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Lechtig A, Hanna P, Nagy JA, Wixted J, Nazarian A, Rutkove SB. Electrical impedance myography for the early detection of muscle ischemia secondary to compartment syndrome: a study in a rat model. Sci Rep 2023; 13:18252. [PMID: 37880267 PMCID: PMC10600169 DOI: 10.1038/s41598-023-45209-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023] Open
Abstract
Acute Compartment Syndrome (ACS) is one of the most devastating orthopedic conditions, affecting any of the body's many compartments, which, if sufficiently severe, may result in disability and amputation. Currently, intra-compartmental pressure measurements serve as the gold standard for diagnosing ACS. Diagnosing limbs at risk for ACS before irreversible damage to muscle and nerve is critical. Standard approaches for diagnosing impending compartment syndrome include clinical evaluation of the limb, such as assessment for "tightness" of the overlying skin, reduced pulses distally, and degree of pain, none of which are specific or sensitive. We have proposed a novel method to detect ACS via electrical impedance myography (EIM), where a weak, high-frequency alternating current is passed between one pair of electrodes through a region of tissue, and the resulting surface voltages are measured via a second pair. We evaluated the ability of EIM to detect early muscle ischemia in an established murine model of compression-induced muscle injury, where we collected resistance, reactance, and their dimensionless product, defined as Relative Injury Index (RII) during the study. Our model generated reproducible hypoxia, confirmed by Hypoxyprobe™ staining of endothelial regions within the muscle. Under conditions of ischemia, we demonstrated a reproducible, stable, and significant escalation in resistance, reactance, and RII values, compared to uninjured control limbs. These data make a reasonable argument for additional investigations into using EIM for the early recognition of muscle hypoperfusion and ischemia. However, these findings must be considered preliminary steps, requiring further pre-clinical and clinical validation.
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Affiliation(s)
- Aron Lechtig
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Philip Hanna
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Janice A Nagy
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - John Wixted
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ara Nazarian
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
| | - Seward B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
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Nguyen TT, Huynh ST, Lam NV, Phan HQ, Le PT. Reduced Time to Surgery and Prophylactic Fasciotomy May Result in Improved Outcomes in Popliteal Artery Injuries. Ann Vasc Surg 2023; 96:292-300. [PMID: 37003357 DOI: 10.1016/j.avsg.2023.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 02/25/2023] [Accepted: 03/18/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Popliteal artery injuries are uncommon and often result in limb loss or long-term limb dysfunction. The aims of this study were (1) to evaluate the association between predictors and outcomes and (2) to validate the rational of systematic early fasciotomy. METHODS This retrospective cohort study included 122 patients (80% men, n = 100) who underwent surgery for popliteal artery injuries from October 2018 to March 2021 in southern Vietnam. Primary outcomes included primary and secondary amputation. The associations between predictors and primary amputation were analyzed using logistic regression models. RESULTS Among the 122 patients, 11 (9%) underwent primary amputation, while 2 (1.6%) had secondary amputation. Longer time to surgery was associated with increased odds of amputation (odds ratio = 1.65; 95% confidence interval, 1.2 to 2.2 for every 6 hr). Severe limb ischemia was also associated with a 50-fold increase in the risk of primary amputation (adjusted odds ratio = 49.9; 95% confidence interval, 6 to 418, P = 0.001). Furthermore, 11 patients (9%) without signs of severe limb ischemia and acute compartment syndrome on admission were found to have myonecrosis of at least one muscle compartment during fasciotomy. CONCLUSIONS The data suggest that among patients with popliteal artery injuries, prolonged time before surgery and severe limb ischemia are associated with increased risk of primary amputation, whereas early fasciotomy may lead to improved outcomes.
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Affiliation(s)
- Thuc T Nguyen
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Son T Huynh
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Nut V Lam
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Hung Q Phan
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Phong T Le
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam.
