The vessel loop shoelace technique for closure of fasciotomy wounds

Compartment syndrome of the extremity may occur after severe trauma secondary to fractures, vascular ischemia, crush, or electrical injury. Treatment consists of expedient fasciotomy to avoid permanent injury to muscles or nerves. Management of the wounds postoperatively has consisted traditionally of primary closure, healing by secondary intention, or split-thickness skin grafting to cover defects. The fasciotomy wound may remain substantial secondary to soft-tissue swelling and edema. The authors present an alternative protocol for fasciotomy wound management, consisting of gradual closure with progressive tension using vessel loops. The vessel loops are placed intraoperatively during the compartment release and are attached to the wound margins using standard skin staples. The loops are tightened progressively postoperatively during routine dressing changes, resulting in closure of the wound within 2 weeks. The advantages over split-thickness grafting include avoidance of donor morbidity and better cosmesis. Sporadic case reports using similar techniques have been published in the orthopedic literature with comparable results. The current series includes 37 patients, ages 9 to 48 years, who were treated for open fasciotomy. There were 11 upper extremity and 26 lower extremity wounds treated, all of which were closed within 3 weeks.     

VADER (vacuum-assisted dermal recruitment): a new method of wound closure

Acute wounds which cannot be closed primarily are usually closed with a split skin graft. However a split skin graft has both functional (where tendons are exposed) and esthetic sequelae (contour deformity, different skin in color and texture). A novel technique is described which allows delayed primary closure of either fasciotomy wounds or full-thickness defects after harvest of a free or pedicle flap. The technique described combines the bootlace suture technique (which achieves wound closure by progressive suture tightening) with the VAC (vacuum-assisted closure) system (which reduces tissue edema, facilitating movement of tissue, and also reduces bacterial contamination of the wound). Twelve of 14 wounds (average width of wound after insertion and tightening of bootlace suture was 5 cm) were successfully closed after an average of 8 days (range, 4-23 days) in 11 patients (mean age, 45 years; range, 18-77 years) using this technique. Of the 2 patients where the technique was not successful, one patient was noncompliant and the other developed wound-edge necrosis. Other complications were self-limiting.The combined use of 2 methods of wound management facilitates delayed primary wound closure.     

The Use of an Innovative Device for Wound Closure after Upper Extremity Fasciotomy

INTRODUCTION: The purpose of this paper is to evaluate the Silver Bullet Wound Closure Device (SBWCD, Boehringer Laboratories, Norristown, PA), a new device for delayed primary closure of fasciotomy wounds. MATERIALS AND METHODS: A retrospective review was performed over a period of 36 months of all patients with an upper extremity fasciotomy that could not be closed primarily. Cases that underwent fasciotomy closure with the SBWCD were separated from the patients that had a split thickness skin graft (STSG). RESULTS: Seven patients had their wound closed with the SBWCD within 10 days (mean of 7.4 days). The seven patients that underwent STSG had their wound closed in an average of 8.4 days. The average number of days between the day of the fasciotomy incision and the date of the placement of the SBWCD was 1.9 days. STSGs were placed on the fasciotomy wounds on an average of 10.3 days after the date of the fasciotomy incision. We found that the SBWCD allowed for starting to approximate the edges of the fasciotomy wound at an earlier time when compare to STSG (2.1 vs 10.3 days). CONCLUSIONS: We feel that the SBWCD as a one-stage procedure provides a consistent and efficacious way to manage upper extremity fasciotomy wounds while minimizing the morbidity associated with STSG. Elimination of a second-stage procedure reduces hospital costs. Our findings may help to inform surgeons about an available alternative when an upper extremity fasciotomy wound is not amenable to primary closure.     

Dermatotraction: an effective technique for the closure of fasciotomy wounds: a preliminary report of fifteen patients

Dermatotraction was evaluated as an alternative technique for the closure of dermatofasciotomy wounds, with a review of literature and of our clinical experience. The dermatotraction technique provides closure of fasciotomy wounds and avoids the use of skin grafting. Patients treated with dermatofasciotomy for an acute compartment syndrome of the limbs, without obvious tissue necrosis and without shock or urgent life saving surgery, had their fasciotomy wound closed with dermatotraction with vessel loops, the skin approximation system, or the prepositioned intracutaneous suture. In our experience, the mean time to wound closure was nine days. Dermatotraction techniques that cause local skin compression should be avoided because skin necrosis might occur (skin approximation system). Dermatotraction with vessel loops or the prepositioned intracutaneous suture provides good skin apposition without the necessity for skin grafting.     

