Classification of Achilles tendon shortening induced by scar contracture and corresponding treatment strategies for pediatric patients - A single unit experience.

BACKGROUND: Achilles tendon shortening of pediatric patients caused by scar contracture poses a challenge for us. It always impairs walking function. In this article, we attempted to introduce a new classification of Achilles tendon shortening of pediatric patients and corresponding treatment strategies in our single center. METHODS: From 2001 to 2018, 65 patients (aging from 13 to 17-years-old, 34 females and 31 males, 21 cases with unilateral Achilles tendon shortening and 44 cases with bilateral Achilles tendon shortening) were recruited. The causes included trauma (n = 13), scald (n = 20) and burn (n = 32). The distance between the heel and the ground was from 3 to 18 cm. They were classified into three types: ≤5 cm, mild, n = 9; 5-10 cm, moderate, n = 30; ≥10 cm, serious, n = 26. They had a history from 7 months to 4 years (28 cases with less than 1.5 years and 37 cases with more than 1.5 years). Treatment methods: Scar-Achilles-Tendon (SAT) flaps and skin graft were used for moderate cases before special external fixation shoes were used for fixation for at least 6 months. External special shoes fixation was used for mild cases except 5cases still received SAT flap and skin graft. In serious cases, bone extraction was used for at least 6 months before receiving SAT flap and skin graft. RESULTS: The distance between the heel and the ground was 0 cm after treatment in 54 cases (mild, n = 9; moderate, n = 28; serious, n = 18). Recurrence was found in 11 cases (mild, n = 0; moderate, n = 5; serious, n = 6) after six months follow-up. There were 13 cases of tangential excision of eschar and 8 cases of escharectomy (P < 0.05) with flap necrosis affection. Among them, 9 cases with a medical history of less than 1.5 years had partial necrosis, 6 cases with a medical history of more than 1.5 years had partial flap necrosis(P < 0.05). Local necrosis was covered by skin graft again. Bone exposure was found in 5 serious cases. It was repaired by negative pressure therapy first and then skin graft was used. The walking ability (P < 0.05) and function (P < 0.05) of lower limbs were statistically improved after treatment. CONCLUSIONS: Different methods can be used according to the shortening degree of Achilles tendon of pediatric patients based on the new classification, which may be useful for future clinical work.

[Non-inflammatory muscle pain]. / Nichtentzündliche Muskelschmerzen.

Muscle pain as a common symptom in daily practice frequently occurs as a non-specific accompanying symptom in multiple internal and neurological diseases. Primarily inflammatory or autoimmune muscular diseases are causing muscle pain. However, a number of non-inflammatory causes of pain can also be considered for differential diagnosis. These are presented in this article. In principle, a distinction must be made between focal and diffuse muscle pain. As an invasive diagnostic procedure, a muscle biopsy should only be performed as the last step in the diagnostic alogorithm. If diffuse muscle pain is only associated with slight muscle weakness or is completely absent, there is usually a primary rheumatic cause. Statins (HMG-CoA reductase inhibitors) can lead to rhabdomyolysis, muscle fiber atrophy and muscle necrosis by damaging the muscle fiber membrane. Myotonias are autosomal dominant or autosomal recessive inherited disorders of muscle function. The genetic defect leads to pronounced muscle stiffness. The cause of metabolic myopathies can be disorders of the carbohydrate, fat or purine metabolism. Fibromyalgia syndrome (FMS) is a non-inflammatory disease and, according to the current knowledge, recognized as the result of an exposure to physical, biological and psychosocial factors (biopsychological disease model). To help diagnosing FMS, pain regions and core symptoms (fatigue, sleep disturbances) can be detected using questionnaires (Widespread Pain Index [WPI] and Symptom Severity Scale [SSS]).

Postburn Neck Contracture: Principles of Reconstruction and a Treatment Algorithm.

