Development Of Compartment Syndrome Research Articles

CURRENT ISSUES OF TREATMENT AND REHABILITATION OF VICTIMS WITH A COMBAT INJURY OF THE LOCOMOTOR SYSTEM ON THE MODERN STAGE (REVIEW)

With a beginning of active battle actions in Ukraine the number of victims with gunshot, mine-explosive and shrapnel injuries of the locomotor system among both the military and the civilian population increased sharply. Therefore, the problems of treatment and rehabilitation of victims of hostilities have become especially acute in the last year. Aim. To analyze literary sources on the issue of providing medical aid for gunshot injuries of the musculoskeletal system, to identify problems and prospective directions of rehabilitation treatment of the consequences of combat trauma. Methods. An analytical review of scientific works on the treatment of gunshot and mine-explosive injuries of the musculoskeletal system and their consequences was conducted. Results. It is shown that in recent decades, as a result of the creation of modern firearms and explosive shells, the scale and severity of traumatic injuries have increased significantly, and the frequency of multiple and combined injuries has also increased. Fire injuries of the musculoskeletal system are accompanied by many complications and unsatisfactory anatomical and functional results of treatment. Such injuries are characterized by a traumatic disease that develops in response to combat trauma and has a long and complicated course, high rates of mortality and severe disability. Extremity injuries are the most common — 65‒75 %, and in some combat operations — 80 % or more. The most serious injuries include mine-explosive injuries, which are accompanied by massive damage to the soft tissues of the limbs, main vessels and nerves, and the development of compartment syndrome. 19.1–52.9%) and permanent disability. Conclusions. Damages of the spine and spinal cord lead to high mortality (19.1–52.9 %) and permanent disability. Conclusions. Despite the significant number of developed restorative treatment and rehabilitation technologies victims with gunshot and mine-explosive injuries, specialists continue to improve methods of physical rehabilitation, and work on eliminating problems and shortcomings that still exist in the organization of rehabilitation measures.

Necessity, Role, and Outcomes of Fasciotomy in Patients with Acute Limb Ischemia

The incidence of compartment syndrome in patients with acute lower limb ischemia (ALLI) and the effects of fasciotomy on outcomes are largely undefined. This study aimed to define the incidence of compartment syndrome in patients with ALLI and to examine whether different fasciotomy strategies are associated with specific patient outcomes. A single-center retrospective study of patients who had ALLI between April 2016 and October 2020 at a tertiary care center. Patients were categorized into groups as having received early and late therapeutic fasciotomy (TF), early prophylactic fasciotomy (PF), early exploratory fasciotomy, and no fasciotomy. Primary outcome was 30-day amputation rate. Secondary outcomes were 30-day and 1-year mortality, 1-year amputation rate, and length of stay. Groups were compared using descriptive statistics to assess the association of fasciotomy approach with outcomes. During the study period, 266 patients were treated for ALLI, and 62 patients (23%) underwent 66 fasciotomies. A total of 41TF, 23 PF, and 2 exploratory fasciotomies were done. There were 58 early fasciotomies performed (88% of 66 limbs): 33 (57%) early TF, 23 (40%) PF, and 2 (3%) exploratory. There were 8 patients who developed compartment syndrome after their revascularization operation and received delayed TF (12% of 66 limbs). The total number of TF was 41, which was 15% of all ALLI patients. The mean±SD time to fasciotomy closure was 6.7±5.7days, which did not differ between PF and TF groups. Significantly more patients in the TF group had an amputation at 30days (11 [29%] vs. 1 [5%]; P=0.03) and at 1year (6 [18%] vs. 2 [9%]; P=0.02) than those in the PF group. Length of stay was increased in both TF (16days) and PF (19days) patients compared to nonfasciotomy patients (10days; P<0.01) but did not differ between the 2 fasciotomy groups (P=0.4). Thirty-day limb loss was highest in patients who underwent early TF (10/33, 33%), intermediate in those with delayed TF (1/8, 13%), and lowest in PF (1/23, 5%; P=0.03). Approximately 15% of patients with ALLI in our cohort required a TF for compartment syndrome. Close postoperative monitoring of ALLI patients who did not undergo early fasciotomy did detect delayed compartment syndrome; however, this approach did not prevent limb loss. To optimize limb salvage, physicians treating patients with ALLI should be experienced in how to recognize and treat compartment syndrome.

