Management of a large complex wound using a micronized lyophilized extracellular matrix (porcine small intestine submucosa) and a viable cryopreserved placental membrane

Introduction: Porcine small intestinal submucosa (SIS) contains similar extracellular matrix components as those found in the human dermis including structural proteins, GAGs, glycoproteins and proteoglycans. The tissue survives one of the harshest environments in the body and can support rapid cell turnover while maintaining strength.

A micronized form of the matrix allows for direct contact with wound crevices. Cryopreserved amnion retaining the extracellular matrix, growth factors and native cells of the placenta provides another option with abundant clinical evidence demonstrating faster wound closure. In this study, a micronized SIS was used to help in granulating a large wound with exposed tendon and was followed by grafting with placental membrane allograft to achieve epithelialization.

Methods and Results: A 63-year-old patient with a history of asthma and thyroidectomy was admitted to the hospital with a diagnosis of sepsis secondary to left foot cellulitis. She presented with bilateral wounds on left leg and feet. Necrotic tissue was excised all the way to the dorsal aspect of the leg and distal aspect of the foot. Debridement was deep down to the tendons in the dorsal aspect of the foot as well as the posterior and medial aspect of the foot (21 x 6 x 16 cm). The wound bed was prepped, and the micronized SIS matrix was spread evenly. About 500 mg was taken, 2 ml of blood was drawn by anesthesia and mixed and applied in the surgical site. The surgical site was covered with Adaptic followed by application of Negative Pressure Therapy. Good granulation was observed in a week. Negative Pressure was removed, and a placental membrane allograft (meshed 1:1) was applied to the wound bed and to the posterior area around the Achilles tendon. The grafts were stabilized using SteriStrips and dressed using Adaptic, 4 X 4 gauge saturated with sterile kerlix and ACE bandage.

Discussion: Significant epithelialization was observed within 4 weeks. This case demonstrates a novel approach of using a micronized matrix to reach wound crevices of deep wounds to assist in granulation tissue formation followed by a bioactive structural matrix to achieve wound closure.