Lower Extremity Reconstruction using Bilayer Wound Matrix- A Retrospective Review of 191 Wounds
Sameer Shakir, MD, Ari M. Wes, MD, MTR, Charles A. Messa, IV, BS, Robyn B. Broach, PhD, Irfan A. Rhemtulla, MD, Brett Chatman, DPM, Albert D'Angelantonio, DPM, Lawrence S. Levin, MD, Stephen J. Kovach, III, MD, Joseph M. Serletti, MD, John P. Fischer, MD.
University of Pennsylvania, Philadelphia, PA, USA.
Lower extremity wound management is a significant challenge to care providers, as there are many products available in the wound care arena and different surgical procedures to address these issues. Recent literature has described the use of bilayer wound matrices in the reconstruction of complex soft tissue wounds throughout the body in order to delineate the comparative effectiveness of these dermal regenerative matrices to autologous tissues. We present a multihospital experience of reconstructive surgeons utilizing bilayer wound matrices in lower extremity soft tissue reconstruction with the goals to (1) characterize a suitable patient population, (2) categorize failures in order to optimize patient selection, and (3) determine wound characteristics and anatomic locations affecting success.
The investigators designed a retrospective case-control study of patients undergoing Integra-based lower extremity wound reconstruction from May 2010 to June 2017. 180-day graft success served as the outcome variable. Predictor variables included demographics, medical comorbidities, and perioperative and postoperative complications. The investigators also derived cost-related data for each patient's hospital course, wound-related admissions, and reoperations.
A total of 147 subjects with 191 lower extremity wounds underwent reconstruction. Average age was 60.1 years with an average BMI of 30.5 kg/m2. The most prevalent comorbidities included hypertension (76.9%), diabetes (52.4%), and peripheral vascular disease (44.9%). 70.0% lower extremity wounds were successfully salvaged at the 180-day time point. The majority of wounds treated were localized between the knee and ankle (50.8%) and foot (46.1%). Exposed bone, tendon, and preoperative infection rates did not differ between groups. Wound area treated did not differ, however wound age significantly differed. Amputations occurred in 47.4% of all failures. When comparing successfully treated wounds with those that failed, length of stay, direct and total costs, total charges, and average income significantly differed. Multivariate risks factors associated with failed reconstruction at the 180-day time point included government insurance (OR 2.12), African American race (2.07), tendon exposure (2.09), and wound age (1.32).
We present the largest multihospital experience to date with bilayer wound matrices in the reconstruction of lower extremity soft tissue wounds of varying size, location, and depth. We report a 70% salvage rate at the 180-day time point. Neither wound factors such as size and bone exposure nor wound location such as the foot contributed to failure. Future directions include direct comparison of bilayer wound matrices with vascularized free tissue transfer in the reconstruction of complex lower extremity wounds.
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