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Bihari A, McClure JA, Inculet C, Del Balso C, Vinden C, Schemitsch E, Sanders D, Lawendy AR. Fasciotomy and rate of amputation after tibial fracture in adults: a population-based cohort study. OTA Int 2024; 7:e333. [PMID: 38623265 PMCID: PMC11013697 DOI: 10.1097/oi9.0000000000000333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 12/13/2023] [Accepted: 02/16/2024] [Indexed: 04/17/2024]
Abstract
Objectives Limb amputation is a possible outcome of acute compartment syndrome. We undertook this study to investigate the occurrence of fasciotomy and amputation in patients with tibial fractures in the Ontario adult population, aiming to evaluate variables that may be associated with each of these outcomes. Design Retrospective, population-based cohort study (April 1, 2003-March 31, 2016). Setting Canadian province of Ontario. Participants Patients with tibial fracture, aged 14 years and older. Interventions Fasciotomy after tibial fracture. Main Outcomes and Measures The primary outcomes were fasciotomy and amputation within 1 year of fasciotomy. Secondary outcomes included repeat surgery, new-onset renal failure, and mortality, all within 30 days of fasciotomy. Results We identified 76,299 patients with tibial fracture; the mean (SD) age was 47 (21) years. Fasciotomy was performed in 1303 patients (1.7%); of these, 76% were male and 24% female. Patients who were younger, male, or experienced polytrauma were significantly more likely to undergo fasciotomy. Limb amputation occurred in 4.3% of patients undergoing fasciotomy, as compared with 0.5% in those without fasciotomy; older age, male sex, presence of polytrauma, and fasciotomy were associated with an increased risk of amputation (age odds ratio [OR] of 1.03 [95% CI, 1.02-1.03], P < 0.0001; sex OR of 2.04 [95% CI, 1.63-2.55], P < 0.0001; polytrauma OR of 9.37 [95% CI, 7.64-11.50], P < 0.0001; fasciotomy OR of 4.35 [95% CI, 3.21-5.90], P < 0.0001), as well as repeat surgery within 30 days (sex OR of 1.54 [95% CI, 1.14-2.07], P = 0.0053; polytrauma OR of 4.24 [95% CI, 3.33-5.38], P < 0.0001). Conclusions Among tibial fracture patients, those who were male and who experienced polytrauma were at significantly higher risk of undergoing fasciotomy and subsequent amputation. Fasciotomy was also significantly associated with risk of amputation, a finding that is likely reflective of the severity of the initial injury.
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Affiliation(s)
- Aurelia Bihari
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada
| | | | - Clayton Inculet
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - Christopher Del Balso
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | | | - Emil Schemitsch
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - David Sanders
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - Abdel-Rahman Lawendy
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada
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Correia G, Mendes Santos P, Campos JP, Camelo Barbosa N, Carvalho L. Acute Compartment Syndrome of the Thigh After Contusion in a Football Player. Cureus 2024; 16:e53617. [PMID: 38449983 PMCID: PMC10916738 DOI: 10.7759/cureus.53617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 03/08/2024] Open
Abstract
Acute compartment syndrome of the thigh is an exceptionally uncommon condition that can have severe consequences if not promptly and effectively treated. A 19-year-old man presented to our emergency department with severe and progressive pain in his left thigh after sustaining a direct trauma during a football game 24 hours prior. Compartment pressure was assessed, confirming the diagnosis of compartment syndrome arising from a sizable intramuscular hematoma without detection of any other contributing factors. Fasciotomy incisions were closed using the shoelace technique with excellent functional results. This case highlights the importance of high suspicion and intra-compartmental pressure measurement to diagnose this condition accurately.
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Affiliation(s)
| | - Pedro Mendes Santos
- Orthopedics and Traumatology, Unidade Local de Saúde de Matosinhos, Matosinhos, PRT
| | - João Pedro Campos
- Orthopedics and Traumatology, Unidade Local de Saúde de Matosinhos, Matosinhos, PRT
| | - Nuno Camelo Barbosa
- Orthopedics and Traumatology, Unidade Local de Saúde de Matosinhos, Matosinhos, PRT
| | - Luís Carvalho
- Orthopedics and Traumatology, Unidade Local de Saúde de Matosinhos, Matosinhos, PRT
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Akgun E, Emet A, Sibar K, Çatma FM, Kocyigit IA, Şahin A, Imat E, Adiguzel IF, Fırat A. Risk Factors for Surgical Site Infections Following Fasciotomy in Patients With Acute Compartment Syndrome: A Study on the February 2023 Kahramanmaraş Earthquake. Cureus 2023; 15:e46880. [PMID: 37841991 PMCID: PMC10568196 DOI: 10.7759/cureus.46880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 10/17/2023] Open
Abstract
INTRODUCTION Surgical site infections (SSIs) developing after fasciotomy are difficult to treat, costly, and an important source of mortality and morbidity. This study aimed to determine the risk factors affecting the development of SSI in patients who underwent fasciotomy with the diagnosis of acute compartment syndrome (ACS) within 72 hours after two consecutive earthquakes of 7.7 and 7.6 magnitude that occurred in Kahramanmaraş on February 6, 2023. METHOD A total of 116 patients were retrospectively analyzed. Patients were divided into two groups: those who developed SSI and those who did not. In this study, variables such as basic demographic characteristics, time of fasciotomy, center performing fasciotomy, type of wound closure, affected extremity, concomitant renal failure, hyperbaric oxygen (HBO) therapy, blood creatine kinase (CK) level were examined. RESULTS Of 116 patients, 58 (50%) had SSI. It was statistically observed that patients who underwent treatment with vacuum-assisted closure (VAC), those who underwent primary closure with the shoelace method, those who went into renal failure, and those whose fasciotomy was performed in an earthquake zone had a higher incidence of SSI (p<0.001). Blood CK level above 17.839 seemed to be a risk factor according to receiver operating characteristic (ROC) analysis (P<0.01). Age (p=0.193), gender (p=0.125), fasciotomy time (p=0.843), lower extremity (p=0.234), upper extremity (p=0.806), and HBO treatment (p=0.56) were not associated with SSI. Infection was found to be a significant risk factor for amputation (p<0.001). CONCLUSION The use of VAC as a wound closure technique for SSI after fasciotomy in patients who developed ACS due to the earthquake, the presence of renal failure in the patients, and performing fasciotomy in the earthquake zone were independent risk factors. A blood CK level above 17.839 was also determined as a risk factor, but the confidence interval was found to be low.
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Affiliation(s)
- Erkan Akgun
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Abdulsamet Emet
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Kemal Sibar
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Faruk M Çatma
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | | | - Ali Şahin
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Emrah Imat
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | | | - Ahmet Fırat
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
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4
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Onoe A, Muroya T, Nakamura Y, Nakamura F, Yagura T, Nakajima M, Kishimoto M, Sakuramoto K, Kajino K, Ikegawa H, Kuwagata Y. Efficacy of the shoelace technique for extremity fasciotomy wounds due to compartment syndrome. BMC Musculoskelet Disord 2023; 24:704. [PMID: 37667241 PMCID: PMC10476399 DOI: 10.1186/s12891-023-06849-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 08/31/2023] [Indexed: 09/06/2023] Open
Abstract
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 its 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 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 outcome. RESULTS There were no significant differences between the two groups in patient background. Compared with the N group patients, all of the S group patients avoided skin grafting (S group: n = 0, 0%; N group: n = 6, 50.0%; p < 0.01). However, there was no significant difference in the number of days to final wound closure (S group: 39.5 [IQR 24.3-58.0] days; N group: 24.0 [IQR 18.5-31.0] days, p = 0.06). CONCLUSIONS We considered the shoelace technique to be a useful wound closure method for fasciotomy wounds caused by compartment syndrome because it can significantly reduce the need for skin grafting and tends to shorten the wound closure period.
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Affiliation(s)
- Atsunori Onoe
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan, 573-1010.
| | - Takashi Muroya
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan, 573-1010
| | - Yoshihiro Nakamura
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan, 573-1010
| | - Fumiko Nakamura
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan, 573-1010
| | - Takuma Yagura
- Department of Orthopaedic Surgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Mari Nakajima
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan, 573-1010
| | - Masanobu Kishimoto
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan, 573-1010
| | - Kazuhito Sakuramoto
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan, 573-1010
| | - Kentaro Kajino
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan, 573-1010
| | - Hitoshi Ikegawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan, 573-1010
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan, 573-1010
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Kakagia DD, Georgiadis G, Drosos G. Dermal Matrices: Game Changers in Leg and Foot Soft Tissue Reconstruction? A Case Series. THE INTERNATIONAL JOURNAL OF LOWER EXTREMITY WOUNDS 2023; 22:56-62. [PMID: 34060922 DOI: 10.1177/1534734621990311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The present article aims to present the use of dermal matrices in severe degloving, avulsion, and necrotizing injuries of the leg and foot in 3 patients. Conventional reconstruction would require the use of free flaps, since exposure of vessels, nerves, joints, and tendons rendered the mere resurfacing with skin grafts insufficient, and extensive cutaneous detachment precluded the use of local fasciocutaneous flaps. All injuries underwent thorough and repeated surgical debridements and wash outs, followed by negative pressure wound therapy (NPWT). Once negative tissue cultures were obtained, the extremities were resurfaced with dermal matrix and immediately covered by split thickness skin grafts. NPWT on the grafted area for a week effectively secured the grafts on the recipient area. Complete healing was achieved in all grafted areas within 7 to 12 days. The function of joints and tendons as well as the quality of resurfacing at the weight bearing areas were tested and found satisfactory within a follow-up period of 5 to 15 months. The use of combined NPWT and dermal matrices in carefully selected patients provides a reliable and durable reconstructive option for leg and foot injuries with satisfactory functional outcomes.
