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PubMed2000

Effectiveness of a bed positioning program for treating older adults with knee contractures who are institutionalized.

BACKGROUND AND PURPOSE: Although contractures in patients in long-term care institutions are an important issue, there have been only a few studies that have evaluated interventions for contractures. The purpose of this study was to determine the effectiveness of a bed positioning program (BPP) for the treatment of patients with knee flexion contractures. SUBJECTS: Sixteen patients with a high level of cognitive and functional impairment (mean age=82 years, SD=6.48, range=71-93) in a chronic care hospital participated in the study. METHODS: The BPP consisted of stretching a patient's knee into extension and then securing and maintaining the position for a period of 40 minutes, 4 times per week. Participants were randomly assigned to 2 groups (n=8 in each group). One group received a BPP for 8 weeks, followed by 8 weeks of no intervention. The other group received the intervention in the reverse order. Once a week, participants were assessed for range of knee extension, knee pain, and skin integrity. RESULTS: Twelve participants completed the study. There was no improvement in participants' range of knee extension during the intervention period. Overall, there was no difference in mean range of knee extension between the intervention period and the no-intervention period. CONCLUSION AND DISCUSSION: The results of this study do not support the use of a BPP for treating patients with knee flexion contractures.

Aged↗
PubMed1992

Prediction of malignant hyperthermia susceptibility in low-risk subjects. An epidemiologic investigation of caffeine halothane contracture responses. The North American Malignant Hyperthermia Registry.

The most commonly used laboratory test for predicting malignant hyperthermia susceptibility is the caffeine halothane contracture test. However, the specificity and sensitivity of proposed North American diagnostic guidelines for this test have never been evaluated in a large, human study population. Therefore, the authors conducted a multiinstitutional, prospective study of skeletal muscle contracture responses in a subject population at low risk for malignant hyperthermia susceptibility to help determine the specificity of the proposed guidelines. Subjects were selected arbitrarily from a population of patients undergoing surgery unrelated to performance of a diagnostic muscle biopsy. Subjects were admitted to this study and were presumed nonsusceptible if there was no evidence of any of the following malignant hyperthermia risk factors: prior abnormal response to triggering anesthetic agents, myopathy, or family history of malignant hyperthermia susceptibility. The authors suggested rejection of the proposed diagnostic guidelines if an 85% specificity estimate among subjects could not be obtained. The authors analyzed the responses of 1,022 muscle fascicles, derived from 176 subjects, to the following: 1) separate administration of 3% halothane or incremental caffeine concentrations, or 2) the joint administration of 1% halothane and incremental caffeine concentrations. The following contracture results were obtained. First, for individual fascicles, 9.2% exceeded a greater than 0.7 g threshold for 3% halothane, 15.2% exceeded a greater than or equal to 0.2 g threshold for 2 mM caffeine, 32.4% exceeded a 1-g increase for less than 4 mM caffeine, 2.6% had a greater than 7% maximal increase in tension at 2 mM caffeine, and 63.5% had a "halothane caffeine-specific concentration" at less than or equal to 1 mM caffeine. Second, the percentages of subjects with 1 or more fascicles exceeding the proposed threshold were as follows: 45.8% for the four-component, 28.8% for the three-component, and 32.7% for the two-component contracture test. Third, the percentages of subjects with 1 or more fascicles exceeding the proposed threshold for both halothane and caffeine were as follows: 9.5% for 3% halothane and 2 mM caffeine, 2.0% for 3% halothane and 7% maximal increase in tension at 2 mM caffeine, and 11.0% for 1% halothane and 2 mM caffeine. Fourth, center-to-center differences were the major source of variation in the rate that subjects exceeded proposed thresholds. These data demonstrate that proposed diagnostic guidelines must be modified to improve specificity estimates before adoption by diagnostic centers.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1994

Dupuytren's contracture in the black population: a review.

There is general agreement that Dupuytren's contracture is a genetic disorder that occurs predominantly in white men of Northern European ancestry. It appears rarely in the purely black population. We present our experience from Temple University of 8 black patients with Dupuytren's contracture. We also present a review of the world literature dealing with the black population and Dupuytren's disease. A total of 23 patients are reviewed, including our group. They all fall into the category of no Caucasian admixture and negative family history of Dupuytren's contracture. Every patient reviewed has at least 1 hand involved. History and presentation of disease, as well as epidemiological associations (e.g., age distribution, diabetes, and epilepsy), in our review are similar to that seen in the Caucasian population. The diathesis or predisposition for Dupuytren's contracture appears to be less extensive in our series of 8 black patients. History taking, with regard to occupation and possible traumatic etiology, remains a very useful tool.

