Use of glycerolized human allografts as temporary (and permanent) cover in adults and childrenJ. Hussmann1, R. C. Russell2, J. O. Kucan2, D. Hebebrand', T. Bradley2 and H. U. Steinau1 1Division of Plastic Surgery and Bum Centre, BG-University Hospital Bergmannsheil, Bochum, Germany and 2Southem Illinois University School of Medicine, Division of Plastic and Reconslructive Surgery, Springfield, Illinois, USA JOHN 0. KUCAN, M.D., HANs Suci, B.S., KEVIN BUSH, M.D., TIM BRADLEY, M.D., RIcRD E. BROWN, M.D.Institute for Ptastic and Reconstructive Surgery, Southern Ittinois University, School ofMedicine, Springfietd, Ittinois 62 794-9230 Submitted for publication May 12, 1994
Multiple efforts to achieve immediate and complete bum wound closure following early debridemeni have been attempted to prevent septic complications, and to decrease the morbidity and mortality associated with major burns. The BG University Hospital Bergmannsheil Bochum (BGUBB) Burn Centre admitted 157 patients with deep partial thickness and full thicknessskin bums during 1991 and 1992. Twenly-eight of these patients (18 per cent) were treated withglycerolized human allografts. A total of 5 7 allografttransplantations were perfornzedon these 28 patients. Our indicationsfor the use of glycerolized human allografts, as well as our results, are presented and discussed.
The most challenging problem in the care of patients with large area body surface bums is the lack of available donor sites for wound closure. Presently, there is no ideal artificial skin substitute. It is well-known that severely burned patients are best treated by early bum wound excision of all devitalized tissue, as soon as their vital signs are stabilized after resuscitation (Burke et al., 1974, 1976). Others recom- –. mend the excision of only 15-20 per cent of the body surface area at one operation (Chih-Chun et al., 1982). More recently, however, due to the highly specialized intensive care regimen now available, the percentage of bum wound excision may be considerably higher (Hermans, 1971).
The best coverage for a full thickness bum wound is transplantation of a full thickness skin graft (Corps, 1969). Unfortunately there are often inadequate donor areas available to obtain full thickness grafts. The use of skin expanders to increase the area of skin available for grafts is presently only useful for secondary reconstruction, because of the ti¡ne required for expansion. A number of methods have been proposed to obtain primary wound coverage after the initial debridement but, to date, none of these have provided stable, long-term coverage.
Jackson et al. (1954) reported the use of homografts from related and unrelated living donors. The mean survival time in two different groups was reported to be 7 and 17 days respectively. Nystrom, in 1959, proposed a method of sowing multiple full thickness autograft patches on the
burned wound to overcome a relative lack of donor sites. Tanner et al., in 1964, introduced the meshed skin graft technique, by which a graft could be expanded to cover a larger area. The use of temporary wound coverage with
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xenografts (pig skin) was discussed by Bromberg (1965) . Harris et al. (1976) and Basile (1982) compared the application of fresh, glycerolized and lyophilized porcine skin. The use of HLA complex to determine suitability of human skin allografts was first published by Converse (1982). Hewitt
(1990) reported the use of composite tissue allografts with immune suppression by cyclosporin. Takiuchi (1991) showed histochemical proof of allograft survival for over 7 months in some cases. Numerous combinations of these methods to achieve major bum wound coverage have been
published (Alexander et al., 1981; Gang et al., 1981; ChihChun et al., 1982; Kreis et al., 1989; Herndon et al., 1992).
A wound bed after excision of a full thickness bum which is left to heal by secondary intention develops scarring and contracture without formation of new dermis. The sequelae of this scarring are decreased elasticity, hypertrophie scarring, and wound contracture, which is especially obstinate in peri-articular areas resulting in permanent functional impairment. Efforts have been made to improve the conditions in
the wound milieu (Abramo and Viola, 1992), and to overcome the lack of dermis in full thickness bums by the development of bi-laminate (Yannas, et al., 1989) or collagen matrix-fibroblast membranes (Hansbrough, 1990).
