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Fanstone R, Price P. Global perspectives on risk factors for major joint burn contractures: A literature review. Burns 2024; 50:537-549. [PMID: 37977897 DOI: 10.1016/j.burns.2023.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/31/2023] [Accepted: 09/22/2023] [Indexed: 11/19/2023]
Abstract
Contractures are a frequent consequence of burn injuries, yet our knowledge of associated risk factors is limited. This paper provides an extensive review of relevant literature from both High-Income Countries (HICs) and Low-Middle Income Countries (LMICs). Ninety-four papers (up to June 2019) and eight subsequent publications (up to March 2022) were included, 76% of which were from HICs. The majority of publications were either descriptive studies (4 from HICs, 9 from LMICs) or papers citing putative risk factors (37 from HICs, 10 from LMICs). Seventeen publications (all from HICs) reported on the effects of individual non-surgical therapeutic interventions, often with conflicting results. Two published systematic reviews emphasised the poor quality of evidence available. Only fifteen studies (3 from LMICs) examined potential contracture risk factors with statistical comparisons of outcomes; significant findings from these included demographic, burn, comorbidities, and treatment risk factors. LMIC papers included socioeconomic and healthcare system factors as potential risks for contracture; these were rarely considered in HIC publications. Methodological issues identified from this review of literature included differences in contracture definitions, populations studied, standards of care, joints included and the timing and nature of contracture assessments.This review is the first to collate existing knowledge on risk factors for burn contractures from both HIC and LMIC settings, revealing a surprising lack of robust evidence for many accepted risk factors. In LMICs, where burns are particularly common, universal health provision is lacking and specialist burn care is both scarce and difficult to access; consequently, socioeconomic factors may have more immediate impact on contracture outcomes than specific burn treatments or therapies. Much more work is indicated to fully understand the relative impacts of risk factors in different settings so that context-appropriate contracture prevention strategies can be developed.
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Affiliation(s)
- RuthAnn Fanstone
- Centre for Global Burn Injury Policy and Research, Swansea University, UK.
| | - Patricia Price
- Centre for Global Burn Injury Policy and Research, Swansea University, UK
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2
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Spronk I, Wood FM, Fear MW, Lansdorp CA, Edgar DW. The Short- and Long-Term Outcome Priorities of a Western Australian Adult Burn Population. J Burn Care Res 2024; 45:451-458. [PMID: 37936534 PMCID: PMC10911694 DOI: 10.1093/jbcr/irad175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Indexed: 11/09/2023]
Abstract
To optimize patient recovery, understanding which outcomes are most important to burn patients is key. However, research to determine what outcomes are patient priorities is limited. Therefore, we assessed what outcomes are most important to Western Australian burn patients, separately in the short-term (<6 months) and long-term (6-24 months) after injury. Adult patients who had a burn injury 3-36 months ago completed a survey, rating the importance of 36 short- and long-term outcomes. The survey items were ranked according to the number of patients reporting the outcome as "very important." Results were compared between subgroups based on age, gender, burn size, and number of surgeries. Ninety-three patients were included. In the short-term, "not having a wound infection" (87.1%), "good wound healing" (83.9%), and "walking or moving around" (74.7%) were the most important outcomes. "Lifting or moving something" (67.6%), "walking or moving around" (66.2%), and "being independent" (66.2%) were reported as most important in the long-term. Scar-related outcomes were more important to females and to patients with multiple surgeries; mental health outcomes were priorities for females and patients with major burns; walking and moving around to males and older patients; and social and financial outcomes were rated highly by patients with major burns and multiple surgeries. In conclusion, the most important outcomes were consistent across time periods, indicating the importance of core outcomes in longitudinal follow-up. The wide range of priority outcomes and differences between subgroups underlines the need for multidisciplinary care and a patient-centered approach to support patients.
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Affiliation(s)
- Inge Spronk
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, 3000CA, The Netherlands
- Association of Dutch Burn Centres, Maasstad Hospital, Rotterdam, 3007AC, The Netherlands
- Dutch Burns Foundation, Beverwijk, 1941AJ, The Netherlands
| | - Fiona M Wood
- State Adult Burn Unit, Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, WA 6150, Australia
- Burn Injury Research Unit, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia
- Fiona Wood Foundation, Murdoch, WA 6150, Australia
| | - Mark W Fear
- Burn Injury Research Unit, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia
- Fiona Wood Foundation, Murdoch, WA 6150, Australia
| | - Corine A Lansdorp
- Department Plastic, Reconstructive and Hand Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, 1007MB, The Netherlands
| | - Dale W Edgar
- State Adult Burn Unit, Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, WA 6150, Australia
- Burn Injury Research Unit, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia
- Fiona Wood Foundation, Murdoch, WA 6150, Australia
- Institute for Health Research, Burn Injury Research Node, The University of Notre Dame Australia, Fremantle, WA 6959, Australia
- Safety and Quality Unit, Armadale Kalamunda Group Health Service, East Metropolitan Health Service, Mt Nasura, WA 6992, Australia
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3
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Management of Severe Extended Burn Axillary Contracture in a Low-resource Setting. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4893. [PMID: 36923714 PMCID: PMC10010848 DOI: 10.1097/gox.0000000000004893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/03/2023] [Indexed: 03/14/2023]
Abstract
Contracture is a common complication of deep burn injury, affecting up to one-third of patients. Although some degree of contracture occurs in any setting, severe extended axillary contractures are more often due to unavailable or inappropriate care. Very few cases have been described in the literature. Their management can be especially challenging in a low-resource environment. The purpose of this article is to present two cases in which severe postburn axillary contractures were effectively managed in a low resource setting, using an island perforator flap coupled with a skin graft or advancement flap. In severe extended axillary contracture, more than one technique is often required to cover the large defect created after contracture release.
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Schouten HJ, Nieuwenhuis MK, van Baar ME, van der Schans CP, Niemeijer AS, van Zuijlen PPM. The degree of joint range of motion limitations after burn injuries during recovery. Burns 2022; 48:309-318. [PMID: 34955294 DOI: 10.1016/j.burns.2021.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/01/2020] [Accepted: 01/08/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The aim of this study was to determine the degree of ROM limitations of extremities, joints and planes of motion after burns and its prevalence over time. METHOD The database of a longitudinal multicenter cohort study in the Netherlands (2011-2012) was used. From patients with acute burns involving the neck, shoulder, elbow, wrist, hip, knee and ankle joints that had surgery, ROM of 17 planes of motion was assessed by goniometry at 3, 6 weeks, 3-6-9 and 12 months after burns and at discharge. RESULTS At 12 months after injury, 12 out of 17 planes of motion demonstrated persistent joint limitations. The five unlimited planes of motion were all of the lower extremity. The most severely limited joints at 12 months were the neck, ankle, wrist and shoulder. The lower extremity was more severely limited in the early phase of recovery whereas at 12 months the upper extremity was more severely limited. CONCLUSION The degree of ROM limitations and prevalence varied over time between extremities, joints and planes of motion. This study showed which joints and planes of motion should be watched specifically concerning the development of scar contracture.
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Affiliation(s)
- H J Schouten
- Association of Dutch Burn Centers, Burn Centre, Red Cross Hospital Beverwijk, The Netherlands; Burn Centre and Dept of Plastic & Reconstructive Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Department of Physiotherapy, Red Cross Hospital, Beverwijk, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Science's Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; The Dutch Working Group on Burn Rehabilitation, The Netherlands.
| | - M K Nieuwenhuis
- Association of Dutch Burn Centers, Burn Centre, Martini Hospital Groningen, The Netherlands; Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, The Netherlands; The Dutch Working Group on Burn Rehabilitation, The Netherlands
| | - M E van Baar
- Association of Dutch Burn Centers, Burn Centre, Maasstad Hospital Rotterdam, The Netherlands; Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - C P van der Schans
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences Groningen, The Netherlands; Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, The Netherlands; Health Psychology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - A S Niemeijer
- Association of Dutch Burn Centers, Burn Centre, Martini Hospital Groningen, The Netherlands; Research Institute, Martini Hospital Groningen, The Netherlands
| | - P P M van Zuijlen
- Burn Centre and Dept of Plastic & Reconstructive Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Science's Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; The Dutch Working Group on Burn Rehabilitation, The Netherlands; Pediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
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Almodumeegh AS, AlKhudair MR, Altammami AF, Alsuhaim RH, Alhumaidan AI, Alothman AM. Patient Satisfaction After Conservative Treatment for Burn Scars in Saudi Arabia. Cureus 2022; 14:e21896. [PMID: 35265422 PMCID: PMC8898341 DOI: 10.7759/cureus.21896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 11/27/2022] Open
Abstract
Background Burn injury is a typical physical injury that occurs as a result of a thermal, electrical, or chemical stimulus. Burn injuries to the skin cause complicated issues, including scar marks, psychological impacts, and affect quality of life (QOL). The preferred treatment technique for burn scars is controversial, as attempts to control the contraction rate remain a challenge, often leading to a poor outcome. Thus, treating burn scar patients is one of the biggest challenges in reconstructive surgery. In this study, we aimed to assess the patients’ perception of pain and QOL after conservative treatment for burn scars in Saudi Arabia. Methodology This was a cross-sectional study conducted on Saudi Arabian patients who underwent conservative treatment for their burn scars. Information was obtained using a self-reported questionnaire which was distributed online using Google Forms on several social media platforms. MS Excel was used for data entry, while SPSS version 23 was used for data analysis. Results We collected 523 responses to our questionnaire. Among respondents, 70.2% were aged between 18-29 years and 62.1% were single. Most burns were on the upper limbs (74.2%), and 78% of burns were caused by a thermal stimulus (exposure to heat). In terms of emotional status, most respondents did not report significant emotional issues related to their burn scars with a mean emotional score of 12.5 out of 24. Overall, burn scars did not affect the respondents’ ability to work or independence in performing daily work. Regarding the impact of the burns on the patients’ appearance, 29.4% of respondents reported that their scars bothered them significantly, 64.2% reported that their appearance never bothered them, and 11.5% reported that they sometimes tried to forget how their appearance had been changed. Conclusions We found that conservative treatment of burn scars is effective in controlling the pain associated with the burns and can improve the patient’s ability to perform work and other daily activities. However, it did not completely improve the psychological distress associated with scars. Further investigations are required to understand the impact of adherence to conservative treatment for burn scars on the psychological status of patients.