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Lam D, Pierson D, Salaria O, Wardhan R, Li J. Pain Control with Regional Anesthesia in Patients at Risk of Acute Compartment Syndrome: Review of the Literature and Editorial View. J Pain Res 2023; 16:635-648. [PMID: 36891457 PMCID: PMC9987529 DOI: 10.2147/jpr.s397428] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 02/15/2023] [Indexed: 03/05/2023] Open
Abstract
Acute compartment syndrome (ACS) is a devastating complication that can happen in almost every part of the human body, most noticeably after long bone fractures. The cardinal symptom of ACS is pain in excess of what would otherwise be expected from the underlying injury and unresponsive to routine analgesia treatment. There is paucity of literature on major analgesic management strategies including opioid analgesia, epidural anesthesia, and peripheral nerve blocks with regard to their differential efficacy and safety of pain management in patients at risk of developing ACS. The lack of quality data has led to recommendations that are perhaps more conservative than they should be, particularly when it comes to peripheral nerve blocks. In this review article, we attempt to make recommendations in favor of regional anesthesia in this vulnerable group of patients and strategies that will optimize adequate pain control and improve surgical outcome without jeopardizing patient safety.
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Affiliation(s)
- David Lam
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Doris Pierson
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Osman Salaria
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Richa Wardhan
- Department of Anesthesiology, Florida University College of Medicine, Gainesville, FL, USA
| | - Jinlei Li
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
- Correspondence: Jinlei Li, Department of Anesthesiology, Yale University School of Medicine, 20 York Street, New Haven, CT, 06510, USA, Tel +1-203-785-2802, Fax +1-203-785-6664, Email
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Sonawane K, Dhamotharan P, Dixit H, Gurumoorthi P. Coping With the Fear of Compartment Syndrome Without Compromising Analgesia: A Narrative Review. Cureus 2022; 14:e30776. [DOI: 10.7759/cureus.30776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 11/06/2022] Open
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Torrie AM, Brookman JC, Samet RE. Regional Analgesia and Acute Compartment Syndrome. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00528-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Compartment Syndrome following Below-Knee Amputation. Case Rep Orthop 2022; 2022:1256823. [PMID: 35237457 PMCID: PMC8885273 DOI: 10.1155/2022/1256823] [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: 10/26/2021] [Accepted: 02/02/2022] [Indexed: 11/18/2022] Open
Abstract
In the setting of below-knee amputation, compartment syndrome is a rare complication. Early clinical symptoms of an acute compartment syndrome following below-knee amputation can mimic or be masked by postoperative pain management. We present the case of a 38-year-old male with a significant past medical history of Proteus syndrome who underwent an elective transtibial below-knee amputation. Following surgery, the patient had extensive postoperative pain and high pain medication requirements and returned to the operating room for irrigation and debridement due to suspicion of an infection. Upon return to the operating room to manage the infection, the necrotic tissue was discovered and removed which had developed due to a suspected missed acute compartment syndrome. The necrotic tissue secondary to the compartment syndrome subsequently resulted in infection. Multiple irrigation and debridement procedures were performed to further manage the infection, and ultimately, the patient was deemed stable for discharge. Acute compartment syndrome (ACS) following below-knee amputation (BKA) is a rarely documented but critical complication. This case describes the unique setting in which a compartment syndrome can be masked due to postoperative pain management and infection. Orthopedic surgeons should be aware of the varying risk factors and presentations of an acute compartment syndrome (ACS) as it can occur and is a devastating complication.