BACKGROUND: Various techniques have been developed for postburn neck reconstruction, but a treatment algorithm is needed. METHODS: We retrospectively reviewed all patients treated for postburn neck contracture at our institution between February 2008 and December 2015. Necks were divided into one anterior subunit and two lateral subunits marked by the sternocleidomastoid muscle. Deformities were categorized into three types according to their size and location. Type I deformities involve less than one subunit, type II deformities involve at least one subunit but less than two subunits, and type III deformities affect two or more subunits. Type II deformities were further divided into type IIa deformities, which mainly involve the anterior region, and type IIb deformities, which mainly involve the lateral region. RESULTS: Local random pattern flaps were constructed for type I deformities. Pedicled flaps from the anterior chest and supraclavicular areas were preferred for type IIa deformities, and pedicled flaps from the back were preferred for type IIb deformities. Pedicled flaps from other areas were the second choice for type II deformities, followed by free and prefabricated flaps. For type III deformities, bipedicled flaps were usually required. At a follow-up of at least 12 months, all patients showed near-normal neck function, and aesthetic features were significantly improved. CONCLUSION: The proposed classification and treatment algorithm for postburn neck reconstruction may help achieve satisfactory outcomes.

Outcome measures in older persons with acquired joint contractures: a systematic review and content analysis using the ICF (International Classification of Functioning, Disability and Health) as a reference.

BACKGROUND: Joint contractures are a common health problem in older persons with significant impact on activities of daily living. We aimed to retrieve outcome measures applied in studies on older persons with joint contractures and to identify and categorise the concepts contained in these outcome measures using the ICF (International Classification of Functioning, Disability and Health) as a reference. METHODS: Electronic searches of Medline, EMBASE, CINAHL, Pedro and the Cochrane Library were conducted (1/2002-8/2012). We included studies in the geriatric rehabilitation and nursing home settings with participants aged ≥ 65 years and with acquired joint contractures. Two independent reviewers extracted the outcome measures and transferred them to concepts using predefined conceptual frameworks. Concepts were subsequently linked to the ICF categories. RESULTS: From the 1057 abstracts retrieved, 60 studies met the inclusion criteria. We identified 52 single outcome measures and 24 standardised assessment instruments. A total of 1353 concepts were revealed from the outcome measures; 96.2% could be linked to 50 ICF categories in the 2nd level; 3.8% were not categorised. Fourteen of the 50 categories (28%) belonged to the component Body Functions, 4 (8%) to the component Body Structures, 26 (52%) to the component Activities and Participation, and 6 (12%) to the component Environmental Factors. CONCLUSIONS: The ICF is a valuable reference for identifying and quantifying the concepts of outcome measures on joint contractures in older people. The revealed ICF categories remain to be validated in populations with joint contractures in terms of clinical relevance and personal impact.

Development of an International Classification of Functioning, Disability and Health (ICF)-based standard set to describe the impact of joint contractures on participation of older individuals in geriatric care settings.

INTRODUCTION: Joint contractures are characterized as impairment of the physiological movement of joints due to deformity, disuse or pain and have major impact especially for older individuals in geriatric care. Some measures for the assessment of the impact of joint contractures exist. However, there is no consensus on which aspects should constantly be measured. Our objective was to develop a standard-set based on the ICF for describing functioning and disability in older individuals with joint contractures in geriatric care settings, giving special emphasis to activities and participation. METHODS: The ICF-based standard set was developed in a formal decision-making and consensus process and based on an adapted version of the protocol to develop ICF Core Sets. These are sets of categories from the ICF, serving as standards for the assessment, communication and reporting of functioning and health for clinical studies, clinical encounters and multi-professional comprehensive assessment and management. RESULTS: Twenty-three experts from Germany and Switzerland selected 105 categories of the ICF component Activities and Participation for the ICF-based standard set. The largest number of categories was selected from the chapter Mobility (50 categories, 47.6%). CONCLUSIONS: The standard set for older individuals with joint contractures provides health professionals with a standard for describing patients' activity limitations and participation restrictions. The standard set also provides a common basis for the development of patient-centered measures and intervention programs. The preliminary version of the ICF-based standard set will be tested in subsequent studies with regard to its psychometric properties.

Changes in burn scar contracture: utilization of a severity scale and predictor of return to duty for service members.