Vacuum-assisted closure for fasciotomy wounds following compartment syndrome of the leg

This study evaluated the efficacy of vacuum-assisted closure (VAC) for treatment of fasciotomy wounds for traumatic compartment syndrome. The authors reviewed the records of a consecutive series of 34 patients who had compartment syndrome of the leg requiring the standard two-incision release of all four compartments and received the application of VAC therapy until the time of definitive wound closure or coverage. A matched series of 34 consecutive antecedent patients with the same entry criteria, except for the use of the VAC, were also studied and served as a control group. The main parameter of interest was the time to "definitive closure" (delayed primary closure with sutures or skin graft coverage) of the wounds. Of the 68 wounds in 34 patients managed with VAC, the average time to definitive closure for both the lateral and the medial wounds was 6.7 days. For the 70 wounds in the 34 control patients, the average time to definitive closure was 16.1 days. This difference in time to wound closure between the VAC group and the non-VAC group was statistically significant (p < .05). Subatmospheric treatment for compartment syndrome of the leg after fasciotomy theoretically helps to speed the resolution of the swelling and tissue edema that are often components of this clinical entity. Experimental work has shown vacuum-assisted wound management to be effective in hastening the resolution of wound edema, enhancing local blood flow, promoting granulation tissue, and thwarting bacterial colonization. These factors may account for its utility in the management of fasciotomy wounds in the setting of compartment syndrome of the leg.     

应用皮肤牵张带延期闭合骨筋膜室减张切口

目的观察应用皮肤牵张带延期直接缝合骨筋膜室减张切口的效果。方法因骨筋膜室综合征而行切开减压术导致皮肤缺损患者 21例,年龄 7～ 36岁,小腿皮肤缺损 17例、前臂皮肤缺损 3例、足部皮肤缺损 1例。缺损区最小 5 cm× 15 cm,最大 11 cm× 28 cm,合并骨外露和肌腱外露者各 1例。于骨筋膜室切开减压后第 4～ 7 d放置皮肤牵张带,此后 3～ 7 d天待牵拉至两侧皮缘靠近时延期缝合伤口, 2周后拆线。结果 21例患者, 20例伤口一期愈合,形成线状瘢痕; 1例在放置皮肤牵张带之前伤口红肿,有较多分泌物,置皮肤牵张带 2 d后分泌物仍较多,故拆除 3根硅胶带,伤口引流,遗留 2 cm× 5 cm创面,经换药、小块游离皮片植皮后伤口愈合。 2例合并骨外露和肌腱外露者伤口愈合良好。随访 3～ 15个月,患肢远端关节活动自如,无肌肉挛缩现象。结论急性骨筋膜室综合征切开减压后,使用皮肤牵张带延期缝合伤口,安全、有效。其优点 :(1)操作方法简便、快速,病程短,费用相对较低; (2)无需游离皮片植皮,愈合后形成线状瘢痕,局部皮肤质量较好,对美观影响小; (3)同样适用于伴骨外露和肌腱外露者,可避免施行皮瓣转移覆盖手术。     

The influence of suture technique on early wound healing.

The burst strength, swelling, and microcirculatory dynamics were compared in model skin wounds closed by interrupted or continuous suturing techniques. Incised skin wounds of the midline abdomen and anteromedial and anterolateral knee of the pig were used. Microcirculatory kinetics were assessed by means of skin fluorescence following intravenous fluorescein at intervals of up to 12 days. The burst strength of wounds was measured at 12 days using an Instron Tensiometer. In wounds closed with an interrupted suture technique a 30 to 50% greater tensile strength, less edema and induration, and less impaired microcirculation at the wound margin was demonstrated in comparison to that observed in wounds closed with a continuous suture technique. The results support the use of interrupted rather than continuous suture technique for skin wound closure in instances where impaired healing can be anticipated due to disease or age, or where early stress on the healing wound is planned as in incisions about a moveable joint.     

