Tissue engineering as a tool in a novel approach to the comprehensive treatment and management of a deeply and extensively burned patient: case report.

症例は81歳の男性で，田んぼでの野焼き中に衣服へ着火して受傷し，当院へ搬送された。腹部から両下肢にかけて皮膚の著明な炭化を認め，両膝より遠位では熱傷が筋層に達していた。深達性II度熱傷7%，III度熱傷46%で熱傷予後指数（prognostic burn index: PBI）は130.5であり，予測される死亡率は98%以上であった。検査所見では血清CPK値の上昇，急性腎傷害，高カリウム血症を認めた。受傷から約4時間後，股関節から10cmの部位での両下肢切断術を施行し，ICUへ入室した。4日目に昇圧剤を終了，7日目に抜管，人工呼吸器離脱に至った。分層植皮術を繰り返し，119日目の転院時には車椅子で自走可能な状態であった。高齢者の広範囲火焔熱傷に対する受傷初日の四肢切断術がその後の集中治療管理や手術戦略に寄与し，救命し得た。過去に熱損傷での両下肢切断術を受傷初日にしたとする症例報告はなく，その臨床経過について詳述した。 An 81–year–old man who suffered a flame burn during burning on the soil presented to our hospital. His skin from the abdomen to bilateral lower limbs seemed to be carbonized. The burn depth extended to the muscles on the distal area from the knees. Because 7% of his body surface area was covered in deep dermal burn (DDB) and 46% was covered in deep burn (DB), his prognostic burn index was 130.5, so mortality was estimated more than 98%. Laboratory test results were consistent with elevation of serum CPK and revealed acute kidney injury and hyperkalemia. Four hours after the accident, an emergency amputation of the bilateral limbs at an area 10cm distal from his hip was performed, and he was admitted to the intensive care unit. Vasopressor was discontinued on day 4, and he was extubated and weaned from the ventilator on day 7. After several split thickness skin graft and debridement, on day 119 he could use a wheelchair at the time of his transfer. In the case of an elderly patient with an extensive flame burn, performing amputation on day 1 may affect subsequent critical care and operative strategy, and in this case, the patient survived. This is a detailed first report of bilateral limb amputation for thermal injury on day 1. 熱傷患者の予後予測の手段として熱傷指数（burn index: BI）や熱傷予後指数（prognostic burn index: PBI）がある。PBI 85以上では有意に死亡率が上昇し 1，とくにPBI 130以上では死亡率98%を超え，救命困難とされる 2。また，熱傷では四肢の切断に至ることがあるが，その適応や時期について未だ議論が残る。今回我々は，受傷初日の両下肢切断術が救命に寄与したと考えられる高齢者の広範囲火焔熱傷の1例を経験したため報告する。 なお倫理委員会の承認を要する内容はなく，本人の同意を得たうえで匿名化した。 患 者：81歳の男性 主 訴：腹部・腰部より尾側の熱傷 既往歴：高血圧症 現病歴：田んぼの野焼きをしていたところ着衣に火がつき，受傷から約1時間後に当院へ救急搬送された。 入院時現症：呼吸数40/分，SpO2 97%（酸素15L/min，リザーバーマスク），脈拍121/分・整，血圧175/131mmHg，意識 Glasgow coma scale 14点（E3V5M6）であった。血液検査所見ではCPK 22,221IU/L，AST 396IU/Lと筋原性酵素の上昇を認め，Cre 1.23mg/dL，K 6.6mEq/L，base excess –6.9mmol/Lと急性腎傷害，高カリウム血症，代謝性アシドーシスを呈した（Table 1）。鼻腔の煤と鼻毛の焦げを認め，腹部から両下肢にかけて皮膚が炭化しており，両足背動脈は触知不能であった。深達性II度熱傷7%，III度熱傷46%，熱傷面積（total body surface area， %TBSA）53，BI 49.5，PBI 130.5であった（Fig. 1）。 Physical examination on the first day. 7% of his body surface area was covered in DDB and 46% was covered in DB. DDB: deep dermal burn, DB: deep burn 入院後経過：両膝より遠位では炭化が筋層にまで達していたため，今後歩行などの荷重に耐えられるまでの機能回復は見込めないと予想された。また，PBI 130.5から予測される救命率は1%程度と推定されるものの上半身の損傷が比較的軽微であり，下肢切断による大幅な熱傷面積の減少が達成できれば予測値よりも救命率を向上できる可能性も考えられた。以上をふまえ，本人・家族に対して一般的な熱傷治療戦略では救命の可能性が極めて低いこと，下肢機能の回復が望めず遅かれ早かれ切断術に至る可能性が極めて高いこと，緊急での両下肢切断により救命率が向上する可能性があること，長期の集中治療管理や人工肛門造設術を要して日常生活動作の著しい低下を伴うこと，緩和医療への移行という選択肢もあることを説明し，両者ともに積極的治療を望まれた。 術式決定に際しては機能的予後の見込めない患肢救済よりも救命を最優先とし，熱傷面積を可能な限り軽減できるよう大腿近位での切断を想定した。また，軟骨面などに感染が生じた際に治療に難渋することが予想され，股関節離断は回避する方針とした。 気管支鏡検査で気道熱傷を否定した後に気管挿管を実施し，Parklandの公式に則った大量輸液（4×62.4kg×53%：13.2×103mL/day）と高カリウム血症の是正を行いながら，受傷から約4時間後に緊急で両下肢切断術を施行した。 