Efficacy of the shoelace technique for extremity fasciotomy wounds due to compartment syndrome

doi:10.21203/rs.3.rs-1839661/v1

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Efficacy of the shoelace technique for extremity fasciotomy wounds due to compartment syndrome

https://doi.org/10.21203/rs.3.rs-1839661/v1

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Background

The shoelace technique for compartment syndrome allows application of sustained tightening tension to an entire wound and intermittent tightening of the shoelace without requiring replacement or anesthesia. We retrospectively evaluated the usefulness of the shoelace technique in the management of extremity fasciotomy wounds before and after its introduction in our institution.

Methods

Results

There were no significant differences between the two groups in patient background. Compared with the N group patients, a significant number of S group patients avoided skin grafting (S group: n = 0, 0%; N group: n = 6, 50.0%; p < 0.01) and experienced fewer days to final closure (S group: 26.3 ± 13.7 days; N group: 49.6 ± 36.2 days, p = 0.041).

Conclusions

We considered the shoelace technique to be a useful wound closure method for fasciotomy wounds caused by compartment syndrome because it can reduce skin grafting and shorten the wound closure period.

Shoelace technique

extremity fasciotomy wound

compartment syndrome

Compartment syndrome results in increased intramuscular compartment pressure due to compression by the fascia and impairs microvascular blood flow. The main cause is ischemia-reperfusion injury, when an initial restriction of the blood supply to muscle during injury is followed by perfusion and concomitant reoxygenation. The muscles in the affected extremity may produce edema, resulting in exudate and inflammatory responses [1]. Untreated, the syndrome can cause serious damage to the nervous and muscular tissue of the involved compartment, which might lead to permanent functional deficit of the involved limb. Therefore, it is important to perform extremity fasciotomy as soon as possible after the diagnosis of compartment syndrome to decrease the pressure in the intramuscular compartment [2–5].

For fasciotomy wounds, even after improvement of muscle swelling, simple closure is difficult due to skin retraction, and the classic management of fasciotomy wounds is skin grafting. However, this results in an unsightly appearance, hypesthesia of the skin graft area, and a long time to manage the fasciotomy wound [2–5]. In 1993, Harris first reported the shoelace technique for fasciotomy wounds due to compartment syndrome and achieved delayed primary closure in all five treated cases [6]. The shoelace technique allows the application of sustained tightening tension to the entire wound and intermittent tightening without replacing the shoelace or requiring anesthesia [6]. In this study, we retrospectively evaluated the usefulness of the shoelace technique in the management of extremity fasciotomy wounds before and after its introduction in our institution.

Study design, setting, and population

We targeted 25 patients who were diagnosed as having compartment syndrome and underwent extremity fasciotomy at our hospital from April 2012 to December 2021. The N group, comprising 12 patients treated without the shoelace technique, and the S group, comprising 13 patients treated with the shoelace technique, were compared retrospectively for each study endpoint. Cases of increased intramuscular compartment pressure due to hematoma formation were excluded. We introduced the management of fasciotomy wounds with the shoelace technique in November 2016. The study protocol was performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Kansai Medical University (approval no.: 2021355). The requirement for individual informed consent was waived in accordance with the Personal Information Protection Law and National Research Ethics Guideline in Japan.

Shoelace technique (Wound management method of S group)

The shoelace technique was performed in the operating room about 48 hours after the fasciotomy. Staples were placed about 1 cm from the fasciotomy wound edge to prevent the wound edge from turning inward and at 2–3 cm intervals along the edge of the fasciotomy wound. Double vessel loops were passed through these staples to cross the fasciotomy wound like a shoelace. The vessel loops were tightened to maintain uniform tension at each anchor point along the edge of the wound, and knots were placed at both ends of the vessel loops. This method allows for constant traction on the wound edge and constant tightening of the vessel loops until final wound closure is achieved. The use of vessel loops in the shoelace technique has the advantage of maintaining continuous gentle traction at the fasciotomy wound margin due to their elasticity [7]. Because reoperation would be needed if the vessel loop breaks during treatment, we usually use two vessel loops with this technique.

Negative pressure wound therapy (NPWT) is applied after the shoelace technique is applied in cases of heavy effusion or severe muscle swelling. Thereafter, the shoelace is tightened at the bedside every 2–3 days. Finally, delayed primary closure is performed when it is thought that the wound edges are sufficiently apposed to allow suturing without significant tension. We show a representative case of the shoelace technique in Fig. 1.

Wound management method of N group

The fasciotomy wound is washed at the bedside with saline solution at 2–3 times a week. If it is possible to suture the edge of the fasciotomy wound, a few stitches should be placed during wound care. The fasciotomy wound is then covered with gauze or NPWT.

Outcomes

The primary outcome was the avoidance of the skin grafting, and the secondary outcome was the time from fasciotomy to closure of the fasciotomy wound.

Statistical analysis

Comparison of results between the two groups were done with the Student t-test for normally distributed items and the Mann-Whitney test for non-normally distributed items. All tests were 2-tailed, and P values of < 0.05 were considered statistically significant. All statistical analyses were performed with use of the SPSS statistical package ver. 23.0J (SPSS, Inc., Chicago, IL).

Twenty-five patients were enrolled in the study. The characteristics of the 25 patients are shown in Table 1. There were no significant differences between the two groups in any of the characteristics.

