A Review of Post-Burn Contracture Release Procedures at the National Orthopaedic Hospital, Enugu

Background: Contracture release surgeries are done to correct functional impairment, pain or discomfort, recurrent ulceration and cosmetic challenges associated with contractures across joints and mobile structures such as the eyelids. Aim: This article aims to review all the surgical procedures for post-burn contracture release, in the National Orthopaedic Hospital Enugu (NOHE). Method: This is a 5-year retrospective surgery of post burn contracture release carried out in NOHE from January 2013 to December 2017. The data for post- burn contracture surgeries was retrieved from the theatre registers, as well as patients’ folders from the medical records department. Ninety-four folders were retrieved from the medical record department. Results : A total of one hundred and thirty- nine surgical sessions were recorded for these patients. The age range was 2 months to 59 years. The record showed the highest number of post burn contracture release surgeries in ages below 3 years while the least was observed in ages between 41 and 60 years. Gender mostly affected were females (53%). The burn agent that resulted to most of the injuries was flame (52%) followed by Scald (32%). Palmodigital contracture release procedures recorded the highest (30%), followed by elbow (16%) and mento-sternal (13%) contractures. Conclusion: The choice of contracture release procedures was largely influenced by the contracture location and availability of unaffected adjacent skin. Training on post burn contracture prevention for all tiers of health practitioners must be considered a necessity.

with the typical disposition being that of metacarpophalangeal joint extension, proximal interphalangeal joint and distal interphalangeal joint flexion. The wrist may be flexed or extended depending on the site of the scarring. Web space contracture is a common deformity of the web space following severe burns of the hand. Thickened scar or graft contracture along the dorsal edge of the web can produce dorsal hooding or distal creep. Lack of use of splints to maintain injured fingers in an abducted position, usually results in an adducted position at rest; this will result in the burned web healing with contractures. Palmar contracture, on the other hand, occurs in patients, particularly children who grasp hot object and sustain deep burn injuries. It is also seen in children with seizure disorders who have sustained burns.

Introduction
Contracture is a clinical term, meaning a decrease in passive range of motion at mobile parts of the body or across joints, which may be the result of excessive fibrosis or due to loss of length in muscle or peri-articular connective tissues (cartilage, capsule and ligaments) with increased stiffness in these structures. They develop when normal elastic connective tissues are replaced with inelastic fibrous tissue [1]. All neurological conditions which involve muscle weakness and spasticity are prone to developing contracture. Contractures are long term complications of poor and prolonged wound healing of skin and tissues across a joint, limiting range of motion and function. Burn survivors are often burdened with long-term complications such as scars and contractures. Post burn contractures are largely preventable, but when they occur, they often result in functional limitation necessitating surgical treatment.  extensive, and severe depending on what fraction of the anterior part of the neck is involved in the contracting band. Contracture of the neck has also been classified by other authors into Type 1 to Type 4 neck contractures [2].

Contractures can occur in different parts of the body
Ankle contractures range in severity and may significantly impact the patient's range of motion and ambulation. Dorsal contractures are the most commonly seen, and they are treated via scar release and soft tissue coverage [5]. Deformities of the foot and ankle depend on the extent of the initial burn. For instance, the scarring and contractural deformities of the toes and the ankle joint are minimal if the burn depth is superficial. The contractural problems more commonly seen in individuals with extensive burns have been traditionally managed with the skin grafting technique and splinting and physiotherapy, which form essential components of the therapeutic reconstruction regimen of burn foot deformities.
This article aims at analyzing all procedures adopted for post-burn contracture release, in the National Orthopaedic Hospital Enugu (NOHE).

Materials and Methods
This is a 5-year retrospective surgery of post burn contracture release carried out in NOHE from January 2013 to December 2017.
The data for post-burn contracture surgeries was retrieved from the theatre registers, as well as patients' folders from the medical records department. Ninety-four patient records were retrieved from the medical record department. A total of one hundred and thirty-nine surgical sessions were recorded for these patients. The age range was 2 months to 59 years. There was no standardized record of the degree of deformities in these patients across the various anatomical locations of the contractures. The records show that splints were applied over all the areas resurfaced with skin grafts alone after contracture release, in order to prevent re-contracture.

Results
A table of age distribution, frequency and percentage was prepared from the data as shown in table 1 below. The record showed the highest number of post burn contracture release surgeries in ages below 3 years while the least was observed in ages between 41 and 60 years. The gender mostly affected were females (53%) as shown in the pie chart ( Figure 1).
The burn agent that resulted to most of the injuries was flame (52%), followed by Scald (32%) as shown in table 2. The duration of burn to presentation in the hospital was observed most from two months to one year (Table 3).
Palmo-digital contracture occurred mostly as an isolated contracture site in the presentation pattern with a record of 33% (Table 4). Contractures in multiple sites were observed more in upper limb (20%) as presentation pattern. Other regions with contractures had similar presentation pattern with the upper limb.
Palmo-digital contracture release procedures carried out within the period under consideration recorded the highest percentage frequency (30%). This was followed by elbow (16%) and mento-sternal (13%) contractures, as shown in table 5.

