Investigating the intra- and inter-rater reliability of a panel of subjective and objective burn scar measurement tools

BackgroundResearch into the treatment of hypertrophic burn scar is hampered by the variability and subjectivity of existing outcome measures. This study aims to measure the inter- and intra-rater reliability of a panel of subjective and objective burn scar measurement tools.MethodsThree independent assessors evaluated 55 scar and normal skin sites using subjective (modified Vancouver Scar Scale [mVSS] & Patient and Observer Scar Assessment Scale [POSAS]) and objective tools. The intra-class correlation coefficient was utilised to measure reliability (acceptable when >0.70). Patient satisfaction with the different tools and scar parameter importance were assessed via questionnaires.ResultsThe inter-rater reliabilities of the mVSS and POSAS were below the acceptable limit. For erythema and pigmentation, all of the Scanoskin and DSM II measures (except the b* value) had acceptable to excellent intra and inter-rater reliability. The Dermascan ultrasound (dermal thickness, intensity) had excellent intra- and inter-rater reliability (>0.90). The Cutometer R0 (firmness) had acceptable reliability but not R2 (gross elasticity). All objective measurement tools had good overall satisfaction scores. Patients rated scar related pain and itch as more important compared to appearance although this finding was not sustained when corrected for multiple comparisons.ConclusionThe objective scar measures demonstrated acceptable to excellent intra- and inter-rater reliability and performed better than the subjective scar scales.     

Direct comparison of reproducibility and reliability in quantitative assessments of burn scar properties

IntroductionDetermining the efficacy of anti-scar technologies can be difficult as qualitative, subjective assessments are often utilized instead of systematic, objective measures. Perceptions regarding the reliability of instruments for quantitative measurements along with their high cost and increased data collection time may discourage their use, leading to use of scar scales which are relatively quick and low-cost. To directly evaluate the reliability of instruments for quantitative measurements of scar properties, instruments and two qualitative scales were compared by assessing a variety of cutaneous scars.MethodsScar height and surface texture were evaluated using a 3D scanner and a mold/cast technique. Scar color was evaluated by using a spectroscopy-based tool, the Mexameter®, and digital photography with image analysis. Scar biomechanics were evaluated using the BTC-2000?, Dermal Torque Meter (DTM®), and ballistometer®. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) were used to qualitatively evaluate the same scar properties. Intraclass correlation coefficients (ICC) were used to determine inter- and intra-user reliability (poor, moderate, good, excellent) with all instruments and the kappa reliability statistic was used to asses inter-user reliability (poor, fair, moderate, good, very good) for VSS and POSAS. Time for measurement collection and after collection analysis was also recorded.ResultsThe Mexameter® was the most reliable method for evaluating erythema and pigmentation compared to digital photography and image processing, POSAS and VSS. Digital photography and analysis was more reliable than POSAS and VSS. Assessment of scar height was significantly more reliable when using a 3D scanner versus VSS and POSAS. The 3D scanner and mold-cast techniques also offered an additional benefit of providing an absolute value of scar height relative to the surrounding tissue. Intra-user reliability for all mechanical tests was moderate to good. Inter-user reliability was greater when using the BTC-2000? and ballistometer® versus the DTM®. All quantitative measurements took less than 90 s for collection, with the exception of the mold/cast technique.ConclusionNon-invasive instruments allow scar properties to be quantitatively assessed with high sensitivity and as a function of time and/or treatment without the need for biopsy collection. Overall, the reliability of scar assessments was significantly improved when quantitative instruments were utilized versus scar scales. Quantitative assessment of color and biomechanics were swift, requiring less than 90 s per measurement while assessments of texture and height required additional analysis time after collection. With proper training of clinical staff and well-defined protocols for measurement collection, reliable, quantitative assessments of scar properties can be collected with little disruption to the clinical workflow.     

A systematic review of the quality of burn scar rating scales for clinical and research use

Introduction

Scar rating scales have the potential to contribute to better evaluation of scar properties in both research and clinical settings. Despite a large number of scars assessment scales being available, there is limited information regarding the clinimetric properties of many of these scales. The purpose of the review was to inform clinical and research practice by determining the quality and appropriateness of existing scales. This review summarises the available evidence for the clinimetric properties of reliability, validity (including responsiveness), interpretability and feasibility of existing scales.