Ty-raps in trauma: a novel closing technique of extremity fasciotomy wounds

The challenge of closing extremity fasciotomy wounds is well known to every trauma and orthopedic surgeon. We developed a new, easy, and inexpensive dermatotraction technique based on the simple use of Ty-Raps and report on the first pilot study using this novel technique for the closure of 23 extremity fasciotomy wounds. The Ty-Rap system consists of several combinations of two Ty-Raps and four surgical staples. Immediately after fasciotomy, the system is secured to the skin by the surgical staples, and once the swelling of the affected limb is subsided, the Ty-Raps are tightened every 24 hours to 48 hours until full approximation of the skin edges is achieved. We recorded the time to closure of the wound, the time to removal of the Ty-Raps, and the complications related to the procedure. Also, a cost analyses was calculated. The mean time of approximation of the skin was 6.3 days, and after a further 9.4 days, the Ty-Raps could be removed. The majority of the wounds (91%) healed without complications, and only one patient in our series required a secondary surgical procedure for the closure of one fasciotomy wound. The total cost to close a fasciotomy wound of 30 cm with the use of Ty-Raps is US dollar 23.33. We regard the use of Ty-Raps a good alternative for the current closing techniques of extremity fasciotomy wounds. We value its low cost, general availability, effectiveness, and the fact that, in this pilot study, both the application and the tightening of the Ty-Raps were well tolerated by our patients with a minimal need for secondary procedures. Knowledge of this technique is a useful adjunct to the existing surgical array for every trauma and orthopedic surgeon for the closure of extremity fasciotomy wounds, especially in austere or military environments.     

Dermotaxis v/s loop suture technique for closure of fasciotomy wounds: a study of 50 cases

Fasciotomy incisions lead to large, unsightly, chronic wounds after surgical intervention. Classic management was to use split-thickness skin grafts, but this leads to insensate skin with reports that as many as 23% of patients are dissatisfied by the appearance of the wound. Since no skin loss has occurred with the fasciotomy incision, utilizing the dermal properties of creep, stress relaxation and load cycling, closure can be achieved in a better way. We describe using dermotaxis for skin edge approximation that is done using inexpensive equipment available readily in any standard operating room. Twenty-five patients had fasciotomy wounds closed either by dermotaxis or a loop suture technique with the inclusion criteria being closed fractures, no concomitant skin loss, fracture-related compartment syndrome and fasciotomy performed within 36 h. The fasciotomy incision was closed in a single stage by loop suture technique or gradually by dermotaxis once the oedema had settled between 3 and 5 days. Results were graded as excellent if approximation could be achieved, good if sutures had to be applied for protective care and poor if wounds needed to be skin-grafted. In the dermotaxis group, results were excellent in 15, good in 8 and poor in 2 cases. In the loop suture technique group, results were excellent in 20, good in 4 and poor in 1 case. Dermal apposition using inexpensive, readily available equipment is an alternative method for closure of fasciotomy wounds. If limb oedema has settled sufficiently, closure using a loop suture can be done in a single stage. If the limb remains oedematous, gradual closure can be done using dermotaxis.     

Delayed primary closure of fasciotomy wounds with Wisebands, a skin- and soft tissue-stretch device

BACKGROUND: Fasciotomy incisions for limb compartment syndrome usually cannot be closed primarily. The conventional method of wound closure with split-thickness skin grafting is effective, but it results in an insensate and disfiguring wound and is associated with donor site morbidity. We present our experience in delayed primary closure of fasciotomy wounds with Wisebands (WB), a skin- and soft tissue-stretching device. PATIENTS: Between 2000 and 2003, we treated 16 patients with extremity fasciotomy wounds for which primary closure was not feasible. RESULTS: The Wisebands devices achieved controlled stretching of the wound edges, including skin and underlying soft tissue, until primary closure was feasible. Fourteen patients (88%) had successful wound closure, two patients (12%) had minor wound complications that did not necessitate the removal of the device, and two patients had local wound complications (infection, intractable pain) and their devices were removed prematurely. Delayed primary closure was achieved at the initial surgery using intraoperative skin stretching in 3 of the 14 cases (21%). After a 2-year follow-up (1.3-4 years), the treated area showed stable scarring with good aesthetic outcome and no functional deficit. CONCLUSIONS: The Wisebands device facilitates closure of fasciotomy wounds with low complication rates and good functional and aesthetic outcome. Its application is simple and safe and requires a short learning curve. Nevertheless, appropriate patient selection, intraoperative judgment and close postoperative supervision are essential for optimal results.     

Fasciotomy closure using simultaneous vacuum-assisted closure and hyperbaric oxygen

Fasciotomies performed for compartment syndrome and ischemic vascular disease often requires closure in 2 to 4 weeks by skin graft. This leaves the patient with an unsightly scar and a limb with reduced strength. The use of vacuum-assisted closure (VAC) and hyperbaric oxygen therapy (HBOT) quickly reduce the edema and permit earlier closure with adjacent skin. A study of three trauma patients with compartment syndrome, fasciotomies, and the use of the VAC and HBOT to close the fasciotomy wounds with adjacent skin is presented. The pathophysiology of compartment syndrome and ischemia-reperfusion syndrome is discussed. These patients had closure of the fasciotomy wounds in 3 to 18 days. The simultaneous use of HBOT and VAC accelerates the reduction of edema in a synergistic fashion, permitting early closure of fasciotomy wounds.     