Table 1

Patient background
	N group (n = 12)	S group (n = 13)	P value
Age (years), mean (S.D.)	43.0 ± 20.6	50.7 ± 16.0	0.31
Male, n (%)	8 (66.7)	11 (84.6)	0.32
ISS (points), mean (S.D.)	8.5 ± 9.6	7.9 ± 12.7	0.73
Diabetes, n (%)	0	2	0.17
Immunodeficiency, n (%)	0	0	―
Steroid user, n (%)	0	0	―
Injury location (forearm/lower leg), n (%)	5 (41.7)/7 (58.3)	6 (46.2)/7 (53.8)	0.83
Injury mechanism (trauma/crush), n (%)	6 (50.0)/6 (50.0)	7 (53.8)/6 (46.2)	0.855
Complications of fracture, n (%)	5 (41.7)	3 (23.1)	0.34
Maximum muscle compartment pressure (mmHg), mean (S.D.)	75.2 ± 29.4	71.1 ± 22.9	0.82
Use of NPWT, n (%)	9 (75.0)	10 (76.9)	0.92
Time from onset to incision (min), mean (S.D.)	887.5 ± 692	682.3 ± 480	0.40
Neurological disorder, n (%)	7 (58.3)	7 (53.8)	0.83
S.D. standard deviation, ISS Injury Severity Score, NPWT negative pressure wound therapy

All patients in the S group avoided skin grafting, resulting in a significant difference between the number of patients requiring a skin graft in the N group (S group: n = 0, 0%; N group: n = 6, 50.0%; p < 0.01). Significantly fewer days were required to final wound closure in the S group compared to the N group (S group: 26.3 ± 13.7 days; N group: 49.6 ± 36.2 days; p = 0.041) (Table 2).

Table 2

Outcomes
	N group (n = 12)	S group (n = 13)	P value
Skin grafting, n (%)	6 (50.0)	0 (0)	< 0.01
Days from incision to wound closure, mean (S.D.)	49.6 ± 36.2	26.3 ± 13.7	0.041

We have shown in this study that the use of the shoelace technique for fasciotomy wounds caused by compartment syndrome can avoid the need for skin grafting and shorten the time required for closure of fasciotomy wounds. As there has been no consensus on an optimal technique for fasciotomy wound closure [8], our results may help surgeons realize the efficacy of the shoelace technique for the management of fasciotomy wounds.

There are various methods of fasciotomy wound management, and the recent introduction of NPWT has facilitated wound management. However, about 20% of NPWT-only cases required skin grafting. Pain and other sequelae occurred in 95% of cases in which skin grafting was performed, and in some cases, additional cosmetic surgery was performed [9, 10]. In our institution, we were able to close the wound in all cases, without any skin grafting, using both the shoelace technique and NPWT and the shoelace technique only in about 26 days after the fasciotomy. Johnson et al. report that NPWT alone is more likely to require skin grafting and that skin grafting increases the length of hospitalization and medical costs [11]. The material used in the shoelace technique is readily available in any standard operating theatre, making this procedure also useful in countries with limited resources [12]. The mean daily cost of treatment for each patient managed by the shoelace technique was reported to be as low as about 14 Euros [9]. The use of the shoelace technique is expected to contribute to shorter hospital stays and lower medical costs by avoiding the need for skin grafting and shortening the closure period of fasciotomy wounds.

Dodenhoff and Howell used the shoelace technique at fasciotomy and reported that the fasciotomy wound could be gradually closed by tightening the vessel loops from 48 hours after the fasciotomy with attention to any increase in intramuscular compartment pressure [11, 13]. In our institution, fasciotomy only was performed on the day of diagnosis of compartment syndrome. Because of the severe muscle swelling after fasciotomy, we similarly performed the shoelace technique at about 48 hours after the fasciotomy in a operating room. However, Dodenhoff and Howell did not recommend the use of the shoelace technique if the intramuscular compartment pressure continues to increase at 48 hours after fasciotomy [13].

This study confirms the usefulness of the shoelace technique as a management method for fasciotomy wounds.

Limitations

The limitations of this study are its small size and that the volume of intravenous infusion during treatment, which may affect the degree of swelling at the fasciotomy site, is unknown.

We investigated the usefulness of the shoelace technique for fasciotomy wounds caused by compartment syndrome. We consider the shoelace technique to be a useful wound closure method for fasciotomy because it can reduce skin grafting and shorten the wound closure period.

NPWT

Negative pressure wound therapy.

Authors’ contributions

AO: Involved in surgical treatment and inpatient care, study conception and design, collection of data, analyses and interpretation of data, writing of the manuscript. TM: Study conception and design, interpretation of data, revision of manuscript. YN: Involved in surgical treatment and inpatient care, collection of data. FN: Interpretation of data, revision of manuscript. TY: Involved in surgical treatment and inpatient care, collection of data. MN, MK, KS, KK, HI, and YK: Interpretation of data, revision of manuscript.

Funding source

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study protocol was performed in accordance with the Declaration of Helsinki, and was approved by the Ethics Committee of Kansai Medical University (approval no.: 2021355 ). The requirement for individual informed consent was waived in accordance with the Personal Information Protection Law and National Research Ethics Guideline in Japan.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

¹ Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan

² Department of Orthopaedic Surgery, Kansai Medical University, Hirakata, Osaka, Japan

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Efficacy of the shoelace technique for extremity fasciotomy wounds due to compartment syndrome

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Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Methods

Study design, setting, and population

Shoelace technique (Wound management method of S group)

Wound management method of N group

Outcomes

Statistical analysis

Results

Discussion

Limitations

Conclusions

Abbreviations

Declarations

References

Status:

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