Secondary Contracture Research Articles

Simultaneous Reconstruction of Mandibular and Maxillary Defects Using the Single Free Fibular Osseocutaneous Flap: Case Series and Review of the Literature.

The facial profile requires adequate maxillary and mandibular projection. Although oral cancer tumor ablation might create ipsilateral maxillary and mandibular defect, fibular flap is popular in mandibular defect reconstruction. However, the maxillary defect results in sunken cheek or oral contracture. A single fibular flap can provide several struts to rebuild 2 jaws with adequate 3-dimensional spatial placement. In total, 7 cases of secondary oral contracture and 2 cases of primary oncologic tumor ablation underwent single fibular flap for 2 jaws. Using multiple osteotomies, the distal fibular struts were used for the upper jaw, the second struts were discarded (3-4 cm), and proximal struts were used for mandible defect reconstruction. There were 5 accompanying free flaps for facial lining (2) and contralateral oral contracture release (3). All flaps survived without distal strut avascular necrosis, but 2 patients died from tumor metastasis. These patients presented adequate middle and lower facial profile. One patient underwent mandibular fibula strut distraction osteogenesis followed by integrated teeth on both jaws. Single fibular transfer can accomplish 2 jaw bony defects and facial profile reconstruction. It can release oral contracture functionally and correct sunken cheek aesthetically. The reconstructed fibula can allow secondary teeth implantation rehabilitation.

Fourteen-year follow-up of a child with acroscyphodysplasia with emphasis on the need for multidisciplinary management: a case report

BackgroundAcroscyphodysplasia has been described as a phenotypic variant of acrodysostosis type 2 and pseudohypoparathyroidism. In acrodysostosis, skeletal features can include brachydactyly, facial hypoplasia, cone-shaped epiphyses, short stature, and advanced bone age. To date, reports on this disorder have focused on phenotypic findings, endocrine changes, and genetic variation. We present a 14-year overview of a patient, from birth to skeletal maturity, with acroscyphodysplasia, noting the significant orthopaedic challenges and the need for a multidisciplinary team, including specialists in genetics, orthopaedics, endocrinology, and otolaryngology, to optimize long-term outcomes.Case presentationThe patient presented as a newborn with dysmorphic facial features, including severe midface hypoplasia, malar flattening, nasal stenosis, and feeding difficulties. Radiologic findings were initially subtle, and a skeletal survey performed at age 7 months was initially considered normal. Genetic evaluation revealed a variant in PDE4D and subsequent pseudohypoparathyroidism. The patient presented to the department of orthopaedics, at age 2 years 9 months with a leg length discrepancy, right knee contracture, and severely crouched gait. Radiographs demonstrated cone-shaped epiphyses of the right distal femur and proximal tibia, but no evidence of growth plate changes in the left leg. The child developed early posterior epiphyseal arrest on the right side and required multiple surgical interventions to achieve neutral extension. Her left distal femur developed late posterior physeal arrest and secondary contracture without evidence of schypho deformity, which improved with anterior screw epiphysiodesis. The child required numerous orthopaedic surgical interventions to achieve full knee extension bilaterally. At age 13 years 11 months, she was an independent ambulator with erect posture. The child underwent numerous otolaryngology procedures and will require significant ongoing care. She has moderate intellectual disability.Discussion and conclusionsKey challenges in the management of this case included the subtle changes on initial skeletal survey and the marked asymmetry of her deformity. While cone-shaped epiphyses are a hallmark of acrodysostosis, posterior tethering/growth arrest of the posterior distal femur has not been previously reported. Correction of the secondary knee contracture was essential to improve ambulation. Children with acroscyphodysplasia require a multidisciplinary approach, including radiology, genetics, orthopaedics, otolaryngology, and endocrinology specialties.

Trapezoid Advancement Flaps for the Treatment of Severe Upper Extremity Burn Contractures Limiting the Risk of Recurrence.

