Release Of Post-burn Contractures Research Articles

Closed Incision Negative Pressure Wound Therapy Assisted Full Thickness Graft Aite Wound Dressing to Prevent Surgical Site Infection

Closed incision Negative Pressure Wound Therapy (CiNPWT) which is a topical application of negative pressure over the wound plays a key role in healing and prevention of surgical site infections. We have used full thickness graft following post burn contracture release. We then applied negative pressure wound therapy over to this flap to assess its efficacy and safety in aiding healing.

A Technique of Immobilization of Digits by Spinal or Intracath Needle Following Soft Tissue Surgery.

After release of post burn flexion contracture and repair of soft tissue injury of digits, it is desirable to maintain the digits in full extension. This is conventionally done by insertion of Kirschner wires across the interphalangeal or metacarpophalangeal joints. We have been inserting a spinal or intracath needle in a dorsal supra-periosteal plane for immobilizing digits after release of post burn contractures or repair of soft tissue injury. The needle is maintained for 2-3 weeks, and all patients achieved stable immobilization of digits. There were no major complications. This procedure is minimally invasive, simple to perform, and provides stable immobilization. Level of Evidence: Level V (Therapeutic).

Study of management of postburn flexion contracture of finger by glabrous versus nonglabrous split skin graft

Aims and Objectives: This prospective study was designed to determine the outcome of split-thickness glabellar and nonglabellar skin graft for the coverage of defects on palmar aspect of hand after release of postburn contracture in terms of graft take, complications, recurrence, and patient satisfaction for color and texture match.Materials and Methods: This prospective comparative study was carried out on patients from December 2018 to December 2020. Fifty patients were randomly divided into two groups by simple randomization method. Group A was offered treatment with split-thickness graft from glabellar region and other Group B was offered treatment with split-thickness graft from nonglabellar skin. Frequencies and percentages of both recipient and donor sites complications such as infection, hypertrophic scarring on the Vancouver scar assessment scale, recurrence, and difficulty in walking were noted. Patient satisfaction for colour and texture match to neighboring skin at recipient site were assessed 3 months after the operation using five points Likert scale.Results: At follow-up of the Group A, the donor areas were completely healed in all the cases 100%. The grafted area showed excellent color and texture match with the adjacent palmer skin. The graft was mobile, stable and without any pigmentation. There was also no hypertrophic scarring, hyperpigmentation or pain at the donor site as compared to ordinary skin graft. Walking and weight bearing were smooth and the instep curvature appeared normal. In Group B, 100% of patients had hyperpigmentation, 20% had marginal scarring and scar hypertrophy at hand. While 40% had scar hypertrophy at 80% had hyperpigmentation over the donor site. Recurrence was noted in 32% of patients in Group B as compared to 8% in Group A.Conclusions: Glabellar skin of the instep is the best replacement for the palmar skin of the digits and hand because of the similarities in their characteristics. Results are excellent in terms of color and texture match, no hyperpigmentation, less marginal scarring, scar hypertrophy, and less recurrence of contracture in patients with area grafted with glabellar skin. Donor site morbidity is very low and hardly any donor site scar is visible. So in conclusion for the management of postburn flexion contracture of the finger. An ideal skin substitute is glabellar skin grafts from the instep region of foot.

Novel use of Pedicled Medial Sural Artery Perforator flap for Post Burn Knee Contractures

<br><b>Background:</b> Postburn flexion contractures of the knee may arise even with adequate treatment of the burn injury. Pedicled medial sural artery perforator (MSAP) flap has been described for the reconstruction of defects of the knee and proximal third of the leg. Its use in the management of postburn contracture release is sparse. We are presenting the use of a medial sural artery pedicled flap for the reconstruction following postburn knee contracture release. <b>Materials and Methods:</b> This study included six patients with postburn unstable scars and a mild degree of knee contractures who underwent release of the contracture and coverage using MSAP pedicled flap. The results in terms of flap size, recurrence, complications, functional outcome, and cosmesis were assessed. <b>Results:</b> The flap size ranged from 7 cm × 6 cm to 13 cm × 7 cm with a mean pedicle length of 9.41 cm. All six flaps survived without any complications with a satisfactory outcome. The patients were followed up for 6–18 months. There was no recurrence of contracture without any restriction of knee joint mobility. <b>Conclusion:</b> MSAP flap is a reliable flap and should be considered for the management of postburn knee contracture of grade 2 and grade 3 contractures, as it provides optimum and ideal coverage with fewer chances of recurrence.<br>

