A Rare Case of Multiple Scar Contractures after Burn Injury

A nine-year-old girl sustained extreme postburn contractures of the face, neck, both axillae, elbows, wrists, and ankles, due to flame injury 5 years ago. No primary and plastic surgical burn treatment was available in a remote area of China. From October, 2005 to April, 2007, all adhesions were released in five operations and the huge defects covered with local musculo-cutaneous flaps, z-plasties, and with thick split skin gafts. This led to an optimal functional result and an aesthetic restoration of the face, giving her, back her self-esteem in daily life.

Errors in visual estimation of flexion contractures during total knee arthroplasty

AIM: To quantify and reduce the errors in visual estimation of knee flexion contractures during total knee arthroplasty(TKA).METHODS: This study was divided into two parts: Quantification of error and reduction of error. To quantify error, 3 orthopedic surgeons visually estimated preoperative knee flexion contractures from lateral digital images of 23 patients prior to and after surgical draping. A repeated-measure analysis of variance was used to compare the estimated angles prior to and following the placement of the surgical drapes with the true knee angle measured with a long-arm goniometer. In an effort to reduce the error of visual estimation, a dual set of inclinometers was developed to improve intraoperative measurement of knee flexion contracture during TKA. A single surgeon performed 6 knee extension measurements with the device during 146 consecutive TKA cases. Three measurements were taken with the desired tibial liner trial thickness, and 3 were taken with a trial that was 2 mm thicker. An intraclass correlation coefficient(ICC) was calculated to assess the testretest reliability for the 3 measurements taken with the desired liner thickness, and a paired t test was used to determine if the knee extension measurements differed when a thicker tibial trial liner was placed.RESULTS: The surgeons significantly overestimated flexion contractures in 23 TKAs prior to draping and significantly underestimated the contractures after draping(actual knee angle = 6.1°± 6.4°, pre-drape estimate = 6.9°± 6.8°, post-drape estimate = 4.3°± 6.1°, P = 0.003). Following the development and application of the measurement devices, the measurements were highly reliable(ICC = 0.98), and the device indicated that 2.7°± 2.2° of knee extension was lost with the insertion of a 2 mm thicker tibial liner. The device failed to detect a difference in knee extension angle with the insertion of the 2 mm thicker liner in 9/146 cases(6.2%).CONCLUSION: We determined the amount of error associated with visual estimation of knee flexion contractures, and developed a simple, reliable device and method to improve feedback related to sagittal alignment during TKA.

Modified Z-Plasty for Reconstruction of Webbed Scar Contractures

Rationale: Webbed scar contractures deformity caused by burns and other factors will lead to joint disorders and affect the mental health of patients, resulting in a severe decline in quality of life. Rapid, effective and less complicated surgical methods can help patients with post-burn rehabilitation. Objective: This article argues that a modified Z-plasty can quickly improve the range of motion caused by webbed scar contractures in joint areas, including surgical methods, postoperative care and prognosis. Methods and Results: The study took place from 2018 to 2022. Thirty-two patients with joint scar contracture deformity, with a mean age of 32.5 years, were included in the study. All patients underwent contracture scar revision and modified Z-plasty repair under anesthesia. All the flaps survived and the joint function was improved. Compared with the traditional Z-plasty, the duration of the operative procedure of the modified Z-plasty was significantly shorter, more surrounding scar tissue was mobilized, and the effectiveness of postoperative scar contracture release was better. Discussions: The modified Z-plasty for scar contracture deformity in joint area is simple, rapid, effective and easy to manage.

“Syndrome of Contractures”According to Prof.Hans Mau;Problems of Shanks,Knees,Hips,Pelvis and Spine;Children,Adolescents,Adults,Diagnosis,Treatment

The problems of movement apparatus in children, youth and even adolescents aren’t connected with “a weakness of muscles” but with a shortening of muscles, tendons, and capsules which in orthopaedic literature is called “contracture” [1] [2] [3] [4]. The older way of thinking about the problem was based on the conviction that “weak muscles” cause and make problems;we, however, present on many examples that “restriction of movements” doing by shortening of soft tissues makes contracture and incorrect position of joints, body parts, the serious and frequent clinical problems.

