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The Service des Brûlés, Hôpital Léon Bérard, Hyeres, Cedex 83400, FranceCentre des Brûlés, Hôpital d' Instruction des Armées Sainte-Anne, Toulon Naval, France
Adequate acute treatment of the deeply burned hand and any subsequent reconstructive procedures may be hampered by the lack of sufficient suitable graft material and the risks of donor site morbidity and scarring. This investigation was designed to determine the feasibility of treating deep hand burns using a dermal regeneration template. Patients with deep hand burns underwent either acute treatment or reconstructive procedures with Integra® dermal regeneration template. Wound sites were first grafted with the dermal regeneration template, and then 2–3 weeks later after neodermis formation the silicone layer of the Integra was removed and a very thin split-thickness epidermal autograft placed. Acute grafting was performed on 15 hands in 11 patients and reconstructive surgery on 14 hands in 11 patients. Median follow-up was 12 months. Integra take was 100% on all treated hands. After acute grafting the wound site skin was flexible and supple and did not adhere to the deeper layers, thus permitting free articular and functional movement. Cosmetic results of acute surgery were judged satisfactory by both patients and surgeons. After reconstructive procedures, significant improvements were achieved in cosmetic status, based on Vancouver Scar Scale (p=0.0002), and in three measures of function, namely, thumb opposition score (p=0.0005), fingertip-to-palm distance (p=0.0039) and prehensile score (p=0.0039). Favourable cosmetic and functional outcomes were consistently attained using a synthetic dermal regeneration template for treatment of deep hand burns either by acute grafting or reconstructive surgery.
Prompt closure of burn wounds is key to the successful treatment of patients with major thermal injury, and yet early wound closure using autograft is seldom possible if the total body surface area (TBSA) involved with deep burn approaches or exceeds 50%. Burns of the hand account for a disproportionate share of TBSA burned,
but nevertheless treatment priorities often must be assigned to areas such as the trunk and lower limbs where injury can be more life-threatening.
Hands serve key functional and social roles, and crippling hand injuries can have long-lasting consequences. Successful management of hand burn injuries is essential in the overall functional rehabilitation of the patient.
Unsuccessfully treated severe hand burns can result in joint stiffness, scar contracture and ultimately severe disability.
Hand burn injury typically involves the dorsum. Healing of the hand is complicated by the thinness of the dorsal skin and the superficial location of joints in the hand. Lax, flexible and pliable dorsal skin is critical for normal mobility of the metacarpophalangeal joints and abduction-flexion of the thumb.
Limited autograft donor site availability can pose challenges for both acute and reconstructive surgery. Even if donor sites are available, patients may be reluctant to undergo a procedure entailing creation of a new wound site itself susceptible to scarring. Sequelae at the donor site can include pain, delayed healing, infection and hypertrophic scarring, and such risks increase with greater thickness of the harvest. Donor sites of thin split-skin autografts heal readily and can be reharvested frequently without long-lasting scarring.
The desirability of additional therapeutic options, particularly to minimise donor site morbidity, has prompted a concerted effort over the last several decades to develop skin substitutes. One currently available permanent skin substitute consists of a dermal regeneration template (Integra® Dermal Re-generation Template, Ethicon, Inc., Somerville, NJ, USA). Integra has been shown to be effective in treatment of primary acute full- and partial-thickness burn injuries and in reconstructive surgery.
This study was undertaken to evaluate the value of Integra in the treatment of both acute 3rd-degree hand burn injuries and in restoration of hand function in reconstructive procedures subsequent to deep burn injury.
