Home
| Current
Issue | Archives
| Instructions
for Authors | Disclaimer
| Printable
Version
Surgical Options For Axillary Contractures
P. B . Olaitan
Department of Surgery
Lautech Teaching Hospital
Osogbo Osun
state Nigeria
I. I. Onah
Department
of Plastic Surgery
National Orthopaedic Hospital
Enugu Nigeria
A. O. Uduezue
Department of Surgery
Ebonyi State University Teaching Hospital
Abakaliki Ebonyi state Nigeria
N. E. Duru
Department
of Plastic Surgery
National Orthopaedic Hospital
Enugu Nigeria
Citation:
P. B . Olaitan, I. I. Onah, A. O. Uduezue, N. E. Duru: Surgical
Options For Axillary Contractures . The Internet Journal of Plastic
Surgery. 2007. Volume 3 Number 1.
Table of Contents
Abstract
Introduction
Materials
And Methods
Results
Discussion
References
AbstractBackground: The axilla is
one of the most frequently affected areas by post burn
contractures with associated cosmetic and functional problems. A
variety of therapeutic options exist but when this is not properly
chosen or post operative rehabilitation is not properly adhered
to, recurrence is often seen. The aim of this paper is to
highlight the various management options used in managing these
problems in a burn unit and itemize complications commonly
encountered.
Materials And Methods: This is a
retrospective review of cases of axillary contractures managed at
the National Orthopaedic Hospital over a period of 5 years. The
sources of information were the operation registers and the case
notes of the patients. Information obtained include age, sex, part
of the axilla involved, other associated post burn problems,
option(s) of treatment, complications and results.
Results: A total of 37 patients presented with axillary
contractures involving 42 axillae. Their ages range between 2 and
47 years with a mean of 23.1 years. There were 20 males and 17
females. Surgical options used includes local fasciocutaneous
flaps, 18(42.8%)axillae, single z-plasty in 6 (14.3%) axillae,
split thickness skin graft in 6(14.3%) axillae, multiple z-plasty
in 3(7.1%)and myocutaneous flaps including latismus dorsi in
5(11.9%), double opposing z-plasty in 2(4.8%) while v-y plasty and
5-flaps z-plasty were used in 1(2.4%) each.
Conclusion:
Contracture release with skin grafts has the highest recontracture
rate with local flaps in many forms giving good results with
minimal complications. |
Introduction
Axillary contractures commonly result from deep burn to the trunk
especially when adequate rehabilitation is not given to the patients. It
is often seen in our environment following poorly treated burn injuries
especially when the conservative approach is the method of achieving
cover for a burn wound around the shoulder joint. This often interferes
with the ability to feed and perform other important upper extremity
functions. Contracture release should therefore encompass the entire
axis of rotation of the shoulder to facilitate complete range of motion.
A variety of therapeutic methods such as skin grafting, z-plasties,
local flaps, island flaps, and free flaps have been reported for
treatment of axillary contractures.
A review of options of managing this problem in a burn unit of a
developing country is hereby presented with various options and
complications following each of the options.
Materials And Methods
A retrospective review of all axillary contractures managed
surgically in our burn unit at the National Orthopaedic Hospital, Enugu
was carried out. The period of study was between 2000-2004. Sources of
information were the patients' folders as well as the operation
register.
The age, sex, involved axillae; methods of surgical correction and
accompanying results of these methods and complications of each method
were noted.
Results
A total of 37 patients presented over the study period with axillary
contractures involving a total of 42 axillae. Their ages range between 2
years and 47 years with a mean of 23.1 years. There were 20 males and 17
females.
The right axilla was involved in 19(51.4%) patients, left axilla in
14(37.8%) patients while both axillae were involved in 4(10.8%)
patients.
Agents responsible for the burn injuries in these patients were flame
(48%), corrosive (32%) and scalds (20%).
Anterior axillary fold was involved in 22 axillae, posterior axillary
folds in 9 axillae while both axillae were involved in 4 axillae and the
apex of the axilla was involved in 2 patients while the part of the
axilla affected in one patient was not stated in the folder.
