1. CORRESPONDENCE AND COMMUNICATION
TheuseofMatridermâ
inthemanagementofanexposed
Achilles tendon secondary to a burns injury
Soft-tissue defects over exposed Achilles tendons represent
a difficult reconstructive challenge. The large array of
techniques previously reported high-lights the lack of
a single acceptable treatment modality. We have success-
fully used the dermal substitute Matridermâ
in such a case.
A 42-year-old male was admitted to the Chelsea and
Westminster Hospital with 2% full thickness flame burns to the
right Achilles (Figure 1). Early management included
debridement and reconstruction with split thickness skin
grafts over preserved paratenon. Initial graft take was 100%.
Byday 24,however, an area overtheAchilleshadbroken down
(Figure 2a). This was debrided with Versajet hydro surgeryâ
(Smith and Nephew, Hull, UK). The resultant 4.5 cm by 3 cm
defect was reconstructed with 1 mm thick Matridermâ
(Dr.
Suwelak Skin and Health Care, Billerbeck, Germany)
(Figure 2b) and simultaneous fenestrated 8/1000 inch split
skin grafts, secured with a V.A.Câ
dressing on a continuous
setting at 75 mmHg. Graft taken four days post operatively
was >98%. Five months following reconstruction, the area
remains stable and the patient is able to plantar and dorsi flex
at the ankle (Figure 2c and see Supplementary video).
Previous treatments for exposed Achilles tendon have
included local muscle flaps; perforator and fascial flaps;
and microsurgical techniques. Negative-pressure therapy
has also been advocated alongside grafting.1
Use of the
two-stage dermal substitute, Integra, has also been repor-
ted.2
Matridermâ
is a second generation dermal substitute
that can be used in one or two stages. Its collagen matrix is
supplemented by elastin and has previously been shown to
have a marked improvement in the quality of dermis and
skin elasticity,3
and range of motion for hand burns.4
It must be assumed that the graft itself has taken by the
phenomenon of bridging. Traditionally one would expect
this to be limited to defects smaller than 1 cm across.5
Integra is less reliant on bridging and may be able to cover
larger avascular beds as it does not rely on immediate
imbibition or inosculation in the early post operative
period. Simple skin grafting applied to exposed Achilles
wounds that have already been allowed to granulate is also
a recognised technique, although generally reserved for the
elderly, less mobile patient. Nonetheless, the implication is
that with a suitable bed, whether that is granulation tissue
or artificial dermis; a stable wound can be attained. The
advantage of the Matridermâ
over a simple graft is the
interposition of a dermal layer, increasing the durability
and preventing direct adherence of the graft onto tendon.
To our knowledge, this is the first documented case using
Matridermâ
and simultaneous overlying split skin grafts for
burn wound closure on exposed Achilles tendon. The wound
remains stable and supple 5 months post operatively with
the patient able to wear his normal footwear. He retains an
excellent range of pain-free motion through a technically
straight forward procedure while avoiding bulky flaps and
potential donor site problems beyond that of a graft. We
therefore feel this may be a useful reconstructive tool for
the future.
Conflict of interest
None of the authors has any commercial associations that
might pose or create a conflict of interest with information
presented in this article. Such associations include consul-
tancies, stock ownership or other equity interests, patent
licensing arrangements, and payments for conducting or
publicizing a study described in this article. No intramural
or extramural funding supported any aspect of this work.
Figure 1 Full thickness flame burn to the right ankle.
DOI of original article: 10.1016/j.bjps.2008.12.027.
ARTICLE IN PRESS
1748-6815/$-seefrontmatterCrownCopyrightª2009PublishedbyElsevierLtdonbehalfofBritishAssociationofPlastic,ReconstructiveandAestheticSurgeons.Allrightsreserved.
doi:10.1016/j.bjps.2009.02.054
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) xx, 1e2
+ MODEL
Please cite this article in press as: Boyce A et al., The use of Matridermâ
in the management of an exposed Achilles tendon secondary to
a burns injury, J Plast Reconstr Aesthet Surg (2009), doi:10.1016/j.bjps.2009.02.054

2. Supplementary data
Supplementary data associated with this article can be
found in the online version, at doi: 10.1016/j.bjps.2009.
02.054.
References
1. Repta R, Ford R, Hoberman L, et al. The use of negative-pressure
therapyandskingraftinginthetreatmentofsofttissuedefectsover
the Achilles tendon. Ann Plast Surg 2005;55:367e70.
2. Jeng JC, Fidler PE, Sokolich JC, et al. Seven years’ experience with
Integra as a reconstructive tool. J Burn Care Res 2007;28:120e6.
3. Ryssel H, Gazyakan E, Germann G, et al. The use of MatriDerm in
early excision and simultaneous autologous skin grafting in
burns- a pilot study. Burns 2008;34:93e7.
4. Haslik W, Kamolz LP, Nathschla¨ger G, et al. First experiences
with the collagen-elastin matrix Matriderm as a dermal
substitute in severe burn injuries of the hand. Burns 2007;33:
364e8.
5. Mellette Jr JR, Swinehart JM. Cartilage removal prior to skin
grafting in the triangular fossa, antihelix and the concha of the
ear. J Dermatol Surg Oncol 1990;16:1102e5.
Alexandra Boyce
Duncan D. Atherton
Raymond Tang
Mohammad Jawad
Chelsea and Westminster Hospital,
369 Fulham Road,
London, UK
E-mail address: ali.boycey@googlemail.com
Figure 2 a) Exposed right Achilles tendon following partial breakdown of the previous split thickness skin graft. b) 1 mm thick
Matridermâ
applied to exposed Achilles tendon of right ankle. c) Right ankle showing healed wound 54 days post application of
Matridermâ
and split thickness skin graft.
ARTICLE IN PRESS
2 Correspondence and communication
+ MODEL
Please cite this article in press as: Boyce A et al., The use of Matridermâ
in the management of an exposed Achilles tendon secondary to
a burns injury, J Plast Reconstr Aesthet Surg (2009), doi:10.1016/j.bjps.2009.02.054