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Li J, Ng SKH, Xi W, Zhang Z, Wang X, Li H, Su W, Wang J, Zhang Y. Efficacy and safety of a dual-scan protocol for carbon dioxide laser in the treatment of split-thickness skin graft contraction in a red Duroc pig model. BURNS & TRAUMA 2022; 9:tkab048. [PMID: 34988232 PMCID: PMC8720306 DOI: 10.1093/burnst/tkab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 10/29/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Fractional CO2 laser plays an important role in scar management post split-thickness skin graft by loosening the graft contracture and restoring the smoothness of the surface. However, the optimal treatment protocol remains unknown. This study applied a dual-scan protocol to achieve both releasing and ablation of contracted skin graft. We comprehensively describe this treatment method and compare the efficacy and safety between this dual-scan method and the conventional mono-scan mode. METHODS A hypercontracted scar model after split-thickness skin grafting in red Duroc pigs was established. All scars meeting the inclusion criteria were randomly divided into four groups: high fluence-low density (HF-LD), low fluence-high density (LF-HD), combined group and control group. The energy per unit area was similar in the HF-LD and LF-HD groups. Two laser interventions were performed at a 6-week interval. The efficacy of the treatment was evaluated by objective measures of scar area, release rate, elasticity, thickness and flatness, while the safety was evaluated based on adverse reactions and melanin index. Collagen structure was observed histologically. The animals were followed up for a maximum of 126 days after modeling. RESULTS A total of 28 contracted scars were included, 7 in each group. At 18 weeks postoperatively, the HF-LD and the combined groups showed significantly increased scar release rate (p = 0.000) and elasticity (p = 0.036) and decreased type I/III collagen ratio (p = 0.002) compared with the control and LF-HD groups. In terms of flatness, the combined group was significantly better than the HF-LD group for elevations <1 mm (p = 0.019). No significant skin side effects, pigmentation or scar thickness changes were observed at 18 weeks. CONCLUSIONS Dual-scan protocol could achieve superficial ablation and deep release of contracted split-thickness skin graft in a single treatment, with similar contraction release and texture improvement compared to a single deep scan. Its main advantage is to restore a smoother scar appearance. Adequate laser penetration was necessary for the release of contracted scars.
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Affiliation(s)
- Jie Li
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Sally Kiu-Huen Ng
- Department of Plastic Surgery, Austin Health, Melbourne 3084, Australia.,Victorian Adult Burns Service, Alfred Health, Melbourne 3181, Australia
| | - Wenjing Xi
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Zheng Zhang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Xiaodian Wang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Hua Li
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Weijie Su
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Jingyan Wang
- Department of Plastic and Reconstructive Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
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Khor D, Liao J, Fleishhacker Z, Schneider JC, Parry I, Kowalske K, Richard R, Wibbenmeyer L. Update on the practice of splinting during acute burn admission from the ACT study. J Burn Care Res 2021; 43:640-645. [PMID: 34490885 DOI: 10.1093/jbcr/irab161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Burn scar contracture (BSC) is a common pathological outcome following burn injuries, leading to limitations in range of motion (ROM) of affected joints and impairment in function. Despite a paucity of research addressing its efficacy, static splinting of affected joints is a common preventative practice. A survey of therapists performed 25 years ago showed a widely divergent practice of splinting during the acute burn injury. We undertook this study to determine the current practice of splinting during the index admission for burn injuries. METHODS This is a review of a subset of patients enrolled in the Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) database. ACT was an observational multicenter study conducted from 2010-2013. The most commonly splinted joints (elbow, wrist, knee and ankle) and their 7 motions were included. Variables included patients' demographics, burn variables, rehabilitation treatment and hospital course details. Univariate and multivariate analysis of factors related to splinting was performed. P< 0.05 was significant. RESULTS Thirty percent of the study population (75 patients) underwent splinting during their hospitalization. Splinting was associated with larger burns and increased injury severity on the patient level and increased involvement with burns requiring grafting in the associated cutaneous functional unit (CFU) on the joint level. The requirement for skin grafting in both analyses remained independently related to splinting, with requirement for grafting in the associated CFU increasing the odds of splinting 6 times (OR =6.0, 95% CI=3.8-9.3, p<0.001). On average splinting was initiated about a third into the hospital length of stay (LOS, 35 ± 21% of LOS) and splints were worn for 50% (50 ± 26%) of the LOS. Joints were splinted for an average 15.1 ± 4.8 hours a day. The wrist was most frequently splinted joint being splinted with one third of wrists splinted ( 30.7%) while the knee was the least frequently splinted joint with 8.2% splinted. However, when splinted, the knee was splinted the most hours per day (17.6 ± 4.8 hours) and the ankle the least (14.4 ± 4.6 hours). Almost one third had splinting continued to discharge (20, 27%). CONCLUSIONS The current practice of splinting, especially the initiation, hours of wear and duration of splinting following acute burn injury remains variable. Splinting is independently related to grafting, grafting in the joint CFU, larger CFU involvement and is more likely to occur around the time of surgery. A future study looking at splinting application and its outcomes is warranted.
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Affiliation(s)
- Desmond Khor
- Department of Surgery, University of Iowa Hospitals and Clinics
| | - Junlin Liao
- Department of Surgery, University of Iowa Hospitals and Clinics
| | | | - Jeffrey C Schneider
- Spaulding Rehabilitation Hospital, Spaulding Research Institute, Department of Physical Medicine and Rehabilitation, Harvard Medical School
| | - Ingrid Parry
- Department of Occupational and Physical Therapy, Shriners Hospital for Children, Northern California, University of California, Davis
| | - Karen Kowalske
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern
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Parry IS, Schneider JC, Yelvington M, Sharp P, Serghiou M, Ryan CM, Richardson E, Pontius K, Niszczak J, McMahon M, MacDonald LE, Lorello D, Kehrer CK, Godleski M, Forbes L, Duch S, Crump D, Chouinard A, Calva V, Bills S, Benavides L, Acharya HJ, De Oliveira A, Boruff J, Nedelec B. Systematic Review and Expert Consensus on the Use of Orthoses (Splints and Casts) with Adults and Children after Burn Injury to Determine Practice Guidelines. J Burn Care Res 2021; 41:503-534. [PMID: 31504622 DOI: 10.1093/jbcr/irz150] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The objective of this review was to systematically evaluate the available literature addressing the use of orthoses (splints and casts) with adult and pediatric burn survivors and determine whether practice guidelines could be proposed. This review provides evidence-based recommendations specifically for rehabilitation professionals who are responsible for burn survivor rehabilitation. A summary recommendation was made after the literature was retrieved using a systematic review and critical appraisal by multiple authors. The level of evidence of the literature was determined in accordance with the Oxford Centre for Evidence-based Medicine criteria. Due to the low level of evidence in the available literature, only one practice guideline could be recommended: orthotic use should be considered as a treatment choice for improving range of motion or reducing contracture in adults who have sustained a burn injury. To address the rehabilitation-specific gaps found in the literature regarding orthotic use in burn rehabilitation and provide guidance to clinicians, a formal expert consensus exercise was conducted as a final step to the project. The resultant manuscript provides a summary of the literature regarding orthotic use with burn patients, one practice guideline, proposed orthotic terminology and additional practice recommendations based on expert opinion. The limitations in the current literature are also discussed, and suggestions are made for future studies in the area of orthotic use after burn injury.
