected] (M. Hiersche).

1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2012.05.021

Integra coverage of tendons

Introduction Soft tissue defects overlying exposed tendon with loss of paratenon often precipitate poor clinical outcomes due to the dichotomous demands of both closing the overlying soft tissue defect and providing a “gliding” surface for the underlying tendons.1 While the avoidance of adhesions and the restoration of function are the primary goals of the procedure, satisfactory cosmesis is also desirable.1 Likewise, any form of coverage should ideally provide good vasculature required for complete healing and an early form of closure following debridement.2 Simple skin grafts and many flaps do not adequately meet these demands because they result in a high rate of tendon adhesions.3 In order to reduce the frequency of tendon adhesions by creating a “gliding” surface, the use of interpositional materials, both artificial and biologic, has been employed with varying success. Previously used materials include cellophane, chitosan membrane, fibrin sealant, autogenous fascial flaps and autogenous venous grafts.4e8 Many of the autogenous flaps and grafts have been employed with good success.9 However, complications and donor site morbidity encourage alternative procedures including the use of artificial substances.2,9e11 Therefore, we present our clinical series of forty-two patients who underwent the successful placement of Integra Bilayer Matrix Wound Dressing (Integra Lifesciences Corp, Plainsboro NJ) directly over their exposed tendons with a subsequent splitthickness skin graft several weeks later. In our experience, Integra offers the promise of immediate coverage unrestricted by wound size, provides a shorter operative time and decreased donor site morbidity than flap coverage, while demonstrating excellent range of motion and good skin graft survival.

1545 indicated including stabilization of fractures, repair of tendon injuries, debridement of the wound bed, and/or tumor excision. Following wound bed preparation, thorough hemostasis was accomplished through the use of electrocautery and epinephrine-soaked nonadherent sponges. Integra was placed directly over the tendons and secured with either 4e0 chromic sutures or surgical staples. Likewise, nonadherent sponges, moist cotton balls and Reston foam were placed over the Integra and affixed to the skin using staples to bolster the wound. Last, each wound was stabilized with the support of a plaster splint or cast over the bolster dressing. On postoperative day 6e7, the first dressing change was performed; after which a weekly wound inspection to evaluate for infection and to note the degree of vascularization of the neodermis beneath the silicone layer was performed. Stage II After noting a highly vascularized neodermis, the silicone layer was removed and an STSG, usually from the patient’s thigh, was placed. The thickness of the graft was per the surgeon’s preference. The same bolster dressing system was utilized with plaster immobilization with the first dressing change performed between post-operatives days 3 and 5.

Rehabilitation All patients were restricted from any form of range of motion until there was evidence of adequate vascularization of the Integra and subsequent adherence of the skin graft. At that time, both active and passive range of motion activity was resumed.

Patients and methods

Follow-up

Patient characteristics

Upon successful completion of the second stage, all of the patients were followed and evaluated for complete wound healing. When available and appropriate, occupational and/or physical therapy was instituted to achieve maximum functionality for reconstructed and/or covered tendons.

Between January 2001 and September 2003, forty-two patients underwent soft tissue reconstruction over their exposed tendons using Integra Bilayer Matrix Wound Dressing. Only patient’s whose tendons demonstrated loss of paratenon and did not require tendon grafting were included in the study. Data analyzed included the patients’ age, defect size, operative time of skin grafting, length of hospital stay, immediate complications and time interval between last Integra application and final reconstruction. The size of the Integra graft was used to determine the size of the defect. During the course of follow-up, tendon function, graft take and long-term complications were assessed (Table 1) The IRB committee at our institution approved the study as a retrospective review.

Reconstructive protocol The procedures were performed per the manufacturer’s specifications, resulting in a minimum of two stages of reconstruction, except in one case of “single stage” reconstruction with immediate skin grafting and simple bolster dressing (Shown as Figures 2e7). Stage I During the first stage, debridement of the wounds and other appropriate reconstructive procedures were performed as

Active range of motion (AROM) analysis In analyzing the post-operative AROM, Total Active Motion (TAM) was assessed and recorded for both the injured tendons and the contralateral uninjured tendons. It was then hypothesized that the AROM of the uninjured tendons represented the ideal, pre-operative AROM of the injured tendons. Then, the injured AROM was divided by the uninjured AROM to assess what percentage of the ideal, preoperative AROM was attained post-operatively. The equation utilized to evaluate post-operative is shown in Figure 1.

Literature search In order to compare the results of our study to those found in the literature for fasical flaps, a Medline literature search was performed searching for “exposed tendons” and “fascial flaps.” All case series found in the English literature were included, however single case reports were excluded.

1546 Table 1

J.T. Shores et al. Patient demographics.