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Affiliation(s)
| | | | - George Drosos
- Democritus University Hospital, Alexandroupolis, Greece
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6
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Muacevic A, Adler JR. Seven-Compartment Fascial Release of the Lower Extremity: A Case Report. Cureus 2022; 14:e32023. [PMID: 36589178 PMCID: PMC9797870 DOI: 10.7759/cureus.32023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
Compartment syndrome of the lower extremities is a condition that can lead to permanent nerve and muscle damage if not treated in an emergent fashion. Fasciotomy of the medial compartment of the thigh is exceedingly rare, and a review of the literature revealed only one reported case where compartment syndrome was present in both the thigh and lower leg compartments simultaneously. Given the rarity of compartment syndrome in all seven compartments of the leg, in this case, we report the development of full leg compartment syndrome in a 29-year-old male who fell asleep on a hard surface for an extended period following heroin intoxication, which was treated with seven compartment fasciotomies. We conclude with a discussion about how medial release of the thigh for compartment syndrome is rare enough that careful consideration of the anatomy must be made before proceeding with the procedure. Additionally, wound closure has many proposed options, but current literature favors skin staples with an interlaced elastic band to minimize delays in wound closure.
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7
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Principles of Fasciotomy Closure After Compartment Syndrome Release. J Am Acad Orthop Surg 2022; 30:879-887. [PMID: 36001887 DOI: 10.5435/jaaos-d-21-01046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/04/2022] [Indexed: 02/01/2023] Open
Abstract
Acute compartment syndrome is a surgical emergency in the extremities resulting from increased compartmental pressure, requiring immediate fasciotomy to resolve muscular compromise. As the mainstay treatment, fasciotomies involve substantial skin incisions and are thus prone to complications such as skin necrosis, wound infection, and permanent disability. Multidisciplinary care instituted at the time of fasciotomy can facilitate timely closure and minimize the complication profile. Several approaches are available to enhance outcomes of fasciotomy wounds, and a comprehensive knowledge of these options affords the treating surgeon greater flexibility and confidence in optimal management. Common techniques include early primary closure, gradual approximation, skin grafting, and negative pressure therapy. There is currently no consensus on the best method of closure. The purpose of this study was to review fasciotomy wound management from the time of initial release to final closure. Highlights include preparation for closing these wounds; the various techniques for fasciotomy closure, including adjunct options; evaluation of timing and staging; and injury-specific features, such as fracture management, limited subcutaneous tissues, and hand fasciotomies. Combining the perspectives of orthopaedic and plastic surgery, this review evaluates the benefits of multiple closure methods and highlights the importance of planning closure at the time of release.
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8
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Factors Associated With Surgical Site Infections After Fasciotomy in Patients With Compartment Syndrome. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202202000-00012. [PMID: 35188898 PMCID: PMC8863120 DOI: 10.5435/jaaosglobal-d-22-00002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/04/2022] [Indexed: 11/18/2022]
Abstract
Fasciotomy is the standard of care to treat acute compartment syndrome (ACS). Although fasciotomies often prevent serious complications, postoperative complications can be notable. Surgical site infection (SSI) in these patients is as high as 30%. The objective of this study was to determine factors that increase the risk of SSI in patients with ACS.
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9
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Tong X, Lu J, Zhang W, Wang S, Huang R, Zhang X, Huang J, Zhu Y, Xiao S, Ji S, Xia Z. Efficacy and safety of external tissue expansion technique in the treatment of soft tissue defects: a systematic review and meta-analysis of outcomes and complication rates. BURNS & TRAUMA 2022; 10:tkac045. [PMCID: PMC9741868 DOI: 10.1093/burnst/tkac045] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/26/2022] [Accepted: 09/07/2022] [Indexed: 12/14/2022]
Abstract
Abstract
Background
Currently, various external tissue expansion devices are becoming widely used. Considering the scarcity of relevant application standards, this systematic review was performed to explore the effectiveness and safety of external tissue expansion techniques for the reconstruction of soft tissue defects.
Method
A systematic review and meta-analysis on the efficacy and safety of external tissue expansion technique was conducted. A comprehensive search was performed in the following electronic databases: PubMed/Medline, Embase, Cochrane Library (Wiley Online Library), and Web of Science. Studies reporting patients with soft tissue defects under the treatment of external tissue expansion technique were included.
Results
A total of 66 studies with 22 different types of external tissue expansion devices met the inclusion criteria. We performed a descriptive analysis of different kinds of devices. A single-arm meta-analysis was performed to evaluate the efficacy and safety of the external tissue expansion technique for different aetiologies. The pooled mean wound healing time among patients with defects after fasciotomy was 10.548 days [95% confidence interval (CI) = 5.796–15.299]. The pooled median wound healing times of patients with defects after excisional surgery, trauma, chronic ulcers and abdominal defects were 11.218 days (95% CI = 6.183-16.253), 11.561 days (95% CI = 7.062-16.060), 15.956 days (95% CI = 11.916-19.996) and 12.853 days (95% CI=9.444-16.227), respectively. The pooled wound healing rates of patients with defects after fasciotomy, excisional surgery, trauma, chronic ulcers and abdominal defects were 93.8% (95% CI=87.1-98.2%), 97.2% (95%CI=92.2-99.7%), 97.0% (95%CI=91.2-99.8%), 99.5% (95%CI=97.6-100%), and 96.8% (95%CI=79.2-100%), respectively. We performed a subgroup analysis in patients with diabetic ulcers and open abdominal wounds. The pooled median wound healing time of patients with diabetic ulcers was 11.730 days (95% CI = 10.334-13.125). The pooled median wound healing time of patients with open abdomen defects was 48.810 days (95% CI = 35.557–62.063) and the pooled successful healing rate was 68.8% (95% CI = 45.9-88.1%). A total of 1686 patients were included, 265 (15.7%) of whom experienced complications. The most common complication was dehiscence (n = 53, 3.14%).
Conclusions
Our systematic review is the first to demonstrate the efficacy and safety of external tissue expansion in the management of soft tissue defects. However, we must interpret the meta-analysis results with caution considering the limitations of this review. Large-scale randomized controlled trials and long-term follow-up studies are still needed to confirm the effectiveness and evaluate the quality of healing.
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Affiliation(s)
- Xirui Tong
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Jianyu Lu
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Wei Zhang
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Siqiao Wang
- Tongji University School of Medicine, Tongji University , Shanghai, 200092 , China
| | - Runzhi Huang
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Xianliang Zhang
- Hospital of the 92426 Troops of the Chinese People’s Liberation Army , Tsingtao, 266400 , China
| | - Jie Huang
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Yushu Zhu
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Shichu Xiao
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Shizhao Ji
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Zhaofan Xia
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
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10
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Chan PYW, Colon AF, Clune J, Shah A. External Tissue Expansion in Complex Extremity Reconstruction. J Hand Surg Am 2021; 46:1094-1103. [PMID: 34688502 DOI: 10.1016/j.jhsa.2021.07.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/30/2021] [Accepted: 07/23/2021] [Indexed: 02/02/2023]
Abstract
Skin grafting and flap-based reconstruction have been the conventional treatments for complex extremity wounds. However, these methods can be associated with relatively high complication rates and involve increasing levels of complexity. External tissue expansion has recently emerged as an attractive alternative to its conventional counterparts. It is a technically simple and low-morbidity technique for complex wound reconstruction. This article provides a review of internal and external tissue expansion with a focus on the evolution, indications, and recent successes of external expansion for soft tissue coverage.
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Affiliation(s)
- Peter Y W Chan
- The Center for Hand and Upper Extremity Surgery, Institute for Advanced Reconstruction, Shrewsbury, NJ
| | - Anthony F Colon
- Division of Plastic Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - James Clune
- Division of Plastic Surgery, Yale University School of Medicine, New Haven, CT
| | - Ajul Shah
- The Center for Hand and Upper Extremity Surgery, Institute for Advanced Reconstruction, Shrewsbury, NJ.
