Adult Contractures in Burn Injury: A Burn Model System National Database Study

The Fractured Insurance Landscape of Laser Therapy for Scar Revision

Fractional laser therapy improves skin texture, range of motion, and quality of life for patients with traumatic scars. Nevertheless, anecdotal evidence suggests declining insurance coverage for laser therapy. We aimed to characterize the landscape of insurance coverage for fractional laser therapy present our 6 year reimbursement trends. We cross-sectionally analyzed the 60 largest American health insurers by enrollee size and market share. For each, we identified their laser therapy policy for scar revision and extracted their documentation, prior and continuing authorization requirements and treatment guidelines. We also collected retrospective institutional claims data from 2017 to 2022 to investigate trends in reimbursement. Of the 60 largest health insurers, we identified 11 (18.3%) policies on scar revision and 40 policies (66.7%) on reconstructive surgery, including scar revision. Nineteen policies considered laser therapy medically necessary with evidence of functional impairment refractory to prior treatment. Three insurers denied laser coverage under any circumstance. Of the 1,531 claims submitted by our institution for burn scar laser therapy, 13.8% were denied. Patients with Medicare (ORadj, 3.78) or Medicaid (ORadj, 2.80) had significantly greater odds of coverage than privately insured patients (P < .01). There was a 14.5% annual reduction in the odds of reimbursement during the study period (ORadj, 0.86, P < .01). Laser therapy is a powerful treatment that is not widely available to patients with traumatic scars. Our institutional data suggest this access may be further eclipsed by decreasing trends in coverage since 2017. Strategies are needed to protect patient access to this life-changing treatment.

Update burn surgery: overview of current multidisciplinary treatment concepts

The treatment of severe burn injuries is an essential part of plastic-reconstructive surgery. Severe burned patients are treated in burn centers, which have highly specialized technical and personnel equipment. In addition to clear recommendations for prehospital management, intensive care therapy is usually required for extensive burn wounds. Shock therapy in burns primarily involves balanced fluid resuscitation according to hemodynamic monitoring, vasopressor support, pain management, temperature regulation, oxygen therapy, and comprehensive supportive care to stabilize the patient's condition. Surgical treatment is still based on wound debridement and the gold standard of autologous split-thickness skin grafting. Besides skin transplantation, surgical management of burns may also involve the application of various topical therapies to promote wound healing, reduce pain, and prevent infection. These therapies may include antimicrobial dressings, skin substitutes, growth factors, or specialized wound care products. Once the acute treatment has been completed, multidisciplinary rehabilitation treatment takes place, which begins in the acute hospital and continues in the outpatient and inpatient rehabilitation areas. Surgical treatment of the secondary complications of burns and scars is also an important component of burn care. Comprehensive knowledge of the various components and players involved in the care of severely burned patients is, therefore, required in order to achieve the best possible outcome for the patient.

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.

Higher energy delivery is associated with improved long-term survival among adults with major burn injury: A multicenter, multinational, observational study

BACKGROUND

Numerous feeding strategies have been used to mitigate the catabolism of major burn injury. Whether higher energy and/or protein delivery results in better long-term outcomes is unknown.

METHODS

We performed a secondary analysis of data from adults with major burn injuries enrolled in the Randomized Trial of Enteral Glutamine to Minimize the Effects of Burn Injury at 54 burn centers in 18 countries. The sample was restricted to those who were mechanically ventilated within 72 hours of injury and for ≥7 days. Our key exposure was adequacy of energy, and protein ([Delivered i /Prescribed i ] × 100) was categorized into three groups each: low, 0% to 50%; moderate, ≥50% to 79%; and high, ≥80%. We also analyzed adequacy using restricted cubic splines. Primary and secondary outcomes included 6-month mortality and functional outcomes (i.e., 36-Item Short-Form Health Survey, Katz Index of Independence in Activities of Daily Living, Lawton Activities of Daily Living scores), respectively. Regression models were adjusted for age, body mass index, Charlson Comorbidity Index, baseline Acute Physiology and Chronic Health Evaluation II and modified Sequential Organ Failure Assessment scores, burn size, energy/protein adequacy, and study site.

RESULTS

A total of 493 participants met the cohort restriction criteria; 336 participants were alive at 6 months. 36-Item Short-Form Health Survey, Katz Index of Independence in Activities of Daily Living, and Lawton Instrumental Activities of Daily Living Scale were completed by 218, 216, and 215 participants, respectively. The mean ± SD age was 48 ± 17 years, and 74% were male. The mean ± SD burn size was 41% ± 18% total body surface area. Participants who received 25% of recommended calories had nearly four times the hazard of death during the 6-month follow-up period than participants who received 100% of prescribed calories (adjusted hazard ratio, 3.89; 95% confidence interval, 1.35-11.20) ( p = 0.02). There was no significant association between protein and 6-month mortality or energy/protein delivery and 6-month functional outcomes.

CONCLUSION

There was a positive association between higher doses of energy and 6-month survival. This relationship conflicts somewhat with several energy studies among critically ill and non-burn-injured patients. The lack of consistent evidence on optimal nutrition for critically injured patients, a fundamental component of burn care, suggests potential for a randomized trial of lower versus higher energy to improve long-term outcomes after burn injury.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

The Myofibroblast Fate of Therapeutic Mesenchymal Stromal Cells: Regeneration, Repair, or Despair?

Mesenchymal stromal cells (MSCs) can be isolated from various tissues of healthy or patient donors to be retransplanted in cell therapies. Because the number of MSCs obtained from biopsies is typically too low for direct clinical application, MSC expansion in cell culture is required. However, ex vivo amplification often reduces the desired MSC regenerative potential and enhances undesired traits, such as activation into fibrogenic myofibroblasts. Transiently activated myofibroblasts restore tissue integrity after organ injury by producing and contracting extracellular matrix into scar tissue. In contrast, persistent myofibroblasts cause excessive scarring-called fibrosis-that destroys organ function. In this review, we focus on the relevance and molecular mechanisms of myofibroblast activation upon contact with stiff cell culture plastic or recipient scar tissue, such as hypertrophic scars of large skin burns. We discuss cell mechanoperception mechanisms such as integrins and stretch-activated channels, mechanotransduction through the contractile actin cytoskeleton, and conversion of mechanical signals into transcriptional programs via mechanosensitive co-transcription factors, such as YAP, TAZ, and MRTF. We further elaborate how prolonged mechanical stress can create persistent myofibroblast memory by direct mechanotransduction to the nucleus that can evoke lasting epigenetic modifications at the DNA level, such as histone methylation and acetylation. We conclude by projecting how cell culture mechanics can be modulated to generate MSCs, which epigenetically protected against myofibroblast activation and transport desired regeneration potential to the recipient tissue environment in clinical therapies.

