Sunday, October 10, 2004

Coverage of Exposed Joints with Acellular Allograft Dermis in Deep Thermal Injury of Hand in Patients with Very Few Options

Mayer Tenenhaus, MD, Dhaval Bhavsar, MD, and H O Rennekampff, MD.

Objectives: One of the most devastating complications of deep injuries to the hand and finger is the exposure of joint, tendon, and neurovascular structures. The inevitable consequence of such injuries often results in severe deformity often requiring joint fusions and digital amputations. The anatomic limitation is that there are few reliable large soft tissue flaps available for this intricate distribution. This is particularly true for the patient who has suffered very large distribution and deep thermal injuries.

Methods: In this series of cases, thin and meshed Alloderm was chosen to cover the exposed joint, tendon and neurovascular structures and to secure the position of the lateral tendinous bands. Alloderm is a decellularised human allograft dermis. It is used in Plastic Surgery for burn and facial reconstruction and has very good acceptance amongst plastic surgeons regarding its biocompatibility.We assumed that thin Alloderm will get vascularized from surrounding tissues and will provide a stable coverage as well as prevent desiccation of joint and infection. Allograft coverage was utilized in all cases as a provisional biologic coverage. It was secured with a combination of sutures and a dilute thrombin glue spray. In all cases, the soft tissues were maintained in dilute Sulfamyelon solution moistened dressings and the extremities splinted. The fingers and joints were gently ranged when the allograft appeared to show adherence. After 2 weeks and one allograft change in the operating theatre, thin and whenever possible non - meshed skin grafts were applied.

Results: Out of 23 digits treated in this manner, 18 digits showed good outcome. 1 digit had to be amputated due to infection. 3 digits developed Boutonniere's deformity. Other required reconstructive surgeries were offered and all patients are well rehabilitated now.

Conclusions: Early flap coverage whenever possible remains our preferred method of treatment for exposed joint, tendon and neurovascular structures. Early and judicious use of splinting and gentle range of motion and subsequent strengthening regimens are similarly advocated. When flaps are not feasible and faced with potentially salvageable yet terribly injured hands and fingers with complicated exposure, thin and meshed Alloderm may facilitate and provide durable and vascularized soft tissue coverage while minimizing eventual deformities.