Efficacy of Reverse – Flow Lateral Arm Flap for Coverage of defects Around the Elbow in Pediatric Patients

Background: Coverage of defects around the elbow can be treated by a variety of procedures as skin grafts, regional flaps, muscle flaps and free flaps. The reverse flow lateral arm flap (LAF) is a valuable option in coverage of these defects. The vascular basis of this flap, viz, the multiple communications around the elbow between the collateral and recurrent arteries, is consistent and reliable.Aim of the study: To explore the utility of the distally based lateral arm flap (LAF) in management of defects around the cubital fossa region.Patients and methods: This work was executed at The Menoufia University Hospitals, from October 2017 to December 2018, following our cases postoperatively for average one year. It entailed eight patients, six boys and two girls. The age of our cases was from 4 to 11 years. Six patients had post-burn contracture release defects, and 2 patients had traumatic avulsion of antecubital skin. All the defects were covered by the reverse- flow lateral arm flap (LAF) with skin grafting of the donor site.Results:All the flaps survived completely, except one case showed distal superficial necrosis and healed spontaneously. We applied skin graft to the flap donor site in the eight patients. Flap size ranged from 15x7 cm. to 12x5cm. Aesthetically, the flap and donor sites were satisfactory, and functionally, the range of motion of elbow was very adequate. One patient developed transient radial nerve palsy and completely recovered by conservative treatment and physiotherapy.Conclusion: The reverse flow lateral arm flap (LAF) is a valuable single-stage option in coverage of defects around the elbow. It provides reliable and stable coverage of these defects without sacrificing major vessel or functional muscle unit. The flap had satisfactory aesthetic and functional outcome.

Outcome of the acellular dermal matrix and split thickness skin graft in release of post burn contractures in hand.

Objective: To determine the frequency of success of acellular dermal matrix and split thickness skin graft in release of post burn contractures in hand using Vancouver scar scale. Study Design: Descriptive Case Series. Setting: Department of Plastic Surgery, Jinnah Burn and Reconstructive Surgery Center, Lahore. Period: 1st March, 2019 to 30th October, 2019. Material &amp; Method: A descriptive case series conducted at Plastic Surgery Department, Jinnah Burn and Reconstructive Surgery Center, Lahore. A sample size of 75 patients, who full filled the inclusion criteria, was selected through non probability consecutive sampling Informed consent was obtained from all the patients. Pre-operative photography was done to compare the post-operative results. After the release of contractures, coverage with acellular dermis and split thickness skin graft was performed. All the patients were followed up to 2 months and the outcome was assessed by Vancouver Scar Scale. The collected data was entered and analyzed by using SPSS version 20. Descriptive statistics were calculated. Quantitative variables like age, size of scar were presented as mean, ± standard deviation. Qualitative variables were presented as frequencies and percentages. Results: Mean age of patient was 30 ± 9 years. Among them 40 were males and 35 females. Vancouver scale showed successful outcome (score ≤4) in 70.66 % of the patients. Partial release of contracture was the major complication seen in 5.33% of cases. Conclusion: Acelluar dermal matrix followed by split thickness skin graft is a very reliable option for coverage after release of post-burn contractures in hand as it provides very pliable, thin and lax skin with good color match and better contour to surrounding tissue.

ARC technique – An innovative method to assess true defect in postburn contracture release

Most commonly, skin grafts are used to resurface the raw areas resulting after the release of postburn contractures but in the extensively burned patient, donor sites may be limited. There is no accurate technique described in literature for the assessment of the true defect preoperatively. We describe a technique to accurately assess the true defect which helps to determine the amount of skin graft required preoperatively.

A Review of Post-Burn Contracture Release Procedures at the National Orthopaedic Hospital, Enugu

Background: Contracture release surgeries are done to correct functional impairment, pain or discomfort, recurrent ulceration and cosmetic challenges associated with contractures across joints and mobile structures such as the eyelids.

Pedicled Split Hypogastric Flap (Superficial Inferior Epigastric Artery flap): A New Technique for Coverage of Nonadjacent Defects in the Hand.

Flap coverage of soft tissue defects on both surfaces of the hand or of nonadjacent defects in the hand is a challenge. Two flaps are needed or if a single flap is used, the intervening normal area or part of the flap must be deepithelialized or the flap tunneled under the normal bridge segment. We are presenting a new technique whereby the hypogastric flap based on the superficial inferior epigastric artery is split into 2 components for the coverage of such defects. The hypogastric flap is separated into a cutaneous component and an adipofascial component at the level of Scarpa fascia. The flaps are separated almost to the base to increase mobility. Now it can be used to cover 2 defects separated by 5 to 7 cm or for defects in the dorsum and the palm. We have used it in 3 patients, in 2 for the coverage of palmar and dorsal aspect of the hand and in one for the coverage of nonadjacent defects on the dorsum of the hand and distal forearm after postburn contracture release. We achieved good results with no flap-related complications.