Minimally invasive burn reconstruction with subcutaneous scar contracture release

BACKGROUND

Scar contracture bands after burns are frequent problems that cause discomfort and physical limitation. This study investigates the efficacy of a minimally invasive contracture band release technique (MICBR) inspired by closed platysmotomy.

METHODS

Patients with burn scars treated with MICBR in our center were included retrospectively. Our routine scar and contracture treatments (non-invasive and invasive) were utilized prior to undergoing MICBR. Range of motion (ROM) and Vancouver Scar Scale was measured before and after the procedure when feasible.

RESULTS

Forty-five patients were included, with 97 total contracture sites treated all over the body. An average of 1.6 sites were treated per patient, with a maximum of six. Patients age was 6-68 years; total burn surface area ranged from 0.5% to 85%. 24% were performed under local anesthesia. 84% were in originally skin grafted areas. We found significant improvements in ROM and VSS. 84% of patients surveyed were "satisfied" or "very satisfied". 95% reported improved mobility. No significant adverse events occurred.

CONCLUSION

This MICBR technique is a versatile, safe, and well-tolerated adjunct procedure that can help patients regain mobility after a burn injury.

Free Flap Failure and Contracture Recurrence in Delayed Burn Reconstruction: A Systematic Review and Meta-analysis

Background

Free tissue transfer is often considered a last resort in burn reconstruction due to its complexity and associated risks. A comprehensive review on free flap outcomes in delayed burn reconstruction is currently lacking. The study aimed to evaluate the available evidence on the failure and contracture recurrence rates in free flap delayed burn reconstruction.

Methods

A systematic review and meta-analysis was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The protocol was registered on PROSPERO (CRD42023404478). The following databases were accessed: Embase, PubMed, Web of Science, and Cochrane Library. The measured outcomes were free flap loss and contracture recurrence rate.

Results

Of the 1262 retrieved articles, 40 qualified for inclusion, reporting on 1026 free flaps performed in 928 patients. The mean age was 29.25 years [95% confidence interval (CI), 24.63-33.88]. Delayed burn reconstruction was performed at an average of 94.68 months [95% CI, - 9.34 to 198.70] after initial injury, with a follow-up period of 23.02 months [95% CI, 4.46-41.58]. Total flap loss rate was 3.80% [95% CI, 2.79-5.16] and partial flap loss rate was 5.95% [95% CI, 4.65-7.57]. Interestingly, burn contracture recurrence rate was 0.62% [95% CI, 0.20-1.90].

Conclusions

This systematic review provides a comprehensive evaluation of the free flap outcomes in delayed burn reconstruction. The flap loss rate was relatively low, given the complexity of the procedure and potential risks. Furthermore, burn contracture rate was found to be extremely low. This study demonstrates that free flaps are a safe and effective option for delayed burn reconstruction.

Optimising Scar Management Intervention in the Case of a Head-and-Neck Burn for a Patient with a Learning Disability

Scars following burns can often prove complex to manage, particularly when crossing joints or special areas such as the head and neck, due to contractures. This case report discusses the individualised care and rehabilitation provided to a burn patient with a learning disability. The patient suffered both full and partial thickness burns equating to a total body surface area (%TBSA) of 7% of the face, neck, and anterior chest via the self-ignition of clothing. Acute treatment was provided at a regional burn unit followed by further in-patient care and rehabilitation at our burn facility. A motion rehabilitation instrument was employed to manage potential orofacial contracture; however, due to the patient's impaired social functioning, this device was found to be unsuitable. Subsequently, a bespoke mouth-opening device replicating an ice lolly was fabricated utilising computer-aided design (CAD), enhancing the patient's understanding along with encouraging independence. Microstomia was a risk in this case; however, this was prevented via the discussed regime, and successful patient rehabilitation was achieved.

Quality indicators for hospital burn care: a scoping review

BACKGROUND

Burn treatments are complex, and for this reason, a specialised multidisciplinary approach is recommended. Evaluating the quality of care provided to acute burn patients through quality indicators makes it possible to develop and implement measures aiming at better results. There is a lack of information on which indicators to evaluate care in burn patients. The purpose of this scoping review was to identify a list of quality indicators used to evaluate the quality of hospital care provided to acute burn patients and indicate possible aspects of care that do not have specific indicators in the literature.

METHOD

A comprehensive scoping review (PRISMA-ScR) was conducted in four databases (PubMed, Cochrane Library, Embase, and Lilacs/VHL) between July 25 and 30, 2022 and redone on October 6, 2022. Potentially relevant articles were evaluated for eligibility. General data and the identified quality indicators were collected for each included article. Each indicator was classified as a structure, process, or outcome indicator.

RESULTS

A total of 1548 studies were identified, 82 were included, and their reference lists were searched, adding 19 more publications. Thus, data were collected from 101 studies. This review identified eight structure quality indicators, 72 process indicators, and 19 outcome indicators listed and subdivided according to their objectives.

CONCLUSION

This study obtained a list of quality indicators already used to monitor and evaluate the hospital care of acute burn patients. These indicators may be useful for further research or implementation in quality improvement programs.

TRIAL REGISTRATION

Protocol was registered on the Open Science Framework platform on June 27, 2022 ( https://doi.org/10.17605/OSF.IO/NAW85 ).

The Development and Management of Neck Burn Scar Contracture Recurrence: A Single-Center Retrospective Cohort Study

INTRODUCTION

Burn neck contractures pose a great challenge for reconstructive surgeons. A paucity of literature exist regarding long-term outcomes based on different surgical management strategies. The aim of this study was to evaluate the long-term outcomes of the treatment of neck burn scar contractures and evaluate surgical strategies according to their long-term effectiveness and associated complications.

METHODS

A retrospective cohort study was conducted to review outcomes of neck contractures release after burn injury. All patients operated on between January 2009 and February 2023 at a single institution were included.

RESULTS

A total of 20 patients developed neck burn scar contracture and were included in this study. The mean age was 32.9 ± 20.3 years. The burn injuries were most commonly thermal (n = 19, 95%). All burn injuries were full-thickness burns, with an average neck defect size of 130.5 ± 106.0 cm2. Overall, 45 surgical scar release procedures were performed on the 20 patients who developed a neck contracture. Patients underwent 1.65 ± 1.04 surgeries on average to address neck contracture. Although 25% of patients only received 1 surgery to treat neck contracture, some patients underwent as many as 8 surgeries. Contracture recurrence (CR) was the most common complication and occurred in 28.9% of the cases. The mean percentage total body surface area did not significantly differ in CR patients (26.7% ± 14.9%) and no-CR patients (44.5% ± 30.2%). However, there was a significant difference (P = 0.01) in the average neck defect size between CR patients (198.5 ± 108.3 cm2) and no-CR patients (81.1 ± 75.1 cm2).

