Acute compartment syndrome (ACS) is a surgical emergency with significant morbidity caused by increased pressure in an extremity that develops following crush injuries.1 The main underlying cause is an ischemia-reperfusion injury, when an initial restriction of blood supply to an organ during injury is followed by rapid perfusion and concomitant reoxygenation. The muscles in the affected extremity may develop edema, resulting in fluid extravasation or inflammatory responses.2 The rapid increase in intracompartment pressure may lead to ACS.
Delayed diagnosis of ACS can lead to irreversible ischemia of the nerve fibers and muscle fascicles in the extremity, resulting in a disabled extremity or extremity loss.3 However, early diagnosis and rapid management of ACS can often lead to full recovery. A fasciotomy of the affected compartments to relieve tension and pressure is the only known treatment.4
In a fasciotomy, the retraction of the skin, even after the recession of the edema, precludes primary closure. Usually, closure requires a second intervention. Many skin closure techniques have been described, including dermatotraction, skin grafts, negative-pressure wound therapy (NPWT) assisted skin closure, and shoelace techniques.5,6 Because wound complications are common after these techniques, there is broad interest in alternative closure methods,7 and there is no consensus on an optimal technique for fasciotomy wound closure.8 These authors hypothesized that wound closure with the shoelace technique plus NPWT could decrease wound complications.
The shoelace technique involves the placement of tensioning devices across the wound (elastic vessel loops or sutures) that provide a continuous pull on wound margins and are intermittently tightened without replacement or the need for anesthesia.9 Complementing these efforts, NPWT prompts primary closure through induced cell division and ensuring that the tension is equally applied to the entire wound area, thereby preventing retraction.10 This article aims to present a useful method involving both techniques for wound management after fasciotomy for ACS.
The protocol for this study was approved by the local ethics committee, and informed consent was obtained from all patients, including permission to publish any associated photographs. The research took place at the Kartal Dr Lütfi Kirdar Training and Research Hospital, a public tertiary teaching hospital affiliated to the University of Health Sciences, Istanbul, Turkey. This prospective study included a series of patients with ACS related to extremity fractures and/or blunt injuries treated with fasciotomies managed by NPWT (V.A.C. Therapy; KCI, San Antonio, Texas) and the shoelace technique between May 2017 and May 2018. All of the patients were referred to the orthopedics and traumatology department by emergency physicians after suspicion of ACS. The diagnoses were made clinically.
The inclusion criteria were (1) open fasciotomy needed immediately after initial diagnosis, (2) manageable local and/or systemic infection, and (3) admitted within 8 hours of the reported time of injury. The exclusion criteria were patients with (1) concomitant extremity burns, (2) amputations, (3) severe soft tissue loss, (4) head injury, (5) history of peripheral vascular disease, (6) uncontrolled diabetes, (7) cardiovascular disease, or (8) drug abuse and immunosuppression.
All of the surgeries were performed by the same surgeon. For leg fasciotomies, a standard dual medial-lateral incision was performed to release all four compartments. For thigh fasciotomies, a single anterolateral incision over the length of thigh was performed to release anterior and posterior compartments. For foot fasciotomies, standard dual dorsal and mini-medial incisions were performed to release all nine compartments.
Elastic vessel loops (SURGI-LOOP; Scanlan, Minneapolis, Minnesota) were applied to both wound margins in a shoelace pattern. The vessel loops were anchored using skin staples approximately 1 cm away from the wound margin so as not to endanger the skin flap marginal circulation (Figure 1). The vessel loops were pulled until the capillary refills of the wound margins disappeared. The tightening was continued for approximately 10 minutes, and then the capillary circulation of the skin margins was evaluated. If there was continuous absence of capillary circulation, the vessel loops were loosened by a few centimeters. This tightening was repeated until the skin flaps reached maximum tension through vessel loop traction with proper capillary circulation of both wound flap margins.
A sponge cut to the exact width of the wound was placed under the vessel loops to avoid skin maceration (Figure 2). Transparent surgical drapes were placed over the sponges (Figure 3), and the wounds were covered with the NPWT device. The pressure of the NPWT device was set at a continuous 100 mm Hg. The clinic’s surgical assistant changed the NPWT device every second day and tightened the shoelace traction tension at the same time. The NPWT was used until complete wound closure in all patients. In patients with tension-free skin margin approximation after NPWT, the fasciotomy wounds were closed directly with sutures (Figure 4).
The study included seven patients with nine fasciotomy wounds involving the leg, foot, or thigh. Patient demographic data and clinical results are summarized in the Table. The mean age was 24.9 years (range, 5–59 years), and the mean time from fasciotomy to wound closure was 11.8 days (range, 5–30 days). The mean time from injury to fasciotomy was 3.6 hours (range, 2–5 hours) with a mean initial wound width of 7.2 cm (range, 4.2–13.5 cm). There was no skin flap necrosis in any patient. No skin grafts or flaps were required.
All of the patients were followed up for 1 year. During the follow-up period, all of the patients achieved direct wound closure and showed satisfactory outcomes without any wound complication. Two patients presented with signs and symptoms of local infection, which were managed with antibiotics. There were no residual skin defects in any patient.
Current literature defines ACS as “an increase in intracompartmental pressure causing a decrease of perfusion pressure, leading to hypoxemia of the tissues.”4 Most cases of ACS are associated with traumatic injuries, but the condition also occurs after prolonged limb compression, reperfusion, and following a period of ischemia. Tibial diaphyseal (40%) and forearm (18%) fractures are the most common fractures that cause ACS, but it may also be seen in some soft tissue injuries (23%).11,12 Of the nine ACS cases in this series, only four had fractures. Most of extremities (n = 5) had only soft tissue injuries.
There have been occasional reports of cases and case series in the literature related to the shoelace technique plus NPWT closure in fasciotomy wounds, especially in recent years. Kakagia et al13 stated that both NPWT and the shoelace technique are effective, safe, and reliable methods for closure of fasciotomy wounds. However, they also reported a longer time to definite skin closure using the shoelace technique (mean, 19.1 days) compared with NPWT (mean, 15.1 days). In the current study, the shoelace technique plus NPWT provided skin closure in mean 11.8 days. It appears that the combination of both techniques shortens the time to skin closure. That said, Kakagia et al13 found that NPWT alone is more expensive than the shoelace technique, especially when additional skin grafting is required. In the present case series, there was no control group with which to compare cost of treatment. However, the combination of the two techniques may be cost-effective, considering that it may prevent complications and additional surgical interventions.
Previous studies including adult patients who received a fasciotomy for postburn ACS have reported that NPWT can increase the rate of primary closure, and the rate of skin grafting was 16.5% to 28.6%.14,15 Further, Mittal et al16 found that patients who underwent NPWT-assisted closure were at higher risk of skin grafting than patients who underwent vessel loop closure. In the current study, no patient needed skin grafting, so it is possible that NPWT alone may not sufficiently reduce the need for skin grafting, whereas the shoelace technique plus NPWT may do so. Of course, skin grafting remains an important method of wound closure, but the need for skin grafting may be reduced by the combination of techniques applied in this study.
The major limitations of this study were the lack of a control group and a lack of generalizability because of the small case series size. Another potential limitation was the clinical diagnosis of ACS.
The use of the shoelace technique plus NWPT may be a suitable alternative for current fasciotomy wound closure techniques. Further study with larger patient cohorts and a control group is required to determine the precise clinical effectiveness of this technique and clarify the patient group(s) that would most benefit from its use.
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