Closing fasciotomy wounds using plastic bands: an alternative simple and cheap method

Fasciotomy incisions are essential to relieve pressure on the neurovascular structures in the limbs. However, closing such wounds often becomes a challenge to the surgeon. The aim of this study is to describe a simple and cheap method of closing these wounds. Plastic bands were used to gradually close fasciotomy wounds in five patients. All fasciotomy wounds in the five patients closed successfully within 4-12 days. Only two patients developed minimal complications in the form of minor wound infection and a hypertrophic scar. We conclude that the plastic band method used here is cheaper and simpler in comparison to similar techniques using the same device.     

A simpler, less expensive technique for delayed primary closure of fasciotomies

A variety of techniques have recently been advanced for delayed primary closure of wounds following emergent fasciotomy for compartment syndrome. We introduce a very simple, effective method for gradual reapproximation of margins using daily reapplication of Steri-strips (3M Surgical Products, St. Paul, Minnesota). This method allows final closure of fasciotomy wounds with simple suture in 5-8 days without scar contractures, marginal necrosis, infection, or significant pain. Moreover, because it requires no specialized equipment and can be applied in skilled nursing centers or at home by trained nurses, this technique could reduce the cost of caring for fasciotomy patients.     

A comparison of fasciotomy wound closure methods following extremity compartment syndrome at a regional trauma centre

Background

Extremity fasciotomy wound closure following acute compartment syndrome is often prohibited by residual swelling, producing wounds that significantly contribute to patient morbidity. The aim of this study was to assess patient and fasciotomy wound outcomes associated with dynamic closure (DYN), delayed primary closure (DPS) and split skin grafting (SSG) techniques.

Methods

A retrospective review of all trauma-related compartment syndrome patients managed between January 2000 and March 2010 was conducted, and a comprehensive patient and wound outcomes analysis was performed.

Results

DYN was employed in 109 wounds, DPS in 66 wounds and SSG in 7 wounds. DPS wounds achieved closure in a significantly shorter timescale than other methods (p?=?<0.05). DYN and SSG group wound closure times were comparable; however, SSG techniques were employed later post-fasciotomy. SSG patients had longer hospital stays (p?=?<0.05) and the lowest wound complication rate (0 %). Wound complication rates were significantly higher in the DYN (55 %) and DPS groups (15 %) (p?=?<0.05), and these wounds required a higher number of further surgical procedures. The need for repeated wound debridements was higher in the DYN group than any other (p?=?<0.05).

Conclusions

DPS provided the fastest method of fasciotomy wound closure and the shortest inpatient stay. DYN techniques were associated with higher wound complication rates and the need for further surgical procedures. SSG techniques were associated with low complication rates and fewer surgical procedures and, if applied earlier, could result in shorter inpatient stay.Level of evidence IV, therapeutic study.

     

Dynamic wound closure for decompressive leg fasciotomy wounds

Decompressive fasciotomy for preservation of lower extremity function and salvage is an essential technique in trauma. The wounds that result from the standard two incision four-compartment leg fasciotomy are often accompanied by a wide soft tissue opening that in the face of true compartment syndrome are often impossible to close in a delayed primary fashion. We describe a technique using a device that allows for dissipation of the workload across the wound margin allowing for successful delayed primary closure. Consecutive patients who presented to the 28th Combat Support Hospital in Baghdad, Iraq with a diagnosis of compartment syndrome of the leg, impending compartment syndrome of the leg, or compartment syndrome of the leg recently treated with fasciotomies were followed. All patients underwent placement of the Canica dynamic wound closure device (Canica, Almonte, ON, Canada). Eleven consecutive patients treated at a combat support hospital in support of Operation Iraqi Freedom underwent four-compartment fasciotomies for penetrating injuries. There were five patients that underwent a vascular repair [three superficial femoral artery (SFA) injuries and two below knee popliteal artery injuries] and six patients that had orthopedic injuries (three comminuted tibial fractures, two fibula fractures, and one closed pilon fracture). Patients returned to the operating room within 24 hours for washout and wound inspection. Mean initial wound size was 8.1 cm; mean postplacement size was 2.7 cm; average time to closure was 2.6 days. All patients were able to undergo primary wound closure of the medial incision and placement of the Canica device over the lateral incision. Ten of the 11 patients (91%) could be closed in delayed primary fashion after application of the device. In our series of patients with penetrating wartime injuries and compartment syndrome of the leg we have found the use of this dynamic wound closure device to be extremely successful and expedient.     

