A total of 3 patients with complex cutaneous wounds—skin lesions owing to calciphylaxis, abdominal fistula, and necrotizing fasciitis of the hand and forearm—were included in this preliminary case series. In all cases, treatment following the use of the synthetic matrix resulted in significant healing.
A 42-year-old female presented to the renal dialysis unit with calciphylaxis of the bilateral breasts, hips, thighs, and abdomen. The patient had multiple comorbidities, including end-stage renal disease, hypertension, prior mitral valve replacement, and a current smoking history. The calciphylaxis skin lesions were initially managed with sodium thiosulfate daily for 8 weeks and then with heparin for 2 weeks. The lesions required surgical incision and drainage. Postoperatively, the lesion on the right thigh was managed with the synthetic hybrid-scale fiber matrix in conjunction with NPWT with instillation weekly for 5 weeks, during which time a total of 5 matrices were applied and accelerated healing was noted (Figure 1A, 1B). At that time, the transition was made to dry gauze dressing affixed with paper tape. The majority of the wound had reepithelialized by 75 days postoperatively (Figure 1C).
Case 1. Calciphylaxis skin lesion. (A) 3 days postoperatively, the wound measured 14.5cm x 19.0cm x 3.5cm. (B) Example of application of synthetic nanofiber matrix. (C) Seventy-five days after surgery, most of the wound had reepithelialized and measured 3.3cm x 5.5cm with.
The bedside protocol developed by the lead author for this case (LF) is shown in Figure 2. The synthetic matrix was meshed at a ratio of 3 to 1 using a surgical mesher (Zimmer Skin Graft Mesher; Zimmer Biomet) and trimmed to size prior to application. The protocol consisted of 5 bedside applications of the synthetic matrix with NPWT, with each application having a duration of 7 days. For all applications, the wound was irrigated with instillation fluid prior to NPWT and placement of the synthetic matrix. For the second application, a silver collagen dressing (Promogran Prisma Matrix; 3M) was applied as a synergistic adjunct for locoregional control of bacterial growth in the wound.
Case 1. Bedside application protocol, developed by the lead author (LF), for the patient with calciphylaxis. The synthetic hybrid-scale fiber matrix was meshed using a surgical mesher prior to application and used in conjunction with negative pressure wound therapy with instillation fluid. The bedside protocol process was as follows: (A) surgical mesher; (B) 3:1 mesh expansion with the synthetic matrix; (C) small- and medium-sized synthetic matrices; (D) synthetic matrix placed and secured with thin adhesive strips; (E) nonadherent contact layer applied; and (F, G) negative pressure wound therapy initiated.
To determine a valid cost comparison of therapy, an institutional surgical standard practice (ISSP) treatment plan using a comparison of the cost of use of amniotic tissue or placental tissue allograft matrix was used. The synthetic matrix was applied to the patient's wound once per week for 5 weeks on the same wound; no applications of the synthetic matrix on this patient were done in the OR but instead in the inpatient unit setting. The ISSP treatment plan would have used 1 application of the amniotic tissue over the placental tissue allograft matrix once per week for 5 weeks. These once-weekly applications are not unique to the ISSP, as the instructions for many similar products indicate weekly application. The amniotic tissue sizes selected in the ISSP assessment were based on the wound size and healing pattern of the wound from the actual synthetic matrix applications.
When considering the present institution's implant costs only (amniotic and placental allografts and synthetic matrix), and keeping all floor materials, equipment, and labor costs equal, this analysis determined that the ISSP treatment method would have yielded an increase in cost of care of 86% compared with application of the synthetic matrix. The difference in cost expenditure between the ISSP and synthetic matrix therapy was most pronounced in week 1 through week 4 when using larger sizes of material to cover the larger wound surface area, with a very similar cost variance noted during week 5 of therapy (Figure 3). Based on this economic analysis, the ISSP is 86% more costly over 5 weeks than the synthetic matrix applications.
Cost comparison of synthetic matrix material (n=1 case) versus institutional surgical standard practice (ISSP) allograft material for case study 1, the calciphylaxis skin lesion.
