Integra™ in burns reconstruction: Our experience and report of an unusual immunological reaction.

Limited availability of autologous donor sites poses significant challenges for soft-tissue reconstruction in severe and complex burns. Integra™ is a bi-layered dermal regeneration template (DRT) which has played a significant role in soft tissue reconstruction since its initial use for full-thickness burn defects. The purpose of this study is to report our institutional experience of Integra™ in burns management over a 4-year period and highlight an unusual reaction to its second application. Twenty-four cases underwent Integra™ resurfacing for burn management from September 2007 to August 2011. Data on patient demographics, including co-morbidities, indications, operative data, complications, secondary reconstruction and outcomes were recorded. Integra™ was used in 24 patients on 37 anatomical sites. One patient died 3 weeks after injury and first stage of Integra™ application, and was therefore excluded from the study. Split-thickness skin grafting was performed within an average of 23 days (with a range of 7-55 days) and mean graft take was 87% (with a range of 75-100%). Five cases of local infection at the graft site were recorded. The average length of hospital stay was 47 days (with a range of 1-162 days). The mean follow-up time was 17 months (with a range of 9-34 months). Overall, our experience with DRT was mixed, that is to say we found it satisfactory with acute burns resurfacing but very good with secondary reconstruction. The main advantage of Integra™ is its immediate availability in unlimited quantities for soft-tissue reconstruction in major and complex burns. The main drawbacks are financial implications, twostage procedure, complex wound care and risk of infection. We believe that Integra™ can be considered as a promising modality in burns management.

La disponibilité limitée des sites donneurs autologues pose des défis importants pour la reconstruction des tissus mous des brûlures graves et complexes. Integra™ est un modèle de régénération dermique à double-couche qui a joué un rôle important dans la reconstruction des tissus mous depuis sa première utilisation pour des défauts des brûlures de pleine épaisseur. L'objectif de cette étude est de rapporter notre expérience institutionnelle d'Integra™ dans la gestion des brûlures, pendant une période de 4 ans et mettre en évidence une réaction inhabituelle à sa deuxième application. De Septembre 2007 à Août 2011 l'Integra™ a été utilisé dans la gestion des brûlures dans vingt-quatre cas. Les données sur les caractéristiques démographiques des patients, y compris les co-morbidités, les données opératoires, les complications, la reconstruction secondaire et les résultats ont été enregistrés. Integra™ a été utilisée chez 24 patients dans 37 sites anatomiques. Un patient qui est décédé 3 semaines après la blessure et le premier stade de l'application Integra™ a été exclus de l'étude. La greffe de peau mince a été réalisée dans un délai moyen de 23 jours (avec une gamme de 7-55 jours) et la moyenne prise de greffon était de 87 % (avec une gamme de 75-100%) Cinq cas d'infection locale au site de la greffe ont été enregistrées. La durée moyenne d'hospitalisation était de 47 jours (extrêmes: 1-162 jours). Le temps moyen de suivi était de 17 mois (extrêmes: 9-34 mois). Dans l'ensemble, notre expérience avec Integra™ a été mélangé : c'est satisfaisant avec le resurfaçage des brûlures graves mais très bon avec la reconstruction secondaire. Le principal avantage d'Integra™ est sa disponibilité immédiate en quantités illimitées pour la reconstruction des tissus mous des brûlures importantes et complexes. Les principaux inconvénients sont les incidences financières, la procédure en deux étapes, les soins de plaies complexes et les risques d'infection. Nous croyons qu'Integra™ peut être considéré comme une modalité prometteuse pour la gestion des brûlures.

The use of Osmed(TM) tissue expanders in paediatric burns reconstruction.

Background. Tissue expansion has been a major advance in reconstructive burn surgery. The conventional tissue expander requires serial filling with the possibility of painful procedures, which can be a major challenge and source of anxiety in children. The osmotic self-inflating tissue expander, on the other hand, is a device that does not require external filling, offering apparent benefits particularly in the paediatric population. We used Osmed(TM) tissue expanders for secondary burn reconstruction in children and teenagers who had sustained burns during childhood. Methods. Patients who were treated with Osmed(TM) expanders for secondary burns reconstruction were recorded. Patient demographics (i.e. burn injury data, indications for surgery), Osmed(TM) tissue expander data (i.e. operative data, complications, problems encountered during and after treatment, explantation time, final expander volume) and overall success were recorded. Results. Twelve Osmed(TM) self-inflating tissue expanders were used in patients for secondary burns reconstruction between October 2007 and January 2009. All our patients sustained their burns during childhood. There were three females and one male; the age range was 14-19 yr (mean age, 16 yr). Tissue expanders were removed on average at 6-7 weeks except in two patients. We noted four complications in our cohort. Overall the mean expansion was 65% of the proposed final volume. Discussion. We found the Osmed(TM) tissue expander simple to implant and well tolerated by our patients. However, none of the devices achieved full expansion and overexpansion was not possible. We believe conventional tissue expanders are still the gold standard, although osmotic expanders may have a role in burn reconstruction in younger children.

Reconstruction for basal cell carcinoma in an anatomical region where the sun does not shine: an attractive option!

