Perforator-Based Interposition Flaps Perform Better Than Full-Thickness Grafts for the Release of Burn Scar Contractures: A Multicenter Randomized Controlled Trial.

BACKGROUND: Burn scar contractures remain a significant problem for the severely burned patient. Reconstructive surgery is often indicated to improve function and quality of life. Skin grafts (preferably full-thickness grafts) are frequently used to cover the defect that remains after scar release. Local flaps are also used for this purpose and provide healthy skin subcutaneous tissue. The vascularization and versatility of local flaps can be further improved by enclosing a perforator at the base of the flap. Until now, no randomized controlled trial has been performed to determine which technique has the best effectiveness in burn scar contracture releasing procedures. METHODS: A multicenter randomized controlled trial was performed to compare the effectiveness of perforator-based interposition flaps to full-thickness skin grafts for the treatment of burn scar contractures. The primary outcome parameter was change in the surface area of the flap or full-thickness skin graft. Secondary outcome parameters were width, elasticity, color, Patient and Observer Scar Assessment Scale score, and range of motion. Measurements were performed after 3 and 12 months. RESULTS: The mean surface area between flaps (n = 16) and full-thickness skin grafts (n = 14) differed statistically significantly at 3 months (123 percent versus 87 percent; p < 0.001) and 12 months (142 percent versus 92 percent; p < 0.001). In terms of the secondary outcome parameters (specifically, the Patient and Observer Scar Assessment Scale observer score and color), interposition flaps showed superior results compared with full-thickness skin grafts. CONCLUSION: Perforator-based interposition flaps result in a more effective scar contracture release than full-thickness skin grafts and should therefore be preferred over full-thickness skin grafts when possible. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Analyzing contraction of full thickness skin grafts in time: Choosing the donor site does matter.

BACKGROUND: In reconstructive burn surgery full thickness skin grafts (FTSGs) are frequently preferred over split thickness skin grafts because they are known to provide superior esthetic results and less contraction. However, the contraction rate of FTSGs on the long term has never been studied. METHODS: The surface area of FTSGs of consecutive patients was measured during surgery and at their regular follow up (at approximately 1, 6,13 and 52 weeks postoperatively) by means of 3D-stereophotogrammetry. Linear regression analysis was conducted to assess the influence of age, recipient- and donor site and operation indication. RESULTS: 38 FTSGs in 26 patients, with a mean age of 37.4 (SD 21.9) were evaluated. A significant reduction in remaining surface area to 79.1% was observed after approximately 6 weeks (p=0.002), to 85.9% after approximately 13 weeks (p=0.040) and to 91.5% after approximately 52 weeks (p=0.033). Grafts excised from the trunk showed significantly less contraction than grafts excised from the extremities (94.0% vs. 75.7% p=0.036). CONCLUSIONS: FTSGs showed a significant reduction in surface area, followed by a relaxation phase, but remained significantly smaller. Furthermore, the trunk should be preferred as donor site location over the extremities.

The application of platelet-rich plasma in the treatment of deep dermal burns: A randomized, double-blind, intra-patient controlled study.

Platelet-rich plasma (PRP) is a fraction of blood with a platelet concentration above baseline. When platelets get activated, growth factors involved in wound healing are released. The application of PRP has shown good results in wound care, however, up to date no substantial research has been performed on the effect of PRP in burn treatment. This randomized double blind intra-patient controlled study investigates the effect of autologous PRP on wound healing in burns that require surgery with a meshed split skin graft (SSG). Fifty-two patients with various areas of deep dermal to full thickness burns, receiving surgery with a SSG were included after informed consent. Comparable study areas A and B (intra-patient) were appointed, randomized and either treated with a SSG and PRP or with a SSG alone. At day 5 to 7 postoperative, the epithelialization and graft take rate were assessed. Three, six, and twelve months postoperative, follow-up measurements were performed in the form of POSAS-questionnaires, DermoSpectroMeter, and Cutometer measurements. There was no statistically significant difference between the mean take rate nor the mean epithelialization rate at day 5-7 between the PRP-treated and control areas. However, PRP-treated wound areas showed more often better or equal epithelialization and take rates at day 5-7 than the standard treated areas. Minor effects were also seen in the reoperated and early operated subgroups. At 3, 6, and 12 months postoperative, POSAS scores from the patients and the observers, Dermaspectro-, and Cutometer measurements did not depict a significant difference between the PRP and standard treated areas. Concluding, the addition of PRP in the treatment of burn wounds did not result in improved graft take and epithelialization, nor could we demonstrate better scar quality. There was, however, a considerable variation in our clinical population.

Cost-Effectiveness of Laser Doppler Imaging in Burn Care in The Netherlands: A Randomized Controlled Trial.

