An eighteen-year review of intensive care requirements for paediatric burns in a regional burns service

INTRODUCTION

Advances in burns management have reduced mortality. Consequently, efficient resource management plays an increasingly important role in improving paediatric burns care. This study aims to assess the support requirements and outcomes of paediatric burns patients admitted to a burns centre intensive care unit in comparison to established benchmarks in burns care.

METHOD

A retrospective review of burns patients under the age of 16 years old, admitted to a regional burns service intensive care unit between March 1998 and March 2016 was conducted.

RESULTS

Our analysis included 234 patients, with the percentage of TBSA affected by burn injury ranging from 1.5% to 95.0%. The median (IQR) %TBSA was 20.0% (11.0-30.0), and the observed mortality rate was 2.6% (6/234). The median (IQR) length of stay was 0.7 days/%TBSA burn (0.4-1.2), 17.9% (41/229) required circulatory support and 2.6% (6/234) required renal replacement. Mortality correlated with smoke inhalation injury (P < 0.001), %TBSA burn (P = 0.049) and complications (P = 0.004) including infections (P = 0.013).

CONCLUSIONS

Among children with burn injuries who require intensive care, the presence of inhalational injury and the diagnosis of infection are positively correlated with mortality. Understanding the requirements for organ support can facilitate a more effective allocation of resources within a burns service.

Tibialis Posterior Tendon Transfers to Correct Bilateral Postburn Ankle Equinus: A Case Report

ABSTRACT

Treatment of joint contractures after burn injury is challenging because various factors influence the treatment options including the lack of local tissue, significant fibrotic changes with associated loss of joint pliability, increased prevalence of infection in burn patients, and patient-related medical comorbidities.We present a case of a 60-year-old woman who had severe bilateral postburn ankle equinus deformities after self-immolation in the setting of significant soft tissue injury, fibrosis, and loss of joint movement. This deformity deprived her of the ability to walk, even aided, and she was unable to progress with her rehabilitation. We used the tibialis posterior tendon transfer to completely correct her postburn ankle equinus allowing for the restoration of both her feet to a neutral position, which enabled the patient to walk unaided after the surgery. This is a simple and effective solution to a complex problem when soft tissue reconstruction is limited. Patients with this complication are wheelchair dependent, and we suggest that posterior tibialis transfer should be considered as a surgical intervention for burns with severe equinus contracture even if there is a fixed deformity to allow for their full rehabilitation after injury.

St Andrew's COVID-19 surgery safety (StACS) study: The Burns Centre experience

Background

The COVID-19 pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has the potential to significantly impact burns patients both directly through infective complications of an immunocompromised cohort, and indirectly through disruption of care pathways and resource limitations. The pandemic presents new challenges that must be overcome to maintain patient safety; in particular, the potential increased risks of surgical intervention, anaesthesia and ventilation. This study comprehensively reviews the measures implemented to adapt referral pathways and mitigate the risk posed by COVID-19 during the height of the pandemic, within a large Burns Centre.

Methods

A prospective cohort study was designed to assess patients treated at the Burns Centre during the UK COVID-19 pandemic peak (April–May 2020), following implementation of new safety measures. All patients were analysed for 30-day mortality. In addition, a prospective controlled cohort study was undertaken on all inpatients and a random sample of outpatients with telephone follow-up at 30 days. These patients were divided into three groups (operative inpatients, non-operative inpatients, outpatients). COVID-19 related data collected included test results, contact with proven cases, isolation status and symptoms. The implemented departmental service COVID-19 safety adaptations are described.

Results

Of 323 patients treated at the Burns Centre during the study period, no 30-day COVID-19 related deaths occurred (0/323). Of the 80 patients analysed in the prospective controlled cohort section of the study, 51 underwent COVID-19 testing, 3.9% (2/51) were positive. Both cases were in the operative group, however in comparison to the non-operative and outpatient groups, there was no significant increase in COVID-19 incidence in operative patients.

Conclusions

We found no COVID-19 related mortality during the study period. With appropriate precautions, burns patients were not exposed to an increased COVID-19 risk. Similarly, burns patients undergoing operative management were not at a significantly increased risk of contracting COVID-19 in comparison to non-operative groups.

Early experience with fat grafting as an adjunct for secondary burn reconstruction in the hand: Technique, hand function assessment and aesthetic outcomes

INTRODUCTION

Fat transfer is increasingly used as part of our reconstructive armamentarium to address the challenges encountered in secondary burn reconstruction. The aim of this study was to review our experience with autologous fat transfer in relation to hand function, scarring and cosmesis, in patients undergoing secondary reconstruction after burns.

METHOD

Retrospective analysis of burn patients (2010-2013) who underwent autologous fat transfer to improve scarring, contour deformity and/or scar contracture was performed. Hand function was assessed using grip strength measurement, Total Active Movement (TAM), the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire and Michigan Hand Outcome Questionnaire (MHQ). Patients' satisfaction was assessed using the Patient Observer Scar Assessment Scale (POSAS).

