Does the shoe-lace technique aid direct closure of fasciotomy wounds after acute compartment syndrome of the lower leg? a retrospective case-control study

Treatment of bilateral Posterior Tibial Compartment Syndrome using a Novel Surgical Approach: A Case Report of the Posterior Approach

Osteofascial compartment syndrome is a serious surgical emergency that requires prompt diagnosis and treatment. It presents a challenge for surgeons due to its high disability rate and difficult management. Early fasciotomy decompression is crucial in preventing severe complications. Classic fasciotomy approaches for tibial osteofascial compartment syndrome include double-incision and single-incision techniques.This paper presents a case of a 24-year-old female with bilateral tibial posterior compartment syndrome resulting from prolonged squatting after alcohol intoxication, which is a relatively rare mechanism. We employed an innovative posterior approach to manage the patient with tibial posterior compartment syndrome. Ultimately, we successfully preserved the patient's legs and achieved a good functional recovery.The paper reported a rare case with bilateral posterior tibial compartment syndrome resulting from squatting for 10 hours after alcohol intoxication. The patient achieved favorable outcomes in lower limb function following treatment with a new fasciotomy approach, the posterior approach.The new approach for treating posterior tibial compartment syndrome can serve as a valuable reference for surgeons.

Suprapatellar tibial fracture nailing is associated with lower rate for acute compartment syndrome and the need for fasciotomy compared with the infrapatellar approach

BACKGROUND

Intramedullary tibial nailing (IMN) is the gold standard for stabilizing tibial shaft fractures. IMN can be performed through an infra- or suprapatellar approach.

PURPOSE

The aim of this study is to compare the rate of fasciotomies for acute compartment syndrome between infra- and suprapatellar approaches.

METHODS

A total of 614 consecutive patients who were treated with IMN for tibial fracture between October 2007 and February 2020 were included in the study. The approach used for IMN was determined by the operating surgeon. Infrapatellar IMN was performed with the knee in deep flexion position, with or without calcaneal traction. Suprapatellar IMN was performed in straight or semiflexed position. The diagnosis of compartment syndrome was based on clinical analysis, but for some patients, a continuous compartment pressure measurement was used. The primary outcome was the rate of peri- and postoperative compartment syndrome treated with fasciotomies.

RESULTS

The study sample included 513 patients treated with infrapatellar IMN and 101 patients treated with suprapatellar IMN technique. The mean age of the patients was 44.7 years (infrapatellar technique) and 48.4 years (suprapatellar technique). High energy trauma was seen in 138 (27%) patients treated with infrapatellar technique and in 39 (39%) patients treated with suprapatellar technique. In the suprapatellar group (n = 101), there were no cases of peri- or postoperative compartment syndrome treated with fasciotomies. In the infrapatellar group (n = 513), the need for fasciotomies was stated in 67 patients, 31 patients (6.0%) perioperatively and in 36 patients (7.0%) postoperatively. The rate of fasciotomies (0/101 versus 67/513 cases) differed significantly (p < 0.001). There were no significant differences in the fracture morphology or patient demographics between the study groups.

CONCLUSIONS

The suprapatellar technique is recommended over the infrapatellar approach in the treatment of tibial shaft fractures. The rate of peri- and postoperative compartment syndrome and the need for fasciotomies was significantly lower with the suprapatellar technique. The major cause of increased rate of peri- or postoperative acute compartment syndrome with infrapatellar IMN technique is presumably associated with the positioning of the patient during the operation.

LEVEL OF EVIDENCE: 3

Suturing Dermatotraction Techniques in Closing Fasciotomy Wounds: A Systematic Review

A surgical patient post-fasciotomy presents a challenge to restore the cover of the muscle groups, and the use of the suturing dermatotraction techniques presents a cheap and easy means of native cover. This systematic review of case series and case-control study explored the trend of this technique, including duration of delayed primary wound closure, complications, and failure rates. A literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted on Medline, Embase, and Cumulative Index of Nursing and Allied Health Literature (CINAHL), yielding a combined total of 820 articles between 1946 and June 18, 2022. Human studies with suturing dermatotraction techniques were included. Sixteen (16) studies reviewed met the criteria. The basic anatomy of the dermatotraction technique involves an anchor point on the skin, a material for traction, and a suture pattern. The shoelace technique was the predominant suture pattern, with staples as skin anchor material/method and silastic vessel loops as traction sling used by 11 studies. Modifications of this method included the use of intradermal Prolene sutures and pediatric catheters. The shortest duration for skin apposition was two days, and the longest was 113 days. Complications were comparable to that of surgical wounds and thus may not be attributable to the technique itself. Studies reviewed showed that superficial and early complications were more likely than deep or delayed complications. Negative pressure wound therapy (NPWT) and skin graft salvaged a few failed closures in two studies. There are varying practices of tightening rates with reports ranging from daily to every 72 hours. The rate of tightening and disease burden may account for the wide range of reported delayed primary closure. Most of the studies reviewed closed fasciotomy wounds with this technique within an average of <10 days. It is relatively cheaper, carries a low morbidity burden, and has multiple reported success in the closure of fasciotomy wounds in this review and thus should have an increased adoption as a first approach in managing fasciotomy wounds, especially in low-income countries.

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.