The effectiveness of different fasciotomy wound management treatment options following acute compartment syndrome: A systematic review protocol

Review question/objective The overall objective of this review is to identify the best available evidence on the effectiveness of treatment options for managing fasciotomy wounds acquired due to treatment for acute compartment syndrome in the limbs. More specifically, the systematic review question is: What is the effectiveness of different treatment options for managing a fasciotomy wound on outcomes such as time to primary wound healing, percentage of patients who need skin grafts to effect closure of the wound and length of stay in hospital following the fasciotomies, in patients with acute compartment syndrome of the limb(s)? Background Compartment syndrome of the limbs can occur in patients following limb trauma such as fractures or crush injuries, or following reperfusion after arterial blockage. Acute compartment syndrome occurs because tissue damage or bleeding in the limb results in increased pressure within the physically confined space or compartment. 1 The increase in local pressure reduces the blood flow into and out of the compartment, resulting in muscle ischaemia, and in the absence of treatment, muscle damage and tissue death. Once the pressures in the compartments rise within 30 mmhg of the diastolic blood pressure2, 3 the only definitive treatment is fasciotomy or cutting down into each compartment to relieve this pressure.4 Fasciotomy must be performed without delay once the diagnosis of compartment syndrome is made to prevent serious adverse events such as amputation and death. 4, 5 The fasciotomy wounds created must be left open until the swelling has reduced enough to allow for closure of the wounds. 6 The resulting wounds can have a number of effects on the patient experience, both short and long term. The wounds are large, painful, may become infected, may be slow to heal or require skin grafting to heal and may have long term consequences. 7 Long term consequences include both physical effects such as reduced limb strength, nerve, tendon or muscle damage, pain, scarring and ulceration, and psychological effects such as changes to behaviour and activity due to embarrassment about the physical appearance of the affected limb. 7 8 9 Fasciotomy is also used as one treatment option for chronic limb compartment syndrome. Chronic limb compartment syndrome typically develops slowly and is not related to trauma. This systematic review will not include fasciotomies performed as an elective treatment for chronic compartment syndrome. This is due to the fact that these wounds can be closed immediately and as such are not subject to the same wound healing challenges as pertain with acute fasciotomies. 10, 11 Compartment syndrome has been extensively studied and a number of systematic reviews have been undertaken,12-15 the latest published in 2011.16 These systematic reviews have focused on the best available overall management of compartment syndrome including early identification, use of pressure monitoring and surgery options. Methods of management of the fasciotomy wounds themselves have been described in the reviews but the effectiveness of the various wound management options has not been systematically examined. The only systematic review that looked at fasciotomies as a separate topic described the outcomes following fasciotomies but did not relate this to the wound management treatment.14 There is an identified gap in the literature on the best available evidence for the treatment of acute fasciotomy wounds. Fasciotomy wounds must be left open long enough to ensure that the compartment syndrome has resolved. This makes the wounds more difficult to treat because the skin edges retract and can become fixed to the underlying muscle. 17 Treatment for fasciotomy wounds initially comprised of basic wound care aimed at reducing the risk of infection, wound desiccation and recurrence of the compartment syndrome. Saline soaked gauze combined with light bandages was commonly used. A case series conducted in 1976 found that 77% of patients who had a fasciotomy which was not closed immediately required a skin graft. 4 A growing understanding of the negative impact of skin grafts on long term functionality led to the development of a range of techniques aimed at achieving wound closure without the need for grafting. These techniques have focused on ways to improve the chances of the wounds healing without skin grafting by applying tension to the wound to pull the wound closed in a controlled fashion over a period of days. Harris 18 then Berman 17 described a deferred primary closure technique involving skin staples and a ‘shoelace’ that resulted in improved patient outcomes including reduced time to definitive closure and reduced need for split skin grafting. Variations and modifications of this technique followed. 19 20-22 More recently Govaert described the use of ty-raps to enable staged closure while avoiding some of the pitfalls of the commercially designed devices which have become available. 23 Chiverton described variation involving subcutaneous sutures. 24 Vacuum assisted closure of fasciotomy wounds have been used either alone or in combination with other closure devices with good initial results. 