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Definitive Closure of a Ballistic Shotgun Injury with Extensive Soft Tissue Loss to the Right Thigh using ABRA Adhesive Dynamic Tissue System (DTS) and Porcine Urinary Bladder Matrix (PUBM)

Authors

Rohan Anand, Jasmin Rahesh, Virginia Tran MD, Yana Puckett MD, Robyn Richmond MD FACS, Catherine Ronaghan MD FACS

Introduction

Buckshot ballistic injuries have unique wounding characteristics, resulting in especially formidable and destructive wounds at close range. The pellets cause an anatomic defect with necrotic tissue and heavy bacterial contamination. The ABRA adhesive Dynamic Tissue System (DTS) closure device provides noninvasive closure of retracted skin defects. Porcine urinary bladder matrix (PUBM) is an acellular matrix product derived from the inner lining of the porcine urinary bladder that imparts constructive remodeling and possible antimicrobial properties.

Methods

We present a case of a 37-year old male who sustained a close-range shotgun wound to the right lateral thigh. Definitive wound closure was achieved using a combination of dynamic tension and a biologic xenograft. Data and information were collected via chart review of EMR at University Medical Center from the initial ER visit, intrahospital course, and post-operative care.

Results

A 37-year old male with no past medical history sustained a close-range shotgun wound to the right lateral thigh. There was extensive soft tissue loss, but no bony, major vascular, or neurologic injuries. The patient was immediately taken to the OR for extensive debridement of nonviable skin, fascia, and muscle. A negative pressure wound therapy (NPWT) device was applied. Postoperatively despite narcotics, the patient was in worse pain than at the initial time of presentation, likely due to the NPWT. Thus he was returned to the OR on post injury day (PID) 2 for removal of the NPWT, additional debridement of soft tissue, and installation of the ABRA adhesive DTS closure device (6 elastomers). After installation, the width decreased from 8 to 2 cm, and the muscle extrusion decreased from 2 cm above the skin to 1 cm below the skin. The 21 cm length and 9 cm blast injury cavity depth remained unchanged. On PID 6, examination of the wound in the OR revealed a maximum width of 1 cm, and it was deemed feasible to proceed with definitive wound closure. Micromatrix 500 mg was implanted into the blast cavity, along with a portion of the Cytal wound matrix sheet. The remainder of the wound matrix sheet was implanted throughout the bidirectional vertical mattress dermal closure. The patient was discharged home on PID 7.

Conclusion

Close range ballistic buckshot injuries cause extensive local tissue destruction. In addition to the pellets, wadding, gunpowder, and foreign bodies such as wood or cloth can be blasted into the wound. The ABRA adhesive DTS closure device utilizes elastomers to create dynamic tension across the soft tissue defect, resulting in decreased wound volume dimensions. The PUBM extracellular matrix is a substrate that serves as the site for cell attachment, migration, proliferation, and differentiation, allowing for deposition of host site-appropriate tissue. This case highlights a particularly extensive ballistic buckshot soft tissue injury. Due to the patient's intolerance of the NPWT, the combination of the ABRA adhesive DTS closure device and PUBM allowed for definitive closure of this complex wound in four days, minimizing patient morbidity. Further research into impact on length of stay, overall cost savings, and long-term patient outcomes are warranted.

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Back to the July 2021 issue of ACP IMpact