Successful Anaesthetic Management of a Patient with Post Burn Contracture and Difficult Airway: A Case Report

The Anaesthetic management of patients with post burn contracture release poses many problems toanaesthesiologist. Airway management in such cases is still challenging to anaesthesiologist as thecontracture and deformity due to fibrous tissue resulting in non-alignment of oral, pharyngeal andlaryngeal planes, makes laryngoscopy and endotracheal intubation very difficult or impossible and thiscan result in many life threatening and serious complications. We report the successful airway managementof a patient with restricted neck extension and fixed flexion deformity by Laryngeal mask airway (LMA)followed by endotracheal intubation. JBSA 2020; 33(2): 107-110

Comparative evaluation of three methods of skin graft fixation for split thickness skin graft after release of post burn contracture of the neck

ObjectivesSplit thickness skin graft is an essential component of release of post burn contracture of neck. There are many methods of fixation of skin grafts; however, there is lack of objective comparison between different techniques. This study has been designed to compare three commonly used techniques of split thickness skin graft fixation methods. Surgical time, advantages, cost factor and post-operative outcome have been compared amongst three techniques. MethodsA randomized interventional comparative study was conducted to compare three methods of skin graft fixation in patients of 10–50 years age group, with contracture of more than 3 month duration having more than 100cm2 skin defects after contracture release. Resurfacing of the defects after contracture release was carried out in all the groups using autologous split skin grafts. Patients were included in three groups; Group 1: tie over method, Group 2: skin stapler fixation and Group 3: Cyanoacrylate glue fixation. ResultsMean duration of fixation procedure was 34min in tie over group, in skin stapler group 7min and in cyanoacrylate group 12min. Mean cost of fixation material was 10.23 USD in tie-over group, 11.23 USD in stapler group and 40.06 USD in cyanoacrylate group. Mean score of pain/discomfort (visual analog score) on dressing removal in tie-over group was 3, for skin stapler group was 2.9 and that for cyanoacrylate glue group was 1.8. mean graft take was found to be 90.1% in tie-over group, 94.1% in skin stapler group & 93.8% in cyanoacrylate glue group. On logistic regression analysis, keeping all the variables constant in the groups the complications as the outcome variable, three groups are comparable. The need for regrafting remains inconclusive. ConclusionsSkin stapler method for skin graft fixation was least time consuming, affordable and highly reliable when graft take success was considered. Cyanoacrylate glue fixation method was least painful and reliable in terms of graft take success though costlier than other two

Airway management of post burn contracture neck – a case report

The Anaesthetic management of patients with post burn contracture release poses many problems to anaesthesiologist. Airway management in such cases is still challenging to anaesthesiologist as the contracture and deformity due to fibrous tissue resulting in non-alignment of oral, pharyngeal and laryngeal planes, makes laryngoscopy and endotracheal intubation very difficult or impossible and this can result in many life threatening and serious complications. We report the successful airway management of a patient with restricted neck extension and fixed flexion deformity by awake nasal fibreoptic bronchoscope guided nasotracheal intubation.

