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PubMed2006

A new method in the treatment of postburn scar contractures: double opposing V-Y-Z plasty.

PURPOSE: Postburn scar contractures are fairly often seen in many parts of the body, and are still a considerable problem for reconstructive surgeons. Although the mild to moderate contractures can easily be managed by numerous surgical methods, serious contractures usually require more comprehensive surgical solutions including multiple Z plasties and rhomboid flaps, each of which have disadvantages. We used a new method called "double opposing V-Y-Z plasty" in this study. This technique is a combination of V-Y plasty with Z plasty in double opposing fashion, both ensuring primary donor site closure. MATERIALS AND METHODS: The technique was applied to 21 postburn scar contractures in 14 patients (9 males and 5 females). The localization most often seen was in the hand. RESULTS: The mean follow-up time was 7.6 months. All flaps healed uneventfully. An adequate lengthening and functional recovery were achieved in all cases. The donor site scars were acceptable in all cases. None of the patients developed contracture recurrence in our series. CONCLUSIONS: Double opposing V-Y-Z plasty, as a good alternative to multiple Z plasties and multiple rhomboid flaps, is a very useful technique to insure more lengthening and to prevent recurrence in the treatment of serious postburn scar contractures.

Adolescent↗

PubMed2006

Use of free dorsoulnar perforator flap in the treatment of postburn contractures of the fingers.

BACKGROUND: Burns of the hand cause not only the impairment of hand function but also cosmetic deformity. Cases with dysfunctional hands with severe contractures increase if rehabilitation of the acutely burned hand is not done properly. PURPOSE: We present the use of free dorsoulnar perforator flap in the treatment of postburn contractures as an alternative when local flaps cannot be used. METHODS: Free dorsoulnar perforator flap was used in the treatment of seven hands with postburn contracture. Five of them had multiple digital postburn flexion contractures. Combined use of cross-finger and side finger transposition flaps was preferred when the adjacent finger was suitable for being cross-finger flap donor. When the adjacent finger was not suitable for being cross-finger flap donor, the free dorsoulnar perforator flap was preferred. Two of the patients had postburn web contractures. Free dorsoulnar perforator flap was used to release the web and to form a new web commissure. CONCLUSION: The free dorsoulnar perforator flap could be a good alternative to cover the defects created with the hand contracture release.

Adult↗

PubMed2004

Rabbit knee model of post-traumatic joint contractures: the long-term natural history of motion loss and myofibroblasts.

Our objective is to describe the natural history of motion loss with time and myofibroblast numbers in a rabbit knee model of post-traumatic joint contractures. Twenty-eight skeletally mature New Zealand White female rabbits had five-mm-squares of cortical bone removed from the medial and lateral femoral condyles of the right knee. A Kirschner wire (K-wire) was used to immobilize the knee joint in maximum flexion. A second operation was performed 8 weeks later to remove the K-wire. The rabbits were divided into four groups depending on the time of remobilization; 0, 8, 16 or 32 weeks. The average flexion contracture of the experimental knees in the 0-week and 8-week remobilization groups (38 degrees and 33 degrees, respectively) were significantly greater when compared with the values of the unoperated contralateral knees (8 degrees). The average flexion contractures of the experimental knees in the 16-week and 32-week remobilization groups were also greater than the unoperated contralateral knees, although they were not statistically significant. The average flexion contractures of the 16-week and 32-week groups were 19 degrees and 18 degrees, respectively, indicating a stabilization of the motion loss. Myofibroblast numbers in the posterior joint capsules were elevated 4-5x in the knees with contractures when compared to the contralateral knees. The initial decrease in severity followed by stabilization of motion loss and the association of motion loss with myofibroblasts mimics the human scenario of permanent post-traumatic joint contractures.

Actins↗

PubMed1995

Reducing iliotibial band contractures in patients with muscular dystrophy using custom dry floatation cushions.

