Correction of postburn equinus deformity.

BACKGROUND: Equinus deformity is characterized by an abnormal tiptoe gait and does not allow normal walking, hence needing correction. Congenital causes of equinus deformity include neurological diseases such as cerebral palsy and poliomyelitis. Acquired causes include injuries such as extensive trauma. We have corrected equinus deformity from extensive lower leg burns by a single operation through excisional release of the scar, Achilles lengthening, and radial forearm free flap. METHODS: Fifteen patients with postburn equinus deformity who were treated between January 2000 and March 2012 were retrospectively studied. We investigated their age, sex, cause and severity of burn injury, equinus degree, ankle range of motion and the changes in the activity, extent of Achilles lengthening, flap size, complication, and the recurrence in these patients. RESULTS: The average degree of equinus deformity before the operation was 45 degrees. With an average Achilles lengthening of 4.6 cm, all patients achieved neutral position. The patients who had poor activity due to tiptoe gait before the operation showed good to fair levels of walking ability postoperatively. During an average follow-up period of 3 years and 9 months, no patients had a recurrence. CONCLUSIONS: Equinus deformity causes significant restrictions to walking and the reconstruction is a challenging problem. Although prevention is more important during the initial stages of treatment, we have successfully corrected patients with existing equinus deformity by scar release, Z-tenoplasty of Achilles, and radial forearm free flap.

Immunohistochemical Analysis of Postburn Scars following Treatment Using Dermal Substitutes.

BACKGROUND: Post-burn hypertrophic scars commonly occur after burns. Studies that compare dermal substitutes with other treatment methods are insufficient. The purpose was to analyze the histopathological differences in hypertrophic burn scars after Matriderm®+split-thickness skin graft (STSG) and compare with AlloDerm®+STSG, STSG, full-thickness skin graft (FTSG), and normal skin. METHODS: Samples of unburned, normal skin and deep 2nd or 3rd degree burns were obtained from patients who experienced a burn injury in the past to at least 6 months before biopsy, which was performed between 2011 and 2012. All subjects received >6 months of treatment before the biopsy. Intervention groups were normal (63), STSG (28), FTSG (6), Matriderm® (11), and AlloDerm® (18). Immunohistochemical analyses of elastin, collagen I, collagen III, cluster of differentiation 31 (CD31), smooth muscle actin (α-SMA), and laminin from scar and control tissues were performed and compared. RESULTS: α-SMA vascular quantity and vessel width, stromal CD31, and basement membrane laminin expression were not significantly different between normal and intervention groups. Matriderm® group showed no significant difference in elastin, collagen III, stromal CD31 and α-SMA, CD31 vessel width, stromal α-SMA, vessel quantity and width, and laminin length compared to the normal group, meaning they were not significantly different from the normal skin traits. CONCLUSION: Dermal substitutes may be an optimal alternative to address the cosmetic and functional limitations posed by other treatment methods.

The risk factors of psychosocial problems for burn patients.

Many burn patients experience psychosocial problems such as personality change, post-traumatic stress disorder, family trouble, and financial burden. The purpose of this study was to identify the risk factors of these psychosocial problems that prevented burn patients from developing appropriate adjustments after burn. Six hundred eighty-six adult burn inpatients were interviewed. Most of them suffered from burns less than 10% of total body surface area. They were asked to fill in a questionnaire for this study, which was a psychosocial problem checklist of 17 items. Descriptive analysis, factor analysis, Chi-square test, and multiple logistic regression analysis were used to analyze the results. Lack of family support and living expense burden were the two significant risk factors for psychosocial problems including, burn treatment problems, rehabilitation problems, and welfare information problems on both acute and chronic burn patients. Medical expense burden was the risk factor among chronic burn patients. These findings suggested that active interventions by the burn team including mental health professionals (psychologist, psychiatrist or social worker) might reduce psychosocial problems of burn patients and encourage social rehabilitation.

Pediatric hand injury induced by treadmill.

Korea has recently seen an increase in pediatric hand injuries associated with treadmills. This study was conducted to identify the frequency, patterns, treatment and outcome of these injuries, in the hope of developing preventive programs. A retrospective review of the medical records of 25 children, all with treadmill-induced friction hand injuries, was conducted at the Hallym Burn Centre, Hangang Sacred Heart Hospital, Seoul, Korea, during the period of January 2002 to March 2004. The injuries constituted 1.4% of the total number of pediatric burn injury admissions. Male toddlers were affected more than female. The mean age of the children was 3.9+/-3.2 (3, 1-15) years old. Most injuries occurred in spring. Treadmill friction inflicted deep second or third degree burns, small in area (1.6+/-1.0% of TBSA). All lesions involved the hands and forearms, with 60% on the right. Most patients (64%) underwent surgical management 13+/-5 days after the injury. The volar surface of the hand was more affected than the dorsal side (27 versus 8). Treatment was mainly with full thickness skin graft (60%) and long-term surgical outcomes were excellent. Such injuries may be prevented by educating the public about the potential risks of the treadmill, and by the development of additional safety designs. Changes in management protocols and treatment policies would improve the provision of appropriate care.