1. Methods
1.1 Patients
Between February 1997 and July 2002, Integra dermal regeneration template was used to treat 22 patients for deep burn injuries of the hand. Patients were eligible for the study if they presented with either acute 3rd-degree deep burns of the hand requiring prompt surgical excision and grafting or hypertrophic scars, contractures or adherent grafts on the hand necessitating reconstructive procedures with full- or split-thickness grafts. Candidates for acute treatment were excluded if they were unfit for early excision and grafting or if wound site infection was present. A total of 15 hands in 11 patients were treated for acute burn injuries, while reconstructive procedures were performed on 14 hands in 11 patients. Informed consent was obtained from the elective surgery patients, and all procedures were conducted in accord with the ethical standards established at the study institutions. All procedures were performed on an inpatient basis under general anaesthesia. Reconstructive surgery patients remained hospitalised between placement of the dermal regeneration template graft and the epidermal autograft in order to receive physical and occupational rehabilitation therapy.
1.2 Dermal regeneration template
Integra® Dermal Regeneration Template consists of a cross-linked collagen and chondroitin-6-sulfate dermal replacement layer covered by a silicone temporary epidermal substitute to retard moisture loss and close the wound bed.
Integra sheets were applied in unmeshed form to the wound bed immediately following excision. Meticulous hemostasis of the wound was achieved in order to prevent hematoma formation, which could result in reduced take. Neodermis forms during the 2–3 week period after Integra application, after which the silicone layer is peeled away and a very thin split-thickness epidermal autograft can be placed.
For acute burn patients, excision of the wound bed was carried out between the third and fifth day after the injury. The preferred level of dissection was the perimysium. In reconstructive surgery patients, excision of scar tissue proceeded until satisfactory articulation and free movement of tendons were attained. In one reconstructive surgery patient, release of the neurovascular bundles of the carpal and Guyon canals was necessary.
Following excision, the clinical protocol for acute and reconstructive surgery patients was the same. The unmeshed Integra graft was placed immediately after excision and fixed into place with staples. The secondary dressing, which consisted of a sterile compress moistened with povidone iodine covered by Velpeau strips, was changed every 48 h to permit observation of the dermis and to detect any complications. When neovascularisation of the dermal component of Integra had taken place—as judged by a pink to reddish graft colour consistent with adequate vascularisation and the ability to separate the silicone easily from the dermal regeneration template—an ultra-thin unmeshed autograft of 0.13 mm thickness taken from the inner thigh or arm was placed. The epidermal autograft was fixed in place by staples. Vaseline gauze was used for the primary dressing, and dry sterile compresses with Velpeau strips as the secondary dressing. Dressings were changed every 48 h.
A palmar splint, maintaining the metacarpophalangeal joints at 90°, the fingers in full extension, the thumb in abduction and the wrist in neutral was used during the entire postoperative healing period. A number of patients were also fitted with a pre-tendinous palmar splint to control metacarpophalangeal articulation. Passive, then aided-active and active physiotherapy was instituted as soon as healing had occurred. Physiotherapy was accompanied by the wearing of static and dynamic restraints and made-to-measure compressive gloves. The physiotherapy regimen was maintained for 8–10 months.
1.4 Outcome measures
Functional results of the Integra graft as well as the mechanical and cosmetic quality at the grafted hands were documented. Dermal and epidermal autograft take were noted, as well as postoperative complications such as infection or mechanical displacement of the graft.
In both acute and reconstructive surgery patients, burn scars were rated according to the Vancouver Scar Scale.
Patients also rated their satisfaction. The surgical team rated both the cosmetic appearance and the mobility of the healed hands. Therapeutic results with Integra were rated as (1) excellent (complete, maximal or optimal feasible restoration of movement and/or function), (2) good (significant restoration of movement and/or function) and (3) poor (transitory restoration of movement and/or function) as compared with results expected after conventional surgery and placement of a full-thickness graft.
In reconstructive surgery patients, articular and functional gains were evaluated by three measures: (1) prehensile ability, (2) opposition of the thumb and (3) measurement of the distances from fingertips to palm. Clinical evaluation of thumb opposition was based on the system of Kapandji with a 1–10 scale, as explained in Table 1.
Each listed constituent contributes 0–3 points to the total score as follows: 0, impossible; 1 limited in amplitude, strength or speed; 2, possible but un-comfortable; 3, normal.
