SLR - October 2019 - Amara Abid
Reference: McMillan, L. J., Parikh, H. R., Cunningham, B. P. Acute Treatment of Open Foot and Ankle Fractures Using a Bioartificial Dermal Regeneration Template and Split-Thickness Skin Grafting: A Report of 2 Cases. JBJS case connector, 2019, 9(2), e0148.Scientific Literature Review
Reviewed By: Amara Abid, DPM
Residency Program: SUNY Downstate Medical Center – Brooklyn, NY
Podiatric Relevance: Treatment of open fractures is a challenging task and requires management of a complex injury of the bone and soft tissue. Since open fractures consist of soft tissue trauma, its reconstruction is vital once fracture reduction is achieved. Irrigation with debridement and early closure of soft tissue can improve the outcomes in degloving injuries of the foot and ankle. Traditional choices of wound coverage includes split thickness skin graft, muscle flaps or free tissue transfers. However each choice has its limitations, including risk of failure, operation time, and the need for revision. Therefore the usage of dermal regeneration templates (DRTs), which are composed of dermal matrix of bovine tendon collagen and chondroitin fibers, can be used as an alternative for managing closure of soft tissue secondary to trauma.
Methods: Two patients with open fractures of the foot and ankle with soft tissue defect presented to the ED sustaining type IIIB ankle fractures. They were treated through aggressive low pressure irrigation and debridement of nonviable tissue initially within four hours of injury along with usage of external fixation for the fracture. Then it was followed by DRT placement which was secured with staples along with application of negative pressure wound therapy. After approximately three weeks of DRT application, patient underwent second procedure where the superficial silicone layer of DRT was removed and debridement with irrigation of soft tissue was performed as well followed by application of split thickness skin graft from anterior thigh. Following the procedure, patients were non-weight bearing. After the removal of external fixation, short leg cast was applied which was then removed five months after the time of injury.
Results: Upon removal of the short leg cast, graft site was stable with normal range of motion of the ankle. Weight-bearing was initiated as tolerated with one year follow up in clinic which demonstrated stable soft tissue envelope at the trauma site.
Conclusions: Utilization of DRT versus free tissue transfers demonstrate more success and offer a novel approach in managing complicated soft tissue defects secondary to trauma. DRTs do not require microvascular surgical method and can be utilized even with exposure of tendon and bone. Primary debridement is vital in the success of DRT graft. However a non-healing DRT graft placement can be corrected by repeating debridement and irrigation along with IV antibiotic therapy. Wound closure should be attempted right after the trauma since it demonstrates lower infection rates, nonunions, number of revisional cases, and time to weight bearing. Therefore acute application of DRT during initial irrigation and debridement of wound is an alternative to free tissue transfer. Although there are favorable results, this is only a series of two patients and further studies are needed with regards to this subject matter.