Methods

Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1990 onwards were used to identify English articles related to burn scar assessment scales. Scales were critically reviewed for clinimetric properties that were reported in, but not necessarily the focus of studies.

Results

A total of 29 studies provided data for 18 different scar rating scales. Most scar rating scales assessed vascularity, pliability, height and thickness. Some scales contained additional items such as itch. Only the Patient and Observer Scar Assessment Scale (POSAS) received a high quality rating but only in the area of reliability for total scores and the subscale vascularity. The Vancouver Scar Scale (VSS) received indeterminate ratings for construct validity, reliability and responsiveness. Where evidence was available, all other criteria for the POSAS, VSS and the remaining 17 scales received an indeterminate rating due to methodological issues, or a low quality rating. Poorly defined hypotheses limited the ability to give a high quality rating to data pertaining to construct validity, responsiveness and interpretability. No scale had empirical testing of content validity and no scale was of sufficient quality to consider criterion validity.

Conclusions

The POSAS, with high quality reliability but indeterminate validity, was considered to be superior in performance based on existing evidence. The VSS had the most thorough review of clnimetrics although available data received indeterminate quality ratings. On the basis of the evidence, the use of total scores has not been supported, nor has the measurement of pigmentation using a categorical scale.     

The effect of Extracorporeal Shock Wave Therapy in the treatment of burn scars: A prospective,randomized, controlled trial

BackgroundCurrent scientific evidence on the effect of Extracorporeal Shock Wave Therapy (ESWT) as adjunctive treatment for burn scars is scarce. However preliminary evidence, indicates it might prove a useful tool.Materials and methodsA prospective, randomized, controlled study was conducted from February 2017 to February 2019. Patients with burn scars were divided into two groups with twenty patients per group. The control group received the standard treatment for burn scars. The ESWT group received the standard treatment and treatment of burn scars with ESWT 512 impulses of 0.15 mJ/mm² in each session, twice per week for 4 weeks. We assessed the appearance of scar with the Vancouver Scar Scale (VSS), pruritus and pain with Visual Analog Scale (VAS) before the start of the treatment and at 2 weeks and 5 months after the treatment.ResultsBoth groups showed improvements in all variables through the study. However, these improvements were only statistically significant for the VSS at the 6th month for the control group and VSS and VAS pain and pruritus for the ESWT group. Nonetheless the results failed to show statistically significant differences between the ESWT and the control group neither at two weeks after treatment nor at 5 months after treatment.ConclusionOur study questions the relevance of ESWT as adjunctive treatment for burn scars as far as outward appearance, pain and pruritus as end-results are concern. Nonetheless, further studies are required to accurately assess the potential benefits of ESWT as an adjunctive treatment for burn scars.     

Ultrapulsed fractional ablative carbon dioxide laser treatment of hypertrophic burn scars: evaluation of an in-patient controlled,standardized treatment approach

In this study, we aimed to quantify the effects of fractional ablative carbon dioxide laser therapy in the treatment of widespread hypertrophic burn scars. While many different pilot studies have described the potential of the technology and expert groups and current guidelines, alike, recommend its use, the level of evidence for the efficacy of fractional CO₂-laser treatment for burn scars is currently very low. Ten patients (three male, seven female) with hypertrophic burn scars were treated with a single course of fractional CO₂-laser therapy in an in-patient controlled setup, using a standardized treatment paradigm. Documentation was based on modern scar scales and questionnaires, like the Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), and Dermatology Life Quality Index (DLQI), as well as state of the art clinical measurements (PRIMOS, Cutometer). Over the course of 6 months after treatment, VSS and POSAS scores showed significant improvement in the rating of scar parameters, as did the quality of life rating according to the DLQI. In the treated scars, surface relief improved significantly, as S _max decreased by 1893 μm (?36.92%) (p = 0.0273) and S _z by 1615 μm (?36.37%) (p = 0.0488). Scar firmness in treated scars could be reduced by 30% after one treatment session, as R ₀ improved by 0.0797 mm (+30.38%) (p = 0.0212). Fractional ablative CO₂-laser treatment is a safe and efficacious option for the treatment of hypertrophic burn scars. While more treatment sessions are required for satisfying results, significant improvement is already apparent after a single course of treatment.     