Severe postburn contractures can lead to partial or total loss of function of the limbs, with devastating socioeconomic and psychosocial impact on the individual, especially in low- and middle-income countries. We present a surgical technique for the treatment of severe burn contractures with the purpose of limiting recurrence of the contracture after surgery, which was developed based on the observation that in most burn contractures, one side of a contracture has unburnt, soft, and pliable healthy skin. By advancing this skin as a flap over the joint crease, a bridge of healthy tissue is interposed. We postulate that the pliable skin, together with the fact that secondary wound contracture progresses away from the joint in the skin-grafted areas adjacent to the flap and not over a mobile joint, promote healing, prevent skin graft breakdown, and limit recurrence of the contracture in the long term. We retrospectively analyzed data of all patients who have undergone surgery for severe burn contractures of elbow and axilla by means of our technique on the MV Africa Mercy between January 2013 and February 2014. In 27 patients (19 female, 8 male) with a mean age of 16.4 years, shoulder range of motion improved significantly from preoperative 111.0° to postoperative 149.4° of abduction-adduction. The elbow range of motion improved from preoperative 76.6° to postoperative 108.6° of flexion-extension, with a significant reduction in the residual elbow contracture from 60.5° preoperatively to 18.5° postoperatively. The average follow-up was 3 months (range, 1.5-7 months). We conclude that this relatively simple and safe technique limits the risk for early postoperative healing complications and recurrence of the contractures in the long term.

854 Modified Millard Forked-flap for Complete Nasal Stenosis After Smoking While on Home Oxygen

Abstract Introduction Nasal stenosis is an uncommon burn scar deformity which can result in breathing obstruction. The reconstruction of nasal stenosis secondary to burns can be challenging due to the limitation of localized tissue, rate of recurrence, and burn injury to the surrounding areas. A vascularized composite flap of local composite tissue (forked flap) from the lip can reliably reconstruct the nasal vestibule and nasal sill diminishing the risk of recurrent nasal stenosis. We describe our use of a modified Millard forked flap, a cleft lip repair technique. Methods A 52-year-old female presented with complete stenosis of the right nares secondary to burn contracture of the nostril, vestibule, and upper lip. She had suffered a flash burn to her face while smoking on home oxygen requiring prolonged ventilatory support and only received topical dressings. Three months after her burn injury she was referred for the reconstruction of her contractures. A lateral rhinotomy was performed to define the nasal floor defect. Scar release of the remaining vestibule and ala and the aesthetic units of the lip were defined. A supple unburned area of the upper lip was harvested as a vascularized composite forked flap and rotated into the vestibule defining the vestibule floor. The ala was rotated outward and full-thickness skin grafts was used to resurface the vestibular portion. The lateral aesthetic subunit of the lip was then resurfaced as a complete unit with a full-thickness skin graft. She later required fabricated nasal splint for nighttime stenting and serial daytime nostril dilatation with Hegar dilators. Results At nine months post-reconstruction, the patient maintains a patent nasal airway with limited vertical lip contraction, resolution of her initial symptoms of sinus congestion, and no further difficulty breathing. Conclusions In 1955, Ralph Millard presented the rotation-advancement technique for cleft lip repair. The Procedure was designed to create a softer, more natural-looking reconstructed lip. In the cleft lip repair, he suggested preserving the prolabial tissue lateral to the central segment as forked flaps that were rotated and banked on the nasal vestibule floor. Had that principle not been appreciated, that tissue might have been discarded in order to respect the aesthetic unit of the lip. The surgeon must utilize reliable principles to restore and retain form and function. The use of this modified forked flap incorporated composite vascularized tissue for the nostril floor reconstruction while respecting the subunit reconstruction of the lip. Applicability of Research to Practice Reconstruction of the injury needs to restore both functional and aesthetic deformities. Utilization of a local vascularized composite graft, taken from an area to be discarded within the upper lip subunit, provided quality tissue that significantly reduces the risk of secondary nasal contracture.