手術所見：大腿部は熱傷の深達度が脂肪組織に留まっていたが，切断高位は両股関節から10cmの部位で離断し，その時点で残存する %TBSAは21，III度熱傷は14%となった。断端皮膚の著しい炭化により一期的な創閉鎖を見込めず骨を筋で被覆し，最後に下腹部から両大腿の断端まで焼痂切開を加えた。術中に血色素尿が出現し，ハプトグロビン製剤4,000単位を投与した。術中出血量は浸出液も含めて1,966mLであり，赤血球濃厚液8単位，新鮮凍結血漿10単位の投与，ノルアドレナリン0.09μg/kg/minの開始下にICUに入院となった。 超早期での手術侵襲もあり，受傷24時間での総輸液量は19.4×103mLに達した。受傷から22時間後より0.5mL/kg/hr，30時間後には1mL/kg/hrの尿量が安定して得られた。4日目に腹部，背部，陰茎，陰嚢に対する分層植皮術を行い，同日昇圧剤を終了して7日目に抜管，人工呼吸器離脱に至った（Fig. 2）。10日目に臀部，両大腿部背側，14日目に腹部，両大腿部腹側に対する分層植皮術，21日目に大腿断端の縫縮術をそれぞれ実施した。栄養療法に関しては，入院初日から乳性ペプチド含有の消化体栄養剤による経腸栄養と便失禁管理システムでの排便管理を行っていたが，プレアルブミン値の改善が得られず，低栄養状態による人工肛門の脱落が懸念された。さらに，本患者の最適人工肛門設置位置である左上腹部の健常皮膚領域は狭く，また同部位の上皮化遅延も重なり，人工肛門造設は53日目となった。その後59日目に会陰部，肛門部に分層植皮術を行った。119日目の転院時には車椅子で自走可能であり，熱傷創は全上皮化して完全創閉鎖を得た（Fig. 3）。受傷より301日経過した現在，精神的問題もなく家族の支えのもと自宅で生活している。 Clinical course from admission. Physical examination on day 89. 熱傷の四肢切断術は古くから行われており，1961年に膝上での両下肢切断術の救命例が報告 3されている。また，熱傷に対する四肢切断術が救命率の向上に寄与したとする報告 4, 5も散見される。熱傷における四肢切断術の頻度は1.5–5.8%と報告 6, 7, 8されているが，自験例のように火焔熱傷といった熱損傷での切断は電撃傷の場合よりも圧倒的に少ない 6。また，熱傷での四肢切断術の適応については，患肢の不可逆的な機能喪失，生命を脅かす感染症といった病態が挙げられ 5, 9，横紋筋融解に起因する全身性病態の併発や易出血性などの要素も加味して主観的に判断されている 5, 8。これらいずれの病態も基本的には入院後一定期間を経て判明するものである。しかし，自験例では少なくとも膝下は不可逆的な機能喪失が強く予想され，かつ急性腎傷害，高カリウム血症といった全身性病態も伴ったことから，初日の段階で四肢切断術の適応と判断した。その切断高位についてはリハビリテーションの見地からも判断されるべきである 8が，救命を第一目標とし，大腿部のうち可能な範囲で近位を選択した。 熱傷における四肢切断術の時期についても定まった見解はない。Parshleyら 10は，電撃傷に対する入院当日の四肢切断術は全身状態への忍容性も十分見込まれ，著明な改善が得られることがあるとしている。またYowlerら 4は，深達度の高い熱傷に対する度重なるデブリドマンが結果的に患肢を無機能にさせ，患肢の不適切な温存がかえって創感染のリスクを高めるとし，電撃傷以外の熱損傷での四肢切断術は受傷から平均18.4日と電撃傷よりも遅い傾向にあったと報告した。これは，電撃傷に比してそれ以外の熱損傷では受傷早期の組織損傷が浅い場合が多いことも関与していると思われる。このように，とくに電撃傷以外の熱損傷における受傷早期の四肢切断術は稀と考えられるが，自験例では患肢の筋を含めた深達度の経過を待たずに初日に施行した。Sotoら 8による原著論文の中で受傷初日に四肢切断術がなされた電撃傷以外の熱損傷症例を含んでいるものの年齢や熱傷面積，転帰などの情報は得ることができず，我々が渉猟した限りでは臨床経過について詳述した報告は見当たらなかった。当初のPBIから推定される死亡率98%以上の重症例に対し，入院後の治療経過で難渋しなかったことは特筆に値する。 Mackieら 11は，気道熱傷がなく人工呼吸管理を要した62例（平均42.2歳，%TBSA 47.4）での人工呼吸器離脱に平均18日を要したとし，受傷から3，7日目までの累積水分出納バランスについてもそれぞれ+23.1×103mL，+34.2×103mLであったとしている。自験例では受傷24時間での総輸液量はParklandの公式よりも多かったが，累積水分出納バランスは受傷から3日目で+16.8×103mL，7日目で+14.5×103mLと著明に少なく，人工呼吸器離脱も7日間と比較的短期間であった。これらの理由として，下肢の切断が炎症を来した異常な血管床を減少させ，利尿期を含めた輸液管理を容易にしたことが一因として考えられた。またその背景として，熱傷が広範囲であるほど炎症反応も強くなる 12が，近位かつ初日の切断が全身の炎症性サイトカインを軽減し，血管透過性亢進の制御に有利に作用した可能性が考えられる。さらに，四肢切断術を要した患者の受傷1，2日目の血清CPK値は要さなかった患者に比して有意に高かったとする報告 6や，切断によりミオグロビンによる急性腎傷害を軽減できるとした報告 10もある。自験例は来院時点で既に著明な筋原性酵素の上昇と急性腎傷害，代謝性アシドーシスといった横紋筋融解症様の病態を来していたが，受傷2日目にはCPK 6,382IU/Lと速やかに減少しており，これらのことからも受傷後数日経過した時期ではなく初日こそ四肢切断術のタイミングとして適切と考えられる。また，重症熱傷において壊死した開放創は容易に菌の侵入門戸となり 5，熱傷面積の増加に伴い感染の確率が上がるとする報告 13もあるが，自験例では昇圧剤を要するような重篤な感染は併発しなかった。この要因として，広範囲熱傷に対して早期手術といった迅速な創閉鎖が求められる 14ように，初日のより近位での切断が熱傷創を，ひいては創感染の機会を大幅に減少させたことが挙げられる。さらに，受傷早期の手術は入院後の手術戦略にも好影響をもたらしたと考えられる。高齢者では頭部をはじめとした採皮による出血が増加して全身状態の悪化を来すことがあるが，今回入院直後から32%にも及ぶ熱傷面積の減少が達成できたため，残る未上皮化創は21%に留まった。大小含め計7回の分層植皮術で一度も頭部からの採皮を行わずに済んでおり，この点においてもより早期かつ近位での切断は合理的と言える。 最後に，自験例は救肢の観点だけで考えれば皮弁を用いて膝下も含めて温存できたかもしれない。また自験例の転帰が良好であったことは受傷前の栄養状態や気道熱傷がなかったことも影響している可能性も否定できない。仮に自験例をふまえての提言をするのであれば，下肢を含む重症の広範囲熱傷の場合，例えばその指標として死亡率が50%を超えるとされる %TBSA 50以上，BI 40以上，PBI 100以上 2などの症例では，年齢，全身状態，上半身の熱傷の程度，下肢の機能的予後から総合判断して受傷初日の下肢切断術を考慮してもよいと思われる。現段階では %TBSA，PBIといった重症度と関連づけて四肢切断術を論じた報告は少なく，とくに重症の熱損傷について知見の蓄積が望まれる。 高齢者の広範囲火焔熱傷に対する受傷初日の四肢切断術がその後の集中治療管理や手術戦略に寄与し，救命し得たと考えられた。過去に熱損傷での両下肢切断術を受傷初日に行ったとする症例報告はないため，その臨床経過について詳述した。 本報告において利益相反はない。

