Evaluation of hand function after early excision and skin grafting of burns versus delayed skin grafting: A randomized clinical trial

burns 37 (2011) 707–713

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Evaluation of hand function after early excision and skin grafting of burns versus delayed skin grafting: A randomized clinical trial§ Mohammed T. Ahmed Omar a,b,*, Ahmed A. Hassan c a

Faculty of Physical Therapy, Cairo University, Cairo, Egypt Member of Rehabilitation Research Chair, College of Applied Medical Science, King Saud University, Saudi Arabia c Department of Plastic Surgery, Ain Shams University, Cairo, Egypt b

article info

abstract

Article history:

Introduction: Thermal injury of the hand is characterized by disfigurement and deformity with

Accepted 11 December 2010

marked problems because the patient is no longer able to perform the daily living activities and function at school or work. Early excision and grafting (E&G) were introduced to decrease

Keywords:

hospital stay, hospital cost, and septic complications and to eliminate burn toxins. In this

Hand burns

study, E&G was compared with delayed skin grafting in deep hand burns.

Early surgical treatment

Materials and method: 40 patients with deep second- and third- degree hand burns with

Physiotherapy

average burn size less than 30% total body surface area (TBSA) were randomly divided into E&G group and delayed grafting group. All hands in both groups were subjected to pre and post operative program of physiotherapy. Measurement of total active motion (TAM) of each digit and grip strength was recorded pre and post operative. Hand function using Jebsen– Taylor hand function test (JTHFT) was recorded three months after operation in both groups. Results: There were statistically significant differences in both groups regarding to TAM, hand grip strength and Jebsen–Taylor hand function test favoring the E&G group. Conclusion: The study concluded that early excision and skin grafting with physiotherapy gave better results than delayed grafting in terms of preservation of hand function and shortened hospital stay. # 2010 Elsevier Ltd and ISBI. All rights reserved.

1.

Introduction

Thermal injury of the hand is characterized by disfigurement and deformity with marked problems because the patient is no longer able to perform the daily living activities and function at school or work [1]. Since the dorsum of the hand has a relatively thin skin and lack of subcutaneous tissue, it is liable to deep burn injuries. Such injuries commonly involve tendons, muscles, and even joints, and induce tissue adhesion §

and stiffness of the joint as a result of localized infection or long-term inflammatory edema and immobility [2]. Following a major burn, the hand adopts a characteristic posture with flexion wrist, hyperextension of metacarpophalangeal (MCP) joints, flexion of proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, and adduction of the thumb. Initially, this appears to be a postural response to pain, but as the edema accumulates the fingers are driven into a semiflexed posture by the accumulation of fluids [2]. At this

Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN: ACTRN1261000081605. * Corresponding author at: Faculty of Physical Therapy, Cairo University, Cairo, Egypt. E-mail addresses: [email protected], [email protected] (M.T.A. Omar). 0305-4179/$36.00 # 2010 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2010.12.012

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burns 37 (2011) 707–713

stage, postural changes are reversible but if left untreated irreversible ligamentous changes may occur within the interphalangeal (IP) joints and MCP joints, resulting in permanent stiffness [3]. The delay in the excision of burn eschar of the hand results in functional disability. Hyperextension at the MCP joints occurs as a result of dorsal scarring [4]. Boutonniere deformity occurs following destruction of the central slip of the extensor tendon over the PIP joint [5,6]. Contracture of the first web space occurs and exaggerated by the hyperextension at the MCP joint of the thumb [7]. In an attempt to avoid all these pitfalls: early excision and grafting (E&G) have been advocated [8–11], to reduce mortality, increase blood transfusion requirements, reduce duration of illness, and reduce the costs and length of hospital stay [12– 16]. While other surgeons prefer to treat hand burns conservatively until spontaneous sloughing of the burn eschar, and then performed skin grafting [17,18]. Both techniques have advantages and limits, although early E&G within 3–6 days from injury is generally considered the best therapy [19–26]. To date no randomized controlled comparisons of early excision and grafting versus the delayed excision burn therapy have been reported on adults. The majority of these studies compared mortality [27–30], number of septic episodes, blood volume loss, number of operative procedures [31–33], while only one study looked at functional and cosmetic outcomes [34]. Ong et al. [12], in their metaanalysis concluded that, there were small number of randomized controlled trials published and commented upon the heterogeneity of the patients in these trials. The participants of the these trials differed in terms of age, percentage of burns and presence of inhalational injury, time of excision of burns, method of conservative treatment and outcomes measured. Another confounding factor was the fact that three out of the six studies [28,31,35] that met the criteria for this meta-analysis were from the same centre. Ideally, we would like to have randomized control trials from as many centers as possible to give a more representative picture. Therefore, this randomized controlled clinical trial E&G versus delayed skin grafting in deep hand burns with physiotherapy was conduced to evaluate objectively hand function to provide justifiable knowledge of.