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Affiliation(s)
- Ingrid S Parry
- From the Shriners Hospital for Children, Northern California, University of California-Davis, Sacramento
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Patricia Sharp
- Cincinnati Children's Hospital, University of Cincinnati College of Allied Health Sciences Program in Occupational Therapy, Ohio
| | - Michael Serghiou
- Bio Med Sciences Inc., Allentown, Pennsylvania Shriners Hospitals for Children Boston, Massachusetts
| | - Colleen M Ryan
- Sumner Redstone Burn Center, Surgical Services, Massachusetts General Hospital, Harvard Medical School, Boston
| | | | | | - Jonathan Niszczak
- Bio Med Sciences Inc., Allentown, Pennsylvania Shriners Hospitals for Children Boston, Massachusetts.,Thomas Jefferson University Burn Center, Philadelphia, Pennsylvania.,Bio Med Sciences, Inc. Allentown, Pennsylvania
| | - Margaret McMahon
- Our Lady's Hopsice and Care Services, Harold's Cross, Dublin, Ireland
| | | | - David Lorello
- The Arizona Burn Center at Maricopa Medical Center, Phoenix
| | | | - Matthew Godleski
- Department of Physical Medicine and Rehabilitation, Ross Tilley Burn Centre, St. John's Rehab, University of Toronto, Ontario, Canada
| | - Lisa Forbes
- Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Sarah Duch
- Westchester Medical Center, Valhalla, New York
| | - Donna Crump
- Parkland Health and Hospital System, PMR Department, Dallas, Texas
| | - Annick Chouinard
- Hôpital de réadaptation Villa Medica, Montreal, Quebec, Canada.,CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Valerie Calva
- Hôpital de réadaptation Villa Medica, Montreal, Quebec, Canada
| | - Sara Bills
- Madonna Rehabilitation Hospitals, Lincoln, Nebraska University of Nebraska Medical Center, Omaha
| | | | - Hernish J Acharya
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ana De Oliveira
- Centre de recherche du Centre Hospitalier de l'Université de Montréal (CHUM), Quebec, Canada
| | - Jill Boruff
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Bernadette Nedelec
- Hôpital de réadaptation Villa Medica, Montreal, Quebec, Canada.,Centre de recherche du Centre Hospitalier de l'Université de Montréal (CHUM), Quebec, Canada.,School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
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Dargan D, Kazzazi D, Limnatitou D, Cochrane E, Stubbington Y, Shokrollahi K, Ralston D. Acute Management of Thermal Hand Burns in Adults: A 10-Year Review of the Literature. Ann Plast Surg 2021; 86:517-531. [PMID: 33675628 DOI: 10.1097/sap.0000000000002755] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns. RESULTS An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes. DISCUSSION The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers. CONCLUSIONS More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.
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Affiliation(s)
| | - Diana Kazzazi
- From the Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital
| | | | - Elliott Cochrane
- From the Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital
| | | | - Kayvan Shokrollahi
- Mersey Regional Burns Centre, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Merseyside, Prescot, United Kingdom
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10
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Ou KL, Tzeng YS, Liu HH, Wu CJ, Chen CY, Chou YY, Hsu KF, Wang CH, Dai NT, Chang CK. Negative Pressure Wound Therapy in Conjunction With Artificial Dermis for Burned Hand Reconstruction. Ann Plast Surg 2021; 86:S13-S17. [PMID: 33438950 DOI: 10.1097/sap.0000000000002676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Proper wound care along with the use of skin grafts over deep burn wounds has been the standard treatment. However, the goal in burn wound care has shifted from achieving a satisfactory survival rate to improving long-term form and function of the healed wound, which is sometimes hindered by scar contracture. This has prompted surgeons to find alternative ways to treat burn wounds without compromising function. Among burn cases, hand injuries are the most problematic when it comes to delicate function recovery. METHODS This study presents the results of conjunctive use of a bilayer artificial dermis, negative pressure wound therapy, and split-thickness skin grafts for grafting over acute burn wounds and scar-releasing defects after severe hand burns. RESULTS Three months after the operation, the scar was soft and pliable, the aesthetic outcome was good, and the patients gained much improvement in hand function and quality oflife. CONCLUSIONS The combined technique achieved a good scar quality and aesthetic effect on burned hands as well as excellent functional outcome, which resulted in major improvements and an independent life for the patient.
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Affiliation(s)
| | - Yuan-Sheng Tzeng
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Hung-Hui Liu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Chien-Ju Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Chun-Yu Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | | | - Kuo-Feng Hsu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Chih-Hsin Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Niann-Tzyy Dai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei
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11
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Hendriks TCC, Botman M, de Haas LEM, Mtui GS, Nuwass EQ, Jaspers MEH, Niemeijer AS, Nieuwenhuis MK, Winters HAH, van Zuijlen PPM. Burn scar contracture release surgery effectively improves functional range of motion, disability and quality of life: A pre/post cohort study with long-term follow-up in a Low- and Middle-Income Country. Burns 2021; 47:1285-1294. [PMID: 33485727 DOI: 10.1016/j.burns.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/10/2020] [Accepted: 12/31/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Burn scar contractures limit range of motion (ROM) of joints and have substantial impact on disability and the quality of life (QoL) of patients, particularly in a Low- and Middle-Income Country (LMIC) setting. Studies on the long-term outcome are lacking globally; this study describes the long-term impact of contracture release surgery performed in an LMIC. METHODS This is a pre-post cohort study, conducted in a referral hospital in Tanzania. Patients who underwent burn scar contracture release surgery in 2017-2018 were eligible. ROM (goniometry), disability (WHODAS 2.0) and QoL (EQ-5D) were assessed. The ROM data were compared to the ROM that is required to perform activities of daily living without compensation, i.e. functional ROM. Assessments were performed preoperatively and at 1, 3, 6 and 12 months postoperatively. RESULTS In total, 44 patients underwent surgery on 115 affected joints. At 12 months, the follow-up rate was 86%. The mean preoperative ROM was 37.3% of functional ROM (SD 31.2). This improved up to 108.7% at 12 months postoperatively (SD 42.0, p < 0.001). Disability-free survival improved from 55% preoperatively to 97% at 12 months (p < 0.001) postoperatively. QoL improved from 0.69 preoperatively, to 0.93 (max 1.0) at 12 months postoperatively (p < 0.001). Patients who regained functional ROM in all affected joints reported significantly less disability (p < 0.001) and higher QoL (p < 0.001) compared to patients without functional ROM. CONCLUSIONS Contracture release surgery performed in an LMIC significantly improved functional ROM, disability and QoL. Results showed that regaining a functional joint is associated with less disability and higher QoL.
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Affiliation(s)
- T C C Hendriks
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Haydom Lutheran Hospital, Haydom, Tanzania; Amsterdam Public Health Research Institute, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands.
| | - M Botman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands
| | - L E M de Haas
- Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands
| | - G S Mtui
- Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands
| | - E Q Nuwass
- Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands
| | - M E H Jaspers
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands
| | - A S Niemeijer
- Burn Center, Martini Hospital, Groningen, The Netherlands; Association of Dutch Burn Centers, The Netherlands
| | - M K Nieuwenhuis
- Burn Center, Martini Hospital, Groningen, The Netherlands; Association of Dutch Burn Centers, The Netherlands
| | - H A H Winters
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands
| | - P P M van Zuijlen
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Burn Center, Red Cross Hospital, Beverwijk, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Amsterdam Movement Sciences, Amsterdam UMC (Location VUmc), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Paediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
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12
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Effects of Virtual Reality-Based Rehabilitation on Burned Hands: A Prospective, Randomized, Single-Blind Study. J Clin Med 2020; 9:jcm9030731. [PMID: 32182742 PMCID: PMC7141182 DOI: 10.3390/jcm9030731] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/28/2020] [Accepted: 03/04/2020] [Indexed: 12/22/2022] Open
Abstract
Hands are the most frequent burn injury sites. Appropriate rehabilitation is essential to ensure good functional recovery. Virtual reality (VR)-based rehabilitation has proven to be beneficial for the functional recovery of the upper extremities. We investigated and compared VR-based rehabilitation with conventional rehabilitation (CON) in patients with burned hands. Fifty-seven patients were randomized into a VR or CON group. Each intervention was applied to the affected hand for four weeks, and clinical and functional variables were evaluated. Hand function was evaluated before intervention and four weeks after intervention using the Jebsen-Taylor hand function test (JTT), Grasp and Pinch Power Test, Purdue Pegboard test (PPT), and Michigan Hand Outcomes Questionnaire (MHQ). The JTT scores for picking up small objects and the MHQ scores for hand function, functional ADL, work, pain, aesthetics, and patient satisfaction were significantly higher in the VR group than in the CON group (p < 0.05). The results suggested that VR-based rehabilitation is likely to be as effective as conventional rehabilitation for recovering function in a burned hand. VR-based rehabilitation may be considered as a treatment option for patients with burned hands.
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13
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Lensing J, Wibbenmeyer L, Liao J, Parry I, Kowalske K, Reg R, Schneider JC. Demographic and Burn Injury-Specific Variables Associated with Limited Joint Mobility at Discharge in a Multicenter Study. J Burn Care Res 2020; 41:363-370. [DOI: 10.1093/jbcr/irz174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Abstract
Burn scar contractures. Existing research on contractures is limited by incomplete analysis of potential contributing variables and differing protocols. This study expands the exploration of contributing variables to include surgery and rehabilitation treatment-related factors. Additionally, this study quantifies direct patient therapy time and patient exposure to rehabilitation prevention therapies. Data from subjects enrolled in the prospective Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) were analyzed to determine variables related to a limited range of motion (limROM) in seven joints and 18 motions (forearm supination) at discharge. Chi-squared and Student’s t-test were used accordingly. Multivariate analysis was performed at the patient and joint motion level to control for confounders. Of the 300-member study group, 259 (86.3%) patients had limROM at discharge. Variables independently related to the development of moderate-to-severe limROM on the patient level were larger TBSA, having skin grafted and prolonged bed rest. Variables independently related to moderate–severe limROM on the joint motion level were the percentage of cutaneous functional unit (CFU) burned (P = .044), increase in the length of stay, weight gain, poor compliance with rehabilitation therapy and lower extremity joint burns. Rates of limROM are increased in patients who had larger burns, required surgery, had a greater percentage of the associated CFU burned, and had lower extremity burns. Attention to adequate pain control to ensure rehabilitation tolerance and early ambulation may also decrease limROM at discharge and quicker return to pre-burn activities and employment.
