Successful Treatment of War Zone Traumatic Lower Extremity Wound With Exposed Tendons Using an Autologous Homologous Skin Construct

Abstract

Extremity injuries are common in contemporary combat and have become more prevalent as fatality rates have dropped to historic lows. Traumatic extremity wounds, especially those sustained in theater, often present with exposed structures such as tendon, bone, and joint, preventing the use of split-thickness skin grafts (STSG) for coverage. Traditional reconstructive options for these complex wounds include skin substitute with delayed STSG, local flaps, debridement of tendons, pedicled distant flaps (such as cross-leg flap), free tissue transfer, and amputation. STSG, whether on top of skin substitutes or after tendon debridement, can result in contracture and functional limitations in the extremities. Flap reconstructions require prolonged procedures, hospital stays, and periods of immobility. As an alternative to traditional reconstructive options, an autologous homologous skin construct (AHSC) uses a small fullthickness elliptical skin harvest from the patient, which is sent to a biomedical manufacturing facility, processed into AHSC, and can be returned and applied to a wound bed as soon as 48 hours after harvest and used up to 14 days after harvest. We present in this case report the treatment of a 42 cm 2 complex dorsolateral ankle wound with exposed tendons in an active duty soldier following a rollover motor vehicle accident sustained in theater. After application of AHSC, the soldier's wound closed in nine weeks with pliable, sensate skin. The patient retained function without contractures limiting ankle motion or adhesions limiting tendon gliding. The successful treatment of this complex war zone injury with AHSC has allowed the soldier to quickly participate in unrestricted physical therapy and is on a trajectory for nearterm return to active duty.

Autologous Heterogeneous Skin Construct Closes Traumatic Lower Extremity Wounds in Pediatric Patients: A Retrospective Case Series

“…We believe that the preserved tendon gliding could be due to (1) a regenerated fat layer beneath the regenerated skin shown on biopsy in a previous case report from the first author, (2) a robust vascular soft tissue that forms over tendons and can be seen early in the healing process prior to epithelial formation (Figures 1C, 2B and C), and (3) early ambulation, weight bearing, and ROM to prevent adhesion formation. 7,9,12 Alternative treatments for these complex traumatic wounds with exposed structures were discussed extensively with the patients and their families. These included free tissue transfer, tissue expansion, and dermal matrix application followed by delayed skin grafting.…”

“…1,5 An autologous heterogeneous skin construct (AHSC) has become available in recent years that has demonstrated the regeneration of full-thickness skin with follicles and glands. [6][7][8][9][10][11][12][13] AHSC utilizes a small, elliptical full-thickness skin harvest from the patient that can be closed primarily. The autologous donor skin is shipped to a biomedical manufacturing facility where it is manufactured into AHSC and can be returned for application to the wound bed as early as 48 hours after harvest and is viable for use for up to 14 days after harvest.…”

A Scarless Healing Tale: Comparing Homeostasis and Wound Healing of Oral Mucosa With Skin and Oesophagus

“…Besides minor traumatic wounds and acne, other cases can arise from clinical surgeries, chemical and thermal burns or in consequence of allergic reactions. Self-harm scarring and combat wounds also a matter of concern ( Mitchell et al, 2019 ; Johnson et al, 2020 ). The traumatic wounds in the hostility of war context come with exposure of bone, ligaments and tendons, as well as contamination, and the limited available resources in conflict zones’ hospitals impede the treatment of these wounds ( Johnson et al, 2020 ).…”

A multicentre, randomised controlled clinical trial evaluating the effects of a novel autologous, heterogeneous skin construct in the treatment of Wagner one diabetic foot ulcers: Interim analysis

“…A novel autologous heterogeneous skin construct (AHSC) created from a small harvest of full thickness, healthy skin may be safe and effective as adjunctive therapy in treating complex and refractory wounds 15‐24 . AHSC is composed of small multicellular segments and contains the endogenous regenerative cellular populations of healthy skin that promote wound closure, so that a single application can regenerate full‐thickness, functionally polarised skin on the wound bed 20‐25 .…”

“…A novel autologous heterogeneous skin construct (AHSC) created from a small harvest of full thickness, healthy skin may be safe and effective as adjunctive therapy in treating complex and refractory wounds. [15][16][17][18][19][20][21][22][23][24] AHSC is composed of small multicellular segments and contains the endogenous regenerative cellular populations of healthy skin that promote wound closure, so that a single application can regenerate full-thickness, functionally polarised skin on the wound bed. [20][21][22][23][24][25] The manufacturing process of the AHSC retains the endogenous regenerative cellular populations associated with wound healing present within hair follicles, glands, and the interfollicular epidermis, facilitating engraftment optimisation and wound closure.…”