857 Reconstruction of the Pediatric Upper Extremity Following High Voltage Electrical Burn Injury

Abstract Introduction High voltage electrical burns are often associated with significant morbidity, posing great acute and delayed reconstructive challenges for plastic surgeons. As survival from these injuries increases, attention has been focused on improving quality of life post burn injury through restoration of sensory and motor function. However, due to the complexity of the upper extremity and its small surface area in pediatric patients, its reconstruction can be a very complex endeavor. Especially in pediatric patients that are still growing, ensuing great risk for upper extremity contracture and deformity. Methods A retrospective chart review was conducted on patients aged 0–18 years admitted to our institution with a high voltage electrical burn involving the upper extremity. The timeframe under study was 13 years from January 1st 2005 to December 1st 2018. This project was undertaken at our institution as an exempt project under 45 CFR 46.101 and, as such, it was not formally supervised by an Institutional Review Board. Results Out of the 68 electrical burns treated at our pediatric burn center, 58 involved the upper extremity. This further divides into 37 patients with high voltage and 31 patients with low voltage upper extremity electric burns. Of the 37 high voltage upper extremity patients, 35 underwent acute surgical management and 18 had delayed surgical reconstruction for the upper extremity. Conclusions The reconstructive techniques employed at our institution following severe electrical injuries typically follow a reconstructive ladder. The majority of chronic contractures in our series were successfully treated with either minimally invasive techniques such as laser and steroid infiltration, local tissue flaps, or release and skin grafting. Applicability of Research to Practice Multidisciplinary treatment of severe electrical injuries to the upper extremity is vital to optimizing a patient’s long-term function. Given the significant depth of injury in cases of electrical burns to the upper extremity the risk of developing contractures is relatively high. The expeditious treatment of secondary contractures is important to maximize a patient’s long-term function. The general treatment of contractures of the upper extremity should be based on the location and severity of the contracture, with considerations made for the patient’s reconstructive goals.

Rat Model of Adhesive Capsulitis of the Shoulder.

This proposal aims to create an in vivo rat model of adhesive capsulitis for researching potential treatment options for this condition and other etiologies of comparable arthrofibrosis. The model includes extra-articular fixation of the shoulder in rats via scapular to humeral suturing, resulting in a secondary contracture without invading the intra-articular space and resulting in decreased rotational ROM and increased joint stiffness. We used 10 Sprague-Dawley rats for the purpose of this study. Baseline ROM measurements were taken before glenohumeral immobilization. The rats were subjected to 8 weeks of immobilization before the fixation sutures were removed and changes in ROM and joint stiffness were evaluated. To evaluate whether immobilization resulted in a significant reduction in ROM, changes in kinematics were calculated. ROM was measured at each time point in the follow-up period and was compared to the baseline internal and external ROM measurements. In order to evaluate the stiffness, joint kinetics were calculated by determining the differences in torque (text and tint ) needed to reach the initial external rotation of 60° and initial internal rotation of 80°. After the removal of the extra-articular suture fixation on follow-up day 0, we found a 63% decrease in total ROM compared to baseline. We observed continuous improvement until week 5 of follow-up, with the progress slowing down around a 19% restriction. On week 8 of follow-up, there was still an 18% restriction of ROM. Additionally, on follow-up day 0, we found the torque increased by 13.3 Nmm when compared to baseline. On week 8, the total torque was measured to be 1.4 ± 0.2 Nmm higher than initial measurements. This work introduces a rat model of shoulder adhesive capsulitis with lasting reduced ROM and increased stiffness.