CONCLUSIONS

This study showed that risk factors for initial burn scar contractures may differ from those associated with CR, highlighting the importance of neck defect size as a predictor. The study also examines various surgical approaches, with Z-plasty showing promise for managing CR. However, the absence of data on neck range of motion is a limitation. This research underscores the complexity of managing CR and emphasizes the need for ongoing postoperative monitoring.

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.

Burn contracture risk factors and measurement in low-middle income countries: A clinical perspective

We find a lack of high-quality published evidence on risk factors for burn contracture formation. The vast majority of research is from High Income Countries (HICs), where many potential risk factors are controlled for by standardised and high-quality healthcare systems. To augment the published literature, burn care professionals with Low Middle Income Countries (LMICs) experience were interviewed for their opinion on risk factors for burn contracture formation. Participants were also asked for their views on identification and measurement of contracture. Seventeen semi-structured interviews were conducted (13 burn surgeons and 4 therapists). The average length of experience in burn-care was 13 years. Participants represented Ghana, Ethiopia, Malawi, Nigeria, South Africa, Nepal, and India. Participants reported ninety risk factors. Risk factors were later collated according to topic: Non burn individual factors (n = 13), Burn injury factors (n = 14), Family and community factors (n = 9), Treatment factors (n = 18), Complications (n = 2), Healthcare capacity factors (n = 19) and Societal and environmental factors (n = 12). The top five most frequently cited risk factors were lack of splinting, lack of physiotherapy, lack of early excision and skin grafting, low socioeconomic status and presence of infection. Although participants had no doubts that they could recognise a contracture, none provided a standardised system of measurement or an operational definition of contracture. Burn care professionals have a wealth of experience and untapped knowledge of risk factors for burn contracture formation in their own population base, but many of the risk factors highlighted by participants have not yet been explored in the literature. Variations in clinicians' diagnosis and measurement of a burn contracture underscores the need for an agreed, standardised, simple and easily reproducible method of diagnosing and classifying burn contractures.

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.

Use of Cultured Epithelial Autograft in Conjunction with Biodegradable Temporizing Matrix in Massive Burns: A Case Series

Intensive care for massively burn patients has increased survival and highlights the need for a solution to the problem of insufficient donor sites for autologous skin coverage. In this case series, we present 10 patients with average burn size of 81% TBSA and mean age of 24 years old, who underwent burn excision followed by either immediate or delayed biodegradable temporizing matrix (BTM) placement. After an integration period, the BTM was delaminated either the day before or immediately prior to placement of cultured epithelial autografts over a widely meshed (4:1 or 6:1) split thickness skin graft. One patient had cultured epithelial autografts alone, without split thickness skin graft, placed on integrated BTM and had successful take. Seven patients survived to discharge and had average 95% wound closure at 135 ± 35 days. The patients had on average 10.4 total operations and 8.7 excision and grafting operations. Five patients had complications related to the BTM requiring removal or replacement including three fungal infections, one bacterial infection and one with bleeding and a large clot burden. In conclusion, this surgical strategy is a viable option for patients with massive burns and insufficient donor for autologous skin grafting.

Establishment and validation of a nomogram to predict the neck contracture after skin grafting in burn patients: A multicentre cohort study

Cervical burn contracture is one of the burn contractures with the highest incidence and severity, and there is no effective method to predict the risk of neck contracture. This study aimed to investigate the effect of combined cervicothoracic skin grafting on the risk of neck contracture in burn patients and to develop a nomogram to predict the risk of neck contracture after skin grafting in burn patients. Data from 212 patients with burns who underwent neck skin grafting were collected from three hospitals, and the patients were randomly divided into training and validation sets. Independent predictors were identified through univariate and multivariate logistic regression analyses and incorporated into a prognostic nomogram. Its performance was assessed using the receiver operating characteristic area under the curve, calibration curve, and decision curve analysis. Burn depth, combined cervicothoracic skin grafting, graft thickness, and neck graft size were significantly associated with neck contractures. In the training cohort, the nomogram had an area under the curve of 0.894. The calibration curve and decision curve analysis indicated good clinical applicability of the nomogram. The results were tested using a validation dataset. Combined cervicothoracic skin grafting is an independent risk factor for neck contracture. Our nomogram demonstrated excellent performance in predicting neck contracture risk.

3D-Printed Auxetic Skin Scaffold for Decreasing Burn Wound Contractures at Joints

For patients with severe burns that consist of contractures induced by fibrous scar tissue formation, a graft must adhere completely to the wound bed to enable wound healing and neovascularization. However, currently available grafts are insufficient for scar suppression owing to their nonuniform pressure distribution in the wound area. Therefore, considering the characteristics of human skin, which is omnidirectionally stretched via uniaxial stretching, we proposed an auxetic skin scaffold with a negative Poisson's ratio (NPR) for tight adherence to the skin scaffold on the wound bed site. Briefly, a skin scaffold with the NPR effect was fabricated by creating a fine pattern through 3D printing. Electrospun layers were also added to improve adhesion to the wound bed. Fabricated skin scaffolds displayed NPR characteristics (-0.5 to -0.1) based on pulling simulation and experiment. Finger bending motion tests verified the decreased marginal forces (<50%) and deformation (<60%) of the NPR scaffold. In addition, the filling of human dermal fibroblasts in most areas (>95%) of the scaffold comprising rarely dead cells and their spindle-shaped morphologies revealed the high cytocompatibility of the developed scaffold. Overall, the developed skin scaffold may help reduce wound strictures in the joints of patients with burns as it exerts less pressure on the wound margin.

Integration of Cutaneous Functional Units Principles in Burn Rehabilitation: A Diffusion of Innovations Assessment

Early recognition of contractures can lead to a more targeted therapy regimen, potentially preventing range of motion losses and improving function and quality of life. Cutaneous functional units (CFUs) allow therapists to explain motion limitations and formulate patient-specific treatment plans. Evidence-based research demonstrates the potential of using these principles to improve the current standard of care. Still, the consistent use of these principles has been slow to diffuse through burn care. Occupational and physical therapists were surveyed to determine the degree to which CFU principles are being integrated into clinical practice. Respondents (297) were occupational therapists (52%) and physical therapists (49%) working in burn units (81%) in North America (70.7%). Most respondents (78.4%) report familiarity with CFU principles. Of those familiar, most respondents reported their knowledge (66.7%) and ability to apply (65.7%) at an intermediate level or greater. A slight majority (59.3%) responded that the concepts influenced their practice, while 40.7% said the concepts did not influence their practice. Forty percent to sixty-nine percent of respondents correctly answered knowledge questions, but only 15% of respondents correctly completed CFUs identification questions. Respondents (77%) report barriers, including difficulty incorporating into practice, time constraints, and the need for more education. Results suggest that diffusion can be improved by developing tools to assist therapists in understanding and incorporating CFUs' principles.