A retrospective analysis of 19,157 burns patients: 18-year experience from Hallym Burn Center in Seoul, Korea.

This is a retrospective, epidemiological study of 19,157 acute burn patients admitted to the Hallym Burn Centre, Hangang Sacred Heart Hospital, Seoul, Korea, during the period 1986-2003. The study was conducted to identify characteristics of burn patients that could lead to development of preventive programs to reduce both the frequency and mortality of burn injury. The majority of patients admitted had relatively minor burns, which were treated conservatively. Males predominated in all age groups with a summer peak seasonal variation. Typical burn in the children <5 years of age was a scald injury, occurring at home, affecting upper limbs and resulting in a relatively short hospital stay. Electrical burns due to steel chopsticks and steam burns due to electric rice cookers were also found in this age group. Adult burns, affecting upper and lower limbs, were caused by flames, hot liquids or electricity. Burns were sustained at the workplace and outdoors. Flame accidents in males were the leading cause of death with overall mortality of 8.2%. 13.9% of admissions needed intensive care and average length of hospital stay was 32.6 days. The annual number of patients undergoing burn related surgery has continuously increased reflecting a more aggressive surgical management. Our ongoing efforts are to promote prevention program and look for changes in the incidence of burn injury based on these epidemiologic features. Further study for implications of changes in management protocols and policies on treatment outcomes would improve the provision of appropriate care for the patients.

Paediatric electrical burn: outlet injury caused by steel chopstick misuse.

Electrical burn in children in compared with adults is rare due to less chance of exposure to electricity. Although studies have been reported regarding pediatric electrical injury, there are no reports concerning outlet injury, especially those suffered by placing a steel chopstick as conducting material into the wall socket. Steel chopsticks are widely used for eating food in Korea. Children have sometimes injured themselves by inserting these into wall sockets (220 V). A retrospective study was conducted to obtain information about the characteristics of pediatric electrical injury resulting from steel chopstick misuse between January 1996 to June 2002. A total of 57 children with outlet injury were involved. Wounds were multiple and localized within the hand. The prevalent age was about 3 years old. The children studied with low voltage minor electrical injuries were deeply injured, had a high operation rate and remarkable sequelae, although wounds were small and localized.

Clinical features and treatment outcomes of skin cancer arising from burn scar: a single-institution experience.

AIMS AND BACKGROUND: This study was conducted to investigate the clinicopathological features and long-term outcomes of patients with skin cancer arising from burn scar (SCBS). PATIENTS AND METHODS: We retrospectively reviewed the medical records of patients diagnosed with SCBS between January 2000 and May 2012. A total of 44 patients were enrolled in this study. RESULTS: The median latent period between burn injury and development of SCBS was 32 years (range, 8-78 years). The most frequent sites of SCBS were the lower limbs (68.2%) followed by the upper limbs (15.9%) and trunk (11.4%). Most patients (95.4%) had squamous cell carcinoma. Of 34 patients with localized disease at the time of diagnosis, 33 patients are alive with no evidence of recurrence. Of 10 patients with regional lymph node metastasis (referred to as locally advanced disease), 4 died of disease progression and 5 are alive with metastatic disease in the lymph nodes, bone or lung. Patients with localized disease survived longer than patients with locally advanced disease ( P = 0.000). In patients with locally advanced disease, the median overall survival time was 16 months (95% CI, 2.88-29.4 months). CONCLUSIONS: While localized SCBS is a potentially curable disease, locally advanced SCBS has a poor prognosis in spite of aggressive treatment. These results suggest that early recognition and aggressive treatment are essential to improve the outcomes of SCBS.

Clinical and histological correlation in post-burn hypertrophic scar for pain and itching sensation.

BACKGROUND: Hypertrophic scar following a burn is caused by the excessive deposit of collagen resulting in an exaggerated wound healing response. The burn patient complains of pain and itching over the scar, which can give rise to cosmetic and functional problems. OBJECTIVE: The aim of this study was to investigate the clinical and histological correlation of a hypertrophic burn scar for itching and pain sensations. METHODS: Thirty-eight patients underwent a scar release and skin graft. the modified Vancouver scar scale and the verbal numerical rating scale were recorded. All biopsies were taken from scar tissue (scar) and normal tissue (normal). Histologically, tissues were observed in the epidermis, the monocytes around the vessels, the collagen fiber, elastic fiber, and the mast cells. RESULTS: The mean total score of MVSS was 8.4±2.7 (pliability 2.0±0.9; thickness 1.8±0.9; vascularity 2.0± 0.9; and pigmentation 2.1±0.9). Pain and itching were 2.4±2.0 and 2.9±3.0. Epidermis were 7.9±2.8 layers (scar) and 4.0±0.8 layers (normal). The collagen fibers were thin and dense (scar) and thicker and loose (normal). The elastic fibers were thin and nonexistent (scar) and thin and loose (normal). Mast cells were 11.2±5.8/high power field (scar) and 7.4±4.1 (normal). CONCLUSION: As the scar tissue thickens, the itching becomes more severe. The stiffness of the scar with the pain appeared to be associated with the condition of the tissue. The correlation between clinical and histological post-burn hypertrophic scars will help further studies on the scar. This helped with the development of the base material for therapeutic strategies.