Treatment of Traumatic Elbow Instability With an Internal Joint Stabilizer

Current options for treating elbow instability include bony and/or ligamentous fixation with orthosis or cast immobilization, transarticular cross-pinning, temporary bridge plating, and hinged or rigid external fixation. Our purpose was to evaluate the recently developed internal joint stabilizer (IJS), which acts as an internal external fixator of the elbow. Our primary end point was to assess whether use of the device results in a stable and congruent reduction of the ulnohumeral and radiocapitellar joints in patients with acute or chronic elbow instability as a result of trauma. In our series, patients with elbow instability as a result of acute or chronic trauma were treated with an IJS. This retrospective study reviewed 20 patients who underwent placement of a U.S. Food and Drug Administration (FDA)-approved IJS for elbow instability. Serial physical examinations and radiographs were performed to verify stability. Patients were instructed that, if they are dissatisfied with their postoperative motion, a secondary contracture release operation will be offered to them. Patients were asked to complete outcome-scoring questionnaires including the Disabilities of the Arm, Shoulder, and hand (DASH) and Mayo Elbow Performance (MEP) score. Complications were monitored for all patients. Twenty patients who underwent placement of an IJS for persistent elbow instability were reviewed. Patients with a flexion-extension arc of 70° or less at 12 weeks were offered a staged arthroscopic contracture release. The average MEP score improved from 12.2 ± 12.4 to 82.5 ± 14.3 and the average DASH score improved from 85.3 ± 23.0 to 37.26 ± 29.3. The average postoperative flexion-extension arc at most recent follow-up was 124.3° ± 14.9°, with a median follow-up of 17 months (8 weeks-25 months). Use of an IJS allows for early, congruent, and stable ulnohumeral and radiocapitellar range of motion in instances of persistent elbow instability. Therapeutic IV.

Correction of Cord Like Scars Using Running Opposing Y-V Plasty

Linear scars are a common problem in the plastic surgerypractice. Release is the first step in surgical treatment. Skingrafts, Z-plasty, local, regional or free flaps are used tolengthen the scar. In this article, we will use running y-v flapsfor scar lengthening. From January 2016 to April 2017, 20linear burn contractures of 15 patients were corrected usingmultiple Opposing Y-V plasty. Patients were followed-up fora period of 6 months at least. All scar contractures werecorrected successfully in all cases. One partial flap necrosiswas observed and managed successfully with dressing changes.During the follow up period, only one case showed recurrenceof contracture and required release and local advancementflap. linear scar contracture treatment modalities vary largely.Options for reconstruction include skin grafts, Z plasty andY-V flaps. Skin grafts carry the risks of recurrence of contractures.Z plasty should include flap undermining before flaptransposition which carries the risks of flap necrosis especiallyin burned skin. Multiple Y-V flaps carry the advantages oflow rate of scar recurrence and secondary contractures andhave the merits of being a safe technique with low incidenceof flap necrosis. Running Opposing Y-V-plasty is an optionfor correction of linear cord-like burn scar contractures. Ithas the advantages of being a safe and effective method withlaw morbidity.

THE POTENTIAL OF PREVENTIVE ACUPUNCTURE FOR THE MANAGEMENT OF THE SECONDARY CONTRACTURE OF MIMIC MUSCLES

The present article is concerned with the substantiation of the main principles of preventive acupuncture for the management of the secondary contracture of mimic muscles taking into consideration the results of clinical and neurophysiological investigations. We have undertaken the analysis of dynamics of clinical, psychological, and neurophysiological characteristics of the patients following a course of basal treatment and maintenance courses of reflexotherapy. It has been shown that manifestations of the pain syndrome in the patients presenting with the secondary contracture of mimic muscles are consistent with high polysynaptic reflectory excitability. It is recommended, based on the results of this study, to carry out neurophysiological monitoring (for the evaluation of the eye-closure reflex) prior to the prescription of preventive acupuncture for the patients presenting with disturbances of polysynaptic reflectory excitability with a view to obviating the development of a relapse of pain syndrome.

