Closure of Fasciotomy wounds. A Dermatotracion technical modification.pptx

Methods for techniques for closure of fasciotomy wounds without skin grafts.
Benefits for orthopedic and vascular surgeons and general surgeons.

1. Closure of Fasciotomy wounds. A Dermatotracion technical modification for delayed primary closure. Submitted by Dr. Ali Ahmed Yahya Barat Supervisor Dr. Nabeel Y. Almedwahi Assist. Pro. Of Cardiovascular Surgery General Co-Ordinator of Cardiovascular Surgery in Yemen Board

2. Introduction 2 A compartment syndrome occurs when pressure inside a closed fascial sheath increases to a degree which damage capillary perfusion within the compartment.

3. 3 PRESSURE * > 30 – 40 mmHg considered diagnostic

4. Introduction 4 Acute compartment syndrome (ACS) is an urgent surgical pathology when delaying medical care leads to serious damage to the limb, such as dysfunction or even loss

5. Introduction 5 Early fasciotomy is the foundation of prophylactic and treatment of compartment syndrome (ACS).

6. 6 Following fasciotomy in the lower leg the edematous muscle and the retracted skin edges make delayed primary closure difficult. Problem statement:

7. Introduction 7 The classic management of fasciotomy wounds was split-thickness skin graft. If the closure of the fasciotomy is performed with skin grafts, the resulting donor and acceptor scars are not cosmetic.

8. Problem statement: 8 Over the past years, many methods have been suggested for using dermatotraction —a continual traction on the skin's margins—to gradually closure of fasciotomy wounds. The use of gradual mechanical dermal apposition techniques has been increased in approval as a successful method for closing fasciotomy wounds

9. 9 Objective Our objective was to examine fasciotomy wound outcomes, including time to definitive closure, comparing two of the most frequently employed methods for delayed primary closure: the Ty-Rap system closure and the shoelace technique. Fig. 1 Showing loop suture technique Plastic bands.

10. Patients and methods: 10 In this study, a total of 17 patients were registered during a 2-year period (January 2021– January 2023) The study was conducted according to the institutional guidelines for clinical studies and all patients received thorough explanation of the study and signed an informed consent.

11. 11 Presentation title 20XX Patients and Methods Study Design and Patients Patients: 17 in tonal. Groups: 2 group, 9 patients in I group, and 14 fasciotomy wounds. And 8 patients in II group, and 12 fasciotomy wounds. . Study Setting: A randomized study

12. 12 Presentation title 20XX Patients and Methods Study Design and Patients The criteria for exclusion : concomitant lower leg burns. Circumferential wound of extremity. Amputations or extensive soft tissue loss . Proximal arterial injury . Head injury, confusion . Presence of active infection. History of diabetes, heart disease, drug abuse . Inclusion and Exclusion Criteria: The criteria for inclusion: Patients having surgical wound which cannot be closed by primary suturing.

13. PATIENTS AND METHODS: 13 Presentation title 20XX Population and Sample of the Study: Conducted patients with acute compartment syndrome due to leg fractures and/or blunt injuries and who underwent decompressive fasciotomies of the leg, and who were treated with leg fasciotomies closure managed by Ty-Raps technique or shoelace technique Parameters Measured Ÿ The time to closure of the wound. Ÿ The time to removal of the Ty-Raps or loop . Ÿ The complications related to the procedure .

14. Surgical Technique and Closure: 14 Presentation title 20XX We used the standard two-incision technique for fasciotomy of the leg using the posteromedial and anterolateral incisions, when single incision was reserved for simply soft tissue injuries. The wound on the lateral side was closed either by Ty-Raps technique or a loop suture technique.

15. Description of each technique 15 Presentation title 20XX The Ty-Rap system consists of a combination of two commercially available Ty-Raps. Immediately after fasciotomy, the Ty-Raps are secured to the skin by four surgical staples Use Skin Stapler; and this is repeated every 2 cm of the fasciotomy wound The Ty-Raps are not tightened at this stage to allow further swelling of the affected limb. At the end of the procedure, the wound is dressed in the usual manner with Vaseline gauzes and a non-compressive dressing. Once the swelling has subsided, the Ty-Raps are tightened until light traction of the skin is noticed, and this procedure is repeated every 24 hours to 48 hours until full approximation of the skin edges is achieved. The Ty-Rap system

16. Vessel Loop Technique Directly after dermatofasciotomy, vessel loops are fixed in a shoelace fashion with staples at the wound edges. As soon as the swelling diminishes (on Days 3 to 5), progressive traction is applied and the vessel loops are shortened. Patients are carefully checked for recurrent symptoms of compartment syndrome. As soon as the wound edges come into contact, vessel loops and staples are removed and the wound is closed definitively. This can be done under local anesthesia . Description of each technique

17. Results “ ” 17 Presentation title 20XX

18. Fasciotomy wound characteristics and parameters in the two groups of patients.

19. Discussion Split-thickness skin grafting. Healing by secondary intention. Vacuum-assisted dressings for negative pressure therapy Dermal apposition. Gradual suture approximation techniques involving stapling of vessel loops , in a shoelace manner, or gradual approximation of wound margins by using Ty-raps system. The different techniques of fasciotomy wound closure are:

20. 20 Table 3 Dermal apposition using inexpensive techniques Discussion These techniques each have advantages or disadvantages as compared with other techniques, including time to wound closure, cost and complications. The technique of closure by gradual compression is further subdivided into the expensive and inexpensive techniques. Device Advantages Disadvantages Ty-Rap technique 1. A mechanism for controlling tension response is in place to prevent excessive skin tensioning. 1. Not readily available   2. The force is evenly distributed over the entire length of the wound. 2. More expensive than vessel loop, but can be founded 3. No need to suture. 3. Numbness of extremity 4. The gradual tightening can be performed at home by the patient.4. 4. Daily tightening Shoelace technique 1. Readily available 1. Point loading on the staples may lead to their failure . 2. Inexpensive 2. No safe mechanism against excess tension. 3. Easy to set up and install and easy to remove 3. Need to suture. 4. Esay to replacement of device, if was their failure. 4. There is stretching on the skin at a point of loading and are labor-intensive requiring the patient to be admitted to hospital.

21. Discussion ​ Low treatment costs compared to skin stretching devices is amongst the significant benefits of gradual suture approximation techniques. A major advantage of the vessel loop technique and Ty-Raps system dermatotraction was that the materials needed were readily available in most operating theatres. 21 Presentation title 20XX ​ Wound edge ischemia or increase of compartmental pressures may rarely occur.

22. Conclusion Both Ty-Raps system closure and the shoelace technique are effective, safe and reliable methods for closure of fasciotomy wounds. Both the methods have significant advantages to other techniques. In conclusion, we present a simple decision tree to guide the closure of dermatofasciotomy wounds. The different techniques of fasciotomy wound closure are:

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