Treatment of acute deep burns in lower extremities of the elderly

Babur M. ShakirovSamarkand State Medical Institute, Burn Department of RSCUMA, Samarkand, Uzbekistan

Treatment of acute deep burns in lower extremities of the elderly

Babur M. Shakirov*
Samarkand State Medical Institute, Burn Department of RSCUMA, Samarkand, Uzbekistan

ARTICLE INFO ABSTRACT

Article history:

Received 6 February 2015

Received in revised form 8 February 2015 Accepted 11 February 2015

Available online 12 February 2015

Keywords:

Deep burns

Lower extremities The elderly

Objective: To study the different surgical treatments in 154 elderly patients with acute deep burns of lower extremities admitted in Burn Department of RSCUMA.

Methods: Skin grafts in extensive burns were performed in 32 patients for the purpose of achieving early closure of the burn area. In 116 patients with burn surface area of 6-25 %, skin grafting was performed on the granulating wound when the wound was ready for accepting skin graft. In these 19 cases, a stamp graft procedure was used in 12 patients and Mowlen-Jackson method of skin grafting in 7 cases.

Results: Analysis of the nearest results showed that 28 out of 154 patients came back to the hospital for new surgery due to loss of ability of normal movement of their extremities. Conclusions: Careful patient selection and timing of surgery will help to avoid any adverse effect on patient outcome.

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E-mail: baburshakirov@yahoo.com

1. Introduction

The management of burn in the elderly patients remains a challenging problem. Several studies have focused on the prognosis in this population subset[1].

Extremes of age and co-morbidities contribute in combination with the severe burn metabolic stress to poor prognosis and high mortality[2-5]. It is well recognized that advanced age is a major factor in increasing the burn severity index (Baux index).

Contrary to conservative treatment of burns requiring a prolonged period of time for eschar separation with inevitable purulence and probable septic complications, early tangential excision and skin grafting has been a major development in burn care that has improved prognosis and reduced mortality in patients with more than 40% total body surface area (TBSA) burns. In less extensive burns, it reduces hospital stay and is associated with decreased incidence of hypertrophic scarring and contractures.

Regardless, the modality of conservative burn wound care combined with careful patients’ monitoring we have adopted for the management of lower extremity burns in the elderly proved to be a valid and safe alternative.

2. Methods and Materials

Over a period of 10 years (1996-2005), 154 patients (86 men and 68 women) aged 60-86 years with acute deep burns of the lower extremities were treated in the Burns Department of RSCUMA, Samarkand, Uzbekistan.

The causes of the burns were: scalds, 89 (57.8%); flame burns, 27 (17.5%); chemicals burns, 18 (11.7%); sandal burns, 11 (7.1%); and other burns 9 (5.8%).

Some patients had deep lower extremities burns caused by sandal heaters[6]. Most burn injuries mainly occurred at home (Table 1).

Table 1Location of burn injuries.

The distribution of the burns is shown in Table 2, indicating that the feet are mostly affected.

Table 2Anatomical site of burns.

Of the 154 patients admitted to the hospital, 64.9% were in shock. All patients with burn shock underwent general clinical examinations of cardiovascular and respiratory systems, functions of the liver, kidneys and gastrointestinal tract. On admission, acid-alkaline balance, blood haemoglobin, platelets, prothrombin time, partial thromboplastin time, glucose, potassium, sodium and calcium levels were determined in all patients. Determinations of urinalysis were performed when indicated. All other patients were transferred from other regional hospitals after anti-shock therapy for 2-3 d after burn injury.

Out of the overall number of 154 patients, 38 patients had minor injuries with acute deep burns not exceeding 5% TBSA. After 3-4 d following admission when the patients became stable, early tangential excision was performed with a drum dermatome and skin grafts were applied immediately. About 29 cases burn wounds healed after the first skin grafting procedure. The second skin grafting procedure was required in 9 patients.

The remaining 116 patients had lower extremity burns up to 6%-25% TBSA. Patients presenting with shock were adequately resuscitated and all burn wounds were covered with sterile dressings.

In 116 patients with burn surface area of 6%-25%, skin grafting was performed on the granulating wound when the wound was ready for accepting skin graft. From the moment that the patients were admitted to hospital, they underwented the following surgical methods of treatment. Necrotomy was performed to prevent secondary necrosis and accelerate the rejection of necrotic tissue. Necrotomy was always performed in a longitudinal direction down to the healthy tissue. After necrotomy, the wound was covered with chemotherapeutic materials (trypsin and chymotrypsin), semiconductor laser therapy and laser therapy with application of such natural biologically active preparation propolis (honey) that accelerated the rejection of the necrotic tissue. Necrectomy was usually performed early 7-10 d after the burn incident if the burned surface area did not exceed 8%-10% of the patient’s TBSA. In patients with extensive burns, that is, covering more than 10% of their TBSA, a partial necrectomy was performed. Wound dressings were changed every other day. Skin grafting was normally performed on the granulated wound when the wound was completely ready for autoplastic closure. Indications of a good wound were bright red, granulated, firm, with little bleeding on touch and no oedema.

