Doctors performed a complex surgery known as Dermal Regeneration Templates (DRT) to give a new lease of life to a 21-year-old patient whose left lower limb was damaged after she met with an accident. The surgery was very complex as the patient had comorbidities. According to the doctors, four months after the accident her wounds have almost healed and now she can walk without any support whatsoever. There is a limp in her walk due to a foot drop which will need some corrective surgery at a later date. Currently, she is using a foot drop splint.
Prajakta Joshi (name changed) a 21-year-old, underwent a massive road traffic accident because of a collision with a heavy-duty dumper that dragged her along the roadside leading to severe injury to her left lower limb. The entire left leg from her thighs downwards had a degloving injury with loss of skin circumferentially from her lower thigh to the ankle joint. She also had severe damage to her leg muscles.
In an emergency, she was moved to a nearby hospital, where doctors suggested to perform an amputation of the leg. It was a shocking moment for parents. They spoke with their family doctor in their hometown, who suggested they get a second opinion with Dr Parag Sahasrabudhe, Plastic and Reconstructive Surgeon.
The family then contacted Dr Parag Sahasrabudhe, Plastic and Reconstructive Surgeon at Lokmanya HSS who asked them to send him the photos of the accident victim. The condition of the patient leg was very bad, as there was total skin loss from mid-thigh to ankle circumferentially. Due to which the surgery had become complicated as there was no skin available to cover such a large defect with exposed and open shin bone, and conventional reconstructive surgery technique (Microvascular flap surgery) was risky and inadequate to cover such a large wound.
“There were several factors due to which survey had become complicated which included patient was morbidly obese. The blood circulation in the limb was compromised and the zone of injury was wide hence microsurgical reconstruction was risky. There was severe contamination in the wound by mud, stones, grease etc. which could have led to infection and eventually amputation of the leg,” he said.
Dr Sahasrabudhe further explained that the patient was admitted at Lokmanya Hospital, Senapati Bapat Road, Pune and at the time of admission there was bleeding from the leg wound. However, the circulation in the left leg was compromised but she had good sensations in her toes and foot. The girl was very young and losing her leg could destroy her future. As microsurgical reconstruction was ruled out because of the above reasons the real challenge was to cover the entire open bone which required complex and complicated limb saving surgery.
“We decided to use the new technology in India named as Dermal Regeneration Templates along with negative pressure wound therapy and conventional reconstructive surgery techniques. The entire shin bone was bare devoid of any soft tissue cover and was open in the wound. After thorough cleaning to prevent the wound from getting infected a negative pressure dressing (an established wound therapy) was applied to the wound,” added Dr Sahasrabudhe.
At the next surgery, the challenge was to cover the entire shin bone which had lost its dermal cover. Just applying a partial thickness skin graft was not an option as it does not take upon bare bone without the soft tissue- dermis layer. The technique of muscle flap surgery was used to cover the upper one-third of shin bone to cover the remaining lower two-third shin bone.
Dermal Regeneration Template is a double layer skin regeneration system. The outer layer is a silicon film that acts as the skin epidermis (outer skin layer). It protects wounds from infection and maintains wound moisture required for the healing. The inner layer is made up of a complex matrix of cross-linked fibres. This porous material acts as a scaffold for regenerating dermal skin cells which enables the growth of the dermis, the inner skin layer in the wound. Once the dermal layer is regenerated the outer silicon layer separates and needs to be replaced with a partial-thickness skin graft.
The main task was to make sure she is kept away from the infection throughout this procedure as infection can melt away this dermal regeneration template quickly. We could prevent infection with the use of appropriate antibiotics, aggressive surgical wound cleaning and early wound cover along with a hygienic and sterile environment in her room throughout her hospital stay.
After ensuring that there was no infection and the dermal regeneration template was well integrated into the wound, she took up a partial thickness skin grafting which was done in two stages to cover the entire circumferential skin loss from mid-thigh to ankle joint. As available donor skin was limited, we used a skin graft mesher to expand the skin so that we cover the wound in totality. All the applied skin graft was taken up well all over the wound, even over the dermal template and the wound was almost fully covered in a month after the date of the accident.
It was extremely gratifying to see her walk with walker support 3 weeks after the accident. She was discharged from the hospital three weeks after admission and her recovery was miraculous. Her fighting spirit and determination to walk helped her recover from such a major trauma remarkably.