Aged↗
PubMed1998

Use of a multiplanar distracter for the correction of a proximal interphalangeal joint contracture.

Proximal interphalangeal (PIP) joint contractures are common complications in hand injuries and conditions such as Dupuytren's contracture. Conventional treatment such as splinting and serial casting may result in inadequate improvement. Operative release of the contracture may be complicated by neurovascular overstretch with injury to the digital nerves or vascular compromise. Gradual distraction of the contracted joint may prevent this neurovascular injury. The multiplanar distracter was designed for three-dimensional distraction of the mandible. Distraction may be obtained in the X, Y, or Z planes. With this device, the angular relationship between two planes may be altered. A 22-year-old male with a PIP joint contraction following replantation failed conventional treatment for release. With the use of a multiplanar distracter, the flexion contraction was reduced from 95 degrees to a more functional 30 degrees using gradual angular distraction. The angle between the proximal and middle phalanges were gradually changed using the ability of the distracter to change the angular relationship in the X-Y plane. At 3 and 6 months postdistraction, the patient has maintained his 30-degree flexion angle. The multiplanar distracter is a simple technique that may be useful for the treatment of PIP joint contractures that fail conventional therapy.

Adult↗
PubMed1999

Free jejunal patch to reconstruct oral scar contracture following caustic ingestion.

Reconstruction of oral scar contracture is often a challenging problem due to the complex structures and functions of the oral cavity. This report describes the treatment of a patient who sustained extensive oral scar contracture following caustic liquid soda ingestion. Surgical release of the scar contracture formed an S-shaped, thin, long defect that was difficult to cover with a conventional flap or skin graft. A jejunal segment was transferred microsurgically as a patch to reconstruct the defect. It sustained a sufficient oral space to provide full opening of the mouth and good movement of the tongue. A free jejunal flap, used occasionally for reconstruction following oral cancer resection, has significant advantages for restoration of function after release of an oral scar contracture.

Burns, Chemical↗
PubMed2000

Treatment of deltoid contracture in adults by distal release of the deltoid.

Twenty-five consecutive adult patients (32 shoulders) with deltoid contracture were treated with distal release and followed up for an average of 4 years (range, 2-8 years). All shoulders achieved full range of motion and complete relief of pain and deformity after 3 months. No muscle weakness was clinically evident. In addition, another five adult patients (nine shoulders) with deltoid contracture were treated with distal release and quantitative measurement of muscle power recovery around the shoulder with Cybex 340 dynamometer before surgery, and 3 months and 1 year after surgery. Isokinetic peak torque of shoulder muscles did not decrease significantly at either 60 degrees per second or 180 degrees per second angular velocity after surgery. In addition, the shoulder extensors showed a twofold increase of isokinetic peak torque after surgical release of deltoid contracture. Distal release was a simple and effective surgical technique to treat deltoid contracture in adults. All patients in this series achieved a satisfactory outcome.

Adult↗
PubMed1988

Reconstruction of axillary burn contractures with the latissimus dorsi fasciocutaneous flap.

Standard management of axillary burn contractures has been scar release and the use of skin grafts, despite the common problem of incomplete graft take, prolonged splinting, extended physical therapy, and recurrent contractures. A recent development in plastic surgery has been the "super flap" or fasciocutaneous flap. A series of axillary burn contractures released with the latissimus dorsi fasciocutaneous flap has been reported by Tolhurst. Our series of ten patients confirms that the latissimus dorsi fasciocutaneous flap is the treatment of choice for the release of severe axillary burn contractures.

Adolescent↗
PubMed1999

Microsurgical combined scapular/parascapular flap for reconstruction of severe neck contracture: case report and literature review.

OBJECTIVE: The reconstruction for severe neck contracture is difficult, because it may include not only the necessity the use of a large flap but also the ability for three-dimensional movement of the neck. METHODS: A 41-year-old woman sustained a severe neck contracture with retraction of the lower lip and limited range of neck motion after a chemical burn. We used the combined scapular/parascapular flap to reconstruct the soft-tissue defect in the neck after excision of hypertrophic scar and release of contracture. The scapular portion was transferred to cover the defect vertically, and the parascapular portion was transferred to cover the transverse portion of the neck. This kind of design would allow the patient to move her neck more easily. RESULTS: Postoperatively, the range of motion of the neck was full in the vertical and horizontal directions after 6 months of rehabilitation. Also, the patient was satisfied with the final aesthetic results. CONCLUSION: The microsurgical combined scapular/parascapular flap, providing a large area of tissue for coverage in three dimensions with a reliable blood supply by only one pedicle anastomosis during surgery, is a good option for reconstruction of the severe neck contracture. We classify the inset of the combined scapular/parascapular flap into three types with six subtypes, according to the location of defects and the relation of the parascapular flap to the scapular flap.

