Abstract:The authors report on a single case of a large, civilian burn cared for at a U.S. military hospital during Operation Iraqi Freedom. The management of the patient, using a large negative pressure wound therapy device and the Meek grafting technique, is reviewed. This is a case report. The patient survived his injury. In Iraq, most patients with this severity of injury succumb to the injury. By using two innovative techniques, the authors found that the patient was able to survive his injury and return to his ho… Show more
“…More recently, the use of micrograft transplantation with immediate 100-fold expansion for epidermal regeneration on both healthy and diabetic wounds in porcine models was reported [ 109 ]. In the same report, it was mentioned early clinical results confirmed the utility of this technique in a case report of a civilian patient with fifty-four percent total body surface area burn admitted to a U.S. Army military hospital in Iraq and successfully treated with the described micrografting technique [ 110 ]. Fig.…”
Current advances in basic stem cell research and tissue engineering augur well for the development of improved cultured skin tissue substitutes: a class of products that is still fraught with limitations for clinical use. Although the ability to grow autologous keratinocytes in-vitro from a small skin biopsy into sheets of stratified epithelium (within 3 to 4 weeks) helped alleviate the problem of insufficient donor site for extensive burn, many burn units still have to grapple with insufficient skin allografts which are used as intermediate wound coverage after burn excision. Alternatives offered by tissue-engineered skin dermal replacements to meet emergency demand have been used fairly successfully. Despite the availability of these commercial products, they all suffer from the same problems of extremely high cost, sub-normal skin microstructure and inconsistent engraftment, especially in full thickness burns. Clinical practice for severe burn treatment has since evolved to incorporate these tissue-engineered skin substitutes, usually as an adjunct to speed up epithelization for wound closure and/or to improve quality of life by improving the functional and cosmetic results long-term. This review seeks to bring the reader through the beginnings of skin tissue engineering, the utilization of some of the key products developed for the treatment of severe burns and the hope of harnessing stem cells to improve on current practice.
“…More recently, the use of micrograft transplantation with immediate 100-fold expansion for epidermal regeneration on both healthy and diabetic wounds in porcine models was reported [ 109 ]. In the same report, it was mentioned early clinical results confirmed the utility of this technique in a case report of a civilian patient with fifty-four percent total body surface area burn admitted to a U.S. Army military hospital in Iraq and successfully treated with the described micrografting technique [ 110 ]. Fig.…”
Current advances in basic stem cell research and tissue engineering augur well for the development of improved cultured skin tissue substitutes: a class of products that is still fraught with limitations for clinical use. Although the ability to grow autologous keratinocytes in-vitro from a small skin biopsy into sheets of stratified epithelium (within 3 to 4 weeks) helped alleviate the problem of insufficient donor site for extensive burn, many burn units still have to grapple with insufficient skin allografts which are used as intermediate wound coverage after burn excision. Alternatives offered by tissue-engineered skin dermal replacements to meet emergency demand have been used fairly successfully. Despite the availability of these commercial products, they all suffer from the same problems of extremely high cost, sub-normal skin microstructure and inconsistent engraftment, especially in full thickness burns. Clinical practice for severe burn treatment has since evolved to incorporate these tissue-engineered skin substitutes, usually as an adjunct to speed up epithelization for wound closure and/or to improve quality of life by improving the functional and cosmetic results long-term. This review seeks to bring the reader through the beginnings of skin tissue engineering, the utilization of some of the key products developed for the treatment of severe burns and the hope of harnessing stem cells to improve on current practice.
