Burns 32 (2006) 251–254 www.elsevier.com/locate/burns
Case report
The use of IntegraTM in necrotizing fasciitis Sohail Akhtar, Saiidy Hasham *, Chris Abela, Alan R. Phipps Department of Plastic Reconstructive and Hand Surgery, Pinderfields General Hospital, West Yorkshire, UK Accepted 10 June 2005
1. Introduction IntegraTM is a skin substitute developed specifically for the management of patients with extensive and life threatening burns by providing early wound coverage. This allows grafting to be delayed until the patient has sufficiently recovered from his/her injuries. The dermis like tissue (‘neodermis’) that forms within the IntegraTM template following application can accept thin skin grafts with the potential for repeated harvesting of donor sites. There is also evidence of reduced scarring and improved skin pliability when compared to conventional meshed grafts [1]. This functional and cosmetic benefit has consequently widened the clinical indications for IntegraTM to encompass its use in smaller burn injuries and in the reconstruction of skin defects where less scarring and wound contracture are desirable. IntegraTM has been utilised in our department since 1996 for the treatment of burns. We describe a case where IntegraTM was successfully used to cover the lower limb following surgical debridement for necrotizing fasciitis. We are not aware of any reported studies of its use in the coverage of post-infective soft tissue defects.
inflammatory markers were raised (C-reactive protein, 419); but his white cell count was normal (7.69 109 L 1). The initial diagnosis was that of a small abscess collection with associated ascending cellulitis. He was duly commenced on broad spectrum intravenous antibiotics and underwent drainage and surgical debridement the following day. Unfortunately, over the next 24 h his condition rapidly deteriorated with the patient becoming increasingly septic. Further areas of skin necrosis developed suggesting a necrotizing soft tissue infection. Two further debridements were required to control the infection and a period of critical care support was necessary. Necrotizing fasciitis was confirmed by histology and was secondary to a bHaemolytic Group A streptococcal infection. Since surgical debridement had left a near circumferential wound of approximately 35 cm 20 cm overlying the knee joint and lower leg (Fig. 1) it was felt that the patient would benefit functionally and cosmetically if the soft tissue loss could be reconstructed using a dermal substitute such as
2. Case report A 45-year-old male with no previous significant medical history presented to the Accident and Emergency Department with a painful left leg. He had been the victim of an alleged assault 10 days previously and had subsequently developed a red and swollen calf with obvious cellulitis and a small area of skin necrosis within. It was noted on admission that he had acute renal impairment (urea, 14.2 mmol/L; creatinine, 200 mmol/L); * Corresponding author at: Flat 2 Lacemakers House, North Road, The Park, Nottingham NG7 1AG, UK. Tel.: +44 7812165230 (mobile). E-mail address:
[email protected] (S. Hasham). 0305-4179/$30.00 # 2005 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2005.06.009
Fig. 1. Soft tissue defect left following surgical debridement for necrotizing fasciitis.
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Fig. 2. The wound temporarily closed using Biobrane1.
IntegraTM. It was decided to undertake the resurfacing of this defect in two stages because of the risks associated with imperfect wound bed haemostasis and bacterial colonization. The first part of the reconstruction involved the application of Biobrane1 (Fig. 2). This is a biosynthetic wound dressing with a bi-laminar structure composed of a semi-permeable silicone membrane which is mechanically bound to a nylon mesh fabric. A layer of peptides derived from porcine dermal collagen is incorporated in to both the silicone and nylon components of the dressing which enhances its bonding to tissue fibrins at the wound surface. Prior to application, the wound was thoroughly cleaned using skin antiseptics and swab abrasion to remove any debris and to decrease the bacterial load. Two days later the Biobrane1 was replaced with IntegraTM which was secured in sheets to the wound margins using a combination of staples and absorbable sutures (Fig. 3). An outer layer of dressing gauze and elastic netting was applied and the limb immobilized in a thermoplastic splint to offer protection against shear forces. The patient was then confined to bed rest. The IntegraTM was inspected regularly for signs of infection and haematoma formation and to monitor the development of neodermis. A few small areas of fluid did develop at 6 days after application of the IntegraTM; in these areas the silicone layer was lifted, cultures were taken and the collections washed out. Subsequent
microbiology demonstrated mixed coliforms and Pseudomonas aeruginosa but no streptococci. Appropriate antibiotics were administered and the IntegraTM was covered with silver impregnated dressings. Staples were progressively removed as these appeared to be foci for infection. Physiotherapy was introduced after 2 weeks to maintain mobility. On the 15 day after IntegraTM application, the silicone top layer was removed revealing a healthy neodermal bed (Fig. 4). A thin (0.008 in.) split thickness sheet skin graft was harvested from the right anterolateral thigh and secured to the neodermis with Histoacryl1 glue and staples (Fig. 5). A further period of immobilisation was required before the graft was inspected 5 days later. Approximately 95% of graft had taken with a small area of graft loss overlying the lateral aspect of the knee. Physiotherapy was continued until the patient was deemed safe to be discharged home nearly 8 weeks following his initial admission. Awound check 3 months later demonstrated both a functional and cosmetically acceptable result (Fig. 6). He is currently under regular review in our scar clinic and is receiving active scar management with pressure garments.
Fig. 3. Application of IntegraTM complete.
Fig. 5. Final result following thin (sheet) split thickness skin grafting.
Fig. 4. Removal of IntegraTM demonstrating a vascularized ‘neodermis’.
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Fig. 6. Appearance of wound 3 months post-operatively.
