Reconstructive surgery after burns: A 10-year follow-up study

The prevalence and predictors of reconstructive surgery in pediatric burn care

OBJECTIVE

This study aimed to examine the prevalence and predictors of reconstructive surgery among pediatric burn patients in the Netherlands.

METHODS

Pediatric burn patients were identified through the Dutch Burn Repository R3. Eligibility criteria included a burn requiring hospital admission or surgical treatment at one of the Dutch burn centers in 2009-2019. First, patient, burn, and treatment characteristics were summarized using descriptive statistics. Second, time to the first reconstructive surgery was modelled using Kaplan Meier curves. Third, a prediction model was developed using univariate and multivariate logistic regression. The model's performance was assessed using calibration, discrimination, and explained variance. Fourth, internal validation was performed using bootstrapping.

RESULTS

Approximately three percent (n = 84) of pediatric patients (n = 3072) required reconstructive surgery between the initial burn-related hospital admission and September 2021. Median time to the first reconstructive surgery was 1.2 (0.7-1.6) years. Most surgeries were performed on the face, arm, neck, hand, or anterior trunk, owing to contractures or hypertrophic scarring. Predictors of reconstruction included the etiology, anatomical site, extent of full-thickness burn, surgical treatment in the acute phase, and length of hospital stay.

CONCLUSION

Our study provided an overview of the prevalence and independent predictors of reconstructive surgery in the pediatric burn population.

Outpatient Follow-Up and Reconstructive Surgery Rates in Massive Burn Survivors: Investigating the Social Determinants

Burn care continues to improve and larger total body surface area (TBSA) burn survival is increasing. These survivors require more extensive care than smaller burns and are at higher risk for wound/scar-related complications. Prior work has shown low rates of follow-up for burn survivors linked to socioeconomic factors such as housing insecurity and substance use. There are limited studies that evaluate socioeconomic factors that contribute to follow-up and reconstructive surgery rates in massively burned patients. Patients who survived to discharge with >50% TBSA burns and planned return to the treating institution were included in the study. Univariate and multivariate analyses were performed on the data collected. Sixty-five patients were included with an average TBSA of 63.1%. Fifty-three patients (81.5%) attended at least one follow-up appointment with median of 4 follow-up appointments. Younger patients (33 ± 9 vs 44 ± 11; P = .0006), patients with larger TBSA burns (65 ± 13 vs 55 ± 5%; P = .02), those with private insurance, and those without housing insecurity (1.8% vs 45.4%; P = .003) were more likely to follow up. On multivariate regression analysis, patients with housing insecurity were independently associated with lack of follow-up (OR: 0.009; CI: 0.00001-0.57). Thirty-five patients had at least one reconstructive surgery and 31 patients had reconstructive surgery after discharge. No patients with housing insecurity underwent reconstructive surgery. Follow-up rates in massive burns were higher than reported for smaller TBSA burns and more than half received reconstructive surgery. Housing-insecure patients should be targeted for improved follow-up and access to reconstructive surgery.

Scar outcomes for conservatively managed children post burn injury: A retrospective study

Hypertrophic scarring is a significant complication post burn injury, especially for delayed healing after 3 weeks. Burn injuries healing prior to 3 weeks also have the potential to develop hypertrophic scarring, even when prescribed prophylactic conservative scar interventions. A retrospective chart audit reviewed 326 burn patients treated at a paediatric tertiary hospital from 2014 to 2019 who sustained a partial thickness burn, healed >14 days and did not receive skin grafting. A scar was deemed hypertrophic if >1 mm in height. Early hypertrophic scar prevalence was defined as 3-6 months post burn, while persistent hypertrophic scarring was defined as 12-18 months post burn. Median days to wound closure was 18. The prevalence of early and persistent hypertrophic scarring was 56.1% and 16.3%, respectively. Seventeen (5.2%) children underwent medical interventions for scar modulation. Early signs of hypertrophic scarring were seen in just over half the patients presenting to burn therapy and despite scar intervention, persistent hypertrophic scarring was seen in 16.3%. At both time points, just over half of the children presenting healed between 14 and 21 days. Therefore, children healing prior to 21 days have potential to develop hypertrophic scarring.

