A new look at the various options available

 A review article recently published in JAAOS by Shafic S. et al reviewed the challenges and options available to surgeons when attempting to close a fasciotomy. Here we summarize the key points from which this comprehensive review highlights the careful planning and techniques required to ensure successful outcomes.

Fasciotomies are crucial surgical interventions used to treat acute compartment syndrome (ACS), a condition where increased pressure within a muscle compartment can lead to muscle and nerve damage. ACS is a medical emergency often triggered by severe injuries, fractures, or vascular events. This increased pressure can cut off blood flow, resulting in tissue necrosis.

Immediate fasciotomy is necessary to relieve the pressure and restore perfusion, but the procedure itself creates large wounds that require meticulous management and proper closure to prevent complications like infection and skin necrosis.

Preparing for Fasciotomy Closure

Proper planning for wound closure should begin at the time of the fasciotomy. At this stage, key considerations include incision placement and postoperative care. Choosing the right location for the fasciotomy incisions is crucial. Preferred sites are selected to optimize access to muscle compartments, minimize the risk of contractures, and facilitate easier extension if needed. Immediately after the fasciotomy, the limb should be elevated to reduce edema, and a splint should be applied to prevent contractures and optimize patient comfort.

Techniques for Fasciotomy Closure

Healing by Secondary Intention

  • Approach: Allowing the wound to heal naturally without surgical closure.
  • Indications: Suitable for wounds without exposed bone or implants, particularly in infected wounds.
  • Care: Frequent dressing changes and the use of negative pressure wound therapy (NPWT) can facilitate healing.

Early Primary Closure

  • Approach: Closing the wound within 48 to 72 hours if the wound base is clean and edema is minimal.
  • Indications: Best for traumatic, non-infected wounds that meet specific clinical criteria.

 Mechanical Dermatotraction Devices:

  • Approach: These devices, such as the DERMACLOSE, apply continuous external tissue expansion, promoting gradual wound closure
  • Advantages: These systems can reduce the need for frequent adjustments and can be more cost-effective

 Gradual Wound Approximation

  • Techniques: Methods like the “shoelace” technique involve gradually tightening sutures or vessel loops to approximate wound edges over time.
  • Benefits: These techniques can reduce the size of the wound and prepare it for final closure or skin grafting.

Skin Grafting:

  • Approach: Using split-thickness skin grafts to cover large wounds that cannot be closed primarily.
  • Indications: Essential for wounds that have been open for an extended period and where gradual approximation alone is insufficient.

Negative Pressure Wound Therapy (NPWT):

  • Benefits: NPWT enhances wound healing by promoting blood flow, reducing edema, and preparing the wound for eventual closure or grafting.

Effective management of fasciotomy wounds requires a multidisciplinary approach and a thorough understanding of various closure techniques. The choice of method should be tailored to the specific clinical scenario, with the goal of optimizing patient outcomes and minimizing complications.

For more detailed information on the principles and techniques of fasciotomy closure, see the article here: https://journals.lww.com/jaaos/fulltext/2022/09150/principles_of_fasciotomy_closure_after_compartment.2.aspx