Singh N, Bluman E, Starnes B, Andersen C.
Am Surg. 2008 Mar;74(3):217-20.
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.
Taylor RC, Reitsma BJ, Sarazin S, Bell MG.
J Am Coll Surg. 2003 Nov;197(5):872-8.
Fasciotomy incisions, which are usually performed for compartment syndrome, cannot be closed primarily because of excessive tension across the wound secondary to post-ischemic swelling of the extremity. Split-thickness skin grafting, the conventional method of fasciotomy closure, is effective but it results in an insensate and cosmetically unappealing wound and is associated with donor site morbidity.
Skin has several unique and useful properties that allow for delayed primary closure of wounds despite large tissue defects or significant retraction. These biomechanical properties, which include inherent extensibility and mechanical and biological creep, have been exploited by a variety of techniques for delayed primary closure of fasciotomy wounds. The vessel loop shoelace technique, use of the Sure-Closure skin-stretching device (Comesa), use of a prepositioned cutaneous suture, and several other techniques have shown reasonable wound closure rates and wound cosmesis, but have been criticized because they are expensive, cumbersome to apply and to tighten, or are associated with increased compartment pressures and skin edge necrosis.