Background: Fasciotomy wounds performed for acute compartment syndrome often cannot be closed primarily due to tissue retraction and edematous muscle. Both split-thickness skin grafting (STSG) and closure by secondary intention are therefore commonly employed, but result in cosmetically unappealing wounds. STSG, in particular, is associated with a thin, insensate wound and donor site morbidity. Delayed primary closure is preferred because wound outcomes are functionally and cosmetically superior.

Purpose: Our objective was to examine upper and lower extremity fasciotomy wound outcomes, including time to definitive closure, comparing traditional wet-to-dry dressings and the Vacuum Assisted Closure (V.A.C.) device.

Methods: In this retrospective study, the CPT code database for our institution was queried and identified a consecutive series of 458 patients who underwent upper or lower extremity fasciotomies between 1995 and 2005. This group represents a total of 804 fasciotomy wounds. Of these, 438 received exclusively V.A.C. dressings until definitive closure; 270 received only normal saline wet-to-dry dressings, and 96 were treated with a combination of both. For each patient, the mechanism of injury, past medical history, closure techniques and time to closure were collected by chart review.

Results: In comparing all upper extremity wounds, there was a statistically significant higher rate of primary closure using the V.A.C. versus traditional wet-to-dry dressings (57.4% vs. 36.5%, p=0.026). The time to primary closure of wounds was shorter in the V.A.C. group (8.9 days) in comparison to the non-V.A.C. group (12.7 days), and significant (p=0.026). The time to skin graft wounds was shorter in the V.A.C. group (8.6 days) in comparison to the non-V.A.C. group (13.0 days); p<0.058. In comparing all lower extremity wounds, there was a significantly (p<0.05) higher rate of primary closure using the V.A.C. (82.7%) versus traditional wet-to-dry dressings (55.6%). By analysis of effects, this represents a fivefold increase in the likelihood of closing a lower extremity fasciotomy wound primarily if the V.A.C. is used. Furthermore, the time to primary closure of wounds was shorter in the V.A.C. group (5.2 days) in comparison to the non-V.A.C. group (6.5 days), p<0.01. The time to skin graft wounds was shorter in the V.A.C. group (8.3 days) in comparison to the non-V.A.C. group (10.0 days), p<0.02.

Conclusions: The use of the V.A.C. for fasciotomy wound closure results in a higher rate of primary closure versus traditional wet-to-dry dressings. In addition, the time to primary closure of wounds or time to skin grafting is shorter, and fewer complications, such as skin graft failure and infection, are found when the V.A.C. is employed. It can be inferred from these results that the V.A.C. used in the described settings decreases hospitalization time, allows for earlier rehabilitation, and ultimately leads to more patient satisfaction. Delayed primary closure using the V.A.C. provides the best functional and aesthetic result in the treatment of open fasciotomy wounds in the upper and lower extremities.