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Keating JF, Duckworth AD. No disputes when there is a simple solution: monitoring in acute compartment syndrome. Anaesthesia 2021; 76:1446-1449. [PMID: 34096044 DOI: 10.1111/anae.15516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2021] [Indexed: 11/30/2022]
Affiliation(s)
- J F Keating
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh and Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - A D Duckworth
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh and Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
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A systematic review of the effect of regional anesthesia on diagnosis and management of acute compartment syndrome in long bone fractures. Eur J Trauma Emerg Surg 2020; 46:1281-1290. [DOI: 10.1007/s00068-020-01320-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/04/2020] [Indexed: 01/09/2023]
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9
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Mortensen SJ, Zhang D, Mohamadi A, Collins J, Weaver MJ, Nazarian A, von Keudell AG. Predicting factors of muscle necrosis in acute compartment syndrome of the lower extremity. Injury 2020; 51:522-526. [PMID: 31767373 DOI: 10.1016/j.injury.2019.11.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/15/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute physiologic compartment syndrome (ACS) is a disorder of increased intra-compartmental pressure leading to decreased tissue perfusion and muscle necrosis. Tissue ischemia can result in irreversible muscle and nerve injury and requires urgent fasciotomy. The aim of this study was to determine the factors associated with the presence of necrotic muscle in patients undergoing leg fasciotomy. METHODS This is a retrospective cohort study of all patients undergoing fasciotomies for ACS of the leg at two level 1 trauma centers from 2000 to 2015. We found 1,028 patients who underwent leg fasciotomies. We excluded ACS at other sites than the leg, the index fasciotomy performed at an outside institution, prophylactic fasciotomy with no clinical signs of ACS, and patients with inadequate medical records. A total of 357 patients were included in the final analysis. We used bivariate analysis to assess which explanatory variables are associated with the main outcome measure, the presence of necrotic muscle at fasciotomy. We used multivariable regression analysis to determine association accounting for any confounding. RESULTS Of 357 cases of ACS of the leg, 14.6% of patients presented with an open fracture and 21.3% of patients were multiply injured. Overall, 14.3% of cases had muscle necrosis at the time of fasciotomy. Fifty-nine percent of patients with necrotic muscle required more than 3 debridements. Open fracture was the only statistically significant predictor of muscle necrosis (OR=2.8). Crush injury (OR=3.1) and soft tissue injuries (OR=2.8) were at an increased odds of necrotic muscle, but only marginally significant. CONCLUSION ACS is a potentially limb threatening condition often associated with poor outcomes, particularly when the diagnosis is delayed. Patients with open fracture have a three-fold increase in odds of necrotic muscle at the time of fasciotomy.
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Affiliation(s)
- Sharri J Mortensen
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Amin Mohamadi
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Jamie Collins
- Orthopedic and Arthritis Center for Outcome Research, Brigham and Women's Hospital, Boston, MA, United States
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, United States
| | - Ara Nazarian
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, United States; Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
| | - Arvind G von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, United States
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Long B, Koyfman A, Gottlieb M. Evaluation and Management of Acute Compartment Syndrome in the Emergency Department. J Emerg Med 2019; 56:386-397. [DOI: 10.1016/j.jemermed.2018.12.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/17/2018] [Accepted: 12/08/2018] [Indexed: 12/30/2022]
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12
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Abstract
Postoperative pain control is a highly studied topic because of its significant effect on costs, hospital course, and, most importantly, patient satisfaction. Opioid use has been the "status quo" of postoperative pain management but prolongs hospital stays and increases complications. Optimizing acute pain management in patients with orthopedic trauma is important and can translate into significant positive physiologic and financial outcomes. Although multiple viable examples of optimizing acute pain management in the literature demonstrate outcome improvements, implementation has not been widespread. Significant outcome success will depend more on systemwide implementation than a specific regimen for postoperative pain control.
