Compartment Of Leg Research Articles

Association of trauma severity scores with limb amputation and death in acute leg compartment syndrome.

Limb amputation and death are devastating sequelae of acute compartment syndrome (ACS), and have been posited to result either from the initial injury burden or from pathophysiologic sequelae, such as rhabdomyolysis leading to acute renal failure. We aimed to test the hypothesis that severity of trauma is associated with limb amputation and death in patients with traumatic leg ACS. We retrospectively reviewed 302 patients with ACS of 302 legs treated with fasciotomies from 2000 to 2015 at two tertiary trauma centers. Our response variables were death and limb amputation during inpatient hospital admission. Three common trauma severity scores, injury severity score (ISS), revised trauma score (RTS), and Glasgow coma scale (GCS), were studied. Patient- and injury-related explanatory variables were studied. Bivariate analyses were used to identify factors associated with limb amputation and death. Of 302 patients, 13 (4%) underwent limb amputation and 10 (3%) died during the inpatient admission. Only one of 10 patients who expired died secondary to acute renal failure. ISS and GCS were significantly associated with limb amputation, and RTS was marginally associated. ISS, RTS, and GCS were significantly associated with death. Moreover, smoking and open fracture were significantly associated with limb amputation, and diabetes mellitus, presence of fracture, closed head injury, and chest or abdominal injury were associated with death. Trauma severity scores are associated with both limb amputation and death during inpatient admission for traumatic leg ACS. These adverse sequelae of leg ACS are likely driven by the initial injury burden.

Dual-incision minimally invasive fasciotomy of the anterior and peroneal compartments for chronic exertional compartment syndrome of the lower leg

To evaluate the risk of iatrogenic injury when using a dual-incision minimally invasive technique to decompress the anterior and peroneal compartments of the lower leg. Forty lower extremities from 20 adult cadavers, embalmed with Thiel’s method, were subject to fasciotomy of the anterior and peroneal compartment using a dual-incision minimally invasive fasciotomy. The first incision was made 12 cm proximal to the lateral malleolus to identify and protect the superficial peroneal nerve (SPN). The second incision was made at the mid-point of the Fibula (half-way between the fibular head and the lateral malleolus). Release of the anterior and peroneal compartments was successful in all specimens. Two nerve injuries of the superficial peroneal nerve were reported. More precisely, in these cases the medial dorsal cutaneous nerve got injured during the fascial opening of the extensor compartment. Two incision minimally invasive fasciotomy to decompress the anterior and peroneal compartments of the lower leg appears to be safe with regard to the results of this study.

Can We Release All Calcaneal Attachments of the Superior Peroneal Retinaculum During Extensile Lateral Approach to the Calcaneus?

During extensile lateral approach to the calcaneus, in order to see all fractured fragments and subtalar joint, all soft tissues including insertion site of superior peroneal retinaculum (SPR) on the calcaneus should be released. The aim of this study was to evaluate the probability of peroneal tendon dislocation by releasing all soft tissues attached to the calcaneus. In 10 fresh cadavers, after standard extensile lateral approach to the calcaneus in right side, all soft tissues attached to the lateral wall of the calcaneus were excised. In the left side of each cadaver, all soft tissues inserted to the superior border of calcaneal tuberosity in addition to the lateral wall of the calcaneus were cut out. Probable anterior dislocation of peroneal tendons in the retromalleolar groove was assessed by placing a clamp into the peroneal tendon sheath from distal to proximal and advancing it to the retromalleolar groove. Also by careful dissection, any instability of peroneal tendons was visualized. Not any anterior dislocation of peroneal tendons to the lateral malleolus tip was seen in any stage of the procedure. Insertions of the SPR to the fascia of the deep posterior compartment of the leg and the Achilles tendon sheath are the main soft tissue stabilizer of the peroneal tendons in the retromalleolar groove. So resection of the insertion site of the SPR to the calcaneus might not result in the peroneal tendon instabilities.

Radiological Prevalence of Popliteal Artery Entrapment in Individuals With Anterior Leg Compartment Chronic Exertional Compartment Syndrome.