A new technique for delayed primary closure of fasciotomy wounds

Fasciotomy for compartment syndrome in the lower limb is a surgical emergency to preserve future limb function. The advised standard procedure involves both medial and lateral dermotomy in addition to the fasciotomy. There is often concern before and after performing fasciotomy about the cosmetic appearance and prolonged hospital stay if split skin grafting is required to cover the resultant skin defect. This is the case in over 50% of lower limb fasciotomies. We have used a technique of subcuticular prolene suture, first described for the delayed primary closure of contaminated abdominal wounds, in six patients who had undergone lower limb fasciotomies. In all of these cases delayed primary closure was easily achieved without the need for skin grafting. Experiments using a synthetic skin model have shown a 60% reduction in suture tension when compared with interrupted vertical mattress suturing. The subcutaneous prolene suture has the advantage of being both the method of approximation and final closure whilst spreading tension evenly across the wound edges without causing skin edge necrosis. It appears to be simpler and more economical than any technique so far described for the successful delayed primary closure of fasciotomy wounds.     

Alternative approaches to abdominal wound closure in severely injured patients with massive visceral edema.

Excessive tension in an abdominal incision line may lead to fascial necrosis and wound sepsis. We utilized two alternative approaches to wound closure in 13 patients with severe abdominal trauma (2 blunt, 11 penetrating) whose midline incision could not be closed primarily without excessive tension at the initial operation because of massive visceral edema. In five patients synthetic mesh was used to bridge the fascial defect. Four patients survived the early postoperative period but had large open midline wounds that required one or more delayed procedures to close the wound or cover the visceral mass with skin graft. Two patients currently have large abdominal wall hernias. In the other eight patients the skin was reapproximated over the visceral mass utilizing towel clips at the initial operation. Six patients survived to be reexplored within 48-96 hours. Acute hemorrhage had stopped, the edema of the bowel and retroperitoneum had largely resolved, and the fascia could be closed primarily without excessive tension. All wounds went on to heal satisfactorily. When massive edema makes fascial closure at the initial operation difficult or impossible, closure of the skin over the visceral mass promotes resolution of the edema and often allows satisfactory primary closure within 48-96 hours. Synthetic mesh should be reserved for cases of abdominal wall tissue loss or dehiscence associated with wound sepsis.     

Compartment syndrome of the thigh: A systematic review

Introduction

Thigh compartment syndrome is a surgical emergency with risk of high morbidity and mortality rates. The purpose of this study was to review the available evidence regarding the causes of thigh compartment syndrome, techniques of fasciotomy (specifically, one versus two incisions), methods of wound closure, and complications.

Methods

This institutional review board-exempt study was performed at a level-one trauma centre. PubMed and Medline OVID databases in the English language were searched for case series of two or more cases of compartment syndrome of the thigh. Cases were reviewed and analysed for causes of thigh compartment syndrome, number of fasciotomy incisions, methods of wound closure, and complications.

Results

A total of 9 papers met our criteria. All were retrospective case studies comprising a total of 89 patients. The most common cause was blunt trauma (90%). Motor vehicle accidents accounted for 36% of cases whilst motorcycle accidents were involved in 9%. Associated injuries included femur fractures in 48%, other limb fractures, renal, cardiovascular and head insults. Eighty-six percent of fasciotomies were performed through a single incision. Fifty-nine percent of fasciotomy wounds were closed by delayed primary closure, 26% had split-thickness skin grafts, and 15% had primary wound closure. Neurological deficits were the most common complications.

Conclusion

There are limited data on thigh compartment syndrome with respect to cause, use of one versus two incisions for fasciotomy, methods of wound closure, and complication rates. Prospective studies are required to better define these variables in order to optimise the management of this problem.     

Shoelace technique for gradual closure of fasciotomy wounds

BACKGROUND: After emergency fasciotomy in acute compartment syndrome, skin graft techniques are usually necessary to cover the wound. METHODS: The shoelace technique for gradual skin closure was retrospectively analyzed after having been applied in 20 patients with acute compartment syndrome. RESULTS: With the application of this technique, none of the cases required new surgical interventions to close the wound. Closure was reached in an average time of 8.8 days, with an average hospital stay of 10 days and a low rate of complications. CONCLUSIONS: Gradual skin closure using the shoelace technique avoids the use of free skin grafts to close the dermotomy-fasciotomy wounds, reducing the need for anesthesia, nursing care, and hospital stays of patients, resulting in lower healthcare costs.     

Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients

BackgroundTibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds.MethodsA retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure.ResultsOf the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39).ConclusionData from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.