The surgical options used in managing these patients following
contracture release includes local fasciocutaneous flap which was the
commonest method in 18(42.8%)axillae, single z-plasty in 6 (14.3%)
axillae, split thickness skin graft in 6(14.3%) axillae, multiple
z-plasty in 3(7.1%), double opposing z-plasty in 2(4.8%) while v-y
plasty and 5-flaps z-plasty were used in 1(2.4%) each and myocutaneous
flaps including latismus dorsi in 5(11.9%) (Table1).
Table 1: Methods used in releasing axillary
contractures.
Associated problems noted in these patients include mentosternal
contractures in 3(8.1%), elbow contractures in 3(8.1%), keloids in
4(10.8%), ulcers in 5(13.5%) and hypertrophic scars in 35(94.6%)
patients.
Graft shift, 4(66%) and recontractures, 3(50%) occurred in patients
who had skin grafts. Recurrence was also observed in one patient with
V-Y flap cover. Tip necrosis was a common problem in patients who had
multiple z-plasty and 5 flap z-plasty. Often these healed with minimal
intervention and with good results. Epidermolysis was also a common
complication among the patients who had multiple z-plasty. These also
healed with no problem.
Bulkiness of the latismus dorsi used in this review was also a
problem necessitating a secondary procedure. No free flaps were used as
there were no facilities for this in our centre.
Figure 1: Axillary contracture involving both anterior and
posterior axillary folds with the dome
Figure 2: Following release using 5-flap z-plasty on both
sides
Figure 3: Linear anterior axillary contracture
Figure 4: Following multiple z-plasty release
Discussion
The rehabilitation of patients who have suffered burns in the large
joint, in particular, the shoulders remains a difficult problem in
reconstructive surgery. Spontaneous epithelialization of burn wounds and
late skin grafting results in various kinds of scar deformation and
contractures. This significantly restricts physical and social
rehabilitation 1 . Skin scar contractures related to
destruction of skin, subdermal fat, and fascia are very frequent.
The axilla is one of the most frequent sites affected by contractures
after severe burns and it often causes cosmetic problems and functional
deficiency. Secondary contractures involve muscles and tendons
(shortening, serous induration and scarring of tissues around a joint),
after which joint contractures develop. Primary arthro-osseous
contractures result from direct deep burns in a joint, leading to severe
and irreversible processes 2 .
Kurtzman 3 and stern have classified axillary
contractures as
- Type 1A- Anterior axillary fold involved
- Type 1B –Posterior axillary fold involved
- Type 2 – Both Anterior and Posterior axillary folds involved
- Type 3- type 2 plus axillary dome
The purpose of reconstructive operations in a shoulder joint with
post burn contractures is therefore the removal of scarring, the
elimination of contractures and the restoration of full movement to a
joint without the relapses of contractures. The particular method used
in releasing these contractures and covering them depends on the class
of the contractures as observed above.
For example skin graft is difficult to apply to the concave surface
of the axilla and prolonged splinting in abduction for up to 6 months is
necessary to prevent recontracture.
Local flaps tend to be required for types1 & 2 viz; single or
multiple Z-plasties, or five-flap Z-plasty whereas regional
fasciocutaneous and myocutaneous flaps are usually considered for type 3
axillary contractures.
Successful use of medial fasciocutaneous flaps in reconstructing
axillary contractures have been reported 4 . Two of our patients had this option of
surgery with good results. In other instances, correction of axillary
burn scar contracture with the thoracodorsal perforator-based cutaneous
island flaps 5 , seven-flap plasty 6 , axial bilobed flaps 7 have all been reported. Nisanci et al 8 used a variety of surgical treatments for
reconstruction of axillary contracture, covering defects with simple
things such as grafting, Z-plasties and locally pedicled flaps and found
that the island scapular flap is a good choice for reconstruction of all
types of axillary contractures, releasing defects with satisfactory
results in terms of function and cosmesis. The concept of a triceps
muscle flap has been recently proven valid 9 . By using only the long head portion,
necessary function preservation may be achieved.
