Case Reports

Coverage of Hand Defects with Exposed Tendons: The Use of Dermal Regeneration Template

Publish date: May 11, 2018

TAKE-HOME POINTS

Full thickness skin grafts are generally considered unreliable for coverage of 3-dimensional defects of the hand with tendon exposure.
Integra (Integra LifeSciences) is a bilayer skin substitute. The “dermal” (lower) layer is a bovine collagen base with glycosaminoglycan chondroitin-6-sulfate while the upper layer is a silicone sheet that acts as a temporary epidermis.
Despite its popularity of Integra in burn reconstruction, little has been published regarding its utility in complex hand wounds with exposed tendons.
Small areas of exposed tendons without remaining paratenon can be successfully grafted with Integra.
In the presence of a healthy wound bed and no necrotic tissue or infection, Integra offers a reconstructive option that allows immediate coverage of complex hand wounds.

References

1. Flügel A. Kehrer C. Heitmann C, German G, Sauerbier M. Coverage of soft tissue defects of the hand with free fascial flaps. Microsurgery.2005;25(1):47-53.

2. Chen H, Buchman MT, Wei FC. Free flaps for soft tissue coverage in the hand and fingers. Hand Clin. 1999;15(4):541-554.

3. Chia J, Lim A, Peng YP. Use of an arterialized venous flap for resurfacing a circumferential soft tissue defect of a digit. Microsurgery. 2001; 21(8):374-378.

4. Wheeldon T. The use of cellophane as a permanent tendon sheath. J Bone J Surg Am; 1939;21(2):393-396.

5. Frykman E, Jacobsson S, Widenfalk B. Fibrin sealant in prevention of flexor tendon adhesions: an experimental study in the rabbit. J Hand Surg Am. 1993;18(1):68-75.

6. Jones NF, Lister GD. Free skin and composite flaps. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative hand surgery. 6th ed. New York, NY: Churchill Livingstone; 2011:1721-1756.

7. Yan D, Shi X, Lui Q. Reconstruction of tendon sheath by autogenous vein graft in preventing adhesion. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 1997;11(1):38-39.

8. Pederson WC. Upper extremity microsurgery. Plast Reconstr Surg. 2001;107(6):1524-1537; discussion 1538-15399, 1540-1543.

9. WintschK, Helaly P. Free flap of gliding tissue. J Reconstr Microsurg. 1986;2(3):143-151.

10. Meland NB, Weimar R. Microsurgical reconstruction: experience with free fascia flaps. Ann Plast Surg. 1991;27(1):1-8.

11. Bray PW, Boyer MI, Bowen CV. Complex injuries of the forearm. Coverage considerations. Hand Clin. 1997;13(2):263-278.

12. Levin LS. The reconstructive ladder: an orthoplastic approach. Ortho Clin North Am. 1993; 24(3):393-409.

13. Hallock GG. Utility of both muscle and fascia flaps in severe lower extremity trauma. J Trauma. 2000;48 (5):913-917. doi:10.1097/00005373-200005000-00016.

14. Hallock GG. The utility of both muscle and fascia flaps in severe upper extremity trauma. J Trauma. 2002;53(1):61-65. doi:10.1097/00005373-200207000-00013.

15. Khouri RK, Cooley BC, Kunselman AR, et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg. 1998;102(3):711-721.

16. Woods JM 4th, Shack RB, Hagan KF. Free temporoparietal fascia flap in reconstruction of the lower extremity. Ann Plast Surg. 1995;34(5):501-506. doi:10.1097/00000637-199505000-00008.

17. Chung KC, Cederna PS. Endoscopic harvest of temporoparietal fascial free flaps for coverage of hand wounds. J Hand Surg Am. 2002;27(3):525-533.

18. Sanger C, Molnar JA, Newman CE, et al. Immediate skin grafting of an engineered dermal substitute: P37. Plast Reconstr Surg. 2005;116(3S):165.

19. McCash CR. The open palm technique in Dupuytren’s contracture. Br J Plast Surg. 1964;17:271-280.

color:black">20. Shaw DL, Wise DI, Holms W. Dupuytren's disease treated by palmar fasciectomy and an open palm technique. J Hand Surg Br. 1996;21(4):484-485.

ABSTRACT

Soft tissue defects associated with exposed tendon pose difficult reconstructive problems because of tendon adhesions, poor range of motion, poor cosmetic appearance, and donor site morbidity. Dermal regeneration template is a skin substitute widely used in reconstructive surgery, including the occasional coverage of tendons. However, postoperative functionality of the tendons has not been well documented. We report a case of using dermal regeneration template for soft tissue reconstruction overlying tendons with loss of paratenon in a patient with Dupuytren’s contracture. Dermal regeneration template may offer an alternative option for immediate tendon coverage in the hand.

Soft tissue defects overlying exposed tendon with loss of paratenon often precipitate poor clinical outcomes because of the dichotomous demands of both closing the overlying soft-tissue defect and providing a gliding surface for the underlying tendons.¹ Although avoidance of adhesions and restoration of function are the primary goals of the procedure, satisfactory appearance is also desirable. Likewise, any form of coverage should ideally provide good vasculature required for complete healing and an early form of closure following débridement.² Simple skin grafts do not adequately meet these demands because they result in a high rate of tendon adhesions,³ and also are limited in patients with limited donor skin availability or questionable underlying wound bed viability, such as in scleroderma.

In order to reduce the frequency of tendon adhesions by creating a gliding surface, the use of interpositional materials, both artificial and biologic, has been employed with varying degrees of success, including cellophane, chitosan membrane, fibrin sealant, autogenous fascial flaps, and autogenous venous grafts.^4-7 Many of the autogenous flaps and grafts have been employed with good success.⁸ However, complications and donor site morbidity encourage alternative procedures, including the use of artificial substances.^2,8-10

We present our clinical experience with a patient who underwent successful placement of Integra (Integra LifeSciences) Dermal Regeneration Template (DRT) directly over exposed tendons with a subsequent full-thickness skin graft several weeks later. The procedures were performed per the manufacturer’s specifications, resulting in 2 stages of reconstruction. In our experience, DRT can offer immediate coverage unrestricted by wound size, and provides shorter operative time and decreased donor site and surgical morbidity compared with flap coverage, while demonstrating good cosmetic results. The patient provided written informed consent for print and electronic publication of this case report.

CASE

A 74-year-old right-handed man with Dupuytren’s contracture was evaluated for recurrent symptomatic contracture causing difficulty with daily activities. He reported palpable cords and contractures in the ring and small fingers of the right hand. He had 2 prior open surgical procedures, including palmar and digital fasciectomy of both hands. On the right hand, the ring and small fingers demonstrated 90° proximal interphalangeal (PIP) and 60° metacarpophalangeal (MCP) flexion contractures. Palpable central cords were present on the flexor surfaces of both the ring and small fingers. A well-healed surgical incision, performed 22 years earlier, was present over the palmar aspect of the ring finger.

Continue to: With consideration given...