Stata 7.0 (Stata Corp., College Station, TX, USA) and StatXact 5.0.3 (Cytel Software Corp., Cambridge, MA, USA) software programs were used for statistical analysis. The significance of pre- vs. posttreatment changes in measures of cosmetic and functional status was evaluated by exact Wilcoxon signed rank test for paired data. Point estimates of median pre- vs. posttreatment changes in these outcome measures and corresponding exact 95% confidence intervals (CI) were calculated by the Hodges–Lehmann method for paired data.
2. Results
2.1 Acute surgery patients
Eleven patients with acute 3rd-degree burns, (eight men and three women) were treated with Integra on a total of 15 hands. Fourteen grafts were to the dorsum and one to the palmar region. Patient characteristics, TBSA burned, number of hands grafted, and time from injury to surgery are presented in Table 3. The median age of the patients was 52 years (range 18–73 years), with a median TBSA of 40% (range 1–60). Excision and grafting were performed on day two or three after the burn injury, except in one case in which surgery was delayed to day five after injury.
Table 3Characteristics of acute surgery patients with 3rd-degree burns to the dorsum of the hand
Patient
Sex
Age (y)
Initial% TBSA burned
Days to graft
Hands grafted
Vancouver Scar Scale
Follow-up (mo)
Comment
1
M
18
45
5
1
4
12
2
F
41
40
3
1
3
12
Spontaneous healing after mechanical dislodgment of epidermal autograft on left hand; Z-plasties required for interdigital contractures on second, third and fourth web spaces of both hands
3
F
62
28
3
1
0
12
4
M
45
6
3
1
2
12
Localised infection of the epidermis resolved with use of topical antibiotics
Spontaneous healing after mechanical dislodgment of epidermal autograft on right hand; Z-plasties performed to treat interdigital web contractures on first and fourth web spaces of left hand and 1st, second and third of right hand
10
M
56
54
2
2
4
12
Supplementary epidermal graft necessitated by partial loss of initial epidermal graft on both hands
11
M
58
60
3
1
–
9
Integra grafted directly over exposed bones obviated amputation
Abbreviations: TBSA, total body surface area. Size of Integra graft 250 cm2 in all cases except patients 4 and 7, who received 125 cm2 grafts. Take of Integra graft was 100% in all cases. Thickness of subsequent epidermal autograft was 0.13 mm. Median epidermal autograft takes was 100% (range, 60–100%).
Take of the Integra dermal regeneration template, which was 100% on all hands, occurred, on average, on day 17 (range 14–23). The 0.13 mm thick epidermal autografts were placed between days 15 and 23, and sites healed on average 12 days after autograft surgery.
The dermal regeneration template vascularised without incident in all patients, without any infections or loss, even though the silicone layer detached prematurely in two patients. As noted in Table 3, minor epidermal graft problems were encountered in several patients, but in only one patient was a supplementary epidermal graft necessary.
Median length of follow-up was 12 months (range 1–12), and regular assessments were made of articular and functional gains. Restoration of normal function occurred between 1 month and 3 months after the burn injury and was dependent upon the length of intensive care and the commencement of rehabilitation. Compared with movement regained after full thickness grafting, the surgical team judged the outcomes achieved with Integra to be excellent. Articular and functional results remained stable over time for all the patients treated (Fig. 1, Fig. 2) .
Fig. 1A 51-year-old male with acute burn injuries to the left hand: (a) preoperative view, (b) perioperative view on day 3 after grafting of 250 cm2 of the dermal regeneration template, (c) cosmetic results at 1 year, and (d) functional results at 1 year.
Fig. 2A 29-year-old male with acute burn injuries to the left palm: (a) preoperative view, (b) result at 18 months after surgery showing that skin at healed site was supple and that there was no adherence to deeper layers, (c) excellent functional recovery with normal finger extension and normal thumb opposition, and (d) complete finger flexion.