The Use of “Damage Control Orthopedics” Strategy in the Treatment of Severe Gunshot Wounds of the Limbs

Objectives: The objectives of this study were to evaluate the incidence and nature of gunshot wounds of the limbs in the general structure of combat trauma, and study the features of DCO (Damage Control Orthopedics) patient management strategy in the conditions of a regional hospital as a stage of care for this pathology. Background: Limb injuries account for between 52.3% and 60.1% of combat casualties. The problem of surgical management of limb gunshot wounds is of particular relevance at the present stage of active use of firearms. Thus, adequate choice of surgical treatment strategy for limb gunshot wounds is an important condition for preserving life and preventing severe complications in combat casualties. Methods: The study was conducted among 1000 injured from the combat zone during the period from 24.02.22 to 15.04.22. The trauma and orthopedic surgery department of “Dnipropetrovsk Regional Clinical Hospital named after I.I. Mechnikov” mainly performed secondary surgical debridement of wounds, comprehensive surgical and medical prevention of complications in the injured. Injury severity was assessed using the ISS (Injury Severity Score) based on the AIS (Abbreviated Injury Scale), which assesses the severity of injuries to several areas of the body. Results: DCO strategy was used in 287 (55.1%) injured patients in severe and extremely severe condition (16 points or higher on the ISS scale). A total of 602 surgical operations were performed in 287 injured patients. On average, 2.1±0.6 interventions per one injured person were performed. Overall mortality among victims with gunshot wounds of the limbs was 3.6% (19 wounded out of 521). In all cases there were polytrauma (100%), in 4 (21.1%) cases they were through-and-through injuries, in 2 (10.5%) - with the compartment syndrome development. Conclusions: Differentiated DCO strategy in the surgical treatment of the critically and severely injured (16 points and above on the ISS scale) are essential to save the lives of soldiers in the first period of traumatic illness and to prevent complications of the second and third periods of traumatic illness

Forearm compartment syndrome after a trans-ulnar coronary intervention in a patient with ST segment elevation myocardial infarction

Compartment syndrome is a very rare but possibly devastating complication of coronary angiography when a trans-radial approach is used. The trans-ulnar approach is an attractive option in cases with anatomic variations of the radial artery or weak radial pulses. Even though it is expected that the trans-ulnar approach has a similar risk of developing compartment syndrome like trans-radial approach, the literature does not have many case reports describing this complication. Here we report a case of a woman who developed forearm compartment syndrome after trans-ulnar coronary intervention in the setting of ST-segment elevation myocardial infarction.

Hamat Kırığına Eşlik Eden 3-4 İntermetakarpal Ayrışması. Olgu Sunumu

Introduction: Hamate body fractures are rare hand injuries and are accompanied by serious complications. Our study is one of the rare case reports reported in the literature.&#x0D; Case report: Our case is an industrial injury case of a 51-year-old male patient who was working as a printing machine operator and got his hand stuck between the wheels of the machine. It has been observed that hamate bone fracture accompanying the intermetacarpal decomposition after the accident has developed. Reduction and fixation of hamate bone fractures and intermetacarpal dehiscence were performed, and fasciotomy was performed due to compartment syndrome. Adequate recovery was achieved after the treatment of the patient.&#x0D; Conclusion: As far as we know, no carpal bone injury similar to our case has been reported in the literature before. We recommend rigid screw fixation for fracture osteosynthesis, K-wire fixation for metacarpal dissociation, and early fasciotomy to prevent the development of compartment syndrome in intermetacarpal separation injuries accompanied by hamate bone fractures.