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Klucka J, Stourac P, Stouracova A, Masek M, Repko M. Compartment syndrome and regional anaesthesia: Critical review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2017; 161:242-251. [DOI: 10.5507/bp.2017.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 05/05/2017] [Indexed: 11/23/2022] Open
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Driscoll EBS, Maleki AH, Jahromi L, Hermecz BN, Nelson LE, Vetter IL, Evenhuis S, Riesenberg LA. Regional anesthesia or patient-controlled analgesia and compartment syndrome in orthopedic surgical procedures: a systematic review. Local Reg Anesth 2016; 9:65-81. [PMID: 27785097 PMCID: PMC5063486 DOI: 10.2147/lra.s109659] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A systematic review of the literature on the use of regional anesthesia (RA) and patient-controlled analgesia (PCA) was conducted in patients who require orthopedic extremity procedures to determine whether either analgesic technique contributes to a delayed diagnosis of compartment syndrome (CS). A total of 34 relevant articles (28 case reports and six research articles) were identified. Of all case report articles published after 2009, the majority (75%) concluded that RA does not put the patient at an increased risk of a delayed diagnosis of CS. Of these, only two relevant prospective research studies focusing on RA or PCA and their relationship to CS were identified. Neither study resulted in any cases of CS. However, both had relatively small sample sizes. Given the lack of evidence identified in this systematic review, prospective studies or large-scale retrospective data reviews are needed to more strongly advocate the use of one modality of analgesia over the other in this patient population.
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Affiliation(s)
| | - Ana Hosseinzadeh Maleki
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Leila Jahromi
- Department of Biology, Georgia State University, Atlanta, GA
| | - Brittany Nelson Hermecz
- Department of Diagnostic Radiology, University of Alabama at Birmingham School of Medicine, Birmingham
| | | | - Imelda L Vetter
- School of Health Professions, Lister Hill Library, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Spencer Evenhuis
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Lee Ann Riesenberg
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
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Abstract
Acute compartment syndrome (ACS) is a well-known pathophysiologic complication of trauma or tissue ischemia. ACS affects the appearance, function, and even the viability of the involved limb, and demands immediate diagnosis and treatment. However, ACS is difficult to diagnose and the only effective treatment is decompressive surgical fasciotomy. The clinical signs and symptoms may easily be attributed to other aspects of the injury, which further complicates the diagnosis. This article highlights the latest information regarding the diagnosis of ACS, how to perform fasciotomies, how to manage fasciotomy wounds, and also reviews complications and outcomes of ACS.
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Affiliation(s)
- Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin County Medical Center, 701 Park Avenue South, Mail Code G2, Minneapolis, MN 55415, USA.
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17
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Abstract
Regional anaesthesia is very effective in alleviating pain due to trauma, and is also used to provide anaesthesia for trauma surgery. It has the advantage of producing localized but complete pain relief, whilst avoiding the side effects of systemic analgesics or anaesthetics. However, regional anaesthetic drugs and techniques have potentially life-threatening complications, which the practitioner must be able to manage. This article discusses the use of regional anaesthesia, and the benefits and disadvantages of specific regional techniques in various traumatic conditions.
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Affiliation(s)
- JM Elliot
- Department of Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK
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18
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von Keudell AG, Weaver MJ, Appleton PT, Bae DS, Dyer GSM, Heng M, Jupiter JB, Vrahas MS. Diagnosis and treatment of acute extremity compartment syndrome. Lancet 2015; 386:1299-1310. [PMID: 26460664 DOI: 10.1016/s0140-6736(15)00277-9] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute compartment syndrome of the extremities is well known, but diagnosis can be challenging. Ineffective treatment can have devastating consequences, such as permanent dysaesthesia, ischaemic contractures, muscle dysfunction, loss of limb, and even loss of life. Despite many studies, there is no consensus about the way in which acute extremity compartment syndromes should be diagnosed. Many surgeons suggest continuous monitoring of intracompartmental pressure for all patients who have high-risk extremity injuries, whereas others suggest aggressive surgical intervention if acute compartment syndrome is even suspected. Although surgical fasciotomy might reduce intracompartmental pressure, this procedure also carries the risk of long-term complications. In this paper in The Lancet Series about emergency surgery we summarise the available data on acute extremity compartment syndrome of the upper and lower extremities in adults and children, discuss the underlying pathophysiology, and propose a clinical guideline based on the available data.
