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Bui VDA, Le MM, Nguyen D, Pham CTV, Thomas H, Nguyen DH. Compartment syndrome following minimally invasive mitral valve repair: A case report. SAGE Open Med Case Rep 2022; 10:2050313X221135995. [PMID: 36388639 PMCID: PMC9647293 DOI: 10.1177/2050313x221135995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 10/13/2022] [Indexed: 11/11/2022] Open
Abstract
A 38-year-old Asian male with severe mitral valve regurgitation underwent
elective minimally invasive mitral valve repair with artificial chordae and
concomitant Cox-Maze procedure. Cardiopulmonary bypass required large peripheral
cannulas due to the patient’s increased body surface area with a total bypass
time of 216 min. At 10 h, the patient reported progressive right lower extremity
pain with evidence of swelling, diffuse paresthesias, and weak peripheral
pulses. The patient underwent double-incision lower leg fasciotomies, revealing
significant interstitial fluid and bulging muscle chambers. Compartment syndrome
demonstrates non-traumatic etiologies. Elevated body mass index, Kawashima Type
D femoral artery classification, prolonged bypass times, driven partially due to
concomitant Cox-Maze, and larger cannula sizes should increase the index of
suspicion.
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Affiliation(s)
- Vinh Duc An Bui
- Department of Thoracic and Cardiovascular Surgery, Hue Central Hospital, Hue City, Vietnam
| | | | - Dang Nguyen
- Department of Medical Engineering, University of South Florida, Tampa, FL, USA
| | - Chuong Tran Viet Pham
- Department of Adult Cardiovascular Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Hannah Thomas
- Department of Chemistry, University of South Florida, Tampa, FL, USA
| | - Dinh Hoang Nguyen
- Department of Adult Cardiovascular Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
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Zhang D, Janssen SJ, Tarabochia M, von Keudell A, Earp BE, Chen N, Blazar P. Factors Associated With Poor Outcomes in Acute Forearm Compartment Syndrome. Hand (N Y) 2021; 16:679-685. [PMID: 31690144 PMCID: PMC8461206 DOI: 10.1177/1558944719884662] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: There is limited literature on risk stratification of patients with acute forearm compartment syndrome. The primary objective of this study was to identify factors associated with poor outcomes in patients with acute forearm compartment syndrome. Methods: We retrospectively identified 130 patients with acute compartment syndrome of 130 forearms treated with fasciotomies from January 2000 to June 2015 at 2 Level 1 trauma centers. Poor outcome was defined as a composite variable, including: (1) death; (2) limb amputation; (3) persistent neurological deficit; and (4) contracture. Patient- and treatment-related variables were collected. Bivariate analyses were used to screen for variables associated with poor outcome, and explanatory variables with a value of P < .05 were included in our multivariable logistic regression analyses. Results: Of the 130 patients, 43 (33%) with acute forearm compartment syndrome had poor outcomes, including 5 deaths, 5 limb amputations, 21 persistent neurological deficits, and 31 contractures. Multivariable logistic regression analyses showed that elevated serum creatine kinase at presentation (P < .05) was associated with poor outcomes in patients with acute forearm compartment syndrome. Receiver operating characteristic curve analysis showed that a serum creatine kinase cutoff of 300 U/L yields 92% sensitivity and a serum creatine kinase cutoff of 10 000 U/L yields 95% specificity for poor outcomes in acute forearm compartment syndrome. Conclusions: Elevated creatine kinase levels above 300 U/L are a useful screening test for the highest risk patients with acute forearm compartment syndrome. Levels above 10 000 U/L may play a role in informed consent and counseling regarding expectations.