Translated article] The use of arthroscopy does not increase the incidence of complications in the management of Schatzker IV–VI tibial plateau fractures

Background and objectiveThe use of arthroscopy for tibial plateau fractures type I, II and III according to Schatzker classification has increased, yet its employment for tibial plateau fractures Schatzker IV, V and VI is controversial due to the potential risk of compartment syndrome, deep vein thrombosis and infection. We aimed to compare the rate of operative and postoperative complications among patients with these types of tibial plateau fractures treated with and without arthroscopy at the time of definitive reduction and osteosynthesis. MethodsRetrospective cohort study. Patients with diagnosis of tibial plateau fracture Schatzker IV, V or VI who underwent reduction and definitive osteosynthesis with or without the use of arthroscopy were included. The development of compartment syndrome, deep vein thrombosis, and fracture-related infection was evaluated up to 12 months after the definitive surgery. ResultsTwo hundred eighty-eight patients were included: 86 with arthroscopic assistance and 202 without it. The overall complication rate in the group with and without arthroscopic assistance was 18.60% and 26.73%, respectively (p=.141). No statistical association was found between the use of arthroscopic assistance and the development of the analysed complications. Discussion and conclusionThe use of arthroscopy to support reduction or addressing concomitant intra-articular injuries did not increase the risk of complications in patients with high-energy tibial plateau fractures at 12 months of follow up.

El uso de artroscopia no aumenta la incidencia de complicaciones en el manejo de fracturas de mesetas tibiales Schatzker IV-VI

Background and objectiveThe use of arthroscopy for tibial plateau fractures type I, II and III according to Schatzker classification has increased, yet its employment for tibial plateau fractures Schatzker IV, V and VI is controversial due to the potential risk of compartment syndrome, deep vein thrombosis and infection. We aimed to compare the rate of operative and postoperative complications among patients with these types of tibial plateau fractures treated with and without arthroscopy at the time of definitive reduction and osteosynthesis. MethodsRetrospective cohort study. Patients with diagnosis of tibial plateau fracture Schatzker IV, V or VI who underwent reduction and definitive osteosynthesis with or without the use of arthroscopy were included. The development of compartment syndrome, deep vein thrombosis, and fracture-related infection was evaluated up to 12 months after the definitive surgery. ResultsTwo hundred eighty-eight patients were included: 86 with arthroscopic assistance and 202 without it. The overall complication rate in the group with and without arthroscopic assistance was 18.60% and 26.73%, respectively (P=.141). No statistical association was found between the use of arthroscopic assistance and the development of the analyzed complications. Discussion and conclusionThe use of arthroscopy to support reduction or addressing concomitant intra-articular injuries did not increase the risk of complications in patients with high-energy tibial plateau fractures at 12 months of follow up.

An unexpected case of neonatal compartment syndrome associated with congenital anomalies of kidney and urinary tract

Abstract Objectives Neonatal compartment syndrome (NCS) occurs when increased pressure within the fasciocutaneous compartment decreases capillary perfusion, causing irreversible tissue damage from ischemia. NCS is a rare condition that requires prompt diagnosis and treatment. Diagnosing NCS is highly dependent on the examination, which can be difficult in newborns. Prompt recognition provides the best chance for good outcomes. Case presentation We present a case of NCS diagnosed and treated based on physical examination findings. Fetal ultrasonography showed bladder distension, bilateral hydroceles, urethra dilation, and abdominal urinary ascites concerning for lower urinary tract obstruction and possible bladder rupture. At 1 h after birth, examination of the infant’s left upper extremity showed no spontaneous movement, the hand and forearm appeared dusky, and the hand had a large blister with desquamation. No pulse distal to the antecubital fossa was detected via Doppler ultrasonography. The infant was diagnosed with NCS and underwent urgent fasciotomy. The clinical appearance and perfusion of the left upper extremity gradually improved. At four months of age, the wounds were healed and the patient had full passive range of motion of the left upper extremity. Recovery of active motion is ongoing. Conclusions The presence of blistering and desquamation should provoke suspicion for NCS. Once NCS is diagnosed, prompt intervention is necessary to reduce the risk of poor functional outcomes. This case highlights the need for increased awareness of the risk developing compartment syndrome in utero as part of the rare sequalae in infants with congenital anomalies of kidney and urinary tract.