RESULTS

Thirteen patients were included in this analysis. The average time from burns and from fat transfer were 2.3 years (10 months-3.9 years) and 9.1 months (3 months-1.3 years), respectively. There was a statistically significant improvement in TAM measurement. The total score, activity of daily living score and satisfaction score of the MHQ also statistically increased following fat transfer. The changes in function score, work score and pain score of the MHQ were not significant. Grip strength measurement and DASH score did not show improvement. For scar assessment, total score and overall score of POSAS improved significantly. Similarly, scores for scar colour, scar thickness, scar stiffness and scar regularity increased significantly.

DISCUSSION

Autologous fat transfer directly replaces volume loss in the subcutaneous layer, physically releases tethered skin from underlying tissues and exerts downstream regenerative effects. Skin quality improvements combined with replacement of the subcutaneous adipose volume in the hand reduces overall scar tightness and tissue tethering and has the potential to enhance hand therapy. In our series, modest improvement in range of movement, scar quality and hand outcome scores were demonstrated following a single session of fat transfer.

Copper wire theft and high voltage electrical burns

High voltage electrical burns are uncommon. However in the midst of our economic recession we are noticing an increasing number of these injuries. Copper wire is a valuable commodity with physical properties as an excellent conductor of electricity making it both ubiquitous in society and prized on the black market. We present two consecutive cases referred to the National Burns Unit who sustained life threatening injuries from the alleged theft of high voltage copper wire and its omnipresence on an international scale.

Prognostic scoring systems in burns: a review

Survival after burn has steadily improved over the last few decades. Patient mortality is, however, still the primary outcome measure for burn care. Scoring systems aim to use the most predictive premorbid and injury factors to yield an expected likelihood of death for a given patient. Age, burn surface area and inhalational injury remain the mainstays of burn prognostication, but their relative weighting varies between scoring systems. Biochemical markers may hold the key to predicting outcomes in burns. Alternatively, the incorporation of global scales such as those used in the general intensive care unit may have relevance in burn patients. Outcomes other than mortality are increasingly relevant, especially as mortality after burns continues to improve. The evolution of prognostic scoring in burns is reviewed with specific reference to the more widely regarded measures. Alternative approaches to burn prognostication are reviewed along with evidence for the use of outcomes other than mortality. The purpose and utility of prognostic scoring in general is discussed with relevance to its potential uses in audit, research and at the bedside.

Purpura fulminans skin loss: surgical management protocols at a regional burns centre

SUMMARY

People with significant skin loss after sepsis frequently require skin grafting; as such, they are often referred to regional burns units for definitive soft-tissue cover. Such individuals have complex requirements after severe sepsis, and usually have complicated wounds. We have developed a protocol for managing these patients and their wounds within a high dependency, intensive-care unit, using allograft as an adjunct in preparing the tissue bed before autografting. This protocol includes optimisation of nutritional needs, microbiological surveillance and definitive soft tissue cover. We retrospectively reviewed all children referred over 18 months for management of skin and soft tissue loss after meningitis purpura fulminans. We reviewed the initial management of the septicaemia, associated co-morbidities, site and size of soft tissue defect, time to presentation for definitive skin cover, surgical procedure performed, timing of surgical intervention, and recovery of the patient's wounds. A total of six people (all children), with a mean age of 7 months (age range 4-21 years) were admitted to our unit between March 2004 and September 2005. Total percentage skin loss was 12% (6-20%). All of the children underwent debridement, received allograft to areas of skin loss and necrosis as a primary procedure, and subsequently underwent autograft. Two children required amputation of one or more limbs, and the stumps were covered with allograft followed by skin autograft. All patients had excellent autograft skin taken using this protocol.

Idiopathic Granulomatous Mastitis: Surgery, Treatment, and Reconstruction

Idiopathic granulomatous mastitis is a rare inflammatory breast disease that mimics breast diseases such as inflammatory breast carcinoma, infective mastitis, and inflammatory breast disease of known cause. It is a diagnosis made only after excluding other causes, and although the disease is nonmalignant it may be both locally aggressive and recurrent. Definitive treatment may require radical excision and adjunctive treatment with immunosuppressants. Reconstruction following excision of disease has not been previously described. In those patients who undergo reconstruction, both the surgeon and the patient must be aware of complications associated with residual disease, and the potential involvement of donor sites. Treatment should be undertaken as part of a multidisciplinary team including surgeons and physicians with an interest in inflammatory breast disease. We present two patients diagnosed with idiopathic granulomatous mastitis who were referred to our unit for consideration of reconstruction. One patient underwent autologous breast reconstruction and the other contra lateral surgery to achieve symmetry.

Urethral Reconstruction Using the Radial Forearm Free Flap: Experience in Oncologic Cases and Gender Reassignment

OBJECTIVES

Urethra reconstruction in men remains a complex problem, particularly in patients who have had previous amputation for penile tumour or who have undergone gender reassignment. Many reconstructive techniques currently in use recreate the urethra but are prone to recurrent stricture formation and fail to achieve micturition with a good stream when standing. The authors propose using the radial forearm fasciocutaneous free flap as a single-stage technique of male urethral reconstruction.