Surgical Treatment of Complex Axillary Scare Contractures: One Case Report

Background: Axillary scar contracture is frequently observed after severe burn insult and is usually accompanied by scarred adjacent area. These scars result in adduction deformity, which may be severe and diffuse. The lack of adequate treatment in the acute phase leads to complex scars that require different surgical techniques depending on the clinical examination of surgeon. Aim: Expose the possible surgical techniques, their advantages and disadvantages in the case of burning of the entire axillary hollow. The surgical management of linear scares contractures will not be discussed in this article. Case presentation: This is a rare clinical case of a 12-year-old girl who was burned at the age of 5 with disabling functional sequelae of the axillary area (limitation of the abduction to 30 degrees). The patient is treated at ALGHASSANI Hospital in Fes city/Morocco. Parental consent was taken for scientific publication. Results: We did two surgical interventions: the first starting with excision of the scar tissue leaving a loss of skin covered by a laterothoracic IC fasciocutaneous flap. The second one was a semi-thick skin graft to cover the supero and infero external quadrants of the left breast. We obtain the abduction at 110 degrees. Conclusion: Early surgical management of deep lesions within 21 days of the burn associated with prolonged rehabilitation and the wearing of compression garments and splints are essential elements in the prevention of these axillary contractures.

Joint contractures in severe burn patients with early rehabilitation intervention in one of the largest burn intensive care unit in China:a descriptive analysis

Background:Joint contracture is the major clinical complication in burn patients,especially,the severe burn patients.This study aimed to investigate the number and severity of joint contractures in patients with burns affecting greater than or equal to 50%of the total body surface area(TBSA)undergoing early rehabilitation in a burn intensive care unit(BICU).Methods:We analyzed burn patients with burns affecting greater than or equal to 50%of the TBSA admitted to a BICU who received early rehabilitation within 7 days post-injury from January 2011 to December 2015.Demographic and medical information was collected.The range of motion(ROM)of different joints was measured 1 month post-admission.Spearman’s correlation coefficient and logistic regression analysis was used to determine predictors of the presence and severity of contractures.Result:The average affected TBSA of the included burn patients was 67.4%,and the average length of stay in the BICU was 46.2±28.8 days.One hundred and one of 108 burn patients(93.5%)developed at least one joint contracture.The ROM in 67.9%of the affected joints was mildly limited.The majority of contractures in severe burn patients were mild(37.7%)or moderate(33.2%).The wrist was the most commonly affected joint(18.2%),followed by the shoulder,ankle,hip,knee,and elbow.A predictor of the presence of contractures was the length of hospital stay(p=0.049).The severe contracture was related to the area of full-thickness burns,the strict bed rest time,and the duration of rehabilitation in BICU.The length of rehabilitation stay(days)in patients with moderate contracture is 54.5%longer than that in severe contracture(p=0.024)Conclusion:During the long stay in BICU,the length of rehabilitation stay in a BICU could decrease the severity of contractures from severe to moderate in the patients with equal to 50%of the TBSA.Hence,this research reveals the important role of early rehabilitation interventions in severe burn patients.

A review and critical appraisal of central axis flaps in axillary and elbow contractures

Contractures of the axilla and elbow can produce a significant impact on quality of life by reducing the ability to perform activities of daily living. Varieties of techniques are available for resurfacing defects following contracture release but graft or flap loss, donor-site morbidity, esthetics, and recurrences are still challenges for reconstructive surgeons. Central axis 'propeller' flaps based on a random, subcutaneous pedicle were first described for axillary and elbow contractures to deploy the unburnt skin of axillary dome in type Ⅰ and Ⅱ contractures (Kurtzman and Stern) by moving them 90° to straddle the contracting bands. This strategy provided better esthetics and avoided prolonged splinting. Over more than two decades, there have been several design modifications of these flaps with extended applications to cubital fossa. A comprehensive review of published literature on the topic is presented to discuss classifications, design modifications, and applications of such flaps in managing axillary and elbow contractures.

Perforator-based flaps for the treatment of burn scar contractures: a review

Patients with burn scars often experience functional problems because of scar contractures. Surgical treatment may be indicated for those burn scar contractures. If the contractures are small and linear, the contraction bands can be treated with local transposition flaps like the Z-plasty. Broader, diffuse contractures are more challenging and require a different surgical approach, such as the use of local tissue. The use of perforator-based flaps is promising;however, their true clinical significance for this type of burn reconstructions still needs to be determined. Therefore, we performed a review to evaluate the role of perforator-based flaps for burn scar contracture treatment. Electronic databases were searched using a predefined search strategy. Studies evaluating the long-term outcome of perforator-based flaps for the treatment of burn scar contractures were included. The methodological quality was tested and data was summarized. Five hundred and ten papers were identified of which eleven met the inclusion criteria. One study was a randomized controlled trial;ten were cohort studies of a pre-postoperative design. The papers described outcomes of free flaps and local flaps. Most studies had methodological shortcomings and used inappropriate statistical methods. Perforator-based interposition flaps appear to be highly relevant for burn scar contracture treatment. However, due to the paucity and low quality of the studies that were assessed, no definitive conclusions about the true clinical significance could be reached. And therefore, only recommendations could be given for improvement of the quality of further primary research on the effectiveness of perforator-based flaps for burn scar contracture release.