25, 26 To date systematic reviews 12, 13, 15, 16of compartment syndrome management have not identified one definitive treatment. This is partly due to the lack of any large scale randomised controlled trials comparing different treatment options. Most of the available literature describes quasi experimental designs such as case series. None of the systematic reviews attempted to synthesis the evidence that was available. Therefore the aim of the present systematic review is to synthesis the best available evidence on the effectiveness of treatment options for managing fasciotomy wounds acquired due to treatment for acute compartment syndrome in the limbs. A preliminary search of the JBI library of systematic reviews, Cochrane library and PubMed and have found no systematic reviews on this exact topic. Keywords anterior tibial syndrome; compartment syndromes; muscles; muscular diseases; ischemia; fasciotomy; fasciectomy; Fascia and surgery; Decompression surgery Inclusion criteria Types of participants The participants of interest are patients of any age who have acquired a fasciotomy wound as a result of treatment for acute compartment syndrome of the limb occurring as a result of injury (excluding compartment syndrome resulting from burns), regardless of co-morbidities or severity of injury. The co-morbidities, injury type and age will be taken into account when analysing the outcomes due to the impact of these factors on wound healing separate to the wound management options chosen. Types of interventions of interest This review will consider any human studies that evaluate the effectiveness of different treatment options for managing fasciotomy wounds. Types of treatment will include wound management aimed at both optimising the health of the open fasciotomy wound to prevent deterioration before the wound can be closed, and at achieving wound closure, including staged closure. Comparator The review will consider as a comparator the usual care of fasciotomy wound or other treatments of their fasciotomy wound. Types of outcomes This review will consider studies that include the following outcome measures: Time to wound closure without skin grafting, measured in days between fasciotomy operation and definitive wound closure. Time to wound closure where skin grafts have been used, measured in days between fasciotomy operation and wound closure. Rate of wound healing without need for skin grafting. The numerator will be all fasciotomy wounds that require skin grafts to effect a definitive wound closure and the denominator will be all fasciotomy wounds included in the study cohort Degree of scaring measured by the width of the scar at the widest part of the fasciotomy wound in all fasciotomy wounds in the study cohort Length of stay following fasciotomy measured.by the number of days between fasciotomy surgery and discharge home for the study cohort. Patients who are discharged to a rehabilitation facility or other healthcare facility will be excluded from this measure because of the wide variation in availability of these facilities as well as the wide variation in need for ongoing care depending on the severity of the original injury Wound infection rates. The numerator will be the number of fasciotomy wounds reported as infected due to presence of signs of infection and/or with positive bacterial growth from wound swabs and the denominator will be the total number of fasciotomy wounds in the study cohort Wound dehiscence rates. The numerator will be all fasciotomy wounds assessed as having dehisced and the denominator will be all fasciotomy wounds Neurological deficit rates. The numerator will be the neurological deficits in the affected limb reported by the patients and the denominator will be all patients who had a fasciotomy performed in the study cohort. It is acknowledged that neurological deficits may result from the primary injury, the compartment syndrome or the fasciotomy or any combination. Pain experienced by the patient as a result of the wound management options chosen Types of studies This review will consider for inclusion any studies that used a quantitative design including; randomised controlled trials, non-randomised controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies. The review will look for randomised controlled trials and non-randomised controlled trials first but will consider the lower levels of evidence if required. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies in English, with human subjects and published from 1960 onwards will be considered for inclusion in this review. The cutoff date was chosen due to the absence of any studies that evaluate the effectiveness of wound management techniques on fasciotomy wounds published prior to 1960. The databases to be searched include: Medline CINAHL EMBASE Cochrane Central Register of Controlled Trials (CENTRAL) Database of Abstracts of Reviews of Effects PsychInfo Scopus The search for unpublished studies will include: Mednar Australian Digital Theses Program, The Networked Digital Library of These and Dissertations (NDLTD) Proquest Dissertations Index to Theses Conference proceedings from major international Orthopaedic and Plastic Surgery conferences Initial keywords to be used will be: anterior tibial syndrome; compartment syndromes; muscles; muscular diseases; ischemia; fasciotomy; fasciectomy; Fascia and surgery; Decompression surgery Definition of key terms: Fasciotomy: incision through the fascia 27 Compartment syndrome: a condition in which increased pressure in a confined anatomic space adversely affects the circulation and threatens the function and viability of the structures therein.27 Acute: Referring to a health effect, usually of rapid onset, brief, not prolonged; sometimes loosely used to mean severe.27 Fascia: A sheet of fibrous tissue that envelops the body beneath the skin; it also encloses muscles and groups of muscles and separates their several layers or groups.27 Fascial: pertaining to the sheet of fibrous tissue Dermotomy: incision through the dermis27 Decompression: removal of pressure27 Wound dehiscence: disruption of apposed surfaces of a wound27 Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest The primary and secondary reviewers and the supervisors have no conflict of interest. Acknowledgments As this systematic review will be submitted towards the award of Master of Clinical Science, a secondary reviewer will be used only for critical appraisal. The primary reviewer gratefully acknowledges and thanks her supervisors, Dr Kylie Porritt and Professor Debbie Kralik for their input and support.