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Affiliation(s)
- Jonathan Lensing
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Lucy Wibbenmeyer
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Junlin Liao
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Ingrid Parry
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Karen Kowalske
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Richard Reg
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Jeffrey C Schneider
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
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Moortgat P, Anthonissen M, Van Daele U, Vanhullebusch T, Maertens K, De Cuyper L, Lafaire C, Meirte J. The effects of shock wave therapy applied on hypertrophic burn scars: a randomised controlled trial. Scars Burn Heal 2020; 6:2059513120975624. [PMID: 33312712 PMCID: PMC7716075 DOI: 10.1177/2059513120975624] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION A wide variety of non-invasive treatments has been proposed for the management of hypertrophic burn scars. Unfortunately, the reported efficacy has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a new non-invasive type of mechanotherapy to treat wounds and scars. The aim of the present study was to examine the objective and subjective scar-related effects of ESWT on burn scars in the early remodelling phase. MATERIAL AND METHODS Evaluations included the Patient and Observer Scar Assessment Scale (POSAS) for scar quality, tri-stimulus colorimetry for redness, tewametry for trans-epidermal water loss (TEWL) and cutometry for elasticity. Patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group, and were tested at baseline, after one, three and six months. All patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or placebo) once a week for 10 weeks. RESULTS Results for 20 patients in each group after six months are presented. The objective assessments showed a statistically significant effect of ESWT compared with placebo on elasticity (P = 0.011, η2P=0.107) but revealed no significant effects on redness and TEWL. Results of the clinical assessments showed no significant interactions between intervention and time for the POSAS Patient and Observer scores. CONCLUSION ESWT can give added value to the non-invasive treatment of hypertrophic scars, more specifically to improve elasticity when the treatment was already started in the first three months after wound closure. LAY SUMMARY Pathological scarring is a common problem after a burn injury. A wide variety of non-invasive treatments has been proposed for the management of these scars. Unfortunately, the reported efficacy of these interventions has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a relatively new non-invasive therapy to treat both wounds and scars. The aim of the present study was to examine the scar-related effects of ESWT on burn scars in the early phase of healing.The scars were subjectively assessed for scar quality by the patient and an observer using the Patient and Observer Scar Assessment Scale (POSAS). Objective assessments included measurements to assess redness, water loss and elasticity. Forty patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group (the device simulated the sound of an ESWT treatment but no real shocks were applied), and were tested at four timepoints up to six months. All patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or placebo) once a week for 10 weeks.The objective assessments showed a significant improvement of elasticity in the intervention group when compared with placebo but revealed no significant effects on redness and water loss. Results of the clinical assessments showed no differences between the groups for the POSAS Patient and Observer scores.ESWT can give added value to the non-invasive treatment of pathological scars more specifically to improve elasticity in the early phase of healing.
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Affiliation(s)
| | - Mieke Anthonissen
- OSCARE, Antwerp, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Ulrike Van Daele
- OSCARE, Antwerp, Belgium
- University of Antwerp, Rehabilitation Sciences and Physiotherapy, Antwerp, Belgium
| | - Tine Vanhullebusch
- OSCARE, Antwerp, Belgium
- University of Antwerp, Rehabilitation Sciences and Physiotherapy, Antwerp, Belgium
| | - Koen Maertens
- OSCARE, Antwerp, Belgium
- Department of Clinical and Lifespan Psychology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieve De Cuyper
- OSCARE, Antwerp, Belgium
- ZNA Stuivenberg, Burns Center, Antwerp, Belgium
| | - Cynthia Lafaire
- OSCARE, Antwerp, Belgium
- ZNA Stuivenberg, Burns Center, Antwerp, Belgium
| | - Jill Meirte
- OSCARE, Antwerp, Belgium
- University of Antwerp, Rehabilitation Sciences and Physiotherapy, REVAKI-MOVANT, Antwerp, Belgium
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15
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Course of prevalence of scar contractures limiting function: A preliminary study in children and adolescents after burns. Burns 2019; 45:1810-1818. [DOI: 10.1016/j.burns.2019.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/28/2019] [Accepted: 05/01/2019] [Indexed: 10/25/2022]
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16
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Schouten H, Nieuwenhuis M, van Baar M, van der Schans C, Niemeijer A, van Zuijlen P. The prevalence and development of burn scar contractures: A prospective multicenter cohort study. Burns 2019; 45:783-790. [DOI: 10.1016/j.burns.2019.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 11/30/2018] [Accepted: 03/03/2019] [Indexed: 11/28/2022]
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17
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Tan J, Chen J, Zhou J, Song H, Deng H, Ao M, Luo G, Wu J. Joint contractures in severe burn patients with early rehabilitation intervention in one of the largest burn intensive care unit in China: a descriptive analysis. BURNS & TRAUMA 2019; 7:17. [PMID: 31139664 PMCID: PMC6526598 DOI: 10.1186/s41038-019-0151-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 03/22/2019] [Indexed: 01/17/2023]
Abstract
Background Joint contracture is the major clinical complication in burn patients, especially, the severe burn patients. This study aimed to investigate the number and severity of joint contractures in patients with burns affecting greater than or equal to 50% of the total body surface area (TBSA) undergoing early rehabilitation in a burn intensive care unit (BICU). Methods We analyzed burn patients with burns affecting greater than or equal to 50% of the TBSA admitted to a BICU who received early rehabilitation within 7 days post-injury from January 2011 to December 2015. Demographic and medical information was collected. The range of motion (ROM) of different joints was measured 1 month post-admission. Spearman’s correlation coefficient and logistic regression analysis was used to determine predictors of the presence and severity of contractures. Result The average affected TBSA of the included burn patients was 67.4%, and the average length of stay in the BICU was 46.2 ± 28.8 days. One hundred and one of 108 burn patients (93.5%) developed at least one joint contracture. The ROM in 67.9% of the affected joints was mildly limited. The majority of contractures in severe burn patients were mild (37.7%) or moderate (33.2%). The wrist was the most commonly affected joint (18.2%), followed by the shoulder, ankle, hip, knee, and elbow. A predictor of the presence of contractures was the length of hospital stay (p = 0.049). The severe contracture was related to the area of full-thickness burns, the strict bed rest time, and the duration of rehabilitation in BICU. The length of rehabilitation stay (days) in patients with moderate contracture is 54.5% longer than that in severe contracture (p = 0.024) Conclusion During the long stay in BICU, the length of rehabilitation stay in a BICU could decrease the severity of contractures from severe to moderate in the patients with equal to 50% of the TBSA. Hence, this research reveals the important role of early rehabilitation interventions in severe burn patients. Electronic supplementary material The online version of this article (10.1186/s41038-019-0151-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jianglin Tan
- 1Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injuries, Chongqing Key Laboratory for Disease Proteomics, Southwest Hospital, Third Military (Army) Medical University, Chongqing, 400038 China
| | - Jian Chen
- 1Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injuries, Chongqing Key Laboratory for Disease Proteomics, Southwest Hospital, Third Military (Army) Medical University, Chongqing, 400038 China
| | - Junyi Zhou
- 1Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injuries, Chongqing Key Laboratory for Disease Proteomics, Southwest Hospital, Third Military (Army) Medical University, Chongqing, 400038 China
| | - Huapei Song
- 1Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injuries, Chongqing Key Laboratory for Disease Proteomics, Southwest Hospital, Third Military (Army) Medical University, Chongqing, 400038 China
| | - Huan Deng
- 1Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injuries, Chongqing Key Laboratory for Disease Proteomics, Southwest Hospital, Third Military (Army) Medical University, Chongqing, 400038 China
| | - Ming Ao
- 1Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injuries, Chongqing Key Laboratory for Disease Proteomics, Southwest Hospital, Third Military (Army) Medical University, Chongqing, 400038 China
| | - Gaoxing Luo
- 1Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injuries, Chongqing Key Laboratory for Disease Proteomics, Southwest Hospital, Third Military (Army) Medical University, Chongqing, 400038 China
| | - Jun Wu
- 1Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injuries, Chongqing Key Laboratory for Disease Proteomics, Southwest Hospital, Third Military (Army) Medical University, Chongqing, 400038 China.,2Department of Burns, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 China
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18
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Godleski M, Lee AF, Goverman J, Herndon DN, Suman OE, Kowalske KJ, Holavanahalli RK, Gibran NS, Esselman PC, Simko LC, Ryan CM, Schneider JC. Quantifying Contracture Severity at Hospital Discharge in Adults: A Burn Model System National Database Study. J Burn Care Res 2018; 39:604-611. [PMID: 29901805 PMCID: PMC9218764 DOI: 10.1093/jbcr/irx027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Contracture is a common complication of burn injury and can cause significant barriers to functional recovery and rehabilitation. There are limited studies of quantitative range of motion after burn injury. The purpose of this study is to examine quantitative contracture outcomes by anatomical location, burn size, and length of stay in adults. Data were obtained from the Burn Model System National Database from 1994 to 2003. All adult patients with a joint contracture at acute discharge were included and 16 joint motions were examined. Contractures were reported as both mean absolute loss of normal range of motion in degrees and percent loss of normal range of motion. Analysis of variance was used to assess for a linear trend for contracture severity by burn size and length of stay. Data from 659 patients yielded 6,228 instances of contracture. Mean absolute loss of normal range of motion ranged from 20° to 65° representing an 18 to 45% loss of normal movement across the studied joint motions. In the majority of joint motions, contracture severity significantly increased with larger burn size and longer length of stay; however, wrist and many lower extremity joint movements did not demonstrate this trend. The data illustrate the quantitative assessment of range of motion deficits in adults with burn injury at discharge and the relation to burn size and length of stay.