BACKGROUND: In patients with burns, an early accurate diagnosis of burn depth facilitates optimal treatment. Laser Doppler imaging combined with clinical assessment leads to an accurate estimate of burn depth. However, the actual effects of the introduction of laser Doppler imaging on therapeutic decisions, clinical outcomes, and costs are unknown. METHODS: A randomized controlled trial was conducted in the Dutch burn centers, including 202 patients with burns of indeterminate depth. In the standard care group, estimation of burn depth was based on clinical assessment only; in the laser Doppler imaging group, clinical assessment and laser Doppler imaging were combined. Primary outcome was time to wound healing. Furthermore, therapeutic decisions and cost-effectiveness were analyzed. RESULTS: Mean time to wound healing was 14.3 days (95 percent CI, 12.8 to 15.9 days) in the laser Doppler imaging group and 15.5 days (95 percent CI, 13.9 to 17.2 days) in the standard care group (p = 0.258). On the day of randomization, clinicians decided significantly more often on operative or nonoperative treatment in the laser Doppler imaging group (p < 0.001), instead of postponing their treatment choice. Analyses in a subgroup of admitted patients requiring surgery showed a significant earlier decision for surgery and a shorter wound healing time in the laser Doppler imaging group. Mean total costs per patient were comparable in both groups. CONCLUSIONS: Laser Doppler imaging improved therapeutic decisions. It resulted in a shorter wound healing time in the subgroup of admitted patients requiring surgery and has the potential for cost savings of €875 per scanned patient.

In a clinimetric analysis, 3D stereophotogrammetry was found to be reliable and valid for measuring scar volume in clinical research.

OBJECTIVES: Volume is an important feature in the evaluation of hypertrophic scars and keloids. Three-dimensional (3D) stereophotogrammetry is a noninvasive technique for the measurement of scar volume. This study evaluated the reliability and validity of 3D stereophotogrammetry for measuring scar volume. STUDY DESIGN AND SETTING: To evaluate reliability, 51 scars were photographed by two observers. Interobserver reliability was assessed by the intraclass correlation coefficient (ICC), and the measurement error was expressed as limits of agreement (LoA). To assess validity, 60 simulated (clay) scars were measured by 3D stereophotogrammetry and subsequently weighed (gold standard). The correlation of volumes obtained by both measures was calculated by a concordance correlation coefficient (CCC), and the measurement error was expressed as a 95% prediction interval. RESULTS: The ICC was 0.99, corresponding to a high correlation of measurements between two observers, although the LoA were relatively wide. The correlation between 3D stereophotogrammetry and the gold standard was also high, with a CCC of 0.97. Again, the plot of the differences and LoA showed moderate agreement for the validity. CONCLUSION: Three-dimensional stereophotogrammetry is suitable for the use in clinical research but not for the follow-up of the individual patient.

Dynamic in vivo evaluation of radiocarpal contact after a 4-corner arthrodesis.

PURPOSE: To understand the mechanisms that preserve joint integrity after 4-corner arthrodesis (FCA). METHODS: We investigated the long-term changes of the radiolunate articulation after an FCA for different motions of the wrist in a cross-sectional study that included wrists of 10 healthy participants and both operated and nonoperated wrists of 8 individuals who had undergone FCA on 1 side. The average postoperative follow-up period of the FCA group was 5.7 years. The radiolunate articulation was assessed from dynamic 3-dimensional distance maps during wrist motion. Contact surface area, centroid position of the articular area, and distance between radiolunate articular surfaces were measured and compared between healthy subjects and operated and nonoperated wrists of FCA patients. RESULTS: The total radiolunate articulation area was larger in patients with FCA. The average radiolunate joint space thickness was preserved in the operated FCA wrists. The centroid of the articulation area was shifted radially and dorsally in FCA wrists. CONCLUSIONS: Changes of the motion pattern of the lunate during radioulnar deviation and flexion-extension of the wrist after FCA can explain the shift of the centroid radially and dorsally. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

A systematic review on burn scar contracture treatment: searching for evidence.

Treating burn scar contracture remains a challenging problem for reconstructive surgeons. At present, no consensus exists on when to use what kind of technique. Therefore, a systematic review was performed on the effectiveness of the different surgical techniques after burn scar contracture release. Electronic databases were searched using a predefined search strategy. Studies evaluating the outcome of surgical techniques for the treatment of burn scar contractures were included. The methodological quality was tested and the data were summarized. One thousand six hundred fourty-nine papers were identified of which 17 met the inclusion criteria. Three papers reported on a controlled trial, 14 were cohort studies, including 10 of a pre-post operative design and 4 of a comparative design. The papers described outcomes of grafts, flaps with random or defined vascularization, and dermal substitutes. All studies had methodological shortcomings and most used inappropriate statistical methods. The current evidence on the effectiveness of reconstruction techniques for burn scar contractures was summarized. Due to the scarcity and low quality of the included studies, no definitive conclusions could be reached about the effectiveness of different techniques. Therefore, no direct implications for daily practice could be made. However, recommendations could be given for improvement of the quality of further primary research on the effectiveness of surgical treatment strategies for burn scar contracture release.