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Affiliation(s)
- Dafang Zhang
- Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Dafang Zhang, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | | | - Matthew Tarabochia
- Harvard Medical School, Boston, MA, USA,Massachusetts General Hospital, Boston, USA
| | - Arvind von Keudell
- Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Brandon E. Earp
- Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Neal Chen
- Harvard Medical School, Boston, MA, USA,Massachusetts General Hospital, Boston, USA
| | - Philip Blazar
- Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
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Vaynrub M, Or O, Drill E, Saulan M, Boland PJ. Postoperative extremity compartment syndrome in a cancer center: Incidence and risk factors. Surg Oncol 2021; 38:101563. [PMID: 33857839 DOI: 10.1016/j.suronc.2021.101563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/24/2020] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Postoperative compartment syndrome is a reported complication with known patient- and treatment-specific risk factors. Cancer patients carry unique risk factors associated with their underlying disease and long, complex procedures. While elevated serum lactate in traumatic and intensive care settings portends higher risk, no laboratory parameter has demonstrated utility in postoperative risk stratification. Postoperative extremity compartment syndrome in the study institution's cancer population was examined and whether intraoperative serum lactate correlates with postoperative compartment syndrome risk was investigated. METHODS A 1:2 case-control study was performed, which compared cancer patients with postoperative compartment syndrome to those who underwent similar surgical procedures without this complication. Twelve patients were matched to 24 controls by sex, age, surgical procedures, and duration of surgery. Patient and operative variables were analyzed for prognostic significance. RESULTS The compartment syndrome rate was 0.09% of all cases (n = 13,491); 0.12% of cases ≥ 3 h' duration (n = 9,979), and 0.25% of cases ≥ 5 h (n = 4,811). Compared with controls, the case group had higher median BMI (31.7 kg/m2 vs. 25.4 kg/m2, P = 0.001), and median intraoperative lactate level (4.05 mmol/L vs. 1.5 mmol/L, P = 0.047). CONCLUSION Our institutional incidence of postoperative compartment syndrome was similar to that of non-oncologic institutions. While many traditional risk factors did not prove to be influential in our patients, elevated median body mass index and intraoperative serum lactate were identified as risk factors for postoperative compartment syndrome in a cancer population.
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Affiliation(s)
- Max Vaynrub
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Omer Or
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Esther Drill
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - May Saulan
- Department of Nursing, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Patrick J Boland
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
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Compartment Syndrome: Evaluation of Skeletal Muscle Ischemia and Physiologic Biomarkers in Controlled Conditions Within Ex Vivo Isolated Muscle Bundles. J Orthop Trauma 2020; 34:518-523. [PMID: 32379231 DOI: 10.1097/bot.0000000000001799] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To identify potential physiologic markers of muscle ischemia to serve as diagnostic indicators of compartment syndrome. We hypothesize that muscle bundles in hypoxic conditions will elicit decreases in potential hydrogen (pH) and increases in lactate and potassium that correlates with decreased muscle twitch forces. METHODS We performed an ex vivo evaluation of individual skeletal muscle bundles obtained from a swine's diaphragm that were exposed to hypoxic conditions and compared with control groups. Over a 4-hour period, we evaluated the following parameters for each muscle bundle: muscle twitch forces and levels of potassium, lactate, and pH. Comparisons between the hypoxic and control groups were calculated at each time point using the 2-tailed Wilcoxon rank sum test for nonparametric data. Longitudinal associations between biomarkers and muscle twitch forces were tested using repeated measures analyses. RESULTS The hypoxic group elicited more significant decreases in normalized muscle twitch forces than the control group at all time points (0.15 g vs. 0.55 g at 4 hours, P < 0.001). Repeated measures analyses of the hypoxic group demonstrated a statistically significant association between potassium, lactate, and normalized peak force over the course of time. Potassium demonstrated the strongest association with a 1 mmol/L unit increase in potassium associated with a 2.9 g decrease in normalized peak force (95% confidence interval -3.3 to -2.4, P < 0.001). The pH of all muscle baths increased over the course of time at similar rates between the study groups. CONCLUSIONS This study used an ex vivo ischemic skeletal muscle model as a representation for pathophysiologic pathways associated with compartment syndrome. In this experimental approach we were unable to evaluate the pH of the muscle bundles due to continuous applied gassing. Our findings support further evaluations of potassium and lactate levels as potential diagnostic markers.