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Affiliation(s)
| | - Michael J Weaver
- Orthopedic Trauma Initiative at Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul T Appleton
- Orthopedic Trauma Initiative at Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA, USA
| | - Donald S Bae
- Orthopedic Trauma Initiative at Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - George S M Dyer
- Orthopedic Trauma Initiative at Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marilyn Heng
- Orthopedic Trauma Initiative at Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jesse B Jupiter
- Orthopedic Trauma Initiative at Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark S Vrahas
- Orthopedic Trauma Initiative at Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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McQueen MM, Duckworth AD. The diagnosis of acute compartment syndrome: a review. Eur J Trauma Emerg Surg 2014; 40:521-8. [DOI: 10.1007/s00068-014-0414-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 05/10/2014] [Indexed: 01/05/2023]
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Vegari DN, Rangavajjula AV, Diiorio TM, Parvizi J. Fasciotomy following total knee arthroplasty: beware of terrible outcome. J Arthroplasty 2014; 29:355-9. [PMID: 23786987 DOI: 10.1016/j.arth.2013.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 05/08/2013] [Accepted: 05/10/2013] [Indexed: 02/01/2023] Open
Abstract
There is a paucity of literature on compartment pressure thresholds and complications following fasciotomy in postoperative Total Knee Arthroplasty (TKA) patients. The purpose of this study is to identify the postoperative course in a series of patients who had surgical decompression following TKA. We identified six patients who underwent fasciotomy for proven or suspected compartment syndrome following primary TKA between 2000 and 2010. The etiology of compartment syndrome was indirect (5 cases) vascular injury and one unknown. Complications after fasciotomy were: periprosthetic infection (2), foot drop (2), fasciitis (1), cellulitis (1), above the knee amputation due to periprosthetic infection (1). Currently, it is unknown if the same principles in the trauma patient apply for both diagnosis and treatment of compartment syndrome after TKA. We conclude that surgeons need to maintain a relatively higher threshold for performing a fasciotomy following TKA.
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Affiliation(s)
- David N Vegari
- Rothman Institute of Orthopedics, Thomas Jefferson University, Philadelphia, Pennsylvania; Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Ashwin V Rangavajjula
- Rothman Institute of Orthopedics, Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - Timothy M Diiorio
- Rothman Institute of Orthopedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Institute of Orthopedics, Thomas Jefferson University, Philadelphia, Pennsylvania
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21
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Hansen EN, Manzano G, Kandemir U, Mok JM. Comparison of tissue oxygenation and compartment pressure following tibia fracture. Injury 2013; 44:1076-80. [PMID: 23265784 DOI: 10.1016/j.injury.2012.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 11/10/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We investigated the ability of direct continuous measurement of intramuscular tissue oxygenation (PmO(2)) to detect acute ischaemia in the leg in patients at risk for acute extremity compartment syndrome. Following tibia fracture treated by intramedullary nailing, we compared the proportions of PmO(2) and compartment pressure (CP) measurements that met the warning criteria for compartment syndrome. METHODS Participants included 10 patients sustaining acute isolated closed tibia shaft fractures treated by intramedullary nailing. A tissue oxygenation probe and a CP probe were percutaneously placed into the anterior compartment of the leg. PmO(2) and CP in the anterior compartment were measured in the injured leg for 48 h postoperatively. Measurements meeting the warning criteria were defined as PmO(2) < 10 mmHg, CP > 30 mmHg and perfusion pressure ΔP < 30 mmHg. RESULTS None of the patients developed compartment syndrome. Comparison of CP and PmO(2) showed a CP > 30 mmHg in 50.39% of CP measurements in all patients and a PmO(2) < 10 mmHg in 0.75% of PmO(2) measurements in two patients (P = 0.005). Comparison of ΔP and PmO(2) showed a ΔP < 30 mmHg in 31.01% of ΔP measurements in nine patients and a PmO(2) < 10 mmHg in 0.76% of PmO(2) measurements in one patient (P = 0.01). CONCLUSION In the absence of compartment syndrome, pressure measurements following tibia fracture treated with intramedullary nailing often met the warning criteria, whereas PmO(2) did not, suggesting that measurement of intramuscular tissue oxygenation may represent a potential method for the identification of acute compartment syndrome that deserves continued investigation.
