Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : PC01 - PC07 Full Version

Staged Management of Severe Postburn Contracture of Elbow and Knee- A Prospective Interventional Study


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/57159.17273
Anup Kumar Tirkey, Rasmi Ranjan Mohanty, Bibhuti Bhusan Nayak

1. Senior Resident, Department of Plastic Surgery, Maharaja Krushna Chandra Gajapati Medical College and Hospital, Berhampur, Odisha, India. 2. Assistant Professor, Department of Plastic Surgery, Maharaja Krushna Chandra Gajapati Medical College and Hospital, Berhampur, Odisha, India. 3. Professor and Head, Department of Plastic Surgery, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India.

Correspondence Address :
Dr. Rasmi Ranjan Mohanty,
Plot No. C/37, Sector 7, CDA, Cuttack, Odisha, India.
E-mail: kingrasmi.r@gmail.com

Abstract

Introduction: Long-standing burns at major joints like the elbow and knee often lead to contractures, despite of best treatments and their management poses a great challenge owing to underlying contracted tendons, neurovascular bundle, and joint ligaments. Attempts at release and correction of contractures may lead to injury to the adjacent neurovascular structures.

Aim: To evaluate the effectiveness of staged release as a means of definitive treatment of severe burn contracture.

Materials and Methods: A prospective interventional study was conducted on 30 patients in the Department of Burns, Plastic and Reconstructive Surgery Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India, from December 2018 to December 2020. In the first stage, the maximum excisional release of contracture was done, avoiding any stretching of the neurovascular bundle, then bedside graded traction was applied at the joint until the complete release of contracture was observed. The resultant raw area was covered with a split-thickness skin graft in the second stage. The collected data included- site and side of the contracture, cause of initial burn, Improvement in flexion arc (in degrees), duration of splintage after surgical release, complications and Patient and Observer Scar Assessment Scale (POSAS). Paired t-tests were performed to analyse changes in preoperative versus postoperative measurements.

Results: Eighteen cases of knee contractures and 12 cases of elbow contractures were included in the study. Among the patients that were analysed, 17 were females and 13 were males, with a female-to-male ratio of 1.3:1. The age range was 18-50 years, with a mean age of 36±8.79 years. The mean Range Of Motion (ROM) of elbow contracture with a severe degree of contracture improved from 25% of functional ROM to 124.29% at 6 months postoperatively. Similarly, the mean ROM of knee contracture with a severe degree of contracture improved from 25.76% of functional ROM to 102.58% at 6 months postoperatively. For both elbow and knee contracture cases the differences in mean ROM were statistically significant with all p-values <0.05. The average time at which the patients reported to the hospital, after developing contracture was 36.8 months, and it ranged from 24 months to 62 months. According to POSAS patient scale, the overall score was 6 and 5 for the elbow and knee respectively and the POSAS observer scale overall score was 6 for both the elbow and knee, respectively.

Conclusion: The staged release procedure applied in the present study was an effective way of dealing with long-standing contractures with minimal complications.

Keywords

Physiotherapy technique, Range of motion, Scar, Splints, Tractions

Burn injury is still a common cause of trauma, especially in low and middle-income countries and the prevalence of postburn contractures is high in India but exact data can not be obtained as it varies considerably between studies (1). The mortality and morbidity from burns have reduced tremendously over the past few decades, but the inevitable postburn scars, contractures, and other deformities collectively have aesthetic and functional considerations (2). Joint contractures in severe burn patients can only be minimised by early rehabilitation but not eliminated completely (3).

The management of deep burns around the elbow and knee joints presents a great challenge. Inadequate treatment and rehabilitation after deep burn injuries inevitably become complicated by debilitating contractures that can severely compromise extremity functions and result in serious disability (4),(5),(6),(7). Methods used to treat these deformities and restore function have ranged from nonsurgical procedures such as splinting and serial casting in milder cases to multiple sessions of surgical release and reconstruction with various flaps like local transposition flap, propeller flap, pedicle flap, free flap or split-thickness skin graft in severe cases (4),(5),(7),(8). Nevertheless, all these methods either do not initially achieve full correction or have high recurrence rates because of unsatisfactory scar release limited by the contracted tendons, neurovascular bundle, and joint ligaments. Moreover, these severe deformities often cannot be corrected in a one-stage open surgical procedure because the skin and neurovascular structures may not tolerate acute stretching and lengthening (7).