Global perspectives on risk factors for major joint burn contractures: A literature review

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.

Risk factors for burn contractures: A cross-sectional study in a lower income country

Risk factors for burn contractures require further study, especially in low and middle-income countries (LMICs); existing research has been predominantly conducted in high income countries (HICs). This study aimed to identify risk factors for burn contractures of major joints in a low-income setting. Potential risk factors (n = 104) for burn contracture were identified from the literature and a survey of clinicians with extensive experience in low and middle-income countries (LMIC). An observational cross-sectional study of adult burn survivors was undertaken in Bangladesh to evaluate as many of these risk factors as were feasible against contracture presence and severity. Forty-eight potential risk factors were examined in 48 adult patients with 126 major joints at risk (median 3 per participant) at a median of 2.5 years after burn injury. Contractures were present in 77% of participants and 52% of joints overall. Contracture severity was determined by measurement of loss of movement at all joints at risk. Person level risk factors were defined as those that were common to all joints at risk for the participant and only documented once, whilst joint level risk factors were documented for each of the participant's included joints at risk. Person level risk factors which were significantly correlated with loss of range of movement (ROM) included employment status, full thickness burns, refusal of skin graft, discharged against medical advice, low frequency of follow up and lack of awareness of contracture development. Significant joint level risk factors for loss of ROM included anatomical location, non-grafted burns, and lack of pressure therapy. This study has examined the largest number of potential contracture risk factors in an LMIC setting to date. A key finding was that risk factors for contracture in low-income settings may differ substantially from those seen in high income countries, which has implications for effective prevention strategies in these countries. Better whole person and joint outcome measures are required for accurate determination of risk factors for burn contracture. Recommendations for planning and reporting on future contracture risk factor studies are made.

Prevention and Treatment of Burn Scar Contracture: A Practical Review

Burn contracture affects close to one-third of all burn patients, leading to significant functional impairment and costs. Effective prevention and treatment strategies are necessary to decrease morbidity and unnecessary costs. This scoping review aimed to summarize prevention and treatment strategies used for management of burn scar contractures published in the literature since 2000. A comprehensive PubMed review was performed in October 2022 to identify methods of burn contracture prevention and treatments. Non-English, duplicate, and unavailable articles were excluded. Data were extracted including publication year, techniques, and outcomes. A total of 327 publications met criteria for inclusion. Most articles were published in 2011 (n = 22). Treatment strategies were discussed in 82.9% of studies, prevention in 16.5%, and both in 0.6%. The most common areas discussed included the upper extremity (n = 127) and neck (n = 102). Flaps were the most frequently used method (n = 208), followed by autografts (n = 89). Most preventative therapies were still in early stages of development. Burn contracture management requires a highly individualized approach with many available reconstructive techniques available. Further research is needed to improve prevention techniques and decrease morbidity and cost to patients.

Management of Severe Extended Burn Axillary Contracture in a Low-resource Setting

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.

A six-week physical therapy exercise program delivered via home-based telerehabilitation is comparable to in-person programs for patients with burn injuries: A randomized, controlled, non-inferiority clinical pilot trial

BACKGROUND

Exercise programmes are essential for burn rehabilitation, however patients often have barriers accessing these services. Home-based telerehabilitation (HBT) may be an alternative. This study aimed to determine if exercise programs delivered via HBT were as effective as in-person (IP) programs with respect to clinical outcomes and participant and therapist satisfaction.

METHODS

A single center, randomized, controlled, non-inferiority pilot trial with blinded assessment was undertaken. Forty-five adults with ≤ 25% total body surface area (TBSA) burns were randomized to receive a 6-week exercise program delivered either by HBT or IP. The primary outcome was burn-specific quality of life (Burn Specific Health Scale - Brief). Secondary outcomes included health-related quality of life, burn scar-specific outcomes, exercise self-efficacy, pain severity, muscle strength and range of motion (ROM). Participant and therapist satisfaction, technical disruptions and adverse events were also recorded.

