[Use of vacuum-assisted closure therapy for the conditioning of soft-tissue defects]

[Acute lower leg compartment syndrome]

OBJECTIVE

Decompression of all four muscle compartments of the lower leg to normalize tissue pressure and prevent permanent neuromuscular dysfunction.

INDICATIONS

Incipient compartment syndrome (characterized by excessive pain, muscle pain on extension, tensely swollen and shiny skin, and Δp>30 mmHg without neuromuscular deficit) and no clinical improvement after conservative treatment and/or acute compartment syndrome (symptoms as for incipient compartment syndrome with neuromuscular deficit and Δp<30 mmHg).

CONTRAINDICATIONS

None. There is some dispute about indications and timing of fasciotomy and necrectomy when the need for dermatofasciotomy is recognized late (e.g. intubated intensive care patients).

SURGICAL TECHNIQUE

In unilateral compartment release as described by Matsen, the lateral compartment is decompressed first through a parafibular approach. After identification of the anterior and superficial posterior compartments by transverse incision of the fasciae, these muscles are also decompressed longitudinally. Finally, the deep posterior compartment beneath the lateral compartment is decompressed. In bilateral dermatofasciotomy, the fasciae of the anterior and lateral compartments are incised through a proximal anterolateral approach and the superficial and deep posterior compartments through a distal dorsomedial approach.

POSTOPERATIVE MANAGEMENT

Synthetic skin substitute or vacuum-assisted wound closure until definitive closure by secondary suture or mesh grafting after about 5 days. Patient mobilization generally depends on the concomitant bone injury.

RESULTS

During the period from October 2001 to November 2008, 37 dermatofasciotomies were performed at our hospital to treat acute posttraumatic compartment syndrome. On the day of dismissal, symptoms of neuromuscular dysfunction after acute compartment syndrome had not disappeared completely in 5 patients. One patient received intermittent dialysis for acute kidney failure after crush syndrome. There were perioperative complications in a total of 6 patients: iatrogenic neurotomy (n=1), hematoma requiring revision (n=2), deep wound infection (n=2), and superficial disturbed wound healing (n=1).