Acellular Dermal Allograft for Coverage of Exposed Joints and Tendons in Major Burn Injury Patients

Background: Large surface area deep burn involving digital joints is a devastating injury. The exposed joints and tendons need to be covered rapidly and reliably otherwise it can result in significant functional deficit. There are very few options available for coverage in these instances as local flaps are not possible and patients are too unstable for free flaps. We have utilized acellular dermal allograft (ADA) for coverage of exposed joints and tendons following major burn injury.

Methods: Major burn injury patients with exposed joints, joint capsule or tendon are selected for coverage of these critical areas with extra thin (<0.020 inch) ADA. The wounds are thoroughly debrided of all devitalized tissues. ADA is applied to cover the exposed joint with at least 5 mm overlap on to healthy surrounding wound bed to derive blood supply. When applied to PIP joint, lateral bands and central slip are secured and stabilized by anchoring them to ADA. Digit is covered with cadaveric allograft and dressed with Mafenide Acetate soaked gauze dressings or covered with silver dressing and placed in negative pressure wound dressing. Hand is placed in a form fitting intrinsic plus splint. Once ADA is vascularized (7-10 days), thin skin graft is applied to ADA for completion of coverage. Hand therapy is started after 7 days of skin graft coverage.

Results: Between 2003 and August 2012, we have utilized this technique in 20 patients (age 6 to 61 years) covering 82 digits (and one knee joint). Of these, we achieved stable coverage in 69 digits with follow-up ranging from 1 month to 5 years. We revised ADA use in 3 instances with eventually successful coverage. The failed coverage, mostly due to infection, required amputation of digit at the corresponding joint level (6) or joint fusion after clearance of infection (7). We observed mild to moderate Boutonniere deformity in 8 digits that did not require any surgical intervention. Patients achieved good functional result.

Conclusion: ADA can provide reliable coverage for exposed but potentially salvageable joints over severely burned digits when local flaps are not feasible. Thin ADA may help minimize eventual deformities in selected patients with exposed digital joint.