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Traumatic Amputation: Healing the Acute Lawn Mower Injury- A Case Report

Open AccessPublished:September 13, 2022DOI:https://doi.org/10.1016/j.fastrc.2022.100247

      Abstract

      Background

      An estimated 84,944 lawn mower injuries occur annually in the United States, of those 16.2% involving the lower extremity.
      • Harris C
      • Madonick J
      • Hartka TR.
      Lawn mower injuries presenting to the emergency department: 2005 to 2015.
      Often, a significant soft tissue deficit is present leaving limited reconstructive options available to the surgeon or wound care provider. Split-thickness skin graft (STSG) has long been considered the mainstay for treatment of large skin defects caused by traumatic wounds. Issues related to graft loss, scar contracture, loss of elasticity, adhesions to tendons and unfavorable aesthetic results are regarded as limitations of skin grafting alone.
      • Ünal S
      • Ersoz G
      • Demirkan F
      • Arslan E
      • Tütüncü N
      • Sari A.
      Analysis of skin-graft loss due to infection: infection-related graft loss.
      As a result, acellular dermal matrices have seen an increase in usage due to their potential to overcome these limitations.
      • Park JY
      • Lee TG
      • Kim JY
      • Lee MC
      • Chung YK
      • Lee WJ.
      Acellular Dermal Matrix to Treat Full Thickness Skin Defects: Follow-Up Subjective and Objective Skin Quality Assessments.

      Keywords

      In this case report, we used an acellular fish skin dermal matrix due to its native dermal structure, porosity and biomechanical properties. It also provides a natural bacterial barrier rich in Omega-3 fatty acids.
      • Taylor BC
      • Triplet JJ
      • Wells M.
      Split-Thickness Skin Grafting: A Primer for Orthopaedic Surgeons.
      Compared to xenografts derived from other species, fish skin matrices have been show to have lower risks of disease transmission and autoimmune responses, and are additional reasons as to why we chose to utilize this graft in this setting.
      • Taylor BC
      • Triplet JJ
      • Wells M.
      Split-Thickness Skin Grafting: A Primer for Orthopaedic Surgeons.

      Case Report

      A 19-year-old male with no significant PMH sustained a traumatic partial amputation of the left 2nd digit due to a lawn mower injury. He was transferred to a level 1 trauma center for further evaluation by the foot and ankle surgical service. The injury site was flushed with copious amounts of sterile saline in the ED and a temporary dressing was applied. Radiographs confirmed partial amputation of the 2nd digit with remnant 2nd digit proximal phalanx left comminuted. No other osseous injuries were identified.
      The following morning, he was taken to the OR for debridement of non-viable soft tissue and amputation of the remaining 2nd digit proximal phalanx. There was inadequate soft tissue to close the amputation site, and there was exposure of the first metatarsophalangeal joint due to the loss of the dorsal joint capsule. Particulate form of a fish skin acellar dermal matrix (Kerecis Micrograft) was packed into the amputation site and covered the dorsal first metatarsophalangeal joint. The remainder of the de-gloved dorsal foot was covered with a sheet form of the fish skin acellar dermal matrix (Kerecis SurgiClose).
      The acelluar dermal matrix had 100% incorporation within the first week, covering all tendinous and osseous structures with granulation tissue. No signs of infection were represent, and the wound bed was appropriate for split thickness skin grafting. 15 days following the initial acellar dermal matrix application the patient went to the OR for repeat debridement and application of STSG. Complete “take” of the graft was noted with 100% healing at 2 weeks s/p STSG. 8 weeks s/p STSG the patient remained healed with minimal scaring/contracture and no pain.