Application of free medial sural artery perforator flap for repair of severe thumb web scar contracture

Objective To explore the clinical effect of free medial sural artery perforator (MSAP) flap for repair of severe thumb web scar contracture. Methods From October 2012 to March 2015, 14 cases of severe thumb web scar contracture were repaired with free MSAP flap after scar excision. The flap areas ranged from 5 cm×4 cm to 9 cm×6 cm. The clinical outcomes were evaluated by the appearance of transplanted flaps, sensory recovery, opening angle and width of thumb web and donor site recovery at postoperative follow-up. Results All 14 flaps survived uneventfully. The thumb webs were well-stacked with satisfactory shapes. There was no secondary contracture. Primary healing was achieved at donor sites. Postoperative follow-up ranged from 12 to 18 months, with an average of 14 months. Postoperative angle of repaired thumb webs was enlarged to (80±6)° from preoperative angle of (15±5)°. And the width was enlarged to (45.0±5.6) mm from (20.0±3.5) mm. Thumb functions of abduction, adduction and opposition were all improved obviously. All flaps restored protective sensation. Six cases with anastomosis of medial sural cutaneous nerve recovered to S3. No functional damage was observed at donor sites. Conclusion MSAP flap is an effective way to repair severe thumb web contracture because of its constant perforator, satisfactory shape of repaired thumb webs and minor damages to donor sites. Key words: Surgical flaps; Transplantation; Medial sural artery perforator; Thumb web contracture

Contracted Nose after Silicone Implantation: A New Classification System and Treatment Algorithm.

BackgroundSilicone implants are frequently used in augmentation rhinoplasty in Asians. A common complication of silicone augmentation rhinoplasty is capsular contracture. This is similar to the capsular contracture after augmentation mammoplasty, but a classification for secondary contracture after augmentation rhinoplasty with silicone implants has not yet been established, and treatment algorithms by grade or severity have yet to be developed.MethodsPhotographs of 695 patients who underwent augmentation rhinoplasty with a silicone implant from May 2001 to May 2015 were analyzed. The mean observation period was 11.4 months. Of the patients, 81 were male and 614 were female, with a mean age of 35.9 years. Grades were assigned according to postoperative appearance. Grade I was a natural appearance, as if an implant had not been inserted. Grade II was an unnatural lateral margin of the implant. Clearly identifiable implant deviation was classified as grade III, and short nose deformation was grade IV.ResultsGrade I outcomes were found in 498 patients (71.7%), grade II outcomes in 101 (14.5%), grade III outcomes in 75 (10.8%), and grade IV outcomes in 21 patients (3.0%). Revision surgery was indicated for the 13.8% of all patients who had grade III or IV outcomes.ConclusionsIt is important to clinically classify the deformations due to secondary contracture after surgery and to establish treatment algorithms to improve scientific communication among rhinoplasty surgeons. In this study, we suggest guidelines for the clinical classification of secondary capsular contracture after augmentation rhinoplasty, and also propose a treatment algorithm.

Change in Angular Alignment Is Associated With Early Dysphagia After Anterior Cervical Discectomy and Fusion