Prolonged, recurrent, spontaneous massive gluteal and femoral bleeding in a patient with five metachronous primary malignancies

Purpose: This study aimed to present the case of prolonged, recurrent, spontaneous massive bleeding in a patient with five metachronous primary malignancies.&#x0D; Case presentation: A 70-year-old male patient presented with massive hematomas in the gluteal and femoral regions and a 6-year history of prostatic, urethral (penile), right colonic, and right pulmonary carcinoma, with a myeloproliferative disease that recently ended with lymphatic leukemia. Fasciotomies with the evacuation of massive hematomas were performed due to the development of compartment syndrome, which were followed by persistent recurrent bleeding. Despite several surgical interventions with packing, local hemostatic agents and sutures, and selective embolization with immediate clinical discontinuation of bleeding, the digital subtraction angiography showed recurrent bleeding from the peripheral branches of the internal iliac and deep femoral arteries always a few days after the procedures. The coagulation and aggregation parameters and bleeding disorders tests were within normal ranges. The histology showed no malignancy in the affected regions, and no relapse was reported in any regions with previously operated malignant diseases on control computed tomography and positron emission tomography scans.&#x0D; Conclusion: We could stop the bleeding only with more aggressive, nontarget gradual embolization. Subsequently, hemostasis was achieved, with gradual healing of incisions.

Alternate Soft-Tissue Free Flaps for Head and Neck Reconstruction: The Next Generation of Workhorse Flaps.

There is little debate regarding the workhorse flaps for soft-tissue defects in head and neck reconstruction. However, in certain circumstances, the workhorse flaps are not available or suitable, and an alternate flap is needed. The author performed a retrospective review of a single-surgeon experience with alternate soft-tissue flaps performed over a 10-year period. Overall, 156 alternate soft-tissue free flaps were performed in 155 patients. The distribution of free flaps was 60 ulnar artery perforator (UAP), 28 lateral arm perforator (LAP), 33 medial sural artery perforator (MSAP), and 35 profunda artery perforator (PAP) flaps, with one patient receiving two PAP flaps. Defects included glossectomy, facial defects following parotidectomy or resection of cutaneous malignancies, and other intraoral defects. Eleven patients had donor-site complications: two patients with UAP flap with partial skin graft loss, two patients with delayed wound healing in the MSAP donor-site group and one who developed compartment syndrome with primary closure of the MSAP donor site, one patient with a radial nerve palsy following an LAP flap, and six patients with delayed wound healing in the PAP donor site, which healed secondarily with conservative management. There was one total flap loss each of an LAP and MSAP flap. Reconstructive microsurgeons performing high-volume head and neck reconstruction may need to incorporate alternate donor sites into their armamentarium when the primary workhorse flaps are not suitable or available. Therapeutic, IV.

Bromelain-based enzymatic debridement in hand burns – an easier way to manage a difficult patient: case report

Introduction. Bromelain-based enzymatic debridement may be considered the standard in patients with upper extremity burns management, regarding the low risk of bleeding, wound infections, reduction of surgical timing, and the decreased risk of compartment syndrome development. Case presentation. We present the case of hand and face burns in a patient presenting deep venous thrombosis of the lower limb extended to the level of the vena cava, and bilateral pulmonary embolism. The enzymatic debridement reduced periprocedural bleeding and allowed a faster recovery and therefore the resumption of oral anticoagulation and antiplatelet medication in a patient with important cardiac, arterial, and renal comorbidities. Conclusion. Bromelain-based enzymatic debridement use is recommended in patients presenting upper limb deep burns, especially in anatomically challenging areas, like hand fingers, and especially in those with a previous medical history that predisposes them to periprocedural bleeding and increased risk of poor healing.

Circumferential upper extremities burn, bilateral Dupuytren's disease and COVID-19 disease – an unfavorable triad: a case report

Upper extremities are frequently involved in fire burns due to the natural protective reflexes. The presence of bilateral Dupuytrenʼs disease and COVID-19 disease in patients with circumferential upper extremity burns can negatively impact the outcome, through severe contracture and a tendency to hypoxia or infections, which affects normal wound healing. Enzymatic debridement with a concentrate of proteolytic enzymes enriched in bromelain prevents compartment syndrome development in such patients, reduces blood loss, surgery duration, and appears to favor a more rapid recovery.