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11
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Olivia G, Petter L, Håkan P. Acute Compartment Syndrome Following Thrombolysis For Acute Lower Limb Ischemia. Ann Vasc Surg 2021; 79:182-190. [PMID: 34644632 DOI: 10.1016/j.avsg.2021.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute Compartment syndrome (ACS) with subsequent need for fasciotomy is a serious and insidious complication after revascularization for acute lower limb ischemia (ALI). The development of ACS during endovascular catheter directed thrombolysis is particularly difficult to identify. The aim was to identify the incidence, predisposing factors, wound treatment, and outcome in terms of amputation and survival for patients presenting with ALI that develop ACS during catheter directed thrombolysis. Patients who did not develop ACS after thrombolysis were analyzed as controls. METHODS Descriptive retrospective analysis of prospective databases from two large tertiary-referral vascular centers. Patients with ACS after thrombolysis for ALI between 2001-2017 were analyzed. RESULTS Seventy-eight cases and 621 controls were identified. Mean age was 72 years and 30 (38.5%) were women in the ACS group. Patients that developed ACS presented with significantly more severe preoperative ischemia. With 38.5% having Rutherford 2b classification as compared to 22.7 % in the control group (P = 0.002). Occluded popliteal artery aneurysms were also associated with a higher incidence of ACS (P = 0.041). Treatment of the fasciotomy wound was most commonly treated with regular wound dressing in 45 (58%) of cases, while wound dressing and foot pump and vacuum assisted closure were used in 14 (18%) and 19 (24%) respectively. These differing approaches did not affect the number of wound infections and amputations, which was similar regardless of treatment type. Vacuum assisted closure was associated with a higher degree of skin graft closure (P = 0.001). The median time to complete wound closure was 10 days. One year after thrombolysis, the major amputation rate in the ACS group was 31% as opposed to 17% in control group, P = 0.003. Mortality measured at 16.7% and 15.3%, respectively, P = 0.872. Amputation-free survival in the ACS group was 62% vs. 73% in the control group, P = 0.035. These differences level out, however, when applying long-term analysis of amputation-free survival in Kaplan-Meier analysis (log-rank 0.103). CONCLUSIONS Patients that developed ACS during endovascular CDT presented with a more severe pre-operative ischemia, more occluded popliteal artery aneurysms and had a higher amputation rate during the first year, compared to controls. The development of ACS during endovascular treatment of ALI with thrombolysis is not uncommon and warrants both clinical awareness and rapid treatment.
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Affiliation(s)
- Grip Olivia
- Uppsala University, Department of Surgical Sciences, Section of Vascular Surgery, Uppsala, Sweden
| | - Lindahl Petter
- Lund University, Department of Clinical Sciences, Faculty of Medicine, Lund, Sweden
| | - Pärsson Håkan
- Linköping University, Department Biomedical and Clinical Sciences, Linköping, Sweden.
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12
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Wu Y, Chen L, Mao X, Ru Z, Yu L, Chen M, Wang J, Chen J, Pang Q. Closure of Complex Wounds by a Simple Skin Stretching System Associated With Vacuum Sealing Drainage-Clinical Outcome of 34 Patients. INT J LOW EXTR WOUND 2021:15347346211032046. [PMID: 34279133 DOI: 10.1177/15347346211032046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Management of complex wounds with large skin defects presents a real challenge for orthopedic or reconstructive surgeons. We developed a simple skin stretching system associated with vacuum sealing drainage to examine the efficiency and complication. A total of 34 patients with different types of complex wounds were retrospectively included from January 2015 to March 2021. All patients in the study were underwent the treatment by 2 stages. The method was used to the wounds from 4.71 to 169.65 cm2 with a median defect size of 25.13 cm2. The median time for wound closure was 11.5 days (range: 5-32 days), although the median absolute reduction was 2.08 cm2/day (range: 0.15-25.66 cm2/day). Depending on the site of the wounds, the cause of the wound, and the rate of max-width/max-length (W/L), these complex wounds could be separately divided into several groups. There were statistically significant differences in the median value of the above variables (P < .05 Kruskal-Wallis test). The results showed that different anatomical sites had different viscoelastic properties, the complex wounds caused by trauma were easier to close than caused by diabetic foot and the complex wounds in group A (W/L > 0.5) were more difficult to close than in group B (W/L ≤ 0.5). No major complications were encountered in this study. In summary, the results of our study showed that the simple skin stretching system associated with vacuum sealing drainage was a safe approach for closure of complex wounds. Nevertheless, more attention should be paid to the viscoelasticity of the wounds to ensure closure and avoid undue complications when applying the method.
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Affiliation(s)
- Yaojun Wu
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,74782Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Liang Chen
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,74782Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Xinliang Mao
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,74782Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | | | - Liying Yu
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,74782Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Mimi Chen
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,74782Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Jingnan Wang
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,74782Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Jiejie Chen
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,74782Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Qingjiang Pang
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,74782Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
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13
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Tawfik A, Hozack B, Melendez J, Varghese B, Katt BM, Beredjiklian P, Nakashian M. Impending Upper Arm Compartment Syndrome Secondary to Intravenous Fluid Infiltration. Cureus 2021; 13:e15671. [PMID: 34277262 PMCID: PMC8282358 DOI: 10.7759/cureus.15671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 11/27/2022] Open
Abstract
We report the case of an 81-year-old female who developed an upper arm anterior compartment syndrome from the mass effect caused by an infiltrated intravenous access catheter. The patient’s anterior compartment became tense and uncompressible, and the patient developed radial nerve palsy. A fasciotomy was performed, resulting in the evacuation of 100 mL of fluid. Over the course of the patient’s follow-up, motor and sensory function slowly returned. In atraumatic patients with intravenous access, the development of a tense compartment with developing nerve palsies should warrant workup for possible compartment syndrome due to mass effect. If treated promptly with fasciotomy, the complications of this limb-threatening condition can be minimized or possibly reversed.
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Affiliation(s)
- Amr Tawfik
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA.,Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, New Brunswick, USA
| | - Bryan Hozack
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Justin Melendez
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, New Brunswick, USA
| | - Bobby Varghese
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, New Brunswick, USA
| | - Brian M Katt
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, New Brunswick, USA
| | - Pedro Beredjiklian
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
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14
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Suomalainen P, Pakarinen TK, Pajamäki I, Laitinen MK, Laine HJ, Repo JP, Mattila VM. Does the shoe-lace technique aid direct closure of fasciotomy wounds after acute compartment syndrome of the lower leg? a retrospective case-control study. Scand J Surg 2021; 110:492-497. [PMID: 34078192 PMCID: PMC8688972 DOI: 10.1177/14574969211019639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background and objective: Tibia fractures are relatively common injuries that are accompanied with acute compartment syndrome in approximately 2% to 20% of cases. Although the shoe-lace technique, where vessel loops are threaded in a crisscross fashion and tightened daily, has been widely used, no studies have compared the shoe-lace technique with the conventional one. The aim of this study was to compare the shoe-lace technique with the conventional technique. Methods: We identified 359 consecutive patients with intramedullary nailed tibia fracture and complete medical records including outpatient data between April 2007 and April 2015 from electronic patient database of our institute. The use of the shoe-lace technique was compared to conventional one (in which wounds were first left open with moist dressings). Main outcome measurement is direct closure of fasciotomy wounds. Results: From 359 consecutive patients with intramedullary nailed tibia fracture, fasciotomy was performed on 68 (19%) patients. Of these, the shoe-lace technique was used in 47 (69%) patients while in 21 (31%) patients, the shoe-lace technique was not applied. Side-to-side approximation was successful in 36 patients (77%) in the shoe-lace+ group and 7 patients (33%) in the shoe-lace– group (p = 0.002). Conclusions: The main finding of our comparative study was that the shoe-lace technique seems to ease direct closure of lower leg fasciotomy wounds, and thus reduces the frequency of free skin grafts. Our finding needs to be confirmed in a high-quality randomized controlled trial.
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Affiliation(s)
- P Suomalainen
- Department of Orthopaedics and Traumatology, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland
| | - T-K Pakarinen
- Department of Orthopaedics and Traumatology, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland
| | - I Pajamäki
- Department of Orthopaedics and Traumatology, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland
| | - M K Laitinen
- Department of Orthopaedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - H-J Laine
- Department of Orthopaedics and Traumatology, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland
| | - J P Repo
- Department of Orthopaedics and Traumatology, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland
| | - V M Mattila
- Department of Orthopaedics and Traumatology, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland.,The School of Medicine, Tampere University, Tampere, Finland
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15
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Arumugam PK, Muthukumar V, Bamal R. Utility of Shoelace Technique in Closure of Fasciotomy Wounds in Electric Burns. J Burn Care Res 2021; 42:538-544. [PMID: 33161435 DOI: 10.1093/jbcr/iraa200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Fasciotomy is indicated to relieve compartment syndrome caused by electric burns. Many techniques are available to close the fasciotomy wounds including vacuum-assisted closure, skin grafting, and healing by secondary intention. This study assessed the shoelace technique in fasciotomy wound closure in patients with electric burns. The study included 19 fasciotomy wounds that were treated by shoelace technique (Group ST, n = 10 fasciotomy wounds) or by skin grafting/healing by secondary intention (Group C, n = 9 fasciotomy wounds). Data were collected for wound surface area, time to intervention, time to wound closure, rate of decrease in wound surface area after application of shoelace technique and associated complications. The mean time to intervention after fasciotomy was significantly lower in Group ST-7.6 ± 3.8 days as compared to 15.8 ± 5.3 days in Group C (P = .004). The median time to closure was also significantly lower in Group ST-7 days (range 6-10) as compared to Group C-20 days (range 12-48) (P < .001). Primary closure was achieved in 80% cases in the group ST and no complications were recorded. The shoelace technique is an economical, fast, and effective method of fasciotomy wound closure in electric burns, especially in high volume centers and resource-limited areas.
