HOWIDOIT
Shoelace Techni~e for Delayed Primary Closure
of Fasciotomies
Scott S. Berman, MD,Jolyon D. Schilhng, MD,TWSW~ri~na Kenneth E. McIntyre, MD,cialvestoa,TWO
Glen C. Hunter, MD, Victor M. Bernhard, MD, TUCKSI,Arizona
Performing a timely fasciotomy for compart-
ment Syndrome prevents ischemic injury to
muscles and nerves. Fasciotomy entails incision
of the overlying skin and investing fascia of the
compartment, relieving pressure and enhancing
tissue perfusion. Delayed primary closure is
ideal, but because of skin edge retraction, the
open wound must either heal secondarily or be
closed with a split-thickness &in graft. The
shoelace technique involves running a silastic
vessel loop through skin staples placed at the
skin edge along the initial fasciotomy incision.
Daily tightening of the shoelace permits gradual
reapproximation of the skin edges while com-
partment edema resolves. Closure using a simple
suture or Steri-strip (3M Surgical Products,
St. Paul, Minuesota) ia then possible after 5 to
10 days. The shoelace technique allows for
gradual primary closure of open fasciotomy
wounds, thereby avoiding the morbidity and cost
associated with skin graft or secondary closure.
Cpressure
ompartment syndrome occurs from increased tissue
within a closed space and may cause ischemic
injury to the nerves and muscles if not adequately treated
in a timely fashion. When tissue pressure rises, the capil-
lary hydrostatic pressure is exceeded by the compartment
pressure and the critical perfusion pressure is overcome.
If unchecked, the ensuing &hernia injures nerves and mus-
cles within the confined compartment. Compartment syn-
drome has many causes.’ Pressure within the compartment
may increase because of a decrease in compartment size,
as occurs with constricting casts or bum eschars. The syn-
drome can also result from an increase in compartment
contents, as from hemorrhage after trauma or reperfusion
edema after prolonged ischemia.2 Because of its many eti-
ologies, compartment syndrome is managed by surgeons
from several disciplines.
Fasciotomy is the mainstay of treatment for the com-
partment syndrome. The technique involves an incision in
the investing fascia of the compartment to relieve pressure,
thereby allowing perfusion of the tissues within the com-
partment. The fasciotomy skin incision is not closed dur-
ing the initial procedure. Alternatives for achieving clo-
From the Department of Surgery, Section of Vascular Surgery,
University of Arizona Health Sciences Center, Tucson, Arizona. and the
Department of Surgery, University of Texas Medical Branch, Galveston
Texas.
Requests for reprints should be addressed to Kenneth E. McIntyre, MD,
University of Texas Medical Branch, Department of Surgery, E-41 Room
6.110, 301University Blvd., Galveston, Texas. 77555
Manuscript submitted December 7, 1992, and accepted February 15,
1993.
THE AMERICAN JOURNAL OF SURGERY
sure of the wound during the early postoperative period
are delayed primary closure and split-thickness skin graft-
ing. The skin edges of the fasciotomy wound retract be-
cause of the bulging of edematous muscles, and in spite
of the resolution of compartment edema, the skin becomes
fixed to underlying muscle and delayed closure cannot be
done in the usual 3 to 5 days. Therefore, skin grafting is
often required. We describe a technique performed during
the initial fasciotomy that allows gradual reapproximation
of the skin edges over the course of 5 to 10 days. This
technique accomplishes delayed primary closure with no
need for skin grafting of the gaping fasciotomy wound.
TECHNIQUE
A silastic vessel loop is used as a “shoelace” to approx-
imate the edges of the wound. The vessel loop is laid per-
pendicular to one end of the wound so that the apex of the
incision bisects the silastic. Two staples are applied over
the vessel loop into the skin at this point to anchor it. Both
ends of the vessel loop are crossed at an angle to ensure
that the silastic will intercept the edge of the wound about
2 cm from the staples. A single staple is then applied over
the vessel loop-parallel to and a few millimeters from the
skin edge-to function as an “eye” for the lace on each
side (Figure). The vessel loops are then crossed again and
spaced so that they continue to meet the skin edge 2 cm
from the last staple.
