Burn Contractures Research Articles

Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps

Burn contractures of the anterior neck result in severe functional and aesthetic deformities. The release of wide contractures leads to defects that cannot be closed with local flaps. In these cases, tissue expansion of local tissues may be a solution. However, when local tissues are also burned or inadequate, microsurgical free tissue transfer may be necessary. In order to increase the surface are of the transferred flap, pre-expansion of the donor site can be combined with the procedure. Five patients with burn contractures of the anterior neck were treated using pre-expanded free anterolateral thigh (ALT) perforator flaps. The anterolateral thigh was dissected on top of the fascia lata in an avascular plane. The borders of the dissection were kept 2 cm lateral to the pre-identified perforators. A 1000cc rectangular tissue expander was placed. The time of expansion ranged from 4–11 months with a final over expanded volume of 1200cc. The defect sizes ranged from 10 × 21 cm to 20 × 27 cm. There were either one or two perforators included in the flaps. All flaps survived completely with good functional and aesthetic outcomes. Donor areas were closed primarily in one patient and with various amounts of skin grafts in five patients. Overall, pre-expansion decreased the amount of total skin grafted area in the donor site. Pre-expanded ALT perforator flap can be a good option in extensive burns with wide contractures where the regional donor areas are also affected. This technique has several advantages: 1) large flaps can be safely harvested, 2) the expanded skin thins out making it more aesthetically appropriate to resurface superficial defects, 3) expansion period of the thigh is well tolerated by the patients, 4) two teams can work simultaneously, decreasing the operating time, 5) the donor area can be closed either primarily or with minimal skin graft application, and 6) there is no functional loss in the donor area and the donor scar stays under the clothes.

Reconstruction of burn contractures with free anterolateral thigh flap in various anatomic sites.

Burn contractures that cause a restriction in extremity movements have to be reconstructed. Free microvascular flaps are generally needed in cases of severe contractures. The ideal free flap for severe contracture defects has to have a large skin island without bulk and a long pedicle for preventing recurrence and tension-free adaptation. Anterolateral thigh flap (ALT flap) that meets these features has widely been used for several indications in reconstructive surgery. Usage of ALT flap in burn contracture was described for burn and axillary contractures in literature. In this study, the usage of free ALT flaps in various anatomic contracture sites was reported. Fifteen free ALT flaps were performed in 14 (12 male, two female) patients with a mean age of 36.6. Burn contracture defects in neck, axilla, popliteal, cubital region, plantar foot and hand were reconstructed with ALT flap. No total flap loss was encountered. Distal flap necrosis was seen in one case. All patients had significant improvement in a range of motions. Recurrence in contracture was seen in one patient with hand flexor contracture due to lack of physical treatment. ALT flap can safely be used in various anatomic contracture sites. Suprafascial elevation of the flap can be preferred for better adaptation in the neck, hand and foot and prevention of bulky appearance.

Lipofilling in Burn Sacrs: Our Experience

Introduction: Management of burn scars is a challenging and a complex topic. Various surgical and non-surgical options are present. Recently, a minimally invasive procedure known as autologous fat transfer is being used as an alternative technique to surgical excision for scar management. Although fat grafting may be a promising modality for scar management, there is a limited numbers of studies about their use in burn scars. Methods: We conducted an observational retrospective study for patients referred to our private clinic for the treatment of burn scars and contractures using autologous fat grafts between February 2009 and May 2018. All patients were surgical candidates for burn reconstruction. The end result was the patients’ level of satisfaction and plastic surgeons’ evaluation at 1 year. Results: 20% (n=40) were mildly satisfied with the results, 50% (n=100) were moderately satisfied, and 30% (n=60) were extremely satisfied. Only 40% of the moderately satisfied patients were willing to undergo more procedures for scar improvement. 45% (n=90) of the patients had a clinical improvement greater than 50%. Conclusion: Lipofilling can be considered a safe, simple, minimally invasive, and autologous technique for plastic surgeons to benefit from in burn reconstruction before trying more invasive surgical procedures.