RESULTS

We found no significant within- or between-group differences for any outcome measures except ROM. Achievement of full ROM was significantly different between groups at Week 12 (IP=100% vs HBT=70%, p = 0.005). Non-inferiority was inconclusive. Participant satisfaction was high (median ≥ 9.8/10), with no significant between-group differences. Therapist satisfaction was high (median ≥ 8.9/10), major technical disruptions low (8%) and no adverse events reported.

CONCLUSION

HBT is a safe, effective option to deliver exercise programs for patients with burn injuries ≤ 25% TBSA with comparable clinical outcomes to in-person programmes. Ongoing research is required to further analyze ROM and investigate the effectiveness of HBT for patients with larger burns.

Comparison Between Human Amniotic/Chorionic Membrane and Cryopreserved Allografts in the Treatment of Genital Burns

BACKGROUND

Genital burns have devastating effects on patient and have been classified by the American Burn Association as major burn injury. The management of these injuries continues to challenge reconstructive surgeons. Cryopreserved skin allografts have been successfully used to manage partial-thickness skin burns; however, dehydrated human amniotic/chorionic membrane (DHACM) represents novel technology. Dehydrated human amniotic/chorionic membrane outcomes have not been sufficiently studied to guide its use on genital burns. The objective of this study was to report on the outcomes of dehydrated amniotic membrane as a biologic skin dressing on genital burns injury compared with cryopreserved allografts.

METHODS

Retrospective review of data collected from our institutional burn registry from 2012 to 2017. The study population included patients with partial-thickness genital burns admitted between 2012 and 2017 treated with either dehydrated human amniotic/chorionic membrane or cryopreserved allografts. Demographic characteristics and outcome measures were compared between the 2 groups.

RESULTS

Thirty patients with genital burns who received DHACM skin and cryopreserved allografts were included in the analysis. The mean age for the DHACM group was 27.6 years compared with 33.5 years for the cryopreserved group. The mean total body surface area was 3.8% in the DHACM group compared with 7.2% in the cryopreserved group (P = non-significant (ns)). The mean injury severity score was not significantly different between groups. Patients receiving cadaveric allografts had a higher number of skin substitute surgical reapplications as compared with the DHACM group (28% vs 0%, P ≤ 0.05). All patients who received DHACM skin substitutes healed by 2 weeks postoperative compared with 76% of patients who received cryopreserved skin allografts (P = 0.03, χ).

CONCLUSIONS

Dehydrated amniotic membrane skin substitutes are a safe alternative in the treatment of genital burns. Its use achieves comparable benefits with no major significant difference in terms of complication, supporting the safety of amniotic membrane to treat genital burns.

The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up

OBJECTIVE

The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country.

METHODS

Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury.

RESULTS

Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns.

CONCLUSION

The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.

Outcomes of Early and Intensive Use of a Palm and Digit Extension Orthosis in Young Children After Burn Injury

Burns to the palmar aspect of the hand are prevalent in young children. The development of scar tissue across the flexor surface of the hand combined with the years of growth ahead may result in considerable complications. This study was undertaken to describe outcomes of early and intensive use of a palm and digit extension orthosis with the elbow immobilized at 90° flexion following a palmar hand burn. A retrospective review of 107 children (mean age 18 months [SD 10]) treated at a statewide Pediatric Burns Unit from 2012 to 2016 was performed. Three children (3%) developed contracture during the 24-month study follow-up period. The other 104 children (97%) had full ROM at 24 months or at either the point of discharge or loss to follow-up. Early signs of contracture, defined as loss of full movement or significant banding, developed in 26 children (24%) in the first 9 months after burn. With intensive physiotherapy, 23 children regained full movement by 12 months after burn. Children who did not achieve complete wound healing at 1 month after burn and children with hypertrophic scarring at 2 months after burn were significantly more represented among cases of early signs of contracture (P = .013). When undertaken with regular clinical review, early and intensive use of a palm and digit extension orthosis can maintain full extension of the palm and digits in children after palmar burn.