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Affiliation(s)
- Matthew Godleski
- Department of Physical Medicine & Rehabilitation, Ross Tilley Burn Centre, St. John’s Rehab, University of Toronto, Toronto, Ontario, Canada
| | - Austin F. Lee
- Department of Surgery, Massachusetts General Hospital, Shriners Hospitals for Children, Harvard Medical School, Boston, Massachusetts
| | - Jeremy Goverman
- Department of Surgery, Massachusetts General Hospital, Shriners Hospitals for Children, Harvard Medical School, Boston, Massachusetts
| | - David N. Herndon
- Department of Surgery, University of Texas Medical Branch, Shriners Hospitals for Children, Galveston, Texas
| | - Oscar E. Suman
- Department of Surgery, University of Texas Medical Branch, Shriners Hospitals for Children, Galveston, Texas
| | - Karen J. Kowalske
- Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Radha K. Holavanahalli
- Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicole S. Gibran
- Department of Surgery, University of Washington, Seattle, Washington
| | - Peter C. Esselman
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Laura C. Simko
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts
| | - Colleen M. Ryan
- Department of Surgery, Massachusetts General Hospital, Shriners Hospitals for Children, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey C. Schneider
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts
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19
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Lewinson RT, Capozzi LC, Johnson K, Harrop AR, Fraulin FOG, Nickerson D. A Review of Perforator Flaps for Burn Scar Contractures of Joints. Plast Surg (Oakv) 2018; 27:66-77. [PMID: 30854364 DOI: 10.1177/2292550318767433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Perforator flaps are one possible surgical treatment for burn scar contractures; however, a review of evidence on this topic is lacking. Methods MEDLINE was searched for articles related to perforator flaps for burn contractures. Following title and abstract screen, full texts were searched to identify articles describing perforator flaps for burn scar joint contractures. Data were extracted and summarized descriptively. Only articles that contained ≥10 patients with burn scar contracture were considered. Results Two hundred forty-eight articles were identified, of which 17 met criteria for review. Of these, 16 were low-quality case series, while 1 was an open randomized controlled trial. In total, perforator flaps were performed on 339 patients (age range: 3-75 years), with the most common contracture locations being cervical (n = 218) and knee (n = 41). Nine of the 17 articles described a rehabilitation strategy. In general, functional outcomes were excellent, with the majority of patients experiencing return of normal joint range of motion and no recontracture. Compared to full-thickness skin grafts, perforator flaps showed greater improvements in joint range of motion. Cosmetically, perforator flaps were shown to have good color match with surrounding tissue, good contour around anatomical landmarks, and improved overall patient appearance. The most common complications were marginal flap necrosis (n = 26 patients) and venous congestion (n = 17 patients). Conclusions Preliminary evidence from low-quality case series and 1 high-quality trial suggests perforator flaps may be successful for resurfacing released burn scar contractures; however, there is a need for additional trials comparing perforator flaps to other approaches.
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Affiliation(s)
- Ryan T Lewinson
- Leaders in Medicine Program, University of Calgary, Calgary, Alberta, Canada
| | - Lauren C Capozzi
- Leaders in Medicine Program, University of Calgary, Calgary, Alberta, Canada
| | - Kody Johnson
- Section of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alan Robertson Harrop
- Section of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada.,Section of Pediatric Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Frankie O G Fraulin
- Section of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada.,Section of Pediatric Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Duncan Nickerson
- Section of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada
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Goverman J, Mathews K, Goldstein R, Holavanahalli R, Kowalske K, Esselman P, Gibran N, Suman O, Herndon D, Ryan CM, Schneider JC. Adult Contractures in Burn Injury: A Burn Model System National Database Study. J Burn Care Res 2018; 38:e328-e336. [PMID: 27380122 PMCID: PMC10032147 DOI: 10.1097/bcr.0000000000000380] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
As the overall survival rate for burn injury has improved, increased emphasis is placed on postburn morbidity and the optimization of functional and cosmetic outcomes. One major cause of morbidity and functional deficits is that of joint contractures. The true incidence of postburn contractures and their associated risk factors remains unknown. This study examines the incidence and severity of contractures in a large, multicenter, burn population. The associated risk factors for the development of contractures are determined. Data from the National Institute on Disability and Rehabilitation Research Burn Model System database, for adult burn survivors from 1994 to 2003, were analyzed. Demographic and medical data were collected on each subject. The primary outcome measures included the presence of contractures, number of contractures per patient, and severity of contractures at each of nine locations (shoulder, elbow, hip, knee, ankle, wrist, neck, lumbar spine, and thoracic spine) at time of hospital discharge. Regression analysis was performed to determine predictors of the presence, severity, and numbers of contractures, with P < .05 used for statistical significance. Of the 1865 study patients, 620 (33%) developed at least 1 contracture at hospital discharge. Among those with at least one contracture, the mean is three (3.38) contractures per person. The shoulder was the most frequently contracted joint (23.0%), followed by the elbow (19.9%), wrist (17.3%), ankle (13.6%), and knee (13.4%). Most contractures were mild (47.2%) or moderate (32.9%) in severity. Statistically significant predictors of contracture development were male sex, black race, Hispanic ethnicity, medical problems, neuropathy, TBSA grafted, and TBSA burned. Predictors of the severity of contracture included male sex, black race, medical problems, neuropathy, TBSA grafted, and TBSA burned. Predictors of the number of contractures included male sex, medical problems, flash burn, neuropathy, TBSA burned, and TBSA grafted. Similar to a previous single-center study on postburn contractures, approximately one third of the patients with an eligible burn injury requiring autografting developed a contracture at hospital discharge. It is likely that these contractures develop despite early therapeutic interventions such as positioning and splinting; therefore, the challenge to the burn community remains, to identify new and better prevention strategies.
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Affiliation(s)
- Jeremy Goverman
- Surgical Services, Sumner Redstone Burn Center, Massachusetts General Hospital, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Shriners Hospitals for Children®-Boston, Massachusetts
| | - Katie Mathews
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Richard Goldstein
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Radha Holavanahalli
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas
| | - Karen Kowalske
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas
| | - Peter Esselman
- Department of Surgery, University of Washington Medicine Regional Burn Center, University of Washington, Seattle
| | - Nicole Gibran
- Department of Surgery, University of Washington Medicine Regional Burn Center, University of Washington, Seattle
| | - Oscar Suman
- University of Texas Medical Branch, Shriners Hospitals for Children, Galveston
| | - David Herndon
- University of Texas Medical Branch, Shriners Hospitals for Children, Galveston
| | - Colleen M. Ryan
- Surgical Services, Sumner Redstone Burn Center, Massachusetts General Hospital, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Shriners Hospitals for Children®-Boston, Massachusetts
| | - Jeffrey C. Schneider
- Surgical Services, Sumner Redstone Burn Center, Massachusetts General Hospital, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Shriners Hospitals for Children®-Boston, Massachusetts
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Abstract
Burn scar contractures (BSCs) are a frequently recognized problem for survivors of burn injury. In the burn literature, many reports focus on the frequency and factors associated with the BSC development. To the contrary, few burn rehabilitation publications report on patients who are able to successfully avoid developing BSC. From a prospective, multicenter study, data were extracted and reviewed on a group of 56 adult burn survivors who were discharged from their acute hospitalization without any measured BSCs. Forty-three variables with a recognized or presumed association with the development of BSCs were analyzed and are reported. Highlighted features of the noncontracted group included being an adult male with an educated background and few associated physical, medical, or social problems. The group had relatively small burn sizes that nonetheless required hospitalization. Despite the overall TBSA, the majority of the burn areas required skin grafting, although this area also represented a small area. The patient group had a longer than expected hospital stay. Rehabilitation was provided to patients on 80% of their hospital days. In addition, patients received sufficient rehabilitation treatment based on the number of cutaneous functional units involved in the burn injury. Patients were judged to have a high pain tolerance and compliant with rehabilitation. The results of this study document the clinical circumstances that patients with burn injury can be discharged from their acute hospitalization with the development of BSC. This study challenges the rehabilitation personnel to expand the upper limit of burn severity that can result in similar positive outcomes.
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Abstract
Joint contractures are a major cause of morbidity and functional deficit. The incidence of postburn contractures and their associated risk factors in the pediatric population has not yet been reported. This study examines the incidence and severity of contractures in a large, multicenter, pediatric burn population. Associated risk factors for the development of contractures are determined. Data from the National Institute on Disability and Rehabilitation Research Burn Model System database, for pediatric (younger than 18 years) burn survivors from 1994 to 2003, were analyzed. Demographic and medical data were collected on each subject. The primary outcome measures included the presence of contractures, number of contractures per patient, and severity of contractures at each of nine locations (shoulder, elbow, hip, knee, ankle, wrist, neck, lumbar, and thoracic) at time of hospital discharge. Regression analysis was performed to determine predictors of the presence, severity, and numbers of contractures, with P < .05 used for statistical significance. Of the 1031 study patients, 237 (23%) developed at least 1 contracture at hospital discharge. Among those with at least one contracture, the mean was three (3.3) contractures per person. The shoulder was the most frequently contracted joint (27.9%), followed by the elbow (17.6%), wrist (14.2%), knee (13.3%), and ankle (11.9%). Most contractures were mild (38.5%) or moderate (36.3%) in severity. The statistically significant predictors of contracture development were age and intensive care unit (ICU) length of stay. The statistically significant predictors of severity of contracture were age, ICU length of stay, presence of amputation, and black race. Predictors of the number of contractures included total age, length of stay, length of ICU stay, presence of amputation, TBSA burned, and TBSA grafted. This is the first study to report the epidemiology of postburn contractures in the pediatric population. Approximately one quarter of children with a major burn injury developed a contracture at hospital discharge, and this could potentially increase as the child grows. Contractures develop despite early therapeutic interventions such as positioning and splinting; therefore, it is essential that we identify novel and more effective prevention strategies.