3D printing of patient-specific neck splints for the treatment of post-burn neck contractures

Dear Editor,Burn scar contracture is a common problem in healing burn wounds of the neck. It can cause both pain and dysfunction if not treated adequately (1)The treatment of such wounds often involves a combination of surgery and splinting therapy (2)A variety of splints, including the thermoplastic static neck splint [3], the Watusi collar [4], manually fabricated splints, and pre-fabricated splints such as the Philadelphia collar have been used for the management of scar contractures. However, each type of splint has its own advantages and disadvantages, and none of these splints seem to reduce the need for skin reconstruction nor delays the time until surgical re-construction [5].

Outcome ofJudet＇s quadricepsplasty for knee contractures and the effect of local infiltration of epinephrine on reducing blood loss

Objective： To evaluate the effectiveness ofJudet＇s quadricepsplasty for treatment of knee contractures and to identify the effect of local infiltration of epinephrine on blood loss associated with this procedure. Methods： A retrospective cohort study was conducted in which all cases of knee contractures managed with Judet＇s quadricepsplasty from 1st January 2009 to 31st December 2013 were included and were divided into two groups. The epinephrine group included patients who were infiltrated with diluted epinephrine （1：400,000） along with xylocaine, around the operative field 15 min prior to the incision time, while the control group did not receive any infiltration. Judet＇s outcome, blood loss, drop in he- moglobin and required blood transfusion were noted for all patients and compared between both groups. Results： Most common preceding pathology identified for the development of knee contractures was periarticular fracture while ilizarov application was the most common etiology. Both groups were found similar in all preoperative characteristics except preoperative flexion contracture （p = 0.02）. All func- tional outcome measures including Judet＇s outcome were similar in both groups. In contrast, duration of surgery （p = 0.01）, blood loss （p = 0.02）, drop in hemoglobin （p = 0.01） and number of transfusions （p = 0.03） were significantly reduced in epinephrine group. Conclusion： Judet＇s quadricepsplasty is a useful procedure to increase the range of motion of rigid knees and local infiltration of epinephrine is effective in decreasing the amount of subsequent blood loss and transfusion requirements.

Dupuytren’s disease:A review

Dupuytren’s disease is a well-known benign fibroproliferative disorder that affects the palmar and digital fasciae of the hands.This spectrum includes nodule formation,cord formation,and flexion contracture of the digits,which may result in functional limitations.These deformities are often progressive and irreversible.Surgery is a cornerstone therapy.This review discusses the epidemiology,pathophysiology,risk factors,clinical manifestations,and management of Dupuytren’s disease.

Nursing Care and Causative Analysis of Grade IV Capsular Contracture Following Breast Cancer Expander Implantation

Objective: By observing the treatment and nursing care of a patient with Grade IV capsular contracture following breast cancer expander implantation and subsequent Stage II reconstruction, we aim to analyze the reasons for the formation of capsular contracture after Stage I expander implantation and prevent its recurrence following Stage II reconstruction. Methods: In May 2020, the patient noticed an increase in the size of a breast mass. In August, she underwent AC-THP neoadjuvant chemotherapy, followed by a “right breast-conserving nipple-areolar subglandular excision + right axillary lymph node dissection + expander implantation” surgery in November 2020. Radiation therapy began in January 2021. During radiation therapy, the patient experienced severe breast hardening, distortion, tenderness, and was diagnosed with Grade IV capsular contracture. To relieve the capsular contracture, the patient underwent a “contracted capsule incision and release procedure + removal of the right breast expander + right breast implantation” surgery in July 2021. Postoperatively, measures were taken to prevent incision infection, emphasizing aseptic techniques, ensuring smooth negative pressure drainage, reducing skin flap tension, monitoring skin flap blood supply, actively preventing subcutaneous effusion and hematoma, and applying appropriate compression dressings. Results: The patient was discharged after the removal of the drainage tube. During the postoperative follow-up at 3 and 6 months, there was no recurrence of capsular contracture, and the breast appeared full, upright, and relatively soft. There were no complications such as hematoma, infection, breast implant rupture, breast sagging, or displacement. The patient had a good outcome without additional financial or surgical burdens. Conclusion: The occurrence of Grade IV capsular contracture in the patient is generally related to infection after Stage I expander implantation, improper compression dressing, excessive saline injection causing content infiltration, and radiation therapy. Therefore, it is recommended to enhance the intraoperative and postoperative prophylactic use of antibiotics after Stage I expander implantation. Intermittent saline injection after surgery, with the amount of saline gradually increasing rather than filling all at once, is advisable. This helps the breast tissue gradually adapt to expansion, reducing the risk of capsular contracture. Postoperatively, patients should be instructed to wear pressure garments and breast elastic bandages while intensifying breast monitoring during radiation therapy and increasing postoperative follow-up.

