Case Series
Shoelace Technique Plus Negative-Pressure Wound
Therapy Closure in Fasciotomy Wounds
Engin Eceviz, MD and Hüseyin Bilgehan Çevik, MD
ABSTRACT
BACKGROUND: Fasciotomy incision closure is often performed with skin grafts
that can lead to cosmetic and functional complications after surgical intervention.
Because fasciotomy incisions do not result in skin loss, the authors hypothesized that
Downloaded from http://journals.lww.com/aswcjournal by BhDMf5ePHKbH4TTImqenVBMHby7N9qoLVfmYj0p/hERVhyFdMhnTkrXkTkvAIRm9 on 09/15/2020
better closure can be achieved by reducing tissue edema with negative-pressure
wound therapy (NPWT) and reducing stress on the skin with the shoelace surgical
technique.
METHODS: This 1-year prospective study included eight patients with acute
compartment syndrome after extremity fractures and/or blunt injuries. Patients were
treated with fasciotomies closed with the shoelace technique and NPWT for wound
margin approximation. The NPWT device was changed every second day; the
shoelace traction tension was tightened at the same time.
MAIN RESULTS: The mean time from fasciotomy to wound closure was 11.8 days
(range, 5–30 days). There was no need for a skin graft or flap in any patient.
CONCLUSIONS: The shoelace technique plus NPWT may be successful in closing
skin fasciotomies after acute compartment syndrome without causing additional
morbidity.
KEYWORDS: fasciotomy, wound closure, dermatotraction,
vessel-loop suture technique, negative-pressure wound therapy
ADV SKIN WOUND CARE 2020;33:497–500.
DOI: 10.1097/01.ASW.0000672492.38463.58
Engin Eceviz, MD, is Assistant Professor, University of Health Sciences, Department of Orthopaedics and Traumatology, Kartal Dr Lütfi Kırdar Research and Training Hospital, İstanbul, Turkey. Hüseyin
Bilgehan Çevik, MD, is Assistant Professor, University of Health Sciences, Department of Orthopaedics and Traumatology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara. The authors have
disclosed no financial relationships related to this article. Submitted June 21, 2019; accepted in revised form October 31, 2019.
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INTRODUCTION
Acute compartment syndrome (ACS) is a surgical
emergency with significant morbidity caused by increased
pressure in an extremity that develops following
crush injuries.1 The main underlying cause is an
ischemia-reperfusion injury, when an initial restriction
of blood supply to an organ during injury is followed
by rapid perfusion and concomitant reoxygenation. The
muscles in the affected extremity may develop edema,
resulting in fluid extravasation or inflammatory responses.2
The rapid increase in intracompartment pressure may
lead to ACS.
Delayed diagnosis of ACS can lead to irreversible ische-
mia of the nerve fibers and muscle fascicles in the extremity,
resulting in a disabled extremity or extremity loss.3 How-
ever, early diagnosis and rapid management of ACS can
often lead to full recovery. A fasciotomy of the affected
compartments to relieve tension and pressure is the only
known treatment.4
In a fasciotomy, the retraction of the skin, even after
the recession of the edema, precludes primary closure.
Usually, closure requires a second intervention. Many
skin closure techniques have been described, including
dermatotraction, skin grafts, negative-pressure wound
therapy (NPWT) assisted skin closure, and shoelace tech-
niques.5,6 Because wound complications are common after
these techniques, there is broad interest in alternative clo-
sure methods,7 and there is no consensus on an optimal
technique for fasciotomy wound closure.8 These authors
hypothesized that wound closure with the shoelace tech-
nique plus NPWT could decrease wound complications.
The shoelace technique involves the placement of ten-
sioning devices across the wound (elastic vessel loops or
sutures) that provide a continuous pull on wound mar-
gins and are intermittently tightened without replace-
ment or the need for anesthesia.9 Complementing these
efforts, NPWT prompts primary closure through induced
cell division and ensuring that the tension is equally
applied to the entire wound area, thereby preventing
retraction.10 This article aims to present a useful method
involving both techniques for wound management after
fasciotomy for ACS.