Adult↗
PubMed1997

Capsular contracture with textured versus smooth saline-filled implants for breast augmentation: a prospective clinical study.

Texturization of silicone-filled breast implants has been shown to reduce the incidence of capsular contracture. A double-blind clinical study was undertaken to compare this incidence in saline-filled implants with textured or with smooth surfaces. Twenty-one women underwent mammary augmentation with a textured implant in one breast and a smooth implant in the other. The implants were placed subglandularly. All operations were performed by the same surgeon and all follow-up examinations by another. Breast hardness was evaluated 6 months postoperatively with applanation tonometry, using Baker's grading, and after 12 months, now also with a questionnaire concerning the patient's evaluation. Capsular contracture (Baker 3) had occurred in 33 percent of the breasts at the end of the study, and was bilateral in five cases. The incidence of contracture and the patients' views on the results did not differ between textured and smooth prostheses or between right and left breasts. Five patients requested reoperation, two of them because of breast hardness. Texturization of saline-filled implants thus did not reduce the incidence of capsular contracture.

Adult↗
PubMed1997

Tendency to capsular contracture around smooth and textured gel-filled silicone mammary implants: a five-year follow-up.

The aim of this prospective, controlled clinical investigation was to compare the capsular contracture rate between silicone implants with a smooth and those with a textured surface. The implants were otherwise identical. Twenty-five women with bilateral mammary hypoplasia underwent augmentation mammoplasty. All received a textured implant on one side and a smooth implant on the other. Before surgery the patients were told that they could have the implants changed if the study showed that one type was better than the other. The investigation was conducted with the double-blind technique, with the code broken 1 year after surgery. At 1-year follow-up (reported previously) three parameters were used to estimate the tendency to capsular contracture: (1) the patient's opinion on differences in hardness of the breasts, (2) the investigators' classification of capsular contracture, and (3) applanation tonometry. All parameters showed unequivocally that the breasts augmented with textured implants had a lower tendency to develop capsular contracture than those with smooth implants. Five years after surgery 17 patients had had their smooth implant changed to a textured one because of hardness. Only one of the textured implants had been removed. A comparison between the 1-year and 5-year tonometric results of the 24 breasts that still had the original textured implants showed that after 5 years, a small but statistically significant increase in hardness had occurred compared with that after 1 year.

Adult↗
PubMed2000

Latissimus dorsi myocutaneous flap reconstruction of neck and axillary burn contractures.

Neck and axillary burn contractures are both a devastating functional and cosmetic deformity for patients and a challenging problem for reconstructive surgeons. Severe contractures are more commonly seen in the developing world, a result of both the widespread use of open fires and the inadequacy of primary and secondary burn care in these vicinities. When deep burns are allowed to heal spontaneously, patients develop hypertrophic scarring of the neck and axillary areas. The back is typically spared, however, remaining a suitable donor site. We have used nine latissimus dorsi myocutaneous flaps in a total of six patients, finding the flaps effective in resurfacing both the neck and the axillary regions after wide release of burn contractures. Before flap mobilization, surgical neck release is often necessary to ensure safe, effective control of the airway in patients with significant neck contractures. Flap bulkiness in the anterior neck region can eventually be reduced by dividing the thoracodorsal nerve. Anchoring the skin paddle to its recipient site through the placement of tacking sutures will also help achieve a more normal anterior neck contour.

Adult↗
PubMed2001

Optimizing the correction of severe postburn hand deformities by using aggressive contracture releases and fasciocutaneous free-tissue transfers.

Severe postburn hand deformities were classified into three major patterns: hyperextension deformity of the metacarpophalangeal joint of the fingers with dorsal contracture of the hand, adduction contracture of the thumb with hyperextension deformity of the interphalangeal joint, and flexion contracture of the palm. Over the past 6 years, 18 cases of severe postburn hand deformities were corrected with extensor tenotomy, joint capsulotomy, and release of volar plate and collateral ligament. The soft-tissue defects were reconstructed with various fasciocutaneous free flaps, including the arterialized venous flap (n = 4), dorsalis pedis flap (n = 3), posterior interosseous flap (n = 3), first web space free flap (n = 3), and radial forearm flap (n = 1). Early active physical therapy was applied. All flaps survived. Functional return of pinch and grip strength was possible in 16 cases. In 11 cases of reconstruction of the dorsum of the hand, the total active range of motion in all joints of the fingers averaged 140 degrees. The mean grip strength was 16.5 kg and key pinch was 3.5 kg. In palm reconstruction, the wider contact area facilitated the grasping of larger objects. In thumb reconstruction, key-pinch increased to 5.5 kg and the angle of the first web space increased to 45 degrees. Jebsen's hand function test was not possible before surgery; postoperatively, it showed more functional recovery in gross motion and in the dominant hand. Aggressive contracture release of the bone,joints, tendons, and soft tissue is required for optimal results in the correction of severe postburn hand deformities. Various fasciocutaneous free flaps used to reconstruct the defect provide early motion, appropriate thinness, and excellent cosmesis of the hand.

