What is the optimal wound care for dehiscence of fasciotomy (surgical incision of the fascia) sites?

From the Guidelines

Negative pressure wound therapy (NPWT) is the most effective treatment for dehiscence of fasciotomy sites, as it promotes granulation tissue formation, reduces edema, and removes exudate, thereby improving wound closure rates and reducing complications. Management of dehisced fasciotomy wounds requires a systematic approach focusing on infection prevention, promoting granulation tissue formation, and achieving eventual wound closure. Initially, the wound should be thoroughly cleaned with normal saline or antiseptic solutions like 0.5% chlorhexidine to remove debris and reduce bacterial load, as recommended by the ERAS society 1. Necrotic tissue should be debrided, either surgically or through enzymatic agents such as collagenase. For ongoing wound care, NPWT at pressures of 75-125 mmHg is highly effective, with dressing changes every 48-72 hours, as supported by a systematic review and meta-analysis 1. This creates a moist healing environment, reduces edema, removes exudate, and stimulates granulation tissue formation.

Some key benefits of NPWT include:

• Reduces wound complications, including wound dehiscence, as observed in a comparative study 1
• Supports healing of high-risk abdominal incisions, as reported in retrospective studies 1
• Aid patient mobility by supporting the wound, as believed to aid patient mobility by supporting the wound 1
• Reduced incidence of infection, as observed in comparative retrospective studies 1

Alternatively, advanced dressings like hydrocolloids, alginates, or foam dressings can be used, changed every 1-3 days depending on exudate levels. Nutritional support is crucial, with protein intake of 1.2-1.5 g/kg/day and adequate vitamin C (500-1000 mg daily) and zinc (15-30 mg daily) to support tissue repair. Pain management should be addressed with appropriate analgesics before dressing changes. Once the wound bed shows healthy granulation tissue, closure options include delayed primary closure, skin grafting, or allowing healing by secondary intention for smaller wounds. Throughout treatment, the wound should be monitored for signs of infection such as increasing pain, erythema, purulent discharge, or systemic symptoms, which would necessitate culture-guided antibiotic therapy, as recommended by the ERAS society 1.

From the Research

Wound Care for Dehiscence of Fasciotomy Sites

• Dehiscence of fasciotomy sites is a significant concern, with surgical site infection (SSI) rates as high as 30% 2.
• The time to closure after fasciotomy is associated with the incidence of SSI, with a "golden period" for closure at 4 to 5 days after fasciotomy 2.
• Various wound management techniques have been described, including:
  • Vacuum dressing (VAC) 3
  • Dynamic tension (DYN) 3
  • Gauze packing 3
  • Gradual approximation techniques, such as the simple or modified shoelace technique 4, 5
  • Negative pressure therapy 5
  • Skin grafting 4, 5
• The choice of wound management technique depends on various factors, including the patient's condition, ease of application, availability of resources, cost of treatment, and aesthetic outcomes 5.
• Multidisciplinary care instituted at the time of fasciotomy can facilitate timely closure and minimize the complication profile 6.
• There is currently no consensus on the best method of closure, and a comprehensive knowledge of available techniques is essential for optimal management 4, 6.
• Combining the perspectives of orthopaedic and plastic surgery can help evaluate the benefits of multiple closure methods and highlight the importance of planning closure at the time of release 6.