The application of cultured epithelial autografts improves survival in burns

This prospective observational study was performed to analyze the clinical outcomes of patients with massive burns treated using cultured epithelial autografts (CEAs) and to determine the association of this treatment with survival outcomes. During 2006–2013, total 177 massive‐burns subjects treated with (96 subjects) or without (81 subjects) CEAs. Data were analyzed using the independent t test or chi‐square test. Multivariate logistic regression, Kaplan–Meier survival, and Cox regression analyses were performed to evaluate the factors that influenced mortality. Age, percentage of total body surface area burned, incidence of inhalation injury, allograft‐application rate, Abbreviated Burn Severity Index score, length of hospital stay, and mortality significantly differed between the CEA and noncultured epithelial autograft groups. Mortality and other clinical parameters did not differ between the sheet‐type and spray‐type CEA groups. Allograft application (odds ratio, 4.44; p < 0.01) significantly influenced CEA application. The CEA group showed significantly higher survival rates (p = 0.05). Cultured epithelial autografting had a hazard ratio of 0.55 (p = 0.02) and 0.59 (p = 0.05) according to the uni‐ and multivariate Cox regression analysis, respectively. In conclusion, early and aggressive allograft application is required to facilitate CEA application. Furthermore, the use of CEAs was associated with a lower mortality, but this result should be interpreted with caution as the groups were not randomized.     

Outcomes of sprayed cultured epithelial autografts for full-thickness wounds: a single-centre experience

Introduction

The lack of autograft donor sites with major burns provides the impetus to develop innovative solutions due to the difficulty of wound closure. Autograft donor sites are particularly limited in patients with burns involving over 50% total body surface area (TBSA). The introduction of cultured epithelial cell autografts offers a potential solution to assist in wound closure. The objective of this study was the assessment of clinical results after sprayed application of the cultured epithelial autograft (CEA, Keraheal™, Seoul, Korea, MCTT) suspension onto the wounds of extensively burned patients.

Materials and methods

This retrospective clinical audit of major burn patients (n = 16) describes the use of CEA which was combined with 6:1 meshed expansion grafts in those with the burn over 40% TBSA in our hospital between the period of August 2007 and January 2010. The burn patients included 12 males and 4 females with a mean age 41.5 and a burn area of 51.3 ± 3.1% TBSA (30–70%; median: 50.5%) and a mean third burn area of 32.5 ± 3.0% TBSA (median 34.0%).

Results

The take rates were 37.6%, 68.0% and 90.0% on average at 2, 4 and 8 weeks after treatment with the suspension, respectively, and the transplantation of the cultured cells was applied to full-thickness burns, with the coverage of a skin area of 497.5 cm² per 1 ml of the cultured cells. For clinical follow-up, 12 patients were observed for 21.5 months on average, with a maximum follow-up period of 39 months. Six patients were excluded from the surveillance because two died during hospitalisation and the other four were impossible to trace.

Conclusion

The use of a sprayed cultured epithelial cell autograft (Keraheal™) in treating a full-thickness skin wound in severely burned patients results in favourable quality of scars and also good potential to save lives by providing epidermal cover.     

Cultured epithelial autografts in massive burns: a single-center retrospective study with 63 patients

Cultured epithelial autografts (CEAs) have long been used to tackle limited donor site availability and difficulty of permanent skin coverage in massive burns, but this approach still has limited documentation.

Methods

In this retrospective, single-center study, medical records of patients treated with CEAs in our burn center from 1991 until 2008 were analyzed in search of factors associated with outcome.

Results

Out of 68 patients, 63 records were analyzable. Patients were aged 29 [17-41.5] years (seven children). Total body surface area (TBSA) burned was 81 ± 10%, of which 69 ± 14% TBSA full thickness. CEAs were first applied after 45 ± 34 days, on a surface of 32 ± 14% TBSA. Success rate at take down was 65 ± 19%, correlating only with young age (r² = 0.18; p = 0.0006). At discharge, CEAs covered 26 ± 15% TBSA. Infections (4.3 ± 2 per patient), most frequently of skin, often complicated the clinical course. Mortality was 16% (10 patients). In multivariate analysis, the number of infections was the only factor associated with mortality (OR = 2.05 per single infection, 95%CI 1.03-4.07, p = 0.04).