The full-thickness burns involving the full-thickness skin to superficial subcutaneous tissue and the deep partial-thickness burns extending into the deep dermis and not to heal within 21 days post burn, are the deep burns that need to be repaired by autoskin grafting. For patients with deep burns over 40% total body surface area, the condition is usually critical, and the uninjured skin for grafting is relatively deficient. Early excision and skin grafting is a key technology of improving the survival and consequences of patients with extensive deep burns (EDB). This paper presents a review of the representative monographs, academic articles and our experiences on burn wound management with the aim of exploring and discussing the several key issues in early excision and skin grafting of EDB. The accurate assessment about burn wound depth and the profound understanding on wound development process are the pathophysiological basis of the wound management. The appropriate timing and area of excision burn wound should be chosen with the concept of damage control operation. Tangential excision is applicable to not only deep partial-thickness but also full-thickness burn wounds. The depth of tangential excision should effectively remove necrotic tissues and reach down to the level of the underlying viable dermis or subcutaneous tissue. Tourniquet can be not used during limb tangential excision surgery, instead, the wounded limb has been kept elevated as much as possible, meanwhile the surgery is quickly performed. If fresh wound after tangential excision is still obviously dropsical, multipoint puncture reaching down to fascia should be performed for drainage. The wound after tangential excision within 14 days especially 7 days post burn should be grafted with viable alloskin or xenoskin for temporary coverage and later on autoskin for permanent coverage. Grafting of autologous microskin overlain with sheet alloskin should be applied onto the wound after tangential excision, of which the blood supply tend to be improved after 7 days post burn. Perioperative especially intraoperative management should be strengthened. Although the treatment strategy on early excision and skin grafting of EDB has obtained the good curative effect, much of the treatment is derived from a compromise between empiricism and pragmatism and needs still to be confirmed by controlled clinical trials. Key words: Burns; Skin transplantation; Tangential excision; Alloskin; Xenoskin