Study Design: Retrospective analysis of a prospective cohort. Objective: Change in cervical angular alignment may be associated with dysphagia. Summary of Background Data: Bony deformities of the cervical spine may be associated with secondary contractures of soft tissues in the neck. Acute surgical deformity correction causes in changes in soft tissue tension in the anterior neck, resulting in dysphagia. Methods: The study population included patients undergoing 1 and 2 level elective anterior cervical discectomy and fusion for cervical myelopathy or radiculopathy. Preoperative and postoperative radiographs at 2 weeks were measured by a blinded observer for C2–C7 endplate angle, C2–C7 posterior vertebral body length, and occipital condyle plumb line distance on upright lateral radiographs at 2, 6, and 12 weeks postoperatively. Patients were prospectively queried about dysphagia incidence and severity using a numeric rating scale. Multiple linear regression analysis was used to determine the effect of change in radiographic parameters controlling for demographic characteristics. Results: The study population included 25 patients with complete radiographs. The mean change in C2–C7 angle was −0.6 degrees (SD 9), the mean change in C2–C7 length was 1.7 mm (SD 26), the mean change in occipital condyle plumb line distance was 2.3 mm (SD 20). Multiple linear regression analysis was performed including operative time, age, sex, number of levels, and change in radiographic parameters as independent variables and using dysphagia score as the dependent variable. The change in C2–C7 angle and operative time were the only statistically significant predictors of change in dysphagia at 2 and 6 weeks postoperatively. Conclusions: These results indicate that lordotic change in spinal alignment and longer operative times are associated with increased postoperative dysphagia. Surgeons should counsel patients in whom a large angular correction is expected about the possibility for postoperative dysphagia. Furthermore, future studies on dysphagia incidence should include radiographic alignment as an independent predictor of dysphagia.

Bifurcated Superficial Temporal Artery Island Flap for the Reconstruction of a Periorbital Burn: An Innovation.

Background:Facial burns represent between one-fourth and one-third of all burns. The long-term sequelae of periorbital burns include significant ectropion and lagophthalmos as a result of secondary burn contractures in the lower and upper eyelids, in addition to complete or incomplete alopecia of the eyebrows.Methods:A retrospective study of 14 reconstructive procedures for 12 postburn faces was conducted with all procedures performed since 2010 at the Department of Plastic Surgery, Al-Hussein University Hospital, and at the Craniofacial Unit, Nasser Institute Hospital. Four patients experienced chemical burns, and 8 patients experienced thermal burns. All patients underwent periorbital reconstruction using a bifurcated superficial temporal artery island flap to reconstruct the eyebrows, correct the lagophthalmos, and release the ectropion in both the upper and the lower eyelids. Two patients underwent bilateral periorbital flap reconstruction. The mean age of patients was 29 years, and the study was conducted on 8 males and 4 females. Patient satisfaction was assessed using a questionnaire completed by all patients postoperatively.Results:The complete release of both the upper and the lower eyelids was achieved in all cases, together with ideal replacement of brow hair; no complications were noted, apart from one case in which a loss of hair density in the new eyebrow was observed, combined with the partial loss of the flap in the lower eyelid. Patient satisfaction results were collected and assembled in a table.Conclusion:A bifurcated superficial temporal artery island flap is an innovative flap for reconstructing both burned eyebrows and eyelids.

Painful bladder syndrome with secondary urinary bladder contracture and bilateral vesicoureteral reflux with hydronephroureters associated with ketamine abuse

Painful bladder syndrome with secondary urinary bladder contracture and bilateral vesicoureteral reflux with hydronephroureters associated with ketamine abuse

Neurodegeneration in multiple sclerosis is a process separate from inflammation: No

My argument is that SPMS, characterised by steadily progressive, predictive disability, cerebral and spinal cord atrophy and neuroaxonal death is, purely and completely, a secondary effect of the preceding and ongoing inflammatory disease process. The disappearance of hand surgeons in rheumatology The management of rheumatoid arthritis, the corresponding disorder in rheumatology, has been revolutionised in the last ten years by the active management of the inflammatory process.1,2 Thus secondary contractures, joint ankylosis and the need for prosthetic joint surgery has diminished by early medical intervention and the concept of ‘treating to target’ in rheumatology. Rheumatologists have the advantage over neurologists is that their target is easily seen and palpable. It is also measurable with accessible biomarkers and radiological changes. Neurologists do not have these luxuries; their target is hidden, as discussed below. Multiple Sclerosis Journal