Well Leg Compartment Syndrome: Pathophysiology, Prevention, and Treatment.

The development of compartment syndrome involving the lower limb is a potentially devastating complication of prolonged surgery in patients held in the lithotomy position. Well leg compartment syndrome (WLCS) was recognized in 1953. The incidence of this condition has been reported to range from 0.20% to 0.03%. The mechanism of WLCS development in the absence of trauma appears to be related to prolonged hypoperfusion of the limb, pressure on the muscle compartments, and in some cases, reperfusion of the ischemic limb. This grave complication develops either during or immediately after prolonged surgery in which the patient was held in the Lloyd-Davies lithotomy or hemi-lithotomy position. Surgeons must be aware of the potential for WLCS development during prolonged surgery. Signs of developing WLCS include swelling, increased firmness of the muscle compartments, discoloration, and cooling of the limb. Preventive measures can be taken without contaminating the surgical field by returning the limb to the right atrium level. Once the diagnosis has been made, failure to prevent the development of WLCS requires extensile fasciotomy of each leg compartment to restore perfusion and relieve elevated intra-compartment pressures. This article reviews the pathophysiology, prevention, and treatment of WLCS.

Coping With the Fear of Compartment Syndrome Without Compromising Analgesia: A Narrative Review.

Pain management in trauma or surgery with a high risk of developing compartment syndrome (CS) is always challenging due to fears of masking symptoms that could delay diagnosis and treatment. Regional anesthesia/analgesia (RA) can facilitate enhanced postoperative recovery and improve patient satisfaction by providing excellent postoperative analgesia. However, its consideration in surgeries with a high risk of developing CS remains controversial and contentious. Studies suggest focusing more on early diagnosis through regular vigilant monitoring with a high index of suspicion rather than discontinuing the analgesic method alone. The most consistent features in all reported cases of CS were altered sensation in the affected limb, disproportionate pain in the presence of a functional nerve block, and an escalating need for analgesics. Several extrinsic or intrinsic factors are responsible for the progressive increase in compartment pressure that can lead to vascular compromise and subsequent ischemic changes in muscles, tissues, and nerves. Measurement of intracompartmental pressure (ICP) has always been considered the gold standard for diagnosing CS. An ICP of 30 mm Hg is considered the cut-off point for fasciotomy that helps restore muscle perfusion and avoid irreversible tissue damage. The chronology of symptoms can sometimes provide clues to the severity of CS, the pathophysiology involved, and the management required. Therefore, it is necessary to look for warning signs, further investigate the causes, and make quick decisions to diagnose and treat CS and its complications on time. Any delay in the diagnosis and treatment of CS can result in high morbidity and poor outcomes. A well-integrated interprofessional team of health professionals can deliver the required complexity of care through a holistic and multidisciplinary approach. This review article highlights the symptoms, risk factors, and pathophysiology involved in CS. It can guide readers in choosing various options to diagnose, prevent, and treat CS. It also discusses the role of RA in patients or surgeries prone to developing CS.

Multiple stab incision technique to prevent postoperative acute compartment syndrome of leg in proximal and segmental fracture tibia and fibula: a prospective study

&lt;p&gt;The objective is to study the effectiveness of Multiple stab incision technique in preventing acute compartment syndrome (ACS) in proximal and segmental fractures of both bones (Tibia and fibula) in leg. This study is prospective done&lt;strong&gt; &lt;/strong&gt;at K. S. Hospital Koppal, Karnataka spanning for a period of one year (April 2020 to April 2021). A total of 20 patients of both genders aged 20-60 years were included in the study. Multiple stab incision technique was performed in patients after fixation of Tibia by either closed nailing or MIPPO plating. This procedure was done under spinal anesthesia. Multiple stab incision technique significantly decreased the chances of post-op ACS in proximal and segmental fractures of both bones (tibia and fibula) in leg. Multiple stab incision technique is help full in preventing developing compartment syndrome.&lt;/p&gt;&lt;p&gt;&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;&lt;h2&gt; &lt;/h2&gt;