Proposed treatment protocol for frostbite: a retrospective analysis of 17 cases based on a 3-year single-institution experience.

BACKGROUND: This paper discusses the treatment protocol for patients with frostbite. METHODS: We performed a retrospective analysis of a series of 17 patients with second- and higher-degree frostbite who had been treated at our medical institution between 2010 and 2012. RESULTS: Our clinical series of patients (n=17) included 13 men and four women, whose mean age was 42.4±11.6 years (range, 22-67 years). The sites of injury include the foot in six patients (35.3%), the hand in six patients (35.3%) and the facial region in five patients (29.4%). Seven patients with second-degree frostbite were completely cured with only conservative treatment during a mean period of 12.7±3.3 days (range, 8-16 days). Of the five patients with third-degree frostbite, two underwent skin grafting following debridement, and the remaining three achieved a complete cure with conservative treatment during a mean period of 35±4.3 days (range, 29-39 days). Five patients with fourth-degree frostbite were treated with surgical procedures including amputation. CONCLUSIONS: With the appropriate conservative management in the early stage of onset, surgeons should decide on surgery after waiting for a sufficient period of time until the demarcation of the wound. Continuous management of patients is also needed to achieve functional recovery after a complete cure has been achieved. This should also be accompanied by patient education for the avoidance of re-exposure to cold environments.

Roles of spheroid formation of hepatocytes in liver tissue engineering.

The liver plays an important role in a broad spectrum of physiological functions and detoxifies endogenous and exogenous substances. The liver failure is associated with a high risk of mortality because it is one of important organs in our body. Various bioartificial liver (BAL) systems have been used for clinical trials as a bridge for liver transplantations in patients with liver failure. Long term and stable liver-specific functions of hepatocytes in the development of BAL support systems should be considered. Spheroid formation of hepatocytes enhances liver-specific functions. In this review, hepatocyte spheroid formation methods such as galactose density, topology of extracellular matrix, micro-molding technique, hanging-drop culture, non-adhesive surface, positive charged surface, spinner culture, rocked technique, medium component, external forces, coculture system and polymeric nanospheres are explained for enhancing liver-specific functions.

Esthetic and functional reconstruction for burn deformities of the lower lip and chin with free radial forearm flap.

Burn injury often has produced deformity both of contours and cover in face and neck. Hypertrophic burn scar contracture of the lower face and neck is one of the most difficult subjects to solve because it produces problems with function and appearance. In planning the correction, the restoration of normal form and function is the best way in reconstruction. From January 1998 to January 2002, we had 7 patients who had scar contractures of the lower face and neck. We reconstructed their deformities with free radial forearm flap and skin graft. We could get restoration of the facial form to normal shape, position, and quality of the facial skin cover homogeneity. No remarkable complications have been found in all 7 patients. For better outcomes, there are some considerations. The lowest margin of the flap should be limited to at least 1 finger breadth above the hyoid bone because low setting of the flap may deteriorate the cervicomental angle. The skin graft is undertaken in the cervical region. Adhesion between the flap dermis and wound bed may be necessary for reconstruction of the labiomental sulcus. Burn deformities of the lower face and neck area were resurfaced with free radial forearm flap and skin graft. Flaps did not look completely normal, but those were compatible with the adjacent skin. We could have an adequate functional resurfacing and optimal esthetic outcomes while minimizing recurrent contractures.

Use of the artificial dermis for free radial forearm flap donor site.

The radial forearm free flap has been popular in many area of reconstructive surgery. Despite the many attributes of this flap in surgical reconstruction, one of the clear disadvantages has been the morbidity of the donor site. To solve problems associated with closure of the radial forearm flap donor site, the artificial dermis was used for better outcome in the donor site. From July of 2001 to October 2003, 13 patients (12 male, 1 female) ranging in age from 27 to 67 years underwent free radial forearm transfers. Flap size measured 49 to 144 cm2. Donor-site defects secondary to the flap elevation was closed first with the artificial dermis (Terudermis), marketed by Terumo Inc, Japan, and secondary split-thickness skin graft to the artificial dermis was performed in 15 days (range, 13 to 17 days) on average. There was no flap failure in all cases. Partial loss of the artificial dermis graft was noticed in 2 cases, but it was negligible. Secondary skin graft take was noticed in about 7 days, and there was no remarkable skin graft loss. The artificial dermis was used successfully in 13 patients with the donor defects of free radial forearm flap. Despite the disadvantage to need the secondary split-thickness skin graft, use of the artificial dermis gave us not only soft-tissue augmentation and graft-skin quality similar to full-thickness skin graft but also fast graft healing and diminished morbidity of the skin-graft donor site.