OBJECTIVE: Custom dry floatation cushions were used to potentially reduce iliotibial band (ITB) contractures in long-term wheelchair users. DESIGN: Time-series with repeated measures pretreatment and posttreatment with follow-up at 6 and 12 months. SETTING: Community wheelchair users seen in private office. PATIENTS: A volunteer sample of nine subjects diagnosed with Duchenne's or limb-girdle muscular dystrophy, nonambulatory at least 3 years, and able to lie prone were included. One subject dropped out owing to adverse effects, one for technical reasons. Seven subjects completed the study and were contacted 6 months later; two were evaluated 1 year later. The participants ranged in age from 9 to 69 years, were nonambulatory an average of 7 years, and spent 12 to 16 hours a day in their wheelchairs. INTERVENTION: Subjects used custom dry floatation (ROHO) wheelchair cushions for 9 weeks. The cushions were designed with a sunken middle portion and separately inflated lateral portions, providing adduction to the thighs. MAIN OUTCOME MEASURES: ITB contractures were measured using goniometry every 3 weeks, twice before and three times after cushion delivery. RESULTS: After 9 weeks, a 13 degrees average decrease in ITB contracture was noted, representing a 34% change from baseline (p < .001, 99% confidence intervals, paired one-tailed t test). CONCLUSION: Using a custom dry floatation cushion for 9 weeks reduced ITB contractures in nonambulatory muscular dystrophy patients by an average 34%. Patients with large initial ITB contractures benefited the most. Such a cushion could be used to reduce ITB contractures in similar patient populations.

Adolescent↗

PubMedDate not supplied

Arthroscopic release of shoulder contracture secondary to birth palsy: an early report on findings and surgical technique.

PURPOSE: Internal rotation contractures are common in children with external rotation weakness secondary to brachial plexus birth palsy. Surgical release of the contracture, with or without latissimus dorsi transfer, is an established treatment through a variety of open methods. This article describes an arthroscopic method of contracture release in this patient population. TYPE OF STUDY: New surgical technique. METHODS: Forty-one children with contractures, ranging in age from 8 months to 12 years (mean, 3.5 years), underwent arthroscopic release of the shoulder with a 2.7-mm arthroscope used for visualization. The release consisted of a subscapularis tenotomy and release of the anterior capsular ligaments. Eighteen children underwent a subscapularis release as an isolated procedure. Twenty-three of the children also underwent latissimus dorsi transfer. RESULTS: Arthroscopic release was successful in achieving at least 45 degrees of passive external rotation at surgery in all but one case. This case was in the oldest child, a 12-year-old with severe deformity, who needed an open release. No other complications were noted. Glenohumeral deformity was common. The primary contracted elements were the subscapularis and the anterior capsular ligaments. CONCLUSIONS: Arthroscopic contracture release was effective in the restoration of passive external rotation in children with internal rotation contractures secondary to birth palsy.

Arthroscopy↗

PubMed1983

Fixed post-traumatic flexion-contractures of digits. Review of thirty-three cases.

A fixed post-traumatic flexion contracture of a finger is usually secondary to multiple previous operations. We have observed that a former flexor tendon laceration is not constant and is missing in 18% of our cases. The flexor tendons are, nevertheless, always involved in the contracture. A volar skin contracture was present in all cases, but only in half of them was noted a retraction of the volar components of the PIP joint. This articular involvement has no statistical correlation with the time elapsed from the onset of the contracture. We have reviewed 33 cases of post-traumatic flexions contractures of the digits all secondary to volar trauma. In every case there was at least a flexor tendon adhesion and skin contracture. They have all been submitted to both objective and statistical analysis. Results have been evaluated by comparison between the normal functional range of motion for each digit and the actual post-operative active range of motion. On the basis of our study we conclude that the age of the patient is an important prognostic factor. We obtained 75% satisfactory results in patients younger than 27 years, but only 22% in the older group. Good results are more easily obtained in radial (65%) than ulnar digits (31%). While the authors rated 39% of the results bad, half of the patients in this group were satisfied with the result. A volar PIP joint release has been necessary in half of the cases with no significant secondary joint stiffness. A skin flap is necessary to cover the cutaneous defect secondary to the release. There is no statistically significant advantage to cross finger flaps. Therefore we feel that local flaps are indicated except in the cases where local scar tissues would not make it, feasible. The prognosis is independent of the number of previous operations and of associated nerve lesions. Therefore amputation is not the only solution for a multi-operated finger fixed in flexion.

Adolescent↗

PubMedDate not supplied

Splinting in the management of proximal interphalangeal joint flexion contracture.

