Use of Artificial Dermal Substitute as a Bridge in Complex Finger Reconstruction

  Abstract: Few reports exist regarding the use of an artificial dermal substitute ([ADS] Integra™) in the treatment of finger injuries. This retrospective case series evaluated the use of ADS as a bridge for finger reconstruction following complex injuries. The authors’ facility treated 26 complex finger injury patients using ADS. Graft take was 92.3% (22/26), with most patients experiencing satisfactory range of motion (88.5% or 23/26). The authors conclude that ADS, as a bridge for reconstruction of complex finger injuries, offers advantages, such as improved contour, functionality, and decreased need for native flaps.

Introduction

  Since its introduction by Yannas and Burke, the artificial dermal substitute (ADS), Integra™ (Integra Lifesciences, Plainsboro, NJ), has had many applications in wound care, such as treating burns, chronic wounds, and contractures.¹ The majority of reports reveal improved range of motion, skin quality, and contour with use of ADS in treatment of the aforementioned conditions. Few reports exist regarding the use of ADS in finger injuries. This report presents the authors’ experience with the use of an ADS (Integra) as a bridge for reconstruction of complex finger injuries, in order to demonstrate ADS as a viable alternative to address such injuries and improve outcomes.

Methods

  Twenty-six patients (22 men and 4 women [43 years ± 16.15 years]) underwent finger reconstruction in the authors’ facility using ADS. The cause for injury was traumatic in 24 and infectious in 2. Two of the 26 patients had been treated initially at different facilities. Both patients were referred to the authors’ facility with post-traumatic contractures following primary closure or native flap failure; both required excision and coverage with ADS. Additionally, 2 of the 26 patients were treated in the authors’ facility only with full-thickness skin grafts (FTSG) for their injuries. Postoperatively, 1 graft failed and 1 developed contracture, both leading to subsequent use of ADS. Preoperative comorbidities included: diabetes (2), tobacco use (7), coronary artery disease (4), history of stroke (1), and hypertension (1). One patient was in chronic renal failure, required daily dialysis, and had arterio-venous Steal Syndrome.   All patients presented with some degree of exposed bone. Sixteen (61.5%) sustained some degree of tip amputation with pulp nail bone (PNB) deficit at initial presentation, and 14 (58.3%) had exposed tendons (Figure 1). Eighteen (69.2%) patients had concomitant fractures, of which 10 (38.5%) were treated with bone debridement, and 6 (23.1%) were treated with open reduction internal fractures. Two (8.3%) patients required ADS after wide debridement to treat finger infection with skin necrosis. At initial presentation, 18 (69.2%) patients were treated with ADS alone, 6 (23.1%) with ADS and local flap or FTSG, and 2 (8.3%) with FTSG only. Eleven patients did not require subsequent coverage, 12 required a pinch FTSG, and 1 required a split-thickness skin graft (STSG). Skin grafts (STSG or FTSG) were bolstered with Xeroform™ petrolatum gauze (Covidien, Mansfield, MA), intraoperatively, and subsequent dressing changes were performed by a Certified Hand Therapist (CHT) with Mepitel® (Mölnlycke Health Care US, LLC, Norcross, GA) 7 to 14 days thereafter.   Surgical technique. Following surgical debridement, ADS dressings (perforated and trimmed to wound contour) were applied either by sutures or staples to the patient’s surrounding native tissue. Wet-to-dry dressings were applied in the operating room setting and addressed by a CHT with Mepitel 2 to 3 days thereafter. Splints (fabricated by the CHT) were utilized in all cases for stabilization and increased ADS take. Minimal physician follow-up occurred at 7 to 9 days, 21 days, and 6 weeks. Additionally, PNB classification for fingertip injuries, devised by Evans and Bernardis,² was utilized to select the correct treatment. Sutures were removed at 21 days. The silicone layer was removed 7 days later, if it had not exfoliated. Recipient wound beds were routinely ready for skin graft application by 35 days post ADS application.

