Long-term follow-up of one-stage artificial dermis reconstruction surgery for fingertip defects with exposed phalanx

doi:10.1016/j.hansur.2022.02.012

Hand Surgery and Rehabilitation

Volume 41, Issue 3, June 2022, Pages 353-361

https://doi.org/10.1016/j.hansur.2022.02.012 Get rights and content

Abstract

Fingertip injuries are among the most common injuries of the hand. Although numerous treatment methods have been described in detail in the literature, there are a few alternatives that require exploration. We analyzed 24 patients who underwent one-stage artificial dermis (Pelnac®) reconstruction surgery between 2012 and 2016 to assess the effectiveness of this alternative reconstruction method for extensive fingertip injury with exposed phalanx. There were 16 males and 8 females, with ages ranging from 2 to 75 years. There were 16 type III injuries, 6 type IV, and 2 type II on the Allen classification. Complete epithelialization was achieved by the 4th week in 19 cases and by the 6th week in 5. The wounds of all patients healed completely, without infection. All the injured fingers developed various levels of hooked nail and length shortening except for the 2 type II injuries. There was nail spicule formation in 1 case. There were no cases of cold intolerance, but 2 cases of hypersensitivity and 5 of numbness. Overall 2-point discrimination ceased improving by the 2nd postoperative year. This technique is simple, allows spontaneous healing of the fingertips, and is mostly free from the major complications associated with other treatment methods.

Résumé

Les blessures du bout des doigts sont parmi les blessures les plus courantes de la main. Bien que de nombreuses méthodes de traitement aient été décrites en détail dans la littérature actuelle, il existe quelques autres alternatives de traitement possibles qui nécessitent d’être explorées. Nous avons analysé 24 patients qui avaient subi des chirurgies reconstructrices en un temps avec un derme artificiel (Pelnac®) entre 2012 et 2016 pour évaluer l'efficacité de cette méthode alternative de reconstruction pour les blessures étendues du bout des doigts avec exposition de la phalange. Parmi les 24 patients, il y avait 16 hommes et 8 femmes, âgés de 2 à 75 ans. Il y eut 16 blessures de type III, 6 blessures de type IV et 2 blessures de type II selon la classification d’Allen. Dans 19 cas, une épithélialisation complète a été obtenue à la 4^ème semaine, alors que dans les 5 cas restants, elle a été atteinte à la 6^ème semaine. Les plaies de tous les patients ont guéri complètement sans infection. Tous les doigts blessés ont développé un ongle en crochet de différents niveaux et un raccourcissement, à l'exception de deux blessures de type II. Il y eut formation de spicules unguéaux dans un cas. L'intolérance au froid n'a pas été observée ; cependant, une hypersensibilité et un engourdissement ont été observés chez respectivement deux et cinq patients. La discrimination des 2 points (2PD) globale a cessé de s'améliorer à la 2^ème année postopératoire. Cette technique est simple, permet la cicatrisation spontanée du bout des doigts et est en grande partie exempte des complications majeures associées aux autres méthodes de traitement.

Introduction

The skin is the largest sense organ of the body and also the first line of defense against microorganisms. It plays vital roles in thermoregulation, vitamin D synthesis, and esthetics. Therefore, it is of utmost importance to treat skin injuries that could negatively impact skin functions.

According to currently available data, work accidents to the hand are more common in the working population, whereas domestic hand traumas are more common in children, with the fingers and fingertips being the most frequently injured parts, leading to morbidity and significant psychological and financial burden [1], [2]. Types of injury vary widely: fracture, crushing, avulsion, degloving, laceration, amputation, hyperflexion, and hyperextension [3], [4], [5]. Traumatic hand and fingertip injuries are therefore commonly encountered in emergency departments. Depending on the type and location of injury and degree of soft tissue and perionychium involvement, various management options are available consisting in either conservative topical treatment or surgical reconstruction [6], [7]. Extensive knowledge of local and regional anatomy is paramount when selecting the optimal treatment option. The main goals are complete restoration and conservation of finger length, shape, mobility, tactility, stability, fine touch and painless temperature and pressure sensations, while minimizing possible complications [8], [9]. Treatment options for fingertip injury are both difficult and problematic, particularly in terms of restoring cosmesis and sensation. At present, surgical options for fingertip injury comprise primary closure, full-thickness autologous skin grafting, and flap reconstruction with pedicled or free flaps. However, novel technological advances, such as artificial dermis and revision reconstructive methods without autograft, have been gaining momentum in treatment plans.