Proximal interphalangeal (PIP) flexion contracture is a common complication following hand injuries and conditions. This study investigated the treatment outcome of 20 subjects with PIP flexion contracture who followed a dynamic splinting program using either a Capener or low-profile outrigger. The splint applied a 250-g force to the distal end of the middle phalanx. Each patient was instructed to wear the splint for 8 to 12 hours per 24 hours for 8 weeks followed by a 2- to 3-week weaning period. Passive extension was evaluated objectively using torque range-of-motion measurement. The average pretreatment flexion contracture was 39 degrees. Final extension deficit averaged 21 degrees, an improvement of 18 degrees. There was no statistically significant effect on final results based on joint stiffness (as expressed by the slopes of the torque angle curves). Total end-range time (TERT) averaged 10 hours per 24 hours, for an average period of 4.3 months. Statistical analysis showed that splinting time was the only statistically significant factor affecting outcome. The correlation coefficients showed that the longer the contracture was present, the stiffer the joint and the less the contracture resolved. Dynamic splinting was an effective form of treatment for PIP flexion contracture.

Adult↗

PubMed1985

Contractures complicating spinal cord injury: incidence and comparison between spinal cord centre and general hospital acute care.

One hundred and eighty-one spinal cord injured patients admitted to the Rehabilitation Institute of Chicago after acute care following a spinal cord injury were studied. The presence or absence of contractures as well as significant abnormalities with loss of range of motion greater than 15% was recorded. Patients were either admitted from general hospitals or the acute care unit of our spinal centre, Northwestern Memorial Hospital. Patients treated in the general hospitals had a statistically significant increased incidence of contractures compared to spinal centre patients. Patients treated in the spinal centre were transferred to the rehabilitation hospital sooner post injury. An increased time from onset to rehabilitation admission correlated with a statistically significant increased incidence of contractures. Tetraplegic patients had a statistically significant increase over paraplegic patients and were more likely to have contractures of several upper extremity joints. Contracture development was not related to fractures of the extremities. This evidence further supports the need for spinal cord centres and provides data on the incidence of contractures in spinal cord injured patients which has not been reported previously.

Adult↗

PubMed2006

Comparison of muscular and articular factors in the progression of contractures after spinal cord injury in rats.

STUDY DESIGN: Experimental, controlled trial. OBJECTIVES: To identify the relationship between the muscular and articular factors in the progression of contractures after spinal cord injury (SCI). SETTING: Hiroshima University, Hiroshima, Japan. METHODS: In total, 48 female Wistar rats were used. The 24 experimental rats that underwent a spinal cord transection and the other 24 control rats that underwent a sham-operation were assessed at 2, 4, 8, 12, 16, or 24 weeks postsurgery. Knee joint motion was measured for flexion and extension. Myotomy of the transarticular muscles was then performed and range of motion was measured again. The degree of contractures was assessed by goniometry measuring the femorotibial angle before and after the myotomies. RESULTS: The spinal cord-injured rats demonstrated flaccid paralysis during the first few days postsurgery and thereafter spastic paralysis. Intra- and inter-rater reliabilities for all measurements were >0.814. Knee flexion contractures developed in the all experimental rats, and progressed for the first 12 weeks and plateaued thereafter. Both the muscular (48+/-5%) and articular (52+/-5%) factors contributed almost equally to the overall progression of the contracture. CONCLUSION: The present findings may shed light on the underlying pathophysiology of contractures and should help guide research towards finding the elucidation of contracture development after SCI.

Animals↗

PubMed2001

Contractures in orthopaedic and neurological conditions: a review of causes and treatment.

PURPOSE: To examine the techniques used for the treatment of contracture in the context of current scientific knowledge of muscle. METHOD: Synthesis of data available from MEDLINE, RECAL, EMBASE, the Cochrane Library and relevant texts. RESULTS: The development of contractures through immobilisation, muscle weakness and spasticity is described. The effects of passive stretching, continuous passive movement, serial plastering, splinting, electrical stimulation, botulinum injections and surgical tenotomies in the treatment of contractures in persons with neurological and orthopaedic conditions are identified. The strengths and weaknesses of these modalities are discussed. CONCLUSION: Predisposing factors persist after treatment of contractures thus for treatment to be effective long-term management programmes need to be developed. New treatment techniques, used in series or combined, offer the prospect of improved management of contracture. Scientific and clinical research is needed to investigate the effect of contracture treatment.

Activities of Daily Living↗

PubMed1963

CONTRACTURE OF SLOW STRIATED MUSCLE DURING CALCIUM DEPRIVATION.