Conclusion

Although complex and costly, CEAs can be used with reasonable success and satisfying survival results for the treatment of massive burns. In this study, favorable outcome was principally associated with young age and low number of infectious complications.     

Clinical study of cultured epithelial autografts in liquid suspension in severe burn patients

We address the clinical application of the suspension type cultured epithelial autografts (CEAs), Keraheal™ (MCTT, Seoul, Korea), along with the effects, application method, merits and demerits thereof. From February 2007 to June 2010, 29 burn patients with extensive burns, participated in the suspension type of CEA clinical test. A widely meshed autograft (1:4-6 ratio) was applied to the wound bed and the suspension type CEA was sprayed with a Tissomat cell sprayer, followed by a Tissucol spray, a fibrin sealant. The patients’ (men/women = 26/3) median (interquartile ranges) age was 42 (30-49) years old, the burned TBSA was 55 (44-60) %, and the full thickness burn area was 40 (30-46.5) %. The area of Keraheal™ applied was 800 (400-1200) cm². The take rate was 96 (90.5-99) % and 100 (98.5-100) % at 2 and 4 weeks after treatment with Keraheal™, respectively. The Vancouver burn scar scale was 5 (4-6.5), 4 (3-6), and 3 (2-4) at 8, 12 and 24 weeks after the Keraheal™ application. Widely meshed autograft must be applied in massive burns but it's take rate is greatly reduced. The CEAs enhance the take rate of a wide meshed autograft in massive burns and allow for grafting wide meshed autograft together with acellular dermal matrix in some cases.     

The use of the Meek technique in conjunction with cultured epithelial autograft in the management of major paediatric burns

Background

The management of major paediatric burns remains challenging, in part due to limited donor sites. Skin graft expansion facilitates rapid closure of the burn wound, reducing the risk of sepsis. We reviewed our unit's experience with a combined modified Meek technique and cultured epithelial autograft (CEA).

Methods

A retrospective chart review over a seven year period from April 2004 to April 2011 was conducted of patients whose burns were treated with Meek and CEA.

Results

The Meek technique was combined with meshed split skin grafts and CEA to either donor, graft site or both in 7 cases. One case had Meek skin grafts alone with cultured cells applied to both donor and graft sites. There were two scald burns and five flame burns, with total body surface area ranging from 30% to 70%. Mean length of stay was 51 days (range 41–74 days). The average number of surgical procedures undergone to obtain good coverage was 3.3. There were small (1–3%) areas of breakdown in six cases which received regrafting. Two of these patients had confirmed wound infections. All patients had varying degrees of hypertrophic scarring (HTS) but remained well at follow up.

Conclusions

The Meek technique facilitates high expansion ratios, allowing for a greater area of skin coverage. Epithelialisation in the burn wound appeared to be enhanced by the application of CEA. The Meek technique in combination with CEA would appear a useful additional option in achieving wound closure in the severely burned paediatric patient.     

Increased Survival of Experimental Skin Flaps in Rats Following Treatment with Antiadrenergic Drugs

The effect upon the survival of skin flaps of several drugs which affect the adrenergic system was studied in rats. In control animals 41% of the skin flaps had survived seven days after the operation. Reserpine (1 mg/kg) injected intraperioneally (i.p.) three days and one day before the flap operation increased the surviving flap area by 75% (p<0.001) as compared to control rats injected with saline. I.p. injection of guanethidine (5 mg/kg) or bretylium (10 mg/kg) every 12 hours, starting 24 hours before surgery and continued for 5 consecutive days, also increased the surviving flap area (19 and 33% respectively p<0.001). The surviving flap area was unchanged when desipramine (5 mg/kg) was injected in the same way and was decreased by 15% (p<0.05) following i.p. injection of the MAO inhibitor pheniprazine (5 mg/kg). Treatment with α-methyl-p-tyrosine (75 mg/kg), i.p. 30 min before surgery or 6-hydroxydopamine (50 mg/kg) i.v. 24 hours prior to surgery also increased the flap survival (56 and 49% increase in surviving flap area, respectively, p<0.001). The results demonstrated that the survival of skin flaps increased when the function of the adrenergic nervous system was inhibited. Enhanced sympathetic nervous activity slightly reduced or did not affect skin flap survival.     