Post burn perineal contractures: case series and a classification system

Introduction: Perineal burn contractures remain under reported in our region. We have set out to study the pattern of presentation, describe the formation of these contractures and identify any recurring patterns that will form a basis for a classification that will be useful in planning their management. Methods: A retrospective study of the patients seen over a three year period (2009–2011) at the National Orthopaedic hospital Dala is presented. Information was retrieved from case notes in the medical records department. The bio-data, type of care received post injury associated percentage burns, formation of contractures, were all noted. Results: All the seven patients seen were children of which five were females. Flame burn was the main type of burn. All burns occurred at home. Four major types of contractures were identified as transverse bands, hooding, fusion and obliteration. An equal number of patients presented following home versus hospital care. Conclusion: The relative rarity of post burn perineal contractures leaves little experience for the young surgeon to take advantage of when in training. A classification system will help to make it easier to identify what structures are involved and make planning easier. In the absence of specialized care it is doubtful that there is any statistical difference in the likelihood of perineal contracture development of patients managed at home by traditional healers versus those presenting in peripheral centers lacking formal burn management protocols. Most childhood burns still occur at home. There is a need to continually educate the public on the need to make the home a safe place for children.

Surgical Management of Post Burn Hand Deformities.

Objective:To evaluate the efficacy of different surgical procedures on post burn contracture of hand.Methods:A quasi-experimental study design was conducted at the Department of Plastics and Reconstructive Surgery, Dow University of Health Science, DR. Ruth KM Pfau, Civil Hospital, Karachi, Pakistan from 1st June 2019 to 30th November 2019. Ninety-three participants of burned hand contracture of either gender, aged between 6- 60 years were included in the study. Resurfacing surgery with skin graft and loco-regional flaps were done according to type of contracture with individualization for each patient. All patients were kept under follow up for ninety days to assess efficacy of contracture release for each surgical procedure was noted. SPSS version 23 was used to analyse data.Results:Full thickness skin graft (FTSG) was performed in 60.2% cases, 17.2% with split thickness skin graft (STSG) and 12.9% with cross finger flaps. About 25% of recurrence was observed in cross finger flaps, whereas no recurrence was seen in Z-plasties and posterior interosseous flap. The significant association was between recurrence and surgical procedures (p<0.05).Conclusion:Z-plasty followed by FTSG was effective in the management of post burn contractures of hand.

Managing the airway of acid burn contracture of the neck in a 12-year-old girl

Managing the airway of patient with postburn contracture at the neck is often challenging for otolaryngologists and anesthesiologists. It affects the oro-pharyngo-laryngeal airway axes because of anatomical and functional deformities because of the long-standing contracture in the face and neck region. We present a case of extensive neck postburn contractures distorting anatomy, whose airway was assessed and managed using a video fiberoptic bronchoscope (FOB) (Ambu® aScope™). Our experience of the utility of FOB mirrors the experience and literature in the management of difficult airway.

Functional Reconstruction of Post-Burn Hand Contractures

Most patients who have survived severe burn injury may not have truly escaped the aftermath of severe scars which is post burn contractures. Hands are one of the most prevalent site of burn injury leading to contractures, which are important in terms of function and cosmesis. There is great deal of functional limitation, whereof contractures in both hands can make a burn survivor a total cripple. Moreover poor cosmetic result must also be considered as it gives impact towards patient’s self-esteem and quality of life. Treatment algorithm must be based on clinical presentation and severity of range of motion. Release of contracture, wound resurfacing and choice of reconstructive procedures must be based on timing of scar maturity as well as through a case-by case approach.

Pediatric burn contractures in low- and lower middle-income countries: A systematic review of causes and factors affecting outcome.

In low- and lower middle-income countries (LMICs), timely access to primary care following thermal injury is challenging. Children with deep burns often fail to receive specialized burn care until months or years post-injury, thus suffering impairments from hypertrophic scarring or joint and soft tissue contractures. We aimed to examine the correlation between limited access to care following burn injury and long-term disability in children in LMICs and to identify specific factors affecting the occurrence of late burn complications. A systematic literature search was conducted to retrieve articles on pediatric burns in LMICs using Medline, Embase, the Cochrane Library, LILACS, Global Health, African Index Medicus, and others. Articles were assessed by two reviewers and reported in accordance with PRISMA guidelines. Of 2896 articles initially identified, 103 underwent full-text review and 14 met inclusion criteria. A total of 991 children who developed long-term burn sequelae were included. Time from injury to consultation ranged from a few months to 17 years. Factors associated with late complications included total body surface area burned, burn depth, low socio-economic status, limited infrastructure, perceived inability to pay, lack of awareness of surgical treatment, low level of maternal education, and time elapsed between burn injury and reconstructive surgery.

POST BURN CONTRACTURE OF NECK A CLINICAL STUDY.