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Affiliation(s)
- Praveen Kumar Arumugam
- Department of Burns, Plastic and Maxillofacial Surgery, V.M. Medical College and Safdarjung Hospital, Delhi, India
| | - Vamseedharan Muthukumar
- Department of Burns, Plastic and Maxillofacial Surgery, V.M. Medical College and Safdarjung Hospital, Delhi, India
| | - Rahul Bamal
- Department of Burns, Plastic and Maxillofacial Surgery, V.M. Medical College and Safdarjung Hospital, Delhi, India.,School of Medicine, Griffith University, Gold Coast, Australia
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16
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Retention Sutures and Negative Pressure Wound Therapy for Delayed Primary Closure of Fasciotomy Wounds. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3530. [PMID: 33854866 PMCID: PMC8032358 DOI: 10.1097/gox.0000000000003530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 02/14/2021] [Indexed: 11/26/2022]
Abstract
Achieving primary closure of lower extremity fasciotomy wounds is difficult. Surgeons are faced with the option of waiting potentially long periods of time for edema to reside, in order to attempt delayed primary closure (DPC) versus closing at an earlier time with a split thickness skin graft. DPC offers superior aesthetic outcomes than split thickness skin grafts but traditionally cannot occur until later in the clinical course once excessive edema has subsided. We present a case of a young athlete with compartment syndrome, which was managed with an alternative technique for achieving DPC: serial partial closure under tension with retention sutures and negative pressure wound therapy. The successful outcome in this single case should prompt further studies investigating the objective benefits of this novel method to achieve DPC following fasciotomy.
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17
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Cable Tie Dynamic Wound Closure. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Muñoz Pérez DF, Medina Rojas R, Sanjuan Mar´ín JF, Rodríguez Florez RJ, Sánchez Arroyo ND. Síndrome compartimental agudo del miembro inferior: estado actual. REVISTA COLOMBIANA DE CIRUGÍA 2021. [DOI: 10.30944/20117582.663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
El síndrome compartimental agudo del miembro inferior es una urgencia médica, que puede conllevar una importante morbilidad para el paciente y que puede tener implicaciones medicolegales para el personal médico. Afecta cerca de 3,1 por 100.000 habitantes en el mundo occidental, con predominio de hombres y jóvenes. Debido a una alteración de la perfusión tisular, por la disposición de los músculos de las extremidades en compartimientos compactos, con poca tolerancia a variaciones en la presión, puede causar isquemia, con cambios irreversibles a nivel muscular y nervioso, falla multiorgánica y la muerte, de no tratarse oportunamente.
El trauma de la extremidad inferior asociado a fractura es la principal causa del síndrome compartimental agudo. El diagnóstico puede realizarse por evaluación clínica, mediante las clásicas seis “P” de la isquemia, u de manera objetiva, al medir la presión intracompartimental con dispositivos especializados. La fasciotomía descompresiva es un procedimiento quirúrgico mediante el cual se inciden las fascias de los compartimientos musculares, permitiendo la disminución de las presiones a ese nivel, y se constituye en el único tratamiento eficaz para el síndrome compartimental agudo. Las complicaciones posquirúrgicas no son infrecuentes, siendo la perdida de la extremidad la más grave de todas. Un correcto conocimiento y aplicación de la técnica quirúrgica evitará procedimientos inadecuados, que impliquen mayor riesgo de resultados adversos.
Presentamos una revisión de los aspectos fundamentales de esta patología potencialmente catastrófica.
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19
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Zens Y, Barth M, Bucher HC, Dreck K, Felsch M, Groß W, Jaschinski T, Kölsch H, Kromp M, Overesch I, Sauerland S, Gregor S. Negative pressure wound therapy in patients with wounds healing by secondary intention: a systematic review and meta-analysis of randomised controlled trials. Syst Rev 2020; 9:238. [PMID: 33038929 PMCID: PMC7548038 DOI: 10.1186/s13643-020-01476-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 09/07/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Negative pressure wound therapy (NPWT) is a widely used method of wound treatment. We performed a systematic review of randomised controlled trials (RCTs) comparing the patient-relevant benefits and harms of NPWT with standard wound therapy (SWT) in patients with wounds healing by secondary intention. METHODS We searched for RCTs in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and study registries (last search: July 2018) and screened reference lists of relevant systematic reviews and health technology assessments. Manufacturers and investigators were asked to provide unpublished data. Eligible studies investigated at least one patient-relevant outcome (e.g. wound closure). We assessed publication bias and, if feasible, performed meta-analyses, grading the results into different categories (hint, indication or proof of a greater benefit or harm). RESULTS We identified 48 eligible studies of generally low quality with evaluable data for 4315 patients and 30 eligible studies with missing data for at least 1386 patients. Due to potential publication bias (proportion of inaccessible data, 24%), we downgraded our conclusions. A meta-analysis of all wound healing data showed a significant effect in favour of NPWT (OR 1.56, 95% CI 1.15 to 2.13, p = 0.008). As further analyses of different definitions of wound closure did not contradict that analysis, we inferred an indication of a greater benefit of NPWT. A meta-analysis of hospital stay (in days) showed a significant difference in favour of NPWT (MD - 4.78, 95% CI - 7.79 to - 1.76, p = 0.005). As further analyses of different definitions of hospital stay/readmission did not contradict that analysis, we inferred an indication of a greater benefit of NPWT. There was neither proof (nor indication nor hint) of greater benefit or harm of NPWT for other patient-relevant outcomes such as mortality and adverse events. CONCLUSIONS In summary, low-quality data indicate a greater benefit of NPWT versus SWT for wound closure in patients with wounds healing by secondary intention. The length of hospital stay is also shortened. The data show no advantages or disadvantages of NPWT for other patient-relevant outcomes. Publication bias is an important problem in studies on NPWT, underlining that all clinical studies need to be fully reported.
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Affiliation(s)
- Yvonne Zens
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Michael Barth
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
- Basel Institute for Clinical Epidemiology & Biostatistics, University Hospital Basel and University of Basel, Basel, Switzerland
- Düsseldorf, Germany
| | - Heiner C. Bucher
- Basel Institute for Clinical Epidemiology & Biostatistics, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Katrin Dreck
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Moritz Felsch
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Wolfram Groß
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Thomas Jaschinski
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Heike Kölsch
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Mandy Kromp
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Inga Overesch
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Stefan Sauerland
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
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Lonneman MK, Devasahayam RJ, Phillips CJ. Leclercia adecarboxylata causing necrotising soft tissue infection in an immunocompetent adult. BMJ Case Rep 2020; 13:13/9/e235633. [PMID: 32994267 DOI: 10.1136/bcr-2020-235633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 72-year-old woman presented with concern for a necrotising soft tissue infection (NSTI) 6 days after a tree branch impaled her left lower extremity while hiking in Hawaii. The wound was irrigated and closed at a local clinic in Hawaii. She completed a 5-day course of clindamycin. She presented to our emergency department 1 day after completion of antibiotics due to worsening erythema and malodorous drainage. Local wound exploration revealed bullae and easy dissection of fascial planes. CT scan revealed complex heterogeneous fluid and inflammatory stranding in the posterior calf. Clinical and radiographic findings raised concern for NSTI prompting initiation of broad spectrum antibiotics and urgent operative debridement. Wound cultures and deep tissues cultures returned positive for pansusceptible Leclercia adecarboxylata She underwent two additional operative debridements and transitioned to negative pressure wound therapy during her hospitalisation. She was discharged home on oral amoxicillin/clavulanate on hospital day 6.
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Affiliation(s)
- Molly K Lonneman
- School of Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
| | | | - Cody J Phillips
- General Surgery, Madigan Army Medical Center, Tacoma, Washington, USA
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21
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Abstract
BACKGROUND Fasciotomy incision closure is often performed with skin grafts that can lead to cosmetic and functional complications after surgical intervention. Because fasciotomy incisions do not result in skin loss, the authors hypothesized that better closure can be achieved by reducing tissue edema with negative-pressure wound therapy (NPWT) and reducing stress on the skin with the shoelace surgical technique. METHODS This 1-year prospective study included eight patients with acute compartment syndrome after extremity fractures and/or blunt injuries. Patients were treated with fasciotomies closed with the shoelace technique and NPWT for wound margin approximation. The NPWT device was changed every second day; the shoelace traction tension was tightened at the same time. MAIN RESULTS The mean time from fasciotomy to wound closure was 11.8 days (range, 5-30 days). There was no need for a skin graft or flap in any patient. CONCLUSIONS The shoelace technique plus NPWT may be successful in closing skin fasciotomies after acute compartment syndrome without causing additional morbidity.