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Effects of Topical Tamoxifen on Wound Healing of Burned Skin in Rats. Arch Plast Surg 2017; 44:378-383. [PMID: 28946718 PMCID: PMC5621812 DOI: 10.5999/aps.2017.44.5.378] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 08/08/2017] [Accepted: 08/29/2017] [Indexed: 11/11/2022] Open
Abstract
Background This study aimed to assess the effects of the topical application of tamoxifen on wound healing of burned skin in Wistar rats by evaluating 3 healing characteristics: fibrotic tissue thickness (FTT), scar surface area (SSA), and angiogenesis in the healed scar tissue. Methods Eighteen male Wistar rats were used in this study. A third-degree burn wound was made on the shaved animals’ back, measuring 2×2×2 cm. In the first group, a 2% tamoxifen ointment was applied to the wound twice daily for 8 weeks. The second group received a placebo ointment during the same period. The third group did not receive any treatment and served as the control group. Results The median (interquartile range=[Q1, Q3]) FTT was 1.35 (1.15, 1.62) mm, 1.00 (0.95, 1.02) mm, and 1.25 (0.8, 1.5) mm in the control, tamoxifen, and placebo groups, respectively (P=0.069). However, the FTT in the tamoxifen group was less than in the placebo and control groups. The median angiogenesis was 3.5 (3.00, 6.25), 8.00 (6.75, 9.25), and 7.00 (5.50, 8.25) vessels per high-power field for the control, tamoxifen, and placebo groups, respectively (P=0.067). However, the median angiogenesis was higher in the tamoxifen group than in the control group. No significant difference was observed in the mean SSA between the tamoxifen group and the control group (P=0.990). Conclusions Local application of tamoxifen increased angiogenesis and decreased the FTT, with no change in the SSA in burned skin areas. These effects are expected to expedite the wound healing process, reducing contracture and preventing hypertrophic scar and keloid formation.
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Tyack Z, Kimble R, McPhail S, Plaza A, Simons M. Psychometric properties of the Brisbane Burn Scar Impact Profile in adults with burn scars. PLoS One 2017; 12:e0184452. [PMID: 28902874 PMCID: PMC5597202 DOI: 10.1371/journal.pone.0184452] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 08/24/2017] [Indexed: 01/23/2023] Open
Abstract
Objective The aim of the study was to determine the longitudinal validity, reproducibility, responsiveness and interpretability of the adult version of the Brisbane Burn Scar Impact Profile, a patient-report measure of health-related quality of life. Methods A prospective longitudinal cohort study of patients with or at risk of burn scarring was conducted at three assessment points (at baseline around the time of wound healing, one to two weeks post-baseline and 1-month post-baseline). Participants attending a major metropolitan adult burn centre at baseline were recruited. Participants completed the Brisbane Burn Scar Impact Profile and the 36-item Short Form Health Survey and Patient Observer Scar Assessment Scale. Intraclass Correlation Coefficients (ICCs), smallest detectable change, percentage of those who improved, stayed the same or worsened and Area under the Receiver Operating Characteristic Curve (AUC) were used to test the aim. Results Data were included for 118 participants at baseline, 68 participants at one to two weeks and 57 participants at 1-month post-baseline. All groups of items had acceptable reproducibility, except for the overall impact of burn scars (ICC = 0.69), the impact of sensations which was not expected to be stable (ICC = 0.63), mobility and daily activities (ICC = 0.63, 0.67 respectively). The responsiveness of six out of seven groups of items able to be tested against external criterion was supported (AUC = 0.72–0.75). Hypothesised correlations of changes in the Brisbane Burn Scar Impact Profile items with changes in criterion measures generally supported longitudinal validity (e.g., nine out of thirteen hypotheses using the SF-36 as an external criterion were supported). Internal consistency estimates, item-total and inter-item correlations indicated there was likely redundancy of some groups of items, particularly in the relationships and social interaction, appearance and emotional reactions items (Chronbach’s alpha range = 0.94–0.95). Conclusion Support was found for the reproducibility, longitudinal validity, responsiveness and interpretability of most groups of Brisbane Burn Scar Impact Profile items and some individual items in the test population. Potential redundancy of items should be investigated further.
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Affiliation(s)
- Zephanie Tyack
- Centre for Children’s Burns and Trauma Research, Children’s Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- * E-mail:
| | - Roy Kimble
- Centre for Children’s Burns and Trauma Research, Children’s Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - Steven McPhail
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Centre for Functioning and Health Research, Metro South Health, Buranda, Australia
| | - Anita Plaza
- Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
| | - Megan Simons
- Centre for Children’s Burns and Trauma Research, Children’s Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Department of Occupational Therapy, Lady Cilento Children’s Hospital, South Brisbane, Queensland, Australia
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Abstract
Burn injury can result in hypertrophic scar formation that can lead to debilitating functional deficits and poor aesthetic outcomes. Although nonoperative modalities in the early phase of scar maturation are critical to minimize hypertrophic scar formation, surgical management is often indicated to restore hand function. The essential tenant of operative scar management is release of tension, which can often be achieved through local tissue rearrangement. Laser therapy has emerged as a central pillar of subsequent scar rehabilitation. These treatment tools provide an effective resource for the reconstructive surgeon to treat hypertrophic hand scars.
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Affiliation(s)
- Michael Sorkin
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109, USA
| | - David Cholok
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109, USA
| | - Benjamin Levi
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109, USA; Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109, USA.
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van der Vlies CH, de Waard S, Hop J, Nieuwenhuis MK, Middelkoop E, van Baar ME, van Zuijlen PPM. Indications and Predictors for Reconstructive Surgery After Hand Burns. J Hand Surg Am 2017; 42:351-358. [PMID: 28359638 DOI: 10.1016/j.jhsa.2017.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 02/01/2017] [Accepted: 02/13/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE The objective of this study was to analyze the prevalence, indications, and type of reconstructive surgery and predictors of the outcomes of reconstructive surgery after hand burns. METHODS A retrospective cohort study was conducted that included all patients admitted with acute hand burns in the Dutch burn centers from January 1998 through December 2002. The details of reconstruction including frequency, timing, indication, and techniques were collected over a 10-year follow-up period. RESULTS Hand burns were seen in 42% (n = 562 of 1,334) of all patients admitted with acute burns. Reconstructive surgery during the 10-year follow-up period was required in 15%. Contractures, especially of the first web space and little finger, were the most frequent indications for reconstructive surgery. Web spaces 1 to 3 and the little finger were the location most frequently operated on. The most frequently performed surgical technique was release of the contractures and the use of a random flap. Eighty percent of the reconstructive surgery patients required more than 1 reconstructive procedure, most often within 2 years of the initial injury. Secondary operations at the same location were required in 12%. In 40% of the patients, the first reconstructive surgery was performed within the first postburn year. Significant independent factors related to the need for reconstructive hand surgery were a larger area of full-thickness burns and surgical treatment of the hand during the acute phase. CONCLUSIONS Reconstructive surgery was required in 15% of patients who sustained hand burns. The majority of the patients requiring reconstructive surgery of the hand needed 2 or more operations to correct the contractures of the hand. Contractures of the little finger and first web space were the locations most frequently operated on. Patients with more extensive burns and who required hand surgery during the acute phase were more likely to need reconstructive surgery. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- C H van der Vlies
- Department of Surgery, Burn Centre, Maasstad Hospital, Rotterdam, the Netherlands; Association of Dutch Burn Centres, Maasstad Hospital, Rotterdam, the Netherlands.
| | - S de Waard
- Department of Surgery, Burn Centre, Maasstad Hospital, Rotterdam, the Netherlands
| | - J Hop
- Department of Plastic Surgery, Medical Centre, Leeuwarden, the Netherlands
| | - M K Nieuwenhuis
- Association of Dutch Burn Centres, Martini Hospital, Groningen, the Netherlands
| | - E Middelkoop
- Association of Dutch Burn Centres, Red Cross Hospital, Beverwijk, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, MOVE Research Institute, VU University, Amsterdam, the Netherlands
| | - M E van Baar
- Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, the Netherlands
| | - P P M van Zuijlen
- Association of Dutch Burn Centres, Red Cross Hospital, Beverwijk, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, MOVE Research Institute, VU University, Amsterdam, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, the Netherlands
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Koppenol DC, Vermolen FJ. Biomedical implications from a morphoelastic continuum model for the simulation of contracture formation in skin grafts that cover excised burns. Biomech Model Mechanobiol 2017; 16:1187-1206. [PMID: 28181018 PMCID: PMC5511621 DOI: 10.1007/s10237-017-0881-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 01/25/2017] [Indexed: 12/20/2022]
Abstract
A continuum hypothesis-based model is developed for the simulation of the (long term) contraction of skin grafts that cover excised burns in order to obtain suggestions regarding the ideal length of splinting therapy and when to start with this therapy such that the therapy is effective optimally. Tissue is modeled as an isotropic, heterogeneous, morphoelastic solid. With respect to the constituents of the tissue, we selected the following constituents as primary model components: fibroblasts, myofibroblasts, collagen molecules, and a generic signaling molecule. Good agreement is demonstrated with respect to the evolution over time of the surface area of unmeshed skin grafts that cover excised burns between outcomes of computer simulations obtained in this study and scar assessment data gathered previously in a clinical study. Based on the simulation results, we suggest that the optimal point in time to start with splinting therapy is directly after placement of the skin graft on its recipient bed. Furthermore, we suggest that it is desirable to continue with splinting therapy until the concentration of the signaling molecules in the grafted area has become negligible such that the formation of contractures can be prevented. We conclude this study with a presentation of some alternative ideas on how to diminish the degree of contracture formation that are not based on a mechanical intervention, and a discussion about how the presented model can be adjusted.