The hand held Doppler device for the detection of perforators in reconstructive surgery: what you hear is not always what you get.

BACKGROUND: Perforator-based flaps have become indispensable in the treatment of burn scars. Pre-operative perforator mapping is often performed by use of the hand held Doppler device, partly due to its convenience and the low costs. We expected to find sufficient evidence in literature to support the use of the device, however available literature showed a distinct lack of clinimetric studies that adequately tested the reliability. METHODS: To assess reliability, perforator locations were mapped independently by two clinicians using an 8MHz Doppler device. In healthy volunteers the elbow region or the peri-umbilical region were randomly chosen to be the measurement areas of predefined squares (7cm×7cm). Subsequently, the perforators within the area were mapped with Duplex to establish the validity by means of the positive predictive value. RESULTS: 20 volunteers were included. The hand held Doppler technique showed moderate reliability with a mean Dice coefficient of 0.56. Also, poor validity was found expressed by a mean positive predictive value of 55%. CONCLUSIONS: Surprisingly, this study has shown that performance of the hand held Doppler device was moderate. The Doppler should not be used alone for the detection of perforators.

Three-dimensional digital stereophotogrammetry: a reliable and valid technique for measuring scar surface area.

BACKGROUND: The surface area of scars is an important outcome parameter in scar assessment. It is often used to quantify the extent of scar features, such as pigmentation disturbances, hypertrophy, and contracture. Currently available techniques for measuring the surface area are known to be cumbersome or do not meet the basic clinimetric criteria (i.e., reliability and validity). Three-dimensional stereophotogrammetry is a technique that may improve the quality of surface area measurements. The aim of this study was to investigate the reliability and validity of three-dimensional stereophotogrammetry for measuring scar surface area. METHODS: In a cross-sectional study, two independent clinicians photographed and measured 50 scar areas of 32 patients using a handheld stereographic camera, to assess reliability. Subsequently, using planimetry, the scar surface was traced on a transparent sheet (considered the accepted standard) to assess validity. RESULTS: Three-dimensional stereophotogrammetry showed good reliability, with an intraclass correlation coefficient of 0.99 and a coefficient of variation of 6.8 percent. To visualize the differences between the two observers, data were plotted and the limits of agreement were calculated at 0 ± 0.19 × mean surface area. Also, excellent validity was found, with a concordance correlation coefficient of 0.99. CONCLUSION: This study showed that three-dimensional stereophotogrammetry is a reliable and valid tool for research purposes in the field of scar surface area measurements. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Cost-effectiveness of laser Doppler imaging in burn care in the Netherlands.

BACKGROUND: Early accurate assessment of burn depth is important to determine the optimal treatment of burns. The method most used to determine burn depth is clinical assessment, which is the least expensive, but not the most accurate.Laser Doppler imaging (LDI) is a technique with which a more accurate (>95%) estimate of burn depth can be made by measuring the dermal perfusion. The actual effect on therapeutic decisions, clinical outcomes and the costs of the introduction of this device, however, are unknown. Before we decide to implement LDI in Dutch burn care, a study on the effectiveness and cost-effectiveness of LDI is necessary. METHODS/DESIGN: A multicenter randomised controlled trial will be conducted in the Dutch burn centres: Beverwijk, Groningen and Rotterdam. All patients treated as outpatient or admitted to a burn centre within 5 days post burn, with burns of indeterminate depth (burns not obviously superficial or full thickness) and a total body surface area burned of ≤ 20% are eligible. A total of 200 patients will be included. Burn depth will be diagnosed by both clinical assessment and laser Doppler imaging between 2-5 days post burn in all patients. Subsequently, patients are randomly divided in two groups: 'new diagnostic strategy' versus 'current diagnostic strategy'. The results of the LDI-scan will only be provided to the treating clinician in the 'new diagnostic strategy' group. The main endpoint is the effect of LDI on wound healing time.In addition we measure: a) the effect of LDI on other patient outcomes (quality of life, scar quality), b) the effect of LDI on diagnostic and therapeutic decisions, and c) the effect of LDI on total (medical and non-medical) costs and cost-effectiveness. DISCUSSION: This trial will contribute to our current knowledge on the use of LDI in burn care and will provide evidence on its cost-effectiveness. TRIAL REGISTRATION: NCT01489540.

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.