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Affiliation(s)
- Erik N Hansen
- Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
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22
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Case Scenario: Compartment Syndrome of the Forearm in Patient with an Infraclavicular Catheter. Anesthesiology 2013; 118:1198-205. [DOI: 10.1097/aln.0b013e31828afa96] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Taylor RM, Sullivan MP, Mehta S. Acute compartment syndrome: obtaining diagnosis, providing treatment, and minimizing medicolegal risk. Curr Rev Musculoskelet Med 2012; 5:206-13. [PMID: 22644598 DOI: 10.1007/s12178-012-9126-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute compartment syndrome (ACS) is a surgical emergency. Diagnosis depends on a high clinical suspicion and an understanding of risk factors, pathophysiology and subtle physical exam findings. The typical high risk scenario for ACS is a male patient younger than 35 years of age, involved in a high energy sport or roadway collision, resulting in a tibial shaft fracture. He will go on to develop acute compartment syndrome of the leg in less than 10 hours and require emergent fasciotomy. Diagnosis of ACS in this patient is primarily a clinical one but can be confirmed with invasive intracompartmental pressure monitoring or non-invasive near infrared spectroscopy (NIRS). Delaying the diagnosis will likely result in some degree of permanent disability and places the surgeon at high risk for litigation. This article reviews the salient features of acute compartment syndrome that should be understood by all orthopaedic residents and surgeons.
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Affiliation(s)
- Ryan M Taylor
- Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104-4283, USA,
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Azam MQ, Ali MS, Al Ruwaili M, Al Sayed HN. Compartment syndrome obscured by post-operative epidural analgesia. Clin Pract 2012; 2:e19. [PMID: 24765418 PMCID: PMC3981334 DOI: 10.4081/cp.2012.e19] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 01/16/2012] [Accepted: 01/16/2012] [Indexed: 11/23/2022] Open
Abstract
Compartment syndrome is an orthopedic emergency that require early recognition and urgent intervention to avoid catastrophic complications. High index of suspicion is required for early diagnosis based on a constellation of signs and symptoms that include pain out of proportion and worsened by passive stretching, altered sensorium and palpable tenseness. Any event thus, that masks pain, may lead to delay the diagnosis of compartment syndrome. We report here a case of polytrauma where post-operative analgesia was administered using epidural catheter, which obscured pain and lead to delay in recognition of compartment syndrome. Authors wish to share a lesson, learned at the expense of tragedy.
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Yang J, Cooper MG. Compartment Syndrome and Patient-Controlled Analgesia in Children – Analgesic Complication or Early Warning System? Anaesth Intensive Care 2010; 38:359-63. [DOI: 10.1177/0310057x1003800219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We present two cases of children who developed compartment syndrome after upper limb fractures. Morphine patient-controlled analgesia was used in a bolus-only mode for analgesia (bolus 20 μg/kg, five minute lockout and hourly limit of 150 μg/kg). An increase in patient-controlled analgesia use was observed up to 12 hours before the decision was made to proceed to fasciotomy but neither child exceeded the hourly limit or had an excessive increase in pain scores. Clinical risk factors for compartment syndrome should be identified and appropriate monitoring instituted. A subtle increase in patient-controlled analgesia use may be an early indicator of impending compartment syndrome before classical signs such as reporting of pain, pallor, paraesthesiae, paralysis and pulselessness develop. These cases and review of the literature suggest techniques which may assist earlier diagnosis of compartment syndrome include setting a more conservative hourly limit of morphine patient-controlled analgesia such as 80 to 100 μg/kg/hour and graphing of patient-controlled analgesia demands and boluses, pain scores at rest and pain scores with passive flexion and extension of digits. These practices could identify trends that pain or analgesia requirement is increasing leading to earlier diagnosis of compartment syndrome.