20Aug 2019 POST BURN CONTRACTURE OF NECK A CLINICAL STUDY. K.V.N.Prasad. MS.MCh(Plastic Surgery),AsstProfessor,Dept of Plastic Surgery, Kurnool Medical College,Kurnool,AP,INDIA.

Post burn flexion contracture of hand: a prospective study

Background: Burn contracture of the hand can cause severe functional and psychological deprivement in patients. This study mainly concentrates on different types of hand deformity cases presenting to our department and the various options used to correct them. The postoperative functional outcome is also compared so that standardization of procedures can be done. This study assesses the severity of the deformity, the success of various reconstruction options and the functional outcomes of cosmetic procedures.Methods: This work includes the study of 60 patients who underwent reconstruction for post-burn flexion contracture of the hand including fingers, in the department of plastic surgery, Government Rajaji Hospital, Madurai. The patients were treated between September 2009 to February 2012.Results: Males were twice commonly affected by burn injuries and thermal burns were more common than electrical burns. The little finger was more frequently involved and contracture release followed by grafting was the commonly done reconstructive procedure. Complications like recurrence, residual contracture, partial graft loss and infection were noted.Conclusions: Contracture release by multiple Z–plasty with or without skin grafting was sufficient in most cases of contracture due to thermal burns. Flaps were required for reconstructing electrical burns. Complication rates are higher in children than in adults and postoperative physiotherapy and splinting is mandatory to achieve a better functional outcome.

Innervated Dorsalis Pedis Advancement Flap for Burn Foot Contractures.

Dorsal foot burns in children often result in contractures with hyperextension of the toes and secondary gait disturbances. Skin grafting a wound bed after contracture release can result in early recurrence. Adequate contracture release often requires tenolysis and/or joint releases that may be prohibitive of skin grafting and require flap coverage. Local flaps are often dismissed as inadequate. Free flaps and distraction techniques have both been described as difficult in the pediatric foot. We describe a single-stage V-Y advancement dorsalis pedis (DP) based fasciocutaneous flap technique that releases dorsal foot contractures in children without donor sites by recruiting tissue from the anterior ankle to the dorsal forefoot. DP-based flaps have not been described before in forefoot burn contracture release. The flap is performed on three children (ages 4-9 years) with unilateral dorsal feet contractures. Each child suffered from gait disturbance due to toe hyperextension. Three to four centimeters of advancement was obtained with each child. Contractures involved all toes but were worst in the second toe for all patients. Extensor tenolysis and/or metatarsal joint releases were performed in each case. Surgeries were performed as an outpatient with minimal postoperative pain. Postoperative leg splinting was not performed. All patients' surgical sites healed without complication and with complete correction of contractures. Improved gait was noted postoperatively. The V-Y DP perforator advancement is a safe, effective, and reliable technique for dorsal foot burn contracture release in children without need for donor site or prolonged recovery.

Clinicoepidemiological study of post burn contractures at a tertiary care centre in western India

Background: Burn injuries are one of the commonest form of trauma globally with long term consequences in the form of contractures. The management takes a troll of time, money and stress, despite that the agony remains with the patient only. We intended to study the clinicoepidemiopathological aspects of post burn contractures for a better understanding and management purpose.Methods: This study was conducted from October 2014 to February 2017 in a tertiary care hospital in western India and includes 51 patients.Results: In this study, we observed that the mean age of patients was 21.7 years and females formed 51% of the patient pool. Most of the patients came from a rural background with a mean distance of 77.72 kilometres from the treating hospital. Flame burns contributed to 78% of the cases, with hand (35.7%) being the most commonly involved area, 52.9% patients did not receive splinting or physiotherapy at the initial treatment of burns. Most cases were treated by split skin grafting (64.2%) and the most common complication seen in our study was infection, noted in 15.7% of cases whereas recurrence was seen in only one patient.Conclusions: We observed that young adults were the predominant group of patients with a slight female preponderance. Factors like increased distance from the treating hospital, rural background of patients, poor healthcare facilities with poor rehabilitative facilities and irregular follow up of patients contributed to increased incidence of post burn contractures. We also noted that majority cases can be treated by contracture release with split skin grafting without major complications.