Determine the radiological prevalence of popliteal artery entrapment (PAE) in subjects with anterior leg compartment chronic exertional compartment syndrome (CECS). Retrospective review. Tertiary care center. Of 71 patients diagnosed with anterior leg compartment CECS using an in-scanner exercise-based magnetic resonance imaging (MRI), 64 also completed Fast Imaging Employing Steady-State Acquisition (FIESTA) imaging. Electronic health records of patients diagnosed with anterior leg compartment CECS using an in-scanner exercise-based MRI between 2009 and 2018 were reviewed. Demographics, symptom laterality, and results of vascular work-up. Magnetic resonance imaging was positive for PAE in 33 of 64 (51.6%). Vascular evaluation was performed in 30 of 33 (90.9%). Of these 30, ankle-brachial indices (ABIs) with PAE maneuvers were performed in 29 (96.7%) and positive in 25 (86.2%). Pre-exercise and post-exercise ABIs were performed in 29 (96.7%) and abnormal in 20 (69.0%). Thirteen arterial duplex ultrasounds were performed; 10 were consistent with PAE (76.9%). An MR angiogram was performed in 8 (26.7%) and consistent with PAE in all. One computed tomography angiogram (3.3%) was completed and was normal. Overall, one or more tests were positive for PAE in all 30 with vascular evaluation. The radiological prevalence of PAE and anterior leg CECS was 51.6%. All subjects with vascular studies (90.9%) had one or more tests confirming radiological PAE. These findings suggest that the coexistence of PAE and CECS is common, and the PAE protocol used has a high correlation with vascular studies.

Bilateral injury of deep peroneal nerve in the patient after heart transplant

In March 2015, a 62-year-old patient with advanced heart failure underwent a failed radiofrequency ablation, followed by paresis of muscles in the anterior compartment of the leg. After rehabilitation, partial recovery of the paresis was achieved. Orthotopic heart transplantation was performed 9 months after ablation at the at the Institute of Cardiology, followed by a bilateral paresis of muscles in the anterior leg compartment. Rehabilitation was implemented. The possible cause of paresis is most likely to be due to food shortages, mainly related to a folic acid deficiency.

Reconstruction of the Posterior Compartment of the Leg With Functional Free Latissimus Dorsi Flap to the Medial Sural Neurovascular Pedicle.

Reconstruction of the Posterior Compartment of the Leg With Functional Free Latissimus Dorsi Flap to the Medial Sural Neurovascular Pedicle.

A proposal for a new classification of soleus muscle morphology

IntroductionThe soleus muscle (SM) is located in the superficial posterior compartment of the leg, together with the gastrocnemius muscle (GM) and plantaris muscle. There is little information on the morphological variability (pennation) of the SM. The aim of the study is to characterize the variations in the morphology of the pennation of the SM and to create the first accurate classification. Material and methodsEighty lower limbs (40 left, and 40 right) fixed in 10% formalin solution were examined. The morphology of the central tendon, medial and lateral aponeuroses was evaluated, together with the pennation angle. ResultsIn all cases, the soleus muscle was present. Four types could be distinguished based on muscle fibre morphology. In order of frequency: Type 1 – bipennate (43.75%); Type 4 – non-pennate (36.25%); Type 2 – unipennate (15%); Type 3 – multipennate (5%). No significant difference in type distribution was observed with regard to body side (p=0.9018) or gender (p=0.0844). ConclusionThe soleus muscle is characterized by high morphological variability. Based on the pennation angle, four types (1–4) of soleus muscle are distinguishable.

A strategy to prevent complications of hyperextension type tibial plateau fracture.

