Radiographic goniometry of the PIP-joint: A reliable measurement method.

INTRODUCTION: Arthrodesis of the proximal interphalangeal joint (PIP joint) is a good treatment option for relief of arthritic pain. The angle of the fused PIP joint is considered important for postoperative digital function. It is therefore important to reliably measure the actual angle of fusion. Goniometry performed by hand therapists or hand surgeons can generate measurement errors. PURPOSE OF THE STUDY: The purpose of this study is therefore to investigate the intraobserver and interobserver reliability of measuring the angle of fusion of the PIP joint on X-rays. STUDY DESIGN: A clinimetric study was conducted investigating the reliability of X-ray goniometry. METHODS: Three blinded observers measured the angle of the PIP-joint fusion on a lateral postoperative X-ray. The intraobserver and interobserver reliability was calculated. RESULTS: Ninety-four patient X-rays were measured. The intraobserver reliability showed an intraclass correlation coefficient (ICC) of 0.94, and the ICC for the interobserver reliability ranged between 0.92 and 0.95. DISCUSSION: Because this is the first reliability study on radiographic goniometry, comparison of our data with other similar studies is difficult. The best comparison can be made to in vivo goniometry. Based on the investigation of ICC values of various studies on the reliability of in vivo goniometry, radiographic goniometry seems to be more reliable. CONCLUSIONS: These results indicate an excellent reliability, which is generally higher than the reliability for in vivo goniometry of the PIP joint performed by hand therapists or hand surgeons. We can conclude that radiographic goniometry of the PIP joint is a highly reliable measurement method.

No efficacy for silicone gel sheeting in prevention of abnormal scar formation in children with cancer: a randomized controlled trial.

BACKGROUND: Placement of a totally implantable venous access device in children with cancer often leads to hypertrophic scars after its removal. This study investigates whether the use of silicone gel sheets has a beneficial effect on scar outcome in children with cancer. METHODS: In a three-arm randomized controlled trial, the effects of use of silicone gel sheets for 2 and 6 months were assessed and compared with no intervention in children with cancer after removal of the totally implantable venous access device. Silicone gel sheets were first administered 14 days after surgery. The 1-year follow-up included measurements at seven time points. Next to scar size assessment, the modified Vancouver Scar Scale was used to assess scar outcome. RESULTS: Thirty-six children participated. For hypertrophy, no significant differences were found between the two intervention groups and the control group. However, at 1-year follow-up, the 2-month application group showed significantly smaller scars compared with the group receiving silicone gel sheet treatment for 6 months (p = 0.04), but not when compared with the control group (p = 0.22). Longitudinal multilevel analyses could not confirm these findings and showed no significant intervention effects on both outcomes. CONCLUSIONS: This study provides no strong evidence to support the use of silicone gel sheets after totally implantable venous access device removal in children with cancer. There seems to be a small benefit for scar width with application for 2 months. However, for hypertrophy, the scar outcome shows no significant difference between the control group and the 2-month and 6-month treatment groups.

Skin stretching for primary closure of acute burn wounds.

BACKGROUND: In burn care, a well-acknowledged problem is the suboptimal scar outcome from skin grafted burn wounds. With the aim of improving this, we focused on a new technique: excision of the burn wound followed by primary closure, thereby using a skin-stretching device to stretch the adjacent healthy skin. The short- and long-term effect of Skin Stretch was compared to split skin grafting (SSG) in a randomized controlled trial. METHODS: Patients with burn wounds were randomized for SSG or primary wound closure using Skin Stretch. Follow-up was performed at 3 and 12 months postoperatively. The scar surface area was calculated and the scar quality was assessed, using subjective and objective measurement methods. RESULTS: No significant differences between the SSG and the Skin Stretch group were found for scar surface area. In the Skin Stretch group, a significant reduction of the surface area from 65.4cm(2) (13.6-129.1) to 13.4cm(2) (3.0-36.6) was found at 3 months (p=0.028) and at 12 months postoperatively (65.4cm(2) (13.6-129.1) to 33.0cm(2) (8.9-63.7), p=0.046, Wilcoxon signed ranks test). CONCLUSIONS: Skin Stretch for primary closure of acute burn wounds is a suitable technique and can be considered for specific circumscript full-thickness burn wounds. However, future research should be performed to provide additional scientific evidence.