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22
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Chang G, Fram B, Krieg JC. Single-Incision 4-Compartment Fasciotomy of the Lower Leg: Safe, Effective, and Advantageous. Orthopedics 2020; 43:e225-e230. [PMID: 32271928 DOI: 10.3928/01477447-20200404-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 04/03/2019] [Indexed: 02/03/2023]
Abstract
The optimal surgical approach for acute compartment syndrome (ACS) of the lower leg remains debatable. Although a majority of surgeons tend to use a 2-incision approach to 4-compartment fasciotomies, the authors have used a single-incision technique followed by protocolized, staged skin closure. The purpose of this study was to determine the safety, efficacy, and complication rate of this strategy. This retrospective study included all patients treated for ACS by a single surgeon during a 3-year period. A protocol was used including a single-incision technique followed by vacuum-assisted wound-closure dressing, periodic return to the operating room at 48- to 72-hour intervals, and sequential wound closure with vertical mattress sutures. Complications associated with this protocol were analyzed. Eleven patients were included in the study. Average length of follow-up was 12 months (range, 2-35 months). There were no instances of malunion, deep or superficial infection, intraoperative neurovascular injury, or progressive neurologic deficits-indicating adequate release of all 4 compartments through a single incision. All patients were closed primarily without need for skin grafting. Average time to primary closure was 4.5 days. One patient had a tibial fracture nonunion and 1 had distal wound breakdown, which healed by secondary intention. A single-incision approach to 4-compartment fasciotomies followed by protocolized skin closure is safe and effective and may reduce the need for skin grafting. [Orthopedics. 2020;43(4):e225-e230.].
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Primary Closure of Wide Fasciotomy and Surgical Wounds Using Rubber Band-Assisted External Tissue Expansion: A Simple, Safe, and Cost-effective Technique. Ann Plast Surg 2019; 81:344-352. [PMID: 29905602 DOI: 10.1097/sap.0000000000001506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although decompressive fasciotomy is a limb-saving procedure in the setting of acute compartment syndrome, it leaves a large wound defect with tissue edema and skin retraction that can preclude primary closure. Numerous techniques have been described to address the challenge of closing fasciotomy wounds. This study reports our experience with fasciotomy closure using rubber bands (RBs) for external tissue expansion. METHODS Patients were informed about RB closure and split-thickness skin graft options. Only patients who opted for RB closure and had wounds that could not be approximated using the pinch test underwent the procedure. Starting from the apex and progressively advancing, the RBs were applied to the skin edges at 3 to 4 mm intervals using staples. The RBs were advanced by twisting back-and-forth to create a criss-cross pattern. One week after application, fasciotomy wounds were closed primarily or underwent further RB application, based on clinical assessment of adequacy of skin advancement, compartment tension, and perfusion. Review of a prospectively maintained database was performed, including demographics, comorbidities, etiology, wound and operative details, hospital stay, and complications. RESULTS Seventeen consecutive patients with 25 wounds (22 fasciotomy and 3 other surgical wounds) were treated using the RB technique. Average wound length and width measured 15.7 cm (range, 5-32 cm) and 5.2 cm (range, 1-12 cm), respectively. Locations of wounds included forearm (n = 12, 48.0%), leg (n = 7, 28.0%), hand (n = 4, 16.0%), elbow (n = 1, 4.0%), and hip (n = 1, 4.0%). Eighteen of 25 wounds (72.0%) were closed primarily after 1 RB application. Additional RB application was required for 5 wounds to achieve primary closure. Between stages, patients were discharged home if they did not have other conditions requiring in-hospital stay. No complications were observed, and no revision surgeries were required. Patient satisfaction was 100%, and all indicated that they would choose the RB technique over skin grafting. CONCLUSIONS The modified RB technique is a simple, safe, and cost-effective alternative for treating fasciotomy and other surgical defects resulting in high patient satisfaction and good cosmetic outcome, without the need for split-thickness skin graft or flap coverage.
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Alkhalifah MK, Almutairi FSH. Optimising Wound Closure Following a Fasciotomy: A narrative review. Sultan Qaboos Univ Med J 2019; 19:e192-e200. [PMID: 31728216 PMCID: PMC6839671 DOI: 10.18295/squmj.2019.19.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/11/2019] [Accepted: 04/15/2019] [Indexed: 11/24/2022] Open
Abstract
Compartment syndrome is a surgical emergency that could be resolved by a fasciotomy. However, performing substantial skin incisions may lead to life-threatening complications. This narrative review aimed to present the available methods of wound closure and preferential factors for using each technique. Viable and non-infected wounds were most often treated by gradual approximation techniques, such as the simple or modified shoelace technique, the prepositioned intracutaneous suture or several commercially-available mechanical devices. In addition, applying negative pressure therapy was found to be feasible, particularly when combined with approximation techniques. Skin grafting was reserved for severely-dehiscent wounds while other non-invasive approaches were considered for other subsets of patients with inadvisable surgical interventions. Treatment decision should be made in view of the patient’s condition, ease of application, availability of resources, cost of treatment and aesthetic outcomes.
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Apelqvist J, Willy C, Fagerdahl AM, Fraccalvieri M, Malmsjö M, Piaggesi A, Probst A, Vowden P. EWMA Document: Negative Pressure Wound Therapy. J Wound Care 2019; 26:S1-S154. [PMID: 28345371 DOI: 10.12968/jowc.2017.26.sup3.s1] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.1 NPWT has been described as a effective treatment for wounds of many different aetiologies2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,4-6 dehisced sternal wounds following cardiac surgery7,8 and as a valuable agent in complex non-healing wounds.9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.11 While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.
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Affiliation(s)
- Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, 205 02 Malmö, Sweden and Division for Clinical Sciences, University of Lund, 221 00 Lund, Sweden
| | - Christian Willy
- Department of Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Bundeswehr Hospital Berlin, Research and Treatment Center for Complex Combat Injuries, Federal Armed Forces of Germany, 10115 Berlin, Germany
| | - Ann-Mari Fagerdahl
- Department of Clinical Science and Education, Karolinska Institutet, and Wound Centre, Södersjukhuset AB, SE-118 83 Stockholm, Sweden
| | - Marco Fraccalvieri
- Plastic Surgery Unit, ASO Città della Salute e della Scienza of Turin, University of Turin, 10100 Turin, Italy
| | | | - Alberto Piaggesi
- Department of Endocrinology and Metabolism, Pisa University Hospital, 56125 Pisa, Italy
| | - Astrid Probst
- Kreiskliniken Reutlingen GmbH, 72764 Reutlingen, Germany
| | - Peter Vowden
- Faculty of Life Sciences, University of Bradford, and Honorary Consultant Vascular Surgeon, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom
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Angelis S, Apostolopoulos AP, Kosmas L, Balfousias T, Papanikolaou A. The Use of Vacuum Closure-assisted Device in the Management of Compound Lower Limb Fractures with Massive Soft Tissue Damage. Cureus 2019; 11:e5104. [PMID: 31523535 PMCID: PMC6728788 DOI: 10.7759/cureus.5104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The simultaneous exposure of tissue and bone poses specific management challenges. Patients with extended soft tissue damage and high-grade compound fractures present a demanding clinical challenge, requiring a complex approach and multiple orthopaedic, plastic, and vascular-reconstructive procedures. Management involves combinations of wound debridement and closure by secondary intention, use of vacuum-assisted closure (VAC) devices, and various reconstructive plastic surgery methods. We present three consecutive complicated cases, involving compound fractures of the lower limb with massive soft tissue damage (Gustilo-Anderson type IIIB) that were managed with debridement, application of external fixation and VAC device. The mean wound size was 24 cm in length and 12 cm in width. The aim of treatment was to cover the bone with soft tissue and achieve healing of the fracture without persistent infection. Wound healing was achieved in all three cases within 30-42 days (mean 34). In one case, the skin graft was applied on day 33. Utilizing this method as part of a multi-directional approach, the VAC system helps the patient recover faster. Moreover, it acts as a feasible and valuable method to treat compound fractures with massive soft-tissue defects. VAC can replace microsurgical soft-tissue transfer, reduce the risk of infection and allow salvaging the limb.
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Affiliation(s)
- Stavros Angelis
- Orthopaedics, General Hospital Hellenic Red Cross Korgialenio - Benakio, Athens, GRC
| | - Alexandros P Apostolopoulos
- Orthopaedics, East Surrey Hospital, Surrey and Sussex Healthcare National Health Service Trust, Redhill, GBR
| | - Lefteris Kosmas
- Orthopaedics, General Hospital Hellenic Red Cross Korgialenio - Benakio, Athens, GRC
| | - Theodore Balfousias
- Orthopaedics, General Hospital Hellenic Red Cross Korgialenio - Benakio, Athens, GRC
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Acute compartment syndrome: An orthopedic emergency. Nurse Pract 2019; 44:23-28. [PMID: 30865061 DOI: 10.1097/01.npr.0000554087.90202.2b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute compartment syndrome (ACS) is a true orthopedic emergency. NPs in all settings should be able to recognize ACS to ensure swift surgical intervention is not delayed. This article highlights a systematic approach to exam and diagnosis.