Tibial plateau fractures (TPFs) are the most common among periarticular fractures. Mechanism of injuries is most from varus/valgus and flexion injury. Hyperextension type injuries are rare and easily to be overlooked. We reported 12 cases of this fracture type. Complications of early cases were reported, and treatment strategies of late cases were suggested. From 2010 to 2016, we performed a retrospective analysis of 248 cases of TPFs in our institute and 12 cases of hyperextension bicondylar TPFs were diagnosed. Diagnostic method is from both plain films and CT scans. The features of this injury included sagittal plane malalignment with loss of the normal posterior slope of the tibial plateau, tension failure of the posterior cortex, and compression of the anterior cortex. Surgical approach is predominantly via an anterolateral and/or posteromedial double incision at the first. Then anteromedial with adequate grafting to support the bone defect was modified. Postoperative radiographic analysis, physical examination findings, and complications were reported. Patient reported outcome scores from the Knee Injury and Osteoarthritis Outcome Score (KOOS) were recorded. Twelve patients were followed up for a mean period of 16.6months (range 12-26months). The mean time to radiographic bony union was 3.6months (range 3-9months, SD 8.5). About complications, the incidence of popliteal artery occlusion received PTA was 8% (1/12). And 3/12 (25%) patients had either partial or complete peroneal nerve injury. 2/12 (16%) patients developed a leg compartment syndrome. 33% (4/12) demonstrated associated injuries including posterolateral complex injuries mostly and posterior cruciate ligament avulsion fracture in one case. The average range of motion of the affected knees was 3.4-130° postoperatively. Analysis of complication about surgery included inadequate reduction and fixation in two cases, insufficient bone grafting in one case. The mean mPTA was significantly improved after fixation (preoperative 82° postoperative 3months 86°). The mean posterior slope (PTA) was preoperative -3° and postoperative 3months 3°. And mean KOOS was 80. Hyperextension bicondylar tibial plateau fractures show a special characteristic of changes in posterior tibial slope angle and are easy to be overlooked. Complication rate is high after injury and after ineffective fixation. Choosing correct approach with sufficient grafting and stable fixation for treatment of hyperextension bicondylar tibial plateau fractures should be used to improve patients' outcome.

Cardiac MRI identifies valvular and myocardial disease in a subset of ANO5-related muscular dystrophy patients

Patients with bi-allelic loss-of-function mutations in the gene ANO5 most commonly present with muscular dystrophy. In some studies, patients with ANO5-related dystrophy (ANO5-RD) had evidence of mild cardiac abnormalities; however, cardiac magnetic resonance imaging (MRI) has not been used for myocardial characterization. Ten patients with genetically confirmed ANO5-RD were enrolled in a phenotyping study to better characterize cardiac involvement. Evaluations included medical history, neurological examination and cardiac evaluations (electrocardiogram, echocardiogram and cardiac MRI). All patients were clinically asymptomatic from a cardiac perspective. Muscle MRI was consistent with previous studies of ANO5-RD with increased T1 signal in the posterior and medial compartments of the upper leg and the posterior compartment of the lower leg. Cardiac studies using echocardiography and cardiac MRI revealed dilation of the aortic root and thickening of the aortic valve without significant stenosis in 3/10 patients. There was evidence of abnormal late gadolinium enhancement (LGE) on cardiac MRI in 2/10 patients. In ANO5-RD, the development of cardiac fibrosis, edema or inflammation as demonstrated by LGE has not yet been reported. Cardiac MRI can characterize cardiac tissue and may detect subtle changes before they appear on echocardiography, with potential prognostic implications.

Significantly lower intramuscular pressure in the posterior and lateral compartments compared with the anterior compartment suggests alterations of the diagnostic criteria for chronic exertional compartment syndrome in the lower leg

PurposeTo investigate distributions and identify possible differences in intramuscular pressure (IMP) values at 1 min post-exercise between the four muscle compartments of the lower leg, in patients with exertional leg pain with or without chronic exertional compartment syndrome (CECS).MethodsA consecutive series of patients seeking orthopaedic consultation for exertional leg pain underwent IMP measurements between 2009 and 2018. The diagnosis of CECS was confirmed (n = 442) or ruled out (n = 422), based on the patient’s history, clinical examination, and IMP measurements.ResultsThe median (range) 1 min post-exercise IMP values in affected compartments in the patients diagnosed with CECS were 33 (25–53) mmHg (deep posterior), 35 (27–54) mmHg (superficial posterior), 40 (26–106) mmHg (lateral), and 47 (24–120) mmHg (anterior). In patients with no CECS, the median (range) 1 min post-exercise IMP values in the compartments were 12 (2–28) mmHg (deep posterior), 12 (2–27) mmHg (superficial posterior), 14 (2–26) mmHg (lateral), and 18 (4–34) mmHg (anterior). The IMP was significantly lower in the lateral and both posterior compartments than in the anterior compartment in both patients diagnosed with CECS and patients without CECS.ConclusionThe study demonstrates significantly lower IMP values in the posterior and lateral compartments compared to the anterior compartments. These findings suggest a lowering of the IMP 1 min post-exercise cut-off value for diagnosing CECS in the lateral and both posterior compartments, which may lead to improved treatment of patients with suspected CECS in the lower leg.Level of evidenceLevel II.