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Zhang D, Janssen SJ, Tarabochia M, von Keudell A. Factors associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1089-1095. [PMID: 32350597 DOI: 10.1007/s00590-020-02662-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The objective of this study is to determine factors associated with myonecrosis at the time of fasciotomy in patients with acute leg compartment syndrome. METHODS A retrospective cohort study was conducted of 546 patients with acute leg compartment syndrome treated with fasciotomies from January 2000 to June 2015 at two tertiary trauma centers. The main outcome measurement was clinical myonecrosis diagnosed by the treating surgeon at the time of fasciotomy. RESULTS Eighty-two patients (15.0%) with acute leg compartment syndrome had myonecrosis at time of fasciotomy. Multivariable logistic regression analyses showed that younger age (p = 0.004) and diabetes mellitus (p < 0.001) were associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome. Serum creatine kinase at presentation greater than 2405 U/L was found to be associated with myonecrosis at time of fasciotomy in post hoc analysis (p < 0.001). CONCLUSIONS Myonecrosis is associated with patient-related factors. Younger age by 10 years is associated with a 1.3 times increase and diabetes mellitus with a 3-time increase in the odds of myonecrosis. Serum creatine kinase at presentation greater than 2405 U/L denotes an almost 3 times increase in odds of myonecrosis and may be useful for preoperative counseling.
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Affiliation(s)
- Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, 02115, USA.
| | - Stein J Janssen
- Department of Orthopaedic Surgery, Amphia Hospital, 4818CK, Breda, The Netherlands
| | - Matthew Tarabochia
- Harvard Medical School, Boston, MA, 02115, USA.,Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Arvind von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, 02115, USA
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Mortensen SJ, Vora MM, Mohamadi A, Wright CL, Hanna P, Lechtig A, Egan J, Williamson PM, Wixted JJ, Rutkove SB, Nazarian A. Diagnostic Modalities for Acute Compartment Syndrome of the Extremities: A Systematic Review. JAMA Surg 2020; 154:655-665. [PMID: 31042278 DOI: 10.1001/jamasurg.2019.1050] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Acute compartment syndrome (ACS) can cause catastrophic tissue damage leading to permanent muscle and nerve loss. Acute compartment syndrome is a clinical diagnosis, with intracompartmental pressure (ICP) used in equivocal cases. There are no reliable diagnostic methods. The clinical evaluation is impossible to standardize, and the threshold for ICP has been known to be unreliable; thus, guidelines for diagnosis can result in overtreatment or delayed diagnosis. Objective To present and review the advantages and disadvantages of each diagnostic modality and identify gaps that need to be addressed in the future and to review the most used and appropriate animal and human ACS models. Evidence Review We included clinical studies and animal models investigating diagnostic modalities for ACS of the extremities. A MEDLINE and Web of Science search was performed. The protocol for the study was registered on PROSPERO (CRD42017079266). We assessed the quality of the clinical studies with Newcastle-Ottawa scale and reported level of evidence for each article. Findings Fifty-one articles were included in this study, reporting on 38 noninvasive and 35 invasive modalities. Near-infrared spectroscopy and direct ICP measurement using a Stryker device were the most common, respectively. Cadaveric studies used saline infusions to create an ACS model. Most studies with human participants included injured patients with acquired ACS or at risk of developing ACS. In healthy human participants, tourniquets formed the most commonly used ACS model. Application of tourniquets and infusion of saline or albumin were the most used ACS models among animal studies. Conclusions and Relevance This article reports on the most common as well as many new and modified diagnostic modalities, which can serve as inspiration for future investigations to develop more effective and efficient diagnostic techniques for ACS. Future studies on diagnostic modalities should include the development of tools for continuous assessment of ICP to better identify the earliest alterations suggestive of impending ACS. With the advent of such technologies, it may be possible to develop far less aggressive and more effective approaches for early detection of ACS.
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Affiliation(s)
- Sharri J Mortensen
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Molly M Vora
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Amin Mohamadi
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Casey L Wright
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Philip Hanna
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Aron Lechtig
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Jonathan Egan
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Patrick M Williamson
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - John J Wixted
- Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Seward B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Ara Nazarian
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.,Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
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Abstract
The Management of Acute Compartment Syndrome Clinical Practice Guideline is based on a systematic review of current scientific and clinical research. The purpose of this clinical practice guideline is to guide the clinician's ability to diagnose and treat acute compartment syndrome by providing evidence-based recommendations for key decisions that affect the management of patients with extremity trauma. This guideline contains 15 recommendations including both diagnosis and treatment. In addition, the workgroup highlighted the need for better research in the diagnosis and treatment of acute compartment syndrome.