Cosmetic results were judged satisfactory by both patients and surgeons (Fig. 1(c)). The grafted skin was flexible and supple and allowed free articular and functional movement (Fig. 2(b)–(d)). Hypertrophic scar formation was not observed on areas grafted with Integra, but did occur in some instances on neighbouring injured sites. Two hands required Z-plasties for interdigital contractures (Table 3).
In one case, after the finger extremities were amputated, Integra was successfully grafted directly over the exposed bones of the dorsal area of the fingers in order to salvage the remaining portion of the digits (Fig. 3) . Excellent cosmetic and functional results were achieved (Fig. 3(d)).
Fig. 3A 58-year-old male with acute injury to the left hand: (a) preoperative view showing severe 3rd-degree burns that required the finger extremities be amputated but allowed treatment plan to salvage remainder of fingers, and (b) Integra dermal regeneration template grafted directly over the exposed bones on the dorsal surface of the fingers 3 weeks after excision of fingertips. A 100% successful graft was achieved with excellent functional outcome at 9 months, as evidenced by capability for (c) finger extension, (d) finger flexion, (e) grip and (f) flexion of the proximal phalanx of the index finger.
Fourteen hands of 11 reconstructive surgery patients, five men and six women, were treated with Integra. Ten patients had thermal burn injury and one had electrical burn injury. Patient characteristics, including area of reconstruction and time after initial injury are detailed in Table 4. Median age of the patients was 39 years (range 8–60), with a median TBSA burned of 35% (range 6–75%). Median time after burn was 18 months (range 3–132). Median follow-up after reconstructive surgery was 12 months (range 3–36).
Table 4Characteristics of reconstructive surgery patients
Patient
Sex
Age (y)
Initial% TBSA burned
Months from burn
Hands grafted
Follow-up (mo)
Reconstruction area
1
F
30
57
11
2
36
Contractures, hypertrophy on dorsum of both hands
2
F
43
47
11
1
24
Contracture of left thumb
3
M
45
6
3
1
12
Palmar, wrist scarring with neurovascular compression of median and ulnar nerves
4
M
53
7
12
1
18
Palmar scarring resulting in thumb adduction and extended fingers; normal palmar arch restored
5
F
58
30
18
2
12–20
Adherent grafts on forearm and dorsal hand
6
F
19
55
24
1
3
Adherent grafts of right hand and forearm, finger and wrist flexion impossible
7
M
39
16
24
2
14
Bilateral hypertrophic scars of dorsum, thumb columns and forearms
8
F
32
38
132
1
9
Resurfacing of dorsum of left hand
9
M
25
35
18
1
9
Hypertrophic scarring of dorsum of left hand
10
M
60
75
24
1
5
Adherent grafts on dorsum of left hand
11
F
8
7
8
1
5
Hypertrophic scarring of dorsum of right hand
Abbreviations: TBSA, total body surface area. Take of Integra graft was 100% in all cases. Thickness of subsequent epidermal autograft was 0.13 mm.
The average surface area of grafted Integra dermal regeneration template was 182 cm2 per hand (range 80–250 cm2), and take of the Integra was 100% on all treated hands. Both the cosmetic and functional status of hands treated by reconstructive procedures with Integra improved significantly (Table 5) .
Table 5Cosmetic and functional outcomes in hands after reconstructive procedures
Nine hands in seven patients; analysis was performed using pooled median values for the separate measurements of distance from palm to each of four fingertips on each hand.
c Nine hands in seven patients; analysis was performed using pooled median values for the separate measurements of distance from palm to each of four fingertips on each hand.
Reconstructive patient 7 presented with hypertrophic cords affecting both thumbs and extending to a mass of scar tissue in each forearm. The hypertrophic scar on the left thumb started at the base of the nail and led to radial subluxation of the metacarpophalangeal articulation (Fig. 4(a)) . Excision of the hypertrophic cords permitted freeing of the thumbs and correction of the left thumb. Fifteen months after Integra was grafted on both hands and arms, cosmetic outcome was judged to be excellent (Fig. 4(d)). The skin exhibited excellent pliability, flexibility and normal colour (Fig. 4(d)–(f)), and both thumbs had regained function (Fig. 4(f)).
