Shoelace technique for Delayed Primary Closure

Indication: Delayed primary closure of fasciotomy wounds

Timing of Wound Closure (Primary, Secondary, Tertiary)

Sutures that can be used:

1. Large polypropylene sutures
2. Sialistic vessel loops
3. Large silk sutures
4. Ethibond
5. Pediatric urinary catheter

Anchors: Staples (can apply 2 staples) or Metal clips

• Interval of anchors: 1-2 cm
• Wound to anchor distance: 0.3-0.5 cm

Knotting pattern:

The suture is attached to one side and passed through the incision to be attached on the opposite side, in a sequence that resembles a zigzag from the proximal to the distal regions – in a shoelace manner.

Tightening:

As swelling in the extremity decreases, the tension of the lacing will also decrease and redundancy in the lace will occur. During the wound inspection at the bedside, the lace is tightened using a sterile technique. After untying or cutting the knot, the lace is tightened throughout the length by stretching the suture used. Once the proper tension is reestablished, the ends of the loop are again tied snugly.

• Rate of tightening: 24-72 hourly
• Amount of tightening: can use capillary refill time of wound edges to guide amount of tightening

Time to delayed primary closure: 1-4 weeks (depending on wound)

• After several days, the wound edges approximate, and it is usually possible to perform delayed primary closure with non-absorbable suture.

Complications:

1. Infection
2. Postoperative retractile scarring
3. Partial skin necrosis

References:

1. Obuh OO, Esomu EO, Sydney RO. Suturing Dermatotraction Techniques in Closing Fasciotomy Wounds: A Systematic Review. Cureus. 2023 Apr 13;15(4):e37550. doi: 10.7759/cureus.37550. PMID: 37197103; PMCID: PMC10184723.
2. Berman, S. S., Schilling, J. D., McIntyre, K. E., Hunter, G. C., & Bernhard, V. M. (1994). Shoelace technique for delayed primary closure of fasciotomies. The American Journal of Surgery, 167(4), 435–436. doi:10.1016/0002-9610(94)90130-9