P.P.M. van Zuijlen

The prognostic factors regarding long-term functional outcome of full-thickness hand burns

The treatment of the burned hand has always been a subject of special interest. In order to obtain a better understanding of the parameters involved in the long-term functional outcome of hand burns a retrospective study was performed on 88 consecutive patients with hand burns (143 hands), treated according to a standardised protocol. Patients were followed for at least 12 months postburn. Hand function was assessed by the seven objective test criteria (7-OTC) described by Jebsen. Logistic regression analysis produced five parameters that were found to have a significant predictive value for long-term hand function. In order of predictive value, these were finger amputations, age on admission, impaired autograft take, the full-thickness hand burn surface area and the full-thickness total body burn surface area. By fitting these five variables into an equation, a probability model was obtained, which could be applied to estimate a prognosis concerning the final hand function of an individual patient with a hand burn. No relationship was found between the postburn day of operation and the long-term hand function. This finding is inconsistent with the current consensus that functional outcome is improved by early excision and grafting. In practice, it suggests that hand function is well preserved when burns of uncertain depth are treated expectantly, followed by selective debridement and grafting. Advantages include reduced blood loss, no loss of vital tissue and a reduction of the need for donor sites.

A Clinimetric Overview of Scar Assessment Scales

Standardized validated evaluation instruments are mandatory to increase the level of evidence in scar management. Scar assessment scales are potentially suitable for this purpose, but the most appropriate scale still needs to be determined. This review will elaborate on several clinically relevant scar features and critically discuss the currently available scar scales in terms of basic clinimetric requirements. Many current scales can produce reliable measurements but seem to require multiple observers to obtain these results reliably, which limits their feasibility in clinical practice. The validation process of scar scales is hindered by the lack of a “gold standard” in subjective scar assessment or other reliable objective instruments which are necessary for a good comparison. The authors conclude that there are scar scales available that can reliably measure scar quality. However, further research may lead to improvement of their clinimetric properties and enhance the level of evidence in scar research worldwide.

Nerve outgrowth and neuropeptide expression during the remodeling of human burn wound scars. A 7-month follow-up study of 22 patients.

UNLABELLED Increasing data suggest that the skin nerve system is involved in wound healing. The objective of this study was to investigate the outgrowth of nerve fibers during the burn wound remodeling process and to analyze possible differences between normotrophic and hypertrophic burn wounds. In a prospective study, biopsies were taken from 22 patients with spontaneously healed partial-thickness burns at 1, 4 and 7-month post-burn. Nerve outgrowth and the expression of the neuropeptides substance P, neurokinin A, calcitonin gene-related peptide, vasoactive intestinal peptide and neuropeptide Y was monitored using immunohistochemistry. Our results showed that the number of nerve fibers gradually increased in both the dermis and the epidermis, but that they did not reach the levels of expression present in matched unburned skin of the same patient. A significantly higher number of nerve fibers were observed in normotrophic scars compared with hypertrophic scars. The number of neuropeptides-containing nerves in normotrophic and hypertrophic scars were similar. IN CONCLUSION 7 months after wound closure, burn wound scars contain less nerve fibers than unburned skin. The significantly higher number of nerve fibers in normotrophic, compared with hypertrophic scars suggests a regulatory role for the skin nerve system in the outcome of burn wound healing.

A review on static splinting therapy to prevent burn scar contracture: Do clinical and experimental data warrant its clinical application?

BACKGROUND Static splinting therapy is widely considered an essential part in burn rehabilitation to prevent scar contractures in the early phase of wound healing. However, scar contractures are still a common complication. In this article we review the information concerning the incidence of scar contracture, the effectiveness of static splinting therapy in preventing scar contractures, and specifically focus on the - possible - working mechanism of static-splinting, i.e. mechanical load, at the cellular and molecular level of the healing burn wound. METHOD A literature search was done including Pubmed, Cochrane library, CINAHL and PEDRO. RESULTS Incidence of scar contracture in patients with burns varied from 5% to 40%. No strong evidence for the effectiveness of static splinting therapy in preventing scar contracture was found, whereas in vitro and animal studies demonstrated that mechanical tension will stimulate the myofibroblast activity, resulting in the synthesis of new extracellular matrix and the maintenance of their contractile activity. CONCLUSION The effect of mechanical tension on the wound healing process suggests that static splinting therapy may counteract its own purpose. This review stresses the need for randomised controlled clinical trials to establish if static splinting to prevent contractures is a well-considered intervention or just wishful thinking.