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Affiliation(s)
- Daniël C Koppenol
- Delft Institute of Applied Mathematics, Delft University of Technology, Delft, The Netherlands.
| | - Fred J Vermolen
- Delft Institute of Applied Mathematics, Delft University of Technology, Delft, The Netherlands
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Koppenol DC, Vermolen FJ, Koppenol-Gonzalez GV, Niessen FB, van Zuijlen PPM, Vuik K. A mathematical model for the simulation of the contraction of burns. J Math Biol 2016; 75:1-31. [PMID: 27826736 PMCID: PMC5486856 DOI: 10.1007/s00285-016-1075-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 08/04/2016] [Indexed: 12/31/2022]
Abstract
A continuum hypothesis-based model is developed for the simulation of the contraction of burns in order to gain new insights into which elements of the healing response might have a substantial influence on this process. Tissue is modeled as a neo-Hookean solid. Furthermore, (myo)fibroblasts, collagen molecules, and a generic signaling molecule are selected as model components. An overview of the custom-made numerical algorithm is presented. Subsequently, good agreement is demonstrated with respect to variability in the evolution of the surface area of burns over time between the outcomes of computer simulations and measurements obtained in an experimental study. In the model this variability is caused by varying the values for some of its parameters simultaneously. A factorial design combined with a regression analysis are used to quantify the individual contributions of these parameter value variations to the dispersion in the surface area of healing burns. The analysis shows that almost all variability in the surface area can be explained by variability in the value for the myofibroblast apoptosis rate and, to a lesser extent, the value for the collagen molecule secretion rate. This suggests that most of the variability in the evolution of the surface area of burns over time in the experimental study might be attributed to variability in these two rates. Finally, a probabilistic analysis is used in order to investigate in more detail the effect of variability in the values for the two rates on the healing process. Results of this analysis are presented and discussed.
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Affiliation(s)
- Daniël C Koppenol
- Delft Institute of Applied Mathematics, Delft University of Technology, Delft, The Netherlands.
| | - Fred J Vermolen
- Delft Institute of Applied Mathematics, Delft University of Technology, Delft, The Netherlands
| | | | - Frank B Niessen
- Department of Plastic, Reconstructive and Hand Surgery, MOVE Research Institute, VU University Medical Centre, Amsterdam, The Netherlands
| | - Paul P M van Zuijlen
- Department of Plastic, Reconstructive and Hand Surgery, MOVE Research Institute, VU University Medical Centre, Amsterdam, The Netherlands.,Burn Centre, Red Cross Hospital, Beverwijk, The Netherlands.,Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, The Netherlands
| | - Kees Vuik
- Delft Institute of Applied Mathematics, Delft University of Technology, Delft, The Netherlands
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Abstract
BACKGROUND Postburn axillary contractures are common and significantly impact quality of life. Simple release combined with split thickness skin grafting necessitates a donor site, requires immobilization, and may result in poor functional outcome. Common methods of adjacent tissue rearrangement are not well designed to treat broad linear contractures. Flaps from the back, flank, or arm can be used, but may come with significant donor site morbidity. We demonstrate the use of the STARplasty, a novel adjacent tissue rearrangement initially developed to treat neosyndactyly, as a useful reconstructive option for the release of Kurtzman type 1 posterior or anterior axillary contractures. METHODS A retrospective review was performed to identify patients who underwent STARplasties for treatment of type 1 axillary burn contractures. All reconstructions were performed by a single surgeon at a single ABA burn center (April 2011 to December 2015). A version of the surgical STARplasty technique previously described for treatment of neosyndactyly was modified for use in the axilla. Patient and injury demographics, as well as complications and outcome, were collected. RESULTS Twelve patients with upper extremity burns underwent 16 primary STARplasties for treatment of axillary contractures. Three patients underwent simultaneous bilateral procedures. The majority (15/16) of the primary procedures were used to address contractures of the anterior axillary fold. Mean patient age was 51 (R 38-63) and average burn size was 35% (R 18-80). Average time from initial injury to primary reconstruction was 11.1 months (R 3-54). One patient required revision for persistent contracture and another experienced wound dehiscence that ultimately required split-thickness skin grafting. No other significant complications were noted, and all remaining patients had closed wounds and full range of motion by 30 days postprocedure. CONCLUSIONS Axillary contractures remain common despite improvements in physical/occupational therapy. While common techniques, such as z-plasty, continue to be helpful for the surgical release of narrow contractures with bilateral laxity, axillary contractures are typically broad based and often contain only unilateral unburned tissue. Based on our experience, the axillary STARplasty represents a safe and efficacious technique to be considered in the case of broad-based contractures involving either the anterior or posterior axillary fold.
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Prevalence of scar contractures after burn: A systematic review. Burns 2016; 43:41-49. [PMID: 27639820 DOI: 10.1016/j.burns.2016.08.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/07/2016] [Accepted: 08/02/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Burn scar contractures are the pathological outcome of excessive scarring and ongoing scar contraction. Impairment of joint range of motion is a threat to performing activities in daily living. To direct treatment strategies to prevent and/or correct such contractures, insight into the prevalence, course, and determinants is essential. METHODS A literature search was conducted including Pubmed, Cochrane library, CINAHL, and PEDro. Articles were included if they provided burn scar contracture data to calculate the point prevalence. The quality of the articles was scored. Data were extracted regarding study, subject and burn characteristics, method of scar contracture assessment, point prevalence, and possible determinants. RESULTS Nine articles and one abstract could be included for data extraction. The prevalence at discharge was 38-54%, but with a longer time after burn, the prevalence was lower. Contractures were more likely to occur in more severe burns, flame burns, children, female, the cervical spine, and the upper extremity. CONCLUSIONS The prevalence of burn scar contractures varies considerably between studies. When prevalence is unclear, it is also difficult to investigate potential determinants and evaluate changes in interventions. There is a need for extensive, well-designed longitudinal (inter)national studies that investigate prevalence of scar contractures, their evolvement over time, and risk factors.
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Zhang Y, Zhou S, Cheng X, Yi B, Shan S, Wang J, Li Q. Baicalein attenuates hypertrophic scar formation via inhibition of the transforming growth factor‐β/Smad2/3 signalling pathway. Br J Dermatol 2015; 174:120-30. [PMID: 26301336 DOI: 10.1111/bjd.14108] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2015] [Indexed: 12/19/2022]
Affiliation(s)
- Y.F. Zhang
- Department of Plastic and Reconstructive Surgery Shanghai Ninth People's Hospital Shanghai Jiao Tong University Shanghai 200011 China
| | - S.Z. Zhou
- Department of Plastic and Reconstructive Surgery Shanghai Ninth People's Hospital Shanghai Jiao Tong University Shanghai 200011 China
| | - X.Y. Cheng
- Department of Anesthesiology Renji Hospital; School of Medicine Shanghai Jiao Tong University Shanghai 200011 China
| | - B. Yi
- Clinical College of the General Hospital of Beijing Military Region Anhui Medical University Hefei China
| | - S.Z. Shan
- Department of Plastic and Reconstructive Surgery Shanghai Ninth People's Hospital Shanghai Jiao Tong University Shanghai 200011 China
| | - J. Wang
- Department of Plastic and Reconstructive Surgery Shanghai Ninth People's Hospital Shanghai Jiao Tong University Shanghai 200011 China
| | - Q.F. Li
- Department of Plastic and Reconstructive Surgery Shanghai Ninth People's Hospital Shanghai Jiao Tong University Shanghai 200011 China
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Cen Y, Chai J, Chen H, Chen J, Guo G, Han C, Hu D, Huan J, Huang X, Jia C, Li-Tsang CW, Li J, Li Z, Liu Q, Liu Y, Luo G, Lv G, Niu X, Peng D, Peng Y, Qi H, Qi S, Sheng Z, Tang D, Wang Y, Wu J, Xia Z, Xie W, Yang H, Yi X, Yu L, Zhang G. Guidelines for burn rehabilitation in China. BURNS & TRAUMA 2015; 3:20. [PMID: 27574666 PMCID: PMC4964028 DOI: 10.1186/s41038-015-0019-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 09/11/2015] [Indexed: 02/05/2023]
Abstract
Quality of life and functional recovery after burn injury is the final goal of burn care, especially as most of burn patients survive the injury due to advanced medical science. However, dysfunction, disfigurement, contractures, psychological problems and other discomforts due to burns and the consequent scars are common, and physical therapy and occupational therapy provide alternative treatments for these problems of burn patients. This guideline, organized by the Chinese Burn Association and Chinese Association of Burn Surgeons aims to emphasize the importance of team work in burn care and provide a brief introduction of the outlines of physical and occupational therapies during burn treatment, which is suitable for the current medical circumstances of China. It can be used as the start of the tools for burn rehabilitation.