Surgical treatment of joint burn scar contracture: a 10-year single-center experience with long-term outcome evaluation

Background

Burn patients often have functional problems due to joint scar contracture. Patients suffering from such contracture often experience considerable limitations in daily life. Therefore, surgical treatment is often necessary. Skin grafts, especially full-thickness skin grafts and flaps remain the most commonly used surgical methods in clinical practice. However, there are no clear guidelines stating which technique is the most effective treatment. Herein, we conducted a retrospective cohort study over 10 years of experience at a single center to investigate whether flaps or FTSGs exhibit a better long-term effect.

Methods

We performed a retrospective chart review of patients with joint burn scar contracture and collected data related to patient demographic profiles, and detailed descriptions of the scars, surgical procedures, and follow-up were collected. We performed follow-up evaluation of three aspects: adverse events (recontracture, ache, and pruritus), satisfaction scores for function and aesthetics, and scar quality (Vancouver Scar Scale score).

Results

Follow-up results 1 year after surgery from 88 patients were analyzed. In total, 4 (10%) patients in the flap group and 13 (27.1%) patients in the FTSG group had recontracture; the incidence of recontracture was lower in the flap group than in the FTSG group (P=0.043). The functional satisfaction score of the flap group was higher than that of the FTSG group (P=0.027). Moreover, follow-up results 5 year after surgery for 47 patients were analyzed. In total, 1 (4.8%) patient in the flap group and 7 (26.9%) patients in the FTSG group had recontracture; the incidence of recontracture was significantly lower in the flap group than in the FTSG group (P=0.044). The functional satisfaction score in the flap group was higher than that of the FTSG group (P=0.041). In this study, no significant differences in scar quality were observed between the two groups.

Conclusions

If conditions permit, the application of different types of flaps may represent a better choice than FTSGs in terms of reducing the recontracture rate and improving joint function.

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

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.

Anti-human Leukocyte Antigen Immune Sensitization Effects of Cryopreserved Allograft and Blood Transfusion

Vascularized composite allotransplantation (VCA) is the most advanced reconstructive technique available to patients who suffer devastating burns to the limbs or face. However, VCA requires donor-recipient matching. Burn patients have been reported to experience sensitization, or the development of anti-human leukocyte antigen antibodies, during resuscitation and wound coverage, potentially precluding them from future VCA. This study sought to investigate the contributions of both blood and allograft to sensitization in burn patients. Four groups were compared: burn patients who received blood products and allograft (group 1), burn patients who received blood products only (group 2), trauma patients who received blood products only (group 3), and healthy volunteer controls (group 4). The average calculated panel-reactive antibody (indicating sensitization) was higher in group 1 compared to group 4 (P = .035). Additionally, the incidence of severe sensitization was higher in group 1 relative to the other groups (P = .049). When comparing groups of patients who had no sensitization, mild sensitization, moderate sensitization, and severe sensitization, there were no significant differences in age, sex, blood products received, total body surface area burned, or allograft used between groups, though severely sensitized patients tended to have greater total body surface area involvement and received more units of packed red blood cells and allograft (P = .079, P = .196, and P = .072, respectively). We therefore conclude that while burn patients who received allograft and blood demonstrated a higher incidence of anti-human leukocyte antigen sensitization relative to healthy controls, this difference cannot solely be attributed to either allograft use or transfusion.

The Effectiveness of Burn Scar Contracture Release Surgery in Low- and Middle-income Countries

Supplemental Digital Content is available in the text.

Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC.

