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First webspace contracture recurrence following primary release in the burn population
Rachel A Guest, MD
1; Cameron Etebari, MD
2; Maleika Ramirez, BA
3; Dhaval Bhavsar, MBBS
41University of Cincinnati, Cincinnati, OH; 2University of Kansas Medical Center, Kansas City, KS; 3Ponce Health Sciences University, Ponce, PR; 4Plastic Surgery, University of Kansas Medical Center, Kansas City, KS
Introduction: First webspace contracture (FWC) release is challenging in the burn population. Deep burns involving the forearm, may preclude regional tissue transfers; necessitating use of local tissue rearrangement (LTR) and skin grafts. In addition, patient factors and complicated social situations may create further barriers in achieving a successful outcome. Methods: Electronic medical records for patients undergoing FWC release with LTR over a thirteen-year period was performed. Patients undergoing full thickness skin grafting (FTSG) alone were excluded. Data was collected regarding burn characteristics, surgical techniques, peri-operative therapies, and post-operative outcomes, with specific attention to patients who developed re-contracture. Statistical analysis was performed with
=.05. Results: 27 FWC releases were performed in 18 patients. Patients were followed for an average of 21 months (range: 1-54 months), with three patients lost to follow-up following primary release. Initial procedures included jumping man flap (37%) and z-plasty variations, such as four-flap z-plasty and multiple z-plasty (63%). The re-contracture rate was 38% (10 procedures) following primary release. Gender did not influence re-contracture rates (p=.91), nor did patient age (p=.11). Time from burn injury to primary release was similar across both outcomes (p=.41). Participation in post-operative therapies was significantly lower in patients who developed re-contracture (60% versus 94%, p=.04). Compared to other techniques, patients undergoing jumping man flaps had similar re-contracture rates (p=.49). Three patients underwent bilateral FWC release and developed unilateral re-contracture. Procedure combinations in these patients included double z-plasty and double z-plasty with FTSG, double z-plasty and four-limb z-plasty with FTSG, and FTSG and jumping man with FTSG. In these three patients, re-contracture occurred on the hand treated with double z-plasty alone with FTSG, double z-plasty alone, and jumping man with FTSG, respectively. In general, the webspace that developed re-contracture underwent a more complex primary reconstruction, which may indicate greater severity of contracture. Of the ten patients developing re-contracture, 30% were lost to follow-up, 50% underwent jumping man flap, and 20% were treated with double z-plasty with FTSG. 57% of secondary procedures were unique compared to the technique used for primary release. There were no documented recurrences following secondary FWC release. Conclusions: Re-contracture following primary FWC release with local tissue rearrangement is common and difficult to predict based on patient factors alone. Participation in post-operative therapies is one modifiable risk factor that can lead to increased likelihood of of a successful outcome. Prospective studies are necessary in this complex patient population.
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