A medical records review of Operation Iraqi Freedom and Operation Enduring Freedom burn injury survivors admitted to the U.S. Army Institute of Surgical Research Burn Center from April 2003 to August 2005 was conducted. The study proposed the use of a newly developed scale, the Burn Scar Contracture Severity Scale, to potentially provide standardization in quantifying burn scar contracture severity. Changes in the active range of motion from in-patient discharge to out-patient follow-up of individuals with upper extremity burn injuries were compared. Changes in the impairment via American Medical Association impairment scores and perceived disability using the disabilities of the arm, shoulder, and hand questionnaire scores from the in-patient discharge to the out-patient follow-up were also compared. A weak, yet positive correlation (r = .417, .451, P ≤ .001) between the proposed scale and the disabilities of the arm, shoulder, and hand questionnaire and the American Medical Association impairment scores was found, respectively. A receiver operating characteristic curve analysis revealed a cut-off score of 6.5 for the burn scar contracture severity scale, indicating that individuals scoring below a 6.5 returned to duty and those scoring above 6.5 did not return to duty. Results suggest that the burn scar contracture severity scale is able to discriminate between the individuals who returned to duty and those who did not return to duty.

Shoulder adduction contracture after burn: anatomy and treatment with quadrangular local scar subcutaneous pedicled flap, a new approach.

BACKGROUND: Axillary adduction contracture is caused by scars that tightly surround the shoulder joint impairing the function of the upper limb. Due to severe scar surface deficiency, contracture release presents a challenge for surgeons since a method of release is transfer of tissue in the form of a large pedicled or free flap(s). Thus, development of simpler, less traumatic techniques, using local tissues, persists. METHODS: Anatomic studies of shoulder adduction contractures after burn (pre-operative, during surgery, post-reconstruction) were done in 346 pediatric and adult patients. All were divided into three groups according to contracture types: with edge contractures (80%), medial (6%) and total (14%). Anatomical study covered peculiarities of total contractures and possibilities for their treatment using local scarred tissue. RESULTS: Total contractures (48 patients) were caused by scars tightly surrounding the joint on three sides: anterior, posterior, and axillary. There were two specific forms of contracture: (a) shoulder close to the chest wall (22 of 48 patients) which was treated with thoracic pedicled or free flaps; (b) in 26 out of 48 patients a flat scar and skin graft surface laid along the shoulder and chest wall, in axillary projection, which were used for contracture release in the form of a subcutaneous pedicled quadrangular flap. The flap was mobilized only peripherally, descending to the apex of the axilla, forming the central axillary zone, and suspension of the axilla on a normal level. Wounds aside the flaps were covered with skin graft. Acceptable functional and cosmetic results were achieved in all 26 patients. CONCLUSION: Total shoulder adduction contractures have two forms: (a) shoulder close/fused with the chest wall; and (b) along the chest wall and shoulder there is a flat surface, the tissue of which can be used for reconstruction in a form of scar subcutaneous pedicled quadrangular flap. Based on this flap, a new technique is described which is relatively easy to perform.

[The surgical treatment of scars]. / La prise en charge chirurgicale des cicatrices.

Scars can be functionally or socially disabling. Many patients affected therefore request corrective surgery. The list of surgical techniques is long and the most frequently-used solutions are well-known.

Impact of joint contractures on functioning and social participation in older individuals--development of a standard set (JointConFunctionSet): study protocol.

