Annals of Burns and Fire Disasters - vol. XVI - n. 3 - September 2003
THE ELIMINATION OF POST-BURN SCAR CONTRACTURES AND DEFORMITIES OF THE SHOULDER JOINT
Moroz V.Y., Yudenich A.A., Sarygin P.V., Sharobaro V.I.
Division of Reconstructive and Plastic Surgery, A.V. Vishnevsky Institute of Surgery, RAMS, Moscow, Russia
SUMMARY. Post-burn scar deformations and contractures of a humeral joint are observed in 20 to 50% of patients who suffer burns. Fifty-six patients with post-burn deformations and contractures of a humeral joint were treated in the Division of Reconstructive and Plastic Surgery at the A.V. Vishnevsky Institute of Surgery in Moscow. The analysis of the clinical material made it possible to develop a classification of scar contractures of this joint. Various methods of reconstructive operations using the intact skin from adjacent areas and free tissue transplantation are possible on this basis. The types of operation that were thus suggested permitted the elimination of contractures in the short term and the achievement of good functional and cosmetic effects.
The rehabilitation of patients who have suffered burns in the large joints, in particular the shoulder, remains a difficult problem in reconstructive surgery. Spontaneous epithelialization of burn wounds and late skin grafting result in various kinds of scar deformations and contractures. This significantly restricts physical and social rehabilitation after burns.
Skin scar contractures related to destruction of skin, subdermal fat, and fascia are very frequent. Secondary contractures involve muscles and tendons (shortening, serous induration, and scarring of tissues around a joint), after which joint contractures develop. Primary arthro-osseous contractures result from direct deep burns in a joint, leading to severe and irreversible processes.
Severe joint contractures also occur after extensive superficial II-III?- degree burns when there is growth of hypertrophic and keloid scars.
Surgical rehabilitation has an important social and economic role because of the increased number of patients with post-burn deformations and contractures, their difficulties of treatment, and the high aesthetic requirements. The development of reliable and effective methods of treating burns sequelae is therefore still a matter of great actuality.
Fifty-six patients with post-burn deformations and contractures of a humeral joint were treated in the Division of Reconstructive and Plastic Surgery at the A.V. Vishnevsky Institute of Surgery, Moscow. The age of the patients varied from 20 to 68 yr; 35 were male and 21 were female. Fifty-two patients had flame burns, while four had electric burns.
The burn localization around the joint area varied. The anterior and lateral surfaces were involved more often, and the posterior and internal surfaces less often. This localization of the burn and the subsequent scar growth was caused by the organism’s protective reactions - a joint flexes. As a result, the skin of an axillary fossa (elbow, knee) remains intact. Certain variants of joint contractures are thus formed.
On this basis, we offer the following classification of joint contractures:
When planning a reconstructive operation, we are guided by the anatomical arrangement of the scars, the presence of intact tissues around them, the probable configuration, and the depth and area of the wound formed after scar removal.
The treatment of unilateral contractures
The incision is made on the scar crest, which divides the tissues into two leaves: external (scar) and internal (healthy skin of an axillary fossa). The scar leaf is cut perpendicularly to the first incision. The trapezoid cutaneous flap from axillary tissues is dissected. Lymph nodes are not included in a flap. The flap’s trapezoid shape is due to the trapezoid form of the wound, which after scar excision interferes with the formation of linear scars. The shoulder is abducted. The wound thus formed is closed by the mobilized cutaneous flap. Donor wounds around the flap are closed by single suturing or with the help of small flaps from the scar leaf.
For the correction of the posterior shoulder joint contracture, the flap basis is at the anterior axillary surface (Figs. 1-3), of the anterior type, and vice versa (Figs. 4, 5).
The correction of medial contractures
Only pathologically changed scars are excised in these contractures. Anterior and posterior cutaneous tongue-shaped flaps are dissected from adjacent-lying tissues. The dissection site is determined by an area of normal skin and scar localization. The flaps are designed so that the axillary fossa can be closed by parallel placing of the flaps without formation of a linear scar.
Wounds on the shoulder and chest wall are closed by Z-plasty or, if necessary, by skin grafts.
In some cases of extensive scars in the axillary fossa there is normal skin over the area of the latissimus dorsi and deltoid muscles, which are a good source of plastic material.
Scars in the axillary fossa are excised. The trapezoid cutaneous flap is dissected over the latissimus dorsi muscle and rotated on the axillary wound. The flap size should be designed so that its distal edge reaches the deltopectoral furrow. The end of the flap is shaped like a swallowtail. This flap forms the axillary fossa; wounds to its side - in the internal shoulder surface and chest wall - are closed by skin grafting.