Post-exercise leg compartment pressure measurements in asymptomatic collegiate distance runners: a prospective study

Background: Chronic exertional compartment syndrome (CECS) is an uncommon cause of leg pain in running athletes. Post-exercise compartment pressure measurements are an invasive test that many clinicians use for making the diagnosis of CECS. We sought to determine if intracompartmental pressures in anterior leg compartments of asymptomatic collegiate distance runners meet established criteria for diagnosis of exertional compartment syndrome. Methods: Thirty collegiate running athletes underwent 1-minute post-exercise compartment pressure measurements of bilateral anterior leg compartments. Each was asked to run for 15 min at a moderately intense pace, and then underwent measurements performed at 1-minute postexertion with a needle manometer. Fifteen male and 15 female collegiate running athletes from age 18 to 23 yr (average 20.8 yr) underwent post-exercise compartment pressure testing of the legs. Results: Eleven (six men, five women) demonstrated 1-minute post-exercise compartment pressure measurements that met criteria for diagnosis of exertional compartment syndrome in at least one leg based on established criteria (>30 mmHg). Of these 11, four demonstrated positive measurements bilaterally (two men, two women). Intracompartmental pressure measurements ranged from 16 mmHg to 88 mmHg (average 27.5 mmHg). Measurements of anterior leg compartments performed at 1-minute post-exercise were indicative of exertional compartment syndrome in more than one-third of the asymptomatic running athletes tested (11/30, 36.7%). Conclusions: Elevated anterior leg compartment pressures were prevalent in collegiate distance runners despite a lack of symptoms. Post-exercise compartment pressure measurements should be viewed only as an indicator of exertional compartment syndrome and not relied upon as a confirmatory test. Level of Evidence: Level IV.

Composite Cutaneous Anterolateral Thigh Flap with Rolled Fascia Lata for Tibialis Anterior Tendon Reconstruction.

Background:Rupture of the tibialis anterior tendon (TAT) is a rare phenomenon with limited therapeutic options derived from sparse case reports. Without proper anchoring of the tibialis anterior, dorsiflexion and inversion of the foot become impaired, disrupting patient’s gait. Reported techniques for repair fall into nonoperative (ankle-foot orthosis) or operative (primary closure, tendon transfer, free gracilis) modalities, depending on patient factors, mechanism of injury, and extent of defect. In this report, we outline a novel method of tendon repair and soft tissue coverage for a large defect.Methods:We present a unique case of traumatic TAT rupture with a failed primary closure yielding a large (>15 cm) defect. The patient presented with a defect spanning the entire anterior compartment of the leg, limiting options for coverage and functional restoration.Results:The patient’s large, chronic defect was successfully repaired via a composite cutaneous anterolateral thigh and a rolled fascia lata free flap. The patient had robust return to function and is able to dorsiflex and invert the foot and ambulate.Conclusions:The use of this donor site offers a novel, advantageous option for TAT repair. It should be considered for patients with large defects that make other repair methods unfeasible.

Identification Of Functional Popliteal Artery Entrapment Syndrome In Athletes Who Have Failed Compartment Release

