Surgical treatment of post-burn scar flexion contractures of the fingers of the hand in children

The dissertation is devoted to the surgical treatment of post-burn scar flexion contractures of the fingers of the hand in children. The author analyzes existing classifications of contracture severity and the operative methods used — from simple and modified Z-plasty to microsurgical tissue autotransplantation and balloon dermotension — noting their limitations in the treatment of pediatric finger contractures. The work proposes objective criteria for assessing contracture severity by means of the Is index, systematizes indications for local plastic operations, and develops a new method for eliminating severe contractures using oppositely transposed rectangular flaps. The practical part includes an analysis of the immediate and long-term results of treatment, as well as the implementation of the developed approaches in the clinical practice of several medical institutions.

Post-burn scar contractures of the fingers and hand constitute one of the severe pathologies, particularly in childhood. Children suffering from such contractures lag significantly behind their peers in both physical and psychological development. According to recent reports, the incidence of post-burn scar contractures of the fingers of the hand has been increasing, and the development of disability due to this cause reaches 40% (Usoltseva E.V., Mashion K.I., 1986; Yudenich V.V., Grishkevich V.M., 1986; Azolov V.V. et al., 1992; Azolov V.V., Dmitriyev G.I., 1995; Makhdi F.A., 1998; Petrov S.A. et al., 2000; Samoylenko G.Ye. et al., 2005; Yepifanova N.M. et al., 2005). Post-burn scar deformities of the fingers and hand are characterized by a marked deficit of skin resources suitable for reconstructive-restorative interventions, which considerably complicates the treatment of these patients (Atayasov N.I., 1972; Yudenich V.V., Grishkevich V.M., 1986; Pakhomov S.P., 1990; Dmitriyev G.I., 1992; Menzul V.A., Grishkevich V.M., 1998; Adamskaya N.A., Knyaz V.A., 2005).

The severity of contracture of the affected finger is of great importance in the choice of treatment method. With this in mind, a number of classifications have been proposed that mainly distinguish 3 or 4 degrees of severity of contracture (Matev B.I., Bankov S.D., 1981; Yudenich V.V., 1980; Grishkevich V.M., Salikhbayev B.S., 1985; Yudenich V.V., Grishkevich V.M., 1986; Kuzmenko V.V., Korshunov V.F., Filimonov F.L., 1991; Vozdvizhensky S.I. et al., 1998; Aganina Ye.N., Vedernikova O.L., 2005; Baindurashvili A.G. et al., 2005; Dmitriyev G.I., 2005; Dmitriyev G.I. et al., 2005). However, the criteria by which the severity of contracture is determined are based on the position of the finger, the extent of the scar band, and the range of motion in the affected joint. Nevertheless, a number of these classifications have not found practical application, while others reflect insufficiently objectively the severity of contracture of the fingers of the hand.

Numerous operative techniques are used for the surgical treatment of post-burn scar flexion contractures of the fingers of the hand, such as: simple or serial Z-plasty, modified techniques of Z-plasty, autodermoplasty, transposition of local flaps, and transplantation of free fasciocutaneous flaps. However, the indications for the use of individual techniques depending on the shape and location of the scar band and the degree of contracture expression are not specified concretely by the authors. The majority of specialists advocate the use of opposing triangular flaps (Z-plasty) [Limberg A.A., 1929, 1963; Pakhomov S.P., 1997]. It is known that, alongside its positive aspects, conventional Z-plasty is not an optimal method, since it does not always allow the tissue deficit to be eliminated to a sufficient extent, and the sharp tips of the triangular flaps frequently undergo necrosis (Limberg A.A., 1963; Aucher B.M., 1995; Bartelli J.A., Catarine S., 1997; Grishkevich V.M. et al., 1998).

Modified techniques of Z-plasty (butterfly-type plasty, four-flap plasty, five-flap plasty, seven-flap plasty, and others) have limited possibilities in the elimination of scar contractures of the fingers of the hand, where the scar tissues are insufficiently mobile (Zoltan Ya., 1983; Converse and Smith, 1966; Hirshowitz, 1975; Gibraiel E.A., 1984; Hyakusoku H., Fumiri M., 1987; Rousso M., Wexler M.R., 1988; Karacaoglan N., 1994; Uzunismail A. et al., 1995; Fridman R. et al., 1997), while the use of free skin grafting in such cases carries a high risk of cicatricial shrinkage of the autograft (Povstyanoy N.Ye., Dryuk N.F., 1996; Atayasov N.I., 1996; Green D.R., 1993; Bertelli J., Nogueira C., 1997).

Modern methods of balloon dermotension and microsurgical autotransplantation of tissues make it possible to create a natural, fully adequate skin cover (Yudenich A.A., 1994; 1997; Adamskaya N.A., Knyaz V.A., 2005; Biryukov O.M., Kasparov S.B., 2005; Bogosyan R.A., 2005; Vaganova N.A., Moroz V.Yu., 2005; Grigoryeva T.G. et al., 2005; Olbrish P.P. et al., 2005; Skvortsov Yu.R. et al., 2005). However, they are characterized by considerable complexity and significant labour intensity (Abalmasov K.G., Morozov K.M., 1997; Milanov N.O., Shibayev Ye.Yu., 1998; Wu W.C. et al., 1997) and frequently require repeated corrective interventions (Dmitriyev G.I., 1996; Cho B.C. et al., 1998). The methods of balloon dermotension and microsurgical autotransplantation of tissues are mainly acceptable for the elimination of scar contractures of the region of large joints, whereas they are rarely applied for the elimination of scar contractures of the fingers of the hand.