In the previous studies, either non surgical skin traction methods were used for the treatment of these joint contractures or they were released surgically followed by immediate graft or flap cover (8),(9),(10),(11),(12). However, in this study a combination of both procedures was used to get a complete release. The aim of the present study was to evaluate the effectiveness of two stage release (i.e., the excisional release of elbow/knee joint contracture with postoperative stretching and subsequent cover with a split-thickness skin graft) as a means of definitive treatment of severe burn contracture.

Material and Methods

This prospective interventional study was conducted on 30 patients in the Department of Burns, Plastic and Reconstructive Surgery Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India, from December 2018 to December 2020. The study was approved by the Institutional Ethical Committee (IEC application No- 139).

Inclusion criteria: All the patient with long-standing (more than two year old contracture) severe postburn contracture of elbow and knee with age group more than 10 years were included in the study.

Exclusion criteria: Patients with bony ankylosis or neurological deficit in the affected limb, severe disease/co-morbidities, including malignancy (Marjolin’s ulcer) or infection of the affected limb were excluded from the study. Patients with age group ≤10 years, as they were less co-operative and were more likely to develop pressure injuries due to graded traction with splint usage, were also excluded from the study.

A goniometer with a 360° head, calibrated to the International Standard of Measurements was used to measure the active Range Of Motion (ROM) of the affected joints. Information about the nature and date of the injury, treatment history, previous surgical procedure, splinting during and after wound healing, and follow-up care were taken. The difference in the percentage of functional ROM preoperatively versus postoperatively was analysed. Functional ROM is defined as “the movement required by a joint, to naturally perform activities in daily life” (13),(14) as opposed to normal ROM, which is the maximal ROM value of healthy individuals (15). Functional ROM cut-off values were retrieved from Korp K et al., ROM values to enable comparisons (13).

Both elbow and knee contractures were classified with, (Ogawa R Classification) (16) (Table/Fig 1) which is an anatomical classification for burn contractures depicting the extent of the scar (Table/Fig 2),(Table/Fig 3).

Patients were examined for:

1. Extent and maturity of the scar.
2. Presence of blister, raw area, ulceration, or scar breakdown, if any.
3. Degree of contracture.
4. Range of motion.
5. Condition of the proximal and distal joints.
6. Any associated deformity.

Postoperative scar assessment was done by the POSAS (17),(18).

Definitive procedure (19): The active ROM at each involved joint was measured using a manual goniometer with a standardised technique. Extension and flexion planes of motion were recorded before the surgery for the elbow and knee joints (20),(21). A trial of preoperative physiotherapy for four weeks was required to compensate for the long-term immobilisation, which the patient does at his/her home. On the day of admission, traction was applied across the joint in a graded manner, to precondition the joint for the future process of release, ascertain the patient’s compliance and habituate the patient’s attendants to the future procedure. A custom-made turnbuckle splint was used to extend the elbow joint, and an ankle strap with weights attached was used for knee contracture extension. The weight traction used in this study for knee contracture was 3-6 kilograms in the form of bricks, each brick weighing 3 kg. Weight traction and elbow extension splint used, to be re-evaluated every 24 hours (12). The weight was increased gradually as the patient’s condition permitted. The steps taken were in stages.

First stage: Under anaesthesia and tourniquet control, excision of the scarred and contracted structures was done with fishtailing of the edges. At all stages, an insult to neurovascular structures due to direct trauma or over-stretching was avoided (Table/Fig 4),(Table/Fig 5). The integrity of the vessels was ensured by releasing the tourniquet and palpating the distal arterial pulse. If the need arose, then the tendon lengthening procedure and joint capsule release and repair were done. Following release haemostasis was achieved and dressing of the wound was done. A Plaster of Paris (POP) splintage with cotton padding was given to keep the limb in a maximally extended position. The first dressing was changed on the 3rd postoperative day and a joint traction device was applied across the operated joint.

