Compartment Of Leg Research Articles

The Effect of Kneeling During Spine Surgery on Leg Intramuscular Pressure

Acute compartment syndrome has been an underreported complication during spine surgery with the patient positioned on the so-called 90/90 kneeling frame (with 90 degrees of both hip and knee flexion), presumably because of elevated intramuscular pressures in the dependent leg compartments. The purpose of the present study was to characterize and quantify certain parameters that affect the risk for acute compartment syndrome experimentally and to make objective comparisons with other spine surgery positions. Eight healthy volunteers were positioned in three spine surgery positions: the 90/90 kneeling position, the so-called 45/45 suspended position (with the hips and knees both flexed to 45 degrees with the legs suspended on a sling), and the prone position. Intramuscular pressures were measured in all four left leg compartments with slit catheters. Local blood pressure and applied load beneath the leg were also measured. The 90/90 kneeling position was associated with significantly increased intramuscular pressure in the anterior compartment (30.8 +/- 5.7 mm Hg) in comparison with the prone position (13.5 +/- 1.7 mm Hg) and the 45/45 suspended position (13.8 +/- 1.7 mm Hg). In the 90/90 kneeling position, these values correlated with subject weight (r = 0.72, p = 0.045) and the applied body weight load measured beneath the leg (r = 0.74, p = 0.037). The mean differences between intramuscular pressure and ankle blood pressure were more pronounced as the position of the ankle dropped below the level of the heart in the 45/45 suspended and the 90/90 kneeling positions. The 90/90 kneeling position results in elevated intramuscular pressure in the anterior compartment of the leg. This elevated pressure correlates also with subject weight. The 90/90 kneeling position may predispose patients to the development of an acute compartment syndrome during prolonged spine surgery, with heavier patients being at increased risk. In certain instances, the surgeon may consider using the 45/45 suspended position to minimize this risk.

Poster 244: Lymphedema Therapy in Klippel-Trénaunay Syndrome: A Case Report

Setting: Tertiary medical center. Patient: A 17-month-old girl born with an edematous left leg. Case Description: The patient was found to have an enlarged left leg during a third trimester ultrasound. This finding persisted to the time of birth. At 12 months, she developed a clear drainage from her left leg and cellulitis. The patient was referred at 17 months of age for lymphedema consultation for persistent limb edema. Assessment/Results: On exam, the patient was a healthy 17-month-old child who was friendly and playful. She was an intelligent child and had met her milestones on target. Her left leg was markedly larger than her right throughout, measuring a mean 8cm difference in circumference. Superficial venous vascular malformations were noted, but no port wine stains. There were no further signs of cellulitis. No neurologic abnormalities were present. Scanogram showed a 1.7cm leg-length discrepancy, left longer than right. Magnetic resonance imaging demonstrated extensive vascular malformations present in the subcutaneous tissue and less extensively into deep muscle compartments of the left leg without obvious extensive involvement of the hip, knee, or ankle. She was diagnosed with Klippel-Trénaunay syndrome (KTS). For lymphedema control, she was fitted with a thigh-high compression stocking with a waist attachment. Heel lift was recommended for leg-length discrepancy. Discussion: KTS is a congenital anomaly characterized by unilateral limb overgrowth, venous varicosities, and capillary malformations. 95% of cases involve the lower extremity. Hypertrophy of the extremities can be extreme, requiring amputation. Lymphatic involvement can affect wound healing. Treatment is targeted at symptom management as well as maximizing and maintaining function. Physiatric referral can provide patients with effective conservative measures. Conclusions: KTS poses relevant clinical challenges to the physiatrist, including lymphedema management, leg-length assessment with modifications, gait analysis, and presurgical counseling.

Peroneal nerve palsy due to compartment syndrome after facial plastic surgery

A 25-year-old white man, right after bilateral rhytidoplasty, presented with agitation, necessitating use of haloperidol. Some hours after, he developed severe pain in his legs and a diagnosis of neuroleptic malignant syndrome (NMS) was considered. Even with treatment for NMS he still complained of pain. A diagnosis of lower limb compartment syndrome (CS) was done only 12 hours after the initial event, being submitted to fasciotomy in both legs, disclosing very pale muscles, due to previous ischemia. This syndrome was not explained only by facial surgery, his position and duration of the procedure. It can be explained by a sequence of events. He had a history of pain in his legs during physical exercises, usually seen in chronic compartment syndrome. He used to take anabolizant and venlafaxine, not previously related, and the agitation could be related to serotoninergic syndrome caused by interaction between venlafaxine and haloperidol. Rhabdomyolysis could lead to oedema and ischemia in both anterior leg compartment. This report highlights the importance of early diagnosis of compartment syndrome, otherwise, even after fasciotomy, a permanent disability secondary to peripheral nerve compression could occur.