Results

  Twelve (46.2%) patients required no additional coverage after initial application of ADS. Fourteen (53.8%) patients required subsequent coverage at a later stage, of which 11 (42.3% of total patients) were treated with a pinch FTSG, 1 (4.2% of total) with a STSG, and 1 (4.2% of total) with a FTSG and cross finger flap (CFF). One (4.2% of total) patient required removal of the infected graft and reapplication of ADS and a pinch FTSG. This patient eventually died due to underlying comorbidities. For the patients selected for ADS, CFFs were strongly considered and discussed as an option. Six (23.1%) patients would have otherwise been treated with CFFs, but as a result of ADS application, CFFs were avoided in 5 (83.3%) patients (1 patient required CFF on subsequent operation). Twenty of 26 patients (76.9%) had satisfactory tip sensation with satisfactory 2-point discrimination (this series represents complex heterogeneous soft tissue involvement, and thus, further analysis of this parameter is difficult at best). Five (19.2%) patients developed hypersensitivity, and 6 (23.0%) had poor tip sensation with poor 2-point discrimination.   Eight (30.8%) patients were lost to long-term follow up, 1 of which was due to death. Five (19.2%) developed postoperative infections, of which 4 were treated successfully with antibiotics. Three (11.5%) patients developed contractures that were successfully treated with contracture excision and application of pinch FTSG. Two (7.7%) xenografts (Integra) failed to take, 1 due to necrosis and 1 due to infection. One failed case was treated with antibiotics, ADS removal, partial amputation, and a local flap, while the other with removal, ADS reapplication, and a pinch FTSG. Twenty-three (88.5%) patients had satisfactory range of motion, while 3 (11.5%) did not.

Conclusion

  Even with optimal treatment, complex finger injuries present a great challenge for surgeons and hand therapists, and ultimately affect patients’ quality of life. In the acute setting, tendons, nerves, and bones, if left open, will desiccate, devitalize, and eventually scar, with resulting deformity and poor function. For these reasons, a rapid way to reconstruct soft tissue and provide adequate coverage is paramount in order to achieve good functionality and cosmesis.³   Artificial dermal substitutes, such as Integra, offer a viable alternative for complex wound treatment when primary closure is unachievable. In the present series, 69.2% of the patients were treated with ADS alone without any need for subsequent grafting. When further grafts were required, they were much smaller than what they would have been with native flaps, which translates to less pain (ie, smaller wounds), and lack of additional donor site wounds further improving patient satisfaction, and possibly decreased costs from fewer repeat operations. Additionally, less need for CFFs allows patients without fractures the benefit of earlier mobilization, thus minimizing joint stiffness and hospitalization. Artificial dermal substitute application also allows CHTs to better address concurrent repairs (eg, patients with tendon and pulley repairs can start hand therapy immediately after ADS application), compared to the longer immobilization needed with the use of CFFs (Figure 1).   The authors acknowledge that this particular study is limited due to selection bias, its retrospective nature, and lack of an appropriate control. Even though it has low statistical value, it demonstrates potential benefits from the use of ADS. Larger prospective studies are needed to address the cost effectiveness of using ADS for complex reconstructions compared to traditional methods, as well as studies to evaluate patients’ pain ratings and satisfaction by use of a formal scale, such as Disabilities of the Arm, Shoulder, and Hand (DASH) or the Patient-Rated Wrist/Hand Evaluation (PRWHE).

Acknowledgements

  All patients have been informed of potential publication and all steps to ensure patient confidentiality have been taken. All authors have had access to all data, have seen and approved this manuscript, and have no financial conflicts or other interests to disclose.

References

1. Moiemen NS, Vlachou E, Staiano JJ, Thawy Y, Frame JD. Reconstructive surgery with Integra dermal regeneration template: histological study, clinical evaluation, and current practice. Plast Reconstr Surg. 2006;117(7 Suppl):160S–174S. 2. Evans DM, Bernardis C. A new classification for fingertip injuries. J Hand Surg Br. 2000;25(1):58–60. 3. Bhavsar D, Tenenhaus M. The use of acellular dermal matrix for coverage of exposed joint and extensor mechanism in thermally injured patients with few options. Eplasty. 2008;8:e33. Morgan P. Lorio, MD, FACS; Sarah Howell, BS, MS; and Brandon M. Lewis, AS are from the Neuro-Spine Solutions, P.C., Bristol, TN. Georgios Ziakas, MD is from Grundy Surgical, Richmond, TX. Kimberly Masker, CHT is from The Hand Center, Bristol Regional Medical Center, Bristol, TN. Address correspondence to: Morgan P. Lorio, MD, FACS Neuro-Spine Solutions, P.C. 240 Medical Park Blvd., Ste 2700 Bristol, TN 37620 mplmd@neurospinesolutions.net