Adolescent↗
PubMedDate not supplied

Combined Iliazarov and free flap for severe recurrent flexion-contracture release.

This article discusses the treatment of recurrent flexion-contracture of the knee after circumferential burns involving the entire limb. A two-team approach to surgery is used: the orthopedic team widely excises the scar tissue and releases tendons, muscles, and adjacent soft tissue that limit joint movement. The microsurgery team covers the exposed popliteal neurovascular elements with a latissimus dorsi free flap. However, full range of the knee is still limited by the short neurovascular bundle. Therefore, the orthopedic team applies a circular hinged Iliazarov external-fixator-frame to achieve gradual correction, until full range of the knee is achieved. Intensive physiotherapy and continuing use of extension splints for additional 6 months until the scars are deemed stable compliment the treatment regimen and prevent the recurrence of contractures. Between the years 2002 and 2003, we treated four patients (totaling five knee joints) with recurrent severe flexion-contractures after circumferential burns of the entire lower extremity. A significant limitation was caused by the abnormal scarring, which left the patients confined to a wheelchair. In all our patients, previous attempts to release the flexion-contracture failed. With the aforementioned technique, within 3 months after the procedure, all patients were able to walk. We encountered one major complication (ie, drop foot). At follow-up, all patients enjoyed a full range of motion and were able to walk. The strength of our approach comes from combining a free muscle flap with an Iliazarov external fixation and a detailed postoperative rehabilitation plan.

Adolescent↗
PubMed2006

Total knee arthroplasty in patients with greater than 20 degrees flexion contracture.

Fixed flexion contracture can present a technical challenge in total knee arthroplasty. Various techniques of addressing these deformities have been described including additional bony resection, ligamentous releases, and the use of increasing constraint. We retrospectively reviewed the clinical outcomes of 40 patients (52 knees) with fixed flexion contracture greater than or equal to 20 degrees treated with revision TKA and a stepwise algorithmic approach to treating the contracture. A cruciate-retaining device was used in 31 knees, a posterior stabilized design was used in 14, a posterior stabilized constrained device was used in five knees, and a rotating hinged design in was used in two knees. Full correction was achieved intraoperatively. Ninety-four percent of knees had less than 10 degrees residual contracture at an average followup of 37 months. We revised one case of postoperative instability in the posterior stabilized group and we had one infection in the cruciate-retaining group. No other revisions were performed. The stepwise algorithmic approach to treating fixed flexion deformity presented in this study in primary total knee arthroplasty is safe and effective.

Adult↗
PubMedDate not supplied

Crouched gait in myelomeningocele: a comparison between the degree of knee flexion contracture in the clinical examination and during gait.

The purpose of this study was to quantitatively evaluate, in patients with low lumbar and sacral level myelomeningocele who have knee flexion contractures, whether there are significant differences between the degree of knee flexion contracture measured clinically and the degree of actual knee flexion during gait, measured by computerized gait analysis. Patients were divided into two groups, those who walked with ankle-foot orthoses (AFOs) alone and those who walked with AFOs and crutches. In both groups, the patient's knee flexion contractures were measured clinically, and the degree of knee flexion was measured dynamically at two representative points in the gait cycle. In both groups and at both points of the gait cycle, the degree of knee flexion during gait was significantly greater than the degree of clinical knee flexion contracture. This should be taken into account when evaluating the crouch gait of children with myelomeningocele and planning the proper treatment.

Adolescent↗
PubMed2004

Free split-cutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects.

