Introduction and background
The surgeon, when faced with an acute limb due to compartment syndrome, faces two critical challenges: the emergent need to decompress the compartment syndrome by performing a fasciotomy and the inevitable need to promptly return superficial closure to the muscle groups as close as possible to their natural state or else risk the antecedent complications of loss of skin coverage and its highly revered role as the first line of defense against infections and maintenance of homeostasis of the underlying tissue. A surgical patient post-fasciotomy thus presents a challenge to restore the cover of the muscle groups [1,2].
It is much accepted that wounds ought to be covered as soon as reasonable to prevent complications from arising [3,4]. There are however various methods in the surgeon’s armamentarium to deploy to close the wound. The use of the suturing techniques presents a cheap and easy means of closing fasciotomy wounds; it is also a basic surgical skill to develop [5-7].
The use of the suturing dermatotraction techniques presents a cheap and easy means of native cover [8]. This systematic review of case series and case-control study explored the trend of this technique, particularly the duration of delayed primary wound closure, complications, and failure rates.
Review
Methods
The inclusion and exclusion criteria were tailored to answer the questions of this review, which centered on finding out the trend and practice of the use of dermatotraction techniques using sutures in the existing literature and identifying successes associated with this practice and complications. To this end, all studies included were human studies in patients who had undergone a fasciotomy procedure for the management of an acute limb compartment syndrome. There was no exclusion based on the limb affected. Furthermore, these studies had to have had a dermatotraction technique as one of their means of closure of fasciotomy wounds. Textbooks, letters to editors, commentaries, review studies, case series involving <2 patients, and single case reports were excluded; however, their bibliographies were consulted to ensure all eligible articles were captured. All articles reviewed and retrieved were in English.
A thorough literature search was conducted between 1946 and June 18, 2022, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principles. The search strategy was based on MEDLINE using the Medical Subject Headings (MeSH) terms wound closure techniques, suture techniques, sutures, and fasciotomy; these were then adapted to other databases of Embase and Cumulative Index of Nursing and Allied Health Literature (CINAHL) via OVID (Appendices). Titles and abstracts were screened by two contributors in a blinded approach using the predetermined inclusion and exclusion criteria; studies meeting these criteria were further reviewed in full text. In cases of a conflict of literature selection, a third contributor re-reviewed and made a final decision. The search yielded a total of 820 articles after removing duplicated articles, and 16 articles met the criteria for full-text review (Figure 1).
Figure 1
PRISMA flowchart
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses, CME: continuing medical education
Results
In keeping with the aims of the project, we identified the suturing dermatotraction technique used and the average number of days to achieve closure, including the range, as well as additional methods used to close wounds, complications, and if there was complete fasciotomy closure in most cases, i.e., >50%. Studies were published between 1993 and 2021. There were 14 case series, one case-control study, and one RCT (Table 1).
Table 1
Results of the literature search
NWPT: negative pressure wound therapy
| Author | Year | Number of patients | Study type | Suture/traction material used | Suturing dermatotraction technique | Average duration to achieve closure | Range to achieve closure (days) | Complete wound closure achieved in most patients | Add-on method ab initio | Additional method needed to close wound(s) | Record of failed fasciotomy wound closure | Recorded complications | Rate of tightening |
| Zorrilla et al. [9] | 2005 | 20 | Retrospective case series | Vessel loops | Shoelace with surgical staples at 1.5-2 cm intervals | 8.8 days | 6-19 days | Yes | No | No | No | 5% retractile scar causing limitation to the passive extension of the joint proximal to the scar | 48 hours |
| Kakagia [6] | 2014 | 25 | Prospective case series | Vessel loops | Shoelace with surgical staples | 15.1 days | 11-30 days | Yes | No | No | No | 16% infection with Staphylococcus epidermidis, Pseudomonas, and Acinetobacter baumannii | Daily |
