Case Competition 2024 – All submitted cases Case 4 Wound healing and dermal regeneration in delayed presentation of a burn patient treated with NovoSorb® Biodegradable Temporising Matrix
Keywords: Biodegradable Temporising Matrix; NovoSorb®; Biodegradable polyurethane; Dermal matrix; Burn; Full-thickness burns; Skin graft
Authors: K. Kaushal (MD), D. Jordan (MD), R. Majeed (MD) and L. Dingle (MD). Dundee, Scotland
The purpose of this case study is to describe the surgical treatment of a delayed presentation of a full thickness burn at an anatomically challenging area. We present a case an 81-year-old Scottish lady with a medical background of stroke, atrial fibrillation on Edoxaban who was not surgically fit. Patient was recovering from post COVID-vaccine-flu like symptoms at her residence when she sustained 3% TBSA scald burn to her neck and anterior upper chest. She mentioned that she spilled milk tea onto herself, did not take off her clothing, and received no first aid of any kind. A week later she presented to our services when the pain got unbearable. She underwent surgical excision and Biodegradable Temporising Matrix (BTM) dressing with negative- pressure wound therapy then definitive split thickness skin graft after her infection settled down. She has healed well with a minimal- no neck contracture.
Before and after
Patient examination
Patient presented with fever, a Tmax of 39 degrees centigrade and tachycardia of 100bpm. The burn was of full thickness in nature over her anterior upper chest and neck sparing the back and nape of neck, 3% TBSA, measured using patient’s palmer surface. The burns were non blanching and non-tender in the centre however slightly tender around the zone of hyperaemia. The microbiology wound swab taken on day of admission grew Staphylococcus aureus, Group B Streptococci and Streptococcus dysgalactie. Patient was put on empirical antibiotics which was later changed to co-trimoxazole. Patient was a non-smoker, independent person and on blood thinner. Other than the areas mentioned, there was no injury sustained elsewhere.
Pre-Operative Considerations
The Infected burn was taken to theatre for excision and negative pressure wound therapy until the microbiology team cleared off the pathogens for definitive treatment. The patient was given empirical antibiotics according to hospital protocol. Bloods : Complete blood count, Urea and creatinine, coagulation profile, ECG, Cross match, group and save. Patient was referred to cardiology team as the patient developed atrial fibrillations in the ward.
Step 1: Excision of burn
Tangential excision using Watson knife on anterior chest and versajet on neck
Step 2: NPWT Aplication
Negative Pressure Wound Therapy (NPWT) is used to help the drainage of excess fluid and increase localised blood flow. It has been suggested that the action of NPWT may result in the burn being supplied with increased oxygen and nutrition which could promote healing.
Step 3: BTM application
A promising option for achieving satisfactory aesthetic outcomes is reconstruction using synthetic matrices. Biodegradable Temporising Matrix (BTM) has shown promise as a novel dermal substitute used in complex burns healing, deep infected wounds, reconstruction of subfascial defects and necrotising fasciitis. It is a 2-mm thick synthetic dermal template, with a biodegradable polyurethane open-cell foam bonded via a polyurethane adhesive layer to a superficial transparent nonbiodegradable polyurethane sealing membrane requiring a two stage wound reconstruction in the mainstay. In the first stage, BTM provides physiological wound cover, with fenestration to avoid accumulation of underlying materials, into which cells and blood vessels migrate to form a neodermis. As granulation tissue grows into the foam matrix, the foam itself biodegrades, ultimately leaving a graftable surface. A split thickness skin graft was considered for the second stage. BTM has antibacterial properties and does not supply nutrients from animal tissue in comparison to other dermal substitutes and been demonstrated to be cost effective with greater vascularisation and inflammatory response when compared with other dermal substitutes.
Step 4: BTM
BTM in 4 weeks time, before delaminating BTM for 2nd stage reconstruction.
Step 5: Sheet SSG
2nd stage reconstruction using a sheet split thickness skin graft was used and supported by NPWT dressing.
Step 6: Graft check
1st graft check, post operative day 5.
Step 7: Graft check
Graft check in 3 weeks time, healing with no issue. Patient was given appointments with the physiotherapy after this appointment.
- Burn wound was successfully closed with difficult anatomical region for grafting and delayed presentation of infected burn were considered, then this two-stage strategy of BTM implantation followed by later SSG was carried out.
- Longer duration of stay in the hospital.
References
- Lo CH, Brown JN, Dantzer EJG, et al. Wound healing and dermal regeneration in severe burn patients treated with NovoSorb® Biodegradable Temporising Matrix: A prospective clinical study. Burns. 2022;48(3):529-538. doi:10.1016/J.BURNS.2021.07.014
- Wagstaff MJ, Caplash Y, Greenwood JE. Reconstruction of an Anterior Cervical Necrotizing Fasciitis Defect Using a Biodegradable Polyurethane Dermal Substitute. Eplasty. 2017;17:e3. Accessed May 2, 2023. https://pubmed.ncbi.nlm.nih.gov/28197297/
- Solanki NS, York B, Gao Y, Baker P, Wong She RB. A consecutive case series of defects reconstructed using NovoSorbⓇ Biodegradable Temporising Matrix: Initial experience and early results. J Plast Reconstr Aesthet Surg. 2020;73(10):1845-1853. doi:10.1016/J.BJPS.2020.05.067
- PolyNovo UK Ltd. UK Healthcare Pavilion. https://ukhealthcarepavilion.com/articles/polynovo-launches-pioneering-novosorb-btm-synthetic-wound-matrix-technology-at-medica-2021/.
- Cheshire PA, Herson MR, Cleland H, Akbarzadeh S. Artificial dermal templates: A comparative study of NovoSorbTM Biodegradable Temporising Matrix (BTM) and Integra® Dermal Regeneration Template (DRT). Burns. 2016;42(5). doi:10.1016/j.burns.2016.01.028
