Bone and Tendon Coverage via Dehydrated Human Amniotic/Chorionic Membrane and Split-Thickness Skin Grafting

Extremity wounds are debilitating and complex. When critical structures are not exposed, extremity wounds can be managed with conservative measures such as local wound care or skin grafting.[1] However, exposure of critical structures such as bone or tendon precludes the use of these modalities. Skin grafts do not engraft onto bone and tendon, and with local wound care alone, bone develops osteomyelitis and tendons desiccate and rupture.[2] Without soft tissue reconstruction, osteomyelitis leads to amputation 50% of the time and tendon rupture results in loss of function.[2]

Free flap reconstruction is currently the gold standard for limb salvage. The high technical expertise required for consistent free flap limb salvage poses a barrier for patient access to care, and not all patients are suitable candidates. Additionally, microsurgical free flaps in the lower extremity have an 8% failure rate, 75% of which proceed to amputation.[3] Reliable alternatives to free flap reconstruction that lead to stable wound closure are needed.

Dehydrated human amniotic/chorionic membrane (dHACM) is an FDA-approved biologic device that delivers a large number of growth factors.[4] While dHACM is effective at closing diabetic foot ulcers and venous stasis ulcers,[5] [6] many applications of dHACM over prolonged periods are typically necessary for complete closure. The cost and time to closure makes dHACM alone an unsuitable method for limb salvage.

We developed a novel limb salvage technique using dHACM to generate granulation tissue over critical structures and then definitively closing the wound with split-thickness skin grafts (STSG). Tendon coverage requires 1 week of dHACM treatment before STSG. Bone coverage requires 2 to 3 weeks of dHACM treatment before STSG. We present our early experiences using this innovative approach.

• References

• 1 Colohan S, Saint-Cyr M. Management of lower extremity trauma. In: Neligan PC, ed. Plastic Surgery. 3rd ed. New York, NY: Elsevier; 2013: 63-91
• 2 Hong S. Reconstructive surgery: lower extremity coverage. In: Neligan PC, ed. Plastic Surgery. 3rd ed. New York, NY: Elsevier; 2013: 127-150
• 3 Khouri RK, Cooley BC, Kunselman AR , et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102 (3) 711-721
• 4 Gruss JS, Jirsch DW. Human amniotic membrane: a versatile wound dressing. Can Med Assoc J 1978; 118 (10) 1237-1246
• 5 Zelen CM, Serena TE, Fetterolf DE. Dehydrated human amnion/chorion membrane allografts in patients with chronic diabetic foot ulcers: a long-term follow-up study. Wound Med 2014; 1-4
• 6 Serena TE, Carter MJ, Le LT, Sabo MJ, DiMarco DT ; EpiFix VLU Study Group. A multicenter, randomized, controlled clinical trial evaluating the use of dehydrated human amnion/chorion membrane allografts and multilayer compression therapy vs. multilayer compression therapy alone in the treatment of venous leg ulcers. Wound Repair Regen 2014; 22 (6) 688-693