| Asgari et al. [10] | 2000 | 37 | Case series | Vessel loops | Shoelace with surgical staples at 1 cm intervals and 0.3-0.5 cm from the wound edge | 12 days | Equal/lesser than 3 weeks | Yes | No | Use of surgical staples or 3.0/4.0 nylon suture after the vessel loop had been removed | No | No | Daily |
| Eid et al. [11] | 2012 | 17 | Case series | Pediatric urinary catheter and surgical skin staples | Shoelace with staples | 3.8 weeks | No data | Yes | No | Dynamization and bone grafting in eight patients either to assist in the healing of the fracture or remove the implant (intramedullary nail) | No | No | 48-72 hours |
| Chiverton et al. [12] | 2000 | 6 | Case series | 4/0 nylon sutures and 2/0 or 6/0 Prolene sutures | Interrupted vertical mattress nylon technique and subcuticular Prolene technique | Not clear | 1-3 days | Yes | No | No | No | No | Not specific |
| Johnson et al. [13] | 2018 | 5 | Randomized controlled trial | Not clear | Shoelace with surgical staples | 7.6 days | No data | Yes | No | No | No | No | 48 hours |
| Suomalainen et al. [14] | 2021 | 47 | Retrospective case series | Vessel loops | Shoelace with surgical staples at 0.5 cm from the wound edge | 5.9 days | 2-19 days | Yes in 36 patients | No | No | Yes in 11 patients, free flap used as an intervention | Infection | Daily |
| Arumugam et al. [15] | 2020 | 8 | Prospective case-control study | Vessel loops | Shoelace with surgical staples | 7 days | 6-10 days | Yes | No | No | No | No | 48-72 hours |
| Ozyurtlu et al. [16] | 2014 | 5 | Case series | Barbed suture | Intradermal, horizontal mattress | 8.6 days | 6-14 days | Yes | No | No | No | One case of skin necrosis | 48-72 hours |
| Fowler et al. [17] | 2012 | 49 | Retrospective case series | Vessel loops | Shoelace with surgical staples | 19.2 days in admission (days stated as the duration of admission) | 3-113 days in admission (days stated as the duration of admission) | Yes | No | No | Yes in nine patients | 6.67% infection (three patients) | Not specific |
| Dodenhotf et al. [18] | 1997 | 20 | Case series | Vessel loops | Shoelace with surgical staples | 6 days | 4-10 days | Yes | No | No | Yes in one patient, free flap used as an intervention | None | Not specific |
| Harris [19] | 1993 | 5 | Case series | Vessel loops | Shoelace with surgical staples at intervals of 1.5- 2 cm | 9 days | 7-11 days | Yes | No | No | No | No | Not specific |
| Zenke et al [20] | 2014 | 5 | Case series | Vessel loops | Shoelace with surgical staples | 16.2 days | 9-27 days | Yes | Yes (NPWT) | No | Yes in one patient, skin graft used as an intervention | Yes, partial wound necrosis | Not specific |
| Eceviz et al. [21] | 2020 | 7 | Case series | Vessel loops | Shoelace with surgical staples | 11.8 days | 5-30 days | Yes | No | No | Yes, NPWT used as an intervention | Wound infection | 48 hours |
| Mittal et al. [22] | 2018 | 25 | Comparative case series | Ethilon suture | Shoelace with corrugated drains | 10 days | Not stated | Yes | No | No | Yes in one patient | Wound infection | Not specific |
| Janzing et al. [23] | 2001 | 10 | Case series | Vessel loop (5), monofilament (5) | Shoelace with staples, prepositioned sutures | 9 days | Not stated | Yes | No | No | No | Delayed compartment syndrome (one patient) | Not specific |
Discussion
Suturing Style
The basic anatomy of the dermatotraction suture technique involves an anchor point on the skin/through the skin, a material with properties that enable traction, and a knotting pattern that enables uniform application of traction forces through the pulleys (Figure 2) [24,25]. There are various modifications to this architecture, and various authors have come up with their own adaptations in case reports [26]. The intervals of staples were between 1 and 2 cm in some studies, and the distance from the staples to the wound edge was reported as 0.3-0.5 cm in other studies.
Figure 2
Anatomy of the shoelace technique
The shoelace technique as described was the predominant knotting pattern, with staples as the predominant skin anchor material/method and silastic vessel loops as the predominant traction sling used by 11 studies. Varying modifications of this method included the use of a pediatric urinary catheter as the sling for traction and surgical staples, nylon sutures, Prolene sutures, and barbed suture, with a subcuticular, interrupted vertical and horizontal mattress technique as combinations of both anchor and stretching material, and the use of shoelace with corrugated drains using Ethilon sutures for dermatotraction, all in single cases. In one case, an add-on technique using surgical staples after the removal of the vessel loop was employed; in another, bone grafting was used as it suited the cohort of patients being treated; and in one study, a combination with NWPT ab initio was used.