Clinical effectiveness of dermal substitution in burns by topical negative pressure: a multicenter randomized controlled trial.

Previous research has shown clinical effectiveness of dermal substitution; however, in burn wounds, only limited effect has been shown. A problem in burn wounds is the reduced take of the autograft, when the substitute and graft are applied in one procedure. Recently, application of topical negative pressure (TNP) was shown to improve graft take. The aim of this study was to investigate if application of a dermal substitute in combination with TNP improves scar quality after burns. In a four-armed multicenter randomized controlled trial, a split-skin graft with or without a dermal substitute and with or without TNP was compared in patients with deep dermal or full-thickness burns requiring skin transplantation. Graft take and rate of wound epithelialization were evaluated. Three and 12 months postoperatively, scar parameters were measured. The results of 86 patients showed that graft take and epithelialization did not reveal significant differences. Significantly fewer wounds in the TNP group showed postoperative contamination, compared to other groups. Highest elasticity was measured in scars treated with the substitute and TNP, which was significantly better compared to scars treated with the substitute alone. Concluding, this randomized controlled trial shows the effectiveness of dermal substitution combined with TNP in burns, based on extensive wound and scar measurements.

Rasch analysis of the Patient and Observer Scar Assessment Scale (POSAS) in burn scars.

PURPOSE: The Patient and Observer Scar Assessment Scale (POSAS) is a questionnaire that was developed to assess scar quality. It consists of two separate six-item scales (Observer Scale and Patient Scale), both of which are scored on a 10-point rating scale. After many years of experience with this scale in burn scar assessment, it is appropriate to examine its psychometric properties using Rasch analysis. METHODS: Cross-sectional data collection from seven clinical trials resulted in a data set of 1,629 observer scores and 1,427 patient scores of burn scars. We examined the person-item map, item fit statistics, reliability, response category ordering, and dimensionality of the POSAS. RESULTS: The POSAS showed an adequate fit to the Rasch model, except for the item surface area. Person reliability of the Observer Scale and Patient Scale was 0.82 and 0.77, respectively. Dimensionality analysis revealed that the unexplained variance by the first contrast of both scales was 1.7 units. Spearman correlation between the Observer Scale Rasch measure and the overall opinion of the clinician was 0.75. CONCLUSION: The Rasch model demonstrated that the POSAS is a reliable and valid scale that measures the single-construct scar quality.

Collagen bundle morphometry in skin and scar tissue: a novel distance mapping method provides superior measurements compared to Fourier analysis.

Histopathological evaluations of fibrotic processes require the characterization of collagen morphology in terms of geometrical features such as bundle orientation thickness and spacing. However, there are currently no reliable and valid techniques of measuring bundle thickness and spacing. Hence, two objective methods quantifying the collagen bundle thickness and spacing were tested for their reliability and validity: Fourier first-order maximum analysis and Distance Mapping, with the latter constituting a newly developed morphometric technique. Histological slides were constructed and imaged from 50 scar and 50 healthy human skin biopsies and subsequently analyzed by two observers to determine the interobserver reliability via the intraclass correlation coefficient. An intraclass correlation coefficient larger than 0.7 is considered as representing good reliability. The interobserver reliability for the Fourier first-order maximum and for the Distance Mapping algorithms, respectively, showed an intraclass correlation coefficient above 0.72 and 0.89. Additionally, we performed an assessment of validity in the form of responsiveness, in particular, demonstrating medium to excellent results via a calculation of the effect size, highlighting that both methods are sensitive enough to measure a treatment effect in clinical practice. In summary, two reliable and valid measurement methods were demonstrated for collagen bundle morphometry for the first time. Due to its superior reliability and more useful measures (bundle thickness and bundle spacing), Distance Mapping emerges as the preferred and more practical method. Nevertheless, in the future, both methods can be used for reliable and valid collagen morphometry of skin and scars, whereas further applications evaluating the quantitative microscopy of other fibrotic processes are anticipated.

