Hand trauma commonly requires soft tissue reconstruction. Classical techniques utilize both local and free flap techniques to provide the appropriate vascularized coverage. These techniques often utilize tissue from a neighboring uninjured digit or other part of the hand, thereby extending the zone of injury to the hand. With the advent of synthetic dermal regeneration templates (DRTs), the options for resurfacing areas of soft tissue defects have expanded, and here we report the novel use of NovoSorb Biodegradable Temporising Matrix (NovoSorb BTM; PolyNovo Biomaterials, Port Melbourne, VIC, Australia) for a finger defect. NovoSorb BTM is a completely synthetic DRT recently approved for use in managing full-thickness skin defects. Its principal use has been in the management of burn injuries and has shown promising results in a variety of anatomical areas [1], but there are scant reports on its use in non-burn hand trauma defects [2].

The index case was a 49-year-old right-hand-dominant male construction worker who presented with a significant injury to his right middle finger following an inadvertent circular saw injury. The patient was otherwise fit and healthy, a non-smoker, and did not take any regular medications.

Initial debridement in theatre confirmed significant complex soft tissue loss to the radial border of the middle digit including cortical loss from the distal phalanx and exposure of the middle phalanx, proximal interphalangeal joint (PIPJ), and flexor tendons. The radial neurovascular bundle was non-salvageable (Figs. 1, 2) and there was a complete loss of the radial collateral ligament to the PIPJ, but the joint was stable in both active and passive range of movement exercises. As expected, there was instability with ulnar deviating forces when applied at the PIPJ. The distal tip was well perfused and sensation to the ulnar aspect was preserved.

The patient was strongly averse to any form of shortening and additionally did not wish for a flap reconstruction, thus the decision was taken to treat the wound with NovoSorb BTM. He returned to theatre at 48 hours at which time the wound was minimally debrided and NovoSorb BTM was applied (Fig. 3) with simple non-adherent dressings, but there was no use of negative pressure wound therapy or further surgical management to the fracture of the base of the middle phalanx.

Postoperatively, the NovoSorb BTM was infiltrated by vascularized tissue producing a healthy, graftable bed which was split-thickness skin grafted at 4 weeks, followed by a 1-week pause in hand therapy exercises. A subsequent graft check one week postoperatively revealed 100% take and the donor site healed as expected. Six months after injury, the digit had a full active range of movement at the metacarpophalangeal joint, 5° to 86° at the PIPJ, and 10° to 70° at the distal interphalangeal joint as well as stability of the PIPJ under ulnar deviation (Figs. 4, 5). As expected, the recovered sensation to the radial aspect of the digit was minimal. The soft tissue was robust, soft, and pliable, with durable thickness and excellent contouring even after scar maturation. The patient was extremely positive regarding his functional and aesthetic outcome and reported no limitations to his daily activities, with a Disability of the Arm, Shoulder, and Hand (DASH) outcome instrument score of 0. He has returned to his full activities of daily living as well as his premorbid career.

Written informed consent was obtained from the patient for the publication of this report including all clinical images.

DRTs have been widely used for wound reconstruction where split-thickness skin grafts in isolation are not suitable. In this particular case, the wound precluded the use of many currently available DRTs due to exposed bone and joint surfaces and normally would warrant flap reconstruction, patient choice notwithstanding. The authors acknowledge there is a lead time delay of a number of weeks between the placement of NovoSorb BTM and the final skin graft, with PolyNovo’s instructions for a minimum period of 3 weeks for wound beds of fat, fascia or muscle and 4 to 5 weeks for tendons or bone prior to delamination of the sealing membrane. This lead time to skin graft does not however delay the patient’s rehabilitation and the authors use clinical assessment on a case-by-case basis for the timing of delamination and subsequent grafting instead of a fixed time scale. The patient was able to mobilize his finger and start his rehabilitation from day 1 following placement of NovoSorb BTM, even before his final skin grafting. The authors believe this is possible due to the high adherence of the polyurethane to organic soft tissue from the outset, and that as it is entirely synthetic it allows for a much longer period to incorporate granulation tissue and therefore less prone to failure when faced with early shearing forces in relation to the underlying wound bed than other options. The authors accept that had any fracture fragments been of significant size, or unstable, then a period of immobilization would have been required to ensure good union. In this case, the fragment was small, and due to the relatively tight skin envelope of the PIPJ, along with the continuity provided by the NovoSorb BTM, the authors felt that this contributed to stabilizing the fragment, making an early range of motion exercises safe to begin with a low risk of nonunion. The granulation and scar tissue formed from NovoSorb BTM have also been shown to provide an adequate “pseudo-collateral ligament complex” in such cases where this may be required. In addition to the functional outcome, we found it technically very straightforward to use and negates the additional risk to structures as would be the case in both homo- and heterodigital flap reconstruction. It can be layered in order to add bulk to your reconstruction whilst also preserving all conventional reconstructive options should it fail. NovoSorb BTM is manufactured entirely from biodegradable polyurethane and contains no biological products making it inexpensive to produce, more resistant to degradation by infection, and more acceptable to those with certain cultural and ethical beliefs. Despite these obvious advantages, the authors are aware that NovoSorb BTM provides non-vascularized coverage in place of sensate glabrous skin, but nevertheless, is a powerful resurfacing adjunct in selected cases. Finally, notwithstanding the fact that it is less expensive than alternative DRTs, NovoSorb BTM does still have a cost implication.

We have continued to utilize NovoSorb BTM in several cases and found it to represent a robust and versatile addition to our reconstructive quiver when considering the management of soft tissue defects in the hand.