The rate of tightening was reported as daily in three studies, every 48 hours in three studies, and 48-72 hours in three studies. Other studies used terms such as gradual tightening, which would appear subjective to the operator. A study used the capillary refill time of wound edges as an adjunct to tell how much tightening was allowable with each session [21]. Some tightening was recorded as done under a sedative, general anesthesia, and no anesthesia/analgesia, probably reflecting patient factors in influencing the choice [19], and wound inspections were carried out in most studies in various clinical settings, including theater and by the bedside.
Varying modifications to the use of dermatotraction suture techniques have also been employed in other body wounds with good results [27,28], and there is an emerging technology that does not require manual tightening [29]. It could not be clearly concluded due to limited data if add-on methods such as NWPT or varied modifications offered any advantage in the management of lower limb fasciotomies.
Time to Achieve Primary Closure
For all the reports included in the study, the average time to complete the closure of the fasciotomy wound using the dermatotraction suture technique was the shortest at 5.9 days and the longest at 3.8 weeks. Nine studies had an average duration of closure of within 10 days, four studies within >10 days, and one study within <17 days. In extremis, there was a single study with an average duration of 3.8 weeks. The shortest duration for complete primary closure was two days and the longest was 113 days; the reason for this prolonged duration and discrepancies were not immediately clear. Ten out of 16 studies reported a complete closure of fasciotomy wounds, and all studies had closure in most of the patients included. Four cases had one patient failing a full cover and needing skin grafting and NWPT to treat failed closure. In the study with the largest data set, only 23% of patients had a failed closure. The success of this method is also re-echoed in other studies [8]. It was not clear from many of the studies the extent and size of the wounds and where this was stated if this contributed to failure rates, wound closure time, or if patient factors might have contributed. A study however found no statistically significant correlation between wound closure time and wound length [6], in contrast to another study that found a correlation to wound closure time [23].
Complications
Most studies showed that the shoelace technique would largely have fewer or no complications in comparison to other techniques of fasciotomy wound closure. Superficial and early complications were more likely than deep or delayed complications.
The most recorded complication in the reviewed series was an infection, with one study adding specific causative organisms in 16% as Staphylococcus epidermidis, Pseudomonas, and Acinetobacter baumannii. Postoperative retractile scaring was noted in one series, and partial skin necrosis was another common complication reported in two out of 16 studies. These recorded complications are known to be associated with delayed primary wound closure [30,31].
Fasciotomy wounds in general are not clean wounds. The reported infection rates are as high as 30% [32] and as low as 16.7% [33], and this falls within the range stated for surgical site infections (SSIs) in the general series of 2%-20% [34]. However, as with all wounds, the factors determining infection and these complications would be expected to include the extent of morbidity and host factors.
Conclusions
The dermatotraction suture techniques with their modifications present a cheap, readily available technique for closing fasciotomies. This review was largely limited by the heterogeneous nature of the articles and their objectives, techniques were not clearly defined in most studies, and it was therefore difficult to extrapolate what most authors adopted. There is a need for more detailed studies that investigate this largely successful closure technique. We would recommend future studies incorporating details such as the disease burden of the wound and a standardized method of application of this technique. Case-control studies or randomized controlled trials might be best suited to answer this; however, as is known in the world of surgical innovation, standardization of techniques can be challenging, and refined patient selection and standardized training would be reasonable first steps.
Most fasciotomy wounds closed with suturing techniques can expect to close within 10 days, with minimal complications. There are varying practices of traction rates, and this may account for the wide range of delayed primary closure. This review has highlighted the simple anatomy of this technique, which in all ramifications is also affordable and accessible, especially in the context of low-resource countries, where we have had experience practicing. The success rates are reasonable, and complications are not unexpected in keeping with wound healing. 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. We hope this review will spur increased confident uptake of this technique in low-resource countries and, given their proven efficiency, become a ready tool in the armamentarium of trauma and vascular surgeons in managing fasciotomy wounds.
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