Patient #

Age (yrs)

Sex

Wound etiology

Wound location

Wound size (cm)a

Wound area (cm2)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Total Range Mean SD Median

68 9 26 38 61 41 56 52 42 28 16 24 58 22 18 53 42 21 26 33 14 28 36 51 18 26 38 44 62 41 22 28 33 68 26 48 31 44 66 81 19 62

M F M M M M M F M M M M M M M F M M M M M M F F M M M M F M M M M M M M F M M F M M

Trauma " " " " " " Cancer (sarcoma) Trauma " " " Chronic venous stasis Trauma " " " Cancer (sarcoma) Trauma " " " " " " " " " Diabetic foot ulcer Trauma " " " Chronic arterial ulcer Trauma " " " " " " "

Ankle/Achilles Dorsal wrist Lower leg "" "" "" Ankle/Achilles Knee Ankle Forearm Dorsal hand Ankle Medial ankle Dorsal hand Lower leg Dorsal foot Dorsal wrist Lower leg Pre-tibia Foot Dorsal hand Lower leg Foot Forearm Lower leg Knee Forearm Wrist/Hand Foot Lower leg Ankle Palm Achilles Ant. ankle Palm Lower leg Dorsal wrist Knee Forearm Foot Ankle Thumb/Palm

15  9 43 64 12  4 86 12  8 12  8 21  14 66 16  4 64 93 12  7 86 24  8 18  6 86 28  12 89 84 83 11  4 20  8 64 12  8 62 33 43 75 12  10 84 16  6 85 44 33 65 44 12  4 10  4 84 43 22

135 12 24 48 48 96 96 294 36 64 24 27 84 48 192 108 48 336 72 32 24 44 160 24 96 12 9 12 35 120 32 96 40 16 9 30 16 48 40 32 12 4

a

9e81 38.6 17.5 37

4e336 65.1 71.3 40

Wound size includes size of tendon exposure, equal to size of integra placement.

Results Patients characteristics Clinical characteristics of the patients are shown in Table 1. Thirty-seven of 42 patients presented with traumatic soft tissue defects resulting in exposed tendons. Three patients

had tendon exposure secondary to chronic wounds, and two patients were secondary to tumor excision. The average age of the patients was 38.6 years (range, 9e81 years). Thirty-five of the patients were male and seven were female. Likewise, fourteen of the defects were in the upper extremity and the remaining twenty-eight were defects of the lower extremity with the specific locations of reconstruction seen in Table 2.

Integra coverage of tendons

1547

Figure 1 Pre-operative view of dorsal hand fungating squamous cell carcinoma (Approx. 100 cm2).

Wound characteristics The size of the tissue defect including the area of tendon exposure ranged from 4 cm2 to 336 cm2 with an average of 65.1
71.3 (Table 1).

Reconstruction Removal of the silicone sheet and application of the skin graft was performed on average 35.3
7.0 days after the initial placement (Figure 1) Average split-thickness skin graft thickness was .0011 inches (range .0008e.0012 inches) was placed over the “neo-dermis”. There was 92.5% (range 80e100%) take in all skin grafts. Second stage operations averaged 58.8 min (Range 39e86 min). None of the forty-two patients required hospitalization after the first procedure. The second procedure was performed on an outpatient basis in all cases.

Follow-up Ten of the 42 patients were lost to follow-up. The remaining 32 patients’ follow-up period ranged from 9 to 50 weeks (Average 22.2 weeks, SD 10.3 weeks). All patients

Table 2 Location

a

c d

Discussion Soft tissue defects with exposed tendons and deficient paratenon may offer a number of problems for the reconstructive surgeon. The primary concern is the creation of a gliding surface and thus the restoration of a functional tendon without adhesions.2 However, the surgeon must use their own clinical judgment when choosing the method of repair so as to minimize the effects of donor site morbidity and maximize the overall functional and aesthetic outcomes. All the while selecting a material or flap that is likely to survive in the relatively avascular tendon plane.2,9,12 The options available to the reconstructive surgeon are local flaps, regional flaps, free flaps and the expanding field of skin substitutes. As Levin noted in 1993, decisions regarding repair of any soft tissue defect may follow a well delineated ladder beginning with the primary choice of split-thickness skin grafts and ending with free flaps.13 When tissue defects in the hand or lower extremity are large or complex, free flaps are often indicated as the approach of choice in reconstruction.14,15 Nevertheless, three general disadvantages are

Patient outcomes. Number AROM of STSG Days to STSG Wound Operative Follow-up of cases contralateral (%)a take rateb (integra) size (cm2) time for length (weeks STSG (min.) post STSG)