Thus, many issues concerning the surgical treatment of patients with the sequelae of burn injuries to the fingers of the hand in children remain insufficiently resolved, and the search for and development of new approaches in this direction require further research, to which the present work is devoted.

Aim of the study: to improve the results of surgical treatment of post-burn scar flexion contractures of the fingers of the hand in children.

To achieve this aim, the following tasks were set:

1. To develop objective criteria for assessing the severity of post-burn scar flexion contractures of the fingers of the hand.

2. To systematize existing local plastic operations and to determine indications for their application depending on the severity and location of the scar contracture.

3. To improve existing and to develop new methods of local plastic operations in the surgical rehabilitation of post-burn scar flexion contractures of the fingers of the hand.

4. To study the immediate and long-term results of surgical rehabilitation of post-burn scar flexion contractures of the fingers of the hand.

Scientific novelty of the work:

1. Objective criteria have been developed for evaluating the severity of post-burn scar flexion contractures of the fingers of the hand by means of the contracture severity index — Is, which makes it possible to determine the tissue deficit along the palmar surface of the finger depending on the degree of severity of the scar flexion contracture of the finger (Invention Patent TJ No. 362 RT No. 02000240 of 02.04.2002).

2. The possibilities of previously existing methods of local plastic operations in the elimination of post-burn scar flexion contractures (PO RSK) of the fingers of the hand have been studied.

3. Taking into account the possibilities of eliminating the tissue deficit, existing local plastic operations have been systematized, and indications for their performance have been determined depending on the severity of the contracture.

4. A new method has been developed for the elimination of severe scar flexion contractures of the fingers of the hand — the method of oppositely transposed rectangular flaps, which makes it possible to avoid performing complex and multi-stage operative interventions (Invention Patent TJ No. 361 No. 01000727 of 19.10.2001).

5. Objective criteria have been developed for assessing functional results by means of the index of the degree of contracture elimination; the results of each of the methods of surgical treatment have been studied, and their effectiveness has been evaluated depending on the degree of severity of the contracture.

Practical significance of the work: The developed evaluation criteria have made it possible to assess objectively the severity of scar flexion contractures of the fingers of the hand and to establish the necessity for lengthening along the line of the contractive scar. Indications have been determined for performing various types of local plastic operations depending on the degree of contracture expression and the capabilities of the methods to eliminate the tissue deficit. The development and introduction of the new method of oppositely transposed rectangular flaps in severe scar flexion contractures of the fingers of the hand has made it possible to avoid complex and multi-stage operative interventions, which significantly shortens the treatment periods for patients and is of great socio-economic significance. The use of optical magnification and precision technique has made it possible in all cases to identify the digital neurovascular bundles and to perform the operation more safely. The development of the index of the degree of contracture elimination has made it possible to assess objectively the results of surgical treatment of scar flexion contractures of the fingers of the hand.

Main propositions submitted for defence:

1. The determination of the tissue deficit by the length of the scar band through the contracture severity index simultaneously indicates the degree of tissue deficit along the palmar surface of the finger with the presence of contracture.

2. The main method of surgical treatment of post-burn scar flexion contractures of the fingers of the hand consists of local plastic operations. In this connection, the possibility of lengthening the covering tissues along the contractive scar by means of a local plastic operation should be taken into account.

3. In moderate and severe degrees of PO RSK of the fingers of the hand, when the capabilities of existing LPO are exhausted and the application of skin grafts or distant flaps is required, the method of choice is the method of oppositely transposed rectangular flaps. The advantages of this method consist in the complete release of the finger from the contractive scar bands, the coverage of the resulting defect with fully vascularized flaps, and, most importantly, the absence of the necessity to apply complex and multi-stage operative interventions.

4. The use of optical magnification and precision technique makes it possible to identify the digital neurovascular bundles and to prevent their iatrogenic injury.

5. The evaluation of results according to objective criteria — the index of the degree of contracture elimination — makes it possible to neutralize the subjective factor in the assessment of treatment results.

Implementation of the results of the work: The results of the study have been implemented in the surgical practice of the Department of Plastic and Reconstructive Microsurgery of the Republican Scientific Center for Cardiovascular and Thoracic Surgery, the Republican Self-Financing Scientific, Educational, and Production Center for Restorative Surgery, the Department of Traumatology and Orthopedics of the Republican Clinical Hospital named after Dyakov, the Department of Plastic Surgery of the Maivanad Hospital in Kabul, and the private clinic Khamkor in Kabul.

Approval of the work. The main propositions of the dissertation were reported and discussed at: a meeting of the Society of Traumatologists and Orthopedists (Dushanbe, 2003); the 1st International Conference "Problem Situations in Plastic, Reconstructive, and Aesthetic Surgery and Dermatocosmetology" (Moscow, Russia, 11-13 March 2004); the 2nd Republican Conference dedicated to the 30th anniversary of the cardiology service of the Sogd region (Khujand, 2004); a meeting of the Department of Surgical Diseases No. 2 of the Tajik State Medical University named after Abuali ibni Sino (Dushanbe, 2005); the 4th Congress of Surgeons of Tajikistan (Dushanbe, 2005); a conference of young scientists dedicated to the 2700th anniversary of Kulyab (3-4 April 2006).

Publications. Based on the materials of the dissertation work, 15 scientific works have been published, and 2 invention patents have been obtained.

Volume and structure of the dissertation. The dissertation consists of an introduction, 4 chapters, a conclusion, conclusions, practical recommendations, and a list of references. The work is presented on 132 pages of computer text, includes 8 diagrams, 24 figures, 18 tables, and a bibliography consisting of 213 sources.