The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise

Post-traumatic heterotopic ossification (HO) around the elbow may severely impair joint function. Although surgical excision is effective at restoring range of motion (ROM), traditional surgical treatment is postponed for at least 1 year to prevent recurrence, which leads to secondary contracture of the elbow. Because the optimal timing of resection is controversial, our study was performed to compare recurrence and elbow function between early and late excision in our patients to determine whether the delay is necessary. We retrospectively reviewed 164 patients during a 4-year period. In the control group (112 patients), HO was excised at an average of 23.0 months after initial injury (range, 9-204 months); in the early excision group (52 patients), resection was performed at an average of 6.1 months (range, 3-8 months). HO recurrence was assessed by the Hastings classification system. Final ROM and Mayo Elbow Performance Scores were also evaluated. Recurrent HO was observed in 30 of 112 patients (26.8%) in the control group and 15 of 52 (28.9%) in early excision group. No significant difference in HO recurrence was found between the 2 groups (P = .942). Moreover, there were no notable differences regarding ROM, Mayo Elbow Performance Scores, and complications postoperatively. Early excision associated with early exercise is effective for the treatment of HO aiming at a low recurrence rate and satisfactory function. The conventional surgical delay of more than 1 year may be shortened.

Cerebral palsy: a comprehensive review

Cerebral palsy (CP) includes all the sequelae of infantile encephalopathies occurring during the perinatal period or during infancy. The most common deformity is infantile cerebral hemiplegia, characterised by spasticity associated with various degrees of motor and sensory deficit in the ipsilateral upper and lower limbs. It manifests progressively during growth, but once established, follows a non-progressive course, which makes it amenable to surgical treatment. Clinical examination is the key to successful treatment. It is best performed with all the specialists involved in the child’s care. It is performed with a fourfold goal: • Evaluate spasticity. • Evaluate any secondary muscle and/or joint contracture, which may require a specific treatment • Evaluate the motor and sensory deficit in the upper limb. • Assess the existing function and functional needs of the upper limb. Symptoms may vary with the child’s emotional state and fatigue level. Repeated examination and video recording are most helpful, both in the decision-making and in the evaluation of treatment outcome. Spasticity is rarely an isolated feature. A number of other neurological and orthopaedic impairments may be associated. They also need to be carefully assessed before planning any treatment. Surgery has a limited place in the treatment of spasticity of the upper limb. It is only one element of the rehabilitative care, which includes primarily physiotherapy and splinting, occupational therapy, and pharmacological treatment as needed. Botulinum toxin has a special place in this armamentum, effective both in the diagnosis and in the treatment of sapsticity. We use it routinely before any surgical decision. Any decision-making should include the patient and his/her family, as well as all the physicians and care-givers involved in the treatment. Surgery in CP patients seems more effective if performed earlier in the patient’s life, preferably during childhood. There is some evidence that improved use of an extremity can improve cortical representation of the extremity and hopefully decrease the development of neglect. Otherwise, the growing child develops some ‘tricks’ with the contralateral healthy limb, which often prove difficult to overcome or reverse after surgery, rendering the results of surgical treatment much less functional. Surgery aims at: • Reducing spasticity (selective neurectomy) • Relieving muscle / joint contracture (muscle / tendon lengthening, arthrolysis) • Augmenting paralysed muscles, whenever possible by tendon transfers. All these procedures are preferably performed during a single operative session, in order to restore the balance between hypertonic flexor/pronator muscles, and paralysed or pseudo-paralysed extensor/ supinator muscles Ideally, surgery is undertaken in order to improve function of upper limb. In that perspective, “the ideal candidate is a cooperative 6-year-old child, with stable family support, who has a predominantly spastic upper limb deformity, with satisfactory hand sensibility, hemiplegic or monoplegic and without significant neurological deficits” (Tonkin). But in other groups of patients, surgery can be very helpful in relieving pain, facilitating nursing, or improving cosmesis.

