Keywords
pediatric - complex wound management - biodegradable temporizing matrix
Introduction
Pediatric complex wound management has always been proved to be a challenge due to
donor site morbidity, prolonged hospital stay, prolonged immobilization, and additional
scars and wound infection. Research on a suitable alternative for flap covers for
complex wounds has been ongoing for a few decades. The invention of artificial dermal
matrices has been a cornerstone in the management of complex wounds. NovoSorb Biodegradable
Temporizing Matrix (BTM; PolyNovo Ltd, Port Melbourne, Victoria, Australia) has been
used to manage adult complex wounds since 2015.[1] BTM consists of two layers: an outer sealing membrane, which is a transparent temporary
layer that gives a physiological wound closure and limits evaporative loss,[2] and an inner 2-mm bioabsorbable matrix, allowing cellular infiltration while acting
as a scaffold.[3] It is a two-stage procedure where, after initial debridement of the wound, the BTM
material is applied and allowed to integrate for 3 to 5 weeks. A blanchable tissue
underneath the dressing material indicates the end of integration.[1] After ensuring adequate integration, the outer layer is removed under a sterile
environment, and the underlying granulation tissue is grafted.
The use of BTM has been well documented in burns and complex wounds in adults.[4]
[5]
[6] Only three documented case reports[7]
[8]
[9] and one 63-patient case series are available for the pediatric population, all out
of the country.[10] No reports are available in India regarding the use of BTM in a complex wound in
a child younger than 5 years. We report a case of Achilles' tendon exposure in a 2-year-old
child following trauma, which was successfully managed without a flap cover using
a BTM.
Case Report
A previously healthy 2-year-old boy presented to our emergency department with an
alleged history of sustaining an injury to his right heel when he accidentally put
it in the spokes of a moving motorcycle wheel. The child had no other injuries except
the one he presented with. The child had no other congenital anomalies. He was immunized
to date and attained milestones for age. On examination, he had a 5 × 5 cm raw area
in the right tendoachilles region, exposing the bare tendon. No bony injuries were
noted clinically or radiologically. All investigations were within normal limits.
The child was immediately taken up for debridement under general anesthesia (GA).
The nonviable edges were trimmed, and the base scooped out and sent for tissue culture.
The resultant wound was covered with a 5 × 5 cm BTM and was fixed with skin staples.
The ankle was immobilized with a POP splint.
The first look dressing was done on day 5. No apparent infection was noted. The child
was discharged and was on regular follow-up every 5 days. After adequate matrix adhesion
at 2 weeks, the POP splint was removed, a crepe bandage was applied, and the child
was encouraged to move his ankle. Satisfactory integration was identified by blanchable
granulation tissue under the matrix—this was noted after 4 weeks. In the fifth week,
the child was taken up under GA. Staples were removed, and the outer layer was delaminated.
The tendoachilles was covered with granulation tissue, and there was no breakdown
on moving the ankle. The underlying granulation tissue was superficially scraped to
remove any biofilm, and the wound was grafted with intermediate-thickness split skin
graft (SSG) harvested from the right thigh. The first dressing was done on day 3,
followed by subsequent dressings on day 5, with staple removal on day 7. The child
was discharged on day 8. After postoperative day 14, the child was encouraged to walk
and has recovered fully.
Discussion
Wound healing is a complex process, and wound care products have evolved from simple
gauze dressings to complex bioengineered tissue products. Various matrices have been
developed to convert a complex wound into a graftable wound. Integra consists of a
dermal component of bovine collagen type I and shark chondroitin-6-sulfate directed
to the wound site and an outwardly directed silicone membrane. MatriDerm is a single-use
three-dimensional matrix composed of native, structurally intact bovine collagen fibrils
and elastin for supporting dermal regeneration. The development of BTM began at the
Royal Adelaide Hospital in South Australia at the end of 2004[11] and has since been used in managing various wounds like burns and necrotizing fasciitis.[12] BTM carries the advantage of not containing sensitizing proteins, reducing wound
size, decreased scar formation, and delivering a better aesthetic outcome than by
immediate SSG.[13]
Greenwood et al[14] described using BTM in burns as providing a temporary skin cover postdebridement,
reducing systemic and local infection, decreasing the metabolic need, and helping
in wound bed preparation for grafting.
Although extensively used, literature on BTM application in the pediatric population
is limited. Teelucksingh et al[7] described the use of BTM in a 7-year-old child with a complex wound exposing the
tibia and fibula, where the wound was grafted, and further bone fixation was done
through the stable graft and BTM. Kelly et al[8] used BTM in an 8-year-old boy with 86% burns and reported complete recovery but
minimal hypopigmentation. Crowley et al[9] reported the use of BTM in a 9-year-old child with extensive soft-tissue injuries
to his groin, left and right thighs, and lower abdomen with penile degloving injury,
exposed left iliac crest fracture, and avulsion of scrotum and bilateral testicle
exposure. All the wounds were covered with skin graft.
The most extensive retrospective case series on the use of BTM in children was done
by Storey et al[10] on 63 children with various etiology of complex wounds. They reported that the median
time for application of BTM was 7.5 days and 27 days from the time of application
of BTM to SSG. They also concluded that BTM provided a satisfactory option for early
wound coverage and could convert complex wounds to graftable ones.
Conclusion
BTM is a valuable addition to the plastic surgeon's reconstructive repertoire, particularly
in the pediatric population, where there is a paucity of flaps to reconstruct large
complex wounds. The limitation of our report is that it presents a single case, reporting
only short-term outcome data. A multicenter study with long term follow up would help
to extrapolate our results to the general population.