Background: The success of tissue transplantation and long-term tissue stability after wound healing depends on sufficient tissue perfusion. Laser Doppler-supported procedures allow for an objective measurement of relative tissue perfusion. The development of Speckle-based Laser Doppler imaging now enables a real-time representation of tissue perfusion. The perfusion of tissues relevant in plastic surgery such as scars, phalangeal replantations and burn wounds were systematically analysed by Laser Speckle Contrast Analysis (LASCA) imaging. Method: Perfusion of skin, scars, replanted fingers and different burn wound degrees (IIa, IIb and III) were systematically examined by LASCA imaging. Baseline perfusion of control tissue and perfusion values of compromised tissues were quantified and compared. Results: LASCA imaging shows significant differences in baseline perfusion of skin compared to atrophic scars, hypertrophic scars and keloids. Finger replantations with subsequent replantation failure show a characteristic and significant hypoperfusion in line with the expected clinical feature. A significant difference in tissue perfusion is seen in superficial (IIa) and superficial deep (IIb) burns, which are hard to distinguish on clinical examination. Deep burns (III) are characterised by hypoperfusion, which differs significantly from grade IIa and IIb burn wound perfusion, but not from baseline skin perfusion. Furthermore, the characteristic perfusion values of different burn degrees correspond to the varying treatment strategies. Conclusion: LASCA imaging is a robust method of perfusion imaging, which combines high resolution and speed. Hypoperfusion of tissues relevant to plastic surgery such as scars, phalangeal replantations and the different burn degrees (IIa, IIb and III) can be detected by LASCA imaging with high precision. Ease of use and immediate real-time imaging make LASCA imaging a reliable tool for the evaluation of tissue perfusion after plastic surgery procedures, which may influence further treatment decisions.

