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In 2020, we reported the first human use of a polyurethane composite cultured skin (CCS) in a large wound in our burn centre. Whilst we acknowledge that this is a single case, we believe that this patient's long-term outcomes would interest the burns community. To recap, the patient suffered 95 % TBSA (predominantly full-thickness) burns and underwent the inaugural 'two-stage' therapy treatment. The first stage involved total escharectomy and application of Biodegradable Temporising Matrix (BTM) to 85 % TBSA. The second stage was the serial application of Composite Cultured Skin. As per Burn Service protocols and standard operating regimens, the small available donor site was serially harvested to provide cover for highly functional areas, in this case, the hands. The case has been reported previously with initial patient outcomes described up to 1 year; Greenwood JE, Damkat-Thomas L, Schmitt B, Dearman B. Successful proof of the “two-stage strategy” for major burn wound repair. Burns Open. 2020;4(3):121–31. We now present a long-term follow-up of the patient three years after his injury. It illustrates the patient's mobility and confirms the biophysical properties of the CCS.

Large burns generate significant hypermetabolic and inflammatory responses which increase cardiovascular complications in animal models. A 70 year old male (Fig. 1a) presented with 20% total body surface area flame burns, involving his anterior chest wall. His burn wounds were debrided and temporised with a dermal substitute [NovoSorb® Biodegradable Temporising Matrix (BTM)]. His post-operative course was complicated by acute coronary syndrome requiring coronary artery bypass grafting via sternotomy through the BTM integrating into the chest wall wounds. The patient proceeded to complete BTM integration despite the sternotomy incision carried out through it, with excellent graft take and uncomplicated healing. We describe a previously unreported application of BTM for burn wound reconstruction using a technique that facilitated a surgical incision to carry out open cardiac surgery without compromising wound healing.

In 2004, in response to inadequacies in wound management techniques employed in the management of massive burns and the consequent high mortality and morbidity, a two stage strategy was conceived to reduce the traditional reliance on autograft, where donor sites were scarce, or absent. Over the next 14 years, two products were developed based in a novel, biodegradable polyurethane foam – a Biodegradable Temporising Matrix (BTM) and an autologous, bilayer (dermis and epidermis) Composite Cultured Skin (CCS). Following immediate burn escharectomy, the 1st stage of the strategy (either at the same operation or a few days later) would involve BTM implantation into the resultant wounds and harvesting of a small autograft for keratinocyte and fibroblast isolation for culture and CCS production. The 2nd stage, five weeks later, would involve delamination of the BTM and the application of the prepared CCS to the BTM ‘neo-dermis’. The two stages together designed to reduce the requirement for autograft to the small piece harvested to provide the cells for CCS production. At the end of 2018, an adult male with 95% TBSA burns (85% full-thickness) and significant smoke inhalation was received and was the first to undergo the ‘two-stage strategy’. His treatment course and outcome are described herein.

Serial debridement of tissue affected by necrotising fasciitis results in extensive and deep wounds, sometimes complicated by the exposure of major vessels, tendons, bone or other tissue incapable of supporting healing by skin grafts alone. When skin grafts are used, their contraction can result in contracture of joints, or the neck. On the other hand, reconstruction using tissue flaps can be bulky, with poor contour definition and healing of both reconstruction, and donor site, may be compromised by patient comorbidity and instability. In our institution, concerns regarding infection and loss of dermal substitutes of biological origin in these scenarios (e.g. collagen/glycosaminoglycan) have precluded their use. We present a series of seven consecutive cases of such challenging wounds; temporised and reconstructed with a totally synthetic polyurethane dermal substitute and secondary skin grafting, resulting in durable cover with minimal contracture. The cohort includes anterior neck defects exposing major vessels (2/7), multiple exposed ribs on the chest wall (2/7), lower limbs crossing knee or ankle joints (3/7) and a lower limb amputation by hip disarticulation (1/7). This is the first published series of the use of a completely synthetic dermal substitute in necrotising fasciitis wounds, and the joint largest using any dermal substitute.

Objective: The recovery of patients with partial thickness isolated hand burns managed with an epidermal skin substitute appears to be rapid and the necessity for routine hand therapy interventions in this setting is unknown. This study investigated the need for hand therapy for these patients. Methods: A randomized controlled trial was undertaken. The Treatment Group received routine hand therapy provided by a physiotherapist, including assessment, daily range of motion exercises, education and, if required, edema management and outpatient physiotherapy follow-up. Control Group participants received no hand therapy input. Outcomes included the Michigan Hand Questionnaire (baseline, 1, 2, 4 weeks and 3 months post-injury), finger total active motion, wrist range, grip strength (1, 2 and 4 weeks) and participant satisfaction (4 weeks). Results: Twenty-nine participants were recruited over a 2.3 year period. All outcomes significantly improved over time (p ≤ 0.008). No significant between-group differences were observed for any outcome except the pain subscale of the Michigan Hand Questionnaire. Participants with deeper burns had significantly poorer outcomes for some Michigan Hand Questionnaire data. Study limitations included a small sample size, heterogeneity and some loss to follow-up. Conclusions: While the provision of routine hand therapy interventions for patients with partial thickness isolated hand/forearm burns that were managed with an epidermal skin substitute did not appear to be of benefit, study limitations means these results cannot be extrapolated and reinforces the need for further research. Routine hand therapy input may be of benefit for those with deeper burns. Keywords: Burns, Skin, Artificial, Physical therapy modalities, Hand, Injuries

The NovoSorb™ Biodegradable Temporising Matrix (BTM) has been developed and evaluated over the past 12 years, with publications documenting each step. The final step in our evaluation was a pilot human study of the efficacy of BTM in significant (20–50% TBSA full-thickness) burns. Following immediate (or very early) burn excision, BTM implantation was followed by its monitored integration. The timing of delamination and definitive grafting over the integrated polyurethane foam matrix was determined by the subject’s physiological status and the availability of split-skin autograft donor site but was typically around four weeks after the burn debridement. Donor site shortage forced serial grafting in some, which required the BTM to remain laminated for up to 7 weeks without ill effect (spontaneous delamination, granulation tissue formation and wound contraction). The five subjects survived. Of 122% TBSA covered by BTM over the 5 subjects,