Surgeon Dr. James Gatherwright
Hospital MetroHealth Medical Center, Cleveland, OH
After a failed free flap, NovoSorb® BTM provided robust coverage over exposed bone to support definitive closure.
A young, otherwise healthy male pedestrian sustained a crush injury to his left lower extremity after being struck by a cement barrier from a motor vehicle crash. A split latissimus flap was unsuccessfully attempted on the resulting Grade III B Gustilo injury making amputation a likely option. NovoSorb BTM was applied as an alternative reconstructive option to the wounded area of denuded tibia. Successful integration of the wound bed was achieved with a vascularized neodermis, and a split-thickness skin graft was then applied for a near-complete take.
Figure 1: Intra-operative image of gustilo grade IIIB injury.
Figure 2: Day 21 post NovoSorb BTM application; integration progressing well over exposed bone.
Figure 3: Day 28 post NovoSorb BTM application; sealing membrane delaminated revealing a robust neodermis.
Figure 4: 4 months post NovoSorb BTM application; wound healed with excellent cosmesis, quality and pigment.
A healthy 32-year-old male pedestrian incurred a crush injury to his left lower extremity. The patient suffered a Grade III B Gustilo injury with exposed tibial and fibular bone devoid of periosteum, measuring 25 cm x 7 cm with a total affected area of 675 cm 2 . An attempted free tissue transfer failed secondary to intra-operative arterial thrombosis, despite multiple attempts and pharmacologic therapies.
The patient underwent repeated debridement and negative pressure wound therapy (NPWT), followed by an eventual free tissue transfer and split thickness skin graft to obtain soft tissue coverage. Despite a normal angiogram and clinical evaluation and attempted flap salvage using an arteriovenous loop, reconstruction failed and the patient incurred additional morbidity. The failed reconstruction resulted in the removal of half of his latissimus dorsi muscle. After considering alternative options including a below knee amputation, the decision was made to apply NovoSorb BTM over the exposed defect followed by skin grafting.
A “pineapple” burr was used on the exposed bone and taken down to healthy punctate bleeding (Fig. 1). NovoSorb BTM was applied and secured with staples. An oil-based gauze, woven gauze, abdominal pads, and elastic bandages were applied. Dressing changes were performed in the operating room at weeks 1 and 2 post NovoSorb BTM application. At day 28 post NovoSorb BTM application, NovoSorb BTM’s matrix appeared integrated over the exposed bone and surrounding tissue, and it’s sealing membrane was removed (Fig. 2 and 3). At that time, a split-thickness skin graft was successfully applied with near-complete take.
All wounds were successfully closed with no signs of infection or need for additional complex reconstruction (Fig. 4). The patient is full weight-bearing and has returned to his employment in the military. To celebrate his healing, he completed a full marathon race.