Epidemiology and Predictors for Cervical Burn Scar Contractures: A Multicenter Cohort Study

Cervical burn scar contracture (BSC) affects many important neck functions and the patients' quality of life. However, it remains unclear which patients have a higher risk of neck BSCs. This study aimed to describe the epidemiology and identify the independent risks of cervical BSC formation and severity. Clinical and demographic data of 106 patients with burn scars were retrospectively collated and analyzed from 3 different Chinese hospitals between December 2016 and December 2020. Both univariate and multivariate logistic regression analyses were performed to identify the independent risks for BSC formation and severity at 12 months postburn. Lateral flexion was the most common plane of motion (POM) limited by contractures (29.4%), whereas the POM most commonly limited by severe contractures was the extension (24.6%). Most patients with contractures had those in 3 to 4 POMs (72.1%). Neck skin grafting was an independent risk factor for BSC formation, and cervical and cervicothoracic skin grafting were independent risk factors for BSC severity. These results may help to identify high-risk patients with contractures in the early stages of burns to carry out individualized early prevention and treatment.

Introduction: The Multidisciplinary Team Approach to Burn Care

Since the first burn units were established following World War II, great advances in understanding and treating burn shock, smoke inhalation injury, pneumonia, and invasive burn wound infections, and in achieving early burn-wound closure, have greatly decreased postburn morbidity and mortality. These advances were the result of closely integrated multidisciplinary teams of clinicians and researchers. The team approach to burns is a model for success in the care of any challenging clinical problem.

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.

Evaluation of Clinical and Biomechanical Features of Scars Resulting from the Treatment of Burn Contractures Comparing Acellular Dermal Matrices: A Randomized Clinical Trial

OBJECTIVE

The aim of this study was to compare clinical and biomechanical features of scars resulting from the treatment of burn contractures using different acellular dermal matrices (ADM).

SUMMARY BACKGROUND DATA

Extensive burns often lead to severe sequelae, such as skin contractures, that can be treated using ADM to improve the quality of these scars.

METHODS

A prospective, randomized and controlled clinical trial was performed including patients with burn contractures at least 1-year post-burn, treated using split-thickness skin graft (STSG). These patients were randomized into 4 groups: control (received only STSG without ADM), Integra (ADM + STSG), Matriderm (ADM + STSG), and Pelnac (ADM + STSG). Exclusion criteria were loss of follow-up and graft integration failure. The evaluation was performed using the Vancouver Scar Scale (VSS), the durom-eter, and the cutometer in areas of normal skin, hypertrophic scar, and surgical scar, at least 1 year after the surgery.

RESULTS

In the VSS, durometer, and cutometer evaluation, there was no difference in the comparison of surgical scars among groups. Analyzing each group, with an intraindividual evaluation comparing areas of normal skin with surgical scars, the results suggested a possibility of a surgical scar hardness closer to normal skin for Integra and Matriderm groups measured with the durometer. In the cutometer evaluation, surgical scars were not comparable to areas of normal skin.

CONCLUSIONS

This study suggests that there is no difference in the quality of scar assessed through the analysis of clinical and biomechanical features comparing acellular dermal matrices (Integra, Matriderm, and Pelnac) and only split-thickness skin graft without a dermal matrix.

Prevalence and Severity of Burn Scars in Rural Mozambique

BACKGROUND

Burn injuries are common in low- and middle-income countries (LMICs) and their associated disability is tragic. This study is the first to explore burn scars in rural communities in Mozambique. This work also validated an innovate burn assessment tool, the Morphological African Scar Contractures Classification (MASCC), used to determine surgical need.

METHODS

Using a stratified, population-weighted survey, the team interviewed randomly selected households from September 2012 to June 2013. Three rural districts (Chókwè, Nhamatanda, and Ribáuè) were selected to represent the southern, central and northern regions of the country. Injuries were recorded, documented with photographs, and approach to care was gathered. A panel of residents and surgeons reviewed the burn scar images using both the Vancouver Scar Scale and the MASCC, a validated visual scale that categorizes patients into four categories corresponding to levels of surgical intervention.

RESULTS

Of the 6104 survey participants, 6% (n = 370) reported one or more burn injuries. Burn injuries were more common in females (57%) and most often occurred on the extremities. Individuals less than 25 years old had a significantly higher odds of reporting a burn scar compared to people older than 45 years. Based on the MASCC, 12% (n = 42) would benefit from surgery to treat contractures.

CONCLUSION

Untreated burn injuries are prevalent in rural Mozambique. Our study reveals a lack of access to surgical care in rural communities and demonstrates how the MASCC scale can be used to extend the reach of surgical assessment beyond the hospital through community health workers.

The Impact of Race/Ethnicity on the Outcomes of Burn Patients: A Systematic Review of the Literature

Racial and ethnic disparities are endemic to the United States and are only beginning to attract the attention of researchers. With an increasingly diverse population, focused and tailored medicine to provide more equitable care is needed. For surgical trauma populations, this topic is a small but expanding field and still rarely mentioned in burn medicine. Disparities in prevention, treatment, and recovery outcomes between different racial and ethnic minorities who are burned are rarely discussed. The purpose of this study is to determine the current status of identified disparities of care in the burn population literature and areas of future research. A systematic review was conducted of literature utilizing PubMed for articles published between 2000 and 2020. Searches were used to identify articles that crossed the burn term (burn patient OR burn recovery OR burn survivor OR burn care) and a race/ethnicity and insurance status-related term (race/ethnicity OR African-American OR Black OR Asian OR Hispanic OR Latino OR Native American OR Indigenous OR Mixed race OR 2 or more races OR socioeconomic status OR insurance status). Inclusion criteria were English studies in the United States that discussed disparities in burn injury outcomes or risk factors associated with race/ethnicity. One thousand one hundred and sixty-nine papers were populated, 55 were reviewed, and 36 articles met inclusion criteria. Most studies showed minorities had poorer inpatient and outpatient outcomes. While this is a concerning trend, there is a paucity of literature in this field and more research is needed to create culturally tailored medical care and address the needs of disadvantaged burn survivors.

The degree of joint range of motion limitations after burn injuries during recovery

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.