Joint traction devices included weight traction with a rope & pulley system (dynamic splint) (Table/Fig 6) and a custom-moulded turnbuckle splint (static progressive splint) (Table/Fig 7) (12). For elbow traction, a static progressive splint in the form of a custom-moulded turnbuckle splint was used which provided a low load and gradual prolonged stretching. For the knee, weight traction with a rope and pulley system constituted of weights in the form of bricks tied to one end of the rope hanging from a pulley with the other end attached to a strap on the contracted limb. The weights of the bricks used were 3 kg.

The traction was evaluated every 24 hours and the load was increased gradually as the patient’s condition permitted. Increasing load in the case of the elbow contracture comprised gradual progression in the splint angle and in the case of the knee consisted of adding weights to the pulley traction device. The added load at the maximal tolerable level was maintained by the splint till the next session. A measured progression in the traction load was made daily. Thus, graded traction was applied across the joint till a maximal release was achieved.

Second stage: By end of a few weeks maximal release of the contracture occurs and a healthy granulation tissue appears on the contracture release site. Subsequently, the patient was posted for surgery (Table/Fig 8),(Table/Fig 9). A split-thickness skin graft was used to cover the raw area (Table/Fig 10). The wound is dressed and a POP splintage with cotton padding was given to keep the limb in a maximal extension position. On the 10th day, the POP splint was replaced with a lightweight-padded custom-moulded splint. Any postoperative complications were recorded.

The patients were later seen by a physiotherapist for splinting and mobilisation exercises. Postoperatively the joint needs to be splinted properly for a sufficient period i.e., 6 months otherwise there is a high chance of recurrence of contracture (Table/Fig 11). Patients are also prescribed pressure garments to prevent scar hypertrophy. Pressure stockings or elastic-crepe bandages may be used as a means of pressure dressing. One-month and six months postoperative patient follow-up were done and and contracture angle was recorded. The ROM of the operated joint(s) was measured using a goniometer. The postoperative result was assessed according to donor site morbidity, the cosmetic result of the recipient area and the resultant long-standing improvement. The presence of any complications was sought and recorded.

Statistical Analysis

Paired t-tests were performed to analyse changes in preoperative versus postoperative measurements. Data were analysed using Statistical Package for Social Sciences (SPSS) statistics version 27.0 (IBM Corp.), with alpha at 5%.

Results

Among the patients that were analysed, 17 were females and 13 were males, with a female-to-male ratio of 1.3:1. The age range was 18-50 years, with a mean age of 36±8.79 years. Age-wise and gender-wise distribution for elbow contracture and knee contracture are summarised in (Table/Fig 12).

The most common cause of the initial burn injury was flame burns i.e., 27 (90%). Hot liquids affected 3 (10%) of the participants.

90% (27) of the participants had been treated in a hospital for the initial burn injury. The rest 10% were managed at home with oral medications and the application of ointments. No one had undergone any surgical procedure or splinting following the burn. And none of them was followed-up until the development of contracture.

Eighteen knee contractures and 12 elbow contractures were examined in this study. Sixteen cases were present on the left-side (elbow-nine, knee-seven), 11 were on the right (elbow-three, knee-eight) and three cases were on both sides (knee-three) (Table/Fig 13),(Table/Fig 14).

Out of the 30, 16 cases presented between 2 years to 3 years period (elbow-six, knee-10), 11 cases between >3 years to 4 years (elbow-four, knee-seven) and three cases between >4 years to 5 years (elbow-two, knee-one) (Table/Fig 15).