Sustainable effect of skin stretching for burn scar excision: long-term results of a multicenter randomized controlled trial.

PURPOSE: Primary wound closure of large defects after burn scar excision may be facilitated by intraoperative stretching of the adjacent skin. In a randomized controlled trial (RCT), the effect of skin stretching for wound closure after scar excision (SS) was compared to scar excision without additional techniques (SE). Short-term results already showed that in the SS group larger scars could be excised in a one-step procedure. In this paper, the long-term scar outcome using reliable and valid measurement tools was evaluated. BASIC PROCEDURES: The percentage of total remaining scar area (i.e. remaining scar compared to preoperative scar), the percentage of linear scarring (i.e. surface area of linear scar compared to excised scar) and scar hypertrophy was measured at 3 and 12 months postoperatively. MAIN FINDINGS: At 12 months postoperatively, the percentage of total remaining scar area was significantly lower in the SS group (26%) compared to the SE group (43%). The percentage of linear scarring (SS: 21%, SE: 25%) and the incidence of hypertrophy (SS: 29%, SE: 40%) were not significantly different between the treatment groups. CONCLUSIONS: This RCT demonstrates the long-term beneficial and sustainable effect skin stretching for wound closure after scar excision without leading to wider linear scars or more scar hypertrophy.

Perforator-based interposition flaps for sustainable scar contracture release: a versatile, practical, and safe technique.

BACKGROUND: Problematic scar contractures are frequently observed following extensive (burn) wounds. In this study, the authors investigated the applicability of islanded and nonislanded perforator-based interposition flaps as a technique for release of scar contracture. METHODS: Patients requiring surgery for scar contracture release were included. Preoperatively, a suitable perforator was identified by color Doppler sonography. The flap design was tailored according to the localization of this perforator and the anticipated defect. Flap measurements were obtained intraoperatively and at follow-up. Supple scar tissue was included in the flap design when necessary, to increase the applicability of this concept in extensively burned patients. Flaps were converted into island flaps on indication to circumvent significant kinking of the flap base and compromised tissue perfusion. RESULTS: Twenty-two flaps were performed, of which four were converted into island flaps. All flaps survived, but in four cases necrosis of the tip was observed. After a mean follow-up of 7.8 months, the width and surface area of the flaps had expanded to 123 percent (range, 40 to 311 percent) and 116 percent (range, 60 to 246 percent), respectively. One flap was converted into a full-thickness graft during the initial operation. CONCLUSIONS: This concept of perforator-based interposition flaps was found to be a reliable and versatile technique for broad scar contractures. Moreover, it allows intraoperative tailoring, as the flap base can be islanded when indicated. Nevertheless, additional venous outflow is warranted and operative time is saved if the flap base remains intact.

Objective scar assessment tools: a clinimetric appraisal.

BACKGROUND: Scars may lead to an array of cosmetic, psychological, and functional problems. Different scar features can be distinguished (i.e., color, thickness, relief, pliability, and surface area) that are clinically relevant and contribute to the quality and judgment of a scar. Today, objective evaluation of these scar features is indispensable for practicing evidence-based medicine (e.g., to evaluate the outcome of clinical trials). In this review, an overview and update are given on the most relevant noninvasive objective measurement tools for scar evaluation. METHODS: A PubMed literature search was performed. Articles evaluating the clinimetric properties of noninvasive scar assessment tools were included. The selected objective measurement tools were then critically reviewed with respect to the clinimetric properties of reliability, validity, and feasibility. RESULTS: In total, 75 articles were selected and 23 different noninvasive measurement methods were evaluated. CONCLUSION: Based on the scar features color, thickness, relief, pliability, and surface area, the best measurement tools that are currently available were recommended.

