Single-Incision 4-Compartment Fasciotomy of the Lower Leg: Safe, Effective, and Advantageous

Materials and Methods

Following institutional review board approval, a retrospective review of the authors' hospital database was conducted to identify all patients who had undergone 4-compartment lower-leg fasciotomies performed by the senior author at a Level I trauma center from 2014 through 2017. Patients were identified using Current Procedural Terminology code 27602 (decompression fasciotomy, leg; anterior and/or lateral; and posterior compartments). All patients had single-incision fasciotomies performed because this is the senior author's preferred approach. Medical charts and radiographs were retrospectively reviewed. Demographic data, injury mechanism, fracture type, surgical course, complications, and outcomes were recorded. The primary outcome of this analysis was short-term complications. Patients with less than 8 weeks of follow-up were excluded. Fractures were classified according to the OTA/AO fracture and dislocation compendium. All complications, either associated with injury or not associated with injury, were assessed. Data were stored and analyzed using an Excel 2011 database (Microsoft Corp, Redmond, Washington). Descriptive statistics were used to analyze the clinical characteristics.

Surgical Technique

The skin incision is made along the lateral compartment over the fibula from just below the fibular head to approximately 5 cm proximal to the distal tip, at the musculotendinous junction of the peroneal muscles (Figure 1A). The dissection is taken sharply through skin and subcutaneous tissues. Venous bleeding is controlled with electrocautery. The superficial peroneal nerve is identified penetrating the fascia of the lateral compartment and protected (Figure 1B). The subcutaneous tissue is dissected off the fascia, creating large flaps anteriorly and posteriorly, preserving perforator vessels when possible. The anterior, lateral, and superficial posterior compartments are identified, as are the anterior and lateral intermuscular septae separating them. The anterior compartment is incised longitudinally with a knife and scissors through its full length (Figure 1C). The lateral compartment is similarly opened with a longitudinal incision. If there is any uncertainty where the anterior septum divides the 2 compartments, a transverse T-shaped incision running posteriorly from the anterior compartment fasciotomy can be used to identify the anterior septum (Figure 1D). Care must be taken to remain superficial and not to transect the traversing superficial peroneal nerve. The lateral intermuscular septum is left under tension by not yet releasing the superficial posterior compartment, and the peroneal musculature is bluntly elevated off the anterior aspect of the septum and retracted anteriorly until the posterolateral border of the fibula is identified (Figure 2A). The lateral intermuscular septum is incised just off the fibula with a Cobb elevator, opening the deep posterior compartment (Figure 2B and Figure 2D). Release of the deep posterior compartment can be confirmed by flexing and extending the great toe and identifying the flexor hallucis longus muscle. The superficial posterior compartment is then opened through its full length (Figure 2C). After all 4 compartments are released, the muscles are evaluated for viability, and all necrotic musculature is thoroughly debrided. The wound is irrigated, and a vacuum-assisted closure (VAC) (V.A.C.; Kinetic Concepts Incorporated, San Antonio, Texas) dressing is applied with continuous suction at 125 mm Hg. Lower-extremity splinting is based on the patient's concomitant injuries, but generally the ankle is placed in neutral position, minimizing tension on the muscles.

Figure 1: Cadaveric dissection of the right leg showing single-incision 4-compartment fasciotomies. Skin incision along lateral compartment over the fibula (A). Superficial peroneal nerve identified penetrating the fascia of the lateral compartment (B). Anterior compartment incised longitudinally through its full length (C). Transverse T-shaped incision running posteriorly from the anterior compartment fasciotomy used to identify the anterior intermuscular septum (D).

Figure 2: Peroneal muscles retracted anteriorly off the lateral intermuscular septum, identifying the posterolateral border of the fibula (A). Lateral intermuscular septum incised just off the fibula with a Cobb elevator, opening the deep posterior compartment (B). Superficial posterior compartment released its full length (C). Schematic cross-sectional view of the right leg showing single-incision 4-compartment fasciotomies with arrow guiding path to releasing the posterior deep compartment (D).