Patient-reported scar quality of donor-sites following split-skin grafting in burn patients: Long-term results of a prospective cohort study

BackgroundSkin grafting is the current gold standard for treatment of deeper burns. How patients appraise the donor-site scar is poorly investigated. The aim of this study was to evaluate long-term patient-reported quality of donor-site scars after split skin grafting and identify possible predictors.MethodsA prospective cohort study was conducted. Patients were included in a Dutch burn centre during one year. Patient-reported quality of donor-site scars and their worst burn scar was assessed at 12 months using the Patient and Observer Scar Assessment Scale (POSAS). Mixed model analyses were used to identify predictors of scar quality.ResultsThis study included 115 donor-site scars of 72 patients with a mean TBSA burned of 11.2%. The vast majority of the donor-site scars (84.4%) were rated as having at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and the overall opinion on 80.9% of the donor-site scars was that they deviated from normal skin 12 months after surgery. The overall opinion on the donor-site scar was 3.2 ± 2.1 vs. 5.1 ± 2.4 on the burn scar. A younger age, female gender, a darker skin type, and location on the lower leg were predictors of reduced donor-site scar quality. In addition, time to re-epithelization was associated with scar quality.ConclusionThis study provided new insights in long-term scar quality of donor-sites. Donor-site scars differed from normal skin in a large part of the population 12 months after surgery. Results of this study can be used to inform patients on the long-term outcomes of their scars and to tailor preventive or therapeutic treatment options.     

Combination treatment utilizing fractional ablative and continuous wave CO2 lasers for hypertrophic burn scars

BackgroundHypertrophic scars are devastating outcomes of severe burn injuries, producing physical and mental burdens. Adequate treatment is of benefit to relieve these burdens. Laser therapy has shown scar reducing effects. In this study, we compared outcomes after combination of two different lasers or single laser treatment to treat severe hypertrophic burn scars.MethodsForty patients with hypertrophic burn scars were included in one of two therapeutic groups: continuous wave CO₂ laser and fractional ablative CO₂ laser group (group 1, n = 20) or fractional ablative CO₂ laser alone group (group 2, n = 20). Hypertrophic scars were evaluated by the observer-rated Vancouver Scar Scale (VSS) before and after treatment and by patient-completed questionnaires after treatment. Comparative analyses were performed before and after treatment, and time-dependent improvement was also analyzed.ResultsForty patients (54 hypertrophic scars) completed the laser treatment protocols. Group 1 exhibited significantly more improvement in VSS vascularity, pliability, and height indices than group 2 (p < 0.05). Time-dependent analysis of total VSS scores suggested that group 1 experienced more improvement during a shorter treatment period (p < 0.05). For patient-reported outcomes, group 1 noted better grades than group 2 in four indices, namely scar appearance, scar thickness, pain, and pruritus (p < 0.05).ConclusionEffective scar reduction was achieved using combination laser treatment, with significant improvement in multiple observer- and patient-reported outcomes. The shorter treatment period of the combination method can be a merit, as prolonged hypertrophic scars may increase morbidity. Nonetheless, cautious treatment protocols are necessary to avoid undesirable sequelae related to laser application.     

Effects of combined Pulsed Dye Laser and Fractional CO2 Laser treatment of burn scars and correlation with plasma levels of collagen type I,MMP-2 and TIMP-1