3. Discussion Necrotizing soft tissue infections (NSTIs) represent a large spectrum of clinical entities ranging from mild pyodermas to life threatening necrotizing fasciitis. Fortunately, the condition is rare in the United Kingdom with an estimated incidence of 500 new cases each year. Most studies have demonstrated that necrotizing fasciitis is polymicrobial in nature with the majority of cases yielding a mixture of aerobic and anaerobic organisms. Streptococcus appears to be the most common causative organism but the presence of Group A streptococci is found in only 15% of individuals with the condition [2]. The term ‘necrotizing fasciitis’ was introduced by Wilson [3] in 1952 to describe the most consistent feature of the infection, necrosis of the fascia and subcutaneous tissue with relative sparing of the underlying muscle. It may rapidly progress to systemic toxicity and even death if not promptly diagnosed and treated. Once suspected, treatment involves immediate resuscitation, early surgical debridement and administration of broad spectrum intravenous (IV) antibiotics. Repeated debridement may be required to eradicate the infection and may well leave the patient with a large area of soft tissue loss necessitating surgical reconstruction [4]. For such defects, wound coverage is usually achieved by using meshed split thickness skin grafts. This provides effective wound closure and has a limited morbidity. However, it does have drawbacks both in terms of function and cosmesis. Wound contracture can be problematic if occurring around a joint and may restrict the range of movement with subsequent loss of function. Hypertrophic scarring can also result and grafts may have to be meshed (if covering extensive areas) leaving a characteristic appearance.
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IntegraTM is an artificial dermal substitute developed by Burke and Yannas in the late 1970s for the purpose of achieving early wound coverage following excision of extensive full (and partial-thickness) burns [5]. The concept behind its development was to construct a wound covering that provided the essential barrier functions of the skin but at the same time provided a scaffold for later dermal regeneration. IntegraTM is a bilaminar composite composed of an outer silicone layer and an inner dermal layer of cross linked bovine collagen held in a three-dimensional matrix with shark cartilage chondroitin-6-sulphate. This inner component functions as a template that induces organized regeneration of dermal tissue (‘neodermis’) by the body by promoting the migration of fibroblasts, macrophages, lymphocytes and endothelial cells through various pore sizes (70–200 mm) [6]. As healing progresses, native collagen is deposited by fibroblasts as the collagen part of the dermal layer is biodegraded. Dermal regeneration should take place over 14–21 days (as long as local conditions remain optimal). The silicone layer simulates the characteristics of normal epidermis as it provides immediate wound homeostasis by controlling fluid loss and serves as a protective barrier [7]. It is imperative that IntegraTM be applied on a prepared wound bed to achieve success. Any non-viable tissue will allow infection to develop and ultimately lead to failure. Meticulous haemostasis is also important since excessive cauterization can decrease the wound bed viability. Once applied, regular inspection is necessary looking for signs of infection, and in the early stages, haematoma. Any fluid collections that develop should be treated accordingly since IntegraTM itself does not possess any anti-microbial activity and is thus susceptible to rapid degeneration in the face of unchecked infection. The outer silicone layer should be lifted and the collections washed out using normal saline or povidone iodine solution. Cultures swabs should also be taken and appropriate antibiotics commenced. Reconstruction is usually completed with the application of a thin split thickness skin graft (0.005–0.008 in.) which may be either meshed or unmeshed. Inspection of the graft should take place over the following 4–5 days and once stable, it can be cared for in the usual manner. The use of IntegraTM does have its difficulties. It requires close postoperative care and may involve several procedures to complete reconstruction. Complications such as shearing of the IntegraTM after application may occur as can graft loss, haematoma formation, infection, silicone layer detachment and incomplete epidermal graft take [8]. Infection appears to be the most common complication following IntegraTM application. Although this ultimately affects dermal regeneration and subsequent split thickness graft take, range of motion and function appear not to be significantly affected. As a result, the need for further IntegraTM application in the event of infection is not apparent since only 75% of the defect need coverage with new dermis to yield satisfactory outcomes [1].
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Despite these potential hazards, significant cosmetic and functional benefits of IntegraTM have been demonstrated in the treatment of burns [1,5–7] and other soft tissue defects [8]. Though there is no clear evidence that these benefits are long term, the product does show promise in this regard. We have shown that IntegraTM can be used to cover soft tissue defects resulting from infection. It may therefore be considered a useful addition to the reconstructive ladder when function and cosmesis are important issues for the patient.
References [1] Frame JD, Still J, Lakhel-LeCoadou. et al. Use of dermal regeneration template in contracture release procedures: a multicentre evaluation. Plast Reconstr Surg 2004;113(5):1330–8.
[2] File Jr TM, Tan JS. Treatment of skin and soft-tissue infections. Am J Surg 1995;169(Suppl. 5A):27. [3] Wilson B. Necrotising fasciitis. Am Surg 1952;18:416–31. [4] Edlich RF, Winters KL, Woodard CR, et al. Massive soft tissue infections: necrotizing fasciitis and purpura fulminans. J Long Term Eff Med Implan 2005;15(1):57–65. [5] Burke JF. Successful use of a physiologically acceptable artificial skin in the treatment of extensive burn injury. Ann Surg 1981;194(4):413– 28. [6] Yannas IV, Burke JF, Orgill DP, et al. Wound tissue can utilize a polymeric template to synthesize a functional extension of skin. Science 1982;215:174–6. [7] Tompkins RG, Hilton JF, Burke JF, et al. Increased survival after massive thermal injuries in adults: preliminary report using artificial skin. Crit Care Med 1989;17:734–40. [8] Abai B, Thayer D, Glat PM. The use of a dermal regeneration template (Integra) for acute resurfacing and reconstruction of defects created by excision of giant hairy naevi. Plast Reconstr Surg 2004;114(1): 162–8.