BACKGROUND: Joint contractures are frequent in older individuals in geriatric care settings. Even though they are used as indicator of quality of care, there is neither a common standard to describe functioning and disability in patients nor an established standardized assessment to describe and quantify the impact of joint contractures on patients' functioning. Thus, the aim of our study is (1) to develop a standard set for the assessment of the impact of joint contractures on functioning and social participation in older individuals and (2) to develop and validate a standardized assessment instrument for describing and quantifying the impact of joint contractures on the individuals' functioning. METHODS: The standard set for joint contractures integrate the perspectives of all potentially relevant user groups, from the affected individuals to clinicians and researchers. The development of this set follows the methodology to develop an International Classification of Functioning Disability and Health (ICF) Core Set and involves a formal decision-making and consensus process. Evidence from four preparatory studies will be integrated including qualitative interviews with patients, a systematic review of the literature, a survey with health professionals, and a cross sectional study with patients affected by joint contractures. The assessment instrument will be developed using item-response-theory models. The instrument will be validated. DISCUSSION: The standard set for joint contractures will provide a list of aspects of functioning and health most relevant for older individuals in geriatric care settings with joint contractures. This list will describe body functions, body structures, activities and participation and related environmental factors. This standard set will define what aspects of functioning should be assessed in individuals with joint contractures and will be the basis of the new assessment instrument to evaluate the impact of joint contractures on functioning and social participation.

Postburn shoulder medial-adduction contracture: anatomy and treatment with trapeze-flap plasty.

BACKGROUND: Shoulder-adduction contractures after burn, most frequent among big joints, cause functional deficiency of the upper limb and, therefore, benefits from surgical correction. Many reconstructive techniques and flaps have been suggested for contracture treatment, but the problem in choosing an adequate reconstructive technique based on the anatomy of the contracture remains. Shoulder-adduction contracture has been given less emphasis in research than any other type and its surgical reconstructive technique remains of concern. METHODS: Anatomic features of scar shoulder-adduction contractures were studied in 346 patients, personally operated upon. This allowed us to classify all contractures into three types: edge, medial and total. New surgical techniques specifically for medial contractures were developed. RESULTS: Eighty percent of patients had edge contractures in which the axillary fossa was spared. In 20% of patients, axilla, including the hairy dome, was involved. These cases were anatomically classified into two types: medial, making up 30% of the cases, when contracted scars involved only axilla, and total caused by scars, tightly surrounding the shoulder joint. The scars, causing medial contracture, form a crescent-shaped fold along the medial axillary line. The fold's sheets are scars in which there is skin surface surplus in width, which allows the contracture release with local tissues. Surface deficiency in length has a trapezoid form. Medial contracture can be successfully treated with opposite transposition of trapezoid adipose-scar flaps prepared from both sheets of the fold. CONCLUSION: Medial shoulder-adduction contracture is a newly described type with specific anatomic features. Contracture can be successfully treated with local tissues using trapeze-flap plasty.

Ankle dorsiflexion postburn scar contractures: anatomy and reconstructive techniques.

BACKGROUND: Postburn ankle scar contractures cause functional limitations of all lower extremities and create a serious cosmetic defect, not allowing patients to use normal foot wear, and, therefore, needing surgical reconstruction. The anatomic features of ankle dorsiflexion contractures and their treatment have been covered in the literature far less than other joint contractures, and their treatment is still a challenge for many surgeons. A common treatment method is incisional release of the contracture and defect resurfacing with skin graft. Rarely, distally based sural or free flaps and Ilizarov fixator are used. METHODS: Anatomy of postburn ankle scar contractures in 55 patients was studied and contractures were surgically treated using a specific approach and technique. Follow-up results were observed from 6 months to 16 years. RESULTS: According to the anatomic features, dorsiflexion scar contractures were divided into three types: edge, medial, and total. Edge contractures were caused by burns and scars located on the lateral or medial ankle surface and were characterized by the presence of the fold along the anterior edge ankle; the skin of the anterior ankle surface was not injured. Medial contractures were caused by scars located on the anterior ankle surface and were characterized by the presence of the fold along the medial ankle line. Total contractures were caused by scars tightly surrounding the ankle. In fold's sheets of edge and medial contractures there is a trapeze-shaped surface deficit in length (cause of contracture) and a surface surplus in width which allows contracture release with local trapezoid flaps. For total contractures, wide scar excision and skin grafting were indicated. CONCLUSION: Three anatomic types of ankle dorsiflexion scar contractures were identified: edge, medial, and total. An anatomically justified technique for edge and medial contractures is trapeze-flap plasty; total contractures are effectively eliminated with scar excision and skin grafting.

Management of contractures: a five-year experience at Komfo Anokye Teaching Hospital in Kumasi.

