Hips
A 5 year-old girl had sustained an acute burn wound covering 36% TBSA, that was treated at Haydom Lutheran Hospital in Tanzania. She survived and was treated with three sessions of skin grafting. Despite adequate surgical treatment, she developed contractures involving both hips and also affecting the genital area. She came back to the hospital one year later for contracture release.
Medical history
The patient had been playing in the kitchen when her clothes had caught fire.
The treatment of the acute burn wounds had been complicated by wound infections, but after being admitted for four months and receiving three sessions of skin grafting, the wounds had finally healed.
Contractures were already present at discharge, but the surgical team decided to advise that the patient should go home, regain strength and return to school, while waiting for the scars to mature for couple of months, and to come back for contracture release later.
On the day of admission, one year after the acute burn took place, the patient came back much stronger than before, motivated to undergo surgery again to improve her ability to walk normally and enable her to run like other children.
Physical examination
On admission, the girl was generally healthy.
Abduction of the legs was severely limited, and a clear fold became visible when she tried to abduct the legs with the hips in flexion (photo 3).
Extension (or retroflexion) of the hips was also limited, especially on the medial sides.
Surgery
Surgery 1
The fold had relatively normal tissue on the caudal side and scarred tissue cranially, providing a good foundation to perform a jumping man technique, with the legs of the jumping man being located on the posterior side (photos 5, 6 and 7). Under general anesthesia, the design was marked and lidocaine with adrenaline was injected into the site for hemostasis. The procedure was performed in a suprafascial plane, and as shown in photos 8 and 9, the Y-V advancement worked really well. However, the two most lateral flaps from the caudal side of the contracture contained very scarred tissue, and therefore did not provide much lengthening.
Surgery 2
A second contracture release was planned three years after the first contracture release. On both sides, a double Z-plasty was marked with an additional smaller interposition flap on the medial left thigh (photo 10, infographic 1). Because the double Z-plasty on the right thigh did not provide sufficient lengthening, a FTG was inserted to fully release the contracture.
The post-operative management was the same as before, except for the tie-over dressing: Vaseline gauzes with tetracycline were sutured on top of the FTG (photos 16 and 17).
Postoperative care
Postoperatively, the grafts were covered with tetracycline-coated Vaseline gauzes, with a layer of dry gauzes on top. The patient and caregivers were instructed not to touch the dressings. After five days, the dressings were removed to inspect the local flaps. The healing process is shown in photos 13, 14 and 15.
There was good improvement, but after three years the patient came back requesting an extra contracture release, due to the increasing limitations in her motility during her growth
(photos 16 and 17).
Outcome
The second procedure was only completed three months ago, but the girl could already move her legs much better when she came for the follow-up.
Lessons learned
An important aspect of the design of Z-plasties is the length of the sides of the triangles. In this example, you can see that double Z-plasties were used in the second procedure.
In an ideal situation (when the skin has the same amount of slack everywhere on both sides of a linear contracture), the best design is symmetrical with two triangles with angles of 60 degrees. The three incision lines of symmetrical Z-plasties should be of the same length. The theoretical gain of length in such a symmetrical 60 degree Z-plasty is 75% of the original length. The skin that facilitates the 75% lengthening comes from the width of the Z-plasty. This means that the ‘slack’ in the direction perpendicular to the contracture should be equal to an amount of skin that represents 75% of the length of the sides of the Z. If one big Z-plasty over the full length of the contracture requires more shortening than the slack in the direction perpendicular to the contracture can provide, two smaller Z-plasties are required instead of one big one. This was the case in this example, as shown in the second procedure. If the slack is still not sufficient, three even smaller Z-plasties are required etc.
Another important lesson from this example is the need for long term follow-up. As the child was growing, the movements in the hips started to become more limited. It must be explained to young patients and their relatives that this may happen, but that, if required, further surgeries are still possible to improve function.