Two cases of knee contracture had the presence of a long-standing ulcer at the popliteal region, but the biopsy taken from the site did not reveal any evidence of malignancy. Proximal and distal joints in all the cases were soft and supple with no associated bony deformities. Burn scar contracture severity values from Schneider JC et al., which arbitrarily defined mild, moderate and severe contractures based on the amount of motion at a joint were used to categorise the patients (22),(23). According to Schneider JC et al., classification, five elbow and 10 knee contracture cases fell into the moderate contracture category and seven elbow and eight knee contracture cases fell into the severe contracture category. For the elbow, functional ROM was taken as minimum 100° and maximum 151° and for the knee joint functional ROM was taken as minimum 131° and maximum 138° (24),(25),(26).

In elbow, preoperative mean ROM in the moderate contracture category was 68% of functional ROM (5, 16.81%). At one month and six months postoperatively, the mean ROM was 132% of functional ROM (7.58%). At both time intervals, differences were statistically significant with all p-values <0.05. The preoperative mean ROM in the severe contracture category was 25% of functional ROM (7, 11.55%). At one month and six months postoperatively, the mean ROM was 120% and 124.29%, respectively of functional ROM (8.16% and 10.58%). At both time intervals, differences were statistically significant with all p-values <0.05 (Table/Fig 16).

In knee, preoperative mean ROM in the moderate contracture category was 53.82% of functional ROM (10, 15.89%). At 1 month and 6 months postoperatively, the mean ROM was 106.11% of functional ROM (SD 2.11%). At both time intervals, differences were statistically significant with all p-values <0.001. The preoperative mean ROM in the severe contracture category was 25.76% of functional ROM (n=8, SD 9.16%). At 1 month and 6 months postoperatively, the mean ROM for both was 102.58% of functional ROM (SD 4.17% & 3.20%, respectively). At both time intervals, differences were statistically significant with all p-values <0.001 (Table/Fig 17).

The average time at which the patients reported to the hospital, after developing contracture was 36.8 months, and it ranged from 24 months to 62 months. (Table/Fig 18). The degree of contracture most commonly reported in the case of elbow contracture came under severe category and that of knee contracture came under moderate contracture category (Table/Fig 16),(Table/Fig 17).

The postoperative result was assessed according to donor site morbidity, the cosmetic result of the recipient area and the resultant long-standing improvement. None of the patients had donor site complications and all were satisfied with the cosmetic outcome. In two cases each of the elbow and knee contractures had complications of partial graft loss, which healed by bridging phenomenon and did not require regrafting. In one case each of the elbow and knee contractures there were complications of recontracture after one month of discharge, which did not require re-surgery and improved with physiotherapy (Table/Fig 19). According to POSAS Patient scale, the overall score was 6 and 5 for the elbow and knee respectively and the POSAS Observer scale overall score was 6 for both the elbow and knee respectively.

Discussion

The treatment of postburn knee and elbow flexion contractures has included non surgical and surgical methods. The non surgical method consists of passive stretching with physical modalities, joint mobilisation, traction and serial casting (27),(28), these methods have two main drawbacks: the limited amount of corrective forces because of the skin’s inability to tolerate direct pressure and the danger of knee subluxation (12),(29). Moreover, physical therapy needs experienced therapists and may fail in severe flexion contractures (28),(30) hence, most of these contractures are ultimately treated surgically.

Surgical procedures increase the ROM and enhance function but complications like skin necrosis, tissue infection, subluxation, fracture, nerve palsy and recurrence may occur (12),(30),(31). But if graded sustained traction is applied to a surgically released joint then the probability of these complications decreases, as there is gradual stretching of the contracted joint ligaments and tight neurovascular structures (32). This concept of applying continuous, mild, and graded distraction force to achieve correction in surgically released postburn contracture joints forms the basis of this study. The application of distraction apparatus in such cases allows a near-complete correction by fractional distraction (33).

Following the principle of slow distraction, we have used this two-stage release method in correcting severe long-standing elbow and knee contractures which helps in the early and complete correction of joint contractures and cuts down the number of procedures. Moreover, in a single staged release where due to contour deformity and irregular wound bed of the recipient area the graft take is often not predictable, this two-stage release technique provides a healthy regular surfaced wound bed without any cracks and crevices, as a result the graft take is good and reliable. And since a well-settled skin graft is achieved on a maximally stretched joint the chances of shearing of graft during the postoperative physiotherapy is minimal (33).