Clinical efficacy of negative-pressure wound therapy combined with porcine acellular dermal matrix for repairing deep burn wounds in limbs

Introduction: Burns pose a physical, psychological, health system, and long-term length of stay problem. Surgical treatment of burns is an important intervention in their management. The optimal timing of early tangential excision and split-thickness skin graft varies. Early excision of burned tissue to remove dead tissue and inhibit the inflammatory process decreases the risk of infection. Early excision and grafting of burns is the standard of practice for most major burns. Methods: The research was a cross-sectional study with a descriptive design of secondary data. Burn patients were treated at Dr. Soetomo General Academic Hospital Surabaya, Indonesia, from 2018 to 2022. Inclusion criteria in this study were all patients who underwent early tangential excision and split-thickness skin graft. Achieving statistical analysis and data analysis using SPSS 25 on Windows. Results: A greater amount of time on total body surface area (TBSA) is linked to early tangential excision and split-thickness skin grafts. There are statistically significant variations in the burn area (TBSA 20.5%–30%, P = 0.036 (P = 0.05), TBSA 30.5%–40%, P < 0.001, and burn area (TBSA 40.5%–50%, P = 0.003). The current findings demonstrated that split-thickness skin grafts and early tangential excisions done on burns with TBSA 20% at partial thickness–full thickness depth had statistically significant outcomes, shortening the length of stay for burn patients. Conclusions: An analysis of the current data, burn patients’ duration of stay was reduced when burns with TBSA >20% with partial thickness–full thickness depth underwent early tangential excision and split–thickness skin transplant had statistically positive results.

In thermal injuries, enzymatic debridement is a viable option for treating partial- and full-thickness burns, allowing for rapid removal of damaged tissue with minimal bleeding and without sacrificing healthy dermis. Enzymatic debridement using Nexobrid® combined with negative wound pressure therapy (NWPT) appears to promote healing, as enzymatic debridement helps preserve healthy tissue integrity and epithelial reserves. We explored therapeutic alternatives following enzymatic debridement to assess healing outcomes and reduce reliance on skin grafts. 24 patients with deep or partially deep thermal burns on 5-40% of total body surface area (TBSA) underwent enzymatic debridement; then, half received NWPT and the other half were treated with topicals. Enzymatic debridement effectively removed necrotic tissue and facilitated healing. Only three patients required skin grafts (<10% TBSA). Enzymatic debridement combined with NWPT expedited daily healing, reduced hospitalization days, and eliminated wound secretion, as confirmed by bacteriological examination. This approach was more effective compared to enzymatic debridement followed by topical treatments. Nexobrid® in combination with NWPT is a promising alternative to surgical treatment, improving healing, reducing the need for skin grafts, and alleviating pain associated with dressing changes. It may be particularly useful in extensive burns, where epithelial reserves are limited.

Over the last 50 years, the evolution of burn care has led to a significant decrease in mortality. The biggest impact on survival has been the change in the approach to burn surgery. Early excision and grafting has become a standard of care for the majority of patients with deep burns; the survival of a given patient suffering from major burns is invariably linked to the take rate and survival of skin grafts. The application of topical negative pressure (TNP) therapy devices has demonstrated improved graft take in comparison to conventional dressing methods alone. The aim of this study was to analyze the impact of TNP therapy on skin graft fixation in large burns. In all patients, we applied TNP dressings covering a %TBSA of >25. The following parameters were recorded and documented using BurnCase 3D: age, gender, %TBSA, burn depth, hospital length-of-stay, Baux score, survival, as well as duration and incidence of TNP dressings. After a burn depth adapted wound debridement, coverage was simultaneously performed using split-thickness skin grafts, which were fixed with staples and covered with fatty gauzes and TNP foam. The TNP foam was again fixed with staples to prevent displacement and finally covered with the supplied transparent adhesive film. A continuous subatmospheric pressure between 75-120 mm Hg was applied (VAC®, KCI, Vienna, Austria). The first dressing change was performed on day 4. Thirty-six out of 37 patients, suffering from full thickness burns, were discharged with complete wound closure; only one patient succumbed to their injuries. The overall skin graft take rate was over 95%. In conclusion, we consider that split thickness skin graft fixation by TNP is an efficient method in major burns, notably in areas with irregular wound surfaces or subject to movement (e.g. joint proximity), and is worth considering for the treatment of aged patients.

