There was one moderate strength (Li, 2015) and three low strength (Zannis, 2009; Mittal, 2017; Krticka, 2016) studies evaluating wound management after fasciotomy. Li et al. found that use of negative pressure wound therapy resulted in a decrease in days to wound closure/coverage (9 days versus 14 days). Zannis et al. found that negative pressure wound therapy resulted in decreased need for split thickness skin graft in both the lower limb (17% versus 44%, RR 0.39) and upper limb (43% versus 66%, RR 0.67).
Of the three studies that reported important but rare outcomes including infection and/or other complications, all were underpowered to adequately assess these rare outcomes (subject sizes: 52 patients in Li et al., 63 patients in Krticka et al. and 50 patients in Mittal et al.). Krticka 2016 compared vacuum-assisted closure with dermatotaxis technique versus dressing fabrics and reported that dressing fabrics resulted in a higher rate of infection that was not statistically significant (9.5% versus 14.3%). For context, based on this rate of infection a study would require 1,478 patients (739 per group) to be adequately powered to detect a statistically significant difference with 80% power, assuming an alpha of 5%.
Mittal et al. compared two specific dermatotaxis techniques to aid wound closure without use of negative pressure wound therapy and found that use of tensioned wires (as opposed to sutures) resulted in higher risk of infection (12% versus 4%, RR 3).
POSSIBLE HARMS OF IMPLEMENTATION
We believe that there is no harm associated with use of negative pressure wound therapy to assist wound management/wound closure of fasciotomy wounds, particularly if used in the short term. However, there may be a relationship between time to wound closure/coverage and risk of infection, particularly in the setting of metallic implants. However, this is not been examined in the literature in this patient population. Furthermore, the risk benefit ratio of dermatotaxis techniques are not yet clear.
Future research is needed to further clarify the relative benefits associated with use of negative pressure wound therapy, with particular consideration for austere environments. This work has important implications for forward surgical teams utilized by the military. However, there may be barriers to performing this work in civilian settings due to the substantial benefits of negative pressure wound therapy in terms of patient care (fewer dressing changes, easier nursing care) as well as theoretical benefits (including reduction in nosocomial contamination due to sterile placement in the operating room, improved granulation tissue formation to improve skin graft bed). Adequately powered high quality studies are needed to explore the relationship between management of fasciotomy wounds and complication such as infection as well as rate of and time to delayed wound closure and/or skin graft. Independent variables important to study include type of wound care method (ie negative pressure wound therapy versus wet to dry guaze), use of dermatotaxis techniques (ie “Jacob’s ladder” or “shoestring” technique versus traditional), time to closure or skin graft, timing for definative fixation/definative hardware. Both hard outcomes as well as functional outcomes and health-related quality of life outcomes are needed to adequately guide decision-making.
- Krticka, M., Ira, D., Bilik, A., Rotschein, P., Svancara, J. Fasciotomy closure using negative pressure wound therapy in lower leg compartment syndrome. Bratislavske Lekarske Listy 2016; 12: 710-714
- Li, W., Ji, L., Tao, W. Effect of vacuum sealing drainage in osteofascial compartment syndrome. International Journal of Clinical and Experimental Medicine 2015; 9: 16112-16116
- Mittal, N., Bohat, R., Virk, J. S., Mittal, P. Dermotaxis v/s loop suture technique for closure of fasciotomy wounds: a study of 50 cases. Strategies in Trauma and Limb Reconstruction 2017; 0: 1-7
- Zannis, J., Angobaldo, J., Marks, M., DeFranzo, A., David, L., Molnar, J., Argenta, L. Comparison of fasciotomy wound closures using traditional dressing changes and the vacuum-assisted closure device. Annals of Plastic Surgery 2009; 4: 407-9