Monomelic neurogenic syndromes: A prospective study

Monomelic neurogenic syndromes are rare. Their classification and prognostic features have not been addressed in the European population. A prospective study of 17 patients with monomelic neurogenic amyotrophy, of upper or lower limb onset, with progression limited to one limb for three or more years. Clinical and neurophysiological studies were performed in the subsequent 3 or more years. Fifteen patients were of European origin and two were Asian. Those presenting with proximal monomelic weakness or with involvement of the posterior compartment of the lower leg showed no further progression after the initial period of development of the syndrome. Brisk reflexes in wasted muscles did not predict progression. Electromyographic signs of denervation in the opposite limb at presentation did not predict later progression. Transcranial magnetic stimulation (TMS) features of corticospinal dysfunction were a useful predictor of subsequent progression (p=0.01). One patient with lower limb onset developed conduction block with weakness in an upper limb nine years after presentation, and this upper limb weakness responded to IVIg therapy. This adult-onset European group of patients is different as compared with juvenile-onset Asian cases. The clinical syndromes appear heterogeneous, but neurophysiological investigations, in particular TMS, can be helpful in determining prognosis. Multifocal motor neuropathy should be considered when there is progression, even years after onset.

Atraumatic Compartment Syndrome

Compartment syndrome of the extremity is a condition in which elevated pressure within a fascial compartment compromises perfusion of the enclosed tissues and ultimately leads to loss of function of the extremity1. Presenting acutely, compartment syndrome is usually induced by trauma and requires urgent treatment with fasciotomy to lower compartment pressure and to reduce the amount of myonecrosis that may occur. We present an unusual case of compartment syndrome that was caused by infection and that was not secondary to injury. Our patient and her family were informed that data from the case would be submitted for publication. A previously healthy eleven-year-old girl presented to the emergency room with pain in the left leg and an inability to walk. The leg had become increasingly swollen and painful during the two-day period prior to admission, even though there was no history of trauma. The patient had had fever for eight days preceding the appearance of symptoms in the leg, and this condition had been treated by her primary care provider as influenza. She had had no contact with ill individuals at home, and there was no history of recent travel. Her immunizations were up to date. In the emergency room, she was febrile with a temperature as high as 38.5°C. The systolic blood pressure was in the range of 80 to 90 mm Hg. The left leg was swollen, the leg compartments were tense to palpation, and the patient had severe calf pain with passive dorsiflexion of the ankle. Pitting edema was evident in the dorsum of the left foot, which was erythematous and had a loss of sensation. The active motor examination was limited due to pain. The patient had a palpable dorsalis pedis pulse, and the foot was warm to the touch. An erythematous macular rash of …

Insulin Treatment in Cancer Cachexia: Effects on Survival, Metabolism, and Physical Functioning

The present study was designed to evaluate whether daily insulin treatment for weight-losing cancer patients attenuates the progression of cancer cachexia and improves metabolism and physical functioning in palliative care. One hundred and thirty-eight unselected patients with mainly advanced gastrointestinal malignancy were randomized to receive insulin (0.11 +/- 0.05 units/kg/d) plus best available palliative support [anti-inflammatory treatment (indomethacin), prevention of anemia (recombinant erythropoietin), and specialized nutritional care (oral supplements + home parenteral nutrition)] according to individual needs. Control patients received the best available palliative support according to the same principles. Health-related quality of life, food intake, resting energy expenditure, body composition, exercise capacity, metabolic efficiency during exercise, and spontaneous daily physical activity as well as blood tests were evaluated during follow-up (30-824 days) according to intention to treat. Patient characteristics at randomizations were almost identical in study and control groups. Insulin treatment for 193 +/- 139 days (mean +/- SD) significantly stimulated carbohydrate intake, decreased serum-free fatty acids, increased whole body fat, particularly in trunk and leg compartments, whereas fat-free lean tissue mass was unaffected. Insulin treatment improved metabolic efficiency during exercise, but did not increase maximum exercise capacity and spontaneous physical activity. Tumor markers in blood (CEA, CA-125, CA 19-9) did not indicate the stimulation of tumor growth by insulin; a conclusion also supported by improved survival of insulin-treated patients (P<0.03). Insulin is a significant metabolic treatment in multimodal palliation of weight-losing cancer patients.