An objective device for measuring surface roughness of skin and scars.

BACKGROUND: Scar formation remains a major clinical problem; therefore, various therapies have been developed to improve scar quality. To evaluate the effectiveness of these therapies, objective measurement tools are necessary. An appropriate, objective measuring instrument for assessment of surface roughness is not yet available in a clinical setting. The Phaseshift Rapid In Vivo Measurement of the Skin (PRIMOS) (GFMesstechnik GmbH, Teltow, Germany) could be such an instrument. This device noninvasively produces a 3-dimensional image of the skin microtopography and measures surface roughness. OBJECTIVE: The aim of this study was to investigate the reliability and validity of the PRIMOS for objective and quantitative measurement of surface roughness of skin and scars. METHODS: Three observers assessed skin and burn scars in 60 patients using the PRIMOS and a subjective scale, the Patient and Observer Scar Assessment Scale. Reliability was tested using the intraclass correlation of intraobserver and interobserver measurements. An intraclass correlation coefficient of 0.7 or greater was required for reliable results. To test validity, scores of the PRIMOS were compared with scores of the subjective scale (Pearson correlation). A Pearson correlation coefficient greater than 0.6 was considered a strong positive correlation. RESULTS: All 3 surface roughness parameters of the PRIMOS showed good intraobserver and interobserver reliability for skin and scars (intraclass correlation coefficient arithmetic mean of surface roughness > 0.85, mean of 5 highest peaks and 5 deepest valleys from entire measuring field > 0.88, peak count > 0.86). The parameter arithmetic mean of surface roughness showed a strong correlation with the subjective score (Pearson arithmetic mean of surface roughness 0.70; mean of 5 highest peaks and 5 deepest valleys from entire measuring field 0.53; peak count 0.54). LIMITATIONS: The reliability and validity of the PRIMOS were only tested on skin and burn scars, not in other dermatologic diseases. CONCLUSIONS: The PRIMOS is a valid and reliable tool for objective noninvasive evaluation of surface roughness of both skin and burn scars.

Efficacy of skin stretching for burn scar excision: a multicenter randomized controlled trial.

BACKGROUND: Burn survivors are frequently faced with disfiguring scars. Various techniques exist to improve scar appearance, such as laser treatment and dermabrasion. Next to that, surgical reconstruction, such as scar excision is an option. This randomized controlled trial investigates whether a larger burn scar can be excised using a skin-stretching device for wound closure, thereby optimizing use of adjacent healthy skin. This technique may allow scar excision in a one-step procedure instead of two or more steps, which is necessary for serial excision and tissue expansion. METHODS: Two arms were compared: scar excision and closure by skin stretch and scar excision without additional techniques. The primary outcome measure was scar surface area reduction. In addition, complications were registered. RESULTS: Fifteen patients were randomized for skin stretch and 15 patients were randomized for scar excision only. In the skin stretch group, 10 of 15 scars were completely excised compared with three of 15 in the scar excision-only group (p = 0.025). In the skin stretch group, a significantly larger reduction in scar area was achieved: 95 ± 11 percent of the scar was excised versus 78 ± 17 percent in the scar excision-only group (p = 0.003). One patient in the skin stretch group and three patients in the scar excision-only group experienced partial wound dehiscence (p = 0.598). CONCLUSIONS: In burn scar reconstructions, a significantly larger reduction in scar area can be achieved using a skin-stretching device compared with scar excision with no additional techniques, without an increased risk of complications. It was shown that skin stretching is of added value for scars that cannot be excised in a one-step procedure.

An overview of methods for the in vivo evaluation of tissue-engineered skin constructs.

