Human Reticular Acellular Dermis Matrix (HR-ADM) Graft to Heal a Large Circumferential Ankle Wound with Exposed Bones and Tendons

Introduction: Bone and tendons have poorer blood supply compared to skin and muscle tissues (1). This hinders the delivery of oxygen and nutrients crucial for healing, making the exposed tissues more susceptible to infection and tissue death (2). Additionally, exposed tendons and bones are prone to drying out, leading to necrosis (1). In addition, exposed bone and tendons can be highly vulnerable to infection, which can significantly complicate healing and further damage the tissues and wound bed. Moreover, infection can lead to osteomyelitis and tendonitis which can necessitate amputation (3).   Human reticular acellular dermis matrix grafts (HR-ADM) have emerged as a promising strategy for promoting wound healing. HR-ADM grafts are derived from the reticular dermal layer and aseptically processed without terminal irradiation from deceased donors. They provide a natural scaffold structure composed of preserved collagen, elastin, and glycosaminoglycans, which are all essential components of the dermal extracellular matrix (ECM) (4). This scaffold serves as a temporary structure, supporting host cell migration, proliferation, and integration (5).Methods:An 84 y/o patient was consulted for a large circumferential ankle wound measuring approximately 25cm x 20cm with exposed tibia, exposed and necrotic fibula, and exposed and necrotic peroneal and Achilles tendons. Vascular surgery had deemed this limb unsalvageable and recommended a below the knee (BKA) amputation. All necrotic tissue was resected and debrided until healthy granular tissue was observed. HR-ADM was then subsequently applied onto soft tissue wound bed without negative pressure wound therapy (NPWT).Results:Although the patient was non-compliant with follow up, it took 3 rounds of HR-ADM application and a split thickness skin graft to build the deep soft tissue deficit and close the wound.Discussion: The results of this case make us reconsider what we think we know about wound healing. Interestingly, these results were achieved without the use of NPWT. HR-ADM’s clinical application has the potential to minimize complex localized or free flaps. Long-term studies are necessary to evaluate the durability of the repaired tissue, to solidify its place as a valid standard of care.  References:1. Mak, K. K., Hutcheson, A., & Thoma, A. (2022). Treatment of Deep Full-thickness Wounds Containing Exposed Muscle, Tendon, and/or Bone Using a Bioactive HumanSkin Allograft: A Large Cohort Case Series. Wounds, 34(2), 33-40. 2. Zarins, A., & Millard, M. (2011). Tendon Healing. Journal of Orthopaedic Surgery and Research, 9(1), 13. doi: 10.1186/1743-8242-9-13 3. Eginton, L., McGrouther, D. A., & Bayton, R. (2022). Mini-Review: Tendon-Exposed Wound Treatments. Frontiers in Surgery, 9, 995316. doi: 10.3389/fsurg.2022.995316 4. Young, E. J., Butler, E., & Orgill, D. P. (2018). Acellular dermal matrix for wound healing: Clinical applications and future directions. Wounds International, 9(6), 347-356. 5. Chen, L., Xu, G., Fisher, D. A., Xu, J., & Wu, W. (2019). Human acellular dermal matrix for wound healing. International Journal of Lower Extremity Wounds, 18(3), 233-243. 6. Orgill, D. P., & Butler, E. (2008). Chronic wound healing facilitated by growth factors. Clinics in Plastic Surgery, 35(1), 73-81.