With recent advances in free-tissue transfer, microsurgical techniques have been used more frequently for the reconstruction of postburn contracture defects. Traditional methods, including full-thickness skin grafts and local flaps, often result in a good outcome; however, multiple operative procedures, long periods of splinting, and physical rehabilitation are often required. Free split-cutaneous perforator flaps, consisting of one large cutaneous paddle with two perforating vessels split into two separate skin regions, were used for two kinds of postburn contractures: rectangular and spatially separate defects. From September of 2000 to October of 2002, seven patients underwent this method of reconstruction at Chang Gung Memorial Hospital in Taiwan. A three-dimensional flap harvest method, in which the skin paddle is circumferentially elevated early in the harvest, was used. Postburn scar contractures had resulted from flame burns in six cases and an electric burn in one case. The reconstructive regions included the neck in two patients, the breast in one patient, and the hand in four patients. There were six male patients and one female patient, with a mean age of 34.8 years (range, 25 to 49 years). The size of the excised scar ranged from 120 cm2 to 308 cm2 (mean, 162.3 cm2). The size of the unsplit flaps ranged from 144 cm2 to 337.5 cm2 (mean, 192.1 cm2). The average time for flap harvest using this three-dimensional harvest technique was 39.1 minutes. The average total operative time was 4.3 hours. The average total hospital stay was 7.3 days (range, 6 to 11 days). All flaps survived without major complications. The donor site was closed primarily in all cases. At a mean follow-up time of 9 months, the functional and aesthetic outcomes showed significant improvement as compared with the preoperative condition. In this study, a new method of flap harvest using a three-dimensional technique is introduced, and its application in the reconstruction of postburn contractures is evaluated.

Adult↗
PubMed2004

The use of subcutaneous pedicle rhomboid flap in the treatment of postburn scar contractures.

PURPOSE: To investigate the efficacy and versatility of subcutaneous pedicle rhomboid flap in the treatment of linear or wide postburn scar contractures located in various parts of the body. MATERIALS AND METHODS: Twenty-three patients (aged 5 to 35 years) with postburn linear and wide scar contractures were treated with 31 subcutaneous pedicle rhomboid flaps. Rhomboid flaps were applied in the trunk (4 flaps), head and neck (5 flaps), lower extremity (5 flaps), and upper extremity (17 flaps). In 3 cases, Z-plasty was incorporated to the technique due to inadequate release. RESULTS: All rhomboid flaps healed uneventfully. In 28 contractures, rhomboid flaps alone were efficient to release the tension line (90.3%). Tip necrosis of the triangular flaps of Z-plasty in 1 case was the only complication seen that later led to recontracture. CONCLUSION: Clinical results indicated that subcutaneous pedicle rhomboid flap is a simple, efficient, and versatile technique in release of any postburn scar contracture. As no undermining is carried out, the flaps are more reliable than commonly used Z-plasty. Again contrary to Z-plasty, displacement of anatomic landmarks such as axillary hair and areola is rare with the technique.

Adolescent↗
PubMed2006

Capsular contracture of the breast: working towards a better classification using clinical and radiologic assessment.

BACKGROUND: Breast reconstruction and augmentation have become a standard surgical treatment worldwide as advancements in medicine and technology enable safer and simpler procedures. A variety of implants is used to mimic a natural breast both in appearance and texture. The most common complication of such procedures is capsular contracture encircling the implant, occurring in approximately 10%. As to date, the contracture is mainly estimated by a physical examination of the breast, which is standardized according to the Baker score. METHODS: In a cross-sectional study, we compared the clinical assessment of capsular contractures to a radiologic thickness of the capsule, as evaluated by ultrasound (US) and magnetic resonance imaging (MRI). A total of 20 patients, with 27 implants, were evaluated in the study. All patients were examined by a single senior plastic surgeon and divided into 4 groups according to their clinical Baker score estimation. Following, a US imaging of the implant with emphasis on capsular evaluation was performed. The MRI results, recently done prior to the study, were reevaluated in relation to capsular findings. RESULTS: Thirteen breasts had a clinical capsular contraction with a Baker score of I, 8 breasts with a Baker score of II, and 6 breasts with a Baker score of III-IV. The US and MRI images of breasts graded III-IV revealed a thickened capsule (mean of 2.39 mm by US and 2.62 mm by MRI) compared with the capsular imaging of the breasts with the lower clinical Baker scores (mean of 1.14 mm by US and 1.39 mm by MRI). These differences were statistically significant according to the Kruskal-Wallis test, with P values of 0.002 and 0.017, respectively. Both MRI and US studies revealed distinct appearance of the thickened capsule. CONCLUSION: It seems the capsular thickness as portrayed by US and MRI correlates well with the Baker scoring system and at the same time provides the physician with an objective and consistent evaluation. However, since clinical assessment can be difficult to interpret at times, objective-imaging modalities can be effectively used to assess capsular thickening in women with a clinical suspicion of capsular contraction. A revised classification of capsular contracture, taking into account the imaging of the capsule, is suggested.

Adult↗