2.

Materials and methods

This study was conducted from May 2002 to August 2004 with an average follow-up period of six months. During this period, 180 patients were admitted to the burn unit at a department of burn and plastic surgery, Ain Shams University, Cairo, Egypt. Among all burn patients presented to the department, 118 patients had deep hand burns. Patients had been electrical burn, fourth-degree burn, burn as a component of multiple trauma including fractures or central and/or peripheral nervous system trauma, co-morbid diseases including chronic cardiovascular disease, diabetes mellitus, hypertension and those who had significant inhalation injuries identified by the presence of orofacial burns with the history of a closed-space

injury, bronchoscopic evidence of soot and erythema, or blisters in the trachea or bronchus, needed intensive care and underwent delayed resuscitation more than 24 h after injury were excluded. At the time of this study there was no Human Research Ethics Committee established in either university, but the study was approved by the departmental committee. Forty patients (n = 52 hands) with deep second and third degree hand burn with average total body surface area (TBSA) less than 30% was included. All patients had been admitted to the emergency sector of the burn unit within 24-h of the injury. After enrollment, subjects were divided into E&G (group I), and delayed excision group (group II), using random allocation software developed by Saghaei to maintain equal in each group [36]. We aimed to recruit 40 participants, giving 80% power, a = 0.05 to detect a 14.4% of mean difference in TAM between the two groups based on our previous work, assuming that more than 84% of the patients had poor TAM, at the time of initial evaluation [37–39]. All patients were informed about the aim of the study and the patient’s written consent was obtained one or two days following admission.

2.1.

Delayed excision group

Dressing was carried out until spontaneous separation of eschar. All hands were subjected to vigorous irrigation by saline and application of antimicrobial ointments in the form of betadine or nitrofurazone. Nutrition was emphasized, and intravenous antibiotics for hospitalized cases were started according to the smear and culture result, which was taken if any sign of infection such as cellulitis, abnormal discharge, and fever, severe pain or poor progression occurred. Skin grafting was applied after granulation tissue excision. Spontaneous separation of burn eschar and formation of healthy granulation tissue occurred in a range of 13–23 days after burn with an average of 16 days. Under general anesthesia and sterile conditions, excess granulation tissue was removed to reach a suitable graft bed. Then, the meshed split-thickness skin graft from the healthy skin of thigh or trunk was transferred to the wound bed and fixed with non-absorbable monofilament suture material. Following skin grafting, all hands were splinted in the antideformity position. Commonly, the dressing was removed on the 5th day postoperatively and if there was any sign of infection (fever, malodorous). Then, the dressing was changed sooner. In the E&G group, decision for operation was generally made within 72 h and before the 6th post-burn day. In the operating theatre, under general anesthesia, tourniquets were applied for all patients to control bleeding. The depth at which punctuate bleeding occurred after tangential (layered) excision was used as a final criterion of burn depth. If burn injury remained superficial to the extensor paratenon, the burn was judged to be confined to the cutaneous tissues and the patient was included in the study. If the burn was extending to the extensor tendons, the patient was excluded from the study. Then, after irrigation and careful homeostasis, the tourniquet was inflated and meshed split-thickness skin was transported

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to the wound and fixed; after dressing, the tourniquet was deflated. Following skin grafting, all hands were splinted in the anti-deformity position.

2.2.