Postoperatively, patients are kept on bed rest with strict elevation of their injured extremity. They are taken back to the operating room in a scheduled manner every 48 to 72 hours for repeat irrigation and debridement of any developing nonviable tissue and sequential closure of the wound. Skin closure is performed with a vertical mattress suture technique using 3-0 nylon sutures, starting proximally and distally, until the entire wound is closed. If complete closure is not possible due to tension, a wound VAC is placed over the uncovered wound until the next return to the operating room. This procedure is repeated every 48 to 72 hours until wound closure is complete. Following complete closure, an incisional VAC is placed for 48 to 72 hours of continuous suction at 75 mm Hg, after which nonadherent dressing and dry dressings are applied. Patients are made non-weight bearing, and sutures are removed at 4 weeks.

Results

Eleven patients were identified who had undergone 4-compartment fasciotomies for ACS, diagnosed either clinically or using an intracompartmental measuring device (Intra-Compartmental Pressure Monitor; Stryker, Kalamazoo, Michigan). Mean age of this cohort was 37.7 years (range, 27–53 years), mean BMI was 25.8 kg/m² (range, 18.6–31.0 kg/m²), and 6 (55%) patients were male. One (9%) of 11 patients had diabetes mellitus, and 3 (27%) of 11 were active smokers. Mechanisms of injury included fall from standing (n=4), fall from height (n=2), pedestrian vs motor vehicle (n=3), crush injury (n=1), and physical assault injury (n=1). Ten patients had associated fractures, and 1 had an isolated soft tissue crush injury. Fracture types were tibial plateau (n=5), tibial shaft (n=4), and pilon (n=2). One (9%) fracture was open, Gustilo grade 3A (Table 1). Six patients had documented intracompartmental pressure measurements prior to fasciotomies. The mean highest recording was 67 mm Hg (range, 42–90 mm Hg).

Table 1: Patient Demographic and Injury Characteristics

All fasciotomies were performed within 48 hours of initial injury. All patients were closed primarily using the aforementioned protocol. No patient required skin grafting for coverage. Five (45%) of 11 patients were closed primarily at their first return to the operating room, at an average of 2.8 days after fasciotomies (range, 2–4 days). Six (55%) of 11 patients were partially closed on their first return to the operating room and completely closed on their second trip to the operating room, at an average of 6 days after fasciotomies (range, 5–7 days). No patients required more than 2 return trips to the operating room for wound closure, and the overall average time to closure was 4.54 days.

Of the 10 patients with fractures, 6 were treated staged with temporary external fixation. For these 6 cases, all fasciotomy incisions were closed prior to converting to internal fixation. For fracture fixation, traditional surgical approaches were used, including anterolateral and posteromedial approaches to the proximal tibia, tibial nailing, and anterolateral approach to the distal tibia. Final fixation constructs included 3 patients with a tibial intramedullary nail, 6 with plate fixation, and 2 with combined nail and plate fixation. For patients treated in a staged manner, conversion time from external fixator application to final internal fixation averaged 11.3 days (range, 6–18 days). Length of stay averaged 11.45 days (range, 5–18 days) (Table 2).

Table 2: Surgical Treatment Data

Nine of 11 patients were available for clinical follow-up at least 8 weeks postoperatively. The average length of follow-up was 12 months (range, 2–35 months). Postoperatively, 1 (11%) of 9 patients had distal incision wound breakdown, which was treated with superficial irrigation and debridement and VAC application. The wound eventually went on to heal by secondary intention. One patient with a proximal tibial shaft fracture treated with open reduction and internal fixation (ORIF) had a nonunion, which was treated successfully with compression plating and bone grafting. Three patients had removal of symptomatic implants, and 1 patient underwent knee arthroscopy, synovectomy, and lateral meniscectomy for persistent pain and stiffness. There were no malunions or infections, and no patient required an amputation. At final follow-up, all 9 patients were neurologically intact with no acquired foot deformities (Table 3).