Micronized dermal grafts (Rigenera™) and split-thickness skin grafts alone or in combination for deep dermal burn wounds

This study aims to explore the clinical effect of early rehabilitation training combined with negative pressure wound therapy (NPWT) for treating deep partial-thickness hand burns. Twenty patients with deep partial-thickness hand burns were randomly divided into an experimental group (n = 10) and a control group (n = 10). In the experimental group, early rehabilitation training combined with NPWT was performed, including the proper sealing of the negative pressure device, intraoperative plastic brace, early postoperative exercise therapy during negative pressure treatment, and intraoperative and postoperative body positioning. Routine NPWT was conducted in the control group. Both groups received 4 weeks of rehabilitation after wounds healed by NPWT with or without skin grafts. Hand function was evaluated after wound healing and 4 weeks after rehabilitation, including hand joint total active motion (TAM) and the brief Michigan Hand Questionnaire (bMHQ). Twenty patients were involved in this study, including 16 men and 4 women, aged 18-70 years, and the hand burn area ranged from 0.5% to 2% of the total body surface area (TBSA). There was no significant difference in TAM and bMHQ scores between the two groups after negative pressure removal. After 4 weeks of rehabilitation training, the TAM scores and bMHQ scores were significantly improved in both groups (p < 0.05); among them, those of the experimental group were both significantly better than those of the control group (p < 0.05). The application of early rehabilitation training combined with NPWT to treat deep partial-thickness hand burns can effectively improve hand function.

In the treatment of extensive burns, cultured epithelial autograph (CEA) became available commercially in Japan from 2009. Based on the 6 years multicenter surveillance data on using CEA for extensive burns, it is reported that using 6:1 split thickness skin graft together with CEA is successful after wound bed preparation for extensive deep dermal burn or patients with deep burn [1].

BackgroundDeep partial-thickness burns are traditionally treated by tangential excision and split thickness skin graft (STSG) coverage. STSGs create donor site morbidity and increase the wound surface in burn patients. Herein, we present a novel concept consisting of enzymatic debridement of deep partial-thickness burns followed by co-delivery of autologous keratinocyte suspension and plated-rich fibrin (PRF) or fibrin glue.Material and methodsIn a retrospective case study, patients with deep partial-thickness burns treated with enzymatic debridement and autologous cell therapy combined with PRF or fibrin glue (BroKerF) between 2017 and 2018 were analysed. BroKerF was applied to up to 15% total body surface area (TBSA); larger injuries were combined with surgical excision and skin grafting. Exclusion criteria were age <18 or >70 years, I°, IIa°-only, III° burns and loss of follow-up.ResultsA total of 20 patients with burn injuries of 16.8% ± 10.3% TBSA and mean Abbreviated Burn Severity Score 5.45 ± 1.8 were identified. Of the patients, 65% (n = 13) were treated with PRF, while 35% (n = 7) were treated with fibrin glue. The mean area treated with BroKerF was 7.5% ± 0.05% TBSA, mean time to full epithelialization was 21.06 ± 9.2 days and mean hospitalization time was 24.7 ± 14.4 days. Of the patients, 35% (n = 7) needed additional STSG, 43% (n = 3) of whom had biopsy-proven wound infections.ConclusionBroKerF is an innovative treatment strategy, which, in our opinion, will show its efficacy when higher standardization is achieved. The combination of selective debridement and autologous skin cells in a fibrin matrix combines regenerative measures for burn treatment.Lay SummaryPatients suffering from large burn wounds often require the use of large skin grafts to bring burned areas to heal. Before the application of skin grafts, the burned skin must be removed either by surgery or using enzymatic agents. In this article, we describe a method where small areas of skin are taken and skin cells are extracted and sprayed on wound areas that were treated with an enzymatic agent. The cells are held in place by a substance extracted from patients’ blood (PRF) that is sprayed on the wound together with the skin cells. We believe this technique can be helpful to reduce the need of skin grafts in burned patients and improve the healing process.

