Management of wounds with exposed bone structures using an induced‐membrane followed by polymethyl methacrylate and second‐stage skin grafting in the elderly with a 3‐year follow‐up

Abstract

The treatment of traumatic wounds with exposed bone or tendons is often challenging. An induced membrane (IM) is used to reconstruct bone defects, as it provides an effective and sufficient blood supply for bone and soft‐tissue reconstruction. This study explored a novel two‐stage strategy for wound management, consisting of initial wound coverage with polymethyl methacrylate (PMMA) and an autologous split‐thickness skin graft under the IM. Fifty inpatients were enrolled from December 2016 to December 2019. Each patient underwent reconstruction according to a two‐stage process. In the first stage, the defect area was thoroughly debrided, and the freshly treated wound was then covered using PMMA cement. After 4‐6 weeks, during the second stage, the PMMA cement was removed to reveal an IM covering the exposed bone and tendon. An autologous split‐thickness skin graft was then performed. Haematoxylin and eosin (H&E) staining and immunohistochemical analysis of vascular endothelial growth factor (VEGF), CD31 and CD34 were used to evaluate the IM and compare it with the normal periosteal membrane (PM). The psychological status and the Lower Extremity Function Scale (LEFS) as well as any complications were recorded at follow‐up. We found that all skin grafts survived and evidenced no necrosis or infection. H&E staining revealed vascularised tissue in the IM, and immunohistochemistry showed a larger number of VEGF‐, CD31‐ and CD34‐positive cells in the IM than in the normal PM. The duration of healing in the group was 5.40 ± 1.32 months with a mean number of debridement procedures of 1.92 ± 0.60. There were two patients with reulceration in the group. The self‐rating anxiety scale scores ranged from 35 to 60 (mean 48.02 ± 8.12). Postoperatively, the LEFS score was 50.10 ± 9.77. Finally, our strategy for the management of a non‐healing wound in the lower extremities, consisting of an IM in combination with skin grafting, was effective, especially in cases in which bony structures were exposed in the elderly. The morbidity rate was low.

Reconstruction of foot and ankle defects using the vaccum sealing drainage versus the induced‐membrane the elderly: A retrospective comparative study

“…The angiogenic potential of the IM surrounding the PMMA cement 22 was exploited in combination with skin grafting to repair exposed open wounds in patients with injuries resulting in exposed bone or tendon wounds. The advantage of our approach is that because the wound surface is covered by bone cement, the patient can be discharged from the hospital before IM formation, thus reducing the length and cost of hospitalization 10 . The IM is an initially avascular bed that supports the survival of the skin graft.…”

“…The advantage of our approach is that because the wound surface is covered by bone cement, the patient can be discharged from the hospital before IM formation, thus reducing the length and cost of hospitalization. 10 The IM is an initially avascular bed that supports the survival of the skin graft. IM vascularisation has also been demonstrated in other human and animal studies.…”

“…8,9 Recently, the induction membrane (IM) of cement formation in the treatment of complex wounds has been reported. 10 It is a two-stage strategy for wound management, comprising initial coverage of a fresh wound with PMMA, followed by grafting with an autologous split-thickness skin graft under the IM. The purpose of this study is to compare VSD and IM in the treatment of foot and ankle soft-tissue defects.…”

“…VSD has been widely used in acute and chronic complex wounds, and has achieved acceptable results, but there are the disadvantages of long hospital stay and high cost 8,9 . Recently, the induction membrane (IM) of cement formation in the treatment of complex wounds has been reported 10 . It is a two‐stage strategy for wound management, comprising initial coverage of a fresh wound with PMMA, followed by grafting with an autologous split‐thickness skin graft under the IM.…”