|IDEA AND INNOVATION
|Ahead of print
ARC technique – An innovative method to assess true defect in postburn contracture release
Sujata Sarabahi, KT Ananda Murthy, Praveen Kumar Arumugam, Mula Rohit Babu
Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi, India
|Date of Submission||07-Dec-2020|
|Date of Acceptance||18-Mar-2021|
|Date of Web Publication||03-Feb-2022|
KT Ananda Murthy,
Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Most commonly, skin grafts are used to resurface the raw areas resulting after the release of postburn contractures but in the extensively burned patient, donor sites may be limited. There is no accurate technique described in literature for the assessment of the true defect preoperatively. We describe a technique to accurately assess the true defect which helps to determine the amount of skin graft required preoperatively.
Keywords: Apparent defect, contracture release, split skin grafting, true defect estimation
|How to cite this URL:|
Sarabahi S, Ananda Murthy K T, Arumugam PK, Babu MR. ARC technique – An innovative method to assess true defect in postburn contracture release. Indian J Burns [Epub ahead of print] [cited 2022 May 24]. Available from: https://www.ijburns.com/preprintarticle.asp?id=337210
| Introduction|| |
Incisional or excisional release and skin grafting are the mainstays of treatment in postburn contracture. Incisional release is preferred in patients with soft, pliable scars and limited donor areas. Excisional release is preferred in patients with hypertrophic, atrophic, unstable scars and depigmented areas with adequate donor areas. In former linear incision through the scar tissue overlying the affected joint at the point of maximum tightness is done, which is oriented perpendicular to the line of contracture with added fishtailing. In latter, part of the scar tissue is excised, which depicts an apparent defect, along with multiple darting is used to release the contracture. True defect is the actual raw area created after release of the postburn contracture. To the best of our knowledge, there is no established technique described in literature for the exact assessment of true defect preoperatively.
Prior assessment of defect size helps the operating surgeon to plan the amount of skin graft/flap to be harvested. Since postburn flexion contracture of the neck and elbow is common in India, they have been taken as prototypes to explain this arc technique.
| Technique|| |
Postburn contracture of neck
With the patient in standing or sitting position, first a transverse line is marked over the contracture depicting the line of incisional release. This would span between the neutral lines of the neck anteriorly. Three points are marked over the incision line, one at the center and others are at the ends of marking (Points A, B, and C). Fishtailing at the both ends of the transverse line is marked, about one-third length of incision and two limbs placed at an angle of about 45°–60°. Then, four points are marked at the ends of the fishtailing bilaterally (Points D, E superiorly and Points F, G inferiorly). This gives us a total of 7 points.
In the superior aspect, three fixed bony points are marked, one at the symphysis menti at the lower border of mandible (Point H) and two points marked at the angle of mandible bilaterally (Points I, J). In the inferior aspect, the center point is marked at the sternal notch or center of Angle of Louis More Details (Point K) and two points at the tips of acromion process on both sides (Points L, M) [Figure 1].
|Figure 1: Incisional release markings with fishtailing, for postburn contracture of neck|
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For the true defect, markings are made over a normal person of similar age, sex, build, and stature, with neck in full extension using measuring tape or thread. From the symphysis menti, a point is marked of length HB (Point B). From the angle of the mandible, an arc is drawn with radius of ID, and from the symphysis menti, an arc is drawn with radius HD intersecting the previous arc giving us Point d. Similarly, measurements from other bony landmarks help us to obtain Points b, e, g, and f. Arcs drawn with radii DA and FA intersect to give the Point a. Similarly, EC and GC intersect to give us Point c. Joining all these points give us the shape of two trapezoids (deca and acgf). The area of this shape is derived by doubling the area of each trapezoid, given by bb'x (ac + de) [Figure 2].
|Figure 2: True defect markings (area) obtained after representing the corresponding points over normal person neck|
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Postburn contracture of elbow
Measurements are taken with shoulder in adduction and neutral position. Three points are marked over the incision line, one at the center and others are at the ends of marking (Points A, B, and C) with fishtailing. Then, four points are marked at the ends of the fishtailing bilaterally (Points D, E superiorly and Points F, G inferiorly).
In the superior aspect, 2 fixed bony points are marked, one at the clavicle (at the junction of medial two-third and lateral one-third) and the other at the tip of acromion. These are marked H and I, respectively. In the inferior aspect, Points J and K are marked at radial and ulnar styloid processes, respectively [Figure 3].
|Figure 3: Incisional release markings with fishtailing, for postburn contracture of elbow|
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For the true defect, markings are made over the opposite elbow in extension and shoulder in adduction. Arcs drawn from Points H and I with radii HD and ID intersect to give Point d and with radii HE and IE intersect to give Point e. Midpoint of line de is marked b. Similarly, we can obtain Points f and g. Midpoint of line fg is marked b' and de as b. Arcs drawn from Points D and F with radii DA and FA meet to give Point a. Similarly, we can obtain Point c. The area of this shape is derived by doubling the area of each trapezoid (deac and acfg), given by bb'x (ac + de) [Figure 4].
|Figure 4: True defect markings (area) obtained after representing the corresponding points over contralateral limb or normal person limb|
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A similar technique can be used for excisional release in both the regions, which constitutes the same bony points and with darting of apparent defect at the four angles represents the total 6 points. Resultant true defect shape resembles a rectangle with limbs slightly concave toward defect, area of which can be calculated by length × breadth.
| Discussion|| |
In patients with multiple postburn contractures, there is limited normal donor area for harvesting skin grafts which would be used to resurface the raw areas after release of the contracture. Harvesting the skin graft by considering the apparent defect is unwise because true defect is always more than that of apparent defect. In literature, true defect in postburn contracture of elbow was estimated by single bony points on either side of contracture using scale, which gives rough estimate of actual defect. Arc technique uses two bony points to mark a single point of the defect border, using tape or thread, which is very accurate to assess true defect. Mody et al. have described estimating the mentosternal distance to assess the true defect preoperatively but this may not be very accurate.
This technique can be used for other areas of contractures such as axilla and knee in which the unaffected side is utilized for the true defect assessment.
| Conclusion|| |
It is a refined, simple, easy, accurate technique which is very helpful in estimating the true defect beforehand in postburn contracture patients which helps to plan the amount of skin graft/flap required.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]