Lower Leg Compartment Research Articles

Risk factors for poor outcomes in patients with acute lower leg compartment syndrome: a retrospective study of 103 cases

PurposeThe primary aim of this study was to investigate the risk factors associated with poor outcomes following acute compartment syndrome (ACS) of lower leg. The secondary objective was to determine if delayed fasciotomy is linked to poor outcomes.MethodsIn this retrospective case control study approved by the institutional review board, we identified 103 patients with ACS of the lower leg. Poor outcome was defined as a composite variable that included limb amputation, neurological deficit and contracture. Among these, 44 patients exhibited poor outcome while 59 patients demonstrated a good outcome. Patient-related factors, laboratory values, and treatment-related factors were analyzed using electronic medical records. Univariate statistical and logistic regression analyses were conducted to determine significance.ResultsBivariate analyses showed that the mechanism of injury (P = 0.021), open injury (P = 0.001), arterial injury (P<0.001), hemoglobin levels (HB) (P < 0.001), white blood cell count (WBC) (P = 0.008), albumin levels (ALB) (P<0.001), creatine kinase levels (CK) at presentation (P = 0.015), CK at peak (P<0.001), creatine kinase levels (Ca) (P = 0.004), dehydrating agent (P = 0.036), and debridement (P = 0.005) were found to be associated with the risk of poor outcomes. Logistic regression analyses revealed that arterial injury [ P< 0.001, OR = 66.172, 95% CI (10.536, 415.611)] was an independent risk factor for poor outcomes. However, HB [P = 0.005, OR = 0.934, 95% CI (0.891, 0.979)] was a protective factor against poor outcomes. Receiver operating characteristic (ROC) curve analysis showed that the cut-off values of HB to prevent poor outcome following ACS was 102.45 g/L.ConclusionsACS of the lower leg is a serious complication often associated with a poor prognosis. Patients with arterial injury or lower HB have a significantly increased risk of having poor outcomes. Poor outcomes were not found to be associated with the timing of fasciotomy in this study.

Phlegmasia cerulea dolens with lower leg compartment syndrome.

A 57-year-old man with a history of human immunodeficiency virus infection presented with sudden pain and swelling of the right leg that had developed over the preceding thirty minutes (Panel A). He reported having been taking antiretroviral drugs. Computed tomography (CT) demonstrates partial pulmonary artery embolism and massive deep vein thrombosis extending from the right external iliac to the popliteal veins. Despite commencing anticoagulation, he had severe pain and intense dysesthesia of the right leg. The intramuscular pressure in his right leg was 98 mmHg (reference: <10 mmHg), and his right dorsalis pedis pulse was not palpable. A clinical diagnosis of compartment syndrome secondary to phlegmasia cerulea dolens was made, and he underwent immediate fasciotomy (Panel B). As the dysesthesias did not improve by fasciotomy, catheter-directed venous thrombectomy was performed on day 5 of hospitalization using a 10-French Heartrail ST01 catheter (Terumo, Tokyo, Japan) via a cross-over 12-French DrySeal (WL Gore, Flagstaff, Arizona, USA) from the contralateral femoral vein after placing an inferior vena cava (IVC) filter. Although the final venography revealed restored venous flow, the filter could not be retrieved because of trapped thrombi (Panel C-E, see supplementary data online, Videos S1–S3). Postprocedural CT demonstrated complete thrombosis of the right external iliac vein, and swelling in the right thigh was persistent despite anticoagulation and intermittent pneumatic compression. After the second venous thrombectomy on day 15, the venous flow was completely restored, and the filter was retrieved (see supplementary data online, Videos S4 and S5). He was discharged on apixaban without symptoms of post-thrombotic syndrome (Panel F).

Functional Status After Lower Leg Fasciotomy for Acute Compartment Syndrome: A Single-Center Review

Acute lower leg compartment syndrome can result in limb loss after emergency revascularization procedures. Although a fasciotomy can relieve intracompartmental pressure, not all patients will achieve full functional recovery. The factors that affect the outcome after emergency fasciotomy remain unclear. We reviewed the functional outcomes of a large group of patients who had undergone lower leg fasciotomies after revascularization for limb ischemia.

Lower Leg Compartment Syndrome Detected by Peripheral Angiography

Compartment syndrome occurs when the pressure within a defined compartmental space increases past a critical pressure threshold jeopardizing the blood supply. Compartment syndrome can occur in any area of the body with closed compartments. The below-knee leg is the most likely compartment to develop acute compartment syndrome, followed by the forearm, thigh, and arm. Rapid diagnosis and treatment can be life or limb saving. Any delay in evaluating and treating patients with lower extremity compartment syndrome can be devastating for the patient. High suspicion is needed to diagnose the condition. The classic signs of compartment syndrome, the “6 P's,” can be deceiving. Advanced diagnostic techniques like peripheral angiography at the earliest can be lifesaving.

