Ultra-Thick Amniotic Membrane Allograft as a Successful Treatment for a Traumatic, Complex Lower Extremity Wound

Dr Christopher Stewart:

I am Christopher Stewart, I'm an Orthopedic Trauma Surgeon in Little Rock, Arkansas. I'm presenting a paper on the treatment of traumatic complex wounds using amniotic membrane. My case involves a 39-year-old male who was involved in a high speed motorcycle accident. He had several injuries to his left leg to include an open femur fracture, a large open knee injury, an open tibia fracture with this very large open wound to the posterior knee and was degloved almost circumferentially around his knee with an open knee joint. He had exposed popliteal artery, which wasn't intact. He had exposed sciatic nerve at that point, and he had exposed hamstring tendons. And we used two applications of an amniotic membrane with a vacuum dressing to successfully heal his wound over the posterior knee. And also, he had one manipulation under anesthesia of his knee at 3 months. But otherwise, he returned back to a range of motion of zero to 135 degrees, which was pain free with no block to motion.

It's a very complex injury without many successful solutions to this injury. Obviously, things like flaps require plastic surgery colleagues to intervene. But when the injury is very large, as it was, to the back of the knee, also involving a joint, plastic reconstructive options become limited because of the risk for scarring and loss of motion. So there wasn't very many options available to this gentleman in order to 1) heal the tissue, and 2) to hopefully restore a more normal range of motion without a limit of range of motion. So, with minimal reconstructive options for him, I felt that the amniotic tissue, which allows a form of regenerative healing to occur, would be an ideal solution for him. And we were fortunate enough with just 2 applications in a vacuum dressing for approximately a week and a half and then standard wound care to successfully 1) heal his wound and then, also, 2) to provide range of motion and allow his open fractures to heal essentially uneventfully.

Yes, the range of motion element is definitely surprising. So one of the biggest factors to use in any type of tissue substitution or flap tissue coverage is obviously scarring over the joint. Scarring over the joint will limit range of motion. So there was a very high correlation. We had spoke to the patient that he would have a limited range of motion of his knee and possibly a good outcome, but not an excellent outcome because of the loss of range of motion. But he was able to, with one manipulation only, to return back to a range of motion of 135 degrees. And he essentially has the same range of motion in that knee that he has in the contralateral side, which again is extremely surprising, because the prevailing theory in the wound care paradigm is that they will lose range of motion and you really shouldn't use these type of grafts over joints, and you need to be extremely diligent about using soft tissue coverage, ie, flap coverage, over joints because of the risk of loss of motion.

Obviously, we would like to see, this is a single case study and I can say in my hands, I've used the amniotic tissue several times over joints with successful outcomes. But I believe obviously a prospective, potentially randomized trial would be applicable for this to use it over joints and see if statistically in a randomized trial it does make a difference for range of motion and for outcomes, especially functional outcomes for the patients versus things like standard wound care or flat soft tissue coverage, to see if there's any difference in the application of this, because this may be an avenue where soft tissue coverage is precluded or unavailable to the patient, that may become another reconstructive option for the patient with hopefully the same outcomes as far as range of motion function over joints.

I would say that I've used the amniotic tissue probably 700 to 800 times in my practice, and I think it's a very durable solution for soft tissue coverage, especially in cases such as this where there's limited reconstructive options for the patient and it provides a form of regenerative healing, which has not been shown in some of the previous literature or previous soft tissue coverage solutions. And I would recommend this type of tissue to any wound care physician as an option for their patients.