Splinting and immediate physiotherapy

All burned hands included in the study were splinted at the time of admission in a dorsal static hand splint. The wrist joint was splinted at 300 hyperextension, the MCP joint in 900 of flexion, the IP joints in extension, and the thumb in abduction. The webs of fingers were kept in abduction. The hands were elevated above the level of the heart to minimize post-burn edema. Physiotherapy was consisted of, active assisted and free range of motion exercises. The frequency of exercises was 2–4 times daily with 8–10 repetition for each exercise as reported in our previous work [36–39]. Physiotherapy was also restarted one week after skin grafting in both groups including active free and assisted digit range of motion under direct supervision of the physiotherapist.

2.3.

Measurement

All patients were assessed for total active motion (TAM) and grip strength. These measurements were done for both groups during the initial 72-h of admission, after two weeks and two months postoperatively. The evaluation of hand function and time to return to normal use has been recorded three months postoperative.

709

standardized test designed to evaluate functional capabilities of the hand, with 7 test items representative of various hand activities. The test items include (1) writing a short sentence, (2) turning over 3X5-in cards, (3) picking up small objects and placing them in a container, (4) stacking checkers, (5) simulated eating, (6) moving empty large cans, and (7) moving heavy large cans. The time taken to complete each test item is recorded in seconds. A second measure of function results was the duration needed to return to normal use. This can be defined as the patients’ estimate of time to return to pre-burn function level.

2.4.

Statistical analysis

Statistical analyses were done using statistical package for social science (SPSS Inc., Chicago, IL). The data were expressed as mean and standard deviation (mean  SD), for continuous variables and or range and proportion for dichotomous variables. Repeated-measures analysis of variance (ANOVA), with post hoc tests (Scheffe) was done to identify differences within each group. Student unpaired t-test was used to identify differences between two groups, while chi-square test used for categoral variables The alpha level of significance was less than 0.05.

3.

Results

The TAM of digits was measured through using standard geniometer while the wrist was in the neutral position and the forearm was prone. The TAM for each digit was computed using the method recommended by the American Society for Surgery of the Hand [40]. To calculate the TAM for each joint, a sum of all the flexion measurements at the MCP, PIP, and DIP joints was calculated. For the thumb, measurement of the MCP and IP joints were used, and any extension loss at each of the joints was subtracted from the total flexion. The measurements are classified into four categories. Normal; TAM will be greater than 2608, excellent; TAM lies between 220 and 2598, good; TAM lies between 180 and 2198 and poor; TAM is less than 1808 [41].

Fig. 1 depicts a CONSORT flow chart of the trial where there was no subject withdrawal or dropped out from the study, and Table 1 shows the demographics of the patients in both groups. There were 12 men and 8 women in early excision group. The mean age was 23  7 years. In delayed excision group, there were 13 men and 7 women with a mean age of 25  8 years. The most common cause of burns was flame with a frequency of about 72.5%. The duration interval between burn and graft was 4.9  1.86 days and 16  3.7 days for and the mean hospital stay was significantly lowered in E&G group (16 days) compared to (24 days) in the delayed excision group. Complete take of the graft occurred in 20 hands versus 21 hands, while partial graft loss and re-grafting occurred in 5 hands versus four hands for E&G group compared to delayed excision group.

2.3.2.

3.1.

2.3.1.

Measurement of total active motion (TAM)

Measurement of hand grip strength

Grip strength was measured by portable hand Jamar dynamometer (Lafayette Instrument 78010 Hand Dynamometer), as reported in the literature [42–45]. The measurements were performed while the patients held the dynamometer and seated in back chair, with the shoulder adducted, elbow flexed 908, forearm and wrist in neutral rotation. The participant performed three trials with approximately 15 s rest between trials, and the average of the scores was recorded.

2.3.3.