Long-term quality of life and cost-effectiveness of treatment of partial thickness burns: A randomized controlled trial comparing enzyme alginogel vs silver sulfadiazine (FLAM study)

The clinical effectiveness and scar quality of the randomized controlled trial comparing enzyme alginogel with silver sulfadiazine (SSD) for treatment of partial thickness burns were previously reported. Enzyme alginogel did not lead to faster wound healing (primary outcome) or less scar formation. In the current study, the health-related quality of life (HRQoL), costs, and cost-effectiveness of enzyme alginogel compared with SSD in the treatment of partial thickness burns were studied. HRQoL was evaluated using the Burn Specific Health Scale-Brief (BSHS-B) and the EQ-5D-5L questionnaire 1 week before discharge and at 3, 6, and 12 months postburn. Costs were studied from a societal perspective (health care and nonhealth-care costs) for a follow-up period of 1 year. A cost-effectiveness analysis was performed using cost-effectiveness acceptability curves and comparing differences in societal costs and Quality Adjusted Life Years (QALYs) at 1 year postburn. Forty-one patients were analyzed in the enzyme alginogel group and 48 patients in the SSD group. None of the domains of BSHS-B showed a statistically significant difference between the treatment groups. Also, no statistically significant difference in QALYs was found between enzyme alginogel and SSD (difference -0.03; 95% confidence interval [CI], -0.09 to 0.03; P = .30). From both the health care and the societal perspective, the difference in costs between enzyme alginogel and SSD was not statistically significant: the difference in health-care costs was €3210 (95% CI, €-1247 to €7667; P = .47) and in societal costs was €3377 (95% CI €-6229 to €12 982; P = .49). The nonsignificant differences in costs and quality-adjusted life-years in favor of SSD resulted in a low probability (<25%) that enzyme alginogel is cost-effective compared to SSD. In conclusion, there were no significant differences in quality of life between both treatment groups. Enzyme alginogel is unlikely to be cost-effective compared with SSD in the treatment of partial thickness burns.

One center's experience developing a burn outpatient registry

INTRODUCTION

Recent advances in burn care have resulted in the transition of care from inpatient to outpatient. There is a growing appreciation that with improved survival, meaningful markers of quality need to include recovery of form, function, and reconstruction. Capture of the data describing care delivered in the outpatient setting is being missed.

METHODS

Development of our outpatient database included providers, registrar, program manager, and outpatient nursing staff. Data points were included if they described the population, and epidemiology of our patients, were useful for programmatic changes and improvements as well as anticipated research focus areas.

RESULTS

The database platform chosen was Midas+™ because it was in use by hospital quality and integrated with the electronic medical record. Fields were customized based on changing program needs and are updated for new programs or outcomes measures. Reports can be easily built and both outpatients and inpatients are included. This allows for longitudinal tracking of burn patients. Ongoing additions to original data points include variables to track outcomes related to laser therapy for scar management, time to custom garment donning, and to track functional outcomes. Epidemiologic data collected is used to target high-risk populations for prevention and outreach efforts. Outcome data is used for evaluation of programs and care.

CONCLUSIONS

High quality databases serve to measure effectiveness of care and offer insight for areas of improvement. There is a clear need for inclusion of outpatient activity in the National Burn Registry (NBR).

Differential effects of Losartan and Atorvastatin in partial and full thickness burn wounds

Healing of burn wounds is often associated with scar formation due to excessive inflammation and delayed wound closure. To date, no effective treatment is available to prevent the fibrotic process. The Renin Angiotensin System (RAS) was shown to be involved in fibrosis in various organs. Statins (e.g. Atorvastatin), Angiotensin receptor antagonists (e.g. Losartan) and the combination of these drugs are able to reduce the local RAS activation, and reduced fibrosis in other organs. We investigated whether inhibition of the RAS could improve healing of burn wounds by treatment with Atorvastatin, Losartan or the combination of both drugs. Therefore, full and partial thickness burn wounds were inflicted on both flanks of Yorkshire pigs. Oral administration of Atorvastatin, Losartan or the combination was started at post-burn day 1 and continued for 28 days. Full thickness wounds were excised and transplanted with an autologous meshed split-thickness skin graft at post-burn day 14. Partial thickness wounds received conservative treatment. Atorvastatin treatment resulted in enhanced graft take and wound closure of the full thickness wounds, faster resolution of neutrophils compared to all treatments and reduced alpha-smooth muscle actin positive cells compared to control treatment. Treatment with Losartan and to a lesser extent the combination therapy resulted in diminished graft take, increased wound contraction and poorer scar outcome. In contrast, Losartan treatment in partial thickness wounds decreased the alpha-smooth muscle actin+ fibroblasts and contraction. In conclusion, we showed differential effects of Losartan and Atorvastatin in full and partial thickness wounds. The extensive graft loss seen in Losartan treated wounds is most likely responsible for the poor clinical outcome of these full thickness burn wounds. Therefore, Losartan treatment should not be started before transplantation in order to prevent graft loss. Atorvastatin seems to accelerate the healing process in full thickness wounds possibly by dampening the pro-inflammatory response.

