Dermal Substitute as Bridge in Finger Reconstruction
Dermal Substitute as Bridge in Finger Reconstruction
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.
(Enlarge Image)
Figure 1.
A 46-year-old patient with a complex right middle finger injury.
A) Loss of flexor retinaculum and paratenon with exposed tendon.
B) Immediate postoperative coverage with contoured ADS graft (cross finger flap avoided).
C) Perioperative radiograph.
D) Three weeks post-op (ADS and sutures removed).
E) Eight months post-pinch FTSG.
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, 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.
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.
(Enlarge Image)
Figure 1.
A 46-year-old patient with a complex right middle finger injury.
A) Loss of flexor retinaculum and paratenon with exposed tendon.
B) Immediate postoperative coverage with contoured ADS graft (cross finger flap avoided).
C) Perioperative radiograph.
D) Three weeks post-op (ADS and sutures removed).
E) Eight months post-pinch FTSG.
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, 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.
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