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Vacuum-assisted closure combined with a closed suction irrigation system for treating postoperative wound infections following posterior spinal internal fixation. J Orthop Surg Res 2018; 13:321. [PMID: 30558614 PMCID: PMC6297981 DOI: 10.1186/s13018-018-1024-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Wound infections after posterior spinal surgery are a troublesome complication; patients are occasionally forced to remove the internal fixation device, which can lead to instability of the spine and injury to the spinal cord. The purpose of this study was to evaluate the efficacy of modified vacuum-assisted closure (VAC) for treating an early postoperative spinal wound infection. METHODS We conducted a retrospective study of 18 patients with wound infections after posterior spinal surgery from 2014 to 2017 at a single tertiary center. All patients included in the study received modified VAC treatment (VAC combined with a closed suction irrigation system, CSIS) until the wound satisfied the secondary closure conditions. Detailed information was obtained from the medical records. RESULTS Wound size decreased significantly after 1 week of the modified VAC treatment. Three patients were treated with VAC three times and one patient received the VAC treatment four times; the remaining patients received the VAC treatment twice. The patients had excellent wound beds after an average of 8 days. The wound healed completely after an average of 17 days, and the average hospital stay was 33 days. There was no recurrence of infection at the 1-year follow-up. CONCLUSIONS This study demonstrates that VAC combined with a CSIS is a safe, reliable, and effective method to treat a wound infection after spinal surgery. This improved VAC procedure provides an excellent wound bed to facilitate wound healing and shorten the hospital stay.
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Johnson LS, Chaar M, Ball CG, Perez S, Nicholas JM, Wyrzykowski AD, Rozycki GS, Feliciano DV, Dente CJ. Management of extremity fasciotomy sites prospective randomized evaluation of two techniques. Am J Surg 2018; 216:736-739. [DOI: 10.1016/j.amjsurg.2018.07.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/10/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022]
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Schellenberg M, Chong V, Cone J, Keeley J, Inaba K. Extremity compartment syndrome. Curr Probl Surg 2018; 55:256-273. [PMID: 30470346 DOI: 10.1067/j.cpsurg.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/09/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Morgan Schellenberg
- Fellow in Trauma and Surgical Critical Care LAC + USC Medical Center, Los Angeles, CA
| | - Vincent Chong
- Fellow in Trauma and Surgical Critical Care LAC + USC Medical Center, Los Angeles, CA
| | - Jennifer Cone
- Assistant Professor of Surgery Division of Trauma and Acute Care Surgery, University of Chicago Medical Center, Chicago, IL
| | - Jessica Keeley
- Fellow in Trauma and Surgical Critical Care LAC + USC Medical Center, Los Angeles, CA
| | - Kenji Inaba
- Professor of Surgery, Emergency Medicine, and Anesthesia Medical Director, Surgical Intensive Care Unit Associate Trauma Medical Director University of Southern California, Los Angeles, CA.
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Comparison of lower extremity fasciotomy wound closure techniques in children: vacuum-assisted closure device versus temporary synthetic skin replacement. Eur J Trauma Emerg Surg 2018; 45:809-814. [PMID: 30014272 DOI: 10.1007/s00068-018-0985-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE No clear consensus on the optimal treatment of fasciotomy wounds due to acute compartment syndrome of the lower leg in children exists. We therefore compared two commonly used methods to close fasciotomy wounds, Epigard, a temporary synthetic skin replacement (SSR) and the vacuum-assisted closure (V.A.C.) device, in respect of treatment duration and complication rates. METHODS We studied the cases of 27 patients who were treated at our institution for acute compartment syndrome of the lower leg with a fasciotomy over a 10-year period. The fasciotomy wound was either treated with SSR or V.A.C. device. We recorded the number of procedures to definitive wound closure, days to wound closure, hospitalization days and sequelae rate. RESULTS In the V.A.C. device group (18 patients) the mean number of procedures until definitive wound closure was 3.1, mean days until wound closure was 9.4 and mean days of hospitalization was 16.2. One patient suffered from a wound infection and one patient required a full thickness skin graft. In the SSR group (9 patients), the mean number of procedures was 1.8, mean days until definitive wound closure was 4.9 and mean days of hospitalization was 9.9. No sequelae were recorded. There was a statistically significant smaller number of procedures (p value 0.018), fewer days to definitive wound closure (p value 0.002) and fewer hospitalization days (p value 0.005) in the SSR group. CONCLUSIONS Both SSR and V.A.C. device are safe and reliable for closure of fasciotomy wounds in children, whereas SSR seems to lead to shorter time until definitive wound closure.
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Arain AR, Cole K, Sullivan C, Banerjee S, Kazley J, Uhl RL. Tissue expanders with a focus on extremity reconstruction. Expert Rev Med Devices 2018; 15:145-155. [PMID: 29322847 DOI: 10.1080/17434440.2018.1426457] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Acute traumatic or surgical wounds that cannot be primarily closed often cause substantial morbidity and mortality. This often leads to increased costs from higher material expenses, more involved nursing care, and longer hospital stays. Advancements in soft tissue expansion has made it a popular alternative to facilitate early closure without the need for more complicated plastic surgical procedures. AREAS COVERED In this review, we briefly elaborate on the history and biomechanics of tissue expansion and provide comprehensive descriptions of traditional internal tissue expanders and a variety of contemporary external tissue expanders. We describe their uses, advantages, disadvantages, and clinical outcomes. The majority of articles reviewed include case series with level IV evidence. Outcome data was collected for studies after 1990 using PubMed database. EXPERT COMMENTARY An overall reduction in cost, time-to-wound closure, hospital length-of-stay, and infection rate may be expected with most tissue expanders. However, further studies comparing outcomes and cost-effectiveness of various expanders may be beneficial. Surgeons should be aware of the wide array of tissue expanders that are commercially available to individualize treatment based on thorough understanding of their advantages and disadvantages to optimize outcomes. We predict the use of external expanders to increase in the future and the need for more invasive procedures such as flaps to decrease.
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Affiliation(s)
- Abdul R Arain
- a Resident, Division of Orthopaedic Surgery , Albany Medical Center , Albany , NY, USA
| | - Keegan Cole
- a Resident, Division of Orthopaedic Surgery , Albany Medical Center , Albany , NY, USA
| | - Christopher Sullivan
- b Medical Student , Albany Medical College, Albany Medical Center , Albany , NY, USA
| | - Samik Banerjee
- a Resident, Division of Orthopaedic Surgery , Albany Medical Center , Albany , NY, USA
| | - Jillian Kazley
- a Resident, Division of Orthopaedic Surgery , Albany Medical Center , Albany , NY, USA
| | - Richard L Uhl
- c Chairman, Division of Orthopaedic Surgery , Albany Medical Center , Albany , NY, USA
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Pesonen LO, Halloran BG, Aziz A. Prophylactic Groin Wound Vacuum-assisted Therapy in Vascular Surgery Patients at Enhanced Risk for Postoperative Wound Infection. Ann Vasc Surg 2018; 46:127-133. [DOI: 10.1016/j.avsg.2017.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 07/02/2017] [Accepted: 07/03/2017] [Indexed: 10/19/2022]
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Mittal N, Bohat R, Virk JS, Mittal P. Dermotaxis v/s loop suture technique for closure of fasciotomy wounds: a study of 50 cases. Strategies Trauma Limb Reconstr 2017; 13:35-41. [PMID: 29039127 PMCID: PMC5862706 DOI: 10.1007/s11751-017-0299-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 10/08/2017] [Indexed: 11/30/2022] Open
Abstract
Fasciotomy incisions lead to large, unsightly, chronic wounds after surgical intervention. Classic management was to use split-thickness skin grafts, but this leads to insensate skin with reports that as many as 23% of patients are dissatisfied by the appearance of the wound. Since no skin loss has occurred with the fasciotomy incision, utilizing the dermal properties of creep, stress relaxation and load cycling, closure can be achieved in a better way. We describe using dermotaxis for skin edge approximation that is done using inexpensive equipment available readily in any standard operating room. Twenty-five patients had fasciotomy wounds closed either by dermotaxis or a loop suture technique with the inclusion criteria being closed fractures, no concomitant skin loss, fracture-related compartment syndrome and fasciotomy performed within 36 h. The fasciotomy incision was closed in a single stage by loop suture technique or gradually by dermotaxis once the oedema had settled between 3 and 5 days. Results were graded as excellent if approximation could be achieved, good if sutures had to be applied for protective care and poor if wounds needed to be skin-grafted. In the dermotaxis group, results were excellent in 15, good in 8 and poor in 2 cases. In the loop suture technique group, results were excellent in 20, good in 4 and poor in 1 case. Dermal apposition using inexpensive, readily available equipment is an alternative method for closure of fasciotomy wounds. If limb oedema has settled sufficiently, closure using a loop suture can be done in a single stage. If the limb remains oedematous, gradual closure can be done using dermotaxis.