Compound heterozygous mutation of MUSK causing fetal akinesia deformation sequence syndrome: A case report

BACKGROUND Fetal akinesia deformation sequence(FADS)is a broad spectrum disorder with absent fetal movements as the unifying feature.The etiology of FADS is heterogeneous and mostly still unknown.A prenatal diagnosis of FADS relies on clinical features obtained by ultrasound and fetal muscle pathology.However,the recent advances of next-generation sequencing(NGS)can effectively provide a definitive molecular diagnosis.CASE SUMMARY A fetus presented after 24 wk and 6 d of gestation with absent fetal movements and multiple abnormal ultrasonographic signs.The mother had had a previous abortion due to a similarly affected fetus a year before.A clinical diagnosis of FADS was made.The parents refused cord blood examination and chose abortion.A molecular diagnosis of fetal muscle using NGS of genes found a compound heterozygous mutation in the MUSK gene:c.220C>T(chr9:113449410 p.R74W)and c.421delC(chr9:113457745 p.P141fs).CONCLUSION To our knowledge,this is the first report in China showing that a mutation in MUSK is associated with FADS.This supports previous finding that a lethal mutation of MUSK will cause FADS.A precise molecular diagnosis for genetic counseling and options for a prenatal diagnosis of FADS are very important,especially for recurrent FADS;this may also provide evidence for both prenatal and preimplantation genetic diagnoses.

The Role of Orthotic Service in Modern Rehabilitation of Patients with Charcot-Marie-Tooth Disease

Charcot-Marie-Tooth (CMT) disease, which encompasses several hereditary motor and sensory neuropathies, is one of the most common neuro-muscular disorders. 80% of patients having CMT disease are diagnosed with per cavus deformity. Orthosis is widespread and varies widely in forms. The paper arises the necessity of habilitation at the earliest possible stage as only a few patients use it. The meta-analysis of 412 scientific papers concerning this problem demonstrates the getting better gate, balance and the stopping CMT progression which is scientifically proven. It is also shown that patients with CMT use low prevalence of orthotics, and demonstrate low compliance of patients (for various reasons), high expectations from this habilitation technique.

A Retrospective Analysis of the Gluteal Muscles Contracture and Discussion of the Relative Problems

Summary: The operation methods, clinical classification, postoperative function exercise of gluteal muscles contracture were investigated. Clinically and retrospectively, treatment of 1280 patients with gluteal muscles contracture, being subjected to a 'Z-shaped' release lengthening operation and efficiency exercise, was clearly standardized. All the cases were followed up from 3 months to 2 years with the effective rate being 100 %, the cure rate being 98. 5 %, the recent complications being 5%, and the far complications being 0. 2 %. It was concluded that the clear diagnosis combined with standarized operation and efficiency functional exercise could greatly improve the therapeutic effects of gluteal muscles contracture.

Treatment of Severe Gluteal Muscle Contracture in Children

To investigate the efficacy of a combination therapy on gluteal muscle contracture, 286 definitely diagnosed patients were subjected to surgical treatment, and then functional exercises and physical therapy. The patients with severe symptoms were asked to have a set of specially-designed functional exercises. All the patients were followed up for 3 to 24 months by hospital visit, correspondence or telephone interview. The effective rate was 100%, and the curative rate was up to 94.6%. Few patients developed complications and relapse was rare. It is concluded that the combination therapy, including surgical removal of diseased tissues, functional exercises and physical therapy, is an effective approach for the treatment of severe juvenile gluteal muscle contracture.