Discussion
Wound healing and the rate of formation of scars have been found to be affected by age. Injuries or wound sustained intra-uterine seem to regenerate new tissue and heal without scar formation, whereas wounds sustained by adults tend to heal imperfectly with the formation of scars and possibly leading to contractures which have aesthetic and functional deformation [6,7]. This is not far from the fact that the processes of regeneration of original tissue outside a safe environment can be highly challenging with the constant fight against infection by viruses and bacteria.
Contractures are better prevented than treated, hence the need to promptly commence preventive strategies such as early wound cover, splinting, scar massage, infection prevention and good pain control.    Contracture release surgeries are indicated when contractures impair function, or are associated with pain, discomfort or recurrent ulceration.
Contractures which occur over vital areas such as the eyelids, the lips, the mento-sternal areas require early surgical correction for functional purposes as well as to prevent further complications such as exposure keratitis associated with post burn contractures of the eyelids. The particular procedure selected for contracture release is dependent on factors such as the anatomical location of the contracture, the size of the contracture, the availability of mobile adjacent skin and soft tissue and the functionality of the particular area. The various options of contracture release procedures (Table 5) such as local flaps and skin grafting can be used singly or in combination, depending on the extent of contracture and the mobility of the adjacent soft tissues.
In this study, 65% of the procedures involved skin grafting, while local flaps were used in 30%. This is similar to a study by Iwuagwu FC, et al. [8], with 63% skin grafting and 26% local flaps.This is also in keeping with Ademola SA study [9], where he posited that skin grafting is used very frequently after release of contracture and is probably the commonest method of closure employed in Nigeria. For effective skin grafting, the healing process of the graft must ensure adequate graft adherence to the bed, promote graft vascularisation and subsequently, manage graft contraction adequately to prevent recurrence of contracture [10][11][12].
Abdomino-hypogastric flaps were also used for post-burn hand reconstruction. Lateral Superior Genicular flap (LSG) was used in popliteal contracture release procedures. Al Moktader MABD, et al. [13], also used the LSG flap for reconstruction of post burn contractures around the knee with excellent result without necrosis.
Contractures affecting the palmo-digital region were the most frequent presentation amongst patients in NOHE (33%) as presented in figure 2A and 2B. This appears to be one of the regions of the body where burn injuries occur mostly in patients, particularly children who grasp hot objects. It is also seen in children with seizure disorders who have sustained burns. Contracture release usually involves the excision of scar tissue, leaving a defect which is covered with a skin graft or a flap. Full thickness graft has been reported to be a better option of cover than split thickness graft, as they contract less and reduce the risk of contracture recurrence [14][15][16]. However, the use of full thickness graft is limited to small-sized defects due to the relatively small body surface area available for full thickness harvest.
Patients aged 20 years or younger accounted for 73% of those who had surgery for post-burn contracture, which shows that the majority of patients suffering from post-burn functional and physical limitations are at a young age. Buchan AC [17] and Iregbulem LM [18] reported the differential growth rate between the burn scar and the adjacent normal tissue. Almost half of the patients reviewed had their acute burn care at private hospitals. About 8% of patients had their acute burn care managed in our hospital, another 8% initially received burn care at other tertiary health facilities. This suggests that preventive strategies were either not instituted or ineffective in preventing postburn contractures in more than half of the study participants, despite having their acute burn care in a hospital.
Several factors affect contracture formation. These include age, depth of the burn injury, pain control, infection, early burn wound excision and cover, physiotherapy, anti-contracture positioning and splinting.
There are significant changes in the skin with aging which are responsible for the greater percent of deep burns in the elderly, even after scalds, compared to a younger patient [19][20][21]. Regeneration is faster in young patient than elderly because of the presence of stem cells that can produce stable cells as replacement for the lost cells. In addition, deep dermal and full thickness burn injuries have a higher likelihood to result to contracture formation than superficial dermal burn injuries [22]. This is because of contraction from the edges of deep partial and full thickness burn wounds.
Pain control and infection prevention also have major roles to play in the ideal management of the burn injured patient. The burn injured patient should be kept as pain free as possible to achieve better healing and encourage compliance to anti-contracture positioning and to physiotherapy [23]. Infection has profound effects on tissue repair, surprisingly; infection does not always lead to impaired healing. Studies have shown that contaminating a wound with bacteria does lead to impaired tissue repair [24][25][26]. Other reports have also shown that in some cases contaminated wound can improve tissue repair [27][28][29]. It appears that if minor contamination occurs, then inflammation is augmented and the result is improved healing.
Similarly, report by Gore WL, et al. [30], early closure of burn wounds by excising the burned tissues and promptly covering it with skingrafts or its substitutes within first 'five' post-burns day is the standard of care today [31,32]. In addition to improvement in the prognosis, early excision and grafting procedures have been shown to decrease   Lastly, range of motion exercises should be commenced early for patients with burn injury to prevent contractures and joint stiffness. This may be suspended temporarily at the immediate post operative period to prevent graft dislodgement or excessive tension on flaps during exercises. The exercises are then resumed after sufficient graft take and consolidation, or after the flap edges have healed [37].

Conclusion
Contracture release procedures are largely influenced by the contracture location and availability of unaffected adjacent skin. Postburn contractures often require surgical treatment, which may be multiple. Satisfactory outcome was recorded for most of our patients; however, the burden of surgery and possible donor site morbidity cannot be trivialized. Thus, early and active prevention measures should be instituted, as well as training on post burn contracture prevention for all tiers of health practitioners.