Hypertrophic burn scars remain a significant burden for patients and a challenge for clinicians.The aimAssessement of the efficacy of combined Pulsed Dye Laser and Ablative Fractional CO₂ Laser therapy on hyperthophic scars and correlation with plasma levels of MMP-2, TIMP-1 and alpha-1 type I collagen.Patients and methodsTwenty five pediatric subjects were enrolled into the study. Control group consisted of age-matched subjects admitted for surgical repair of inguinal hernia. For the assessment of the results of laser treatment we used the Vancouver scar scale (VSS), and Patient-Observer Scar Assessment Scale (POSAS). We also correlated clinical results with plasma levels of MMP-2, TIMP-1 and alpha-1 type I collagen.ResultsAll subjects reported the laser treatment resulted in improvement and were somewhat satisfied or very satisfied with their experience. No adverse events were reported. The levels of MMP-2, TIMP-1 and alpha-1 type I collagen in our patients with scars before laser threatment were higher in comparison to controls. We also found statistically significant decrease in the levels of MMP-2, TIMP-1 and alpha-1 type I collagen after laser treatment of burn scarsConclusionsOur study clearly shows that combined CO2-AFL treatment for burn scars improve texture, colour, function and alleviate pruritus. We believe that decrease in the levels of MMP-2, TIMP-1 and alpha-1 type I collagen after laser treatment of burn scars, reflects reduced dynamic of scar.     

A study of using a simple 2D image analysis method to monitor the surface area of hypertrophic scars on hand during pressure therapy

Hypertrophic scars are usually evaluated based on scar assessment scales such as Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS) which are difficult in recording small changes in the scar conditions over time. This study adopts a simple method to quantify the size of hypertrophic scars on hands by using a camera and tripod set-up for image capturing and a free software, ImageJ, for analysis. The ability to record the changes in scars condition and healing progress of this method were investigated. Four hypertrophic scar samples on the hands were captured at 8 time-points during 24-week of pressure therapy. Three operators were trained for 2 h to use the software and then carried out image analysis on 32 scar images to obtain the surface areas of the hand and the scars and repeat the entire measurement for 3 times. The results show that the measured scar surface areas have good intra-operator reliability with an intraclass correlation coefficient (ICC) of 0.943 (0.922, 0.96) and moderate inter-operator reliability with an ICC of 0.554 (0.063, 0.795). No significant within-subject effect of the repeat of measurements (p > 0.05) and between-subject effect of the three operators (p > 0.05) were found on the scar area measurements and the proportion of the scars on hands but significant differences were found between different time-points of the image capturing (p < 0.05). The image analysis method is more sensitive to the change of scars conditions over time than the VSS record. This is an economical and relatively easy method to quantify the changes in the hypertrophic scars which could be useful for monitoring the progress of therapy and encourage treatment compliance.     

Measurement of vascularity in the scar: A systematic review

BackgroundVascularity is an important parameter closely associated with the scar maturation. Reliable and accurate measurement of vascularity helps to monitor the scar change and adopt targeted interventions to prevent excessive scarring and achieve promising outcomes. However, there is no consensus on the assessment tools for the vascularity measurement in scars. This systematic review presents evidence on the available vascularity measurement tools.MethodsA systematic literature search was done using PubMed, CINAHL, Embase and Science Direct databases. Studies, which used non-invasive measurement tools and explored their clinimetric properties, were identified and included in this review.ResultsA total of 1458 articles were obtained, and 26 articles were finally included in this review. Subjective vascularity measurement scales include the Patient and Observer Scar Assessment Scale (POSAS), the Vancouver Scar Scale (VSS) and the modified Vancouver Scar Scale (mVSS) while objective vascularity measurement devices consist of the color-measuring device, the blood flow measuring device and the morphological imaging device.ConclusionSubjective scales are easy to use and have acceptable reliability to give a preliminary impression of the scar vascularity. Three types of objective devices are not equivalent and are mainly based on the blood flow and angiogenesis to quantify the scar vascularity.     

Patient‐reported scar quality of adults after burn injuries: A five‐year multicenter follow‐up study

