Progressive Stretch-Load is a Principle Step in the Surgical Treatment of Burned Knee Contracture

摘要

A prospective study which includes 36 patients who presented with 43 post burn knee contractures was conducted over the period of three years from Oct.2003-Oct.2006. Their mean age incidence was 17 years. Patients with right sided contractures were 16, left sided 13 and bilateral contractures were present in 7. The F/M ratio was 1:2.2. The mean time elapse from the burn injury to the development of contracture was 2.3 years. The mean healing time was 72 days .The degree of the flexion contractures were classified according to range of joint motion limitations into mild (less than 60° ) moderate (60-90°) and sever (more then 90°). The surgical release procedures involved two stages; (1) Incising of the contracted scar with subsequent application of progressive stretch load (PSL) to the limb through incremental weight traction over extended period of time, until the knee joint is fully extended. (2) To cover the created defect by Split Skin Graft (SSG). The weight traction range was 2.25-8.50 kilograms. The mean duration of PSL application was 7 days. The mean hospital stays was11.5 days .The mean follow-up period was 14 months. The complication rate was five (13.88 %), three patients (8.33%) showed partial (10-15°) recurrence in the contracture angle. Two patients (5.55 %) developed popliteal ulcerating graft which required excision and skin graft in six months period. By using the PSL method 31 patients (86.11 %) had full range of movements in the knee joint, and resumed their work in 3 -4 months during post operative periods. Introduction Deep partial or full-thickness burns if untreated, neglected, infected or managed conservatively can develop severe deformity and scar contracture in the joint with significant reduction in patient activities (1,2). Treatment strategy in burns is prevention of contractures rather than their management. Despite the advances in burn management protocols, there are many data supporting high incidence of joints contractures. Schneider et al examined prospectively the incidence of large joint contractures after burn trauma in 985 cases during the period 1993 to 2002, 381 (38.7%) developed at least one contracture at their time of discharge with the mean of three contractures per person; the knee joint was involved in (22%) of them (3).Post burn knee contracture primarily affect the skin while secondary contracture also involve the capsule, ligaments, tendons, muscles, and the neurovascular bundle across the joint .In a long standing contracture, the articulating bones can be subluxated or dislocated as evident clinically by joint deformity and radiologically by forward sliding of lower femoral end on tibial condyle. Additionally, the local bones showed radiological evidences of osteoporotic changes. The management of joint contractures presents a great challenge both for the orthopaedic and the plastic surgeons. Aggressive physiotherapy, manipulation, splinting and various surgical methods; including scar release, tendon lengthening and osteotomies with skin graft , have been described for the treatment of joint contractures, with almost protracted morbidity in most of the cases(4,5). The objective of the study was to use the concept of stretch to the shortened structures in a contracture by applying Progressive Stretch Load (PSL) for extended period of time. This will lead to tissue relaxation with subsequent tissue lengthening of the involved structures. This can only be done after dividing the unyielding scar tissue, which gives a way for the traction forces to exert its effect. Materials And Methods During the three years period from Oct. 2003-Oct.2006, a prospective study of 36 patients, with the age incidence ranging from 7-45 years with a mean of 17, and the age distribution (shown in Table I) was conducted