Clinical Application of Direct Skin Grafting Repair in Popliteal Scar Contracture after Burn in Children

Da-yong CAO,Hai-ping DI,Pei-peng XING,Cheng-de XIA,Ji-dong XUE,Hai-na GUO,Xi-hua NIU

Zhengzhou First People’s Hospital Zhengzhou City,Henan Province,450000,China

ABSTRACT Objective To observe the clinical application of direct skin grafting in repairing popliteal scar contracture after burn in children.Methods From April 2017 to January 2019,30 children with popliteal scar contracture after burn were selected as the research objects.The scar status,knee joint function and quality of life of the patients before and after the operation were compared by direct skin grafting after medium thickness skin removal.Results 30 patients were treated with skin grafting to repair popliteal scar contracture,27 patients healed well,and the survival rate of skin grafting reached 90.00%.The scores of postoperative scar and knee joint function scale (WOMAC)were lower than those before the operation,and the scores of concise health status scale (SF-36)were higher than those before the operation,with statistical significance (P < 0.05).Conclusion Scar contracture of popliteal fossa after burn in children can be repaired by direct skin grafting in the skin extraction area after medium thickness skin cutting,which can effectively improve scar condition,restore knee joint function and significantly improve quality of life.

KEY WORDS Popliteal scar contracture; Skin grafting repair; Knee joint function; Quality of life

Contracture scar is caused by shape changes and dysfunction caused by scar contraction after severe skin injury healing.The reason is that plasma,leukocytes,lymph and the like exuded from the wound,accompanied by inflammatory exudation,cause proliferation of capillary endothelial cells and fibroblasts.Fibroblasts gradually form collagen fibers with the participation of hydroxyproline,glycine,hydroxylysine and other related substances.Due to its high toughness,it can increase the tensile strength of the wound,and make the scar reddish with good hardness and toughness[1-3].When children are burned,popliteal scar healing can cause knee joint dysfunction and even affect normal joint development.At present,in the late repair treatment of burns,early surgical treatment is mostly advocated for scar contracture occurring at functional positions[4-5].The skin graft is a common method for clinical treatment of burns,but related studies point out that there are differences in the effect of direct skin grafting in the skin removal area after medium thickness skin cutting to repair popliteal scar in children[6].Therefore,this study aims at the scar contracture of popliteal fossa after burns in children,and direct skin grafting was used to repair the scar contracture in the skin removal area after medium thickness skin incision,and the postoperative scar condition,knee joint function and quality of life are analyzed.

DATA AND METHODS

Genberal informartion

From April 2017 to January 2019,30 children with popliteal scar contracture after burns admitted to our hospital were selected as the research objects,including 17 males and 13 females.The age ranged from 4 to 12 years,with an average age of (8.34±2.15)years.The body weight was 14-32kg,and the average body weight was (22.51 ± 3.65)kg.The course of the disease was 1-3 years,and the average course of diease was (2.17 ± 0.44)years.All the children suffered from burns and knee joint dysfunction.This study has been approved by the Medical Research Ethics Committee.

Selection criteria

Inclusion criteria:(1)All children were suffering from popliteal scar contracture and underwent skin grafting and repair surgery; (2)The purpose of the informed study of children’s families was to sign the informed consent forms.Exclusion criteria:(1)Those born with physical disability or abnormality; (2)Patients with coagulation dysfunction; (3)Patients with cardiovascular and cerebrovascular diseases and mental abnormalities.Indications for medium thickness skin graft include:(1)Deformity repair of scar contracture on face,neck,hands,feet and joints; (2)Large area of head avulsion injury; (3)Repair of huge tumor on the body surface after soft tissue resection; (4)Covering of fresh granulation wounds;(5)Escharectomy and skin grafting after third-degree burns; (6)Repair of defects in oral cavity,nasal cavity,vagina and other related mucosa.Contraindications for medium thickness skin graft include:(1)Weight-bearing parts:including palm and sole; (2)Deep important tissues and organs:including peripheral nerves,blood vessels,periosteum and tendon; (3)Face:Pigmentation and contracture can still occur after medium-thick skin transplantation on the face.