Rehabilitation and Prosthetic Design after Van Nes Rotationplasty of the Left Leg Due to Severe Burn Contractures in a Patient with Contralateral Amputated Right Femur: A Case Report

Background: Van Nes Rotationplasty (VNRP) is a biological reconstructive surgical method for pediatric sarcoma, complex trauma or severe lower limb deficiencies that often gets overlooked due to cosmetic reasons and psychological aspects. We report a unique case of knee stiffness and severe scarring from burns treated with this technique in a young patient who had also amputated contralateral femur. Case Report: A 15-year-old boy was trapped in a fire 10 years ago and sustained extensive contractures on his left knee due to severe burns and also an above knee amputation on his right thigh. For 10 years the boy had never received rehabilitation or worn any prosthesis and he managed to move bearing mainly on his palms. On admission to our hospital Van Nes rotationplasty was preferred among other treatment options as the most suitable solution for him and was successfully performed without complications. The patient had severe stiffness on his right hip and decreased muscle power in the VNRP leg but after intensive physiotherapy he was able to stand upright and walk again using custom made bilateral prostheses and crutches. Conclusion: VNPR is a reasonable option in severe contractures and scarring of the knee joint.

The scourge of burn contractures: Who will bell the cat?

IntroductionMajority of burn injuries occur in developing world. There have been many advances in burn care management. But this advance comes at a price of ever increasing burn sequel of scarring. Burn scar contractures, in spite of being preventable, continue to be a common reality in our world. This paper aims to evaluate the lacunae in burn care leading to formation of contractures, to evaluate common sites of contractures, practice of advising splintage and anti-deformity positioning. ProcedureThis retrospective observational study was conducted over a period of six years (January 2010–December 2015) at a tertiary Burn unit in Mumbai (India). The records of burn contracture patients were scrutinized to obtain the data regarding patient’s socio-demographic profile, details of burn injury, splinting and exercises advised and details of surgeries required. Data was tabulated and analysed. ResultsThere was a significantly lower prevalence of advice regarding splinting, mobilization exercises and pressure garments. The prevalence of early surgery was also found to be low. ConclusionsAttempt has been made to identify the factors affecting the prevalence of burn scar contractures. Authors recommend that efforts be made for improving the knowledge of the treating doctors. Also, efforts should be made to increase awareness of burn prevention and emergent management.

Versatile use of the posterior interosseous flap in the reconstruction of complex upper limb defects.

Reconstruction of the complex upper extremity defects is a challenging procedure for reconstructive surgeons because of the complex anatomical and functional structure of this region. In reconstruction, local and regional flap options involving the composite tissues are restricted. The posterior interosseous flap (PIO) has been presented 'in a single study' with a wide variety of uses, and in this study, the versatility of PIO has been tried to be emphasized by its multitude uses as well as its chance at adaptability to each case. Hence, due to this, the objective to highlight the versatile utility of the PIO flap in clinical practice and to present a good option for the reconstruction of complex upper limb defects for various cases have been targeted. We used 26 PIO flaps in 25 patients (18 male and seven female patients) with upper limb defects. The main etiological causes were burn contracture, traffic accident, firearm and acute burn injury. Twenty-two flaps were harvested as fasciocutaneous and four flaps as osteo-fasciocutaneous manner, which were applied to the metacarpal defects. In this study, 25 flaps were transferred as pedicled flaps, of which 23 and 2 flaps had reverse and antegrade blood flows, respectively, whereas one flap was used as a free flap. The mean follow-up period was 14 months. All flaps except one, which had partial necrosis and secondary healed, survived completely. All patients were able to gain basic functions for daily routine activities in the late postoperative period. Patients and/or their parents were satisfied with the postoperative functional and aesthetic improvements. Many advantages of the PIO flap make it useful for the reconstruction of upper limb complex defects. It can be versatilely used based on changing its flow direction and enrichment of contents.

Lower pole reconstruction in a post-burn breast using an anterolateral thigh flap: A case report

Severe chest burns in children that prevent breast development at puberty cause challenging problems. Burns result in contracture that lead to size, shape, and positioning problems. In the present case, we used a free anterolateral thigh (ALT) flap to release lower pole contracture in a breast with a burn deformity. A 17-year-old healthy girl had suffered a severed breast deformity due to burn contracture and underwent surgery to release the lower pole contracture of the breast. The patient was followed for 8 months and was satisfied with her final outcome. An ALT flap should be considered as a versatile option for partial breast reconstruction in selected patients who have deformities due to burns.