Scar formation is an important adverse consequence of burns. How patients appraise their scar quality is often studied shortly after sustaining the injury, but information in the long‐term is scarce. Our aim was, therefore, to evaluate long‐term patient‐reported quality of burn scars. Adults with a burn center admission of ≥1 day between August 2011 and September 2012 were invited to complete a questionnaire on long‐term consequences of burns. We enriched this sample with patients with severe burns (>20% total body surface area [TBSA] burned or TBSA full thickness >5%) treated between January 2010 and March 2013. Self‐reported scar quality was assessed with the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS). Patients completed this scale for their—in their opinion—most severe scar ≥5 years after burns. This study included 251 patients with a mean %TBSA burned of 10%. The vast majority (91.4%) reported at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and 78.9% of the patients’ overall opinion was that their scar deviated from normal skin. Patients with severe burns had higher POSAS scores, representing worse scar quality, than patients with mild/intermediate burns, except for color, which was high in both groups. A longer hospital stay predicted reduced scar quality (both mean POSAS and mean overall opinion of the scar) in multivariate analyses. In addition, female gender was also associated with a poorer overall opinion of the scar. In conclusion, this study provides new insights in long‐term scar quality. Scars differed from normal skin in a large part of the burn population more than 5 years after burns, especially in those with severe burns. Female gender is associated with a poorer patients’ overall opinion of their scar, which may be an indication of gender differences in perception of scar quality after burns.     

等离子体射频联合药物皮肤导入早期干预烧伤后面颈部瘢痕

目的观察等离子体射频联合药物皮肤导入早期防治烧伤后面颈部瘢痕的疗效。方法选取自2015年4月至2018年4月收治的烧伤后面颈部瘢痕患者42例,将瘢痕部位分为治疗区和对照区,做自身对照。治疗区采用等离子体射频联合曲安奈德+5-氟尿嘧啶皮肤导入治疗,首次治疗时机为烧伤创面愈合1个月内。治疗后,对治疗区和对照区常规应用弹力面罩压力治疗,并观察瘢痕治疗效果及不良反应情况;采用温哥华瘢痕量表(vancouver scar scale, VSS)进行瘢痕评分。结果治疗区瘢痕VSS评分明显低于对照区,瘢痕痛痒和牵拉紧缩感较对照区明显改善。其中13例瘢痕治疗区出现出血、水疱等并发症。将一定总剂量的药物采用皮肤导入可增加瘢痕治疗面积。结论等离子体射频联合药物皮肤导入用于早期防治烧伤后面颈部瘢痕有较好的疗效,且安全性较高,不良反应少。     

甲状腺手术切口大小对术后瘢痕美观的影响

目的评价甲状腺小切口手术后瘢痕的美观效果是否优于大切口。方法选取2008年3月至2008年6月期间笔者所在医院30例接受甲状腺手术的连续患者并随机均分为2组,小切口组切口长度为6 cm,大切口组为9 cm。3年后采用患者与观察者瘢痕评价量表(POSAS)与温哥华瘢痕量表(VSS)对切口瘢痕进行评价;同时拍摄数码照片并由研究非相关人员进行独立评价。结果 2组均分别有13例患者完成了3年随访。2组患者的一般临床特征差异无统计学意义(P>0.05)。小切口组与大切口组患者的瘢痕总体评分分别为(2.5±1.9)分与(2.2±1.5)分,2组间比较差异无统计学意义(P=0.55);其他的瘢痕评价量表(包括VSS评分、PSAS评分以及OSAS评分),2组间比较差异也均无统计学意义(P>0.05)。研究非相关人员对瘢痕数码照片的评价差异也无统计学意义(P>0.05)。结论从本组有限的病例看,甲状腺手术中应用较大切口并不降低患者对瘢痕的满意度。     

Cross‐cultural adaptation,reproducibility and validation of the Italian version of the Patient and Observer Scar Assessment Scale (POSAS)

The Patient and Observer Scar Assessment Scale (POSAS) is one of the most robust instruments to assess scar quality, but there is no Italian version, and no other competing instruments are available in Italian. The aim of this study was to translate and validate an Italian version of POSAS (POSAS‐I). POSASv2.0 was culturally adapted in accordance with international standards. The psychometric assessment included acceptability/feasibility, internal consistency, reproducibility, construct validity and sensitivity to change. Cultural equivalence of POSAS‐I with the English version was confirmed. The validation study included 102 subjects with surgical scars. Both subscales demonstrated acceptable internal consistency (Cronbach's α = 0·72–0·80). Reproducibility of the OSAS‐I (ICCs = 0·93–0·94; SEM = 1·8 points; MDC₉₅ = 5·1 points) was superior to that of PSAS‐I (ICC = 0·65; SEM = 5·7 points; MDC₉₅ = 15·7 points). OSAS‐I showed moderate to good correlations with the Vancouver Scar Scale (VSS), Global Rating of Change Scale (GRCS) and PSAS‐I. Sensitivity to change was large for PSAS‐I (effect size = 1·08; standardised response mean = 0·96) and moderate to large for OSAS‐I (ES = 0·69; SRM = 0·92). This study confirmed that POSAS‐I can be used to assess patients with surgical scars in the Italian population. OSAS‐I is useful for clinical and research purposes, while PSAS‐I should be better used to capture patients' own opinions and symptoms in clinical settings.     