BACKGROUND: Contractures are common complications of wounds healing by secondary intention; some cases are idiopathic and a few are congenital. Contractures cause significant morbidity to patients. OBJECTIVE: The study was undertaken to document the pattern, spectrum and management of patients with contractures of various types and aetiologies presenting at a Plastic and Reconstructive Surgical Unit in Ghana. DESIGN: Prospective study from January 2004 to December 2008. SETTING: Komfo Anokye Teaching Hospital (KATH) in Kumasi PATIENTS AND METHODS: The age, sex, site, extent and cause of contracture was documented. The patients were examined and functional impairment recorded. A clinical photograph was taken. Patients requiring surgery had their contractures released and the defect repaired with an appropriate reconstructive technique. Patients with minimal functional impairment underwent physical therapy without surgery. RESULTS: Sixty-eight patients comprising 44 males and 24 females were seen. Male to female ratio is 1.83:1. Their ages ranged from 0.66 to 60 years, mean age was 22.53 years. Seventy-six contractures were studied. Fifty-eight of the lesions were in the upper part of the body. Burns, infections and trauma were the main aetiological causes. Seventy-one surgical procedures were performed including release and flap repair (33), full thickness skin graft (23) and partial thickness skins graft and splinting (six). CONCLUSIONS: Thermal burns and soft tissue infections are the commonest causes of contractures presenting at KATH in Kumasi. These causes of contractures are preventable by early and adequate treatment of the acute conditions.

A new Ehlers-Danlos syndrome with craniofacial characteristics, multiple congenital contractures, progressive joint and skin laxity, and multisystem fragility-related manifestations.

We previously described two unrelated patients showing characteristic facial and skeletal features, overlapping with the kyphoscoliosis type Ehlers-Danlos syndrome (EDS) but without lysyl hydroxylase deficiency [Kosho et al. (2005) Am J Med Genet Part A 138A:282-287]. After observations of them over time and encounter with four additional unrelated patients, we have concluded that they represent a new clinically recognizable type of EDS with distinct craniofacial characteristics, multiple congenital contractures, progressive joint and skin laxity, and multisystem fragility-related manifestations. The patients exhibited strikingly similar features according to their age: craniofacial, large fontanelle, hypertelorism, short and downslanting palpebral fissures, blue sclerae, short nose with hypoplastic columella, low-set and rotated ears, high palate, long philtrum, thin vermilion of the upper lip, small mouth, and micro-retrognathia in infancy; slender and asymmetric face with protruding jaw from adolescence; skeletal, congenital contractures of fingers, wrists, and hips, and talipes equinovarus with anomalous insertions of flexor muscles; progressive joint laxity with recurrent dislocations; slender and/or cylindrical fingers and progressive talipes valgus and cavum or planus, with diaphyseal narrowing of phalanges, metacarpals, and metatarsals; pectus deformities; scoliosis or kyphoscoliosis with decreased physiological curvatures of thoracic spines and tall vertebrae; cutaneous, progressive hyperextensibility, bruisability, and fragility with atrophic scars; fine palmar creases in childhood to acrogeria-like prominent wrinkles in adulthood, recurrent subcutaneous infections with fistula formation; cardiovascular, cardiac valve abnormalities, recurrent large subcutaneous hematomas from childhood; gastrointestinal, constipation, diverticula perforation; respiratory, (hemo)pneumothorax; and ophthalmological, strabismus, glaucoma, refractive errors.

Reconstruction of the pediatric burned hand.

Though the hand constitutes only 3% of the total body surface area, a burned hand is a major injury. Reconstruction of the burned hand is key to the overall rehabilitation of the burned patient. Whether an isolated injury, or part of burns to a large overall body surface area, loss of the hand represents a major functional impairment. The American Burn Association recognizes the importance of the burned hand by designating it a major injury. In addition, loss of the hand constitutes a 57% loss of function for the whole person. Thus, successful management of the burned hand is important.

Clinical and morphological conditions in capsular contracture formed around silicone breast implants.