Extensor retinaculum syndrome after distal tibial fractures: anatomical basis

Fractures of the distal extremity of the tibia include physeal injuries among teenagers and more complex fractures among adults. Displacement causes the compression of the muscles located between the distal tibia and the superior extensor retinaculum (SER). Among the muscles of anterior compartment of the leg, the extensor hallucis longus (EHL) is particularly vulnerable due to the amount of muscle fibers extending under the SER. Consequently, a partial anterior compartment syndrome could result, affecting only the distal portion located under the SER. In clinical practice, Mubarak measured the intramuscular pressure isolated under the SER and suggested the physio-pathological hypothesis of a compression of distal muscle fibers. The aim of this study is to compare the ratios of anterior compartment muscle fibers extending under the SER. Twenty legs were dissected in order to study how much of these muscles extend under the SER, their passages possibly dividing into two of the SER, as well as their vascularization and their innervation. On the last seven legs, the engagement of the muscles were measured in the spontaneous position and with a dorsal flexion of 0 degrees . The posterior muscle fibers of this compartment always descend lower than the anterior fibers. EHL muscle fibers and those of the inconsistent fibularis tertius always extend under the retinaculum, unlike those of the tibialis anterior and of the extensor digitorum longus. The EHL muscle extends under the SER more than the other muscles. Its posterior fibers are longer when this muscle goes through a dividing into two of the retinaculum. Its vascularization seems lesser, which could explain why this muscle tends to suffer more. The deep fibular nerve innervates the anterior compartment of the leg, yet no nerve branches can be found under the upper edge of the retinaculum. In all cases, the muscle fibers do not extend as much under the SER in a 0 degrees of dorsal flexion. This anatomical study allows us to explain why the EHL is more likely to suffer from this partial compartment syndrome and confirms that when the latter occurs it is necessary, in all cases, to do emergency surgery opening the distal crural fascia and necessarily including the SER.

Zaspopathy in a large classic late-onset distal myopathy family

Distal myopathies have been associated with mutations in titin, dysferlin, GNE, desmin and myosin. Of these, only titin mutations were previously known to cause dominant late-onset distal myopathy. Recent findings, however, have indicated that patients affected with myofibrillar myopathy have a more distal than proximal muscle phenotype and a proportion of these may have mutations in myotilin, ZASP or filamin C, besides previously known desmin and alphaB-crystallin. Here we report that the disorder in one of the well-characterized autosomal dominant distal myopathy families, the Markesbery et al. family, first reported in 1974, is caused by ZASP mutation A165V. Previous linkage to the titin locus 2q31 proved incorrect. ZASP expression by immunoblotting shows normal presence of the main 32 and 78 kDa bands and immunohistochemistry in patients reveals normal Z-disc localization except for moderate accumulations together with myotilin, desmin alphaB-crystallin and alpha-actinin. Muscle imaging reveals involvement in both the posterior and anterior compartments of the lower leg and considerable affection of proximal leg muscles at later stages. Haplotype studies in this family and in five other unrelated families with European ancestry carrying the identical A165V mutation share common markers at the locus suggesting the existence of a founder mutation.

Well leg compartment syndrome following penetrating abdominal trauma

However,this condition has never been described as a com-plication of abdominal injury and in a supine oper-ating position.The two main theories of WLCS are direct exter-nal compression and vascular insufficiency or hypo-perfusion of the calf muscles, or a combination ofthe two. The common pathway may be hypo-oxyge-nation leading to local ischaemia, tissue oedemaand then fulminant compartment syndrome.Classically compartment syndrome occurs whenpressure within a closed osseofascial compartmentexceeds the perfusion pressure and results in cel-lular anoxia, muscle and nerve ischaemia. Twodistinct conditions are recognised: acute andchronic (exertional) compartment syndromes.

Intraseptal superficial peroneal nerve

Knowledge of the anatomy of the superficial peroneal nerve (SPN) is necessary for surgeons caring for patients with lower extremity pain after ankle, leg, or knee injuries, for athletes with exertional compartment syndrome, and those having reconstructive microsurgery with either soft tissue or vascularized fibular flaps. The anatomy of the SPN is known to be that of a peripheral nerve traveling in the lateral compartment of the lower leg. Recently, clearer descriptions of its variability have documented that between 27 and 43% of patients have the SPN in either the anterior compartment or both the anterior and the lateral compartment of the leg. The present observations record the location of the SPN within the septum that separates the anterior from the lateral compartment. Awareness of this unusual variant location will enable the surgeon to find and preserve the SPN during fasciotomy, neurolysis, neuroma resection, or bony and soft tissue reconstruction.