Fig. 4A 39-year-old male with bilateral hypertrophic scars of the dorsum, thumb columns and forearms requiring reconstructive surgery: (a) preoperative view of hypertrophic and retractile scars on the lower arm extending to the thumb column, (b) neovascularised dermal regeneration template on day 17 with the silicone layer removed prior to epidermal autograft placement, (c) ultrathin epidermal autograft placed on day 17 after harvesting from the arm, (d) final cosmetic results of left hand at 15 months postoperatively with normal skin colour and absence of hypertrophic scars, (e) normal skin pliancy with no adherences to deep planes, and (f) thumb opposition and normal flexibility; on the contralateral hand (not shown) similarly favourable results were evident.
In reconstructive patient 5, who had adherent grafts on the right forearm and hand, excision of the expanded grafts placed initially after his injury exposed the antebrachial muscle bundles and their tendons, as well as the extensor tendons of the hands. Integra was successfully grafted on these exposed musculotendinous layers. At 10 months follow-up, the cosmetic and functional results were greatly improved (Fig. 5(b)–(d)) . Normal range of motion was achieved with no adhesions between the skin and underlying tissue.
Fig. 5A 58-year-old female with adherent grafts on the forearm and dorsal hand resulting from use of expanded grafts after initial injury: (a) perioperative view of excision of primary grafts until total functional freedom of hand had been restored, (b) final cosmetic result at 10 months follow-up, (c) finger flexion at 10 months, (d) normal range of motion with no adherences between the skin and deep planes after grafting of dermal regeneration template over tendons.
Reconstructive patient 3 had developed compression of the carpal and Guyon canals in his right hand following electrical burns. Decompression of the scar and grafting with Integra resulted in the restoration of a normal range of motion (Fig. 6) and substantial improvement in the electrophysiological measures of function in the median and ulnar nerves.
Fig. 6A 45-year-old male with palmar and wrist scarring involving neurovascular compression of the median and ulnar nerves: (a) preoperative view of carpal and Guyon's tunnel freed from scar compression, (b) normal range of motion postoperatively, (c) normal flexion of fingers, and (d) normal opposition of thumb.
Preoperatively, reconstructive patient 6 had developed adherent grafts of the right hand and forearm severely restricting flexion and extension of the wrist and fingers. Integra graft placement combined with tenolysis with stretching of the tendons of the digital flexors resulted in postoperative flexion of 80° and extension of 40°.
Overall, reconstructive surgery patients judged both function and cosmetic outcomes to be very satisfactory. The surgical team rated the results as excellent. Two hands developed secondary interdigital web contractures that were corrected with Z-plasties.
2.3 Donor sites
In both acute and reconstructive surgery patients, an epidermal autograft of 0.13 mm thickness was harvested. While the graft should be as thin as possible, if the autograft is too thin mechanical dislodgment may occur because of failure to reestablish a dermo-epithelial junction. The hydrocolloid dressing was changed at the donor site on the second day after harvesting and then left in place until healing was complete. Donor sites usually healed within 8–10 days, and could be reharvested after 2 week. No infection or appreciable scarring occurred at any of the donor sites.
3. Discussion
This series of 22 patients is the first to focus on the cosmetic and functional results with Integra dermal regeneration template for the surgical treatment of deep burns of the hands either at the acute injury stage (15 hands) or during reconstructive procedures (14 hands). Though preliminary, the study results are promising.