Evaluation of hand function

Hand function was measured by the Jebsen–Taylor hand function test (JTHFT) [46]. The JTHFT is an objective and

Results of range of motion

Measurement of TAM of digits of the hands showed no statistically significant difference between the two groups (P > 0.05) at 72 h after burn. Measurement of TAM of the digits of the hands after two weeks, and two months post-grafting revealed an improvement in the overall range of motion for both groups. However, there was significant (P < 0.05) statistical increase in TAM for hands that underwent early excision and grafting compared to TAM in hands treated by conservative methods (Table 2). Fig. 2 shows that there were significant differences in the hand had normal TAM (68% versus 40%, P = 0.04) for early excision and grafting compared to delayed grafting, while

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[()TD$FIG]

Fig. 1 – Flow of participants through the study.

there were no significant difference in percentage of hand had excellent TAM (24% versus 26%). There were significant decreases in the percentage of digits that had good TAM (8% versus 34%, P = 0.03) for early excision and grafting compared to the delayed grafting group.

Table 1 – Patients’ demographics in both groups. Variables Age (years) Gender (m/f) TBSA% Causes of burn Flame Scald Duration between burn and grafting (days) Depth of burn Deep 3rd degree burn Deep 2nd degree burn Hand dominance (R/L) Hospital stay (days) TBSA, total body surface area. non significant (P > 0.05). * Significant (P < 0.05). ^

Group I

Group II

23  6.86^ 12/8^ 26  3.47^

25  8.3 13/7 24  3.68

15(75%)^ 5(25%)^ 4.9  1.86^

14(70%) 6(30%) 16  2.7

14(56%)^ 11(44%)^ 20/5^ 16  2.5*

1q15(55.6%) 12(44.4%) 19/8 24  3.4

3.2.

Results of hand grip strength

Measurement of grip strength of burned hands in both groups in Table 3, showed no statistical significant difference between the two groups (P > 0.05) at 72 h postburn. The grip strength of hands operated upon by early excision and grafting gave better grip strength than hands treated conservatively. Two months after grafting, there was marked improvement in grip strength in both groups. Hands underwent early excision and grafting gave better grip strength.

3.3.

Results of Jebsen–Taylor hand function test

Mean test scores and standard deviations for both groups are shown in Fig. 3. An increase in time indicates decreasing hand function. There was a significant (P < 0.05) decrease in all items for early excision and grafting compared to conservative treatment after three months postoperatively. The time taken to complete the JTHFT when compared with norms revealed that, subjects in studied groups took longer to complete the test items. Of the seven items, writing a sentence took the longest time and showed the most difference between the groups and the norm scores. A 55% versus 35% of patients had recorded normal use level in eight weeks post-operative and 92% versus 65% of patients returned to the normal function in 12 weeks postoperative for early excision and grafting compared to conservative treatment.

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Table 2 – The mean total active motion of digits in both groups. Digits

Groups

Time of measurements 72 h post burn

Thumb

^

E&G group Delayed group E&G group Delayed group E&G group Delayed group E&G group Delayed group E&G group Delayed group

Index Middle Ring Little

80  24.7 78  23.5^ 170  23.8^ 168  24.3^ 165  22.1^ 165  21.2^ 175  25.3^ 173.  24.8^ 160  22.3^ 163  23.6^

2 weeks post graft *,y

107  19.8 89  26.7* 210  23.6*,y 200  24.3* 218  26.8*,y 205  33.3* 217  27*,y 203  23.2* 205  32.9*,y 195  29.9*

2 month post-graft 120  19.3*,y 107  29.1* 255  27.2*,y 233  24.7*,y 245  39.3*,y 220  26.1* 253  23.3*,y 228  27.3* 243  34.2*,y 218  35.6*

E&G, early excision and grafting. P = non significant (P > 0.05), between groups. * P < 0.05, compared with baseline within group. y P < 0.05, compared between groups. ^

Table 3 – The mean hand grip strength for both groups. Groups

Time of measurements 72 h post burn

2 weeks post graft

2 month post-graft

4.5  1.9^ 4.2  1.7^

13.5  2.9*,y 9.3  2.1*

30  6.8*,y 23  3.59*

E&G group Delayed group

E&G, early excision and grafting. P = non significant (P > 0.05), between groups. * P < 0.05, compared with baseline within group. y P < 0.05, compared between groups. ^

4.

