title: Novel treatment for massive lower extremity avulsion injuries in children: slow, but effective with good cosmesis.
abstract: BACKGROUND
  Extended avulsion injuries are associated with significant loss of skin and subcutaneous fat, leaving the reconstructive surgeon with the challenge of substituting all tissues lost in the best possible way. We wanted to test whether the combined use of a Vacuum Assisted Closure system (VAC) and Integra Dermal Regeneration Template (IDRT) matched the required treatment profile encompassing initial control of infection, remodeling of body contours, and reconstruction of near normal skin.
  
  
  METHODS
  4 children with massive lower extremity avulsion injuries were treated with early necrosectomy, VAC application for 3-5 weeks for wound cleansing and wound bed conditioning, subsequent implantation of IDRT, and finally autologous split thickness skin grafting (STSG) for definitive wound closure. Thereafter, a standard rehabilitation program was used. The key parameters of VAC and IDRT application, take rates of IDRT and STSG, complications, length of stay, and final outcome were recorded.
  
  
  RESULTS
  In all patients, early removal of necrosis and infection control was successfully achieved. Continuous VAC application fostered the formation of a several millimeters thick new tissue layer partly compensating for the lost hypodermis. IDRT implantation and subsequent STSG yielded take rates of nearly 100% and both functionally and cosmetically excellent long-term results. There were no major complications.
  
  
  CONCLUSIONS
  The combination of VAC and IDRT in children with massive leg avulsion injuries is feasible, safe, and delivers high-quality long-term outcomes that appear to justify the multiple operative procedures, the long hospitalization times, and the comparatively high costs entailed.
authors.affiliation: University Children's Hospital Zurich, Pediatric Burn Center, Plastic and Reconstructive, Department of Surgery, Zurich, Switzerland. clemens.schiestl@kispi.uzh.ch
authors.forename: C
authors.initials: C
authors.lastname: Schiestl
authors.forename: K
authors.initials: K
authors.lastname: Neuhaus
authors.forename: T
authors.initials: T
authors.lastname: Biedermann
authors.forename: S
authors.initials: S
authors.lastname: Böttcher-Haberzeth
authors.forename: E
authors.initials: E
authors.lastname: Reichmann
authors.forename: M
authors.initials: M
authors.lastname: Meuli
mesh_terms: D000293:Adolescent; D002648:Child; D003646:Debridement / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007869:Leg Injuries / Q000523:psychology / Q000601:surgery*; D008297:Male; D054843:Negative-Pressure Wound Therapy / Q000379:methods*; D017060:Patient Satisfaction; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D016038:Skin Transplantation / Q000379:methods*; D017768:Skin, Artificial; D017695:Soft Tissue Injuries / Q000523:psychology / Q000601:surgery*; D015599:Trauma Severity Indices; D016896:Treatment Outcome