Patterns and predictors of burn scar outcome in the first 12 months after burn: The patient’s perspective

ObjectiveThis study aimed to provide insight into the patterns and factors that predict burn scar outcomes at 3, 6 and 12 months after burn.MethodsThe Patient and Observer Scar Assessment Scale (POSAS) was used to assess the scar formation of each patient. Structural equation modelling was used. The predictor variables used in this study were sex, three age categories, TBSA, depth of the wound and cause of the burn.ResultsThe POSAS patient total and individual item scores demonstrated a statistically significant decrease in the first 12 months after burn, except for the relief item. Male patients had a lower total and items scores (better scar quality) for pain and pruritus compared with female patients. Full thickness burns had a higher scores for pruritus, pliability, thickness and relief compared to the partial-thickness burns. Ages younger than 5 years, higher TBSA values and flame burns were predictors of various POSAS items at 3 and 6 months after burn.ConclusionThe POSAS patient total and individual item scores demonstrated a statistically significant improvement in the scar quality in the first 12 months after burn, except for the relief. Sex, age, depth of the wound, the percentage of TBSA and flame burns were predictors of various POSAS patient items at 3, 6 and 12 months after burn.     

The use of Suprathel(®) in deep dermal burns: first results of a prospective study

Introduction

While autologous skin grafting has been the standard for coverage of full-thickness areas, several options for deep-partial-thickness defects exist. With regard to economising donor sites, we compared a copolymer based on dl-lactid acid (Suprathel^®) as temporary wound dressing with autologous skin, and analysed time to healing and scar quality in matched areas of deep-partial-thickness burn.

Methods

We recruited 18 patients with a median age of 45 years (range: 25–83 years), for this prospective, non-blinded controlled non-inferiority study, suffering from deep-partial-thickness burns from November 2009 to July 2010. After early tangential excision, matched deep-partial-thickness areas were covered with 1:1.5 meshed autologous skin grafts and the copolymer for direct intra-individual comparison. Scars were evaluated by means of the Vancouver Scar Scale (VSS), the Patient and Observer Scar Assessment Scale (POSAS) and suction cutometry (MPA 580, Courage and Khazaka Electronic GmbH, Cologne, Germany) on days 30 and 90, postoperatively.

Results

Fifteen days after surgery, complete wound closure was present in 44.4% (8/18) of all areas covered with copolymer and 88.9% (16/18) in the split-thickness skin graft (STSG) area (p = 0.008). Evaluation of the total VSS, POSAS and cutometry satisfied the criterion of non-inferiority for Suprathel^® on day 30. Ninety days after surgery, only the Observer Scar Scale showed that Suprathel is non-inferior to STSG, albeit the mean total VSS and Patient Scar Scale were better in Suprathel^® areas.

Conclusion

Suprathel^® represents a solid, reliable epidermal skin substitute with longer healing times in comparison to skin grafts but comparable results concerning early scar formation. Suprathel^® can serve as a tool in treatment portfolio for adult patients suffering from deep dermal burns. Especially in patients with extensive burns, Suprathel^® can be used to cover the deep dermal burn wounds to save STSGs and its donor sites for the coverage of full-thickness burned areas.     