Aortic dissection following “ecstasy” use complicated by compartment syndrome

BackgroundPatients who present to the emergency department (ED) with acute chest pain should receive a thorough history and exam to rule out rare, life-threatening conditions, such as drug-induced acute aortic dissections (AD).Case presentationA 34-year-old man with a history of uncontrolled hypertension, smoking, and “ecstasy” use presented to the ED with an acute type A aortic dissection (AD). Following surgery to repair the dissection, he developed compartment syndrome of the lower extremity requiring muscle excision and neurolysis with subsequent wound debridement procedures.ConclusionPhysicians treating adults with symptoms and signs of aortic dissection should take a focused history about substance use and include AD on their differential. In addition, the extremities should be monitored for signs and symptoms of ischemia throughout the acute peri-surgical period(s).

A Modern Day Timeline for In-Hospital Monitoring in Perfused, Pulseless Pediatric Supracondylar Humerus Fractures.

The perfused, pulseless supracondylar humerus fracture (ppSCHF) remains a consistent topic of discussion in the literature. Inpatient observation of these patients postoperatively for worsening vascular exam or compartment syndrome is frequently recommended but not well studied. The purpose of this study was to evaluate the postoperative complications in a cohort of ppSCHF patients and their timeline to discharge. This study is a retrospective review of a prospectively maintained database of all operatively treated supracondylar humerus fractures from a tertiary pediatric hospital from 2013 to 2019. All patients without a palpable pulse were included. We excluded patients with <4 weeks follow-up. Demographic, operative, and postoperative data were collected, including time from presentation to operating room (OR), time from OR to discharge, and incidence of postoperative complications, including return to OR, compartment syndrome, new neurovascular deficits, and Volkmann contractures. The descriptive statistics were used to summarize the data. Among 1371 operatively treated supracondylar humerus fractures, 39 (2.8%) presented with a ppSCHF. Five (15%) had a signal on doppler ultrasound, whereas 34 (85%) had no signal. Thirty-seven (95%) patients had a Gartland type III fracture and 2 (5%) had type IV fractures. Twenty-two (56%) patients had a neurological deficit, of which 14 had an anterior interosseous nerve deficit. The average time to OR was 6.9 (range 2.2 to 15) hours; 6 (15%) required open reduction. At the time of discharge, 85% of patients had a palpable pulse and 13% had a dopplerable signal. Postoperatively, no patients were returned to the OR for any secondary procedures. The average length of stay after the operation was 25 (range 8.5 to 40) hours, with 92% of patients being discharged by 36 hours postoperatively. No patients developed compartment syndrome, new neurological deficits, or Volkmann contractures at a mean follow-up of 112 (range 34 to 310) days. In our study of 39 patients presenting with ppSCHF, no patient required an unexpected return to the OR, or developed post-treatment compartment syndrome, neurological deficits, or Volkmann contractures. The average time from OR to discharge for ppSCHF was 25 hours. Level II.

Predictors for limb amputation and reconstructive management in electrical injuries

BackgroundElectrical injuries follow a specific pathophysiology and may progressively damage both skin and deeper tissues, frequently ending in amputations. Type and timing of soft tissue reconstruction after electrical burns is crucial for proper outcome. The aim of this study was to assess surgical management and outcome of patients with electrical injuries treated at the Zurich Burn Center over the last 15 years, with emphasis on risk factors for amputation and reconstructive strategy. MethodsPatient charts were reviewed retrospectively to identify cases admitted at the Zurich Burns Center (2005–2019). Patient characteristics and surgical management, with a special focus on amputations, reconstruction and outcome were analyzed and risk factors for amputation were assessed. ResultsEighty-nine patients were identified and a total of 522 operations were performed. Escharotomy and fasciotomies were performed in 40.5% and 24.7% of cases, respectively, mainly at admission. The total amputation rate was 13.5% (23 amputations, 12 patients). Development of compartment syndrome, rhabdomyolysis, high myoglobin and CK blood levels, kidney failure, sepsis and respiratory complications during the course were related to higher risk of amputation (p < 0.001). Sixty-six flap-based reconstructions were performed (25% cases): 49 loco-regional flaps, 3 distant pedicled flaps, 14 free flaps. Two flaps were lost (flap failure rate 14%). Both flap losses occurred in cases of early reconstruction (within 5–21 days). ConclusionsElectrical injuries are still cause of elevated morbidity and mortality, with high amputation rate. Predictors for amputation can support physicians in the surgical care and decision-making. Reconstruction remains challenging in this type of injury: the surgical management with early decompression, serial necrectomies and delayed early reconstruction remains the procedure of choice at our unit.