AMBU Laryngeal Mask Airway: A useful aid in post-burn contracture of neck

Sir, We describe a case of post-burn contracture of neck with limited mouth opening, where upside-down technique of AMBU Laryngeal Mask Airway (ALMA) insertion was successfully used for airway management. A 60-kg, 40-year-old patient with severe post-burn contracture of face, neck, and chest was scheduled for scar release and split thickness grafting surgery. Preoperative assessment predicted difficult intubation due to fixed flexion deformity of neck and reduced mouth opening of less than 2 cm [Figure 1]. Patient was explained about the same and need for tracheostomy or surgical emergency release of post-burn contracture if required.Figure 1: Fixed flexion deformity of neck with limited mouth openingPatient was premedicated with intravenous midazolam 0.5 mg, glycopyrollate 0.2 mg, and fentanyl 25+25 mcg. After preoxygenation for 3 min, incremental inhalational induction with halothane (0.53%) in oxygen was done. Fiberoptic-guided intubation was planned, but the equipment malfunctioned. A size 3 ALMA was tried in an attempt to secure the airway, but this failed as the shaft of the ALMA got stuck on to the chest, hindering its passage into the oral cavity [Figures 2 and 3]. It was now decided to put the ALMA with upside-down technique.Figure 2: Shaft of AMBU LMA got stuck on to chestFigure 3: AMBU LMA inserted with upside-down techniqueThe deflated cup of the mask end of the ALMA was inserted, keeping it pressed against the hard and soft palate. Once the mask portion was inside the mouth up to its angulation, it was rotated by 180°[Figure 4]. The ALMA was then slipped comfortably inside the mouth and the cuff inflated [Figure 5]. Adequacy of ventilation was checked. The entire placement took less than 2 min. Oxygen saturation remained 98-99% during this period. Patient was thereafter administered neuromuscular blockade and the surgery done.Figure 4: Once angulation of AMBU LMA was inside the mouth, it was rotated to 180°Figure 5: Patient well ventilated with AMBU LMAUse of standard laryngoscope is not possible in such cases due to nonalignment of oral/pharyngeal axis, making the intubation difficult. Various options available for intubation in these cases are awake fiberoptic intubation, laryngeal mask airway (LMA), intubating laryngeal mask airway (ILMA), blind nasal intubation, retrograde intubation, and tracheostomy. Fiberoptic intubation is the gold standard in such cases. LMA insertion may not be successful if the angle between oral, pharyngeal, and laryngeal axis is less than 90°.[1] Kumar et al, reported reverse technique of ILMA insertion.[2] ILMA is available in only adult sizes (size 3, 4, and 5), and thus cannot be used in pediatric patients. The width of an ILMA is more than 2 cm and this can hamper its insertion in cases of limited mouth opening. Styleted LMA has been used by the upside-down insertion technique in a pediatric patient,[3] but the use of a stylet may cause trauma. We have used an ALMA which has got a preformed curve replicating human anatomy. The internal ribs built in this curve give flexibility to it. It does not require a stylet and is available in both pediatric and adult sizes (sizes 1-5). It has both reusable and disposable versions, with width at the junction of mask and tube being less than 2 cm (size 3 LMA), and can be used as an intubation conduit. These properties allow an ALMA to safely negotiate the sharp oropharyngeal curve with the upside-down technique and can be used in all age groups.

Pre‐expanded pedicled thoracodorsal artery perforator flap for postburn axillary contracture reconstruction

The axillary region is one of the sites most frequently affected by postburn contractures. In this clinical study, we used pre-expanded pedicled thoracodorsal artery (TDA) perforator flaps for release of postburn contracture of the axillary region. Five patients with severe axillary burn contractures were reconstructed with six pre-expanded pedicled TDA perforator flaps between 2008 and 2010. All were men ranging in age from 20 to 26 years (mean, 22 years). Mean time of follow-up was 12 months. Flap and donor site complications, preoperative, and postoperative range of motion of axillary joint were evaluated. All flaps survived without significant complications. Partial flap necrosis was seen in only one flap. Minimal transient venous congestion occurred in one flap during the early postoperative period. A complete range of motion at the axillary joint was achieved in all patients by the end of the reconstruction period. The donor sites were closed primarily with linear scars in all cases. The pre-expanded pedicled TDA perforator flap is a suitable alternative for coverage of the axillary defects after the release of the burn contractures. A pliable texture and large size flap can be obtained to transfer to the axillary area and the donor site scar is considered as cosmetically acceptable.

Tumescent anaesthesia for post burn contracture release

Tumescent anaesthesia for post burn contracture release

V-M Plasty and Double Z-Plasty

The release of postburn contractures in the hand is one of the most commonly performed procedures in burn injuries. Various local flaps have been described for release of severe postburn contractures. As the largest burn center covering north and northwest of Iran, we always needed acceptable reliable methods to reconstruct postburn syndactyly and make it as a standard treatment. We used double Z-plasties for the first web in severe contractures (23 patients) and V-M plasties for the second, third, and fourth webs and minor first web contractures (V for the dorsal aspect and M for the volar aspect of the webs). A total of 50 patients from September 2005 to June 2007 with 130 web contractures were operated. Their age ranged from 1 to 75 years. In a 1-year follow-up, all of the patients had good mobility of the fingers with no recurrence. Three cases of necrosis of tip of Z-plasties and 2 cases of necrosis of tip of V-M plasties occurred which were under 3 mm and resolved gradually. Double Z-plasty in first web and V-M plasty in second to fourth webs are considered good choices for release and reconstruction of postburn syndactyly. They are straightforward in technique and can be carried out with little complications.

