A Synthetic Biodegradable Temporising Matrix in Degloving Lower Extremity Trauma Reconstruction: A Case Report

Abstract

Presented is the case of an obese, 72 year-old diabetic man with a dorsal foot de-gloving injury. Whilst the tendons of extensor hallucis longus, extensor digitorum longus to all digits, and extensor digitorum brevis to hallux and second toe were intact after surgical debridement, none had any covering paratenon. The joint between the medial cuneiform and first metatarsal was open. Reconstructive options were limited by his age and co-morbidities. A novel, completely synthetic dermal matrix (NovoSorb BTM) was applied, after which the patient was discharged home to attend for dressings and review of integration progress as an outpatient. He was allowed to mobilise without limitation. Because of the poor quality of the wound bed (and patient), the material integrated slowly over 9 weeks. Delamination of the matrix, and definitive closure by application of sheet split skin autograft, produced a robust, soft, mobile and excellent aesthetic result, over which he could wear footwear immediately. Clinically, the paratenon-denuded tendons glided under the neo-dermis without tethering to the overlying integrated matrix, allowing a full range of digital movement. This was confirmed on ultrasound examination, which also demonstrated no inflammation or oedema. Already proven in extensive burns, necrotising fasciitis and complex surgical wounds, BTM represents a useful addition to the reconstructive surgeon's toolbox.

Fig. 1.

Day 0, following debridement of nonviable tissue exposing superior and inferior extensor retinacula, digital extensor expansions (I and II), one of the terminal branches of the superficial peroneal nerve, the terminal branch of the saphenous nerve and the tendons of EHL and EHB, and EDL to all 4 toes. All of the tendons are denuded of paratenon. The joint between the medial cuneiform and the base of the first metatarsal is also open. EDL indicates extensor digitorum longus; EHB, extensors hallucis brevis.

Fig. 2.

BTM applied, held with staples on day 4. Pallor over EHL is obvious, but integration has commenced over the rest of the wound.

Fig. 3.

Delamination and dermabrasion of the underlying neodermis on day 63; this was followed by fenestrated sheet split skin graft application.

Fig. 4.

The result at review on day 486.

Video Graphic 1.

See video, Supplemental Digital Content 1, which displays wound appearance, digital and ankle movement at 9 months (267 days) post-BTM application, and 204 days post graft application, http://links.lww.com/PRSGO/A978.

Video Graphic 2.

See video, Supplemental Digital Content 2, which displays the ultrasound of the unimpeded movement of the EHL tendon deep to the graft over the integrated BTM on day 486, http://links.lww.com/PRSGO/A979.