In the acute surgery patients, compared with movement regained after full thickness grafting, the surgical team judged the outcomes achieved with the Integra to be excellent. Moreover, articular and functional results remained stable over time. Skin was pliable and supple, and hypertrophic scarring did not occur. Use of Integra grafted directly over the exposed bone aided us in preserving a substantial portion of the digits of one patient's deeply burned hand. In the case of severe burns, the unlimited availability of Integra permits the early surgical treatment of functional areas such as the hands, without compromising treatment of other injured areas. If grafting is delayed for more than 2 weeks because of lack of donor sites, hypertrophic contractures are more likely to develop. With the use of this technique, early grafting permits good quality cosmetic and functional recuperation. Donor sites are not required in the early days after burn injury and, because only ultra-thin epidermal autografts are eventually needed to cover the dermal regeneration template, repeated sampling of donor sites at short time intervals is possible.
An overriding goal in reconstruction of a burned hand is to maximise and restore function.
As detailed in Table 5, hands grafted with Integra in the reconstructive surgery patients showed significant improvement in three quantitative measures of functional status: thumb opposition score, fingertip-to-palm distance and prehensile score. In the thumb opposition scale, the median score for patients increased markedly from 3.5 (thumb tip able to reach the lateral or palmar aspect of the distal phalanx of the index finger) to 9.5 (thumb tip reaching palmar aspect of middle or proximal phalanx of little finger) posttreatment. The median distance from fingertip to palm in full flexion decreased to 2.0 cm posttreatment from 6.5 cm pretreatment. Finally, patients scored substantially higher on the prehensile scale reaching a median of 61, starting from a median score of 13.
As judged by the Vancouver Scar Scale, suppleness was also significantly improved in hands undergoing reconstructive surgery. Scores improved to a median of 2 posttreatment from a median of 10 pretreatment. We observed that Integra appears to be able to restore the dermal plane. In contrast, after full-thickness autografts we have observed some adherence of the graft to the deeper tissue planes. It has been shown that the Integra replacement dermis supports the formation of normal dermis rather than scar tissue. The collagen dermal replacement layer serves as a matrix for the ingrowth of fibroblasts, macrophages, lymphocytes and endothelial cells derived from the wound bed. As healing progresses an endogenous collagen matrix is deposited by fibroblasts, while the dermal layer of the dermal regeneration template is degraded over a period of approximately 30 days. Intact dermis is eventually restored with regrowth of apparently normal reticular and papillary dermis.
The surgical technique for grafting Integra is relatively simple. The dermal regeneration template adheres rapidly to the wound bed, and removal of the silicone layer is relatively atraumatic compared to allograft and xenograft that must be excised from the wound. Moreover, the formation of the neodermis can be visually monitored through the silicone layer.
One disadvantage of Integra grafting is the need for two-stage surgery. However, the time interval between the two operations is only 15–21 days, a period comparable to that for placing and subsequently detaching a pedicled flap. Care must also be taken to apply Integra to fresh, clean surgical sites immediately after excision. Also meticulous hemostasis of the surgical wound is required in order to prevent hematoma formation, which can result in reduced take.
Grafting with Integra compares well with other alternatives for treatment of deep hand burns. More complex techniques such as full thickness skin grafts, Colson skin, posterior interosseous flaps, radial forearm or even groin flaps are seldom feasible in the emergency setting, and the required extent of donor sites may also preclude their use in reconstructive procedures on the hand. Skin expansion techniques involve intensive treatments over a 2–3 months period with prospects for achieving only a limited final surface area and the risk of complications.
Frequently, expanded mesh grafts are employed for early treatment; however, after such grafts the optimal long-term properties of the skin are not typically achieved. Moreover, use of such grafts is associated with several problems such as pruritus, hypertrophic scarring and contractures.
In light of the limited number of patients in this study, our results need to be confirmed in further investigations. Nonetheless, we have observed that the final functional and cosmetic qualities achieved with Integra dermal regeneration template were comparable to those with full-thickness skin grafts without the disadvantages of potential adhesion to deep layers and donor site scarring. Based upon the consistently favourable functional and cosmetic results achieved in our patients, grafting with Integra can be regarded as a promising modality for the treatment of deep hand burns, both at the acute injury stage and in reconstructive surgery.
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