Outcome of Split Thickness Skin Grafting and Multiple Z-Plasties in Postburn Contractures of Groin and Perineum: A 15-Year Experience

Background. Groin and perineal burn contracture is a rare postburn sequel. Such postburn contractures causes distressing symptoms to the patients and in the management of these contractures, both functional and cosmetic appearance should be the primary concern. Aims. To study the outcome of surgical treatment (STSG and multiple Z-plasties) in postburn contractures of groin and perineum. Material and Methods. We conducted a study of 49 patients, with postburn groin and perineal contractures. Release of contracture with split thickness skin grafting (STSG) was done in 44 (89.79%) patients and release of contracture and closure by multiple Z-plasties was done in 5 (10.21%) patients. Results. Satisfactory functional and cosmetic outcome was seen in 44 (89.79%) patients. Minor secondary contractures of the graft were seen in 3 (6.81%) patients who were managed by physiotherapy and partial recurrence of the contracture in 4 (8.16%) patients required secondary surgery. Conclusion. We conclude that postburn contractures of the groin and perineum can be successfully treated with release of contracture followed by STSG with satisfactory functional and cosmetic results. Long term measures like regular physiotherapy, use of pressure garments, and messaging with emollient creams should not be neglected and should be instituted postoperatively to prevent secondary contractures of the graft and recurrence of the contracture.

Efficacy of Early Application of Ablative Fractional CO2Laser on Secondary Skin Contracture after Skin Graft

Background Ablative fractional carbon dioxide laser is widely used for the treatment of various scars including burn injuries. We applied ablative fractional CO2 laser on the skin graft scar of faces. Methods Fourteen patients between 2010 and 2013 who underwent facial skin graft were included in this study. The ablative fractional CO2 laser was applied to 7 patients in the laser therapy group. It was initiated at 5th week after the skin graft. Clinical photographs were taken, and Patient Scar Assessment Score (PAS) was obtained during every visit from a patient at the outpatient clinic and 4 weeks after the last laser treatment. In the untreated control group, clinical photographs and PAS were taken at 5th and 21st weeks after the skin graft. Vancouver Scar Scale (VSS) and Observer Scar Assessment score (OAS) was rated by single independent plastic surgeon with the clinical photographs. Results In the laser therapy group, VSS, PAS, and OAS improved after fractional laser treatment. In the untreated group, VSS was also improved by the natural process of scar maturation. However, the laser treated group showed significant improvement compared with the untreated group. Conclusions The ablative fractional CO2 laser can be a viable option for the treatment of skin graft scar. Further study with sufficient patients and long term follow-up is necessary for definite conclusions.

Pelvic Deformity Secondary to Tensor Fascia Lata Tightness Associated With Desmoid Tumor

The iliotibial band is a thick, condensed fascia that, when contracted, leads to a hip flexion, abduction, and external rotation contracture in addition to other joint contractures. Iliotibial band tightness occurs secondary to iliotibial band friction syndrome, which commonly occurs at the lateral femoral epicondylar region. However, a proximal cause of iliotibial band/tensor fascia lata friction syndrome leading to a secondary hip contracture is swelling around the hip; this swelling being a desmoid tumor has not been explicitly described in the literature. The authors present a rare case of a hip contracture in a 28-year-old active man who presented with a functionally disabling hip flexion contracture of 20° with further flexion possible up to 130°, a 45° abduction contracture, and a 20° external rotation contracture with further rotation possible up to 40° with a bony hard swelling in the left gluteal region. Ober’s test was positive. Opposite hip and spine examinations were normal. The goals of treatment were to establish the causality between the 2 and to diagnose the etiology of the gluteal mass. Radiographs were normal, with only a pelvic obliquity evident. Magnetic resonance imaging revealed an extra-articular mass abutting the iliac blade. Histopathology confirmed the mass to be a desmoid tumor in the left gluteal region. A wide surgical excision of the mass was performed with negative margins; no postoperative radiotherapy was administered. After rigorous physiotherapy, the hip deformity disappeared at 6 months and there was no evidence of recurrence at 2.5-year follow-up, with the patient able to sit cross-legged and squat.