23 rd Annual LLRS Meeting

Transcription

1 23 rd Annual LLRS Meeting Daniel Schlatterer, DO Vice Chair, Dept. of Ortho Surgery Director, Ortho Trauma Atlanta Medical Center Atlanta, Georgia Use of Integra and Split Thickness Skin Graft for Coverage of Complex Orthopedic Wounds

2 How do we get it closed?

3 How do we get it closed?

4 Reconstructive Ladder Skin grafts Local flaps Distant flaps Free flaps Simple wounds Complex wounds: Exposed bone Exposed tendons Exposed joint

5 How do we get it closed?

6 How do we get it closed? Sternal wire and plastic mold from Resorbable bead package

7 How do we get it closed?

8 4 Months post-op

9 December 2005 Integra: dermal regeneration template Bilayer membrane system Integra: Integra Life Sciences, Inc., Plainsboro, NJ

10 Integra: dermal regeneration template 1) Silicone layer (temporary, removed prior to STSG) 2) Bovine type I collagen & glycosaminoglycans Integra: Ethicon, Inc., Somerville, NJ

11 40 year old male rollover bus accident - polytrauma Our first case December left tibia fracture open, grade IIIB - free flap to the tibia

12 Partial failure of free flap to the leg Options: 1) Repeat free muscle flap 2) Local muscle flap 3) Integra + Skin Graft

13 Fellowship Integra / Open Fractures JA Molnar, Wake Forest University, North Carolina Case series 8 pts Successful coverage Acceleration of Integra Incorporation in Complex Tissue Defects with Subatmospheric Pressure 2004

14 Partial failure of free flap to the leg Options: 1) Repeat free muscle flap 2) Local muscle flap 3) Integra + Skin Graft

15 Transparent Integra over exposed bone Key points: 1) Fenestrate Integra, allow fluid/hematoma to be pulled out, and 2) Apply negative pressure therapy (VAC) as a bolster

16 8 months post Integra and Split Thickness Skin Grafting

17 Atlanta Medical Center Experience 8 years 30+ cases Exposed Muscle Tendon Joints Bone Multiple stage (most common) Wound preparation Integra + negative pressure 4-7 days STSG + negative pressure Single stage Wound preparation Integra + STSG + negative pressure

18 Exposed tendon and bone, +/- periosteum -- Multiple Stage I know that a flap can be placed if Integra fails

19 Multiple Stage

20 Multiple Stage

21 Multiple Stage

22

23 4.5 months post-op Multiple Stage

24 Different Patient Crush injury from a conveyer One year later Multiple Stage

25 When is the wound ready for: Integra and/or STSG? How many days of negative pressure?

26 Pearls When should we skin graft? When is the silicone layer ready to come off?

27 When is Wound Bed Ready? Day 7 after open femur and negative pressure therapy

28 Day 7 Day 11 Day 14 When is Wound Bed Ready?

29 Great knee range of motion

30 Exposed bone experience

31 19 yo male,

32 Day 10 after Integra placement --- Multiple Stage

33 Multiple Stage Day 12 after STSG Day 22 after Integra Day 24 after injury

34 Multiple Stage 9 months later

35 Multiple Stage

36 Not all cases successful

37 Not All Cases Successful 38 year old male Crush injury left foot Internal / percutaneous Fixation of foot Multiple I/D, wound VAC changes

38 Post Integra Grafting Multiple Stage Post Split Thickness Grafting

39 Graft breakdown / failure Exposed / infected Tendons / bone Foot deformed Foot function??? Multiple Stage

40 3 months post injury Patient elected for amputation

41 What Debridement?

42 Single Stage In general, Requires a very healthy wound bed

43 22 year old male Infected finger

44 44 year old male fight bite Serial VACs leads to non-mobile wound edges

45 Patient would not go to therapy, so we brought therapy to him!

46 3 months post-op

47 SUMMARY Integra Indications Exposed Tendons, joints, bone Sites where goal is to Minimize wound contracture Minimize scar formation / adhesions

48 Summary Wound preparation aggressive debridement Serial negative pressure If wound bed looks like STSG would take Then Integra most likely will take Wound size not an issue Granulation tissue response best predictor

49 Summary If wound bed especially ready Consider single stage Multiple stage: 4-7 days btw Integra and STSG Followed by 4-7 days of negative pressure over the STSG

50 Thank you