The involvement of alpha-melanocyte-stimulating hormone in the hyperpigmentation of human skin autografts

Hyperpigmentation occurs frequently in human skin autografts, resulting in an unsatisfactory appearance.     

Applikation gemischt homolog/autologer gefrierkonservierter Vollhauttransplantate nach drittgradigen Verbrennungen im Tierexperiment

Zusammenfassung An fünf weißen Miniaturschweinen wurden umschriebene drittgradige Verbrennungen gesetzt. Die plastische Deckung nach Escharektomie erfolgte mit gemischt homolog/autologen Transplantaten. Diese waren im Unterschied zur chinesischen Technik homologe Vollhauttransplantate, welche zuvor in einer herkömmlichen Gefriertruhe gefrierkonserviert (–27°C) worden waren. Die Versuche erbrachten bei sämtlichen Tieren eine rasche Epithelialisierung, gute kosmetische und klinische Ergebnisse.

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Animal experiment to test use of intermingled homo/autografts of full-thickness skin preserved by freezing following third-degree burns

Summary In 5 white piglets 3rd-degree burns were applied. After escharectomy the wound-dressing was done by intermingled homo/autografts. In variation of the Chinese method reported, in our experiments the homografts consisted of full-thickness skin preserved by freezing (–27°C). In all piglets this procedure caused a perfect epithelialization and brought good cosmetic and clinical results.

     

自体骨移植在腰椎后路椎间融合中的临床疗效分析

目的探讨腰椎后路手术中应用自体椎板、棘突骨颗粒为植骨材料行椎间融合治疗特殊的腰椎间盘突出症、腰椎管狭窄症及腰椎滑脱症等腰椎退变性疾病的临床效果。方法特殊腰椎间盘突出症、腰椎管狭窄症及腰椎滑脱症并行后路腰椎融合术(PLIF和TLIF)患者184例,按椎间融合材料分为3组,A组61例,单纯自体骨组;B组64例,PEEK椎间融合器组;C组59例,异体骨垫组。平均随访18个月(12~60个月)。统计3组患者术前一般资料、手术时间、术中出血量、术后下床时间、住院天数、术后融合率以及术后椎间高度及融合节段角度的变化情况,按JOA评分标准评价功能恢复情况。结果 3组患者术前一般资料、术中出血量、手术时间、术后下床时间、住院时间、JOA评分、术后1年椎间隙高度及融合节段角度比较,差异均无统计学意义(P0.05);3组患者术后3个月.JOA评分较术前均显著提高(P0.05)。A组术后1年的融合效果高于C组(P0.05);B组术后融合器移位的并发症发生率较高。结论在后路椎间融合中纯自体棘突、椎板骨移植能起到和PEEK融合器和异体骨融合器一样的维持椎间隙高度的作用,不延长术后卧床时间,且具有经济效益。     

Differential expression of matrix metalloproteinase-1 in vitro corresponds to tissue morphogenesis and quality assurance of cultured skin substitutes

OBJECTIVE: To determine if matrix metalloproteinase-1 (MMP-1) was involved in the premature degradation of the dermal component in cultured skin substitutes (CSS) prepared with cells from burn patients. METHODS AND RESULTS: CSS 645 and 647 were prepared from clinical human fibroblasts (HF) and keratinocytes (HK) that demonstrated premature degradation of collagen-glycosaminoglycan sponges in vitro. The control CSS were prepared from clinical HF and HK, CSS 648, and a pre-clinical cell strain, CSS 644 that did not degrade the sponges. Surface electrical capacitance measures surface hydration and was significantly higher for CSS 647 from days 9 through 14. MTT (3-[4,5-dimethylthiazol-2-yl]- diphenyltetrazolium bromide) conversion, an indicator of cellular viability was significantly lower for the 6-mm punch biopsies from CSS 645 and 647 at day 15 as compared to control CSS. MMP-1 protein levels measured by ELISA were significantly higher in medium from HF 645 and 647 than controls on the day of CSS inoculation. At day 14 of incubation, the mean MMP-1 concentration was significantly elevated in the medium from CSS 645 and 647 versus the controls, CSS 644 and 648. Western blots, and casein zymography demonstrated the presence of the latent and active forms of MMP-1 in the HF and CSS media, respectively. CONCLUSION: MMP-1 was significantly higher in the media from two of the four HF strains and CSS after a 24 h incubation period. Elevated MMP-1 coincided with premature degradation of the dermal substitute in vitro, and reduced numbers of CSS that met quality assurance standards for clinical transplantation.     