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Affiliation(s)
- Naveen Mittal
- , #3732 Sector 46-c, Chandigarh, India. .,Government Medical College Hospital, Sector-32, Chandigarh, India.
| | - Robin Bohat
- Government Medical College Hospital, Sector-32, Chandigarh, India
| | | | - Payal Mittal
- Government Medical College Hospital, Sector-32, Chandigarh, India
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Suzuki H, Chang A, Kumagae H, Shimizu Y, Sakai A, Uchida S. Arthroscopic Shoelace Side-to-Side Repair Technique Using Ultratape for the Treatment of Longitudinal Midsubstance Rotator Cuff Tears. Arthrosc Tech 2017; 6:e1845-e1850. [PMID: 29430390 PMCID: PMC5799492 DOI: 10.1016/j.eats.2017.06.058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/29/2017] [Indexed: 02/03/2023] Open
Abstract
Shoulder arthroscopy is a promising tool for assessing and treating patients with a rotator cuff tear. Arthroscopic rotator cuff repair with suture anchor fixation such as the single-row, double-row, and suture bridge technique are popular procedures that can provide excellent clinical outcomes. On the other hand, longitudinal midsubstance, U-shape, or L-shape tears may benefit more from a side-to-side/margin convergence technique. Despite following the standard side-to-side/margin convergence technique, we continue to see disruption at the site of side-to-side suture margin even with strong sutures. Here, we show our preferred arthroscopic shoelace rotator cuff repair technique using the more durable body tape for a longitudinal U-shape rotator cuff tear.
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Affiliation(s)
- Hitoshi Suzuki
- Department of Orthopaedic Surgery, Wakamatsu Hospital of the University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Angela Chang
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Hiroto Kumagae
- Department of Orthopaedic Surgery, Wakamatsu Hospital of the University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Yuki Shimizu
- Department of Orthopaedic Surgery, Wakamatsu Hospital of the University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Akinori Sakai
- Department of Orthopaedic Surgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Soshi Uchida
- Department of Orthopaedic Surgery, Wakamatsu Hospital of the University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan,Address correspondence to Soshi Uchida, M.D., Ph.D., Department of Orthopaedic Surgery, Wakamatsu Hospital for the University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu, Kitakyushu, Fukuoka, Japan.Department of Orthopaedic SurgeryWakamatsu Hospital for the University of Occupational and Environmental Health1-17-1 HamamachiWakamatsuKitakyushuFukuokaJapan
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Cone J, Inaba K. Lower extremity compartment syndrome. Trauma Surg Acute Care Open 2017; 2:e000094. [PMID: 29766095 PMCID: PMC5877908 DOI: 10.1136/tsaco-2017-000094] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/25/2017] [Indexed: 12/11/2022] Open
Abstract
Lower extremity compartment syndrome is a devastating complication if not rapidly diagnosed and properly managed. The classic symptoms of compartment syndrome can be deceiving as they occur late. Any concern for compartment syndrome based on mechanism, or the presence of pain in the affected extremity, should prompt a compartment pressure check. Both absolute compartment pressures above 30 mm Hg and a pressure differential of less than 30 mm Hg are used to make the diagnosis. The treatment goal is first to save the patient’s life and second to salvage the affected limb. Fasciotomy is the only accepted treatment of compartment syndrome and should be performed quickly after the diagnosis is made. Outcomes after fasciotomy are best when there is no delay in treatment.
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Affiliation(s)
- Jennifer Cone
- Trauma and Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California, USA
| | - Kenji Inaba
- Trauma and Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California, USA
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Elastic suture (shoelace technique) for fasciotomy closure after treatment of compartmental syndrome associated to tibial fracture. Rev Bras Ortop 2017; 52:103-106. [PMID: 28194389 PMCID: PMC5290075 DOI: 10.1016/j.rboe.2016.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 12/14/2015] [Indexed: 11/23/2022] Open
Abstract
This article reports the use of elastic suture as an adjuvant in surgical wound closure caused by decompressive fasciotomy after compartment syndrome associated with a compound fracture of the tibia. Widely used in other medico-surgical specialties, this technique is unusual in orthopedics surgery, but the simplicity of the procedure and the successful outcome observed in this case allows for its consideration as indicated for situations similar to that presented in this study.
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Uchida S, Pascual-Garrido C, Ohnishi Y, Utsunomiya H, Yukizawa Y, Chahla J, Sakai A. Arthroscopic Shoelace Capsular Closure Technique in the Hip Using Ultratape. Arthrosc Tech 2017; 6:e157-e161. [PMID: 28373955 PMCID: PMC5368343 DOI: 10.1016/j.eats.2016.09.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 09/09/2016] [Indexed: 02/03/2023] Open
Abstract
Hip arthroscopy is promising tool for assessing and treating intra-articular pathologies including labral tears, cartilage injuries, and ligamentum teres tears of the hip. Interportal capsulotomy allows for better visualization and accessibility of the arthroscope and working instruments. The hip capsule has been defined as a crucial stabilizer of the hip joint. Thus, capsular closure is recognized as an important procedure to prevent postoperative instability after hip arthroscopic surgery. Despite the routine capsular closure during hip arthroscopy, there is a small subset of patients who complain of hip pain and dysfunction after surgery most likely because of disruption of hip closure site after routine complete capsular closure with strong suture for treating hip instability. This technical note describes the arthroscopic shoelace capsular suture technique using Ultratape for treating femoroacetabular impingement with capsular laxity and borderline hip dysplasia.
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Affiliation(s)
- Soshi Uchida
- Wakamatsu Hospital for the University of Occupational and Environmental Health, Fukuoka, Japan,Address correspondence to Soshi Uchida, M.D., Ph.D., Department of Orthopaedic Surgery, Wakamatsu Hospital for the University of Occupational and Environmental Health, 1-17-1 Hamamachi Wakamatsu, Kitakyushu, Fukuoka 808-0024, Japan.Department of Orthopaedic SurgeryWakamatsu Hospital for the University of Occupational and Environmental Health1-17-1 Hamamachi WakamatsuKitakyushuFukuoka808-0024Japan
| | | | - Yasuo Ohnishi
- Wakamatsu Hospital for the University of Occupational and Environmental Health, Fukuoka, Japan
| | - Hajime Utsunomiya
- Wakamatsu Hospital for the University of Occupational and Environmental Health, Fukuoka, Japan
| | - Yohei Yukizawa
- Wakamatsu Hospital for the University of Occupational and Environmental Health, Fukuoka, Japan
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Akinori Sakai
- Wakamatsu Hospital for the University of Occupational and Environmental Health, Fukuoka, Japan
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Enhancement of Bone-Marrow-Derived Mesenchymal Stem Cell Angiogenic Capacity by NPWT for a Combinatorial Therapy to Promote Wound Healing with Large Defect. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7920265. [PMID: 28243602 PMCID: PMC5294348 DOI: 10.1155/2017/7920265] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 12/20/2016] [Indexed: 12/28/2022]
Abstract
Poor viability of engrafted bone marrow mesenchymal stem cells (BMSCs) often hinders their application for wound healing, and the strategy of how to take full advantage of their angiogenic capacity within wounds still remains unclear. Negative pressure wound therapy (NPWT) has been demonstrated to be effective for enhancing wound healing, especially for the promotion of angiogenesis within wounds. Here we utilized combinatory strategy using the transplantation of BMSCs and NPWT to investigate whether this combinatory therapy could accelerate angiogenesis in wounds. In vitro, after 9-day culture, BMSCs proliferation significantly increased in NPWT group. Furthermore, NPWT induced their differentiation into the angiogenic related cells, which are indispensable for wound angiogenesis. In vivo, rat full-thickness cutaneous wounds treated with BMSCs combined with NPWT exhibited better viability of the cells and enhanced angiogenesis and maturation of functional blood vessels than did local BMSC injection or NPWT alone. Expression of angiogenesis markers (NG2, VEGF, CD31, and α-SMA) was upregulated in wounds treated with combined BMSCs with NPWT. Our data suggest that NPWT may act as an inductive role to enhance BMSCs angiogenic capacity and this combinatorial therapy may serve as a simple but efficient clinical solution for complex wounds with large defects.
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Sutura elástica no fechamento de fasciotomia para tratamento de síndrome compartimental associada à fratura da tíbia. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2015.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Jauregui JJ, Yarmis SJ, Tsai J, Onuoha KO, Illical E, Paulino CB. Fasciotomy closure techniques. J Orthop Surg (Hong Kong) 2017; 25:2309499016684724. [PMID: 28176601 DOI: 10.1177/2309499016684724] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We evaluated the risks and success rates of the three major techniques for compartment syndrome fasciotomy closure by reviewing all literature published to date. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically evaluated the Medline (PubMed) database until July 2015, utilizing the Boolean search sting "compartment syndrome OR fasciotomy closure." Two authors independently assessed all studies published in the literature to ensure validity of extracted data. The data was compiled into an electronic spreadsheet, and the wound closure rate with each technique was assessed utilizing a proportion random model effect. Success was defined as all wounds that could be closed without skin grafting, amputation, or death. The highest success rate was observed for dynamic dermatotraction and gradual suture approximation, whereas vacuum-assisted closure had the lowest complication rate.