Level of evidence: IV OBJECTIVE: To evaluate the work up and outcomes of athletes with exertional leg pain, specifically the co-existence of functional popliteal artery entrapment syndrome (FPAES) and chronic exertional compartment syndrome (CECS), in athletes who were unable to return to sport or have significant symptomatic improvement after lower leg compartment fasciotomy. Design: Retrospective case series Setting: Outpatient musculoskeletal sports clinic, outpatient vascular surgery clinic Participants: 36 patients aged 15-67 (average age 26.9) diagnosed with functional popliteal artery entrapment syndrome using CT-angiogram with provocative maneuvers or MRI-angiogram with provocative maneuvers. In our cohort, a moderate number of athletes (11/36 athletes, 19/59 affected limbs) were referred for evaluation by vascular surgery after already having undergone lower leg fasciotomies for chronic exertional compartment syndrome. Interventions: Partial debulking of anterolateral quadrant of the medial head of the gastrocnemius muscle with or without fasciotomy Main Outcome Measures:Return to sport/previous activities RESULTS: Mean follow up was 52.3 ± 22.2 months. 78% (28/36) of the patients were able to fully return to their previous athletic competitive levels. All patients were able to resume their athletic sport at a recreational level. The patients participated in a myriad of sports and athletic activities: 14 runners, 9 soccer players, 3 unspecified, 2 lacrosse, 2 basketball, 1 triathlete, 1 jumper, 1 diver, 1 water polo, 1 rugby, 1 skier. At 6-month follow-up, there were 13% of affected limbs that had recurrent symptoms, at 12 months, only 5% had recurrent symptoms and at three years, no patients had symptoms present. CONCLUSIONS:Many of these patients were unable to return to participate in high levels at their respective sport even after initial fasciotomy for CECS, suggesting that FPAES was unidentified, overlooked, or possibly developed after fasciotomy. FPAES can be a co-existing diagnosis that warrants screening during the evaluation of CECS. Provocative CT-A and MRI-A protocols can help guide the diagnosis as well as location of muscle debulking to alleviate the functional entrapment that occurs in these athletes with exercise. It is important to consider and screen for this diagnosis to allow for proper treatment and return to sport.

Outcomes of Chimney or Snorkel Endovascular Repair for Symptomatic and Ruptured Abdominal Aortic Aneurysms

Symptomatic and ruptured abdominal aortic aneurysms (AAAs) are increasingly managed with endovascular aneurysm repair (EVAR). We aimed to identify the 30-day outcomes of symptomatic and ruptured AAAs that underwent EVAR with chimney or snorkel techniques (Ch-EVAR). A retrospective cohort study was performed using the Vascular Quality Initiative registry from March 2013 to July 2019. All patients with symptomatic and ruptured AAAs with proximal aortic zone of disease from 6 through 9 who underwent Ch-EVAR were included. Outcomes were analyzed per the Society for Vascular Surgery reporting standards for EVAR. Ch-EVAR was performed in 77 patients (35 [45.5%] ruptures, 42 [54.5%] symptomatic). Median age was 73 (interquartile range [IQR], 67-81) years, and 54 (70.1%) patients were male. Maximum aneurysm diameter was 67.5 (IQR, 54.5-83.3) mm. All patients were assigned to American Society of Anesthesiologists class 3 or above, with 56 (72.7%) class 4. Among ruptured AAAs, the mean lowest preoperative systolic blood pressure was 95.3 (±29.3) mm Hg. Fluoroscopy time was 57.4 (IQR, 41.2-79.0) minutes. The proximal aortic zone of disease was zone 6 in 9 (11.7%), zone 7 in 21 (27.3%), zone 8 in 36 (46.8%), and zone 9 in 11 (14.3%) patients. Ch-EVAR involved one vessel in 28 (36.4%) patients, two vessels in 22 (9.1%) patients, three vessels in 19 (24.7%) patients, and four vessels in 8 (10.4%) patients. Configurations of the Ch-EVAR are shown in Table I. Technical success was achieved in 67 (87.0%) patients. Outcomes of symptomatic and ruptured Ch-EVAR are summarized in Table II. Reintervention was required in 10 (13.0%) patients at a median time of 9 postoperative days. This involved the aorta/chimneys in five (6.5%) patients, access ischemia in one (1.3%), complete device removal in one (1.3%), new stent placement in two (2.6%), and glue repair of endoleak in one (1.3%). Postoperatively, 31 (40.3%) patients had a major complication, including 4 (5.2%) access site hematomas, 1 (1.3%) access site occlusion, 2 (2.6%) strokes, 2 (2.6%) pneumonias, 5 (6.5%) reintubations, 8 (10.4%) renal ischemia, 11 (14.3%) postoperative dialysis, 4 (5.2%) intestinal ischemia, 3 (3.9%) leg ischemia, and 1 (1.3%) leg compartment syndrome. Ch-EVAR for symptomatic and ruptured AAAs may be performed with acceptable rates of morbidity and mortality. Long-term data are needed to determine durability.Table IConfigurations of Ch-EVARConfigurationNumber of patients (n = 77) (%)Bilateral Renal10 (13.0)Left Renal11 (14.3)Right Renal10 (13.0)SMA, Bilateral Renal16 (20.8)SMA, Left Renal4 (5.2)SMA, Right Renal5 (6.5)SMA7 (9.1)Celiac, SMA3 (3.9)Celiac, SMA, Left Renal3 (3.9)Celiac, SMA, Bilateral Renal8 (10.4) Open table in a new tab Table IIComparison between ruptured and symptomatic Ch-EVAROutcomeRuptured (n = 35)Symptomatic (n = 42)Overall (n = 77)P-valueMortality4 (11.4%)3 (7.1%)7 (9.1%).695Converted to Open Procedure1 (2.9%)1 (2.4%)2 (2.6%)1.000Type 1 Endoleak7 (20.0%)2 (4.8%)9 (11.7%).071Type 2 Endoleak0 (0.0%)4 (9.52%)4 (5.2%).121Type 3 Endoleak0 (0.0%)1 (2.4%)1 (1.3%)1.000Postoperative length of stay (days)13.67.610.3.110Number of vessels stented1.82.32.1.038 Open table in a new tab