Flame burns

Flame burns lead to significant long-term morbidity and functional consequences. This study analyzed the mortality-related factors in patients with flame burns to compare with the existing literature. This retrospective descriptive study was carried out at the General Surgery Clinic, Gazi Yaşargil Training and Research Hospital, Turkey, to include 131 patients admitted and treated with emergency surgery for flame burns between January 2016 and December 2019. Of the patients hospitalized for flame burn, 103 (78.6%) were male and 28 (21.4%) were female (M:F = 3.6) with a mean age of 25.3 ± 20.78 years. The 15-34 years age group was the most affected by flame burns. The most frequently affected body areas were the upper extremities and face (n = 68, 51.9%); conjunctivitis developed in 49 (37.4%) patients. The wound infection rate was 34.3%, and Staphylococcus epidermidis had the highest growth rate in wound culture results (24.4%). Flame burns were most common in winter and autumn. The majority of patients (n = 95, 72.5%) were treated with escharectomy and dressing, while grafting was performed in 36 (27.5%) patients. A total of 3 (2.2%) patients died-one died in a suicide attempt, one due to inhalation burn after flame burn, and another died due to sepsis. The average length of hospital stay was 8.0 ± 3.9 days. Flame burns are much more common in young men, causing deeper and wider burns and requiring greater surgical intervention. This leads to frequent wound infections and longer hospital stays.

Update on the practice of splinting during acute burn admission from the ACT study

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.

Prevalence and predictors of scar contracture-associated re-hospitalisation among burn inpatients in China

Scar contracture, a common destructive complication causing increased re-hospitalisation rate of burn survivors and aggravated burden on the medical system, may be more seriously in Chinese population because of their higher susceptibility to scar formation. This study aims to evaluate the prevalence and predictors of scar contracture-associated re-hospitalisation among Chinese burn inpatients. This cross-sectional study screened burn inpatients hospitalised during 2013 to 2018 through the Hospital Quality Monitoring System database, among whom re-hospitalised for scar contracture were identified. Variables including sex, age, occupations, burn area, burn site and surgical treatment were analysed. Potential predictors of scar contracture-associated re-hospitalisation among burn inpatients were determined by univariate regression analyses. Of the 220,642 burn inpatients, 2146 (0.97%) were re-hospitalised for scar contracture. The re-hospitalised inpatients were predominantly men and blue-collar workers, showing younger median age at the time of burns, larger burn sizes, and higher percentage of surgical treatment compared other burn inpatients. Significant univariate predictors of scar contracture-associated re-hospitalisation included male sex, age < 50 years, blue-collar work, ≥ 40% total body superficial area burned, inhalation injured, and surgical treatment. Scar contracture is an intractable complication and a significant factor to increase re-hospitalisation rate among Chinese burn inpatients.

Hypertrophic Scarring: Current Knowledge of Predisposing Factors, Cellular and Molecular Mechanisms

Hypertrophic scarring (HSc) is an age-old problem that still affects millions of people physically, psychologically, and economically. Despite advances in surgical techniques and wound care, prevention and treatment of HSc remains a challenge. Elucidation of factors involved in the development of this common fibroproliferative disorder is crucial for further progress in preventive and/or therapeutic measures. Our knowledge about pathophysiology of HSc at the cellular and molecular level has grown considerably in recent decades. In this article, current knowledge of predisposing factors and the cellular and molecular mechanisms of HSc has been reviewed.

Systematic review: Advances of fat tissue engineering as bioactive scaffold, bioactive material, and source for adipose-derived mesenchymal stem cells in wound and scar treatment

Fat tissue (FT) has been used for many years in regenerative surgery as a bioactive material through the lipofilling/fat graft (F-GRF)-nano-fat technique, as a bioactive scaffold when it was enriched with adipose-derived mesenchymal stem cells (AD-MSCs) contained in the stromal vascular fraction (SVF), and as a direct source of AD-MSCs used in wound healing (WH) and scar treatment (ST). This systematic review aims to describe the advances in FT engineering applied to regenerative surgery (from bench to clinic), through the use of AD-MSCs, SVF contained in F-GRF in WH and ST. The work has been performed by assessing in the selected studies autologous graft of AD-MSCs, SVF, and F-GRF compared to any control for ST and WH. The protocol was developed following the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses-Protocols (PRISMA-P) guidelines. A multistep search of the PubMed, MEDLINE, Embase, PreMEDLINE, Ebase, CINAHL, PsycINFO, Clinicaltrials.gov , Scopus database, and Cochrane databases has been performed to identify papers on AD-MSCs, SVF, and F-GRF use in WH and ST in which FT was used as bioactive material-scaffold and source of AD-MSCs. Of the 714 articles initially identified, 453 articles focusing on regenerative strategies in WH and ST were selected and, consequently, only 84 articles that apparently related to AD-MSC, SVF, and F-GRF were analyzed. Of these, 61 articles identified as pre-clinical, experimental, and in vitro, and 5 articles identified as a comment and systematic review were excluded. Only 18 original articles which strictly and exclusively focused on autologous AD-MSCs, SVF, and F-GRF in ST and WH were analyzed. The included studies had to match predetermined criteria according to the PICOS (patients, intervention, comparator, outcomes, and study design) approach. The identified studies described microscopic and clinical outcomes in patients treated with AD-MSCs, SVF, and F-GRF. Collected data confirmed the safety and efficacy of FT both as bioactive material-scaffold and source of AD-MSCs in WH and ST without major side effects.

Successful outcome of giant chorioangioma

Chorioangioma is the most common benign non trophoblastic tumor of the placenta. It is a rare presentation with incidence of 0.6-1% of all pregnancies. It is associated with feto maternal complications like polyhydramnios, cervical incompetence, preterm labor, increased rate of cesarean delivery, abruptio placentae, malpresentation, postpartum hemorrhage, fetal growth restriction, fetal anemia, fetal thrombocytopenia, non immune hydrops, fetal cardiac failure, cerebral embolism, cerebral infarction, intrauterine fetal and neonatal death. Ultrasound is the gold standard for diagnosis . Here we present a case of giant chorioangioma of 6 * 5 cm with complication of polyhydramnios, preterm labor, abruptio placenta and placenta previa successfully managed with good maternal and fetal outcome.