Cryopreserved cadaveric allografts for treatment of unexcised partial thickness flame burns: clinical experience with 12 patients

Partial thickness burns (PTB) usually heal within 3 weeks. Prevention of infection and desiccation of the wounds are crucial for optimal healing. Early tangential excision of the burn eschar and allografting prevent deepening of the burns, and are therefore advocated for treatment with the best functional and aesthetic results. For superficial partial thickness burns (SPTB) conservative use of topical antimicrobial agents with frequent dressing changes are implemented. We compared the conservarive treatment for PTBs and SPTBs to grafting cryopreserved cadaveric allografts with no prior excision.

Twelve patients with flame PTB areas were allografted after mechanical debridement without excision of the burn wounds. The allografts were cadaveric skin cryopreserved by programmed freezing and stored at −180°C for 30–48 months. Matching burns for depth and area were treated with silver sulfadiazine (SSD) one to two times daily until healing or debridement and grafting were required.

It was found that 80 per cent of the cryopreserved allografts adhered well and 76 per cent of the treated areas healed within 21 days, whereas only 40 per cent of the SSD-treated burns healed within 21 days.

Partial thickness burns can be treated successfully with viable human allografts (cryopreserved cadaveric skin) with no prior surgical excision. The burn wounds heal well within 3 weeks. For deep partial thickness burns (DPTB) treatment with allografts has no advantage if they have not been previously excised.     

Total full-thickness skin grafting for treating patients with extensive facial burn injury: A 10-year experience

IntroductionFacial burns are not only a severe burn injury, but result in psychological disturbance. The improvement of the methods of treating facial burns remains topical. The aim of the study was to evaluate the effectiveness of approach based on full-thickness skin autografting for facial burn injuries.MethodsDuring 2000–2019, ninety seven patients with the facial burn were treated in Burn Center. All patient were divided into two groups. The comparative analysis between groups was done.ResultsGroup A was treated with full-thickness skin grafts (42 patients – 43.3%). Since 2010, total full-thickness skin graft was used in 11 patients from Group A. In group B, 55 patients (56.7%) were treated with split-thickness skin grafts, including 9 patients (16.4%) with total split-thickness skin graft transplantation. Total full-thickness skin graft was performed in case of a deep and extensive facial burn and cicatricial deformities. During the long-term period, a positive cosmetic result and the absence of indications for reconstructive operations were noted.ConclusionThe approach of facial burn treatment based on total full-thickness skin graft allows conditions for engraftment and adaptation of autograft, reduces the risk of scar developing and achieves maximum cosmetic results of treatment.     

黑皮素受体-1在自体中厚移植皮片中的表达

目的　检测MC - 1R在自体移植皮片中的表达 ,并与自身正常皮肤作对照 ,初步认识MC - 1R在自体移植皮片过度色素沉着中的作用。方法　利用免疫组织化学方法检测自体中厚移植皮片与供区及受区周围自体正常对照皮肤中MC - 1R的表达 ,并行统计学分析。结果　MC - 1R的表达定位于表皮基底部黑素细胞、角朊细胞的胞浆及胞膜 ,在大部分自体中厚移植皮片中呈强阳性表达 ,其强阳性表达率为 6 7.7% ,与在自体正常对照皮肤中的表达差异有显著意义 (P <0 .0 1) ;MC - 1R在受区周围与供区正常对照皮肤中的表达差异无显著意义 (P >0 .0 1)。结论　MC - 1R在自体中厚移植皮片中的表达较在自体正常对照皮肤中显著增高 ,在自体移植皮片过度色素沉着中起重要调控作用。     

Cartilage repair with osteochondral autografts in sheep: Effect of biophysical stimulation with pulsed electromagnetic fields