497 ADVANCES IN SKIN & WOUND CARE • SEPTEMBER 2020
METHODS
The protocol for this study was approved by the local
ethics committee, and informed consent was obtained
from all patients, including permission to publish any
associated photographs. The research took place at the
Kartal Dr Lütfi Kırdar Training and Research Hospital, a
public tertiary teaching hospital affiliated to the Univer-
sity of Health Sciences, Istanbul, Turkey. This prospective
study included a series of patients with ACS related to
extremity fractures and/or blunt injuries treated with
fasciotomies managed by NPWT (V.A.C. Therapy; KCI,
San Antonio, Texas) and the shoelace technique between
May 2017 and May 2018. All of the patients were referred
to the orthopedics and traumatology department by emer-
gency physicians after suspicion of ACS. The diagnoses
were made clinically.
The inclusion criteria were (1) open fasciotomy needed
immediately after initial diagnosis, (2) manageable local
and/or systemic infection, and (3) admitted within 8 hours
of the reported time of injury. The exclusion criteria were
patients with (1) concomitant extremity burns, (2) am-
putations, (3) severe soft tissue loss, (4) head injury, (5)
history of peripheral vascular disease, (6) uncontrolled
diabetes, (7) cardiovascular disease, or (8) drug abuse and
immunosuppression.
Procedure
All of the surgeries were performed by the same surgeon.
For leg fasciotomies, a standard dual medial-lateral inci-
sion was performed to release all four compartments.
For thigh fasciotomies, a single anterolateral incision over
the length of thigh was performed to release anterior and
posterior compartments. For foot fasciotomies, standard
dual dorsal and mini-medial incisions were performed
to release all nine compartments.
Figure 1. SHOELACE TECHNIQUE
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Figure 2. NEGATIVE-PRESSURE WOUND THERAPY
SPONGE PLACEMENT
Elastic vessel loops (SURGI-LOOP; Scanlan, Minneapolis,
Minnesota) were applied to both wound margins in a
shoelace pattern. The vessel loops were anchored using
skin staples approximately 1 cm away from the wound
margin so as not to endanger the skin flap marginal circu-
lation (Figure 1). The vessel loops were pulled until the
capillary refills of the wound margins disappeared. The
tightening was continued for approximately 10 minutes,
and then the capillary circulation of the skin margins was
evaluated. If there was continuous absence of capillary
circulation, the vessel loops were loosened by a few cen-
timeters. This tightening was repeated until the skin
flaps reached maximum tension through vessel loop trac-
tion with proper capillary circulation of both wound flap
margins.
A sponge cut to the exact width of the wound was
placed under the vessel loops to avoid skin maceration
(Figure 2). Transparent surgical drapes were placed over
the sponges (Figure 3), and the wounds were covered
with the NPWT device. The pressure of the NPWT de-
vice was set at a continuous 100 mm Hg. The clinic’s sur-
gical assistant changed the NPWT device every second
day and tightened the shoelace traction tension at the
same time. The NPWT was used until complete wound
closure in all patients. In patients with tension-free skin
margin approximation after NPWT, the fasciotomy wounds
were closed directly with sutures (Figure 4).
RESULTS
The study included seven patients with nine fasciotomy
wounds involving the leg, foot, or thigh. Patient demo-
graphic data and clinical results are summarized in the
Table. The mean age was 24.9 years (range, 5–59 years),
and the mean time from fasciotomy to wound closure
was 11.8 days (range, 5–30 days). The mean time from
498 WWW.ASWCJOURNAL.COM
injury to fasciotomy was 3.6 hours (range, 2–5 hours)
with a mean initial wound width of 7.2 cm (range, 4.2–
13.5 cm). There was no skin flap necrosis in any patient.
No skin grafts or flaps were required.
All of the patients were followed up for 1 year. During
the follow-up period, all of the patients achieved direct
wound closure and showed satisfactory outcomes with-
out any wound complication. Two patients presented
with signs and symptoms of local infection, which were
managed with antibiotics. There were no residual skin
defects in any patient.
