A simple device for closure of fasciotomy wounds

The efficacy of the Bogota Bag technique for wound closure in limb fasciotomy patients: a prospective cohort study

PURPOSE

Fasciotomy is a surgical procedure that involves the incision of fascial compartments in the body to relieve pressure, prevent tissue damage, and maintain blood flow. This study aimed to investigate the effectiveness of the Bogota Bag technique in closing fasciotomy wounds in patients with lower limb compartment syndrome.

METHODS

A prospective cohort study was conducted between October 2022 and October 2023 to document our experience in employing the Bogota Bag technique for fasciotomy closure. The study included the evaluation of medical files from fifteen patients aged 17 to 61.

RESULTS

The outcomes of the study present the initial series of limb fasciotomies treated with the Bogota Bag technique. Fifteen patients (14 male, 1 female) were included in the study. The average age of the patients was 34.73 ± 13.9 years and the average hospitalization was 8.33 ± 3.2 days. The average closure time of fasciotomy is 3.6 ± 1.4 days.

CONCLUSION

This report makes a significant contribution as the first documented series of limb fasciotomies treated with the Bogota Bag technique. This method exhibits simplicity in execution, cost-effectiveness, and a low incidence of complications.

Principles of Fasciotomy Closure After Compartment Syndrome Release

Acute compartment syndrome is a surgical emergency in the extremities resulting from increased compartmental pressure, requiring immediate fasciotomy to resolve muscular compromise. As the mainstay treatment, fasciotomies involve substantial skin incisions and are thus prone to complications such as skin necrosis, wound infection, and permanent disability. Multidisciplinary care instituted at the time of fasciotomy can facilitate timely closure and minimize the complication profile. Several approaches are available to enhance outcomes of fasciotomy wounds, and a comprehensive knowledge of these options affords the treating surgeon greater flexibility and confidence in optimal management. Common techniques include early primary closure, gradual approximation, skin grafting, and negative pressure therapy. There is currently no consensus on the best method of closure. The purpose of this study was to review fasciotomy wound management from the time of initial release to final closure. Highlights include preparation for closing these wounds; the various techniques for fasciotomy closure, including adjunct options; evaluation of timing and staging; and injury-specific features, such as fracture management, limited subcutaneous tissues, and hand fasciotomies. Combining the perspectives of orthopaedic and plastic surgery, this review evaluates the benefits of multiple closure methods and highlights the importance of planning closure at the time of release.

Pediatric Wound Closure by a Tension-Relief System

Surgical reconstruction in pediatric patients can often be complex. Primary wound closure is almost always the preferred technique in the reconstructive ladder; however, it is not always possible in pediatric patients. We report the pediatric use of the TopClosure Tension-Relief System, an innovative skin-stretching technique for secure primary wound closure of large defects. We modified the technique by fixating it to a protective dressing instead of the patient's skin, thus avoiding both staple scars and pain. A retrospective review of 112 patients aged 7 days to 18 years who underwent Tension-Relief System-assisted surgery at a tertiary medical center from 2010 to 2020 was conducted. Cases included congenital deformities, traumatic wounds, burn scars, and complicated-wounds, with or without hardware or deep tissue exposure. The use of the system avoided the need for multiple surgical sessions and for local or regional flaps. The technique was simple to use, with few complications, and led to satisfactory aesthetic and functional outcomes. The findings support using the technique in children and adolescents with challenging tension wounds. Herein, we report on our experience with the Tension-Relief System and detail four cases in which early or immediate closure was successfully achieved.

