title: Integra™ permits early durable coverage of improvised explosive device (IED) amputation stumps.
abstract: BACKGROUND
  Improvised explosive device (IED) blasts cause serious injury. Survivors are left with multiple amputations, considerable soft tissue loss and open fractures with gross contamination. We present our early experience of Integra™ in the acute management of military wounds.
  
  
  METHODS
  The clinical records of all patients with IED injuries who underwent early reconstruction with Integra™ during the six month period between August and December 2009 in our unit were reviewed and data gathered prospectively.
  
  
  RESULTS
  There were 7 male soldiers, aged 21-31 years (mean=26). All sustained trunk and limb injuries, including multiple amputations. Number of procedures prior to application of Integra™ was 4-10 (mean=5). Application of Integra™ took place 6-24 days post-injury (mean=13). Size of wounds covered with Integra™ was 1-11.5% TBSA (mean=5%). Anatomical sites reconstructed included amputation stumps, and both upper and lower limbs. There was partial take of Integra in 3 wounds in 2 patients. All wounds were eventually treated with delayed split skin grafting and healed satisfactorily.
  
  
  CONCLUSIONS
  IEDs produce a large zone of injury with massive soft tissue damage, multiple discontinuous wounds which are significantly contaminated. The physiological insult is equivalent to a large cutaneous burn and there is a paucity of available donor sites. Multiple amputees also have a greater energy and power requirement(1-4) and cannot spare remaining functional muscles as donors. The literature suggests that microvascular flaps have a high failure rate in military patients.(5) Reconstruction began as soon as wounds were considered sufficiently clean. Integra™ was applied with the aim of providing higher quality coverage than that provided by split skin grafting alone (particularly for amputation stumps) whilst minimising operative time and morbidity. Integra™ allows timely closure of battlefield wounds with minimal operative time and morbidity. The procedure can begin whilst still in the acute phase and certainly before one would consider lengthy complex operations such as free flaps. Our experience suggests that Integra™ can allow early closure with robust tissue, promoting early rehabilitation and return to duties.
authors.affiliation: Registrar Burns and Plastic Surgery, Queen Elizabeth Hospital, Birmingham, UK.
authors.forename: Deborah P S
authors.initials: DP
authors.lastname: Foong
authors.forename: Demetrius
authors.initials: D
authors.lastname: Evriviades
authors.forename: Steven L A
authors.initials: SL
authors.lastname: Jeffery
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D000672:Amputation Stumps / Q000601:surgery; D000673:Amputation, Traumatic / Q000601:surgery*; D001134:Arm Injuries / Q000601:surgery; D001753:Blast Injuries / Q000601:surgery*; D002809:Chondroitin Sulfates / Q000627:therapeutic use*; D003094:Collagen / Q000627:therapeutic use*; D005107:Explosions; D006801:Humans; D007869:Leg Injuries / Q000601:surgery; D008297:Male; D008889:Military Personnel; D016038:Skin Transplantation; D017768:Skin, Artificial; D017695:Soft Tissue Injuries / Q000601:surgery; D055815:Young Adult
chemical_list: C114835:integra artificial skin; D002809:Chondroitin Sulfates; D003094:Collagen
keywords: Amputation; Ballistic; Battle wounds; Blast; Dermal substitute; Improvised explosive device; Injury; Integra; Soft tissue reconstruction; Stump