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Ankle and toes

This example shows the treatment of a post-burn contracture in an approximately 50 year-old man in Bangladesh. He presented to the doctors on one of Friendship’s hospital ships in the northern part of the country, with a contracture of the ankle joint and toes. This example shows the treatment of this contracture with a combination of local flaps and a skin graft: a Z-plasty and a full thickness graft, followed by 6 weeks of immobilization with a plaster of Paris (POP) cast.

Medical history

Burn injuries are common on the densely populated river islands in northern Bangladesh.

The patient in this example sustained a burn injury to his right foot many years ago, but he had never been able to see a doctor after the injury occurred.

Friendship is an organization providing medical care for the population in need on the river islands, and trains health care workers to provide basic health care in the villages.

These health care workers informed the patient about the opportunities for reconstructive surgery by visiting surgical teams on the Friendship hospital ships.

Physical examination

On arrival the man was examined by the Friendship medical team, together with the visiting surgeons and anesthetist. He experienced difficulties when walking, and could not wear shoes because of a contracted ankle joint and toes. On examination and palpation, there was a broad contracture extending from the lower leg to the toes, spreading between the 2nd and 5th toes.

His general condition was good.

Surgery

Due to the broad scarring pattern of the contracture (photos 5 and 6), local flaps alone did not provide enough skin. Proximally, in the contracture just above the ankle, there was a fold palpable where a Z-plasty was planned (photo 7).

Under spinal anesthesia, combined with local Jungle Juice for hemostasis, the contracture was released. The Z-plasty fitted well, but as expected, on the distal lateral side the contracture was broad, and the surrounding tissue did not provide skin suitable for local flaps. After dissection at this level, the contracture of the toes was also released because the skin was now free to move distally.

This created a skin defect on the lateral side of the ankle that was closed with a FTG harvested from the groin. Small drainage holes were made in the FTG to prevent blood accumulation under the skin graft.

Postoperative care

Postoperatively, the wounds were covered with tetracycline-coated Vaseline gauzes, with a layer of dry gauzes on top to provide gentle pressure on the FTG. The ankle and toes were kept in maximal plantar flexion with a back slab of plaster of Paris (POP). The day after the surgery, the patient was transferred from the postoperative room on the ship, to the ward, consisting of a temporary barracks next to the ship (photo 10). Daily ward rounds were carried out by the Friendship nurses. After five days, the dressings were removed to inspect the wound (photo 11).

Outcome

The patient was discharged after six weeks with the ankle still held in extension by POP. Six months later he was seen for follow-up by the Friendship team (photo 12) when he was able to walk much better.

Lessons learned

An important first lesson from this example is the fact that for patients with burn scar contracture release, it is seldom too late to perform reconstructive surgery. In this example, the patient came to the hospital ship many years after the injury. Timing of surgery can be a difficult decision if the contracture is presented shortly after the injury.

After a severe burn injury has occurred, proper burn care including skin grafting and splinting can prevent severe contractures; however, even with proper acute burn care, contractures can still occur in patients with severe deep burns. In these cases it is often wise to wait until the wounds have completely healed, and the patient has regained a good physical condition before carrying out reconstructive surgery.

Additionally, with time, the scars will mature, providing better quality skin for local flaps.

A second lesson from this example is that local flaps can be combined with skin grafts. Local flaps provide better quality tissue compared to skin grafts, which is why local flaps are preferred over skin grafts whenever possible, particularly over joint surfaces. However, if local flaps do not provide enough tissue to cover the defect that is created by releasing the contracture, it is recommended to add skin grafts.

Finally, it was great to see that within a couple of days, dedicated people from different countries can work together as a team in which everyone has the skills and knowledge essential to achieve a good result, as shown in this example.

CASEAnkle and toes

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