Closure of Challenging Pediatric Scalp Wounds by a Tension-Relief System

ABSTRACT

Pediatric scalp defects may be challenging, due to their variant tension level and specific etiologies. Tissue characteristics and pre- and post-management considerations may pose difficulties to reconstruction in the pediatric patient. Primary closure is the preferred surgical technique but is not always possible. Various techniques have been described for facilitating primary wound closure, by reducing tension from the skin wound margins. The authors use a tension-relief system in some challenging scalp wounds when simple primary closure cannot be achieved. This enables primary closure without tension on the surgical margins, and may thus preclude the need for other closure techniques such as tissue-expanders, grafts, and flaps. The authors describe our use of a tension-relief system in 21 pediatric patients treated during 2017-2020, for congenital deformities, vascular malformations and other skin lesions, traumatic wounds, burn scars, and complicated surgical wounds with and without hardware exposure. A tension-relief system is a prompt, simple-to-use, safe, and low-cost surgical solution that offers several advantages over other techniques when tension-free primary intention closure is not possible. These benefits include less extensive surgery, fewer surgeries and associated anesthesia, shorter treatment period and hospitalization, better scarring, lower distress and burden to patients and their families, better pain-control, the absence of donor-site with its comorbidities, and less bleeding and risk of damaging adjacent structures. Based on our experience and the system characteristics detailed, the authors recommend using the described technique, which is convenient, accessible, and reliable, to close challenging scalp wounds in pediatric patients.

Primary Closure of Wide Fasciotomy and Surgical Wounds Using Rubber Band-Assisted External Tissue Expansion: A Simple, Safe, and Cost-effective Technique

BACKGROUND

Although decompressive fasciotomy is a limb-saving procedure in the setting of acute compartment syndrome, it leaves a large wound defect with tissue edema and skin retraction that can preclude primary closure. Numerous techniques have been described to address the challenge of closing fasciotomy wounds. This study reports our experience with fasciotomy closure using rubber bands (RBs) for external tissue expansion.

METHODS

Patients were informed about RB closure and split-thickness skin graft options. Only patients who opted for RB closure and had wounds that could not be approximated using the pinch test underwent the procedure. Starting from the apex and progressively advancing, the RBs were applied to the skin edges at 3 to 4 mm intervals using staples. The RBs were advanced by twisting back-and-forth to create a criss-cross pattern. One week after application, fasciotomy wounds were closed primarily or underwent further RB application, based on clinical assessment of adequacy of skin advancement, compartment tension, and perfusion. Review of a prospectively maintained database was performed, including demographics, comorbidities, etiology, wound and operative details, hospital stay, and complications.

RESULTS

Seventeen consecutive patients with 25 wounds (22 fasciotomy and 3 other surgical wounds) were treated using the RB technique. Average wound length and width measured 15.7 cm (range, 5-32 cm) and 5.2 cm (range, 1-12 cm), respectively. Locations of wounds included forearm (n = 12, 48.0%), leg (n = 7, 28.0%), hand (n = 4, 16.0%), elbow (n = 1, 4.0%), and hip (n = 1, 4.0%). Eighteen of 25 wounds (72.0%) were closed primarily after 1 RB application. Additional RB application was required for 5 wounds to achieve primary closure. Between stages, patients were discharged home if they did not have other conditions requiring in-hospital stay. No complications were observed, and no revision surgeries were required. Patient satisfaction was 100%, and all indicated that they would choose the RB technique over skin grafting.

CONCLUSIONS

The modified RB technique is a simple, safe, and cost-effective alternative for treating fasciotomy and other surgical defects resulting in high patient satisfaction and good cosmetic outcome, without the need for split-thickness skin graft or flap coverage.

Tissue expanders with a focus on extremity reconstruction

INTRODUCTION

Acute traumatic or surgical wounds that cannot be primarily closed often cause substantial morbidity and mortality. This often leads to increased costs from higher material expenses, more involved nursing care, and longer hospital stays. Advancements in soft tissue expansion has made it a popular alternative to facilitate early closure without the need for more complicated plastic surgical procedures.

AREAS COVERED

In this review, we briefly elaborate on the history and biomechanics of tissue expansion and provide comprehensive descriptions of traditional internal tissue expanders and a variety of contemporary external tissue expanders. We describe their uses, advantages, disadvantages, and clinical outcomes. The majority of articles reviewed include case series with level IV evidence. Outcome data was collected for studies after 1990 using PubMed database.