In present study, a good outcome is attained in almost all patients. Moreover, the results can be improved with a good selection of patients and adequate physiotherapy (Table/Fig 20),(Table/Fig 21),(Table/Fig 22).

Some of the surgical procedures used in the treatment of elbow and knee joint contractures are mentioned below. According to Baux S et al., linear contractures surrounded by normal skin require local flaps like Z-plasty (34) technique and others such as seven-flap plasty (35), running Y-V plasty (36), X-plasty (37) and the square flap method (38). Fasciocutaneous, muscle or myocutaneous flaps are other options for contracture release. Yang JY of Taiwan in 1989 released elbow contracture with Reverse medial arm flap in 11 patients. Flap necrosis, ulnar nerve compression and insufficient flap size were a few limitations in an otherwise satisfactory flap (39). The reverse lateral arm adipofascial flap, brachioradialis muscle flap, latissimus dorsi transposition flap, external oblique myocutaneous flap, thoracoepigastric flap and the ulnar artery flap are some of the diverse methods of muscle or fascial flap applications described for elbow contracture release (39),(40),(41),(42). Besides their donor site morbidity, and texture and colour mismatch, these flaps are usually considerably thick and may even impede elbow flexion. De Lorenzi F et al., in the Netherlands presented their experience with free flap reconstruction in 39 burn patients and stated that it allowed the preservation of otherwise unsalvageable deep burns and secondary correction of contracted burn scars (32). El-Khatib H in 1997 described an island fasciocutaneous flap based on the proximal perforators of the radial artery for resurfacing of the cubital fossa [40,41]. Besides their donor site morbidity, and texture and colour mismatch, these flaps are usually considerably thick and impede elbow flexion. The propeller flap was first introduced in 1991 by Hyakusoku H et al., in Tokyo, Japan. In their report, they presented only two cases: one for an elbow contracture and the other for an axillary contracture release with satisfactory results and no complications. For both cases, extensive skin grafting of the donor sites had to be done. The authors identified their flap as a complex of opposed double transposition flaps. They suggested that this flap could also be applied to other flexor regions such as the groin, popliteal fossa, and fingers where burn contractures are known to be common (43). Kumar A and Behera M, in a study assessed the effectiveness of the static progressive knee orthosis for the reduction of knee flexion contracture by the device with a turnbuckle mechanism, which provided low load, gradual and prolonged stretching (44).

A publication from Korea and the Kleinert Institute advocated the correction of severe postburn hand deformities by using aggressive contracture releases and fasciocutaneous free-tissue transfers (45). But the results achieved in many of these cases using this approach are less than optimal. Perforator plus fasciocutaneous flaps in the reconstruction of postburn flexion contractures of the Knee Joint has been studied by Gupta M et al., but all the cases were of 6-15 months duration, hence, complete release was possible. But in the present case, all cases were minimum of two years duration so complete release of contracture was not possible in a single surgery (46). Outcomes achieved in the present study were found to be relatively better than various other similar type of studies (Table/Fig 23) (12),(33),(47),(48).

Limitation(s)

Small sample size, as it was conducted during COVID-19 pandemic period and cases were operated by different surgeons. Patients of the paediatric age group cannot be convinced of continuous stretching of joints.

Conclusion

Full surgical release of contracture is almost never possible in longstanding severe contractures without compromising the function of the joint, as there is a shortening of not only the muscles and tendons but also the neurovascular bundle. This two-staged procedure is a technique of contracture release which incorporates surgical release followed by slow progressive stretching, thus ensuring full correction without any serious complications.

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DOI and Others

DOI: 10.7860/JCDR/2023/57159.17273

Date of Submission: Apr 29, 2022
Date of Peer Review: Jun 21, 2022
Date of Acceptance: Dec 02, 2022
Date of Publishing: Jan 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
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