Upper Average range 14.0 extremity Lower Average range 28.0 extremity Total Average range 42.0

b

exhibited durable skin coverage at the end of their followup periods (Figure 2). Likewise, with physical and occupational therapy, patients’ were able to attain an average range of motion in their affected joints that was 91.2% (SD 6.5%, range 80e100%) compared to their contralateral side (Figure 3 and Figure 4). This range of motion was further categorized by specific location, as seen in Table 2. Of note, the average range of motion in the upper extremity (n Z 14) was 91.6% with 100% follow-up, compared with 90.6% in the lower extremity (n Z 28) with 10 patients lost to follow-up before final range of motion measurements could be attained (Table 2) (Figure 5, Figure 6 and Figure 7). There were no acute complications consisting of infection of Integra, cellulitis, or significant skin graft loss. In two cases tenolysis was required, while in one case a keloid developed around the margin of the wound grafted with Integra and the STSG. No keloid or hypertrophic scarring of any skin grafted or Integra grafted areas was present. The only other complications were initial partial take of the STSG, requiring extended observation and wound therapy.

AROM Z Active range of motion. STSG Z Split-thickness skin graft. 18 of 28. 32 of 42.

91.9 80.0e100 90.6c 80.0e100 91.2d 80.0e100

95.5 85.0e100 91.3 80.0e100 92.5 80.0e100

29.6 24.0e37.0 37.9 24.0e49.0 35.3 24.0e49.0

30.3 4.0e96.0 78.0 12.0e336 65.1 4.0e336

48.1 39.0e60.0 64.6 39.0e86.0 58.8 39.0e86.0

20.4 12.0e40.0 22.8 9.0e50.0 22.2 9.0e50.0

1548

J.T. Shores et al.

Figure 2 Defect following wide local excision of squamous cell carcinoma.

Figure 4 Split thickness Skin graft placement prior to simple bolster dressing placement only.

inherent in any free flap procedure: a requirement for microsurgical technique, increase in operating time and the perennial risk of flap loss.2 In reference to the latter, the rate of flap loss found by Khouri was 4.1% with a 12.1% chance of incurring some measured complication, including wound dehiscence, arterial insufficiency and flap necrosis.16 Likewise, many of the conventional local and free flaps, including cutaneous and muscular flaps, prove ineffective at deterring tendon adhesions, create unsightly postoperative contours or increase the area of trauma on the wounded extremity, encouraging the use of fascial free flaps.12 Among the wide array of potential free fascial flaps the temporoparietal, scapular, lateral arm, radial forearm and free serratus fascial flaps are some of the most popular for hand defects.9,10 However, these procedures require an additional surgical site, meticulous dissection, microsurgical technique, and an increased operating cost and time.2,9e11 Furthermore, free fascial flaps have demonstrated occasional partial flap loss and a decreased survival of the overlying skin graft leading some to advocate delayed skin graft placement.11,17,18 Due to these complications, Bray noted that the utility of free flaps may be

limited in smaller clinical settings.12 Without access to a large team of qualified surgeons and an experienced nursing staff, the feasibility of free flaps as demonstrated by tertiary care centers may diminish.12 While these procedures are an improvement over other flap techniques, the desire to further decrease surgical morbidity continues to encourage the use of artificial substances. The primary disadvantage of using an artificial substitute such as Integra is the necessity for a second operative procedure to harvest and place the split-thickness skin graft. Traditionally, this is performed two to three weeks after the initial Integra application. Nevertheless, as seen in our study, most of the second stage procedures can be performed on an outpatient basis, minimizing the burden to the patient and the medical costs. In response to critics of this two-stage technique, it should be noted that Morykwas has described single stage use of Integra with splitthickness skin grafts with placement of an overlying Wound VAC to help speed incorporation of the Integra and improve survival of the immediately grafted skin.19 Our own recent case series (currently submitted for publication) describes a single staged Integra and split-thickness skin grafting technique without the need for a Wound VAC which

Figure 3 Placement of Integra Bilaminate Wound Matrix with silicone layer removed for single stage use.

Figure 5

Post-operative view 6 weeks after reconstruction.

Integra coverage of tendons

1549

Figure 6 Post-operative digit extension 6 weeks after reconstruction.

has resulted in excellent graft survival. Additionally, the use of free fascial flaps, as opposed to fasciocutaneous flaps, may require delayed skin graft placement as well, ultimately resulting in a second stage operation. Many free fascioucutaneous flaps, while providing robust coverage in a single stage, also may result in further revisional procedures in the form of tenolysis or flap thinning. After analyzing the post-operative range of motion achieved with the use of Integra and finding the average range of motion to be 91.2% in our patients, we desired to compare our outcomes to the results using other surgical techniques as reported in the literature. Therefore a Medline search of the literature was performed searching for exposed tendons and fascial flaps. The literature generally does not report post-surgical range of motion with numerical data.1,10,11,17,20 Rather, most studies simply describe their post-surgical range of motion in subjective descriptions (i.e. excellent, satisfactory, etc.). However, one study by Flu ¨gel et.al. reported their outcomes utilizing fascial flaps in a numerical data set that was comparable to our results.1 After using Flu ¨gel’s data to calculate the percentage of ideal AROM as noted in the results section, it was determined that Flu ¨gel’s results provided an average