Luxations traumatiques du genou associées à une interruption de l’artère poplitée: Étude critique rétrospective d’une série de 14 cas

Luxations traumatiques du genou associées à une interruption de l’artère poplitée: Étude critique rétrospective d’une série de 14 cas

Calcific myonecrosis and tenosynovitis: Sonographic findings with correlative imaging

We report the sonographic appearance of a case of calcific myonecrosis and tenosynovitis with correlative plain radiography and CT findings. Calcific myonecrosis is a rare complication of previous trauma that presents as a tumor-like calcified mass years after an initial injury, most commonly affecting the anterior compartment of the lower leg. Although the clinical, radiographic, and MRI features of calcific myonecrosis have been well described, to our knowledge the sonographic appearance has not been reported previously in the literature.

Peroneal nerve damage by oblique proximal locking screw in tibial fracture nailing: a new emerging complication?

Interlocking intramedullary nailing currently is the preferred treatment for most tibial fractures requiring operative treatment. Good results with a relative low complication rate have been reported in large clinical series, as well as in comparative series. The reported incidence of neurological complications after tibial nailing varies, involving mainly the peroneal nerve. The mechanism of peroneal nerve damage in tibial fracture nailing is usually indirect, caused by leg traction or compartment syndrome. Direct peroneal nerve damage related to the proximal locking screw seems to be very rare since we were able to identify only one report in the English literature. We report a case of partial peroneal nerve damage caused by a long oblique proximal locking screw. Removal of the proximal locking screw leaded to a gradual improvement of the nerve function and a complete resolution at one year. This seems to be a new emerging iatrogenic complication related to nails designed with oblique proximal locking screws. We feel that the placement of the oblique proximal screw from medial to lateral side needs an extra care. Even fluoroscopy, does not give enough safety due to the spatial geometry of the proximal tibia and the known problems of viewing oblique interlocking screws with a two-dimensional image-intensifier.

Severe leg compartment syndrome associated with dorsal lithotomy position during radical hysterectomy

We encountered a female patient with left-leg compartment syndrome; a devastating complication, probably associated with prolonged dorsal lithotomy position during radical hysterectomy using intermittent pneumatic compression. This patient was intensively treated and fortunately recovered. However, leg compartment syndrome is poorly understood by gynecologists. We must always consider the potential risk of this life-threatening complication when patients are placed in the dorsal lithotomy position for a prolonged period during extended surgery using intermittent external compression.

Novel strategies for protection and repair of the central nervous system

Clinical possibilities in many neurological conditions are limited by our current inability to correct structural damage to the nervous system, and treatments to prevent damage are also limited. Current research has produced promising treatments that promote neuroprotection, plasticity, axon regeneration, remyelination and cell replacement. As these treatments go through clinical trials and enter the clinic, the treatment of several neurological conditions will change greatly.

Bilateral Exercise-Induced Compartment Syndrome of the Thigh and Leg Associated with Massive Heterotopic Ossification: A Case Report

Compartment syndrome of the thigh is an infrequent phenomenon, and it is even more rare for it to occur as a result of exercise. The vast majority of cases are associated with femoral fractures, thigh contusions, prolonged compression, and/or vascular injuries1,2. A search of the English-language literature revealed only eleven cases caused by intense or prolonged exercise (Table I). More importantly, we found only one reported case of bilateral thigh and leg compartment syndrome, the outcome of which was death secondary to multiorgan failure3. We are presenting what we believe is the first report on a survivor of exercise-induced compartment syndrome of both thighs and legs. Follow-up at fourteen months demonstrated reasonable functional recovery despite life-threatening medical complications and the development of massive heterotopic ossification. View this table: TABLE I Reported Cases of Acute Compartment Syndrome of the Thigh Secondary to Intense Exercise The patient agreed to have the data concerning the case submitted for publication. A twenty-two-year-old male body-builder had been taking creatine monohydrate (20 g/day) as a nutritional supplement for four months when acute thigh and leg cramping developed, followed by five days of the passage of dark urine. The symptoms developed over a two-week period while the man was performing high-repetition, free-weight lower-extremity exercises. He was admitted to a local community hospital with symptoms of nausea, vomiting, uncontrollable thigh pain, and the inability to walk. Three days after admission, he was transferred to our institution with a delayed diagnosis of acute compartment syndrome of the thighs. Prior to his transfer, anterior thigh compartment pressure was reported to be elevated bilaterally (65 mm Hg). Physical examination performed following the transfer demonstrated tense thighs and legs. The clinical symptoms, however, appeared to have abated slightly compared with the initial presentation three days previously. The patient did not have …