Basal cell carcinoma is one of the common skin malignancies but it is rarely found in sun-protected areas. The soft tissue reconstruction at the perianal region can be challenging and a variety of options are described in the literature. The keystone design perforator island flap is an excellent and attractive option for soft tissue reconstruction. We present a case of perianal basal cell carcinoma that was reconstructed with a unilateral keystone flap.

Paediatric injuries due to home treadmill use: an emerging problem.

INTRODUCTION: The use of home exercise equipment is increasing and treadmills are becoming more popular. This has brought with it an emerging but preventable problem. We present our experience, highlight the importance and promote public awareness of this type of injury. To our knowledge this has not been reported previously in the UK. METHODS: A retrospective review was conducted of the medical records at two regional burn units of children who sustained treadmill-related injuries between July 2003 and July 2009. Data on patient demographics, mechanism of injury, management, surgical intervention and outcome were recorded. RESULTS: Twenty-nine children (15 boys, 14 girls) sustained treadmill-related injuries. The mean age was 3.8 years (range: 1-13 years). All injuries occurred at home and the majority of children trapped their hand under the running belt when an adult was using the machine. Most of the injuries were to the upper limb (97%) with less than 1% of the total body surface area burnt. More than two-thirds of patients had deep burns and 17 (58%) required surgical intervention. Five patients developed hypertrophic scars. All patients achieved a good functional outcome. CONCLUSIONS: Treadmills can pose a significant danger to children. These injuries are preventable. Regulatory authorities, manufacturers and parents should take steps to prevent this emerging health problem.

Vacuum-assisted closure and primary cutaneous aspergillosis in a burn - a management dilemma!

The advent of vacuum-assisted closure (VAC) devices has changed many wound management practices by application of topical negative pressure. A 20-year-old male sustained 21% total body surface area circumferential full-thickness burns to both legs from knees to feet. The VAC dressing was used in the management of his wounds. The patient had persistent pyrexia and graft destruction and subsequently the wounds cultured Aspergillus fumigatus. The increasing popularity of the VAC dressing is well deserved in the management of complex burn wounds. This case highlights the fact that in the care of complex burn patients the development of opportunistic infections should be considered, especially in situations such as persistent pyrexia or following the breakdown of healed grafts, particularly during the use of topical negative pressure.

The surgical management of fistula-in-ano in a specialist colorectal unit.

INTRODUCTION: Fistula-in-ano can be associated with a number of conditions, including Crohn's disease. The majority, however, are classified as idiopathic or cryptoglandular. The aim of this study was to review the outcome of surgical management of fistula-in-ano in a specialist colorectal unit. MATERIALS AND METHODS: One hundred and four consecutive patients underwent surgery for anal fistulae between 1st January 2000 and December 2004. Data was analysed in two main groups, according to the aetiology, cryptoglandular (n = 86) and Crohn's disease (n = 18). Follow-up data was available on 91 patients. RESULTS: In the cryptoglandular group, 62 patients had an inter-sphincteric tract, of which 48 underwent a single-stage fistulotomy. Of those patients with a trans-sphincteric tract, six patients underwent a single-stage fistulotomy, 13 had a seton and staged fistulotomy. Follow-up data revealed that two fistulae recurred. The median number of procedures in this group was 1 (range 1-3). There was a significant difference in the inpatient stay depending of Park's classification (p = 0.001). In the Crohn's group, three patients with an inter-sphincteric tract underwent a single-stage fistulotomy, two patients with a trans-sphincteric tract had single-stage fistulotomy, and five required a loose seton and staged fistulotomy. Eight patients had multiple fistulae which required long-term setons. Four patients from this group eventually required proctectomy. In the Crohn's group, there was a significantly increased complexity of surgery and higher recurrence. This was reflected in an increased inpatient length of stay and a greater reliance on imaging (p = 0.001). The median number of procedures in this group was 3 (range 1-5). DISCUSSION: The majority of cryptoglandular fistula-in-ano were treated by primary fistulotomy or staged fistulotomy with a loose seton. This was associated with a low recurrence rate and low rates of faecal incontinence. There was a low reliance on imaging techniques in this group. However, we would urge caution when dealing with fistula-in-ano related to Crohn's disease. In this group of patients, the fistulae tended to be more complex and require additional imaging and multiple procedures.

Aquacel ag® in paediatric burns - a prospective audit.

A variety of dressings are used for the management of paediatric burns. Aquacel Ag® is a silver-impregnated hydrofibre that releases silver within the dressing for up to two weeks. It has been reported in the literature that it is a beneficial dressing for the management of partial-thickness burns. It promotes an appropriate environment for re-epithelialization of the burn wound. The aim of this study was to evaluate the use and outcomes of Aquacel Ag® dressing in paediatric burn patients. This was a prospective audit carried out in the period January-July 2005. The healing time was satisfactory. The dressing normally adheres to the burn wound for up to two weeks and thus requires less frequent changes. In our study, patients required three to four outer dressing changes. However, Aquacel Ag® has not been compared with other dressings. Overall pain requirements were reduced during subsequent dressing changes. It was also easy to apply the dressing in the majority of our patients. Non-adherence was one of the problems encountered but, overall, Aquacel Ag® appeared to be a safe, effective, and comfortable dressing.