Management and outcome in patients with post burn contracture

Background: Post burn contractures are distressingly common and severe in developing nations and considered as a significant problem in developed countries as well. Despite advances in the overall management of burn injuries, severe post-burn contractures continue to be a formidable foe for reconstructive surgeons in developing countries.Methods: The study was carried out in Department of Surgery, Himalayan Institute of Medical Sciences, SRH University, Swami Ram Nagar, Dehradun over a period of 12months. Cases of the post burn contractures attended in the O.P.D were included in the study.Results: Contracture release with split thickness skin grafting STSG in 25 (55.5%) cases. Contracture release with STSG with flap cover was performed in 7 cases (15.5%), contracture release with K wire insertion with coverage was performed in 8 cases (17.7%) and Z plasty was performed in 5 cases (11%).Conclusions: There have been major advances in burn care in the last three decades and the mortality rates have gone down significantly. The management has shifted to improvement of functional outcome and better quality of life. Proper planning of reconstructive procedures, rehabilitation, restoration to pre-injury status and return to society are the goals that the treating team hopes to achieve.

Clinical profile of patients with post burn contracture

Background: Burns are a major, global public health problem, resulting in an estimated 195,000 deaths annually. Most burns occur in low-and middle-income countries, with almost half occurring in the south-east Asia region. The reasons for the high incidence include widespread ignorance of fire prevention, the rapid increase of poor socio-economic conditions, and the persistence of old traditions and customs.Methods: The study was carried out in Department of Surgery, Himalayan Institute of Medical Sciences, SRH University, Swami Ram Nagar, Dehradun over a period of 12months. Cases of the post burn contractures attended in the O.P.D were included in the study.Results: A total of 45 patients were included in the study. Of these, 22 (48.8%) were males and 23 (51.2%) were females. Ages ranged from 1 to 55year. Flame burn (20 cases = 44.4%) was the most common type of initial burn insult followed by scald burns (14 cases=31.1%).Conclusions: The pitfalls in initial burn care that lead to contractures in the patients include the failure to institute adequate surgical management of deep burns, the lack of physiotherapy/ROM exercises, and failure to provide proper anti-deformity splint age. There is need to revisit the prevalent acute burn care practices and establish focused preventive strategies.

Impact of burn contractures of chest wall and their surgical release on pulmonary function

BackgroundExtensive burn scars and contractures are likely to restrict the movements of the chest wall which may affect the pulmonary ventilation by restricting its expansion during inspiration. We designed this study to evaluate the effect of burn contractures of chest wall on pulmonary function and to estimate the effect of contracture release on pulmonary functions in patients with compromised PFT. MethodsPulmonary function tests (PFT) of 20 patients having chest wall contractures involving more than 50% of the chest circumference were studied. Restrictive lung disease was defined as forced vital capacity (FVC) value less than 80% of predicted normal for the age, weight, and height of that patient. Patients with a restrictive pattern on PFT were subjected to the surgical release of the contracture. PFT was repeated one month after the surgery which was compared with the initial report. ResultsOf the 20 patients included in the study, 5 (25%) patients had a restriction pattern on PFT. 1 patient had a mild restriction, 2 patients had moderate restriction and 2 patients had a severe restriction of pulmonary function. The mean duration of contracture was 58.2±15.75months in patients with a pulmonary restriction as compared to 29.87±6.21months in patients with a normal PFT (p=0.001). All patients having a restrictive pattern on PFT had contracture involvement of >75% of the chest wall circumference (p=0.0036). The mean forced vital capacity (FVC) increased from 1.94L preoperatively to 2.11L after surgical release of the contracture (p=0.047). However, the restriction pattern in PFT did remain. ConclusionLong standing chest wall contractures and contractures involving >75% of the chest circumference are likely to cause a restrictive pattern on PFT. Any significant improvement of pulmonary function after surgical release of the contracture is unlikely.

Preputial Grafts: The Forgotten Donor Site.

The prepuce is an excellent donor site for skin grafts with minimal donor site morbidity. Full-thickness grafts are often required for correction of congenital syndactyly and in burn contractures. Preputial skin was used for grafting in 18 children: 5 with burn contractures and 13 with congenital syndactyly. Excellent graft take was achieved with appropriate postoperative care. Postoperatively, there were occasional milia (42%) and hyperpigmentation. These grafts were noted to have superior mobility and elasticity. There was no donor site morbidity. Preputial skin is accessible, easy to harvest, and hairless and has minimal donor site morbidity. It is especially well suited for the hands and fingers when elasticity of the graft is beneficial.