BACKGROUND: Negative pressure wound therapy (NPWT) is effective for wounds with exposed bones and tendons, but when the wound is accompanied by extensive burns, sealing is difficult. We performed sealing with a hydrocolloid wound dressing on limb burns. CASE REPORT: A 61-year-old woman was burned in a fire at her home. Split-thickness skin grafting was performed 14 and 35 days post injury, but exposure of the right patella and patellar tendon became apparent. The hydrocolloid wound dressing was wrapped around the proximal and distal aspects of a deep wound. The limb was sandwiched from the front and back surfaces and sealed with 2 film dressings, including the hydrocolloid, according to the sandwich method. Using this method, NPWT could be performed without leakage, the exposed tendons and bones were covered with granulation, and skin grafts were performed on day 88 after injury. CONCLUSION: Our method allows NPWT to be easily and effectively performed for deep limb burns with poor normal skin periwound area.

Preclinical assessment of safety and efficacy of intravenous delivery of autologous adipose-derived regenerative cells (ADRCs) in the treatment of severe thermal burns using a porcine model

Use of porcine acellular dermal matrix following early dermabrasion reduces length of stay in extensive deep dermal burns

Despite the fact that early excision and grafting has significantly improved outcome over the last decades, the management of severely burned adult patients with >/=60% total body surface area (% TBSA) burned still represents a challenging task for burn care specialists all over the world. In this article, we present our current treatment concept for this entity of severely burned patients and analyze its effect in a comparative cohort study. Surgical strategy comprised the use of split-thickness skin grafts (Meek, mesh) for permanent coverage, fluidized microsphere bead-beds for wound conditioning, temporary coverage (polyurethane sheets, Epigard; nanocrystalline silver dressings, Acticoat; synthetic copolymer sheets based on lactic acid, Suprathel; acellular bovine derived collagen matrices, Matriderm; allogeneic cultured keratinocyte sheets; and allogeneic split-thickness skin grafts), and negative-pressure wound therapy (vacuum-assisted closure). The autologous split-thickness skin graft expansion using the Meek technique for full-thickness burns and the delayed approach for treating dorsal burn wounds is discussed in detail. To demonstrate differences before and after the introduction of the Meek technique, we have compared patients of 2007 with >/=60% TBSA (n = 10) to those in a matched observation period (n = 7). In the first part of the comparative analysis, all patients of the two samples were analyzed with regard to age, abbreviated burn severity index, Baux, different entities of % TBSA, and survival. In the second step, only the survivors of both years were separated in two groups as follows: patients receiving skin grafts, using the Meek technique (n = 6), were compared with those without Meek grafting (n = 4). When comparing the severely burned patients of 2007 with a cohort of 2006, there were no differences for age (2007: 46.4 +/- 13.4 vs. 2006: 39.1 +/- 14.8 years), abbreviated burn severity index score (2007: 12.2 +/- 1.0 vs. 2006: 12.1 +/- 1.2) or % TBSA (2007: 72.1 +/- 11.7 vs. 2006: 69.3 +/- 8.7% TBSA). In these two rather small groups of severely burned patients with >/=60% TBSA, the overall survival rate of patients was 70.0% (7/10) in 2007 and 42.9% (3/7) in 2006, respectively. Almost all nonsurvivors in both years died within the first 5 days after admission. If assessing the different treatment modalities of the survivors, we found that although the Meek group patients were older (Meek 48.8 +/- 13.3 vs. non-Meek 26.8 +/- 11.5 years, P = .0381) and had consequently higher Baux scores (Meek 124.0 +/- 2.9 vs. non-Meek 93.8 +/- 8.5, P = .0095) than the non-Meek patients, this seemed to have no effect on length-of-stay (80.5 +/- 9.7 vs. non-Meek 79.8 +/- 33.0 days), hospital length-of-stay (85.7 +/- 14.8 vs. non-meek 84.3 +/- 26.1 days) or number of operations (6.5 +/- 1.0 vs. non-Meek 7.0 +/- 4.1 operations). The achieved results represent a combination of various treatment changes and, therefore, cannot be attributed to a single modality. The Meek technique is one of the technical options to choose from, to achieve permanent skin replacement; we think that it has its place if integrated in a whole treatment concept for management of severely burned patients.