This process is repeated, crossing the vessel loops
through the staples, until the silastic is “laced” along the
entire length of the wound. At the opposite end, after the
last two staples are applied near the apex, sufficient ten-
sion on the wound is achieved by pulling the ends of the
lacing together. The vessel loop must not be placed under
too much tension to avoid blanching the skin or compro-
mising the fasciotomy. The vessel loop ends are then tied
to one another with multiple overhand knots. If a single
Figure. Shoelace techniquefor fasciotomy closure. Skin staples
spaced approximately 2 cm apart (insert) function as eyelets for a silas-
tic vessel loop that serves as the lace.
VOLUME 167 APRIL 1994 435
BERMAN ET AL
vessel loop is not long enough to close the entire incision,
one loop may be started from each end and tied together
in the center.
As swelling in the extremity decreases, the tension of the
lacing will also decrease and redundancy in the lace will
occur. During the daily wound inspection at the bedside,
the lace is tightened using a sterile technique. After unty-
ing or cutting the knot, the lace is tightened throughout the
length by stretching the vessel loop. Once the proper ten-
sion is reestablished, the ends of the loop are again tied
snugly. This process may be repeated every day or every
other. After several days, the wound edges approximate,
and it is usually possible to use a Steri-strip (3M Surgical
Products, St. Paul, Minnesota) or a simple suture to close
the wound. The vessel loops and staples are removed as
the wound is closed.
COMMENTS
Fasciotomy effectively treats compartment syndrome. As
the syndrome may be consequent to several causes, sur-
geons from different disciplines need to be familiar with
the technique and with alternatives for managing the open
wound, which may not lend itself to delayed primary clo-
sure.
Although several techniques for closing fasciotomy
wounds have been described, delayed primary closure is
the procedure of choice. It has been accomplished using
staples, and simple and vertical mattress suture tech-
niques.3 For wounds that cannot be closed primarily, early
split-thickness skin grafting has been advocated to hasten
functional recovery. Skin grafting is not without attendant
morbidity, however, including pain at the donor site, in-
fection, incomplete graft adherence, and an unsatisfactory
cosmetic result at the graft site.
The shoelace technique as detailed above was first de-
scribed by Cohn and coworkers for forearm fasciotomy
436 THE AMERICAN JOURNAL OF SURGERY VOLUME 167 APRIL 1994
closure and used rubber vessel loops as the lace compo-
nent.4 The patient was returned to the operating room ev-
ery few days for wound inspection and tightening of the
vessel loops until complete skin edge approximation was
attained. Modifying that technique, Almekinders replaced
the rubber vessel loop with a large nylon suture.5 This tech-
nique permits daily tightening of the suture, with complete
wound closure achieved in 7 to10 days, obviating further
trips to the operating room.
SUMMARY
Delayed primary closure of a fasciotomy wound is often
difficult because of skin edge retraction and fixation to
swollen muscles. Using the shoelace technique of delayed
closure of the wounds allows for gradual closure of open
fasciotomy incisions, thus eliminating the need for split-
thickness skin grafting or reliance on secondary intention
healing.
REFERENCES
1. Matsen FA III, Krugmire RB. Compartmental syndromes. Surg
Gynecol Obstet. 1978; 147:943-949.
2. Hargens AR, Akeson WH. Pathophysiology of the compartment
syndrome. In: Mubarak SJ, Hargens AR, eds. Compartment Syn-
dromes and Volkmann’s Contracture. Philadelphia: WB Saunders;
1981:47-70.
3. Mubarak SJ. Lower extremity compartment syndromes: treat-
ment. In: Mubarak SJ, Hargens AR, eds. Compartment Syndromes
and Volkmann’s Contracture. Philadelphia: WB Saunders; 198 1:
147-165.
4. Cohn BT, Shall J, Berkowitz M. Forearm fasciotomy for acute
compartment syndrome: a new technique for delayed primary clo-
sure. Orthopedics. 1986;9: 1243-1246.
5. Almekinders LC. Gradual closure of fasciotomy wounds. Orthop
Rev. 1991; 20:82-84.