Table 3: Patient Outcomes and Complications

Discussion

This analysis has described the authors' institution's cohort of patients treated with single-incision 4-compartment fasciotomies for ACS. All 11 were able to undergo staged primary closure. At last follow-up, none had required complex skin closure (flap or graft) or return to the operating room following wound closure. These results are in contrast to previously reported rates of STSG following single-incision fasciotomies. Ebraheim et al⁹ reported that 22 (73%) of 30 patients underwent skin grafting following single-incision fasciotomies. Bible et al¹⁴ reported skin grafting rates of 44% (42 of 95) for single-incision fasciotomies and 39% (18 of 46) for double-incision in tibias treated with intramedullary nail fixation or ORIF. Maheshwari et al⁷ reported that 42 (72%) of 58 of their single-incision fasciotomy wounds were treated with dermatotraction, 8 (14%) with concurrent VAC, 3 (5%) with VAC only, and 5 (9%) with nonadherent dressings. Thirty-two (58%) of 55 patients who survived to closure required STSG, 21 (38%) underwent delayed primary closure, and 2 (4%) were treated with open wound care.

The literature on fasciotomies generally reports high complication rates. Velmahos et al¹⁸ performed a retrospective study involving 94 trauma patients who underwent upper- or lower-extremity fasciotomies. They reported that 29 (31%) had fasciotomy-site complications, including necrosis, closure dehiscence, graft infection, and need for debridement. All lower-extremity fasciotomies used a 2-incision technique. Risk was higher for lower extremity vs upper extremity (34.3% vs 20.8%), prophylactic vs therapeutic (42.0% vs 24.6%), more than 8 hours vs less than 8 hours from injury (37% vs 25%), and vascular vs musculoskeletal injury (38.8% vs 22.2%). These factors were likewise negative predictors of primary skin closure. Thirty-seven (53%) of 70 lower-extremity fasciotomies could not be closed primarily. Fasciotomy-site complications during hospital stay occurred in 10 (20%) patients closed primarily compared with 11 (41%) patients who were skin grafted. Whereas some have argued that single-incision fasciotomies in fact increase the risk for certain complications, including damage to the posterior neurovascular structures and incomplete posterior release,^7,14,15 this review found that neither concern resulted in detrimental outcomes in this cohort. Rather, it was found that when familiar with the anatomy through the lateral incision, release of the posterior compartments is straightforward.

It is clear that fasciotomy wounds are a significant source of morbidity, and one that is overlooked in the setting of acute limb-threatening pathology. Surgical technique is one avenue for decreasing fasciotomy wound complications. Postoperative fasciotomy wound dressings is another. A review of the literature seems to support a vessel loop shoelace technique to obtain eventual primary closure by dermatotraction. Two studies have compared VAC with dermatotraction in the closure of lower-extremity fasciotomy wounds, with results of both supporting dermatotraction.^17,19 However, a study by Kakagia et al,¹⁷ which concluded that dermatotraction was superior for wound closure and cost, did not apply the VAC until postoperative day 3 after fasciotomies, at a minimum. A systematic review found limited evidence to warrant changes in practice patterns but concluded that the current literature suggests that the vessel loop shoelace technique achieves wound closure more quickly and with lower STSG rates than VAC, which was better than traditional saline-soaked gauze dressings.²⁰ The current authors achieved good results in their cohort with the use of VAC devices, but they did not have a control group.

This study, which is an update that contrasts the existing literature, had some limitations. Most importantly, it was limited by its small patient population, retrospective nature, lack of a control group or functional outcomes, and variety of patient injury mechanisms and characteristics. It is possible that this cohort consisted of patients with lower-energy injuries compared with prior cohorts. Although there were only 11 patients, the lack of skin grafting when using this single-incision protocol without sequelae is impressive when compared with historical controls. Larger, prospective studies are needed to validate these findings. Finally, in this small analysis of heterogeneous patients, it is not possible to individually evaluate the specific aspects of this protocol (eg, single incision, VAC use, and so on) that may lead to the decreased need for STSG or incidence of wound complications.

Conclusion

It is theorized that the decreased rate of skin grafting in this cohort was attributable to the use of a single-incision approach to 4-compartment fasciotomies, the use of VAC dressings, multiple closure attempts when necessary, and sequential closure using vertical mattress suture technique until complete wound closure was achieved. Single-incision fasciotomies following a protocolized approach appear to be safe and effective and may reduce the need for skin grafting. Further research is needed to substantiate these claims.