Our bum centre has used glycerol-preserved cadaver skin as a short-term biological dressing on wounds with a questionable bed, such as those with remaining necroses, possible infection, phosphorus bums, or as a means of reducing the surgical trauma of obtaining skin grafts in severely ill patients, who must be debrided. We have also used glycerolized human allografts as a longer-term dressing on deep partial and full thickness bum wounds, when donor sites were either insufficient or not ready for reharvesting. In some patients suffering from severe septic complications, glycerolized human allografts served as a permanent wound coverage.
Materials and methods
The BGUBB bum centre admitted 157 patients with deep partial thickness and full thickness skin bums during 1991-92. Twenty-eight of these patients were treated with a total of 5 7 glycerol-preserved human allografts provided by the Euro Skin Bank, Beverwijk, The Netherlands. The
patients ranged in age from 8 months to 43 years (average 23.7 years) with bums of 28-85 per cent total body surface area (average 53.8 per cent). All the allografts were thoroughly rinsed initially, and meshed at a ratio of 1:1.5 in order to allow sufficient drainage from the bum wound. Several methods of allograft application were performed.
(a) Temporary coverage of the bum wound following excision of devitalized tissue.
(b) Permanent coverage of the bum wound following excision of devitalized tissue.
(e) Glycerolized human allograft overgrafting of widely meshed autologous skin grafts or patches.
Temporary coverage of the burn wound following excision of devitalized tissue was performed in 24 patients (Group 1). One patient, a 35-year-old woman, suffered from a 45 per cent deep full thickness skin bum which required epifascial debridement of her upper extremities, as well as anterior and posterior thorax. The resulting wound was deemed inadequate for immediate autografting, and was covered with glycerolized human allograft three times during a 19 day period. The patient’s nutritional status improved, and she was eventually covered with autografts which achieved complete wound closure with a satisfactory range of motion (Figure la,b ).
Another patient, a 40-year-old man, suffered from an occupationally-related yellow phosphorus bum to his left forearm and hand. Following initial treatment with potassium permanganate he was transferred to our bum centre within 5 h of the accident (Figure 2a and b). The immediate débridement revealed a deep full thickness bum requiring epifascial débridement and carpal tunnel release. The wounds were temporarily closed by glycerolized human allograft, as the extent of the phosphorus bum could not be exactly determined (Figure 2c and d).No further phosphorus bum was detected when the wound dressings were changed on the first postoperative day. Definite wound closure with
autologous sheet grafts was performed 3 days after injury (Figure 2e,f). Four weeks after injury, the patient had unimpaired active and passive range of motion of all involved joints.
thickness scald burn, was admitted to the burn centre 8 days posthum. Due to severe septic comphcations from his infected bum wounds, a one-step removal of all dead tissue was attempted. This was followed by autograft transplantation to his right shoulder and left lower leg, and allograft
coverage of his back to reduce surgical trauma. The boy recovered well, and 3 months later the autografts on his right shoulder and left lower leg, as well as the allografts on his back, remained stable without evidence of rejection. There was no macroscopic difference between the two areas
(Figure 3) which have remained closed. The glycerolized human allograft appeared to have been gradually replaced with autologous skin, perhaps from dermal elements.
Glycerolized human allograft overgrafting of an autologous skin graft meshed at a ratio of 1:6 was performed in 20 patients (Group 3). A 4-year-old boy suffered a 65 per cent deep partial and full thickness skin bum due to a fire in his father’s race horse stable. Split thickness skin was harvested from the boy’s shaved scalp and from his left trunk. The skin grafts were then meshed at a ratio of 1:6, and covered with our standard glycerolized human allograft meshed at a ratio of 1:1.5: Six weeks after injury, the boy was discharged (Figure 4) with a good range of motion of all joints. Six other patients had glycerolized human allograft overgrafting of widely spaced small split thickness skin grafts. This technique was performed intentionally in two patients, while in four it occurred because the harvested autologous skin graft was too thin eo be meshed at a ratio of 1:6 and became fragmented.
The BGUBB bum centre began using glycerolized human allograft forbum wound coverage in late 1990 after promising resultswere reported in the literature (Kreis et al., 1989). Fresh human allografts and lyophílized porcine skin had been used in our bum centre in the past. Despite the development of several bi-laminate artificial skin constructions, Pruitt (1984) claimed that allograft remained the optimal biological dressing for temporary wound closure. The preparation of glycerolized grafts was proposed by Basile (1982) when he compared freeze dried porcine xenografts toglycerolized xenograft. He concluded that glycerolizedxenografts were easier to prepare and less expensive, ano were felt to be superior to lyophilized grafts. Hoekstra et al.