Contracture Severity at Hospital Discharge in Children: A Burn Model System Database Study

Contractures can complicate burn recovery. There are limited studies examining the prevalence of contractures following burns in pediatrics. This study investigates contracture outcomes by location, injury, severity, length of stay, and developmental stage. Data were obtained from the Burn Model System between 1994 and 2003. All patients younger than the age of 18 with at least one joint contracture at hospital discharge were included. Sixteen areas of impaired movement from the shoulder, elbow, wrist, hand, hip, knee, and ankle joints were examined. Analysis of variance was used to assess the association between contracture severity, burn size, and length of stay. Age groupings were evaluated for developmental patterns. A P value of less than .05 was considered statistically significant. Data from 225 patients yielded 1597 contractures (758 in the hand) with a mean of 7.1 contractures (median 4) per patient. Mean contracture severity ranged from 17% (elbow extension) to 41% (ankle plantarflexion) loss of movement. Statistically significant associations were found between active range of motion loss and burn size, length of stay, and age groupings. The data illustrate quantitative assessment of burn contractures in pediatric patients at discharge in a multicenter database. Size of injury correlates with range of motion loss for many joint motions, reflecting the anticipated morbidity of contracture for pediatric burn survivors. These results serve as a potential reference for range of motion outcomes in the pediatric burn population, which could serve as a comparison for local practices, quality improvement measures, and future research.

"Living Well" After Burn Injury: Using Case Reports to Illustrate Significant Contributions From the Burn Model System Research Program

The Burn Model System (BMS) program of research has been funded since 1993 by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). The overarching aim of this program is to improve outcomes and quality of life for people with burns in the areas of health and function, employment, and community living and participation. This review reports on BMS contributions that have affected the lives of individuals with a significant burn injury using case reports to associate BMS contributions with recovery. In January 2020, current BMS grantee researchers assessed peer-reviewed BMS publications from 1994 to 2020. Using case report methodology, contributions were linked to three individuals treated at one of the four Burn Model System institutions. With over 25 years of NIDILRR funding, unique BMS contributions to patient recovery were identified and categorized into one of several domains: treatment, assessment measures, sequelae, peer support, employment, and long-term functional outcomes. A second review for significant results of BMS research that add to the understanding of burn injury, pathophysiology, and recovery research was identified and categorized as injury recovery research. The case study participants featured in this review identified select NIDILRR research contributions as having direct, personal benefit to their recovery. The knowledge generation and clinical innovation that this research program has contributed to our collective understanding of recovery after burn injury is considerable. Using case study methodology with three adult burn survivors, we highlight the impact and individual significance of program findings and reinforce the recognition that the value of any clinical research must have relevance to the lives of the study population.

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.

Burn model system national longitudinal database representativeness by race, ethnicity, gender, and age

INTRODUCTION

Representativeness of research populations impacts the ability to extrapolate findings. The Burn Model System (BMS) National Database is one of the largest prospective, longitudinal, multi-center research repositories collecting patient-reported outcomes after burn injury.

OBJECTIVE

To assess if the BMS Database is representative of the population that is eligible to participate.

DESIGN

Data on adult burn survivors who were eligible for the BMS Database from 2015 to 2019 were analyzed.

SETTING

Not applicable.

PARTICIPANTS

Burn survivors treated at BMS centers meeting eligibility criteria for the BMS Database. Eligibility for the database is based on burn size and receipt of autografting surgery.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Race, ethnicity, gender, and age were compared between individuals who did and did not enroll. Regression analysis examined the correlation between demographic characteristics and study enrollment. Additional regression analysis examined the association between enrollment and the intersection of race, ethnicity, and gender.

RESULTS

A total of 982 adult burn survivors were eligible for the BMS database during the study period. Of those who were eligible, 72.1% Enrolled and 27.9% were Not Enrolled. The Enrolled group included more female and more younger survivors compared to the Not Enrolled group. In regression analyses, Black/African American burn survivors were less likely and individuals identifying as female were more likely to enroll in the BMS Database. Furthermore, White men and women were more likely to enroll compared to Black/African American men and women, and non-Hispanic/Latino men were more likely to enroll compared to Hispanic/Latino men.

CONCLUSIONS

This study found differences in BMS Database enrollment by race, ethnicity, and gender. Further research is warranted to investigate causes for the disparities found in this study. In addition, strategies are needed to improve enrollment to ensure future representativeness.

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.

Lower limb functional status and its determinants in moderate/major burns 3-6 months following injury: A two-center observational study

INTRODUCTION

Severe complications which may cause impaired physical functionoften develops over time following severe burn to the lower extremities. The purpose of this study was to clarify the clinical determinants of lower limb functional status, functional mobility and exercise capacity in moderate/major burns 3-6 months following the injury.

METHODS

The study included 42 patients, 12 with moderate injury and 30 with major injury, aged 19-59 years old. Lower Limb Functional Index was used to determine the lower limb functional status. Functional mobility and exercise capacity were evaluated with the Timed Up and Go test and the 6-min walk test, respectively. Scar quality and kinesiophobia were assessed with the Patient and Observer Scar Assessment Scale (POSAS) and the Tampa Scale for Kinesiophobia, respectively. Active range of motion (ROM) was measured with a universal goniometer.

RESULTS

Significant and independent predictors of lower limb functional status, functional mobility and exercise capacity related to POSAS score, kinesiophobia level, gender, burn severity, the number of operations, the presence of burnsinvolving any of the lower limb joints, knee ROM limitations, limitation in any of the lower limb joint ROMs, comorbidities, and truncal burns (p < 0.05).

CONCLUSIONS

Burn characteristics and clinical evaluations of patients are important determinants of the lower limb functional status, mobility and exercise capacity in burn patients. These predictors should be considered to improve physical functions related to the lower limb when creating a personalized rehabilitation program.

A Scoping Review on the Long-Term Outcomes in Persons with Adult-Acquired Burn Injuries

Adult-acquired burn injuries are a life-altering event that can lead to debilitating functional or psychological impairments. With advancements in health care resulting in decreased mortality rates, survivors of burn injuries can expect to live longer. This warrants a shift in focus to better understand what happens to adults once they are discharged from the hospital into the community. Therefore, the purpose of this scoping review was to map the literature regarding the long-term outcomes of community-dwelling adult-acquired burn survivors. A computer-assisted literature search was conducted on literature from January 1, 2000 to August 31, 2018 utilizing four large databases (MEDLINE, EMBASE, CINHAL, and PsycINFO). Articles were included if they had a minimum of five individuals with a burn injury as a result of an accidental injury who were at least 18 years of age at the time of injury. Fifty-four articles were found suitable for inclusion in this review. The majority of studies were conducted in the United States and were longitudinal in design. Four themes were apparent from the articles: postburn complications, psychosocial outcomes, quality of life, and community participation. Data are lacking with respect to outcomes more than 5 years postburn as well as qualitative research. Furthermore, more literature is needed to understand the impact of postburn complications, coping strategies, and posttraumatic growth as well as barriers to community participation. Overall, there is an emerging body of literature that describes the long-term outcomes of adult-acquired burn survivors up to 5 years postburn.