BACKGROUND: A study was performed to investigate histological changes in capsules formed around silicone breast implants and their correlation with the clinical classification of capsular contracture defined by the Baker score. For histological classification, the authors used the classification introduced by Wilflingseder, which identifies four grades of contracture. METHODS: The study included 24 female patients (average age, 40 +/- 12 years) with capsular contracture after bilateral cosmetic breast augmentation with smooth silicone gel implants (Mentor, Santa Barbara, Calif.). The Baker score was determined preoperatively for each patient. Samples of capsular tissue were obtained from all patients for histologic and immunohistochemical analyses. Capsular thickness, age of the collagen fibers, presence of synovia-like metaplasia on the inner surface of the capsule, number of histiocytes, giant cells, and other inflammatory cells, amount of silicone, foreign body granulomas, and capsule calcification were evaluated. RESULTS: There was a positive correlation between capsular thickness (p < 0.05) and Baker score. Silicone-containing deposits were found in all four histological capsule types. A trend toward greater capsular thickness was documented in patients with severe inflammatory reaction. These patients also had more clinical symptoms. Greater capsular thickness was associated with a higher number of silicone particles and silicone-loaded macrophages in the peri-implant capsule. CONCLUSIONS: The authors demonstrated a positive correlation (p < 0.05) between the clinical classification (Baker score I to IV) and the histological classification introduced by Wilflingseder (Wilflingseder score I to IV). An exact histological classification is needed to describe precisely the morphological changes in capsular contracture.

[Histological and immunohistochemical investigations with capsular contracture after breast augmentation with smooth silicone gel implants]. / Histologische und immunhistochemische Untersuchungen bei Kapselkontraktur nach glatten Brustimplantaten.

INTRODUCTION: A prospective study was performed to analyse the cellular and molecular composition of fibrous capsules around silicone breast implants. The necessity of an exact histological classification for comparing objectively the different findings of capsular contracture is shown. PATIENTS AND METHODS: The prospective study (investigation time 1/2003 to 6/2005) included 24 female patients (average age: 40+/-12 years) with contracture after bilateral cosmetic breast augmentation with smooth silicone gel implants (Mentor). In each patient the baker score was determined preoperatively. Samples of capsular tissue from all patients were evaluated histologically and immunohistochemically and classified according to the histological classification introduced by Wilflingseder and co-workers. RESULTS: All capsules showed the same basic histological structure with a three-layer composition. For the correlation analysis we had to exclude one patient with repeated implant change. There was no correlation between the patient's age, time of implantation, length of implant period, and capsular contracture. Greater amounts of silicone particles were associated with increased degrees of capsular contracture (Baker: r = 0.687, n = 23, p < or = 0.001; Wilflingseder: r = 0.784, n = 23, p < or = 0.001). High silicone amounts were associated with an increased local inflammation (r = 0.489, n = 23, p , 0.05). A moderate to severe local inflammation was found in 23 patients (95.8%). In summary, there was a positive correlation (r = 0.797, n = 23; p , or = 0.001) between the clinical classification (Baker score I to IV) and the histological classification (Wilflingseder score I to IV). CONCLUSIONS: We demonstrated in our study, in spite of using implants with high gel cohesiveness (fourth generation), the presence of vacuolated macrophages with microcystic structures containing silicone and silicone particles in the capsular tissue. Greater capsular thickness was associated with an increased number of silicone particles ans silicone-loaded macrophages in the peri-implant capsule. The histological classification introduced by Wilflingseder and co-workers takes into consideration this pathogenetic mechanism of inflammatory reaction which seems to be one of the major key factors in the development of capsular contracture.

Capsular contracture of the breast: working towards a better classification using clinical and radiologic assessment.