The effect of pulsed electromagnetic fields (PEMFs) on the integration of osteochondral autografts was evaluated in sheep. After osteochondral grafts were performed, the animals were treated with PEMFs for 6 h/day or sham‐treated. Six animals were sacrificed at 1 month. Fourteen animals were treated for 2 months and sacrificed at 6 months. At 1 month, the osteogenic activity at the transplant–host subchondral bone interface was increased in PEMF‐treated animals compared to controls. Articular cartilage was healthy in controls and stimulated animals. At 6 months, complete resorption was observed in four control grafts only. Cyst‐like resorption areas were more frequent within the graft of sham‐treated animals versus PEMF‐treated. The average volume of the cysts was not significantly different between the two groups; nevertheless, analysis of the variance of the volumes demonstrated a significant difference. The histological score showed no significant differences between controls and stimulated animals, but the percentage of surface covered by fibrous tissue was higher in the control group than in the stimulated one. Interleukin‐1 and tumor necrosis factor‐α concentration in the synovial fluid was significantly lower, and transforming growth factor‐β1 was significantly higher, in PEMF‐treated animals compared to controls. One month after osteochondral graft implantation, we observed larger bone formation in PEMF‐treated grafts which favors early graft stabilization. In the long term, PEMF exposure limited the bone resorption in subchondral bone; furthermore, the cytokine profile in the synovial fluid was indicative of a more favorable articular environment for the graft. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:631–642, 2008     

自体移植皮片中黑皮素-1受体mRNA的表达及意义

目的：探讨黑皮素-1受体在自体移植皮片过度色素沉着中的作用.方法：利用RT-PCR、Ma sson-Fontana stain方法检测人体自体中厚移植皮片与原供区及受区周围自体正常对照皮肤中黑皮素-1受体mRNA的表达及表皮中黑色素的含量,并行统计学分析.结果：黑皮素-1受体在自体中厚移植皮片中的mRNA表达明显高于自身正常对照皮肤,其表达差异有显著性意义（P＜0.01）;自体中厚移植皮片表皮中黑色素含量较自身正常对照皮肤表皮中的黑色素含量亦明显增多,其含量的差异亦有显著性意义（P＜0.01）;且表皮中黑色素的含量与黑皮素-1受体的mRNA表达量呈正相关.结论：黑皮素-1受体在自体移植皮片过度色素沉着中起重要调控作用.     

Cultured epithelial autografts in extensive burn coverage of severely traumatized patients: a five year single-center experience with 30 patients

OBJECTIVE: We report recent five-year experience in a large, single center series of severely burned and otherwise traumatized patients given cultured epithelial autografts (CEA) from a single commercial laboratory. SUMMARY BACKGROUND DATA: Initial optimism over CEA application has been tempered by subsequent reports asserting that this modality is unreliable and expensive. Discussion continues over its clinical role. METHODS: From 1991 to 1996, CEA were applied to a mean 37+/-17% of total body surface area (TBSA) of 30 patients. These patients had 78+/-10% average burn size, 65+/-16% average third-degree burn size, 90% prevalence of endoscopically confirmed inhalation injury and 37% prevalence of other serious conditions. RESULTS: CEA achieved permanent coverage of a mean 26+/-15% of TBSA, an area greater than that covered by conventional autografts (a mean 25+/-10% of TBSA). Survival was 90% in these severely burned and otherwise traumatized patients. Final CEA take was a mean 69+/-23%. In subset analyses, only younger age was significantly associated with better CEA take (p = 0.0001 in univariate analysis, p<0.04 in multivariate analysis, Student's t-test). CONCLUSIONS: Epicel CEA successfully provided extensive, permanent burn coverage in severely traumatized patients, proving an important adjunct to achievement of a high survival rate in a patient population whose prognosis previously had been poor. In our experience CEA appear to have a very high beneficial value in the management of bur ns >60% TBSA. In some cases studied it is very likely that CEA was a life-saving treatment.     

The use of Biobrane as a delivery method for cultured epithelial autograft in burn patients

Background

Cultured epithelial autografts (CEA) are well described in the literature and are advantageous when dealing with major burns. There have been many methods of CEA application described, however they all have their own difficulties. Here we describe a novel technique of culturing the keratinocytes in Biobrane^®.

Methods

Skin samples were taken from three patients and cultured into pre-confluent keratinocytes. These were seeded in Biobrane^® and applied directly to the patients’ wounds.

Results

Three patients had Biobrane^® with seeded keratinocytes applied. The Biobrane was applied to both donor and burn wound sites, with healing times being similar to the keratinocyte sheets.

Conclusion

The experience of the authors shows that using Biobrane^® seeded with keratinocytes was easier to handle and quicker to produce than confluent sheets of keratinocytes, with no perceived disadvantages to the patients.