All these measures were taken to prepare the wound for autodermoplasty. Free skin grafting was normally performed on the granulated wound when the wound was completely ready for autoplastic closure. The wounds were ready for autoplasty 18-23 d after the burn. The thickness of grafts ranged from 0.2 to 0.3 mm. Grafts from the external and internal surfaces of the hip were normally used. Skin grafts were performed on granulating wounds, using a sheet graft, in the following manner: one stage in 76 patients, two stages in 33 patients and three stages in 18 patients (in all, 196 operations).

Skin grafts in extensive burns were performed in 19 patients for the purpose of decreasing the wound area. In these 19 cases, a stamp graft procedure was used in 12 patients and Mowlen-Jackson method of skin grafting in 7 cases. To increase the skin grafting potential in patients with limited skin resources, meshed grafts were used in 39 patients.

At the same time, priority was given to preservation of the victims’ life, even to the prejudice of functional outcome. Thus priority was given to perforated skin grafts with a expansion ratio 1:1.5, which promoted faster grafts cells epithelialization.

The first bandage was removed on the 2nd or 3rd day after surgery. If the skin engrafted well, we proceeded with physical therapy and remedial gymnastics after about 6th day.

3. Results

Out of the 116 skin graft on granulating wounds, we found completely take of the skin graft in 72 cases, graft survival of 36 cases, and complete loss of the skin graft was found only in 8 cases.

Analysis of the nearest results showed that 28 out of 154 patients came back to the hospital for new surgery due to the loss of ability of normal movement of their extremities.

From the anamnesis, we found out that patients did not follow the doctors’ post operation recommendations (physical training, physical therapy procedure, massage, limitation of physical loading on lower extremities, etc.) and they underwented recurrent operative interventions.

Of all surviving patients, 24 came back after treatmentand burned skin restoration to the hospital for a new surgery because they had lost the ability to exercise normal movement of their affected low extremities. Complications were as follows: contractures, ulcerating scars, complete and partial dislocations, and growth aberrations. Of all patients, 92% showed satisfactory results, and only 8% were unsatisfactory. Unsatisfactory results were reported for the patients who had more than 5 years after the burn incident and irreversible changes in the tissues.

4. Discussion

The management of burn in the elderly patients remains a challenging problem. Several studies have focused on the prognosis in this population subset[1]. Burns and related injuries continue to be major cause of death and disability worldwide[7,8].

This is a growing and often preventable problem with the majority of burn being caused by carelessness. Understandably, this study had a lower incidence of lower extremities injury than in other series. None of the patients was held with treatment on account of the burn of lower extremities co-morbid conditions.

As per the treatment policy in our unit, all patients with full thickness burns who are fit to undergo surgery are treated surgically. The liming of surgery was not found to have an effect on the outcome treatment and hospital stay. In Uzbekistan, severe burns in the elderly burns are of special interest. Severe burns in the elderly have a much higher mortality in comparison with younger population. These patients frequently have coexisting morbid conditions and the impact of these on the outcome is not fully understood.

Ho et al. found that scalds is a commonest type of burn injury in their series of elderly patients, which may account for the lower mortality compared to other series[9,10].

Since the concepts of early excision and skin grafting is proposed by Janzekovic[11], this technique has become established practice.

Burdge et al.[12] reported 12.9% mortality in patients (mean age 73 years) with burns of less than 40% TBSA. Surgery was required in 47.6% of their patients.

We concluded that judicious selection of patients for surgery is important for the best outcome, rather than the use of early excision and grafting as a rule. In our patients with multiple co-morbid factors, conservative treatment was adopted. Hence, there is insufficient data regarding the safety of early surgery in this subgroup.

We found no increase in mortality due to surgery, although operated patients had a longer in-hospital stay. Careful patient selection and timing of surgery will help to avoid any adverse effect on patient outcome.

Conflict of interest statement

The authors report no conflict of interest. Acknowledgements

We wish to thank Fomina M.A. and Dr. Mavlyanova Nargiza for their help with project and the preparation of the manuscript.

References

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*Corresponding author:Babur M. Shakirov, Samarkand State Medical Institute, Burn Department of RSCUMA, Samarkand, Uzbekistan.