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Affiliation(s)
- J. Yang
- Departments of Anaesthesia and Pain Medicine and Palliative Care, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Anaesthetic Registrar, Department of Anaesthesia
| | - M. G. Cooper
- Departments of Anaesthesia and Pain Medicine and Palliative Care, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Johnson DJG, Chalkiadis GA. Does epidural analgesia delay the diagnosis of lower limb compartment syndrome in children? Paediatr Anaesth 2009; 19:83-91. [PMID: 19143952 DOI: 10.1111/j.1460-9592.2008.02894.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
One of the cardinal symptoms of compartment syndrome is pain. A literature review was undertaken in order to assess the association of epidural analgesia and compartment syndrome in children, whether epidural analgesia delays the diagnosis, and to identify patients who might be at risk. Evidence was sought to offer recommendations in the use of epidural analgesia in patients at risk of developing compartment syndrome of the lower limb. Increasing analgesic use, increasing/breakthrough pain and pain remote to the surgical site were identified as important early warning signs of impending compartment syndrome in the lower limb of a child with a working epidural. The presence of any should trigger immediate examination of the painful site, and active management of the situation (we have proposed one clinical pathway). Avoidance of dense sensory or motor block and unnecessary sensory blockade of areas remote to the surgical site allows full assessment of the child and may prevent any delay in diagnosis of compartment syndrome. Focusing on excluding the diagnosis of compartment syndrome rather than failure of analgesic modality is vital. In the pediatric cases reviewed there was no clear evidence that the presence of an epidural had delayed the diagnosis.
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Affiliation(s)
- Doug J G Johnson
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Vic., Australia.
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Hayakawa H, Aldington DJ, Moore RA. Acute traumatic compartment syndrome: a systematic review of results of fasciotomy. TRAUMA-ENGLAND 2009. [DOI: 10.1177/1460408608099028] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Issues around diagnosis and treatment of acute compartment syndrome were investigated through a systematic review that examined results of 55 reports of fasciotomy published over four decades and reporting on 1920 fasciotomies. Most were reported since 2000. Injuries below the elbow and knee accounted for at least 75% of cases. The consensus was that diagnosis of compartment syndrome remains primarily based on a high index of suspicion and interpretation of clinical signs and symptoms over high technology methods of diagnosis. Compartment syndrome related amputation occurred in 5.5% of cases and death in 3.3% overall. Compared with fasciotomy before 6 h, delayed fasciotomy beyond 12 h was associated with a lower rate of acceptable outcome (15% for more than 12 h vs. 88% for <6 h), a higher rate of amputation (14% vs. 3.2%) and death (4.3% vs. 2.0%).
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Affiliation(s)
- Heloise Hayakawa
- Pain Research, Nuffield Department of Anaesthetics, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, OX3 9DU, UK
| | - Dominic J Aldington
- Pain Research, Nuffield Department of Anaesthetics, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, OX3 9DU, UK
| | - R Andrew Moore
- Pain Research, Nuffield Department of Anaesthetics, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, OX3 9DU, UK,
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Mar G, Barrington M, McGuirk B. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis † †Presented as a poster at the European Society of Regional Anaesthesia and Pain Therapy, XXVII Annual Congress, Genoa, Italy, in September 2008 and published in part as an abstract in Reg Anesth Pain Med 2008; 33: e185. Br J Anaesth 2009; 102:3-11. [DOI: 10.1093/bja/aen330] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Sinha S, Munikrishnan V, Montgomery J, Mitchell SJ. The impact of patient-controlled analgesia on laparoscopic cholecystectomy. Ann R Coll Surg Engl 2007; 89:374-8. [PMID: 17535614 PMCID: PMC1963565 DOI: 10.1308/003588407x183337] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Laparoscopic cholecystectomy has revolutionised the management of symptomatic gallstones and is increasingly performed as a day-case procedure. The aim of this study was to assess the impact of opioid patient-controlled analgesia (PCA) on elective laparoscopic cholecystectomy. PATIENTS AND METHODS In a prospective, non-randomised, observational study, 76 consecutive patients who underwent elective in-patient laparoscopic cholecystectomy were reviewed. Six patients with complicated gall stone disease and four patients who converted from laparoscopic to an open operation were excluded. RESULTS Of the 66 remaining in the study group, 25 patients received morphine-PCA and, of these, 9 were fit for discharge. In contrast, 41 patients did not receive PCA and, of these, 27 were fit for discharge (P < 0.05). Median Aldrete score in the PCA group was 16 and in the non-PCA group 18 (P < 0.05). Postoperative nausea and vomiting were more common in patients receiving a morphine-based PCA and with in those with higher anti-emetic requirement (10/25 in PCA and 7/41 non-PCA groups; P < 0.05). CONCLUSIONS Routine postoperative opioid PCA prolongs the recovery and in-patient stay following elective laparoscopic cholecystectomy. Its role in postoperative pain management in routine laparoscopic cholecystectomy should be questioned.