Method

Before the operation,doppler ultrasound blood flow detector was used to mark the perforating points and route of perforating branches of lateral popliteal fossa cutaneous artery and superficial sural artery in all patients.Take the appropriate body position of the patient,perform general anesthesia or continuous epidural anesthesia,completely release the scar position of the patient,keep the knee joint completely straight,confirm the size range of the wound surface,and have no tendon and bones exposed.Then,cloth samples were made according to the size and shape of the wound surface.In the skin removal area,the skin removal machine is used to cut the area and shape of the medium-thick skin graft to be skin grafted.After cutting the skin graft in the skin taking area,the wound surface was treated,covered with aseptic gauze,and corresponding anti-infection measures were taken to make it heal naturally.The cut medium-thick skin graft was covered in the skin grafting area and intermittently sutured and fixed.After the skin grafting area is treated,the skin grafting area is bandaged.During the bandaging process,attention should be paid to avoid excessive tension.After the operation,the knee joint is slightly flexed to promote wound healing.The ward temperature is controlled at 22-25 ℃.Local irradiation can be carried out by an ultraviolet irradiation instrument to speed up wound healing.7-10 days after the operation,remove the packaged suture,check the survival of the skin graft,and perform knee joint functional exercise after good recovery(Fig.1).

Observation index

(1)Compare that scar status of the patients before and one month after the operation.Scar scale was used to score,including the skin color at the scar site (0 point the color is consistent with the color of other parts,1 is lighter in color,2 is divided into mixed colors,3 points for darker color),blood vessel distribution (0 points for color consistent with other parts of the color,1 is divided into pink skin color,2 is red,3 points are purplish red),thickness (0 points are normal,1 point is 0-1mm,2 points are > 1-2mm,3 points are > 2-4mm,4 points are > 4mm),softness (0 points are normal,1 point are soft,deformable under minimum resistance,2 points are soft,deformable under pressure,3 points are hard,there is resistance to pressure,4 points are bending,scar retraction during extension,and 5 points are contracture),with a total score of 15 points.The higher the score,the more serious the scar condition of the patient[7]; (2)To compare the recovery of knee joint function before and one month after surgery,the knee joint function rating scale(WOMAC)was used for evaluation and measurement.The joint function includes 17 items (limp,pain,support,swelling,squatting limitation,etc.),with a full score of 100 points.The higher the score,the worse the recovery of knee joint function of the patient[8]; (3)To compare the quality of life of the patients before and one month After the operation,The Concise Health Status Scale (SF-36)was used for evaluation,which includes 8 indicators of social function,energy,emotional function,mental health,physiological function,physiological function,physical pain and general health status.The full score of each indicator is 100 points.The lower the score,the worse the quality of life of the patient,and the higher the quality of life of the patient[9].

The statistical method

SPSS 22.0 software was used for data processing.The measurement data were expressed by(), T test was used,the counting data were expressed by percentage,andχ2was used to test.The difference is statistically significant(P< 0.05).

RESULTS

Therapeutic effect

30 patients underwent skin grafting to repair popliteal scar contracture,27 patients healed well,27 cases healed well,3 cases healed themselves after dressing change due to poor venous reflux effect and superficial skin necrosis,and the survival rate of skin grafting reached 90.00%..

Scar condition WOMAC

score Patients’ scar score and WOMAC score after the operation were lower than those before the operation,and the difference was statistically significant (P < 0.05).See Table 1.

The quality of life

The score of patients after the operation was higher than that before the operation,and the difference was statistically significant (P< 0.05).See Table 2.