“…In a moist wound dressing environment, the dermal orientation of these micrografts did not matter which makes it an easily adaptable procedure. [ 5 16 25 ] In combination with minced grafts and skin substitute, a single-stage transfer has been described recently, which demonstrates the migration of keratinocytes and fibroblasts into the scaffold, a step towards obviating the necessity of cell cultures. [ 30 ]…”
Section: Dermal–epidermal Graftingmentioning
confidence: 99%
“…[ 3 ] Several reports of successful resurfacing of burns wounds above 60% are emerging using novel grafting techniques. [ 4 5 ] Hitherto available options of wound coverage in a resource-constrained donor site are traditional meshing techniques, multiple re-harvests from donor sites, use of amniotic membrane, allografts, xenografts and engineered skin sheets. [ 6 7 8 ] Skin expansion with a regular mesher is available with an expansion ratio of 1:1.5–1:9.…”
The quest for skin expansion is not restricted to cover a large area alone, but to produce acceptable uniform surfaces, robust engraftment to withstand mechanical shear and infection, with a minimal donor morbidity. Ease of the technique, shorter healing period and reproducible results are essential parameters to adopt novel techniques. Significant advances seen in four fronts of autologous grafting are: (1) Dermal–epidermal graft expansion techniques, (2) epidermal graft harvests technique, (3) melanocyte-rich basal cell therapy for vitiligo and (4) robust and faster autologous cell cultures. Meek's original concept that the sum of perimeter of smaller grafts is larger than the harvested graft, and smaller the graft size, the greater is the potential for regeneration is witnessed in newer modification. Further, as graft size becomes smaller or minced, these micrografts can survive on the wound bed exudate irrespective of their dermal orientation. Expansion produced by 4 mm × 4 mm sized Meek micrografts is 10-folds, similarly 0.8 mm × 0.8 mm size micrografts produce 100-fold expansion, which becomes 700-fold with pixel grafts of 0.3 mm × 0.3 mm size. Fractional skin harvest is another new technique with 700 μ size full thickness graft. These provide instant autologous non-cultured graft to cover extensive areas with similar quality of engraftment surface as split skin grafts. Newer tools for epidermal blister graft harvest quickly, with uniform size to produce 7-fold expansions with reproducible results. In addition, donor area heals faster with minimal scar. Melanocyte-rich cell suspension is utilised in vitiligo surgery tapping the potential of hair root melanocytes. Further advances in the cell culture to reduce the cultivation time and provide stronger epidermal sheets with dermal carrier are seen in trials.
“…A comparison of the NPWT-treated burn with a less severe burn to the patient’s shoulder, which received standard therapy, revealed that NPWT yielded functionally and cosmetically superior results, with less hyperaemia and better skin quality. Another case report detailed the use of NPWT in a 54% TBSA full-thickness burn sustained by a civilian in the Iraqi war zone [92]. Although burns of this severity were typically fatal in Iraq, the patient survived his injury and was eventually discharged home.…”
Background
Although negative pressure wound therapy (NPWT) is widely used in the management of several wound types, its efficacy as a primary therapy for acute burns has not yet been adequately investigated, with research in the paediatric population particularly lacking. There is limited evidence, however, that NPWT might benefit children with burns, amongst whom scar formation, wound progression and pain continue to present major management challenges. The purpose of this trial is to determine whether NPWT in conjunction with standard therapy accelerates healing, reduces wound progression and decreases pain more effectively than standard treatment alone.
Methods/design
A total of 104 children will be recruited for this trial. To be eligible, candidates must be under 17 years of age and present to the participating children’s hospital within 7 days of their injury with a thermal burn covering <5% of their total body surface area. Facial and trivial burns will be excluded. Following a randomised controlled parallel design, participants will be allocated to either an active control or intervention group. The former will receive standard therapy consisting of Acticoat™ and Mepitel™. The intervention arm will be treated with silver-impregnated dressings in addition to NPWT via the RENASYS TOUCH™ vacuum pump. Participants’ dressings will be changed every 3 to 5 days until their wounds are fully re-epithelialised. Time to re-epithelialisation will be studied as the primary outcome. Secondary outcomes will include pain, pruritus, wound progression, health-care-resource use (and costs), ease of management, treatment satisfaction and adverse events. Wound fluid collected during NPWT will also be analysed to generate a proteomic profile of the burn microenvironment.
Discussion
The study will be the first randomised controlled trial to explore the clinical effects of NPWT on paediatric burns, with the aim of determining whether the therapy warrants implementation as an adjunct to standard burns management.
Trial registration
Australian New Zealand Clinical Trials Registry,
ACTRN12618000256279
. Registered on 16 February 2018.
Electronic supplementary material
The online version of this article (10.1186/s13063-019-3223-9) contains supplementary material, which is available to authorized users.
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