Within-Patient, Single-Blinded, Randomized Controlled Clinical Trial to Evaluate the Efficacy of Triamcinolone Acetonide Injections for the Treatment of Hypertrophic Scar in Adult Burn Survivors

Intralesional corticosteroid (triamcinolone acetonide [TAC]) injections have become one of the cornerstone treatments of hypertrophic scar (HSc). However, the evidence is of limited-quality, and published investigations have almost exclusively been performed in linear scars rather than hypertrophic burn scars. Thus, the aim of this study was to perform an appropriately powered, single-blinded, randomized controlled trial to evaluate the impact of TAC injections on burn HSc compared with patient-matched usual care control scars. Fifty burn survivors with two scars (separated by nonscarred skin preferably on the contralateral side or an anatomically similar site) were selected based on high-frequency ultrasound thickness (&gt;2.034 mm to ensure that the site was outside of the range of normal scar). Pretreatment thickness measurements of the two sites were within 0.5 mm of each other, to ensure homogeneity and an erythema index &gt;300 to establish they were immature HSc. The sites were randomly assigned to treatment or control. The treatment HSc received a 10 mg/ml TAC. When necessary, the injection was repeated after 6 weeks and a third final injection 6 weeks later. Objective evaluation of thickness, elasticity, erythema, and melanin was obtained at the treatment and control sites at pretreatment, posttreatment, and follow-up 6 weeks after the last injection. Thirty participants completed the study, reaching the required number for an adequately powered sample based on pilot study data analyses. Ten participants received only one injection, 27 received only two injections, and 13 received three injections of TAC. Analysis of covariance comparing the treatment vs control HSc posttreatment, controlling for pretreatment values and Fitzpatrick skin type, revealed a significant decrease in thickness and increase in elasticity of the treated compared with control HSc (P = .0003), but no significant difference in erythema or melanin. Pretreatment to posttreatment comparisons using paired t-tests revealed a significant decrease in thickness of both the treated and control HSc, an increase in elasticity of the treated HSc during the treatment period, but no significant change in the control HSc elasticity or erythema of either site, and a significant increase in melanin of both the treated (P &lt; .001) and control (P = .02) HSc. A regression model for repeated measures, controlling for pretreatment values and skin type, revealed no significant change in thickness, elasticity, erythema, or melanin during the 6-week follow-up. Although thickness decreased at both the treated and control HSc across time, there was a significantly greater reduction at the TAC injected HSc and a significantly greater increase in elasticity. Melanin significantly increased at both the treatment and control site. There was no significant change during the follow-up period of any of the HSc characteristics.

Reconstruction of postburn contractures due to tandir oven

The aim of the study was to evaluate postburn contracture reconstructions caused by high temperature such as tandir. The records of our 58 patients who were operated for burn contracture between 2008 and 2018 were retrospectively reviewed. Duration elapsed after the burn, localization of contracture, surgery applied, and the recurrence rates were recorded. McCauley classification was used to evaluate the severity of hand contractures. One hundred and thirty-seven contracture release operations were performed in 45 hands in 40 cases. Five patients had bilateral hand contractures. One hundred and sixty-three (84.9%) surgeries out of total 192 contracture release surgery were applied to the hand and foot region. FTSG alone was the most common method of treatment. Z-plasty was used the most frequently by our team as the flap surgery. Tissue damage is more severe due to very high temperature of the tandir and as a result, more frequent and heavier burn contracture occurs on hands and feet than other burn etiologies develops, and reconstructive operations are needed more frequently.

The impact of discharge contracture on return to work after burn injury: A Burn Model System investigation

INTRODUCTION

Despite many advances in burn care, the development of extremity contracture remains a common and vexing problem. Extremity contractures have been documented in up to one third of severely burned patients at discharge. However, little is known about the long-term impact of these contractures. The purpose of this study was to examine the association of extremity contractures with employment after burn injury.

METHODS

We obtained data from the Burn Model System database from 1994 to 2003. We included in the study cohort all adult patients who were working prior to injury and identified those discharged with and without a contracture in one of the major extremity joints (shoulder, elbow, wrist, hip, knee and ankle). We classified contracture severity according to mild, moderate and severe categories. We performed descriptive analyses and predictive modeling to identify injury and patient factors associated with return to work (RTW) at 6, 12, and 24 months.

RESULTS

A total of 1,203 participant records met criteria for study inclusion. Of these, 415 (35%) had developed a contracture at discharge; 9% mild, 12% moderate, and 14% severe. Among 801 (67%) participants who had complete data at 6 months after discharge, 70% of patients without contracture had returned to work compared to 45% of patients with contractures (p < 0.001). RTW increased at each subsequent follow-up time point for the contracture group, however, it remained significantly lower than in no-contracture group (both p < 0.01). In multivariable analyses, female sex, non-Caucasian ethnicity, larger burn size, alcohol abuse, number of in-hospital operations, amputation, and in-hospital complications were associated with a lower likelihood of employment. In adjusted analyses, discharge contracture was associated with a lower probability of RTW at all 3 time points, although its impact significantly diminished at 24 months.

CONCLUSIONS

This study indicates an association between discharge contracture and reduced employment 6, 12 and 24 months after burn injury. Among many other identified patient, injury, and hospitalization related factors that are barriers to RTW, the presence of a contracture at discharge adds a significant reintegration burden for working-age burn patients.

An Examination of Follow-up Services Received by Vulnerable Burn Populations: A Burn Model System National Database Study

While disparities in healthcare outcomes and services for vulnerable populations have been documented, the extent to which vulnerable burn populations demonstrate disparities in long-term care is relatively underexplored. This study's goal was to assess for differences in long-term occupational or physical therapy (OT/PT) and psychological service use after burn injury in vulnerable populations. Data from the Burn Model System National Database (2006-2015) were analyzed. The vulnerable group included participants in one or more of these categories: 65 years of age or older, nonwhite, no insurance or Medicaid insurance, preinjury receipt of psychological therapy or counseling, preinjury alcohol and/or drug misuse, or with a preexisting disability. Primary outcomes investigated were receipt of OT/PT and psychological services. Secondary outcomes included nine OT/PT subcategories. Outcomes were examined at 6, 12, and 24 months postinjury. One thousand one hundred thirty-six burn survivors (692 vulnerable; 444 nonvulnerable) were included. The vulnerable group was mostly female, unemployed at time of injury, and with smaller burns. Both groups received similar OT/PT and psychological services at all time points. Adjusted regression analyses found that while the groups received similar amounts services, some vulnerable subgroups received significantly more services. Participants 65 years of age or older, who received psychological therapy or counseling prior to injury, and with a preexisting disability received more OT/PT and psychological or peer support services at follow-up. Overall, vulnerable and nonvulnerable groups received comparable OT/PT and psychological services. The importance of long-term care among vulnerable subgroups of the burn population is highlighted by this study. Future work is needed to determine adequate levels of follow-up services.