Perforator-Based Interposition Flaps Perform Better Than Full-Thickness Grafts for the Release of Burn Scar Contractures: A Multicenter Randomized Controlled Trial

BACKGROUND

Burn scar contractures remain a significant problem for the severely burned patient. Reconstructive surgery is often indicated to improve function and quality of life. Skin grafts (preferably full-thickness grafts) are frequently used to cover the defect that remains after scar release. Local flaps are also used for this purpose and provide healthy skin subcutaneous tissue. The vascularization and versatility of local flaps can be further improved by enclosing a perforator at the base of the flap. Until now, no randomized controlled trial has been performed to determine which technique has the best effectiveness in burn scar contracture releasing procedures.

METHODS

A multicenter randomized controlled trial was performed to compare the effectiveness of perforator-based interposition flaps to full-thickness skin grafts for the treatment of burn scar contractures. The primary outcome parameter was change in the surface area of the flap or full-thickness skin graft. Secondary outcome parameters were width, elasticity, color, Patient and Observer Scar Assessment Scale score, and range of motion. Measurements were performed after 3 and 12 months.

RESULTS

The mean surface area between flaps (n = 16) and full-thickness skin grafts (n = 14) differed statistically significantly at 3 months (123 percent versus 87 percent; p < 0.001) and 12 months (142 percent versus 92 percent; p < 0.001). In terms of the secondary outcome parameters (specifically, the Patient and Observer Scar Assessment Scale observer score and color), interposition flaps showed superior results compared with full-thickness skin grafts.

CONCLUSION

Perforator-based interposition flaps result in a more effective scar contracture release than full-thickness skin grafts and should therefore be preferred over full-thickness skin grafts when possible.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Scar Management of the Burned Hand

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.

Reconstruction of the Adult and Pediatric Burned Hand

Thermal injuries of the hand can have a great impact on function. Initial treatment should focus on the prevention of contracture through the use of tissue-sparing techniques and optimized occupational therapy. Surgical intervention should follow the standard reconstructive ladder and can involve several techniques from simple to complex including minimally invasive techniques, such as laser and steroid injection, contracture release and skin grafting, and local tissue rearrangement and regional flaps as well as distant pedicled and free flaps. Reconstructive surgery of the hand, when performed well, can lead to meaningful functional improvement in severe burns.

Indications and Predictors for Reconstructive Surgery After Hand Burns

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.

Is there any place for spontaneous healing in deep palmar burn of the child?

Child palm burns arise by contact and are often deep. The singular difficulty of such a disease comes from the necessity of the child growth and from the potential occurrence of constricted scars. In order to avoid sequelae, the actual gold standard is to practice an early excision of the burn, followed by a skin graft. The aim of this study is to evaluate the results of spontaneous healing combined with rehabilitation versus early skin grafting and rehabilitation concerning the apparition of sequelae. We performed a retrospective study in two burn centers and one rehabilitation hospital between 1995 and 2010. Eighty-seven hands have been included in two groups: one group for spontaneous healing and the other group for excision and skin grafting. Every child benefited from a specific rehabilitation protocol. The two main evaluation criteria were the duration of permanent splint wearing and the number of reconstructive surgery for each child. The median follow-up duration is about four years. The two groups were comparable. For the early skin grafting group, the splint wearing duration was 1/3 longer than for the spontaneous healing group. Concerning the reconstructive surgery, half of the grafted hands needed at least one procedure versus 1/5 of spontaneous healing hands. Our results show the interest of spontaneous healing in palmar burn in child, this observation requires a specific and intense rehabilitation protocol.