Evaluation and treatment of internal impingement of the shoulder in overhead athletes

One of the most common pathologic processes seen in overhead throwing athletes is posterior shoulderpain resulting from internal impingement. "Internal impingement" is a term used to describe a constellation of symptoms which result from the greater tuberosity of the humerus and the articular surface of the rotator cuff abutting the posterosuperior glenoid when the shoulder is in an abducted and externally rotated position. The pathophysiology in symptomatic internal impingement is multifactorial,involving physiologic shoulder remodeling,posterior capsular contracture,and scapular dyskinesis. Throwers with internal impingement may complain of shoulder stiffness or the need for a prolonged warm-up,decline in performance,or posterior shoulder pain. On physical examination,patients will demonstrate limited internal rotation and posterior shoulder pain with a posterior impingement test. Common imaging findings include the classic "Bennett lesion" on radiographs,as well as articular-sided partial rotator cuff tears and concomitant SLAP lesions. Mainstays of treatment include intense non-operative management focusing on rest and stretching protocols focusing on the posterior capsule. Operative management is variable depending on the exact pathology,but largely consists of rotator cuff debridement. Outcomes of operative treatment have been mixed,therefore intense non-operative treatment should remain the focus of treatment.

Diabetic foot:Which one comes first,the ulcer or the contracture?

Diabetic foot is among the most common complications of patients with diabetes.One of the known causes of foot ulceration is ankle equinus,which increases the pressure on the plantar surface during ambulation.Conversely,equinus contracture can be caused by a complicated wound,and it may be due to prolonged immobilization.In this paper,we reviewed the pathogenesis of both conditions and their clinical considerations.Poor glycemic control in patients with diabetes may result in angiopathy and neuropathy as an underlying condition.An ulcer can be precipitated by an injury,improper foot care,or increased biomechanical loading as seen in elevated plantar pressure following equinus contracture.Equinus contracture may be a direct effect of hyperglycemia or can arise in combination with another pathway,for example,involving the activation of transforming growth factorβ.Static positioning resulting from any prior foot wound may develop fibrotic changes leading to contracture.Wound healing promoting factors can also result in overhealing outcomes such as hypertrophic scarring and fibrosis.The body’s repair mechanism during the healing cascade activates repair cells and myofibroblasts,which also serve as the main producers and organizers of the extracellular matrix.Considering this intricate pathogenesis,appropriate interventions are essential for breaking the vicious cycle that may disturb wound healing.

Multiple rare causes of post-traumatic elbow stiffness in an adolescent patient: A case report and review of literature

BACKGROUND Joint stiffness after elbow surgery is not a rare complication,and is always accompanied by deformity.The causes of joint stiffness are multiple in different patients,and divided into intrinsic and extrinsic causes.Herein,we report an unusual case of posttraumatic elbow stiffness due to multiple and rare causes.CASE SUMMARY A 19-year-old male was hospitalized with the loss of motion of the left elbow for over ten years.Left limb computed tomography revealed left elbow stiffness with bony block and connection.The patient underwent surgery,and the etiology of joint stiffness was found to be a rare combination of common and uncommon causes.During an 18-mo follow-up period,the patient’s left elbow had normal motion and he was symptom-free.CONCLUSION However,this case combined with multiple and rare causes highlights that the patient with scar physique is likely to be accompanied with more severe soft tissue,nerve contracture,and heterotypic ossification,even during recurrence.

Formation process of extension knee joint contracture following external immobilization in rats

BACKGROUND Current research lacks a model of knee extension contracture in rats.AIM To elucidate the formation process of knee extension contracture.METHODS We developed a rat model using an aluminum external fixator.Sixty male Sprague-Dawley rats with mature bones were divided into the control group(n=6)and groups that had the left knee immobilized with an aluminum external fixator for 1,2,and 3 d,and 1,2,3,4,6,and 8 wk(n=6 in each group).The passive extension range of motion,histology,and expression of fibrosis-related proteins were compared between the control group and the immobilization groups.RESULTS Myogenic contracture progressed very quickly during the initial 2 wk of immobilization.After 2 wk,the contracture gradually changed from myogenic to arthrogenic.The arthrogenic contracture progressed slowly during the 1^(st) week,rapidly progressed until the 3^(rd) week,and then showed a steady progression until the 4^(rd) week.Histological analyses confirmed that the anterior joint capsule of the extended fixed knee became increasingly thicker over time.Correspondingly,the level of transforming growth factor beta 1(TGF-β1)and phosphorylated mothers against decapentaplegic homolog 2(p-Smad2)in the anterior joint capsule also increased with the immobilization time.Over time,the cross-sectional area of muscle fibers gradually decreased,while the amount of intermuscular collagen and TGF-β1,p-Smad2,and p-Smad3 was increased.Unexpectedly,the amount of intermuscular collagen and TGF-β1,p-Smad2,and p-Smad3 was decreased during the late stage of immobilization(6-8 wk).The myogenic contracture was stabilized after 2 wk of immobilization,whereas the arthrogenic contracture was stabilized after 3 wk of immobilization and completely stable in 4 wk.CONCLUSION This rat model may be a useful tool to study the etiology of joint contracture and establish therapeutic approaches.