Uso de sustituto dérmico en niños con secuelas de quemaduras: Tres casos clínicos

Introduccion: En COANIQUEM se realizan cirugias reconstructivas de secuelas de quemaduras en forma ambulatoria, en pacientes pediatricos durante su tratamiento de rehabilitacion. Una de estas cirugias es la tecnica tradicional del desbridamiento mas injerto dermo-epidermico. Una nueva alternativa ha sido la aparicion del sustituto dermico Integra (Dermal Regeneration Template). En Chile, no existe experiencia con este sustituto dermico aplicado en forma ambulatoria en ninos con secuelas de quemaduras. Objetivo: evaluar la utilizacion de un sustituto dermico en forma ambulatoria, en pacientes pediatricos con secuelas de quemadura y su evolucion a dos anos plazo. Casos clinicos: cirugias realizadas durante 2004 en tres pacientes de 9 a 13 anos de edad, con secuelas estetico-funcionales de extremidad superior. Se aplico protocolo de evaluacion de rehabilitacion a 24 meses y administracion de test de calidad de vida (BSHS). Resultados: No hubo complicaciones quirurgicas en los tres pacientes; el porcentaje de prendimiento vario entre 75 y 100%. Todos requirieron presoterapia por 13 meses. La elasticidad y plegabilidad fue similar a la piel normal a los dos anos de evolucion, con ausencia de fibrosis y contraccion del injerto. BSHS resulto favorable. Hubo presencia de infeccion leve en un caso. Conclusion: El sustituto dermico Integra® es una buena alternativa de tratamiento y es posible su uso en forma ambulatoria sin mayores complicaciones quirurgicas.

A study of the use of the supraclavicular artery flap for resurfacing of head, neck, and upper torso defects

The head and neck region is an aesthetically demanding area to resurface because of its high visibility. Tissue defects in this area often require distant flaps or free flaps to achieve an aesthetically acceptable result. The use of the Supraclavicular artery flap represents an extremely versatile and useful option for the resurfacing of head, neck and upper torso defects. Furthermore, islanding the flap gives it a wide arc of rotation and the color and texture match is superior to that of free flaps harvested from distant sites. In our study, we used the flap (both unexpanded and expanded) predominantly for resurfacing neck defects resulting from the release of post-burn contractures. However, its applicability in other indications would also be similar. Except one, all our flaps survived almost completely and the post-operative morbidity was very low. We conclude that the supraclavicular artery flap not only provides a reasonably good color and texture match but also maintains the multi-directional activity in the neck region.

A study of the use of the supraclavicular artery flap for resurfacing of head, neck, and upper torso defects

ABSTRACTThe head and neck region is an aesthetically demanding area to resurface because of its high visibility. Tissue defects in this area often require distant flaps or free flaps to achieve an aesthetically acceptable result. The use of the Supraclavicular artery flap represents an extremely versatile and useful option for the resurfacing of head, neck and upper torso defects. Furthermore, islanding the flap gives it a wide arc of rotation and the color and texture match is superior to that of free flaps harvested from distant sites. In our study, we used the flap (both unexpanded and expanded) predominantly for resurfacing neck defects resulting from the release of post-burn contractures. However, its applicability in other indications would also be similar. Except one, all our flaps survived almost completely and the post-operative morbidity was very low. We conclude that the supraclavicular artery flap not only provides a reasonably good color and texture match but also maintains the multi-directional activity in the neck region.

Are Reverse Flow Fasciocutaneous Flaps an Appropriate Option for the Reconstruction of Severe Postburn Lower Extremity Contractures?

Full thickness burns involving the lower extremity can result in severe contractures, which impair extremity functions if they are not managed with proper treatment and rehabilitation. After release of postburn contracture of the knee, ankle, and metatarsophalangeal joints, defects often require coverage by flaps. Twelve distally based reverse flow flaps were performed for lower-extremity reconstruction after release of postburn flexion contractures. All of the patients were male and their age ranged from 20 to 23 years, with a mean age of 21. After the release of the contractures, 3 flaps were used based on the location of the contractures. The reverse flow anterolateral thigh flap was used for knee reconstruction (n = 4, 33%). The reverse flow sural flap was used for ankle reconstruction (n = 4, 33%), and the reverse flow medial plantar flap was used for metatarsophalangeal reconstruction (n = 4, 33%). The sizes of the flap varied from 2 to 17 cm wide and 3 to 18 cm in length. All defects were covered successfully. Reverse fasciocutaneous tissue transfer to reconstruct the soft tissue defects provide early motion. Sufficient contracture release is achieved without displacement of anatomic landmarks. The reverse-flow flap is a reasonable and reliable choice for each joint level in the lower extremity.