Fig.1

Table 1 Comparison of Scar Status and WOMAC Score Before and After the Operation (,score)

Table 1 Comparison of Scar Status and WOMAC Score Before and After the Operation (,score)

Time Scar Score WOMAC Score Preoperative (n=30) 13.26 ± 1.47 54.52 ± 6.54 Postoperative (n=30) 5.54 ± 1.63 21.21 ± 5.46 t 19.264 21.415 P 0.000 0.000

Table 2 Comparison of Quality of Life Scores of Patients before and After the operation (,Score)

Table 2 Comparison of Quality of Life Scores of Patients before and After the operation (,Score)

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DISCUSSION

When the skin is deeply burned,hypertrophic scars often form,and the location of scars around joints may affect joint function.After children suffer burns,joint deformities and joint dysfunction caused by thin skin and growth and development become more serious,which reduces the quality of life of children and can have a serious impact on their families.Although burn patients can undergo clinical treatment and functional exercise,they cannot completely change the influence of scar contracture on joint function after deep burn.Therefore,effective repair treatment in the later period is of great significance for improving scar condition,restoring joint function and improving quality of life of patients[10-11].

The common surgical methods for clinical treatment of popliteal scar contracture include scar resection and suture,skin flap transfer,skin graft,etc.Among them,skin graft is widely used,mainly because skin graft has strong vitality and can rely on plasma infiltration to maintain survival.Therefore,it is easy to survive in the wounds with poor blood supply and granulation wounds with mild infection,easy to cut and remove,and the skin donor area is not limited.Skin grafts can be cut repeatedly in the same skin donor area,and can be divided into three types in skin graft:blade thickness skin graft,full thickness skin graft and medium thickness skin graft.Among them,the blade thickness skin flap includes the epidermis layer and a few dermal papillae layer,with a thickness of 0.2-0.3 mm,which is the thinnest skin flap.However,there are some shortcomings such as fragile texture,nonwear resistance and lack of elasticity.In the later period,it is often manifested as atrophy,dark color and poor appearance.Full thickness skin graft is the thickest in skin graft,including the whole layer of epidermis and dermis.There are abundant elastic fibers,glands,capillaries and other tissues in the dermis of full-thickness skin graft.It has the advantages of less shrinkage,firmness,flexibility,wear resistance and good color after survival,but its survival conditions are higher[12].The average thickness of the epidermis and part of the dermis of the medium thickness skin graft adopted in this study is 0.3-0.6 mm.The thickness of medium thickness skin is between full thickness and blade thickness skin.It has the advantages of the other two types,easy survival,good function and wide application range[13].During the transplantation process,attention should be paid to the thickness of the skin flap,and the angle between the skin knife and the skin surface should be adjusted in time to make the skin flap reach the required thickness.When the treasure house of subcutaneous fat is on the wound surface of the donor site,it should be sutured in time or covered with another blade thickness skin flap.After the transplantation is completed,it is very important to wrap the medium thickness skin graft under pressure.The pressure should be kept moderate.Too little pressure will cause subcutaneous space,while too much pressure will hinder the blood supply of the wound surface in the recipient area,which will affect the survival of the transplanted skin graft.The pain degree of the patients gradually decreased after the operation.If jumping pain and distending pain occur after 3 days,infection or hematoma may occur.The wound surface should be checked in time,and when examining the wound surface,the strength should be well controlled,and the dressing should be uncovered layer by layer to avoid moving the skin graft[14].The results of this study show that the scar condition score and knee joint function recovery score of patients after the operation are lower than those before the operation.It is suggested that direct skin grafting can improve the survival rate of skin grafting in repairing popliteal scar contracture after burns in children.By utilizing the extension of the skin graft and the contraction of the skin graft,the medium-thick skin graft can be replanted to repair the wound surface of the skin graft,and the larger scar wound surface can be repaired with fewer skin grafts,thus improving the utilization rate of the skin graft,significantly improving the scar condition of the patient,effectively recovering the knee joint function and improving the quality of life of the patient,and benefiting the growth of children[15].After completing skin grafting,attention should be paid to strengthening nursing for patients,keeping the room clean and tidy,paying attention to ventilation and reducing bacteria growth.Patients should keep the skin grafting area clean and dry to avoid touching.In terms of diet,patients can eat more foods rich in collagen.The above nursing contents can speed up wound healing and promote patient recovery.

To sum up,after children’s burns,the popliteal scar contracture can be repaired by direct skin grafting in the skin removal area after medium thickness skin cutting,which can effectively improve the scar condition,restore the knee joint function and improve the quality of life,with remarkable effect and high clinical recommended application value.