Wound closure by dermatotraction after fasciotomy for acute compartment syndrome

Role of Preoperative Skin Stretching in Single-Stage Wound Closure

Background  Mechanical skin stretching (SS) is now becoming one of the commonly sought after procedures for wound healing. This study was aimed to assess the efficacy of preoperative SS for the closure of large wounds and to evaluate various postoperative outcome parameters. Methodology  An observational study was conducted from December 2017 to May 2019 where a sample size of 30 patients was included with inclusion criteria being wounds of ≥5 cm width that require surgical management, presence of sufficient healthy skin edge of the wound/scar (at least one) for the stretching procedure, and age between 18 and 70 years. SS devices used were the top closure tension relief system. Postoperatively, various parameters were recorded to evaluate outcomes and complications. Results  Majority of wounds that is 16 (53.3%) were <50 cm ² , 9 (30%) were between 50 and 75 cm ² , and 5 (16.7%) were >75 cm ² . The mean duration of stretch was 2.3 ± 0.82 weeks. For 30 wounds treated with staged cycles of wound closure, there was a significant difference between every two visit points, i.e., 10%. The mean patient-reported patient and observer scar assessment scale score was 3.5 ± 0.93. Twenty-five cases (83.3%) had uneventful postoperative recovery. Twenty-seven patients (90%) reported an improved aesthetic outcome. Fourteen patients (46.7%) reported some improvement in function. Conclusion  The study concluded that the SS devices are the simple and effective method for the primary closure of large and challenging wounds and skin defects.

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.

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.

Management of Postfasciotomy Wounds and Skin Defects Following Complex Vascular Trauma to the Extremities Using the External Tissue Extender System

Management of large postfasciotomy wounds and/or skin and soft tissue defects after major vascular trauma to the extremities can be challenging. The External Tissue Extender (Blomqvist; ETE), a skin-stretching device, which consists of silicone tapes and plastic stoppers, approximates wound margins and facilitates delayed primary closure. We describe our experience with the use of ETE in 5 patients (4 males) with a total of 8 wounds (7 postfasciotomy, 1 soft tissue defect) over the past 12 years. The mean patient age was 32 (range 17-61) years. The wounds involved the lower limb in 3 patients and the upper limb in 2, whereas the injured arteries were the popliteal in 3, the axillary in 1, and the brachial in 1. The mean wound length was 24 cm (range 9-37 cm), and the mean number of ETE silicone tapes used per wound was 13 (range 5-19). The median duration of ETE therapy was 7 days (range 4-7). ETE therapy resulted in sufficient wound approximation to allow complete closure with conventional suturing in 7 out of the 8 wounds. Of these, one developed infection that required drainage, debridement, and resuturing. All wounds achieved satisfactory healing status and all limbs had been salvaged. In conclusion, the ETE is a useful, easy-to-use, and simple adjunct that may facilitate delayed primary closure of large postfasciotomy wounds or extensive skin and soft tissue defects following complex vascular trauma to the extremities.

Simple Skin-Stretching Device in Assisted Tension-Free Wound Closure

BACKGROUND

Numerous conventional wound reconstruction methods, such as wound undermining with direct suture, skin graft, and flap surgery, can be used to treat large wounds. The adequate undermining of the skin flaps of a wound is a commonly used technique for achieving the closure of large tension wounds; however, the use of tension to approximate and suture the skin flaps can cause ischemic marginal necrosis. The purpose of this study is to use elastic rubber bands to relieve the tension of direct wound closure for simultaneously minimizing the risks of wound dehiscence and wound edge ischemia that lead to necrosis.

MATERIALS AND METHODS

This retrospective study was conducted to evaluate our clinical experiences with 22 large wounds, which involved performing primary closures under a considerable amount of tension by using elastic rubber bands in a skin-stretching technique after a wide undermining procedure. Assessment of the results entailed complete wound healing and related complications.

RESULTS

All 22 wounds in our study showed fair to good results except for one. The mean success rate was approximately 95.45%.

CONCLUSIONS

The simple skin-stretching design enabled tension-free skin closure, which pulled the bilateral undermining skin flaps as bilateral fasciocutaneous advancement flaps. The skin-stretching technique was generally successful.

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.

Use of a continuous external tissue expander in the conversion of a type IIIB fracture to a type IIIA fracture

Various methods have been used for soft tissue coverage of Gustilo-Anderson type IIIB open fractures. These injuries are often contaminated and, by definition, are associated with extensive periosteal stripping and inadequate soft tissue coverage. These characteristics predispose the patient to infection, delayed union, nonunion, and the likelihood of multiple surgeries to achieve durable soft tissue coverage. Although free tissue transfer and rotational flap coverage are the mainstay of treatment for Gustilo-Anderson type IIIB fractures, these procedures typically require additional modalities, such as local wound care, negative-pressure wound therapy, and skin grafting, to expedite wound coverage. Numerous undesirable aspects of these tissue coverage techniques exist, including the requirement for repeated application, potential anesthesia complications, near-constant surveillance, patient compliance, graft failure, and cost. External tissue expanders offer the surgeon a device that can rapidly facilitate closure of full-thickness soft tissue defects. This technique offers the benefit of a 1-time application that is easy to apply and cost-effective and can significantly improve fracture coverage options with a cosmetically acceptable result. Although this technique has been previously described for fasciotomy and ulcer coverage, to the authors' knowledge, continuous external expansion has never been reported in open fracture wound management, specifically in converting type IIIB to type IIIA open fractures. The authors' early success with this method indicates that it may be a valuable tool in the management of Gustilo-Anderson type IIIB open fractures.

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.

[Evaluation of the external tissue extender (Ete) in secondary wound closure]

BACKGROUND

For surgical closure of large skin defects, elaborate reconstructive plastic surgery or other methods such as internal subcutaneous balloon tissue expanders are required in order to avoid tension on the closure margins. Here we point to the benefits and disadvantages of an improved and simple method of secondary wound closure by secondary sutures.

PATIENTS AND METHODS

We employed a system called External Tissue Extender (ETE), which consists of silicone strings and plastic stoppers pulling the corresponding surgical sites together and evenly distributing the tension. Possible indications in dermatologic surgery and our experiences with this technique are outlined.

RESULTS

Implantation and handling of the ETE are very easy and fast. The functional results are good and the cosmetic outcome satisfactory. More invasive surgical procedures can be avoided by using this method. A major disadvantage is the possibility of developing necrosis under the plastic stoppers.

CONCLUSION

According to our experience, the ETE is a useful alternative indicated in certain dermatosurgical situations.