Compartment syndrome of the leg after thyroid hormone withdrawal; two cases and a systematic review of the literature

BackgroundAcute compartment syndrome is a rare complication of severe hypothyroidism. If the symptoms are not recognized promptly and treatment initiated immediately, there is a high risk of permanent damage. Only few other cases of compartment syndrome due to hypothyroidism have been published and the exact pathophysiological mechanism remains unknown.Case presentationsA 59 year old male developed acute compartment syndrome of his right lower leg after thyroid hormone withdrawal prior to radioiodine remnant ablation after total thyroidectomy for follicular thyroid cancer. He underwent emergency fasciotomy of all four compartments of the lower leg. The muscle tissue in the anterior and lateral compartment was necrotic and was therefore excised. The second patient was a 62 year old female with Hashimoto’s thyroiditis, who developed acute compartment syndrome of both lower legs after thyroid hormone withdrawal due to non-compliance. Emergency fasciotomy of all four compartments of both legs was performed. The muscle tissue was viable in all compartments.ConclusionAlthough compartment syndrome due to hypothyroidism is uncommon, it is a complication physicians should be aware of. The majority of reported cases are caused by an acute withdrawal of thyroid hormones and not by undetected hypothyroidism. No previous case of compartment syndrome caused by an iatrogenic hormone withdrawal in preparation for radioactive iodine has been published. However, as shown in this report, it may be beneficial to inform patients of this rare complication prior to hormone withdrawal in preparation for remnant ablation after thyroidectomy.

