Staged Management of Severe Postburn Contracture of Elbow and KneeA Prospective Interventional Study

Abstract

Introduction: Long-standing burns at major joints like the elbow and knee often lead to contractures, despite of best treatments and their management poses a great challenge owing to underlying contracted tendons, neurovascular bundle, and joint ligaments. Attempts at release and correction of contractures may lead to injury to the adjacent neurovascular structures. Aim: To evaluate the effectiveness of staged release as a means of definitive treatment of severe burn contracture. Materials and Methods: A prospective interventional study was conducted on 30 patients in the Department of Burns, Plastic and Reconstructive Surgery Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India, from December 2018 to December 2020. In the first stage, the maximum excisional release of contracture was done, avoiding any stretching of the neurovascular bundle, then bedside graded traction was applied at the joint until the complete release of contracture was observed. The resultant raw area was covered with a split-thickness skin graft in the second stage. The collected data included- site and side of the contracture, cause of initial burn, Improvement in flexion arc (in degrees), duration of splintage after surgical release, complications and Patient and Observer Scar Assessment Scale (POSAS). Paired t-tests were performed to analyse changes in preoperative versus postoperative measurements. Results: Eighteen cases of knee contractures and 12 cases of elbow contractures were included in the study. Among the patients that were analysed, 17 were females and 13 were males, with a female-to-male ratio of 1.3:1. The age range was 18-50 years, with a mean age of 36±8.79 years. The mean Range Of Motion (ROM) of elbow contracture with a severe degree of contracture improved from 25% of functional ROM to 124.29% at 6 months postoperatively. Similarly, the mean ROM of knee contracture with a severe degree of contracture improved from 25.76% of functional ROM to 102.58% at 6 months postoperatively. For both elbow and knee contracture cases the differences in mean ROM were statistically significant with all p-values <0.05. The average time at which the patients reported to the hospital, after developing contracture was 36.8 months, and it ranged from 24 months to 62 months. According to POSAS patient scale, the overall score was 6 and 5 for the elbow and knee respectively and the POSAS observer scale overall score was 6 for both the elbow and knee, respectively. Conclusion: The staged release procedure applied in the present study was an effective way of dealing with long-standing contractures with minimal complications.