A 30-year-old male with type 1 diabetes mellitus presented with multiple blunt traumatic injuries (grade IV to V Couinaud segment 1 liver injury, grade III pancreatic head injury, grade III splenic laceration, grade II right renal laceration, and zone I retroperitoneal peripancreatic and periduodenal hematoma, as well as open facial fractures, a right open patella fracture [Gustilo-Anderson type II], and left open great toe fracture [Gustilo-Anderson type III]) following a motor vehicle accident and was taken emergently to the OR.[21–26] The patient required multiple abdominal surgical procedures to repair and control the complex liver injury (Figure 4). Despite extensive perihepatic and endoluminal drainage, the patient developed a midline abdominal incision dehiscence as a result of biliary digestion of the underlying abdominal wall fascia. The patient also manifested a delayed, midjejunal enteroatmospheric fistula with an output of 1000 mL per day. The fistula was controlled as illustrated in Figure 5.
Case 2. (A) Blue arrow shows grade IV–V liver injury. (B) Yellow arrow shows grade II–III pancreatic injury.
Case 2. Enteroatmospheric fistula. (A) Prior to split-thickness skin graft application. (B) Placement of a silver collagen dressing and nonadherent dressing as well as the ileostomy appliance on peri-enteroatmospheric fistula tissue. (C, D) Placement of negative pressure wound therapy device and drape dressing on peri-enteroatmospheric fistula tissue.
Split-thickness skin grafting was done in an attempt to epithelialize the enteroatmospheric fistula granulation tissue, in order to safely place an ileostomy appliance. Negative pressure wound therapy was applied over the graft, per institutional protocol, with NPWT dressing (V.A.C. GRANUFOAM Dressing; 3M) over nonadherent silicone dressing (ADAPTIC TOUCH Non-Adhering Silicone Dressing; 3M), silver collagen dressing, and a meshed 3 to 1 STSG (Figure 6). The STSG and NPWT did not take to the granulation tissue around the fistula within 5 days, however, because the small intestinal succus that leaked around the ostomy appliance dissolved the STSG.
Case 2. (A) Enteroatmospheric fistula granulation tissue (yellow arrow) with (B) three-toone meshed split-thickness skin graft (blue arrow).
The synthetic hybrid-scale fiber matrix was then applied to the wound in conjunction with NPWT. To begin, the synthetic matrix was meshed at a ratio of 3 to 1. The meshed synthetic matrix was applied to the wound (Figure 7A) and covered with the nonadherent silicone dressing (Figure 7B) and NPWT dressing (Figure 7C). A NPWT device (WOUND CROWN; 3M) (Figure 8A) and ileostomy appliance (Figure 8B) were then applied.
Case 2. (A) Meshed synthetic matrix applied to wound, which was (B) covered with a nonadherent silicone dressing and (C) negative pressure wound therapy dressing.
A total of 4 synthetic hybrid-scale fiber matrix applications over 6 weeks resulted in reepithelialization and complete healing around the fistula (Figure 9). The synthetic matrix remained adherent and incorporated even upon exposure to bile. The patient was taught how to care for and manage the fistula. After a total of 7 months of hospitalization for treatment following the motor vehicle accident, the patient was discharged from the hospital, because he was able to manage the remaining issues at home in part owing to the successful treatment with the synthetic matrix.
Case 2. Abdominal peri-enteroatmospheric fistula (EAF) tissue treated with the synthetic hybrid-scale fiber matrix resulted in significant healing around the fistula after a total of 6 months from initial application. Progression of treatment was as follows: (A) week 1, placement of the synthetic matrix at bedside; (B) week 2, peri-EAF tissue with initial reepithelialization; (C) 3 months, increased epithelial tissue generation around the EAF; and (D) 6 months, completed reepithelial tissue development around the EAF.
Economic data from the failed STSG and the initial surgical application of the synthetic hybrid-scale fiber matrix procedures were collected and compiled in Figure 10. The STSG total procedure cost to the facility was $14 329. The synthetic matrix total procedure cost to the facility was lower, at $5210. Based on the savings calculated in this case, an economic projection analysis of 39 STSG procedures (representing the institutional average for the prior 6 months) showed that using the synthetic matrix rather than the current ISSP (ie, biologic matrix implants) would yield annual total case cost savings of $355 641.
Comparison of case costs for case study 2, the abdominal fistula. Total case costs include the cost of the implant materials, floor materials, equipment, and labor costs.
