Among the many tips, quips and pearls that we have learned over the years, some techniques will stand the test of time better than others. Indeed, some techniques are more a matter of fad than function and will soon fall by the wayside. Valuable techniques, those that become a part of every day practice, serve patients very well and become a part of the standard of care.
One such technique is the use of vessel loops for wound closures. This method of wound closure is simple, inexpensive and easy to perform in just minutes. Despite the fact that authors described this technique as early as the 1920s, some surgeons have never seen the procedure performed. Accordingly, let us take a closer look at this technique and case studies demonstrating the effectiveness of this procedure in achieving wound coaptation without undue tension for a variety of conditions.
There are a host of conditions that may require such closure including trauma, the diabetic foot wound and ulcerations or amputations where skin closure may be challenging. The chronic Charcot foot, with subsequent structural deformity, is often fraught with the development of bone and/or bursal projections that compromise the underlying skin and result in the development of abscess or ulceration. Often skin or soft tissue atrophy or reduced vascularity may result in local soft tissue insufficiency or ischemia. This necessitates a gentle but firm closure to allow the primary wound healing process to begin.
This technique can facilitate a delayed primary closure in the event that the index procedure results in a wound that may be otherwise challenging to close should one allow the wound to heal by secondary intention. The wound retraction that can naturally occur in a plantar wound, especially in the face of intrinsic muscle contractures, may prevent primary closure. Alternately, these wounds may require plastic surgery techniques or even skin grafting to achieve complete wound closure. This technique offers a viable alternative to more invasive approaches that involve greater risks such as host graft site morbidity.
The vessel loop closure involves large vessel loops and skin staples. The surgeons would position the vessel loop just beyond the most proximal or distal extent of the wound with a staple over the center of the vessel loop. Place the second and third staples 2 cm medial and 2 cm lateral to the center staple, creating a triangular pattern to start the process. This serves as the pinnacle of the lace pattern. From here, cross the vessel loop over the wound, using staples to secure the loops 1.0 cm or more away from the wound edge to reduce stress on the wound margins. Once the entire length of the wound has been coapted, the surgeon can hand-tie the vessel loops and place over a drain sponge to prevent pressure necrosis. Doing so creates a long chain to prevent unraveling of the slick rubber material of the vessel loop.
Let us take a closer look at a couple of case studies in which we were able to incorporate the vessel loop closure technique.
Case Study: When A Patient With Diabetes and PVD Has A Chronic Ulceration
A 60-year-old female with diabetes and severe peripheral vascular disease presents with a chronic ulceration. The patient was previously treated at a wound care center. She had continuously draining serous fluid from the longstanding ulceration and was treated with various oral antibtioics over a period of eight months.
Upon the initial consultation for a second opinion, plain radiographs revealed a poorly performed Keller type arthroplasty and a severe hallux extensus. There was no periostitis, cortical defects or resorptive changes in the immediate area of the ulceration although the hallux was fraught with osteopenia from disuse. Indium leukocyte imaging confirmed septic arthritis and we subsequently performed incision and drainage with deep debridement.
The surgical photograph reveals a grossly degenerative fibular sesamoid (see Figure 1). We obtained a biopsy for the underlying metatarsal head and it failed to grow out an organism. Ultimately, we opted for a delayed primary closure with the benefit of an allogeneic tissue graft to fill the soft tissue void. We performed the vessel loop closure technique (see Figure 2) and allowed the wound to be closely coapted without prompting excess tension or ischemia. By eight weeks postoperatively, the surgical wound healed. (See Figure 3.) We debrided a trace residual hyperkeratotic tissue beneath the tibial sesamoid and this revealed a base of well-epithelialized tissue.
Case Study: Facilitating Delayed Primary Closure After Four-Compartment Decompression
A juvenile patient underwent four-compartment decompression of the foot (see Figure 4). Now the patient is ready for delayed primary closure. The wound edges are contracted. This patient will require a staged closure and we employ the benefit of the vessel loop technique to closely draw the wound together. We follow this with 3-0 prolene mattress sutures to achieve final coaptation (see Figures 5a). This technique affords gentle coaptation. However, when significant blanching exists, the surgeon should delay closure until he or she has achieved further edema reduction (see Figure 5B).One can remove the vessel loops at four weeks and later remove the prolene sutures to prevent wound dehiscence. The last two photos at the top (see Figures 6a and 6b) show the foot three months after delayed primary closure.