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Affiliation(s)
- Col Patrick M Osborn
- From San Antonio Military Health System, San Antonio, TX (Dr. Osborn), and Hennepin Healthcare, Minneapolis, MN (Dr. Schmidt)
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Nilsson A, Alkner B, Wetterlöv P, Wetterstad S, Palm L, Schilcher J. Low compartment pressure and myoglobin levels in tibial fractures with suspected acute compartment syndrome. BMC Musculoskelet Disord 2019; 20:15. [PMID: 30611244 PMCID: PMC6320587 DOI: 10.1186/s12891-018-2394-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The intense ischemic pain of acute compartment syndrome can be difficult to discriminate from the pain related to an associated fracture. Lacking objective measures, the decision to perform fasciotomy is often only based on clinical findings and performed at a low threshold. Biomarkers of muscle cell damage might help to identify and monitor patients at risk. In patients with fractures, however, markers of muscle cell damage could be elevated because of other reasons associated with the trauma, which would make interpretation difficult. In a review of all patients who underwent emergency fasciotomy in our health care district we aimed to investigate the decision-making process and specifically the use of biomarkers in patients with and without fractures. METHODS In the southeast health care region of Sweden 79 patients (60 men) with fractures (median age 26 years) and 42 patients (34 men) without associated fractures (median age 44 years) were treated with emergency fasciotomy of the lower leg between 2007 and 2016. Differences in clinical findings, p-myoglobin and p-creatine phosphokinase as well as pressure measurements were investigated. RESULTS P-myoglobin was analyzed preoperatively in 20% of all cases and p-creatine phosphokinase in 8%. Preoperative levels of p-myoglobin were lower in patients with fractures (median 1065 μg/L, range 200-3700 μg/L) compared with those without fractures (median 7450 μg/L, range 29-31,000 μg/L), p < 0.05. Preoperative intracompartmental pressure was lower in the fracture group (median 45 mmHg, range 25-90 mmHg) compared with those without fractures (median 83 mmHg, range 18-130 mmHg), p < 0.05. CONCLUSIONS Biomarkers are seldom used in the context of acute fasciotomy of the lower leg. Contrary to our expectations, preoperative levels of p-myoglobin and intracompartmental pressures were lower in fracture patients. These findings support differences in the underlying pathomechanism between the groups and indicate that biomarkers of muscle cell necrosis might play a more important role in the diagnosis of acute compartment syndrome than previously thought.
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Affiliation(s)
- Abraham Nilsson
- Department of Orthopedics and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Björn Alkner
- Department of Orthopedics, Regional Hospital Eksjö, Region Jönköping County and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Patrick Wetterlöv
- Department of Orthopedics, Regional Hospital Eksjö, Region Jönköping County and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | | | - Lars Palm
- Department of Orthopedics and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Jörg Schilcher
- Department of Orthopedics and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
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Schwartz TM, Day KM, Harrington DT. An early surgical training module for compartment pressure measurement. Am J Surg 2015; 211:350-4. [PMID: 26710668 DOI: 10.1016/j.amjsurg.2015.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/13/2015] [Accepted: 08/19/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND We test a novel simulated teaching module's ability to educate junior residents in the assessment of compartment syndrome (CS) and compartment pressure measurement (CPM). METHODS Twenty-two postgraduate year 1 and postgraduate year 2 surgical residents received a 2-hour didactic and practical teaching module on CS assessment and CPM using a simulated model. A structured teaching session by a postgraduate year 5 surgical resident was assessed by carefully constructed pretest, post-test, and delayed retention tests and a practical testing session by 2 board-certified general surgeons. RESULTS Analysis of variance demonstrated significant difference between pretest (6.1/10), post-test (7.9/10), and retention test (8.2/10) scores [F (2,49) = 9.24, P < .01], with no difference in post-test to retention test comparison (P = .90). Mean CPM scores were 8.5/10 for preparation, 9.0/10 for performance, and 8.5/10 for management components, which did not differ [F (2,57) = .46, P = .63]. CONCLUSIONS We demonstrate an efficient simulated CS and CPM teaching module for the education of junior surgical residents using a synthetic model.
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Affiliation(s)
- Tayler M Schwartz
- The Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI, 02903, USA.
| | - Kristopher M Day
- Department of Surgery, Rhode Island Hospital, Providence, RI, USA
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