Discussion

Over many decades, there was a conflict about prompt hand burn excision and skin grafting and a question was always raised, does it really benefit to graft early over the classic conservative treatment with delayed hand grafting in terms of better hand function? Tangential excision and immediate grafting for deep dermal burns were first used by Janzenkovic [47], as well as Jackson and Stone [48]. The authors stressed that the early closure of this type of wound would lead to decrease scaring and better function. They suggested the second to fifth postburn days as the optimum time for the procedure. Peacock et al. [49], stated that the interphalangeal joints stiffness and

[()TD$FIG]

100 Group I

Group II

% of pdigits on TAM

90 80 70

68

60 50

40

40

34

30

24

26

20 8

10 0 Normal

Excellent

Good

Fig. 2 – The rating scale for total active motion (TAM) in both groups.

fibrosis are secondary to a combination of joints immobility and fixation of edema fluid in connective tissue. They reasoned that if the burn could be excised and grafted before this fixation occurred, the graft would take more quickly, the hand could be exercised sooner, and thus, joint limitation be avoided. Our data are supported by other authors [50], who concluded that, early surgery shortens the healing time, lessens the hospital stay [12], minimizes reconstructive surgery and leads to a good hand functioning with a reasonable aesthetic appearance, enabling the affected patient to return quickly to work and normal routine life. Based on this philosophy, several authors reported on their experience with excision in the deep dermal burns of the dorsum of the hands. Wexter et al. [51] excised eschar of such hands in 18 patients within 6 days of injury. Excellent results were seen in 15 of these patients at one month and three were failures. Malfeyt [52] compared two groups of patients with deep dermal hand burns. The first, 34 patients, was tangentially excised and grafted before the fifth day post-burn day 21, while the remaining patients (n = 11) had wounds that were allowed to granulate before grafting. Patients had early excision in which there was good graft take, with faster healing and better function than others. Understanding the pathophysiology of burn allows surgeons to interfere by burn excision as early as possible to eliminate the consequences of infection and burn toxins. In our study, we planned to excise burn eschar of the hand as well as other areas of the body within 72-h post-burn. The advances in burn resuscitation and mechanical ventilation

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[()TD$FIG]

120 96.6

100

TIME(S)

80

function regarding to total active motion of digits, hand grip strength and daily living activities, and shortens the hospital stay and time required to return to normal use of hand.

66

60

Conflict of interest

40

None.

20 0 Group I

Group II

Fig. 3 – The average test time in seconds to complete the Jebsen–Taylor hand function test in both groups.

of severely injured patients enabled burn surgeon to perform early excision among patients with large surface area of burn. Levine et al. [53] published their study about the efficacy of tangential excision and immediate autografting of deep burns of the hand who promoted this regime of treatment. However, Burke et al. [54] criticized the study in two points. The first point of criticism is the use of skin graft for hand coverage in patients with extensive burn. The second point is the difficulty to judge the exact depth of excision at 72-h postburn which would result in graft loss. In this study, the mean surface area of burn allowed to early excision was 26%, which is similar to TBSA in our study (26 and 23% for early excision and skin grafting, and conservative group, respectively). This average percentage enabled us to interfere safely and to excise burn eschar within the first three days post-burn. Regarding to the second point, excision was done tangentially to achieve punctuate bleeding points. However, graft loss occurred in 4 hands treated by early excision and in 7 hands treated conservatively. Studies, by Edstrom et al. [55] Goodwin et al. [56] and Frist et al. [57] did not find any differences in the functionality of the hand in the non-operative, versus the E&G group, as well as Mohammadia et al. [58] did not show any significant difference between these two methods regarding function, scar formation, daily activity limitation and overall satisfaction. The only reason why one might suggest E&G was to shorten hospital stay for patients with small total body surface burns. The debate regarding the other proposed benefits continues, and it seems that there are some differences in outcomes. XThe outcomes related to this study were functions of the hand included total active motion; hand grip strength and hand function as well as length of hospital stay. However, it not only to be expected as the outcome from the meta-analysis [12], conclude that early excision of burns reduces mortality in patients without inhalational injury, increases blood transfusion requirements and reduces the length of hospital stay in patients. While conclusions on duration of sepsis, operating hours, wound healing time, skin graft take and long term morbidities like hypertrophic scarring were unclear.

5.

Conclusion

We believe that early excision of burned hand with prompt physiotherapy leads to significant and faster regain of hand

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