Ogawa's 10 review shows free skin grafts, local flap
transfers including skin elongation procedures such as z-plasty,
regional flap transfers, i.e. pedicled axial local flap transfers,
latissimus dorsi flaps, para-scapular flaps, superficial cervical artery
flaps (SCA flap) and bilateral combined scapular flaps, free flaps and
scarring flaps with generally satisfactory results.
The use of multiple z-plasties where applicable gave good result in
our current series. These are useful only in linear anterior or
posterior axillary contractures. It was also used successfully in linear
contractures affecting both sides of the axilla.
Parascapular flap was also used as local transposition
fasciocutaneous flaps and five flap z-plasty in linear contracture with
good results. Flap tip necrosis was the commonest complication observed
in these flaps though this is usually minimal and less than 1cm needing
no further surgery.
We also observed the recurrence rate was high among patients who had
skin grafting because the patients' compliance on the continuous use of
axillary splints for a long time was poor. This option is commonly used
therefore where other options are not readily available or as a result
of severe burns involving the entire axilla including the dome.
Bulkiness of the myocutaneous flaps necessitated secondary procedure of
debulking and this should be considered seriously in the use of such
flaps. We did not use any free flap in our series as we do not have
microvascular facilities.
In conclusion, various methods of releasing post burn axillary
contractures abound. Some of the factors to be considered in choosing
the best option for a particular contracture include the type of
contracture and the expertise of the surgeon. However, flap cover gives
the best result with minimal or no flap loss and better range of joint
movement and reduced recontracture rate.
While early eschar excision, wound grafting, and rehabilitation of
the joint would help in preventing this morbidity, the choice of flaps
rather than skin grafts when reconstruction is needed is recommended.
Correspondence
Dr. P.B.Olaitan
Burns and Plastic Surgery Unit,
Department of
Surgery
Ladoke Akintola University of Technology
Teaching
Hospital,
Osogbo,
Osun State,
Nigeria.
E-mail: emiolaitan@yahoo.com
References
1. Yudenic VV, Borisor BG, Yudenich AA. Dermal sieve
autografts in treatment of burns.Khirugia 1979; 8:11-14.
2. Moroz VY,Yudenich AA, Sarygin PV, Sharobaro VI. The
elimination of postburn scar contractures and deformities of the
shoulder joint. Annals of Burns and Fire Disasters. 2003; xvi:140-143.
3. Tanaka A, Hatoko M, Tada H, Kuwahara M. An evaluation of
functional improvement following surgical corrections of severe burn
scar contracture in the axilla. Burns. 2003 Mar;29(2):153-7.
4. Li FC, Guan WX. Clinical application of the medial
fasciocutaneous flap of arm. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi.
2000 Nov; 14(6): 350-1.
5. Kim DY, Cho SY, Kim KS, Lee SY, Cho BH. Correction of
axillary burn scar contracture with the thoracodorsal perforator-based
cutaneous island flap. Ann Plast Surg. 2000 Feb;44(2):181-7.
6. Karacaoglan N, Uysal A. Use of seven-flap plasty for the
treatment of axillary and groin postburn contractures. Burns. 1996 Feb;
22(1): 69-72.
7. Karacalar A, Guner H. The axial bilobed flap for burns
contractures of the axilla Burns 2000 Nov; 26(7): 628-33.
8. Nisanci M, Er E, Isik S, Sengezer M. Treatment modalities
for post-burn axillary contr actures and the versatility of the scapular
flap. Burns. 2002; 28(2): 177-80.
9. Hallock GG. The triceps muscle flap for axillary
contracture release. Ann Plast Surg. 1993 Apr; 30(4): 359-62.
10. Ogawa R, Hyakusoku H, Murakami M, Koike S.
Reconstruction of axillary scar contractures--retrospective study of 124
cases over 25 years. : Br J Plast Surg. 2003 Mar; 56(2): 100-5.
| 
| 
| 
| 
| 
| 