DISCUSSION
Current literature defines ACS as “an increase in intra-
compartmental pressure causing a decrease of perfusion
pressure, leading to hypoxemia of the tissues.”4 Most
cases of ACS are associated with traumatic injuries, but
the condition also occurs after prolonged limb compres-
sion, reperfusion, and following a period of ischemia.
Tibial diaphyseal (40%) and forearm (18%) fractures are
the most common fractures that cause ACS, but it may
also be seen in some soft tissue injuries (23%).11,12 Of
the nine ACS cases in this series, only four had fractures.
Most of extremities (n = 5) had only soft tissue injuries.
There have been occasional reports of cases and case
series in the literature related to the shoelace technique
plus NPWT closure in fasciotomy wounds, especially
in recent years. Kakagia et al13 stated that both NPWT
and the shoelace technique are effective, safe, and reliable
methods for closure of fasciotomy wounds. However,
they also reported a longer time to definite skin clo-
sure using the shoelace technique (mean, 19.1 days)
compared with NPWT (mean, 15.1 days). In the current
study, the shoelace technique plus NPWT provided skin
Figure 3. TRANSPARENT SURGICAL DRAPES WERE
PLACED OVER THE NEGATIVE-PRESSURE WOUND
THERAPY SPONGE
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Figure 4. LAST STAGE OF MARGIN APPROXIMATION IN
WHICH FASCIOTOMY WOUNDS WERE CLOSED
DIRECTLY WITH SUTURES
closure in mean 11.8 days. It appears that the combina-
tion of both techniques shortens the time to skin closure.
That said, Kakagia et al13 found that NPWT alone is
more expensive than the shoelace technique, especially
when additional skin grafting is required. In the present
case series, there was no control group with which to
compare cost of treatment. However, the combination
of the two techniques may be cost-effective, considering
that it may prevent complications and additional surgi-
cal interventions.
Previous studies including adult patients who received a
fasciotomy for postburn ACS have reported that NPWT
can increase the rate of primary closure, and the rate of skin
grafting was 16.5% to 28.6%.14,15 Further, Mittal et al16
found that patients who underwent NPWT-assisted clo-
sure were at higher risk of skin grafting than patients
who underwent vessel loop closure. In the current study,
no patient needed skin grafting, so it is possible that
NPWT alone may not sufficiently reduce the need for
skin grafting, whereas the shoelace technique plus NPWT
may do so. Of course, skin grafting remains an impor-
tant method of wound closure, but the need for skin
grafting may be reduced by the combination of tech-
niques applied in this study.
Limitations
The major limitations of this study were the lack of a
control group and a lack of generalizability because of
the small case series size. Another potential limitation
was the clinical diagnosis of ACS.
CONCLUSIONS
The use of the shoelace technique plus NWPT may be a
suitable alternative for current fasciotomy wound closure
499 ADVANCES IN SKIN & WOUND CARE • SEPTEMBER 2020
 Table. DEMOGRAPHIC INFORMATION
Time from injury Time from fasciotomy
Patient Sex Age Side Injury Type Location Injury to fasciotomy, h to wound closure, d
1 Male 28 Right Motorcycle Leg Segmental tibia, fibula, and patella fracture 3 13
2 Male 18 Left Gunshot injury Leg Peroneal nerve palsy, popliteal artery (trifurcation), 2 30
and tibial plateau fracture
3 Female 59 Left Crush (demolition) Leg Peroneal nerve palsy 5 8
4 Male 8 Left Crush (demolition) Leg 4 8
5 Male 19 Left Crush (demolition) Leg 2 5
6 Female 37 Right Crush (demolition) Foot Lisfranc fracture dislocation 5 9
7 Female 5 Right Crush (demolition) Thigh, Leg, Foot Femoral, peroneal, and tibial nerve palsy; distal 4 11, 12, and 10, respectively
tibia and fibula fracture

techniques. Further study with larger patient cohorts and a
control group is required to determine the precise clinical
effectiveness of this technique and clarify the patient
group(s) that would most benefit from its use. • 9. Harris I. Gradual closure of fasciotomy wounds using a vessel loop shoelace. Injury 1993;24(8):565-6.
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