EXPERT COMMENTARY

An overall reduction in cost, time-to-wound closure, hospital length-of-stay, and infection rate may be expected with most tissue expanders. However, further studies comparing outcomes and cost-effectiveness of various expanders may be beneficial. Surgeons should be aware of the wide array of tissue expanders that are commercially available to individualize treatment based on thorough understanding of their advantages and disadvantages to optimize outcomes. We predict the use of external expanders to increase in the future and the need for more invasive procedures such as flaps to decrease.

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.

Fasciotomy closure techniques

We evaluated the risks and success rates of the three major techniques for compartment syndrome fasciotomy closure by reviewing all literature published to date. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically evaluated the Medline (PubMed) database until July 2015, utilizing the Boolean search sting "compartment syndrome OR fasciotomy closure." Two authors independently assessed all studies published in the literature to ensure validity of extracted data. The data was compiled into an electronic spreadsheet, and the wound closure rate with each technique was assessed utilizing a proportion random model effect. Success was defined as all wounds that could be closed without skin grafting, amputation, or death. The highest success rate was observed for dynamic dermatotraction and gradual suture approximation, whereas vacuum-assisted closure had the lowest complication rate.

How to Close a Limb Fasciotomy Wound

Early fasciotomy is the gold standard of prevention and treatment of compartment syndrome; however, the resulting wounds may significantly increase morbidity. To address the challenge of timely and safe closure of fasciotomy wounds, numerous methods have been described. A thorough search of medical databases PubMed/MEDLINE, ScienceDirect, SCOPUS, EMBASE, and Google Scholar was conducted for articles published between 1976 and 2013 using the search terms “limb fasciotomy wound closure,” “open wound management,” “skin stretching,” and “fasciotomy complications.” A total of 49 articles on technique descriptions, case reports of 2 or more patients, and of complications and comparative studies regarding limb fasciotomy wound closure were included. Details of the duration of treatment, advantages and disadvantages, direct cost, and complications were data extracted for each technique from the 49 studies included in this overview. Thorough knowledge of available techniques and their comparative advantages is essential for their clinical implementation, careful selection of patients, management of possible complications, decreased morbidity, and hospital recovery time and is also crucial for optimization of functional and aesthetic outcomes.

Wound closure of leg fasciotomy: comparison of vacuum-assisted closure versus shoelace technique. A randomised study

BACKGROUND

Fasciotomies, though essential for the prevention and management of compartment syndromes, may increase morbidity and prolong hospitalisation. Two widely applied methods of delayed primary closure are compared in leg fasciotomy wounds.

PATIENTS AND METHODS

Two groups, each of 25 patients with leg fasciotomies due to fractures and soft tissue injuries, who were randomly assigned to be treated either by vacuum assisted closure (VAC®, n=42 wounds, group V) or by the shoelace technique (n=40 wounds, group S), were evaluated in this study. Wound length, time to definite closure, complications, need for additional interventions and daily treatment costs were data collected and statistically assessed.

RESULTS

Wound closure time was significantly higher in group V compared to group S (p=0.001; 95% CI of the difference, 1.8-6.3 days). Five group V patients required split thickness skin grafts. In six group S patients, the vessel loops had to be replaced. The mean daily cost of negative pressure therapy alone was 135 euro (range 117-144 euro), whilst the mean daily cost of treatment for the shoelace technique was 14 euro ranging from 8 to 18 euro (p=<0.001).

CONCLUSIONS

Both VAC® and the shoelace technique are safe, reliable and effective methods for closure of leg fasciotomy wounds. VAC® requires longer time to definite wound closure and is far more expensive than the shoelace technique, especially when additional skin grafting is required.