The Patient and Observer Scar Assessment Scale: Translation for portuguese language,cultural adaptation,and validation

Evaluating scars is fundamental to analyse the outcome of treatments that include surgical intervention. Scales facilitate this type of assessment, but most of these measuring instruments are in different languages. The Patient and Observer Scar Assessment Scale (POSAS) is one of the most robust instruments available in the literature for the evaluation of scars, although there is no validated version in Brazilian Portuguese. The aims of this study were to culturally translate and validate POSAS for the Portuguese language of Brazil and to test its reproducibility, face validity, content, and construct. Following the methodology proposed by Beaton DE, Bombardier C, Guillemin F, Ferraz, MB, Spine 2000, 25, 3186, the questionnaire was translated and adapted to the Brazilian culture. The reproducibility, face, content, and construct validity were then analysed. In all, the scale was applied to 35 patients with postoperative scars (patient version) and 35 hand surgery specialists (version for the observer). The internal consistency was tested by Cronbach's alpha, and construct validation was performed by correlating the translated instrument with the Brazilian Portuguese translation of the Vancouver Scar Scale (VSS). The cultural adaptation of POSAS Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/UNIFESP) was confirmed. Both subscales showed strong internal consistency (Cronbach's α = 0.77‐0.93), demonstrating reliability. The reproducibility was excellent, and the adapted scale demonstrated significant intra‐ and inter‐observer reproducibility (r > 0.9) (P < 0.05). The validity of the construct was significant and showed good sensitivity between POSAS EMP/UNIFESP and the VSS. This study confirmed that POSAS EPM/UNIFESP can be used to evaluate patients with surgical scars in the Brazilian population. It has proven to be useful for clinical and research purposes, lending itself to capturing medical opinions and those of the patients themselves.     

Clinimetric properties of a translated and culturally adapted Norwegian version of the Patient and Observer Scar Assessment Scale for use in clinical practice and research

PurposeTo translate and culturally adapt the Patient and Observer Scar Assessment Scale, POSAS, to Norwegian and explore its test-retest, intra- and inter-tester reliability.MethodsPOSAS was translated into Norwegian following international guidelines in collaboration with an international translation bureau. Twenty-six adults and 24 children were recruited from a burns outpatient clinic. Three observer-categories: doctor, nurse and physiotherapist, assessed the patients’ scars and scored the Observer scale for estimating inter-tester reliability. Photos of the scars were taken and used to score the Observer scale a second time for examining intra-tester reliability. The patients or parents/next of kin rated their scar on the Patient scale at the clinic and after two days at home for examining test-retest reliability. Intraclass correlation (ICC) and Kappa were used for statistical analysis.ResultsA Norwegian version of POSAS (POSAS-NV) was developed. Inter-tester ICC of the Observer parameters varied between 0.203 and 0.728, and for the total sum score, ICC = 0.528 (0.280–0.708). Intra-tester ICC of the Observer scale ranged between 0.575 and 0.858. The Patient scale demonstrated high test–retest reliability.ConclusionsIntra-tester reliability of the Observer scale and test–retest reliability of the Patient scale of POSAS-NV were found satisfactory, but not inter-tester reliability of the Observer scale.     

Comparison of wound closure techniques in median sternotomy scars in children: subcuticular suture versus Steri-Strip™ S

Objectives: The aim of this retrospective study was to compare subcuticular sutures and Steri-Strip? S in closing median sternotomy incisions in children with regard to wound healing and scar formation.

Methods: Fifty-three children and adolescents were enrolled in this study who all underwent a median sternotomy at age 0–18?years and had their presternal cutaneous wounds closed with either a running subcuticular suture (Group 1) or Steri-Strip? S (Group 2). Their scars were assessed using the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcome measures were the scar measurements and the incidence of wound problems post-surgery.

Results: A significant difference was found between both groups in median POSAS observer scale scores for the items thickness (p?=?.027), pliability (p?=?.045), surface area (p?=?.045) and the total score (p?=?.048). All in favor of the subcuticular suture group. There were no significant differences concerning the POSAS patient scale scores. Middle parts of scars of patients in Group 2 were significantly broader (p?=?.001) than scars of patients in Group 1. No significant differences concerning wound problems were found.

Conclusions: There are, according to our results, no significant differences in wound healing of median sternotomy incisions in children closed with either a subcuticular suture or Steri-Strip? S. Significant differences do exist regarding scar formation and final cosmetic results of the scars, in favor of subcuticular closure.