When deprived of calcium the slow striated muscle fibers of the frog develop reversible contractures in either hypertonic or isotonic solutions. While calcium deprivation continues because of a flowing calcium-free solution the muscles relax slowly and completely. Restoration of calcium during contracture relaxes the muscle promptly to initial tension. When relaxed during calcium lack the return of calcium does not change tension and the muscle stays relaxed. When contractures are induced by solutions containing small amounts of calcium relaxation does not occur or requires several hours. The rate of tension development depends upon the rate at which calcium moves outward since the contractures develop slower in low concentrations of calcium and are absent or greatly slowed in a stagnant calcium-free solution. Withdrawal of calcium prevents the contractile responses to ACh, KCl, or electrical stimulation through the nerve. Muscles return to their original excitability after calcium is restored. Origin of the contractures is unrelated to nerve activity since they are maximal during transmission failure from calcium lack, occur in denervated muscles, and are not blocked by high concentrations of d-tubocurarine, procaine, or atropine. The experiments also indicate that the contractures do not originate from repetitive activity of muscle membranes. The findings are most simply explained by relating the outward movement of calcium as a link for initiating contraction in slow type striated muscle.

Animals↗

PubMed1965

THE TIME COURSE OF THE LOSS AND RECOVERY OF CONTRACTURE ABILITY IN FROG STRIATED MUSCLE FOLLOWING EXPOSURE TO CA-FREE SOLUTIONS.

Using area under the contracture curve to quantitate contractures, the diffusion coefficient of calcium ions within the frog toe muscle during washout in a calcium-free solution and subsequent recovery after reintroduction of calcium to the bathing solution was calculated to be about 2 x 10(-6) cm(2)/sec. The diffusion coefficient measured during washout was found to be independent of temperature or initial calcium ion concentration. During recovery it was found to decrease if the temperature was lowered. This was likely due to the repolarization occurring after the depolarizing effect of the calcium-free solution. The relation between contracture area and [Ca](o) was found to be useful over a wider range than that between maximum tension and [Ca](o). The normalized contracture areas were larger at lower calcium concentrations if the contractures were produced with cold potassium solutions or if NO(3) replaced Cl in the bathing solutions. Decreasing the potassium concentration of the contracture solution to 50 mM from 115 mM did not change the relation between [Ca](o) and the normalized area. If the K concentration of the bathing solution was increased, the areas were decreased at lower concentrations of Ca.

Animals↗

PubMed1984

Capsule contracture in animals can be characterized by gross deformation of prostheses and surrounding tissue.

Gel-filled miniprostheses were implanted in rats, recovered, and reimplanted in fresh animals. Experimental contracture characterized by severe, visually detectable distortion of hemispherical prosthesis mounds into pointed ovoid structures oriented laterally was observed. This finding confirms the existence in rats of a phenomenon similar in appearance to clinical contracture in humans. The incidence of contracture was higher than in the first implantation of these prostheses, which suggests that some property of the prosthesis is critical in the occurrence of contracture, and that this property can be altered by prolonged implantation in the tissue so that contracture is more likely. Implants that were overfilled by injection of extra fluid into the gel showed no contracture, but capsules around these implants did not differ from contracted capsules in protein, collagen, glycosaminoglycan composition, weight, thickness, histological appearance, or incidence of myofibroblasts.

Animals↗

PubMedDate not supplied

Ankle, knee, and hip moments during standing with and without joint contractures: simulation study for functional electrical stimulation.

Joint contractures have been one of the contraindications for use of functional electrical stimulation for standing in paraplegic patients. A simulation study using a three-segment link mechanical model of the human body was performed to calculate the muscle moments at the ankles, knees, and hips during standing with and without having joint contractures. The knee and hip angles were varied in 5 degrees increments, whereas the ankle angles were varied in 1 degree increments. It was assumed that energy efficient posture was obtained with the least sum of the squared moments of the ankles, knees, and hips joints by the muscles. Ankles at 5 degrees of dorsiflexion, knees at 0 degrees, and hips at 15 degrees of extension resulted in the most energy efficient posture without joint contractures. The muscle moments increased with the increase in angle of contractures. The joint contractures at ankle angles > or = 6 degrees of plantar flexion, knee angles > or = 20 degrees of flexion, and/or hip angles > or = 20 degrees of flexion produce a potentially unstable posture. These findings suggest that some degree of joint contractures can be tolerated in paraplegic patients using functional electrical stimulation for standing.

Algorithms↗

PubMedDate not supplied

Reconstruction of foot burn contractures in children.