Surgical time was also considered. Review of the surgical reports and anesthesia time in the OR as well as the OR records from this case showed the case time to be much lower with the synthetic matrix than with STSG, specifically, 54 minutes less in the OR and 29.5 minutes less cut-to-close surgical time (Figure 11). These time reductions are indirect savings of surgical resources, floor resources, and OR availability.
Comparison of average (Avg) operating room (OR) and surgery times for case study 2, the abdominal fistula.
A 54-year-old male presented to the emergency department for evaluation of progressive left upper extremity pain, swelling, and stiffness. The patient stated that he jammed his left hand against a car door, and over the next several days progressive pain, edema, and increased warmth developed in the left upper extremity (Figure 12). The patient did not sustain an open wound to his hand during the injury. He was initially admitted for cellulitis and started on intravenous antibiotics.
Case 3. Initial presentation (A) with edema and pain of the left hand and forearm. (B) Visual comparison of the patient's right and left upper extremities.
On hospital day (HD) 2, the patient's clinical signs and symptoms continued to worsen despite the use of broad-spectrum intravenous antibiotics. At the index procedure (postoperative day [OP] 1), the patient underwent incision and drainage of the dorsal hand, volar forearm, and medial-lateral forearm. A large amount of "dishwater" purulent fluid and necrotic material was removed from the dorsum of the hand. Edema without purulence was noted in the volar-lateral forearm. The patient required 6 surgical debridements of the hand and forearm for effective clearing of the infection.
On HD 17/OP 7 (Figure 13), the infection was resolving, and the patient underwent repeat incision and drainage, washout, and application of the synthetic hybrid-scale fiber matrix and NPWT to the volar forearm wound defect (10.5 cm × 4.5 cm) and dorsal hand wound defect (6.5 cm × 5.5 cm).
Case 3. Hospital day 17/postoperative day 7, prior to application of the synthetic hybrid-scale fiber matrix on the dorsum of the right (A) hand and (B) forearm.
On HD 22 (5 days after treatment with the synthetic hybrid-scale fiber matrix), NPWT was removed from the dorsal hand and volar surface of the forearm, and the wounds were inspected at the bedside. The synthetic matrix was well incorporated into the wounds (Figure 14). The patient was transitioned to standard of care at the bedside (ie, gauze/compressive dressing changes 3 times/week). The patient was discharged to home on HD 29 and continued receiving standard of care in the outpatient wound care clinic. Progressive wound healing was observed, and at 7.5 weeks after treatment with the synthetic hybrid-scale fiber matrix, significant epithelial coverage of the wound was achieved (Figure 15–17).
Case 3. Well-incorporated synthetic hybrid-scale fiber matrix observed after 5 days of treatment with the synthetic extracellular matrix (hospital day 22) in the (A) left hand and (B) left upper extremity (LUE).
Case 3. Progressive healing of the (A) left hand and (B) left upper extremity (LUE) observed architecture, which allows for cellular in the outpatient wound care clinic, 10 days after treatment with the synthetic matrix.
Case 3. Excellent epithelial coverage of the wounds of the (A) dorsal hand and (B) volar forearm was observed 7.5 weeks after treatment with the synthetic hybrid-scale fiber matrix.
Case 3. The healing wound exhibited excellent granulation tissue proliferation and near total absorption of the synthetic matrix 19 days after treatment with the synthetic hybrid-scale fiber matrix.
For this case, the ISSP was incision and drainage with subsequent STSG, a common approach and one used in multiple cases at the present authors' institution. The average total case cost, OR time, and cut-to-close surgical time at this institution was collected for STSG and for the synthetic matrix. On average, the overall cost of treatment was $876.45 more for STSG than for synthetic matrix (Figure 18). A projection of 14 incision and drainage and STSG procedures (representing the institutional average for the previous year), using synthetic hybrid-scale fiber matrix in place of current biologic matrix implants, would yield annual total case cost savings of $12 270.30. Compared with the synthetic matrix, for STSG procedures the total OR time was an average of 6 minutes longer and cut-to-close surgical time was an average of 4 minutes longer (Figure 19). These time savings represent indirect savings of surgical resources, floor resources, and OR availability.
Comparison of case costs for case study 3, necrotizing fasciitis of the hand. Total case costs include the cost of the implant materials, floor materials, equipment, and labor costs.
Wounds. 2021;33(9):237-244. © 2021 HMP Communications, LLC