Limb Fasciotomy for COVID-19 Patients: Is the Chance to Cut a Chance to Cure?

Summary:Based on the findings of two consecutive cases of upper extremity compartment syndrome encountered at our institution, we hypothesize that the presence of compartment syndrome in the unstable COVID-19 patient may be associated with high mortality and low limb salvage rates. A literature search was conducted with key search terms, including “compartment syndrome, fasciotomy, COVID, and coronavirus.” Articles describing patients with a confirmed COVID-19 diagnosis who developed extremity compartment syndrome were included in our study. The primary outcome investigated was patient survival. Secondary outcomes included limb survival and limb salvage. Limb salvage was calculated in patients who survived to time of discharge, whereas limb survival was counted for all patients. We then added our two cases to the findings reported in our literature to determine current overall limb salvage and patient survival rates. Our review of the literature yielded six case reports of ten extremities that developed compartment syndrome in the COVID-19 positive patient. Overall survival was four of six patients (67%). The overall limb survival rate at the time of hospital discharge was three of 10 (30%). With the addition of our two cases, overall survival was four of eight (50%) and overall limb survival rate was three of 12 (25%). Furthermore, with inclusion of our two cases, the patient survival rate of hemodynamically unstable patients was only three of seven (43%). The development of compartment syndrome in the unstable COVID-19 patient may be a harbinger of death, and the decision to proceed with operative intervention is challenging, complex, and in some cases must prioritize life over limb.

Outcomes of patients with acute type A aortic dissection and concomitant lower extremity malperfusion

ObjectiveThe occurrence of acute lower limb ischemia (ALLI) is a serious risk within the context of aortic dissection repair. The aim of the present study was to examine the outcomes of patients with acute type A aortic dissection (ATAD) and concomitant lower extremity malperfusion. MethodsWe performed a retrospective medical record review at our tertiary referral center of patients who underwent ATAD repair from January 2002 to June 2018. We used univariate and multivariate analyses to compare the outcomes of patients with and without lower extremity malperfusion. The primary outcomes were 30-day and 1-year mortality. ResultsA total of 378 patients underwent ATAD repair during the study period. Their mean age was 57 years, 68% were men, and 51% were White. A total of 62 patients (16%) presented with concomitant ALLI, including 35 (9%) who presented with isolated ALLI and 27 (7%) who presented with ALLI and concomitant malperfusion of at least one other organ. Of the 62 patients with ALLI, 46 underwent only proximal aortic repair. Of the 378 patients, 6 died within the first 24 hours, and their limb perfusion was not assessed. Among the 40 patients who underwent isolated proximal repair and survived >24 hours, 34 (85%) had resolution of their ALLI. Of the 16 patients who underwent concomitant lower extremity peripheral vascular procedures, 10 had bypass procedures and 1 died within 24 hours due to refractory coagulopathy and hypotension. All six patients with adequate follow-up imaging studies had asymptomatic occlusion of the bypass graft with recanalization of the occluded native arteries. Patients who presented with any organ malperfusion had increased 30-day (odds ratio, 1.8; P = .04) and 1-year (odds ratio, 1.8; P = .04) mortality and decreased overall survival (P < .01). For the patients with isolated ALLI, no significant differences were found in 30-day or 1-year mortality or overall survival (P = .57). ConclusionsProximal repair of ATAD resolves most cases of associated ALLI, and isolated ALLI does not affect short- or long-term survival. All patients with follow-up in our study who underwent extra-anatomic bypass developed asymptomatic graft occlusion, which could be attributed to competitive flow from the remodeled native arterial system. We believe that rapid and aggressive restoration of flow to the lower extremity is the best method to treat ALLI malperfusion syndrome. Close monitoring for the development of compartment syndrome is recommended.