Elevation as a treatment for fasciotomy wound closure

There are currently numerous techniques described in the literature that attempt to optimize wound closure following a fasciotomy. However, primary closure of fasciotomy wounds continues to be difficult to accomplish successfully because of the underlying edema sustained from the compartment syndrome. The approach described in the present report is simple and physiologically sound, and addresses the underlying pathology. The authors focus on alleviating edema by strictly elevating the limb, followed by primary closure. Twelve consecutive fasciotomy wounds, referred from 2005 to 2012, were closed using this approach. The average wound closure time was 3.4 days (range three to five days) following the initial consultation. All 12 fasciotomy wounds responded with no revisions, complications, failures or loss of skin sensation. The approach was successful in all anatomical locations that were closed and conversion to any techniques currently available in the literature was not necessary. There are no costs associated with this approach, making it practical in settings with limited resources. It has a high success rate, superior cosmetic results and, most importantly, it achieves an efficient closure time. Therefore, this approach is superior to current techniques and should be a part of a plastic surgeon's armamentarium.

Vessel loop closure technique in open fractures and other complex wounds in the foot and ankle

A gaping wound of the foot and ankle can be difficult to close. In cases in which wound margin mobility is suitable, the use of a vessel loop, or loops, to provide sufficient tension for wound margin reapproximation can be a useful adjunct to the surgical management of wounds that would otherwise be very difficult to close without the use of a skin graft or flap coverage. In this report, we describe the use of a vessel loop, or loops, for reapproximation of the margins of gaping wounds of the foot or ankle.

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.

Acute limb compartment syndrome: a review

Acute limb compartment syndrome (LCS) is a limb-threatening and occasionally life-threatening condition caused by bleeding or edema in a closed muscle compartment surrounded by fascia and bone, which leads to muscle and nerve ischemia. Well-known causative factors are acute trauma and reperfusion after treatment for acute arterial obstruction. Untreated compartment syndrome usually leads to muscle necrosis, limb amputation, and, if severe, in large compartments, renal failure and death. Alertness, clinical suspicion of the possibility of LCS, and occasionally intracompartmental pressure (ICP) measurement are required to avoid a delay in diagnosis or missed diagnosis. Open fasciotomy, by incising both skin and fascia, is the most reliable method for adequate compartment decompression. The techniques of measuring ICP have advantages and disadvantages, whereas the pressure level that mandates fasciotomy is controversial. Increased awareness of the syndrome and the advent of measurements of ICP pressure have raised the possibility of early diagnosis and treatment. This review reports LCS, including etiology, pathophysiology, diagnosis, ICP measurement, management, and outcome.

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.

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.

Acute compartment syndromes

BACKGROUND

Acute compartment syndrome is both a limb- and life-threatening emergency that requires prompt treatment. To avoid a delay in diagnosis requires vigilance and, if necessary, intracompartmental pressure measurement. This review encompasses both limb and abdominal compartment syndrome, including aetiology, diagnosis, treatment and outcome.

METHODS

A Pubmed and Cochrane database search was performed. Other articles were cross-referenced.

RESULTS AND CONCLUSION

Diagnosis of limb compartment syndrome is based on clinical vigilance and repeated examination. Many techniques exist for tissue pressure measurement but they are indicated only in doubtful cases, the unconscious or obtunded patient, and children. However, monitoring of pressure has no harmful effect and may allow early fasciotomy, although the intracompartmental pressure threshold for such an undertaking is still unclear. Abdominal compartment syndrome requires measurement of intra-abdominal pressure because clinical diagnosis is difficult. Treatment is by abdominal decompression and secondary closure. Both types of compartment syndrome require prompt treatment to avoid significant sequelae.

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.

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 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.

Raised intracompartmental pressure and compartment syndromes

Raised intracompartmental pressure (ICP) has become recognized as the final common pathway of a variety of pathologies which lead to failure of the microcirculation with resultant tissue hypoxia and cell death. While commonly seen after trauma, either accidental or operative, raised ICP may result from either an increase in the volume of tissue within a closed osseo-fascial or fascial compartment or by the application of an external force compressing a compartment, and it is associated with a wide variety of insults. The advent of reproducible techniques of measuring ICP has added science to a well-recognized clinical picture and allowed a rational approach to management. Controversies still remain, particularly in regard to the level of pressure at which intervention becomes mandatory, and the role of prophylactic interventions. This review attempts to present current thinking on the pathophysiology of the microcirculation and the background to these controversies.