Management of Large Postfasciotomy Wound Following Complex Vascular Surgery

Introduction: Management of large post-fasciotomy wounds after major vascular surgery to the extremities can be challenging. Primary closure is often difficult due to excessive and persistent tissue swelling. Furthermore, extensive skin and soft tissue defects due to ischemic-reperfusion injury are associated with multiple closure operations, poor healing, and complications. In this case, we present the management of a large postfasciotomy wound utilizing hyperbaric oxygen therapy (HBOT) and negative pressure wound therapy (NPWT), augmented with umbilical cord (UC) allograft to accelerate robust healing.

Methods: A 55-year-old male smoker with obesity, hypertension, and a history of lower extremity lymphedema was admitted with sudden onset of critical limb ischemia that required limb salvage vascular bypass graft surgery. The case was complicated with ischemic reperfusion injury and compartment syndrome that required fasciotomy. Subsequently, the patient presented to the wound clinic two days post-op with a wound on his left, medial calf with features of ischemic-reperfusion changes. The patient was put on limb salvage protocol and received immediate institution of HBOT and continuous NPWT (125 mmHg). HBOT was carried out under APAI protocol, 30 treatments 2.0 ATA 90 minutes w/ oxygen, no air breaks.

Within 2–4 weeks, the wound was less edematous and mostly covered with granulation. However, to promote further wound closure, a UC allograft was applied. At seven weeks, neoepithelial budding was noted around the wound edge. At 11 weeks, the wound was healing as expected, with no active issues such as leg edema or gross infection. By 15 weeks, the patient was back at work while the wound continued to improve. At 19 weeks, the wound was fully healed and achieved complete epithelialization.

Conclusion: This case demonstrates the successful treatment of an ischemic-reperfusion induced, postfasciotomy wound using HBOT, NPWT, and UC allograft to accelerate robust healing without complications.