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Affiliation(s)
- S Sinha
- Department of General Surgery, Torbay Hospital, Torquay, UK.
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Haggis P, Yates P, Blakeway C, Fick D, Morgan DAF, Holt M, Wood D. Compartment syndrome following total knee arthroplasty: a report of seven cases. ACTA ACUST UNITED AC 2006; 88:331-4. [PMID: 16498006 DOI: 10.1302/0301-620x.88b3.16919] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Compartment syndrome is a rare complication of total knee arthroplasty that requires early recognition and prompt decompression in order to prevent long-term disability. We have found only one previous case report in the literature. We present a series of seven cases from four hospitals and five surgeons. Six of the cases resulted in the loss of at least one compartment, and one resulted in amputation. Four of the cases resulted in legal action. We suggest that important risk factors contributing to the development of this condition include complex surgery, soft-tissue compromise, previous surgery, and possibly vascular disease. Delay in the diagnosis and hence delay in decompression was common in our series, and in five cases appeared to be related to the use of a postoperative epidural infusion for pain relief. The presence of associated neurological compromise may have also been a significant factor in the delay to diagnosis in two cases.
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Affiliation(s)
- P Haggis
- Whittington Hospital, Highgate Hill, London N19 5NF, UK.
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Thonse R, Ashford RU, Williams TIR, Harrington P. Differences in attitudes to analgesia in post-operative limb surgery put patients at risk of compartment syndrome. Injury 2004; 35:290-5. [PMID: 15124798 DOI: 10.1016/s0020-1383(03)00072-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Missed compartment syndrome may result in severe disability. Complete masking of pain, the cardinal symptom of compartment syndrome, may contribute to delayed or missed diagnosis. Scenarios reported in the literature as cases of delayed or missed compartment syndrome (due to analgesia) were included in a questionnaire. Each of the respondents was requested to indicate the preferred choice of post-operative analgesia for each scenario. Significant differences were found between orthopaedic surgeons and anaesthetists regarding the preferred choice of post-operative analgesia in clinical situations which have been previously shown to be associated with a high risk of compartment syndrome. Use of analgesic methods which impair the ability to detect patients with abnormal levels of pain or unusual demands for analgesia may place such patients at risk of the devastating sequelae of a missed compartment syndrome. The differences in attitudes to local and regional nerve blockade between orthopaedic surgeons and anaesthetists suggests that some anaesthetists may be exposing patients to the risk of missed compartment syndrome following extremity surgery.
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Affiliation(s)
- Raghuram Thonse
- Department of Orthopaedic and Trauma Surgery, Hull Royal Infirmary, Anlaby Road, Kingston-upon-Hull HU3 2JZ, UK.
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Affiliation(s)
- P E Macintyre
- Acute Pain Service, Department of Anaesthesia and Intensive Care, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA 5000, Australia
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