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Affiliation(s)
| | | | - Ying Cen
- Department of Burn and Plastic Surgery, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan China
| | - Jiake Chai
- Department of Burn & Plastic Surgery, the First Hospital Affiliated to General Hospital of PLA, Beijing, China
| | - Huade Chen
- Department of Burns, General Hospital of Guangdong Province, Guangzhou, Guangdong China
| | - Jian Chen
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, the Third Military Medical University, Chongqing, China
| | - Guanghua Guo
- Department of Burns, the First Affiliated Hospital of Nanchang Univerisity, Research Center of Technology of Wound Repair Engineering in Jiangxi Province, Nanchang, Jiangxi China
| | - Chunmao Han
- Department of Burns and Wound Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang China
| | - Dahai Hu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shanxi China
| | - Jingning Huan
- Department of Burn and Plastic Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoyuan Huang
- Department of Burns and Plastic Surgery, Central South University, Changsha, Hunan China
| | - Chiyu Jia
- Plastic Beauty and Burn Repair Center, the 309th Hospital of the Chinese PLA, Beijing, China
| | - Cecilia Wp Li-Tsang
- Department of Rehabilitation Sciences, the Hong Kong Polytechnic University, Hung Hom, Hong Kong, China
| | - Jianan Li
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu China
| | - Zongyu Li
- Department of Burns and Plastic Surgery, the Fifth Hospital of Harbin, Harbin, Heilongjiang Province China
| | - Qun Liu
- Department of Burn and Plastic Surgery, the Fourth Hospital of Tianjin, Burn Institution of Tianjin, Tianjin, China
| | - Yi Liu
- Burns and Plastic Surgery Center, PLA Lanzhou General Hospital of Lanzhou Command, Lanzhou, Gansu China
| | - Gaoxing Luo
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, the Third Military Medical University, Chongqing, China
| | - Guozhong Lv
- Department of Burn Surgery, the Third People's Hospital of Wuxi, Jiangsu, China
| | - Xihua Niu
- Department of Burn Surgery, the First People's Hospital of ZhengZhou, Zhengzhou, Henan China
| | - Daizhi Peng
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, the Third Military Medical University, Chongqing, China
| | - Yizhi Peng
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, the Third Military Medical University, Chongqing, China
| | - Hongyan Qi
- Department of Burn Surgery, Beijing Children's Hospital, Beijing, China
| | - Shunzhen Qi
- The Center of Burn and Plastic of Hebei Province, Bethune International Peace Hospital, Shijiazhuang, Hebei China
| | - Zhiyong Sheng
- Department of Burn & Plastic Surgery, the First Hospital Affiliated to General Hospital of PLA, Beijing, China
| | - Dan Tang
- Guangdong Provincial Work Injury Rehabilitation Center, Guangzhou, Guangdong China
| | - Yibing Wang
- Department of Burns and Plastic Surgery, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong China
| | - Jun Wu
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, the Third Military Medical University, Chongqing, China
| | - Zhaofan Xia
- Department of Burn Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Weiguo Xie
- Institute of Burns, Wuhan City Hospital No. 3 & Tongren Hospital of Wuhan University, Wuhan, Hubei China
| | - Hongming Yang
- Department of Burn & Plastic Surgery, the First Hospital Affiliated to General Hospital of PLA, Beijing, China
| | - Xianfeng Yi
- Guangdong Provincial Work Injury Rehabilitation Center, Guangzhou, Guangdong China
| | - Lehua Yu
- Department of Rehabilitation Medicine, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guoan Zhang
- Department of Burns, Beijing Jishuitan Hospital, Forth Medical College of Peking University, Beijing, China
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Mechanical boundary conditions bias fibroblast invasion in a collagen-fibrin wound model. Biophys J 2014; 106:932-43. [PMID: 24559996 DOI: 10.1016/j.bpj.2013.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/17/2013] [Accepted: 12/02/2013] [Indexed: 11/22/2022] Open
Abstract
Because fibroblasts deposit the collagen matrix that determines the mechanical integrity of scar tissue, altering fibroblast invasion could alter wound healing outcomes. Anisotropic mechanical boundary conditions (restraint, stretch, or tension) could affect the rate of fibroblast invasion, but their importance relative to the prototypical drivers of fibroblast infiltration during wound healing--cell and chemokine concentration gradients--is unknown. We tested whether anisotropic mechanical boundary conditions affected the directionality and speed of fibroblasts migrating into a three-dimensional model wound, which could simultaneously expose fibroblasts to mechanical, structural, steric, and chemical guidance cues. We created fibrin-filled slits in fibroblast-populated collagen gels and applied uniaxial mechanical restraint along the short or long axis of the fibrin wounds. Anisotropic mechanical conditions increased the efficiency of fibroblast invasion by guiding fibroblasts without increasing their migration speed. The migration behavior could be modeled as a biased random walk, where the bias due to multiple guidance cues was accounted for in the shape of a displacement orientation probability distribution. Taken together, modeling and experiments suggested an effect of strain anisotropy, rather than strain-induced fiber alignment, on fibroblast invasion.
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AlQahtani SM, Alzahrani MM, Carli A, Harvey EJ. Burn Management in Orthopaedic Trauma: A Critical Analysis Review. JBJS Rev 2014; 2:01874474-201410000-00001. [PMID: 27490295 DOI: 10.2106/jbjs.rvw.n.00010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Saad M AlQahtani
- 1Division of Orthopaedic Surgery, McGill University Health Center, Montreal General Hospital, 1650 Cedar Avenue, Room B5.159.5, Montreal, Quebec, Canada H3G 1A4
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Xiao H, Wang D, Huo R, Wang Y, Feng Y, Li Q. Mechanical tension promotes skin nerve regeneration by upregulating nerve growth factor expression. Neural Regen Res 2014; 8:1576-81. [PMID: 25206453 PMCID: PMC4145962 DOI: 10.3969/j.issn.1673-5374.2013.17.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Accepted: 03/06/2013] [Indexed: 11/18/2022] Open
Abstract
This study aimed to explore the role of mechanical tension in hypertrophic scars and the change in nerve density using hematoxylin-eosin staining and S100 immunohistochemistry, and to observe the expression of nerve growth factor by western blot analysis. The results demonstrated that mechanical tension contributed to the formation of a hyperplastic scar in the back skin of rats, in conjunction with increases in both nerve density and nerve growth factor expression in the scar tissue. These experimental findings indicate that the cutaneous nervous system plays a role in hypertrophic scar formation caused by mechanical tension.
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Affiliation(s)
- Hu Xiao
- Department of Burn and Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, Shandong Province, China
| | - Dechang Wang
- Department of Burn and Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, Shandong Province, China
| | - Ran Huo
- Department of Burn and Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, Shandong Province, China
| | - Yibing Wang
- Department of Burn and Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, Shandong Province, China
| | - Yongqiang Feng
- Department of Burn and Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, Shandong Province, China
| | - Qiang Li
- Department of Burn and Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, Shandong Province, China
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Zhao H, Chen Y, Zhang C, Fu X. Modifications of traditional pressure gloves for improved performance in scar flexion contracture prevention and fingertip circulation inspection. BURNS & TRAUMA 2014; 2:146-7. [PMID: 27602376 PMCID: PMC5012026 DOI: 10.4103/2321-3868.134083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/18/2014] [Accepted: 04/27/2014] [Indexed: 11/04/2022]
Affiliation(s)
- Hongliang Zhao
- General Hospital of People's Liberation Army, Beijing, China ; The First Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Yan Chen
- Department of Pharmacy, General Hospital of Beijing Military Region, Dongcheng, Beijing, China
| | - Cuiping Zhang
- Wound Repair and Tissue Regeneration Laboratory, The First Affiliated Hospital, General Hospital of PLA, 51 Fu Cheng Road, Beijing, 100048 China
| | - Xiaobing Fu
- Wound Repair and Tissue Regeneration Laboratory, The First Affiliated Hospital, General Hospital of PLA, 51 Fu Cheng Road, Beijing, 100048 China
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Sun X, Kim YH, Phan TN, Yang BS. Topical application of ALK5 inhibitor A-83-01 reduces burn wound contraction in rats by suppressing myofibroblast population. Biosci Biotechnol Biochem 2014; 78:1805-12. [PMID: 25351330 DOI: 10.1080/09168451.2014.932666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Burn scar contracture that follows the healing of deep dermal burns causes severe deformation and functional impairment. However, its current therapeutic interventions are limited with unsatisfactory outcomes. When we treated deep second-degree burns in rat skin with activin-like kinase 5 (ALK5) inhibitor A-83-01, it reduced wound contraction and enhanced the area of re-epithelialization so that the overall time for wound closing was not altered. In addition, it reduced myofibroblast population in the dermis of burn scar with a diminished deposition of its biomarker proteins such as α-SMA and collagen. Treatment of rat dermal fibroblast with A-83-01 inhibited transforming growth factor-β1 (TGF-β1)-dependent induction of α-SMA and collagen type I. Taken together, these results suggest that topical application of ALK5 inhibitor A-83-01 could be effective in preventing the contraction of burn wound without delaying the wound closure by virtue of its inhibitory activity against the TGF-β-induced increase of myofibroblast population.
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Affiliation(s)
- Xiaoyan Sun
- a Chemical Kinomics Research Center , Korea Institute of Science and Technology , Seoul , Korea
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38
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Serial splintage: Preoperative treatment of upper limb contracture. Burns 2013; 39:1096-100. [DOI: 10.1016/j.burns.2013.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 12/18/2012] [Accepted: 01/04/2013] [Indexed: 11/18/2022]
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39
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Richard R, Dewey S, Parry I, Jones J. Letter to the Editor. Burns 2013; 39:539-41. [DOI: 10.1016/j.burns.2012.07.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 07/30/2012] [Indexed: 10/27/2022]
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40
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Parashar A, Atla K, Sharma RK. Static splinting in burns. Burns 2013; 39:190-1. [DOI: 10.1016/j.burns.2012.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 04/22/2012] [Indexed: 11/29/2022]
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