NEWS LETTER
Vol.06 JUN 2012

Treatment of Extensive Soft Tissue
Defects Accompanied by Open Fracture

Toshiya Kudo M.D.
Director of Traumatic Reconstructive Center,Juntendo University Urayasu Hospital

Introduction
When skin graft is carried out directly onto soft tissue defects, it is expected that the scar will contract severely andthe mechanical strength of the skin will decrease. For most full-circumferential open wounds, scar contraction anddecreased mechanical strength may lead to reduced ADL and QOL.

PELNAC™, a material composed of atelo-collagen is an artiﬁcial dermis used to treat full-thickness skin defects. Use of this material
allows good formation of a collagen ﬁber layer on muscle ﬂaps, enabling ﬂexible and mechanically strong coverage even for splitthickness skin grafts.
Initially, the conditions required are thorough debridement, prompt coverage with a well-vascularized tissue and future planningwith a long term vision.

Patient background: Male, 30`s
The patient’s left leg was caught in a stone crusher, resulting in exposed bone over the entire length of the tibia, as well
as a de-gloving injury. This patient also presented with a heat-press injury where eschar formed due to the heat from theroller of the stone crusher.
Furthermore, the medial side of the tibia had periosteum defect and the ankle had fracture-dislocation with defect tothe malleolus, however the patient maintained sensation in the plantar region. (Fig. 1).

Fig. 1 Initial examination
The left leg was caught in a stone crusher, resulting in a heat-press
injury accompanied by an ankle fracture dislocation, a bone defectin the medial malleolus, medial femoral condyle fracture andextensive soft tissue defects.

Treatment of Extensive Soft Tissue Defects Accompanied by Open Fracture

Treatment
Since the patient had blood circulation in his lower limb, maintained sensation in the plantar region and given his youngage, the injured limb was preserved under his desire and consent.I
nitially, thorough debridement of the necrotic tissue was performed under anesthesia (Fig. 2a). At that time, we
confirmed that muscle tissue on the posterior aspect of the patient’s lower leg was not affected by burns except fora portion of the medial head of the gastrocnemius muscle. The skin tissue on the lateral side of the ankle was alsounaffected. We decided to cover the fully exposed tibia using local tissues initially. The contaminated area of the ankle
was excised and fixated at the time. (Fig. 2b) The exposed tibia was covered with soleus and gastrocnemius medial headflaps as well as a rotation flap from the lateral side of the ankle to ensure sufficient blood circulation. (Figs. 2c and 2d).
PELNAC was applied as a covering for the muscle flaps (Figs. 3a and 3b).

Fig. 2aFig. 2 Day of injury

Fig. 2bFig. 2cFig. 4c

Thorough debridement (Fig. 2a) and one-stage fixation of the dislocated ankle were performed.
(Fig. 2b)
The exposed tibia was covered with soleus and gastrocnemius medial head flaps (Figs. 2c and 2d).

Fig. 3aFig. 3bFig. 3 Post-surgery (day of surgery)Muscle flaps were covered with PELNAC(Figs. 3a and 3b).

A week later, the silicone film of PELNAC was removed. The wound was cleansed once a day and bFGF and non-adherent
materials were applied at dressing change.
Dermis like tissue partially formed at the PELNAC implanted site due to the effect of bFGF.
To further promote granulation, NPWT (Negative Pressure Wound Therapy) was applied in combination for
approximately 4 weeks (Fig. 4). During this period, dressings were changed approximately every 4 days with bFGF
applied each time.
Due to necrosis of local skin, partial exposure of the tibia occurred temporarily but the site was gradually covered withgranulation tissue. The rough areas of the wound surface were also gradually covered with smooth and newly formedgranulation tissue.

Fig. 4 Two weeks after injury (left figure); 6 weeks after injury (right figure)
After removal of the silicone film, bFGF and non-adherent materials were applied for 1 week. From the 2nd week, bFGF
and NPWT were used in combination for 4 weeks.
Partial exposure of the tibia occurred at the necrotic site (circled) 2 weeks after the injury, but was gradually covered
with granulation tissue and full coverage was achieved after 6 weeks.

Seven weeks after the injury, good formation of granulation tissue was observed and split-thickness skin grafting wasperformed.

Fig. 5 Seven weeks after injury
Second surgery.
No particular additional surgery was subsequently performed.

A week after skin grafting, the graft was completely taken and the areas of skin defects were completely closed andankle joint ﬁxation was completed simultaneously. The patient returned to his former job in an independent andambulatory state.

Fig. 6 One week after skin grafting
The skin graft was completely taken and the areas with skin defects were completely closed.
Ankle ﬁxation was complete and the patient was discharged after two and a half months.

Conclusion
Skin grafts are diﬃcult in cases accompanied by extensive bone exposure. The exposed bone can immediately becovered with local muscle ﬂaps, but if skin grafts are carried out directly, scar tissue may severely contract or themechanical strength of the skin could decrease and possibly lead to reduced ADL and QOL.
As reported above, the application of PELNAC on muscle ﬂaps resulted in “desirable” formation of collagen for patientswith exposed bone over the entire tibia. The skin graft was well taken.
The outcome was superior compared with the simple split-thickness skin grafting techniques in terms of ﬂexibility
and mechanical strength. Furthermore, the combined usage of bFGF and NPWT shortened healing time and also
demonstrated synergy with PELNAC.
It should be noted that thorough initial debridement and prompt coverage with a well vascularized tissue is necessary. IfPELNAC is applied on tissue lacking suﬃcient blood circulation, full eﬀectiveness cannot be expected.