Burn scar contractures of the foot cause significant morbidity. We reviewed 68 children in regard to number and rates of burn scar contracture recurrence, surgical techniques, and functional and aesthetic results. Two surgical techniques of foot burn scar contracture release have been used. Originally, an incision over the metatarsal heads perpendicular to the line of the metatarsals, which releases the longitudinal arch of the foot was used. More recently, additional releasing incisions parallel to the plane of the metatarsals to release the transverse metatarsal arch have been used. The time between burn injury and primary burn scar contracture release was 4.18 +/- 0.76 years, and the time until the first recurrence was 3.44 +/- 0.46 years. With release of only the longitudinal arch, recurrence of burn scar contractures occurred in 3.5 +/- 0.41 years and in 4.29 +/- 1.27 years in six patients who also received release of the transverse arch. Wound closure at the time of acute burn with split-thickness skin graft expansion ratios of 1:2 and 1:4 had burn scar contractures that required release in 4.21 +/- 0.70 and 2.29 +/- 0.52 years, respectively.

Burns↗

PubMed1991

Rate and incidence of capsular contracture: a comparison of smooth and textured silicone double-lumen breast prostheses.

Capsular contracture results in dissatisfaction and deformity among the 2 million women who have had silicone implants. The literature describes contracture rates as high as 74 percent. I present a comparison of rates and incidences of contracture in patients augmented with smooth and textured double-lumen silicone implants. A total of 165 "smooth" and 63 "textured" implant patients were included in this study, which spans 12 years, 1978-1990. All patients underwent bilateral aesthetic augmentation performed by the same surgeon. Of the 165 smooth implant patients, 74 (44.8 percent) experienced contractures requiring treatment. Of the 63 textured implant patients, 3 (4.8 percent) previous contracture patients experienced sudden fibrosis within 3 months. All others remained soft. It appears that deeply textured silicone surfaces delay or decrease the rate and incidence of clinical capsular contracture, at least for 2 years.

Breast↗

PubMedDate not supplied

Quality of life after burn injury: the impact of joint contracture.

We sought to investigate quality of life, and to specifically assess how joint contracture affects it, in patients with burn injuries. The study is involved 22 adults with burn injuries. Patients were divided into two groups according to the presence (n = 11) or absence (n = 11) of any joint contracture. Patient age, sex, date of burn injury, burn type, location, and extent of burn (TBSA) were recorded for each case. Each individual underwent a thorough musculoskeletal system examination, with special focus on range of motion of the joints. Quality of life was evaluated using the Short Form 36 (SF-36). Eight (36.4%) of the patients were women, and 14 (63.6%) were men, and their mean age (+/- SE) was 24.7 +/- 4.68 years. The mean interval from injury to the study assessment was 21.45 +/- 14.69 months. Eleven patients (50%) had at least one joint contracture. The patients with one or more contractures had significantly lower scores for the SF-36 subscales of physical functioning, physical role limitations, bodily pain, and vitality (P = .05, P = .01, P = .04, and P = .02, respectively). In the 22 patients overall, TBSA was negatively correlated with the scores for the SF-36 subscales vitality and emotional role limitations (r = -.586 and r = -.805, respectively). Joint contracture does impact burn patients' quality of life, especially with respect to physical functioning, physical role limitations, bodily pain, and vitality. In addition, the amount of BSA burned is correlated with psychosocial problems and poorer quality of life, regardless of whether joint contractures develop.

Adult↗

PubMed2003

Bone resection and ligament treatment for flexion contracture in knee arthroplasty.

A retrospective study of 103 knees (88 patients) who had primary total knee arthroplasty with a flexion contracture ranging from 20 degrees to 60 degrees was done to tabulate the primary soft tissue structures released during surgery and to identify any residual deformity. The average flexion contracture preoperatively was 27.1 degrees +/- 8 degrees and postoperatively was 2.7 degrees +/- 3.4 degrees (range, 0 degrees -10 degrees ). The average followup was 70.4 months (range, 12-180 months). Only medial or lateral soft tissue balancing procedures were necessary to correct the flexion contracture in 37 knees (35.9%) and no medial or lateral release was necessary in 25 knees (24.3%), of which 16 had a balanced posterior cruciate ligament. The posterior capsule was released on the deformity side of the knee in 15 knees (14.6%) and on the opposite side of the deformity in seven knees (6.8%). The posterior cruciate ligament was balanced in 21 knees (20.4%) and was released in four knees (3.9%). For all knees in which the posterior cruciate ligament was released or balanced, it was done for excessive rollback and tightness in flexion and not for flexion contracture management. In two patients (2%) an additional 4 mm of distal femur was resected for a 45 degrees and a 25 degrees flexion contracture. The data suggest that a contracted collateral ligament is the most likely primary structure whose effective release allows correction of the flexion contracture in most cases.

Arthroplasty, Replacement, Knee↗