Cutaneous wounding often leads to contraction and scarring, which may result in a range of functional, cosmetic, and psychological complications. Tissue-engineered skin substitutes are being developed to enhance restoration of the skin and improve the quality of wound healing. The aim of this review is to provide researchers in the field of tissue engineering an overview of the methods that are currently used to clinically evaluate skin wound healing, and methods that are used to evaluate tissue-engineered constructs in animal models. Clinically, the quality of wound healing is assessed by noninvasive subjective scar assessment scales and objective techniques to measure individual scar features. Alternatively, invasive technologies are used. In animal models, most tissue-engineered skin constructs studied are at least evaluated macroscopically and by using conventional histology (hematoxylin-eosin staining). Planimetry and immunohistochemistry are also often applied. An overview of antibodies used is provided. In addition, some studies used methods to assess gene expression levels and mRNA location, transillumination for blood vessel observation, in situ/in vivo imaging, electron microscopy, mechanical strength assessment, and microbiological sampling. A more systematic evaluation of tissue-engineered skin constructs in animal models is recommended to enhance the comparison of different constructs, thereby accelerating the trajectory to application in human patients. This would be further enhanced by the embracement of more clinically relevant objective evaluation methods. In addition, fundamental knowledge on construct-mediated wound healing may be increased by new developments in, for example, gene expression analysis and noninvasive imaging.

A reliable, non-invasive measurement tool for anisotropy in normal skin and scar tissue.

BACKGROUND: Anisotropy of the skin varies depending on different locations and pathological conditions. Currently, no reliable non-invasive measurement tool is available for tissue anisotropy. The Reviscometer is an anisotropy measurement tool that measures the resonance running time (RRT) of a shock wave. This study was initiated to establish the reliability of the Reviscometer on normal skin and scars, and to provide basic information on tissue alignment in normal skin and scars. METHODS: Fifty volunteers and 50 patients underwent measurements on normal skin and scars, respectively. All measurements were performed by the same two observers. Measurements on normal skin were performed on the forearm, upper arm, and abdomen. RESULTS: The results showed that the intraclass correlation coefficient of the inter-observer reliability was > or =0.79 on normal skin and > or =0.86 on scars. In normal skin, the highest mean RRT was found on the abdomen (156.4+/-48.8), followed by the upper arm (123.2+/-33.6) and the forearm (112.5+/-24.3). A significantly lower mean RRT was found in scars (52.3+/-21.9) compared with normal skin (91.6+/-37.7). CONCLUSION: Reviscometer measurements were reliable for normal skin and scars. In addition, clear differences between scars and normal skin but also within different locations on normal skin were identified. The Reviscometer can be considered for the evaluation of the efficacy of different treatments.

Differences in collagen architecture between keloid, hypertrophic scar, normotrophic scar, and normal skin: An objective histopathological analysis.

Normotrophic, hypertrophic, and keloidal scars are different types of scar formation, which all need a different approach in treatment. Therefore, it is important to differentiate between these types of scar, not only clinically but also histopathologically. Differences were explored for collagen orientation and bundle thickness in 25 normal skin, 57 normotrophic scar, 56 hypertrophic scar, and 56 keloid biopsies, which were selected on clinical diagnosis. Image analysis was performed by fast fourier transformation. The calculated collagen orientation index ranged from 0 (random orientation) to 1 (parallel orientation). The bundle distance was calculated by the average distance between the centers of the collagen bundles. The results showed that compared with all three types of scars, the collagen orientation index was significantly lower in normal skin, which indicates that scars are organized in a more parallel manner. No differences were found between the different scars. Secondly, compared with normal skin, normotrophic scar, and hypertrophic scar, the bundle distance was significantly larger in keloidal scar, which suggests that thicker collagen bundles are present in keloidal scar. This first extensive histological study showed objective differences between normal skin, normotrophic, hypertrophic, and keloidal scar.