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Affiliation(s)
- Julio J Jauregui
- 1 Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, USA
| | - Samantha J Yarmis
- 2 Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, New York, NY, USA
| | - Justin Tsai
- 2 Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, New York, NY, USA
| | - Kemjika O Onuoha
- 2 Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, New York, NY, USA
| | - Emmanuel Illical
- 2 Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, New York, NY, USA
| | - Carl B Paulino
- 2 Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, New York, NY, USA
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Owen C, Cavalcanti A, Molina V, Honoré C. Decompressive fasciotomy for acute compartment syndrome of the leg. J Visc Surg 2016; 153:293-6. [PMID: 27374476 DOI: 10.1016/j.jviscsurg.2016.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- C Owen
- Département de chirurgie générale, Gustave-Roussy Cancer Campus, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France
| | - A Cavalcanti
- Département de chirurgie générale, Gustave-Roussy Cancer Campus, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France
| | - V Molina
- Département de chirurgie orthopédique, CHU de Kremlin-Bicètre, 94270 Kremlin-Bicètre, France
| | - C Honoré
- Département de chirurgie générale, Gustave-Roussy Cancer Campus, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France.
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Abstract
Acute compartment syndrome (ACS) is a well-known pathophysiologic complication of trauma or tissue ischemia. ACS affects the appearance, function, and even the viability of the involved limb, and demands immediate diagnosis and treatment. However, ACS is difficult to diagnose and the only effective treatment is decompressive surgical fasciotomy. The clinical signs and symptoms may easily be attributed to other aspects of the injury, which further complicates the diagnosis. This article highlights the latest information regarding the diagnosis of ACS, how to perform fasciotomies, how to manage fasciotomy wounds, and also reviews complications and outcomes of ACS.
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Affiliation(s)
- Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin County Medical Center, 701 Park Avenue South, Mail Code G2, Minneapolis, MN 55415, USA.
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Price G, Hodgins N, Fogarty B. A comparison of fasciotomy wound closure methods following extremity compartment syndrome at a regional trauma centre. EUROPEAN JOURNAL OF PLASTIC SURGERY 2015. [DOI: 10.1007/s00238-015-1156-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fletcher MDA, Solomin LN. Definitive management of significant soft tissue loss associated with open diaphyseal fractures utilising circular external fixation without free tissue transfer, a comprehensive review of the literature and illustrative case. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:65-75. [PMID: 24659455 DOI: 10.1007/s00590-014-1441-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/12/2014] [Indexed: 11/24/2022]
Abstract
Accepted management of diaphyseal fractures associated with significant tissue loss is rigid intramedullary stabilisation with free or rotational musculocutaneous flap coverage. Circular external fixation is a powerful tool in the management of limb trauma and with recent advances has been developed to provide multiple techniques for which even massive tissue loss can be addressed without the need for free tissue transfer. Gradual and acute shortening, acute fracture deformation and gradual lengthening with restoration of deformity combined with distraction tissue histiogenesis can provide the surgeon with an array of options which can be precisely tailored to the particular personality of a severe open diaphyseal fracture.
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Abstract
OBJECTIVES The primary purpose of this study is to determine whether a strategy of bringing patients back to the operating room for successive debridements allows for the eventual delayed primary closure (DPC) of fasciotomy wounds. DESIGN Retrospective cohort study. Data were collected from medical records and radiographs. SETTING Two urban level 1 trauma centers. PATIENTS One hundred four adult patients with acute compartment syndrome in the setting of a tibia fracture (open or closed). INTERVENTION All patients underwent decompressive fasciotomies with closure by either DPC or split-thickness skin grafting (STSG) during a subsequent surgical procedure. MAIN OUTCOME MEASURE Number of fasciotomy wounds closed by DPC after the initial fasciotomy procedure. RESULTS Of the 104 patients brought to the operating room for their first debridement after their fasciotomies, 19 patients (18%) were treated with DPC, whereas 42 patients (40%) were closed with STSG because they were believed to be too swollen to allow for primary closure by the treating surgeon. Three of the remaining 43 patients were treated with DPC during their second debridement. No patients who underwent more than 2 washouts could be treated with DPC. No patients who sustained open fractures were able to be closed by DPC (P = 0.02). Patients who underwent STSG on their first postfasciotomy procedure had a significantly shorter hospital stay than patients who underwent additional procedures before closure (12.2 vs. 17.4 days; P = 0.005). CONCLUSIONS Fasciotomy wounds that are not able to be primarily closed during their first postfasciotomy surgical procedure are rarely closed through DPC techniques. Early skin grafting of these wounds should be considered, especially in the clinical setting of an open injury, because it significantly decreases the length of hospital stay. Other techniques that avoid repeated debridements and attempted closures might also help reduce hospital stay. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Tuna S, Duymus TM, Mutlu S, Ketenci IE, Ulusoy A. Upper extremity acute compartment syndrome during tissue plasminogen activator therapy for pulmonary embolism in a morbidly obese patient. Int J Surg Case Rep 2015; 8C:175-8. [PMID: 25618841 PMCID: PMC4353933 DOI: 10.1016/j.ijscr.2015.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 01/11/2015] [Accepted: 01/13/2015] [Indexed: 12/21/2022] Open
Abstract
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are more frequently observed morbidly obese patients. As the use of thrombolytic therapy has become more common in the treatment of myocardial infarction (MI) and PE, acute compartment syndrome (ACS) has been reported as a rare complication of thrombolytic therapy. As soon as the diagnosis of compartment syndrome is made, an emergency fasciotomy should be performed. Close follow-up is required to avoid wound healing problems after the fasciotomy.
Introduction Deep vein thrombosis (DVT) and pulmonary embolism (PE) are more frequently observed in morbidly obese patients. Tissue plasminogen activator (tPA) is a thrombolytic agent which dissolves the thrombus more rapidly than conventional heparin therapy and reduces the mortality and morbidity rates associated with PE. Compartment syndrome is a well-known and documented complication of thrombolytic treatment. In awake, oriented and cooperative patients, the diagnosis of compartment syndrome is made based on clinical findings including swelling, tautness, irrational and continuous pain, altered sensation, and severe pain due to passive stretching. These clinical findings may not be able to be adequately assessed in unconscious patients. Presentation of case In this case report, we present compartment syndrome observed, for which fasciotomy was performed on the upper right extremity of a 46-year old morbidly obese, conscious female patient who was receiving tPA due to a massive pulmonary embolism. Discussion Compartment syndrome had occurred due to the damage caused by the repeated unsuccessful catheterisation attempts to the brachial artery and the accompanying tPA treatment. Thus, the bleeding that occurred in the volar compartment of the forearm and the anterior compartment of the arm led to acute compartment syndrome (ACS). After relaxation was brought about in the volar compartment of the forearm and the anterior compartment of the arm, the circulation in the limb was restored. Conclusion As soon as the diagnosis of compartment syndrome is made, an emergency fasciotomy should be performed. Close follow-up is required to avoid wound healing problems after the fasciotomy.
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Affiliation(s)
- Serkan Tuna
- Department of Orthopaedics, Haydarpasa Numune Training Research Hospital, Istanbul, Turkey
| | - Tahir Mutlu Duymus
- Department of Orthopaedics, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Serhat Mutlu
- Department of Orthopaedics, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey.
| | - Ismail Emre Ketenci
- Department of Orthopaedics, Haydarpasa Numune Training Research Hospital, Istanbul, Turkey
| | - Ayhan Ulusoy
- Department of Orthopaedics, Haydarpasa Numune Training Research Hospital, Istanbul, Turkey
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Abstract
Early fasciotomy is the gold standard of prevention and treatment of compartment syndrome; however, the resulting wounds may significantly increase morbidity. To address the challenge of timely and safe closure of fasciotomy wounds, numerous methods have been described. A thorough search of medical databases PubMed/MEDLINE, ScienceDirect, SCOPUS, EMBASE, and Google Scholar was conducted for articles published between 1976 and 2013 using the search terms “limb fasciotomy wound closure,” “open wound management,” “skin stretching,” and “fasciotomy complications.” A total of 49 articles on technique descriptions, case reports of 2 or more patients, and of complications and comparative studies regarding limb fasciotomy wound closure were included. Details of the duration of treatment, advantages and disadvantages, direct cost, and complications were data extracted for each technique from the 49 studies included in this overview. Thorough knowledge of available techniques and their comparative advantages is essential for their clinical implementation, careful selection of patients, management of possible complications, decreased morbidity, and hospital recovery time and is also crucial for optimization of functional and aesthetic outcomes.
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