Reliability of subjective wound assessment

INTRODUCTION Assessment of the take of split-skin graft and the rate of epithelialisation are important parameters in burn surgery. Such parameters are normally estimated by the clinician in a bedside procedure. This study investigates whether this subjective assessment is reliable for graft take and wound epithelialisation. METHODS Observers involved in the field of burns (experienced, medium-experienced and inexperienced observers), and dermatologists specialized in the field of wound healing evaluated the percentage graft take and epithelialisation in 50 photographic skin-grafted burn wounds. Reliability was tested using the intraclass correlation coefficient (ICC). RESULTS Intra- and interobserver reliability of parameter graft take was highest within the experienced observers (ICC average > 0.91), followed by medium- and inexperienced observers (ICC average > 0.80 and ICC average > 0.68). Parameter epithelialisation showed the same pattern of intra- and interobserver ICC scores (experienced > medium > inexperienced). Interobserver ICC single scores of the experienced group were reasonable to good. Interobserver reliability of the dermatologists was similar to medium-experienced observers. CONCLUSIONS Our data show that one experienced observer can obtain adequate reliable results by means of a single assessment of graft take and epithelialisation. Furthermore, experience of the observer results in an increase of reliability.

Reconstructive surgery after burns: a 10-year follow-up study.

BACKGROUND There is minimal insight into the prevalence of reconstructive surgery after burns. The objective of this study was to analyse the prevalence, predictors, indications, techniques and medical costs of reconstructive surgery after burns. METHODS A retrospective cohort study was conducted in the three Dutch burn centres. Patients with acute burns, admitted from January 1998 until December 2001, were included. Data on patient and injury characteristics and reconstructive surgery details were collected in a 10-year follow-up period. RESULTS In 13.0% (n=229/1768) of the patients with burns, reconstructive surgery was performed during the 10-year follow-up period. Mean number of reconstructive procedure per patient were 3.6 (range 1-25). Frequently reconstructed locations were hands and head/neck. The most important indication was scar contracture and the most applied technique was release plus random flaps/skin grafting. Mean medical costs of reconstructive surgery per patient over 10-years were €8342. CONCLUSIONS With this study we elucidated the reconstructive needs of patients after burns. The data presented can be used as reference in future studies that aim to improve scar quality of burns and decrease the need for reconstructive surgery.

Digital image analysis versus clinical assessment of wound epithelialization: A validation study

To evaluate the progress in wound healing, wound assessment is mandatory. Epithelialization is traditionally assessed subjectively by the clinician. In a previous study, subjective assessment of epithelialization was shown to be reliable. In this study, reliability of epithelialization measured by digital image analysis was investigated and then, we validated the subjective evaluation by comparing this assessment to measurements with digital image analysis. Clinicians assessed epithelialization in 50 burn wounds that were treated with a split skin graft. Epithelialization of these wounds was also measured by three observers using digital image analysis. Reliability of digital image analysis was tested using the intraclass correlation (IC). To test validity, subjective clinical assessment was correlated with digital image analysis (IC). The results showed that interobserver reliability of epithelialization measured by digital image analysis was good (IC coefficient 0.74). Subjective clinical assessment of epithelialization showed a strong correlation with digital image analysis (IC coefficient 0.80). In conclusion, subjective clinical evaluation of wound epithelialization is as good as an objective measure, in this study digital image analysis. Since digital image analysis is more time-consuming, we recommend the use of the subjective evaluation for daily practice.

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.

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.

Return to work after specialised burn care: A two-year prospective follow-up study of the prevalence, predictors and related costs

BACKGROUND Burn injuries may cause long-term disability and work absence, and therefore result in high healthcare and productivity costs. Up to now, detailed information on return to work (RTW) and productivity costs after burns is lacking. AIMS The aim of this study was to accurately assess RTW after burn injuries, to identify predictors of absenteeism and to calculate healthcare and productivity costs from a societal perspective. METHODS A prospective cohort study was conducted in the burn centre of Rotterdam, the Netherlands, including all admitted working-age patients from 1 August 2011 to 31 July 2012. At 3, 12 and 24 months post-burn, patients were sent a questionnaire: including the Work and Medical Consumption questionnaire for the assessment of work absence and medical consumption and the EQ-5D-3L plus a cognitive dimension to assess post-burn and pre-burn quality of life (QOL). Cost analyses were from a societal perspective according the micro-costing method and the friction cost method was applied for the calculation of productivity loss. Univariate logistic regression was used to identify predictors of absenteeism at three months. RESULTS A total of 104 patients were included in the study with a mean total body surface area (TBSA) burned of 8% (median 4%). 66 respondents were pre-employed, at 3 months 70% was back at work, at 12 months 92% and 8% had not returned to work at time of final follow-up at 24 months. Predictors of absenteeism at 3 months were: TBSA, length of stay, ICU-admission and surgery. Mean costs related to loss in productivity were €11.916 [95% CI 8.930-14.902] and accounted for 30% of total costs in pre-employed respondents in the first two years. CONCLUSION This two-year follow-up study demonstrates that burn injuries cause substantial and prolonged productivity loss amongst burn survivors with mixed burn severity. This absenteeism contributes to already high societal costs of burn injuries. Predictors of absenteeism found in this study were primarily fixed patient and treatment related factors, future studies should focus on modifiable factors, in order to improve RTW outcomes. Also, more attention in the rehabilitation trajectory is needed to optimally support RTW in burn survivors.