Bacteraemic necrotizing fasciitis with compartment syndrome caused by non-O1 Vibrio cholerae

Non-O1 Vibrio cholerae are gram-negative rods that can cause sporadic gastroenteritis, bacteraemia, and extraintestinal infections, primarily following the consumption of raw seafood or exposure of damaged skin to contaminated saltwater during the summer months. Bacteraemic necrotizing fasciitis caused by non-O1 V. cholerae has rarely been reported. Liver cirrhosis, haemochromatosis, and immunosuppression are important factors contributing to the severity of the infections and outcome. This report describes a case of liver cirrhosis in which right lower leg compartment syndrome and acute renal failure presented as the initial symptoms of bacteraemic necrotizing fasciitis. The organisms growing in the wound and blood cultures were identified as non-O1 V. cholerae. After antibiotic therapy, fasciotomy, right above-knee amputation, repeat debridement of the left lower leg and split-thickness skin grafts, the patient was eventually discharged in a stable condition.

A Case of Foot Drop as an Expression of Brain Metastases?

Foot drop can be defined as a significant weakness in ankle and toe dorsiflexion. Injury to the dorsiflexors or to any point along the neural pathways that supply these muscles can result in a foot drop. Injury to the peroneal nerve is usually the major precipitant. Other causes vary from trauma to surgical nerve injury, as well as leg compartment syndromes or dorsiflexor injuries, peripheral nerve injuries, stroke, neuropathies, drug toxicities, spinal stenosis, L5 sciaticas, systemic diseases such as connective tissue diseases, vasculidities, or diabetes. This report focuses on a patient presenting with a foot drop as an unusual manifestation of brain metastasis. His minimal symptomatology seemed to point towards a local process. Therefore, early recognition and prompt treatment are essential. The central nervous system must be the target of investigations when the workup fails to disclose the proper etiology. Potential diagnostic delays may occur. Certain cases may require a more aggressive approach.

Volkmann Contracture and Compartment Syndromes after Femur Fractures in Children Treated with 90/90 Spica Casts

Nine pediatric patients (mean age 3.5 yrs) with low energy femur fractures were treated with 90/90 spica casts and developed leg compartment syndromes, Volkmann contracture, and ankle skin loss. These cases are detailed and a proposed mechanism leading to this devastating complication is explained. The authors believe the technique of an initial below knee cast, and then using that cast for applying traction while immobilizing the child in the 90/90 spica is potentially dangerous. Alternative spica application methods are advocated.

P.P.5 11 Autosomal dominant congenital fibre type disproportion. Study of a family

Congenital fibre type disproportion (CFTD) is a rare myopathy, with heterogeneous clinical phenotype and inheritance. Muscle biopsy is characteristic, showing predominance and smallness of type 1 fibres. Few cases were studied by magnetic resonance imaging of muscles (mMR). To present mMR data in three cases of CFTD in two successive generations and to analyse topography of muscle involvement and degree of affection. Patients were studied clinically, by muscle biopsy, CK, mMR and neurophysiological exams. MR was performed in a 2-Tesla system, with two sets of T1-weighted axial slices, 6–8 mm thick, of thighs and legs. Each muscle was scored zero (normal) to four (end stage) blindly of clinical data. For each muscle, on both limbs, scores obtained in the three patients were summated and compared between muscles and compartments. The father was 44 years old and his siblings, a girl of 11 and a boy of 9. They had congenital myopathy with hypotonia and delayed motor milestones. All were thin and hypotonic, with arched palate and normal facial and external eye movements. Axial muscle involvement caused scoliosis, severe in the father, moderate and mild in the children. There was diffuse motor deficit with predominance in lower limbs, especially foot and toe dorsiflexors. CK was normal to mildly increased. The father had typical fibre type disproportion in biceps brachii. Two cases had a myopathic pattern in EMG. Total mMR scores were: extensor hallucis longus (18); extensor digitorum longus (18), tibialis anterior (16,5), sartorius (15), adductor brevis (14), adductor magnus (14), adductor longus (13), vastus medialis (12), soleus (12), tibialis posterior (11), peroneus (10), semitendinosus (10), semimembranosus (10), gracilis ( 9), biceps femoris (8), rectus femoris (8), vastus intermedius (8), vastus lateralis (8), gastrocnemius lateralis (7), gastrocnemius medialis (4) Posterior muscles of thighs were relatively spared compared to anterior and medial compartments. Anterior compartments of legs were most affected, followed by deep posterior, superficial posterior and lateral compartments. Scores had correlation with age and clinical severity of disease.