Figure 3. a, An ê-month-old boy with 28 per cent full thickness scald bum requiring tangential debridement. His right shoulder and left lower leg were covered with autograft (meshed at a ratio of 1:6), and his back was covered with allograft (meshed at a ratio of Í:1.5). b, Appearance 3 months
(in press) showed that the inflammatory response seen in glycerolized allografts was less than that in viable donor skin. There was also greater growth of capillaries, fibroblasts and autologous epithelium after overgrafting with glycerolized human allograft. This was shown to be comparable to that obtained using meshed autografts (Kreis et al., 1992).
Our experiences support the beneficial effects of treatment with glycerolized allografts. There appears to be a better preparation of the wound base prior to autograft transplantation, which can be attributed to enhanced fibroblast and capillary ingrowth. The patients also seemed to benefit
from this type of temporary coverage, which may serve as a dermal substitute for later overgraftíng. We believe that this might lead to reduced scar and scar contracture formation, with improved long-term functional results.
The use of glycerolized human allograft has considerably improved treatment of patients with major bum wounds in our bum centre. This approach allows immediate bum wound closure after radical débridement. Additionally, it serves as a moisture barrier and also decreases bacterial invasion. Still, there remains a minor risk of acquiring a viral infection. The technique remains relatively expensive and should not be used merely as a wound dressing.
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Ilike your emphasis on the cost-benefit relation. Actually, for small bums you can very well use Duoderm, as Michel Hermans pointed out.
Iliked your presentation very much. You have the special problem that you mostly receive your patients about 1 week
after the event. Another thing is, you spoke about survival of the allograft …
Well, Iactually prefer to speak about healing in.
But the skin you use, is it viable?
So the epidermal remnants grow into the graft?
Yes, the epidermal remnants grow over the graft and we may run into cosmetic problems afterwards. Sometimes we have to debride again. Our problem is that we do not have a children’s centre, so all the children corne from other hospitals or cities, and are often sent back after débridement and covering. We do not see them again.
I wanted to make clear that the glycerolized graft is dead and what you see here is the epidermal layer of the child.
Stark, Köln: I disagree with your indications. On contaminated wounds.
or wounds wìth necrotic tissue you should never apply an allograft, especially a nonviable graft, because you just get increased infection. Your Wound bed should at least be as good as for an autogralt,
I agree, you should not close contaminated wounds. We often use an allograft if we are concerned that the wound is not clean. We excised a contaminated wound to beneath the contaminated area -and, rather than risk what autograft we have, We place an allograft on at that time. If it adheres, we know it was clean; and then we are ready for an autograft. If it does not adhere we re-debride within a: few days.
We also do our first redressing after I or 2 days to cover .a wound which has remaining necrosis, as we also do not always have ·sufficient autologous skin for grafting these patients.
But why did you not débride any further?
Sometimes the condition of thé patient is too bad to do any more surgery.
Under those circumstances I would not apply anything, especially thinking about the costs. If I had to accept necrotic tissue being left, I would apply a regular dressing. Actually we do not have your problem as we do not adhere to the rule of debriding 15-20 per cent of wounds at a time. We excise up to 80 per cent of the body surfaez.ìn one operation. That takes a lot of time, but we have a blood bank that fulfils all our needs; we work with anaesthesiologists we have known for years, and sometimeswe stop for a wlùle so. they can work up the fluid balance. But if I had to leave necrotic tissue, Iwould be.concerned covering that with an allograft.
What is the difference between necrotic tissue ánd a dead allograft?
There is no difference.
The necrotic tissue may be infected.
Yes, but the material itself is not different?
By closing a wound, in the proper way of course, you cart prevent further colonìzation or even decrease it. Dead tissue does not stop colonization. de Backere, Beverwijk: Necrotic tissue does not have any structural integrity left
Correspondence should be addressed to: Dr Jurgen Hussmann, SIU School of Medicine, Division of Plastic Surgery, P.O. Box 19230, Springfield, Ill 62794-9230, USA.