Demographic and Burn Injury-Specific Variables Associated with Limited Joint Mobility at Discharge in a Multicenter Study

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.

Joint flexibility problems and the impact of its operationalisation

BACKGROUND

Dissatisfaction is being voiced with the generally used way joint flexibility problems are defined (operationalised), i.e. as a range of motion (ROM) one or more degrees lower than normative ROM of healthy subjects. Other, specifically more function-related operationalisations have been proposed. The current study evaluated the effect of applying different operationalisations of joint flexibility problems on its prevalence.

METHOD

ROM data of 95 joints affected by burns of 23 children were used, and data on 18 functional activities (Burn Outcome Questionnaire (BOQ)). Five methods were used to operationalise joint flexibility problems: (1) ROM below normative ROM, (2) ROM below normative ROM minus 1SD, (3) ROM below normative ROM minus 2SD, (4) ROM below functional ROM, and (5) a score of 2 or more on the Likert Scale (BOQ).

RESULTS

Prevalence of joint flexibility problems on a group level ranged from 13 to 100% depending on the operationalisation used. Per joint and movement direction, prevalence ranged from 40% to 100% (Method 1) and 0% to 80% (Methods 2-4). 18% of the children received '2' on the Likert Scale (Method 5).

CONCLUSION

The operationalisation of joint flexibility problems substantially influences prevalence, both on group and joint level. Changing to a function-related operationalisation seems valuable; however, international consensus is required regarding its adoption.

TRIAL REGISTRATION

The study is registered in the National Academic Research and Collaborations Information System of the Netherlands (OND1348800).

Effectiveness of Paraffin and Sustained Stretch in Treatment of Shoulder Contractures Following a Burn Injury

OBJECTIVE

To examine if range of motion of the shoulder treated with paraffin will be better than that of the shoulder treated with sustained stretch alone.

DESIGN

Pilot randomized controlled trial.

SETTING

Regional burn center.

PARTICIPANTS

Patients (N=23) who sustained a burn injury, with a shoulder active abduction and/or flexion in the +70° to +150° degree range, who were 14 years or older, were receiving follow-up physical therapy after discharge from hospital, and provided a signed consent to participate.

INTERVENTIONS

Group A received sustained stretch and paraffin, and group B received sustained stretch only. Both groups had 6 sessions of treatment over 2 weeks.

MAIN OUTCOME MEASURES

Active range of motion (AROM) and active-assisted range of motion (AAROM) for shoulder flexion (SF) and shoulder abduction (SA) were measured before and after each treatment session.

RESULTS

For pretreatment measurements, only the results for SF AAROM had significant time effects. For posttreatment measurements, SF AROM and SF AAROM had significant effects for time. Session 1 was significantly lower than sessions 2, 3, 4, and 6 for both measures, and additionally, session 1 was significantly lower than session 5 for SF AAROM. For SA AROM, a group-by-time interaction effect was significant, with scores for the paraffin group relatively stable across sessions, and the nonparaffin group had peaks at sessions 3 and 6. There were no significant effects for (1) within-session changes to examine improvement during a session or (2) presession scores across the 6 sessions showing maintenance of motion. Total change from the first session presession measurement to the sixth session postsession measurement for the 2 treatment groups were nonsignificantly different.

CONCLUSIONS

As shown in this study, sustained stretching with paraffin may be a valuable adjunct to range of motion intervention for the shoulder after burn injury.

Botulinum Toxin A for Improving Lack of Ankle Dorsiflexion Range of Motion After Major Burns-A Retrospective Chart Review

OBJECTIVE

To review the effectiveness of botulinum toxin A (BTX-A) for treating the loss of maximum ankle dorsiflexion range of motion after burn injury.

DESIGN

Retrospective chart review.

SETTING

Large urban burn center.

PARTICIPANTS

Patients (3-51 y) with major burn injury and loss of ankle dorsiflexion range while hospitalized (N=5).

INTERVENTION

BTX-A treatment in addition to standard care.

MAIN OUTCOME MEASURES

Maximum ankle dorsiflexion range of motion at time of treatment, 1 month and 3 months posttreatment.

RESULTS

Patients' total burn area ranged from 18% to 95%, and time from injury to BTX-A injection (80-125 units) was 19-93 days. Ankle range at the time of injection was -10 to -50 degrees, and all patients had improved ankle range at 1 month postinjection (-30 to +10 degrees). At 3 months postinjection, 3 participants had neutral ranges of motion that were relatively improved compared to preinjection ranges. Patients with additional complications or severe injury showed regression toward preinjection maximum ankle dorsiflexion range of motion.

CONCLUSION

This retrospective study examines BTX-A as a potential tool for treating ankle plantar flexion contractures post major burn injury after failed conservative treatment. Initial review shows some patients may benefit from these injections, but more systematically designed studies are required to assess effectiveness. If effective, further investigation will be needed to validate and standardize treatment protocols, establish dosing, and assess long-term effectiveness in those with burn injury or severe complications.

Outcomes of Early Use of an End of Range Axilla Orthotic in Children Following Burn Injury

Scar contracture is a significant complication of burn injury. This study aimed to describe outcomes of early axilla orthotic use at end of range abduction in children, following a burn to the axilla region. A retrospective review of 76 children (mean age 3.9 years [SD 3.6]) treated at a tertiary children's hospital from 2006 to 2016 was conducted. No child developed axilla contracture for the duration of the 2-year study follow-up with no adverse events recorded. If orthotic use was ceased <60 days post-burn, it was considered not an essential intervention to maintain range of movement, leaving 49 children using the orthotic ≥60 days. Compared with the children who ceased orthotic use in <60 days, children who required the orthotic ≥60 days had a significantly higher frequency of deep-dermal burn (59 vs 25%, p = .01), flame mechanism (25 vs 5%, p = .03), and burn injury distribution involving the anterior trunk, flank, and arm (18 vs 3%, p = .03). Early signs of contracture, considered loss of full axilla range or significant banding, developed in nine children within 3 months post-burn. With intensive therapy, all returned to full axilla range by 9 months post-burn. Children with skin tension at end of range shoulder movement at the 1-month clinical assessment were 11 times more likely to develop early signs of contracture (95% confidence interval [CI]: 1.9-62.1, p = .007). Intensive orthotic use at end of range shoulder abduction in children with axilla burns is well tolerated. When undertaken with ongoing therapist review, full axilla range can be maintained.