METHODS

During 1999-2004, nine patients underwent microsurgical reconstruction of the male urethra using the radial forearm fasciocutaneous free flap. Three patients underwent urethral reconstruction following previous subcutaneous penectomy for penile cancer. Another six patients had urethral reconstruction performed after failure of primary urethra construction as part of their gender reassignment surgery.

RESULTS

The average age at the time of surgery was 35.1 yr (range: 22-55 yr) and average follow-up time was 41.8 mo (range: 13-55 mo). Flap reconstruction was successful in all cases, with no instances of free flap failure; however, two patients developed significant stenosis requiring revision, and no patients had postoperative fistula formation. Therefore, the success rate for urethral reconstruction after the first operation was seven of nine. Two patients with stenosis were treated operatively to release strictures with local flaps. Uroflowmetry demonstrated that these patients had satisfactory flow rates.

CONCLUSION

Patient satisfaction and objective studies have demonstrated that urethral reconstruction with the use of radial forearm free flap is a good reconstructive procedure particularly when the patients need an extensive and long urethral reconstruction.

The innervated free toe web flap for clitoris reconstruction

Clitoris reconstruction is often used in transgender reassignment. Most techniques now reconstruct the clitoris using glans pedicled on the dorsal phallic neurovascular bundle. Other techniques of clitoris reconstruction re-shape retained elements of the proximal segment of the corpora cavernosa, as well as techniques mobilising local flaps. We are presenting a new technique for clitoris reconstruction using an innervated free web space flap. The operative technique and outcome are illustrated and discussed in this case report.

Dual benefit procedures: combining aesthetic surgery with burn reconstruction

Burn accounts for a significant proportion of injuries, and of these, the face, neck, and anterior torso are commonly affected. Burn scars remain a lasting reminder of the insult both for the patient and the outside world. There is little doubt that the changes in appearance, and limitations imposed by the burn scar contribute to a negative body image. We present a series of four women, who sustained full thickness burns in childhood with subsequent burn scarring and contracture. These women were noted to have poor body image in areas less affected by burn injury, notably breast ptosis, breast asymmetry and abdominal skin laxity. They were suitable candidates for planned aesthetic procedures, and the skin excised was used to effect synchronous burn reconstruction or contracture release. We believe the potential to use areas of skin excised during aesthetic procedures as possible donor sites of full thickness skin, confers the dual benefits of improved aesthetic and functional outcome, while minimising unnecessary donor site morbidity.

Urethra reconstruction following resection of penile leiomyosarcoma

Leiomyosarcoma is a rare tumor, particularly in genital area. We present a case of penile lyomyosarcoma. Surgical treatment involved subcutaneous penectomy, preserving a sensate skin envelope, bilateral groin dissection and perineal urethrostomy. Reconstruction of the urethra and soft tissue was carried out using a free radial forearm flap. We believe that subcutaneous penectomy should be considered as a treatment option in selected cases of penile tumor as this facilitates urethral reconstruction.

Evidence of significant sternocleidomastoid atrophy following modified radical neck dissection type III

BACKGROUND

Although modified radical neck dissection type III preserves the spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle, the authors believe there is a significant morbidity to retained structures after neck dissection. Although the effects on accessory nerve function and internal jugular vein patency have been documented, there is little information about sternocleidomastoid morphology and function following modified dissection.

METHODS

Using a SonoSite ultrasound machine, the authors assessed sternocleidomastoid muscle morphology, at rest and during contraction, in a cohort of 45 patients who underwent modified radical neck dissection type III with no radiotherapy. All patients had head and neck cancers and received unilateral neck dissection as part of their primary treatment. Static and dynamic measurements were performed at three different levels of the muscle, with the neck in the neutral position. The contralateral neck of the same patient was used as a control. Local muscle asymmetry patterns were calculated using the Absolute Asymmetry Index.

RESULTS

Significant sternocleidomastoid atrophy was noted on the side of modified radical neck dissection type III (p < 0.05). The atrophy was particularly marked in the caudal and middle portions of the sternocleidomastoid muscle and was likely related to damage to the segmental blood supply in the caudal and middle portions of the muscle as well as injury to the innervation.

CONCLUSION

Despite evidence of significant atrophy, the muscle still underwent morphological changes during contraction that were comparable to those on the normal control side.

Successful free flap transfer following venous thrombectomy in recipient vessel

We report the case of a 53-year-old male patient who suffered a high velocity multiple trauma with bilateral open tibial fractures. At definitive orthopaedic and plastic surgical reconstruction 5 days post initial trauma, he was found peroperatively to have an existing deep venous thrombosis in his popliteal vein on one side. He underwent venous thrombectomy and had subsequent successful latissimus dorsi flap transfer using the unblocked popliteal vein as a recipient vessel.

Successful partial ear replantation after prolonged ischaemia time

We present the case of a 34-year-old male patient who had successful replantation of upper pole of pinna 33 h after amputation. As no vein was anastomosed, systemic heparinisation and subcutaneous injection of heparin to the replanted ear were used to encourage outflow. Complications included arterial spasm and bleeding. Management of similar cases as planned urgent cases rather than emergency cases is discussed.