Figure 7 Post-operative reconstruction.

digit

flexion

6

weeks

after

post-operative range of motion of 83.5%. This indicates that the results from our study are likely comparable with those attained with fascial flaps. While there is still no perfect answer for wound coverage and closure in the extremity with exposed or damaged tendons, Integra certainly performs well as a primary choice by minimizing adhesions, allowing a good range of motion and providing a durable, satisfactory aesthetic outcome. Likewise, an initial treatment with Integra does not preclude later, more invasive reconstructive efforts, such as free flaps, if they continue to be indicated. Integra also does not diminish the ability to revise a tendon reconstruction if a secondary procedure is necessary. In our practice, tendon revision is performed by incising the Integra overlying the tendon and at the close of the procedure approximating the soft tissue over the tendon. Integra gives the surgeon a minimally invasive, efficient, initial alternative to more labor intensive, potentially morbid reconstructive procedures, without sacrificing outcome. Therefore, Integra offers an alternative procedure in the surgeon’s armamentarium for tendon coverage.

Conflicts of interest statement None.

Roles of the funding source Authors have no financial disclosures to report.

Ethics The research project was reviewed and approved by the Loma Linda University IRB committee.

References 1. Flu ¨gel A, Kehrer A, Heitmann C, Germann G, Sauerbier M. Coverage of soft tissue defects of the hand with free fascial flaps. Microsurgery 2005;25:47e53. 2. Chen H, Buchman MT, Wei F. Free flaps for soft tissue coverage in the hand and fingers. Hand Clin 1999;15(4):541e54. 3. Chia J, Lim A, Peng Y. Use of an arterialized venous flap for resurfacing a circumferential soft tissue defect of a digit. Microsurgery 2001;21:374e8. 4. Wheeldon T. The use of cellophane as a permanent tendon sheath. J Bone Jt Surg 1939;21:393e6. 5. Zhang H, Sheng ZJ, Hou CL. Effect of chitosan membrane on tendon adhesion and healing. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 1999;13:382e5. 6. Frykman E, Jacobsson S, Widenfalk B. Fibrin sealant in prevention of flexor tendon adhesions: an experimental study in the rabbit. J Hand Surg 1993;18A:68e75. 7. Greene DP. Operative hand surgery. 3rd ed. New York: Churchill Livingstone; 1993. 8. Yan D, Shi X, Liu Q. Reconstruction of tendon sheath by autogenous vein graft in preventing adhesion. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 1997;11:38e9. 9. Pederson WC. Upper extremity microsurgery. Plast Reconstr Surg 2001;107(6):1524e36. 10. Wintsch K, Helaly P. Free flap of gliding tissue. J Reconstr Microsurg 1986;2:143e50.

1550 11. Meland NB, Weimar R. Microsurgical reconstruction: experience with free fascia flaps. Ann Plast Surg 1991;27:1e8. 12. Bray PW, Boyer MI, Bowen CV. Complex injuries of the forearm. Hand Clin 1997;13(2):263e78. 13. Levin LS. The reconstructive ladder: an orthoplastic approach. Ortho Clin North Am 1993;24:393e409. 14. Hallock GG. Utility of both muscle and fascia flaps in severe lower extremity trauma. J Trauma 2000;48(5):913e7. 15. Hallock GG. The utility of both muscle and fascia flaps in severe upper extremity trauma. J Trauma 2002;53:61e5. 16. Khouri RK, Cooley BC, Kunselman AR, et alInternational Microvascular Research Group. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998;102(3):711e21.

J.T. Shores et al. 17. Woods IVJM, Shack RB, Hagan KF. Free temporoparietal fascia flap in reconstruction of the lower extremity. Ann Plast Surg 1995;34(5):501e6. 18. Chung K, Cederna P. Endoscopic harvest of temporoparietal fascial free flaps for coverage of hand wounds. J Hand Surg 2002;27A(3):525e32. 19. Sanger C, Molnar JA, Newman CE, et al. Poster 37: immediate skin grafting of an engineered dermal substitute. American Society of Plastic Surgery, Plastic Surgery 2005. Chicago, IL. 2428 Sept. Plast Reconstr Surg 2005;116(3S). 20. Upton J, Rogers C, Durham-Smith G, Swartz WM. Clinical applications of free temporoparietal flaps in hand reconstruction. J Hand Surg 1986;11A(4):475e83.