      Discussion

      Lawn mower injuries provide unique challenges due to the potential extent of soft tissue loss and the severely contaminated nature of the wounds. Exposed osseous and relatively avascular tendinous structures add to the complexity of the injury. Appropriate surgical debridement of non-viable tissue along with local wound care is often necessary. Following appropriate debridement, the remaining soft tissue deficit may very well be much larger than what was previously seen. Such injuries may not be amenable to primary closure, therefore, healing through secondary intention is often needed.
      Split thickness skin grafting has been used for thousands of years for reconstruction of deficits not amenable to primary closure.
      • Taylor BC
      • Triplet JJ
      • Wells M.
      Split-Thickness Skin Grafting: A Primer for Orthopaedic Surgeons.
      When applied to clean, vascularized beds, STSG's have shown favorable results across a spectrum of wounds including diabetic and chronic venous stasis ulcerations, as well as those which are trauma induced.
      • Taylor BC
      • Triplet JJ
      • Wells M.
      Split-Thickness Skin Grafting: A Primer for Orthopaedic Surgeons.
      • Ramanujam CL
      • Stapleton JJ
      • Kilpadi KL
      • Rodriguez RH
      • Jeffries LC
      • Zgonis T.
      Split-Thickness Skin Grafts for Closure of Diabetic Foot and Ankle Wounds: A Retrospective Review of 83 Patients.
      • Høgsberg T
      • Bjarnsholt T
      • Thomsen JS
      • Kirketerp-Møller K.
      Success Rate of Split-Thickness Skin Grafting of Chronic Venous Leg Ulcers Depends on the Presence of Pseudomonas aeruginosa: A Retrospective Study.
      Unfortunately, obtaining a healthy and clean wound bed can be difficult, especially in the case of traumatic injuries. While STSG's provide great coverage with ultimate healing of various wounds, they should not be placed over inadequately perfused or prepared wound sites.
      • Martini CJ
      • Burgess B
      • Ghodasra JH.
      Treatment of traumatic crush injury using a synthetic hybrid-scale fiber matrix in conjunction with split-thickness skin graft.
      As such, the evolution of various allo-, xeno-, and synthetic grafting materials has allowed physicians to better manage these difficult wounds by supporting the growth of healthy granular tissue. These grafts have both shared and unique advantages and disadvantages that when compared amongst each other.
      Allografts, being derived from human skin, carry the notable advantage of representing natural skin. While the grafts themselves have been shown to promote epithelialization of wound beds, the availability of donors limits the amount of graft available.
      • Leon-Villapalos J
      • Eldardiri M
      • Dziewulski P.
      The use of human deceased donor skin allograft in burn care.
      Additionally, allogenic grafts carry the risks of disease transmission, increased inflammatory responses, and potential graft rejection.
      • Przekora A.
      A Concise Review on Tissue Engineered Artificial Skin Grafts for Chronic Wound Treatment: Can We Reconstruct Functional Skin Tissue In Vitro?.
      Synthetic grafts, in contrast, are widely available and have seen an increase in usage. Typically made from natural polymers, artificial grafts also have been shown to cause less of an inflammatory reaction and decreased chance of rejection, both of which are seen with more frequency in allogeneic grafts.
      • Przekora A.
      A Concise Review on Tissue Engineered Artificial Skin Grafts for Chronic Wound Treatment: Can We Reconstruct Functional Skin Tissue In Vitro?.
      However, these skin substitutes are usually void of basement membranes and generally lack any semblance of natural skin.
      • Halim AS
      • Khoo TL
      • Shah SJ.
      Biologic and synthetic skin substitutes: An overview.
      Xenografts are those taken from one animal species and transferred to another. Historically, porcine grafts were the most common used due to their similar physical properties to that of human skin. These grafts, while abundant, have numerous flaws which include higher risks of viral and bacterial disease transmission, longer healing times, and increased risk of hypertrophic scar formation.
      • Taylor BC
      • Triplet JJ
      • Wells M.
      Split-Thickness Skin Grafting: A Primer for Orthopaedic Surgeons.
      Due to its derivation from porcine species, cultural and religious aspects must also be taken into account prior to its application.
      • Taylor BC
      • Triplet JJ
      • Wells M.
      Split-Thickness Skin Grafting: A Primer for Orthopaedic Surgeons.
      More recently, skin substitutes sourced from fish have seen an increase in usage due to their advantages over traditional grafting materials, including porcine grafts. To date, piscine acellular dermal matrices have been used successfully across a wide spectrum of pathologies, from burns and traumatic wounds to chronic ulcerations frequently seen in diabetes and venous stasis.
      • Fiakos G
      • Kuang Z
      • Lo E.
      Improved skin regeneration with acellular fish skin grafts.
      ,
      • Wee SY
      • Kim TH
      • Park H
      • Jeong HG.
      The Utility of Novel Fish-Skin Derived Acellular Dermal Matrix (Kerecis) as a Wound Dressing Material.
      Baldursson et al. demonstrated in their study that these grafts demonstrated significantly faster healing times compared to their porcine derived counterparts.
      • Baldursson BT
      • Kjartansson H
      • Konrádsdóttir F
      • Gudnason P
      • Sigurjonsson GF
      • Lund SH.
      Healing rate and autoimmune safety of full-thickness wounds treated with fish skin acellular dermal matrix versus porcine small-intestine submucosa: A noninferiority study.
      On a cellular level, the grafts have been shown to be free of risk in terms of adverse autogenic responses as well as viral and bacterial transmission.
      • Taylor BC
      • Triplet JJ
      • Wells M.
      Split-Thickness Skin Grafting: A Primer for Orthopaedic Surgeons.
      ,
      • Baldursson BT
      • Kjartansson H
      • Konrádsdóttir F
      • Gudnason P
      • Sigurjonsson GF
      • Lund SH.
      Healing rate and autoimmune safety of full-thickness wounds treated with fish skin acellular dermal matrix versus porcine small-intestine submucosa: A noninferiority study.
      Their proven efficacy in wound healing combined with an abundant supply indicate that their use can be sustainable, efficient, and cost effective.
      • Fiakos G
      • Kuang Z
      • Lo E.
      Improved skin regeneration with acellular fish skin grafts.
      In this case report, we presented a patient who suffered a traumatic amputation of a lesser digit with significant soft tissue injury. Surgical debridement with amputation of the remnant second toe was performed with an adjunctive application of a fish skin graft. This allowed for rapid granulation of the wound bed allowing for split-thickness skin grafting two weeks after the initial injury. The patient ultimately underwent a full recovery with no limitations.
      Based on the outcome of this case report, the utilization of a piscine skin acellular dermal matrix appears to be a viable option to optimize traumatic wounds for STSG. It is our hope this can provide future clinical and surgical guidance to practitioners with similar traumatic wounds in the future.

      Financial Disclosure

      None reported

      Informed Patient Consent

      Complete informed consent was obtained from the patient for the publication of this study and accompanying images.

      Uncited References

      • Harris C
      • Madonick J
      • Hartka TR.
      Lawn mower injuries presenting to the emergency department: 2005 to 2015.
      ,
      • Ünal S
      • Ersoz G
      • Demirkan F
      • Arslan E
      • Tütüncü N
      • Sari A.
      Analysis of skin-graft loss due to infection: infection-related graft loss.
      ,
      • Park JY
      • Lee TG
      • Kim JY
      • Lee MC
      • Chung YK
      • Lee WJ.
      Acellular Dermal Matrix to Treat Full Thickness Skin Defects: Follow-Up Subjective and Objective Skin Quality Assessments.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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