The Integra® (Integra LifeSciences, Princeton, NJ, USA) and Pelnac® (Gunze Corp., Osaka, Japan) reconstruction approaches are both remarkable examples of this progress. Pelnac® is a bilayer dermal substitute; the inner layer is made from pig tendon-derived atelocollagen freeze-dried at −135 °C, and the outer layer from a 150 μm thickness silicone polymer. The three-dimensional atelocollagen matrix sponge allows fibroblasts and capillaries to infiltrate, and functions as a scaffold that will gradually integrate in the wound area. This process enables regeneration of the area, while reducing surface irregularities. The superficial silicone layer prevents dehydration, entry of micro-organisms and direct wound exposure to the external environment. Pelnac® is also easy to transport, store and use due to the sterile product process, in contrast to Integra® [10].

The aim of this study was to analyze efficacy and postoperative outcomes of Pelnac® fingertip reconstructive surgery.

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Section snippets

Demographic data

We retrospectively analyzed the data of 24 patients who underwent one-stage Pelnac® artificial dermis reconstructive surgery between 2012 and 2016. Written informed consent was obtained from each patient prior to surgery, and the study was approved by the Ethics Committee of the First Affiliated Hospital of Guangxi Medical University.

Inclusion criteria comprised: (a) any of the various forms of fresh fingertip injury, resulting in exposure of the phalanx with remaining nail bed or nail matrix;

Results

Preoperative waiting time ranged from 1 h to 14 days. In 19 cases, complete epithelialization was achieved by the 4th week, and in 5 by the 6th week. With the exception of 1 patient (patient 4), who rarely used the operated finger for physical activities 1 year postoperatively due fear of pain, all patients used their injured finger for normal activities within 6 weeks postoperatively. Healing was achieved without infection, abnormal pigmentation, or cold intolerance in all cases. Three

Discussion

Fingertip injuries are among the most common domestic and work-related injuries, in children and adults, respectively. Although they appear simple and sometimes respond to simple non-surgical treatment, in some cases of extensive injury considerable functional disability may occur if the injury is not managed in a proper and timely manner. For small digital defects of <1.5 cm² without exposed bones, directed healing is normally implemented, with excellent results [13], [14], [15], [16], [17].

Conclusion

The use of Pelnac® artificial dermis for the reconstructive surgery of extensive fingertip injuries is as effective as, if not better than, conventional reconstructive methods. The procedure is simpler, conserves the maximum possible finger length, restores satisfactory appearance and function, and reduces the rate of stump trimming in amputated fingers. For surgeons, the ease of the procedure makes it especially suitable for trainees and surgeons without adequate microsurgical training. For

Disclosure of interest

The authors declare that they have no competing interest.

Funding

This study was financially supported by Guangxi Universities Research Foundation Project for the improvement of young and middle-aged teachers in basic research skills (2021KY0092).

Ethics

The study was approved by the Ethics Committee of the First Affiliated Hospital of Guangxi Medical University.

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One-stage prosthetic dermal repair of skin defects in the donor area of the great toe nails flap
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This study aimed to evaluate the safety and efficacy of Pelnac artificial skin one-stage surgical direct repair of significant toenail flap donor area defects.
From March 2020 to May 2023, a total of 56 patients with traumatic finger injuries underwent reconstruction using a great toenail flap combined with iliac bone grafting, along with one-stage artificial skin repair of the great toenail flap. These patients were followed prospectively, and their clinical outcomes were systematically evaluated.
The average follow-up was 13.4 months (3 to 30 months). The visual analog scale for pain was 0.23±0.6, and the Vancouver scar scale (VAS) was 2.82±1.06. Among 56 patients, only one case developed postoperative infections. The aesthetic satisfaction of the donor area of the patient's foot was 87.10±5.48 points (out of 100 points). Regarding the sensory recovery, the response “normal or near normal” was obtained in 44 patients (78.6 %). The maximum active mobility of the first metatarsophalangeal joint and the distal interphalangeal joint in the donor area was 66.51±7.38°and 43.21±4.62°, respectively.
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The defect healed in all cases. We found an average static 2-point discrimination of 7 mm (range 4 to 14 mm). Scar formation was evident in all cases. The repair did not restore the bulkiness of the volar finger, especially in the finger with the bony exposure. Nail deformities and joint contracture were observed in some cases.
Dermal template repair does not restore normal sensation and inevitably leads to scar formation when the defect is longer (>1.5 cm). Bulkiness of the volar finger is not restored in most patients, especially when there was bone or tendon exposure in the initial wound site.
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¹: These authors contributed equally to this work and should be considered co-first authors.

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Demographic data

Hand Clin

Hand Clin

Hand Clin

Clin Plast Surg

Br J Plast Surg

Hand

J Hand Surg Br

Injury

Hand Surg Rehabil

Hand Clin

J Pediatr Surg

J Hand Surg Br

J Hand Surg Am

J Plast Reconstr Aesthet Surg

Br J Plast Surg

Br J Plast Surg

J Plast Reconstr Aesthet Surg

J Tissue Viability

J Foot Ankle Surg

Burns

Hand Clin

J Hand Surg Br