Prevalence of scar contractures after burn: A systematic review

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.

Economic burden of burn injuries in the Netherlands: A 3 months follow-up study

INTRODUCTION

Burn care has rapidly improved in the past decades. However, healthcare innovations can be expensive, demanding careful choices on their implementation. Obtaining knowledge on the extent of the costs of burn injuries is an essential first step for economic evaluations within burn care. The objective of this study was to determine the economic burden of patients with burns admitted to a burn centre and to identify important cost categories until 3 months post-burn.

PATIENTS AND METHODS

A prospective cohort study was conducted in the burn centre of Maasstad Hospital Rotterdam, the Netherlands, including all patients with acute burn related injuries from August 2011 until July 2012. Total costs were calculated from a societal perspective, until 3 months post injury. Subgroup analyses were performed to examine whether the mean total costs per patient differed by age, aetiology or percentage total body surface area (TBSA) burned.

RESULTS

In our population, with a mean burn size of 8%, mean total costs were €26,540 per patient varying from €742 to €235,557. Most important cost categories were burn centre days (62%), surgical interventions (5%) and work absence (20%). Flame burns were significantly more costly than other types of burns, adult patients were significantly more costly than children and adolescents and a higher percentage TBSA burned also corresponded to significantly higher costs.

DISCUSSION AND CONCLUSION

Mean total costs of burn care in the first 3 months post injury were estimated at €26,540 and depended on age, aetiology and TBSA. Mean total costs in our population probably apply to other high-income countries as well, although we should realise that patients with burn injuries are diverse and represent a broad range of total costs. To reduce costs of burn care, future intervention studies should focus on a timely wound healing, reducing length of stay and enabling an early return to work.

Outcome of Burns Treated With Autologous Cultured Proliferating Epidermal Cells: A Prospective Randomized Multicenter Intrapatient Comparative Trial

Standard treatment for large burns is transplantation with meshed split skin autografts (SSGs). A disadvantage of this treatment is that healing is accompanied by scar formation. Application of autologous epidermal cells (keratinocytes and melanocytes) may be a suitable therapeutic alternative, since this may enhance wound closure and improve scar quality. A prospective, multicenter randomized clinical trial was performed in 40 adult patients with acute full thickness burns. On two comparable wound areas, conventional treatment with SSGs was compared to an experimental treatment consisting of SSGs in combination with cultured autologous epidermal cells (ECs) seeded in a collagen carrier. The primary outcome measure was wound closure after 5-7 days. Secondary outcomes were safety aspects and scar quality measured by graft take, scar score (POSAS), skin colorimeter (DermaSpectrometer) and elasticity (Cutometer). Wound epithelialization after 5-7 days was significantly better for the experimental treatment (71%) compared to the standard treatment (67%) (p = 0.034, Wilcoxon), whereas the take rates of the grafts were similar. No related adverse events were recorded. Scar quality was evaluated at 3 (n = 33) and 12 (n = 28) months. The POSAS of the observer after 3 and 12 months and of the patient after 12 months were significantly better for the experimental area. Improvements between 12% and 23% (p ≤ 0.010, Wilcoxon) were detected for redness, pigmentation, thickness, relief, and pliability. Melanin index at 3 and 12 months and erythema index at 12 months were closer to normal skin for the experimental treatment than for conventional treatment (p ≤ 0.025 paired samples t-test). Skin elasticity showed significantly higher elasticity (p = 0.030) in the experimental area at 3 months follow-up. We showed a safe application and significant improvements of wound healing and scar quality in burn patients after treatment with ECs versus SSGs only. The relevance of cultured autologous cells in treatment of extensive burns is supported by our current findings.