P1104THE ROLE OF THERAPEUTIC PLASMA EXCHANGE COMBINED WITH HEMODIALYSIS IN MANAGEMENT OF POISONING AND INTOXICATION

Abstract Background and Aims Background: Poisonings, intoxications, and drug overdoses are common occurrences and rapid lowering of the toxin level is key of all effective therapies. Therapeutic plasma exchange (TPE) has several unique characteristics that allow it to be a potentially effective therapy in rapidly achieving this goal with large molecular weight, protein-bound molecules that have a small volume of distribution. Ibuprofen is a commonly used anti-inflammatory, antipyretic, and analgesic drug. The number of reported ibuprofen overdoses (IO) has increased. Although the vast majority of IOs are not consequential, large ingestion can cause severe metabolic acidosis (MA) resulting in multi-organ failure and death. TPE has been reported as solo intervention in IO, however frequently with remaining renal dysfunction. We report two cases of massive IO that responded well to prompt combined TPE with continuous renal replacement therapy (CRRT). Method Literature and chart review of cases of IO in our institute treated with TPE+CRRT. Results Case 1: A 17 year old male presented to the Emergency Department (ED) following intentional IO in coma with serum pH of 7.09, cardiorespiratory failure and acute kidney injury (AKI). Urine drug screen was positive for only ibuprofen. He reportedly took 1381 mg/kg. Supportive care was unsuccessful, therefore TPE+CRRT was soon initiated. After two days of treatment the patient was able to be extubated, maintained normal cardiovascular status and renal function. The patient fully recovered. Case 2: A 17 year old female presented to the ED following intentional IO with serum pH of 6.9, cardiorespiratory failure, AKI, arrhythmia and bilateral leg compartment syndrome. Urine drug screen was positive for ibuprofen. The estimated ibuprofen exposure was above 2000 mg/kg. The initial ibuprofen serum plasma level was 330 µg/mL (therapeutic range is 10-50 µg/mL). Initial Supportive care was unsuccessful and TPE+CRRT was immediately started. Plasma ibuprofen level was normal after the 3rd TPE+CRRT. The patient fully recovered. Conclusion Intentional IO may result in major morbidity and mortality. TPE is more efficient in removing drugs with a high protein binding and/or a low volume of distribution, such as ibuprofen. In settings of massive overdose, hemodialysis may provide additional removal of unbound portion, as well corrects acidosis and allows provision of optimal nutrition. Combined TPE+CRRT is beneficial and may facilitate recovery. To our knowledge this is the first pediatric report of severe IO successfully treated with combined therapy.

A case of well leg compartment syndrome after prolonged lateral decubitus position

A case of well leg compartment syndrome after prolonged lateral decubitus position

Intramuscular venous malformations of the calf: Surgical treatment outcomes of 57 patients.

To report the outcomes of surgical treatment of calf intramuscular venous malformations (IMVMs) on pain, functional limitation, and quality of life. We retrospectively reviewed 57 consecutive patients who had surgery for IMVM of the posterior compartment of the leg between 2010 and 2015. Treatments were all done at a single institution. Patients presented with pain (52), muscle contracture (14), or pulmonary embolism (4). Muscle involvement included the soleus muscle (n = 28, 49%), the gastrocnemius muscle (n = 25, 43%), and deep muscles (n = 4, 7%). Complete excision was possible in 52 patients (91%) and partial excision in 5 (9%). Thirty-five of 46 patients who had an MRI follow-up at six months had no residual venous malformation. At the final follow-up (mean 39 months), 32 of 40 patients seen had no residual pain and 37 had no residual functional impairment. In cases where IMVM is located in one muscle in the leg, we demonstrated that surgery yielded improvement in pain, function, and quality of life.

Factors associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome.

The objective of this study is to determine factors associated with myonecrosis at the time of fasciotomy in patients with acute leg compartment syndrome. 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. 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). Myonecrosis is associated with patient-related factors. Younger age by 10years 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.

Tibialis posterior (TP) tendon transfer for foot drop: A single center experience

BackgroundFoot drop defined as a significant weakness of ankle and toe dorsiflexion. It leads to high stepping gait, functional impairment and deformity of the foot. Objective of this study was to assess the functional outcome of tibialis posterior (TP) transfer for patient with foot drop in a single center. MethodsThis is a retrospective study included 20 patients operated for foot drop of >1 year duration in the last 5 years. Preoperative assessment of muscles of all the three compartment of leg along with radiological assessment of ankle to rule out tarsal disintegration and ankle instability was done. Postoperatively gait, active dorsi/plantar flexion and the range of movement of the ankle and toes were assessed. ResultsTibialis posterior transfer was performed on 20 patients (16 males and 4 females, mean age 31.4 years). Commonest cause of foot drop was Hansen’s disease followed by post traumatic peroneal nerve damage and post injection sciatic neuropathy. At mean follow-up of 2 years, all patients, except one, could walk with heel-toe gait without any orthotic support. There was no pain, ruptures or infections of the transferred tendons. 19 of the 20 operated ankles had mean active dorsiflexion of 7.5°, the active plantar flexion of 36.25°, and the total range of movement 43.75°. The active dorsiflexion of the toes ranged from 5-20°. ConclusionDynamic tibialis posterior transfer gives good results in terms of normal gait, high patients’ satisfaction with minimal donor site morbidity and low complication rate.