The elimination of total contracture
The reconstruction with local flaps is impossible because of the deficit of normal skin (Fig. 6). Skin grafting is used for contracture correction. However, the grafts frequently shrink, and the scar partly regenerates. This results in relapse of contractures and repeated surgical interventions.
We prefer to eliminate this contracture by a free flap transfer, and in particular by a scapular flap. This is rather large in area (10-30 cm), and has a long vascular pedicle and high skin and subdermal fat qualities.
The operation begins with complete scar excision in the axillary area and elimination of the contracture. The scapular flap, of appropriate size for a wound in the axilla, is then dissected. The donor wound is closed by local tissues, and the flap is transferred to the recipient wound. Certain difficulties may arise on flap placement in the axillary fossa and regarding the choice of recipient vessels. In a longitudinal flap placement in the axilla, it is expedient to anastomose the flap vessels with the humeral artery and vein, so that microanastomosis will be against the blood flow. The increase of size of arterial anastomosis by the formation of a platform from a wall of a donor artery does not exclude the danger of thrombosis of microanastomosis as a result of this turbulence. This can cause thrombosis of a humeral artery, and we therefore initiated a search for other, safer recipient vessels. A deltoid branch of the thoracoacromial artery and the vein accompanying it were chosen on the basis of anatomical research.
In the transverse flap position in an axillary area, the vascular pedicle is in a projection of the deltoid furrow where the vessels are located.
The wound in the axillary area is closed by the flap, which is fixed to wound edges. The skin and subdermal fat are excised in a projection of the deltoid furrow for allocation of a vascular pedicle with mobilization of an artery and a vein. Arterial and venous anastomoses are formed by the standard “end-to-end” technique. When the flap is viable it is sutured to the wound edges (Fig. 7). When a large free scapular flap is needed, we enlarge it by tissue expansion before the transfer.
Discussion and conclusions
The purposes of reconstructive operations in a shoulder joint are the removal of scarring, the elimination of contractures, and the restoration of full movement to a joint without the relapses of a contracture.
Various operations are performed for this purpose, but not all of them are applicable in reconstruction. In extensive scar contractures in a humeral joint, in the anterior and posterior surface of a humeral joint, and in the deltoid area the application of local cutaneous flaps is impossible. This kind of operation is possible if scars spread to one of side of the joint.
In some cases, skin in the axillary area remains intact. This circumstance makes it possible to use it for restoration of an armpit, and the wounds around it that form after scar incision are closed with skin grafts.
The most difficult operative treatment is in cases of a total form of contracture of the humeral joint, when the skin over the joint and adjacent-lying areas is burned.
The simplest manner of operating in this kind of deformation is the skin graft. A correction is made by scar incisions in the axillary area and elimination of the contracture, and the wound is closed by two or three wide split-thickness skin grafts.
The basic drawbacks of this method are partial graft lysis, shrinkage, the formation of underlying scars, poorly advanced subdermal fat, and scar regeneration of transplants in patients subject to keloidosis. As a result, shoulder joint function is restored only partially, and there is a relapse of contractures, requiring repeated operations.
The use of full-thickness skin grafts makes it possible to improve the final outcome, although surgical and aesthetic problems may occur on the closure of extensive donor wounds.
In cases of total scar deformation and contracture of a humeral joint we therefore use free scapular flap transfer.9 The normal tissue of a free flap permits the creation of good skin coverage and reliably eliminates contracture.
Long-term follow-up shows good adaptation of the free flap, the absence of contracture relapses, and good cosmetic effect (Fig. 8).
RESUME. On observe des déformations cicatricielles post-brûlure et des contractures d’une articulation humérale dans 20 à 50% des patients brûlés. Les Auteurs ont traité 56 patients atteints de déformations et de contractures post-brûlure d’une articulation humérale joint dans la Division de Chirurgie Reconstructrice et Plastique de l’Institut de Chirurgie A.V. Vishnevsky à Moscou. L’analyse du matériau clinique a permis le développement d’une classification des contractures cicatricielles de cette articulation. Sur cette base il est possible d’utiliser diverses méthodes d’opérations reconstructrices qui emploient la peau intacte des zones adjacentes et la greffe des tissus libres. Ces types d’opération ont permis aux Auteurs d’éliminer dans l’immédiat les contractures et d’obtenir de bons effets fonctionnels et cosmétiques.