BACKGROUND: Breast reconstruction and augmentation have become a standard surgical treatment worldwide as advancements in medicine and technology enable safer and simpler procedures. A variety of implants is used to mimic a natural breast both in appearance and texture. The most common complication of such procedures is capsular contracture encircling the implant, occurring in approximately 10%. As to date, the contracture is mainly estimated by a physical examination of the breast, which is standardized according to the Baker score. METHODS: In a cross-sectional study, we compared the clinical assessment of capsular contractures to a radiologic thickness of the capsule, as evaluated by ultrasound (US) and magnetic resonance imaging (MRI). A total of 20 patients, with 27 implants, were evaluated in the study. All patients were examined by a single senior plastic surgeon and divided into 4 groups according to their clinical Baker score estimation. Following, a US imaging of the implant with emphasis on capsular evaluation was performed. The MRI results, recently done prior to the study, were reevaluated in relation to capsular findings. RESULTS: Thirteen breasts had a clinical capsular contraction with a Baker score of I, 8 breasts with a Baker score of II, and 6 breasts with a Baker score of III-IV. The US and MRI images of breasts graded III-IV revealed a thickened capsule (mean of 2.39 mm by US and 2.62 mm by MRI) compared with the capsular imaging of the breasts with the lower clinical Baker scores (mean of 1.14 mm by US and 1.39 mm by MRI). These differences were statistically significant according to the Kruskal-Wallis test, with P values of 0.002 and 0.017, respectively. Both MRI and US studies revealed distinct appearance of the thickened capsule. CONCLUSION: It seems the capsular thickness as portrayed by US and MRI correlates well with the Baker scoring system and at the same time provides the physician with an objective and consistent evaluation. However, since clinical assessment can be difficult to interpret at times, objective-imaging modalities can be effectively used to assess capsular thickening in women with a clinical suspicion of capsular contraction. A revised classification of capsular contracture, taking into account the imaging of the capsule, is suggested.

The classification and treatment algorithm for post-burn cervical contractures reconstructed with free flaps.

Neck contractures after burn produce restrictions in motion and unacceptable aesthetic outcomes. Proper planning and tissue selection is essential to minimize donor site morbidity while optimizing outcomes. A classification system and treatment algorithm aids in achieving this goal. Between December 1999 and January 2003, 40 burn patients underwent release and reconstruction with free perforator flaps. Neck extensibility and zone of injury were evaluated. Choice of reconstruction was based on available tissue, restriction degree and zones involved. Cervical territories were classified according to movement restrictions and amount of improvement. Reconstructive territories were classified as central above (CA), central below (CB), central above and below (CAB) and lateral (L). Single, split, double and preexpanded free flaps were used for the reconstructions. Maximal gain in motion was noted at 4 weeks and maintained for the average 11 months follow-up. Types of reconstructive territories showed significant effects on range of motion while etiology and time between injury and reconstruction showed no impact on the functional outcome. Classification of neck territories aids in improving outcomes while minimizing donor morbidity. The central above territory, when reconstructed with free flaps, yielded the most rewarding improvement. A classification and treatment algorithm aids in achieving significant improvements in range of neck motion while taking into consideration the donor sites.

A classification system for postburn mentosternal contractures.

HYPOTHESIS: Postburn mentosternal contractures can be clinically classified into 4 major groups based on the location of the contracting band(s) and extent of flexion or extension away from the anatomical position of the neck and jaws. Each group can be further subclassified depending on the width of the contracting segment(s) and availability of surrounding supple skin. DESIGN: Case series. SETTING: Nigerian subregional apex hospital specializing in plastic surgery, orthopedic surgery, and traumatology. PATIENTS: A consecutive sample of 41 patients with postburn mentosternal contractures who underwent surgery between 1997 and 2002 and 4 patients who had not yet had surgery, seen between January and March 2003. Data were obtained from operative records, photographic records, and interview of teams who treated the patients. During data collection, a classification system was devised in which mild, moderate, and severe anteriorly located contractures were designated types 1, 2, and 3, and posteriorly located contractures were considered type 4. Subtypes a through d were included to denote characteristics affecting reconstruction. RESULTS: The classification system was successfully used to classify postburn mentosternal contractures as a guide to management. Sufficient data were available to classify 32 of the 45 patients. The observers were not blinded. CONCLUSION: The classification system is useful in describing severity and guiding reconstructive options, but further study is required before it is used in choice of airway management for anesthesia.