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

May 11, 2018 | Surgery
Eitan Melamed, MD ; Charles P. Melone, Jr, MD
Author and Disclosure Information

Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

Acknowledgment: The authors thank Allison Zur for her help in preparing the manuscript.

Dr Melamed is an Assistant Professor, Division of Hand Surgery, Department of Orthopedic Surgery, NYU Langone Health, Langone Orthopedic Hospital. New York, New York. Dr. Melone is Director of the Division of Hand Surgery, Mount Sinai Beth Israel, and Professor of Clinical Orthopedic Surgery, the Icahn School of Medicine, Mount Sinai. New York, New York. 

Address correspondence to: Eitan Melamed, MD, Division of Hand Surgery, Department of Orthopedic Surgery, NYU Langone Health, Langone Orthopedic Hospital, 301 E 17th street, New York, NY 10003 (email, Eitanme20000@yahoo.com).

Am J Orthop. 2018;47(5). Copyright Frontline Medical Communications Inc. 2018. All rights reserved.

Eitan Melamed, MD and Charles P. Melone, Jr, MD . Coverage of Hand Defects with Exposed Tendons: The Use of Dermal Regeneration Template . Am J Orthop.

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.

With consideration given to the patient’s recurrent contracture after a prior surgical procedure, we discussed surgical excision of the diseased cords in order to eliminate the possibility of a second recurrence and maximize the gain of motion. Following discussion with the patient, we performed palmar and digital fasciectomy of the ring and small finger contractures. Postoperatively, the patient was followed closely for wound complications and vascular status. On his return to our clinic 11 days later, the patient was noted to have dehiscence of the digital wounds in the ring and small fingers (Figure 1). 

The flexor tendons of both digits were exposed with loss of paratenon, with defect sizes of 1 cm × 1.5 cm on the small finger and 1.5 cm × 2 cm on the ring finger.

STAGE 1

During the first stage, completed 14 days following the index procedure, débridement of the wounds was performed, followed by provisional DRT coverage of the tendons, secured with 5-0 nylon sutures (Figure 2). 

Next, nonadherent ADAPTIC dressings (Acelity) were placed over the DRT and affixed to the skin using gauze fluffs. On postoperative day 1, the first dressing change was performed, after which a weekly wound inspection was performed to evaluate for infection and to note the degree of vascularization of the neodermis beneath the silicone layer (Figure 3).

STAGE 2

At approximately 2 weeks after application of the DRT, a full-thickness skin graft was applied. The thickness of the graft was chosen to allow for durable coverage of the palmar skin defects. Upon successful completion of the second stage, the patient was followed and evaluated for complete wound healing. On performing an examination 14 days after surgery, the ring and small fingers demonstrated only partially healed skin graft but significantly improved range of motion (ROM), with 40° to 90° arc of motion in the PIP joint and 25° to 90° arc of motion in the MCP joint (Figure 4). Owing to their limited size, the wounds were treated with dressing changes until successful healing (Figure 5).

 

Hand therapy was instituted to achieve maximum mobility for covered soft tissue and tendons and to maximize tendon gliding. At 1-year follow-up, the skin was fully healed and the patient’s active PIP motion was 30° to 90°, active MCP motion was 0° to 90°, and grip strength was 90 lb on both sides. The tendons glided under a well-vascularized tissue at the DRT placement site, and no secondary tenolysis procedure was deemed necessary.

DISCUSSION

Soft tissue defects with exposed tendons may offer a number of challenges for coverage. The primary concern is the creation of a gliding surface and the restoration of a functional tendon without adhesions.2 However, surgeons must use their own clinical judgment when choosing the method of coverage so as to minimize the effects of donor site morbidity and maximize the overall functional and cosmetic outcomes. All options must be considered while selecting a material or flap that is likely to survive in the relatively avascular tendon plane.2,8,11 When considering the reconstructive ladder, skin grafts may not represent a viable option in the presence of a nonvascularized wound bed, such as exposed tendon or bone, where paratenon or periosteum have been damaged. That leaves the surgeon with local flaps, regional flaps, free flaps, and skin substitutes.

Continue to : Before planning closure...

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