Lower leg compartment syndrome following laparoscopic uterine malignancy surgery for uterine cancer complicated by rheumatoid arthritis: a case report and literature review

Background: Compartment syndrome is a condition in which an increased internal pressure in the upper/lower leg compartment results in circulatory disturbance causing muscle and nerve dysfunction. There have been five case reports of compartment syndrome following gynecologic laparoscopic surgery. We present this rare case herein with a review of the related literature. Case: The patient was a 44-year-old woman. She underwent laparoscopic modified radical hysterectomy for uterine cancer. During surgery, she wore elastic stockings from her toes to her knees. She also had intermittent pneumatic compression of the thighs and lower legs with the head down at 15 degrees. The operative time was 6 h and 49 min. She was diagnosed with compartment syndrome, and a decompression incision was indicated. Conclusion: After experiencing this case, we use the open leg position, releasing the high pelvic position for 10 min every 3 h, during which the nurse should decompress the foot.

Non-invasive monitoring method for lower-leg compartment syndrome using a wireless sensor system and finite element analysis

In this study, a non-invasive pressure monitoring system that is portable and convenient was designed for detecting compartment syndrome. The system combines a wireless module and smartphone, which aids in the achievement of mHealth objectives, specifically, the continuous monitoring of the compartment pressure in patients. A compartment syndrome detecting method using a wireless sensor system and finite element analysis is developed and verified with an in vitro lower-leg model by rapid prototyping. The sensor system is designed to measure a five point pressure variation from the outside of the lower leg and transmit the data to a smartphone via Bluetooth. The analysis model based on the finite element method is employed to calculate the change of pressure and volume inside the four compartments of the lower leg. The in vitro experimental results show that the non-invasive detecting method can monitor the compartment pressure and provide a warning for the occurrence of compartment syndrome if the compartment pressure is higher than 30 mmHg. Furthermore, the theoretical simulation of the real lower leg shows similar trends to those of the in vitro experiments and can promptly detect the occurrence of compartment syndrome. Measured pressure values exceeding 6.3, 2.7, and 2.8 kPa for the three sensors contacting the outside centers of the superficial posterior, anterior, and lateral compartments, respectively, can indicate that each compartment contains a pressure higher than 30 mmHg. These results can provide a warning for the risk of compartment syndrome of each compartment. In addition, the measured values from the three sensors contacting the superficial posterior compartment at the outside center, close to the tibia, and close to the lateral compartment exceeding 1.8, 0.7, and 0.7 kPa, respectively, can indicate the risk of deep posterior compartment syndrome.

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.

Peripheral nerve block for pain control in lower leg compartment syndrome after relaxing incision and acute lower limb arterial occlusion

Peripheral nerve block for pain control in lower leg compartment syndrome after relaxing incision and acute lower limb arterial occlusion

Acute compartment syndrome of the lower leg causing cardiac arrest after resection of the right external iliac vein for autologous graft: a case report

BackgroundThe right external iliac vein (REIV) is often used for portal vein reconstruction in patients undergoing pancreatoduodenectomy with portal-superior mesenteric vein resection. We report a case of cardiac arrest caused by acute lower leg compartment syndrome as a result of REIV resection.Case presentationA 53-year-old man underwent pancreatoduodenectomy with portal vein resection. Hyperkalemia progressed during surgery due to intestinal reperfusion injury, which caused recurrent ventricular arrhythmia required for cardio-pulmonary resuscitation. The surgery was discontinued after resuscitation, and portal vein reconstruction using the REIV was performed 2 days post-operatively. Acute compartment syndrome was diagnosed immediately following the surgery. Hyperkalemia progressed, causing pulseless ventricular tachycardia. Emergent fasciotomy was performed, but right leg dysfunction persisted after discharge.ConclusionREIV resection can cause lower-extremity acute compartment syndrome. The status, including intracompartmental pressure, of the lower extremity should be carefully observed after REIV resection during and after surgery.

Selective fasciotomy for acute traumatic lower leg compartment syndrome: is it feasible?

The standard treatment for an acute compartment syndrome (ACS) of the lower leg is a four compartment fasciotomy. It can be performed through either one lateral or a lateral and medial incision. Selective fasciotomy, only opening the compartments with elevated pressure, is a less invasive procedure. The aim of this study was to describe a procedure of selective fasciotomy after pressure measurement and to determine its feasibility in a retrospective cohort study. All patients with an ACS of the lower leg due to a proximal or tibia shaft fracture (AO 41 or 42) who received either a four compartment fasciotomy or a selective fasciotomy after pressure measurement between 2006 and 2016 were included. Every compartment with an intracompartment pressure of more than 30mmHg was opened. The primary outcome was any missed compartment syndrome after selective fasciotomy. Secondary outcomes were reoperations for completing four compartment fasciotomy and persistent sensomotoric deficits. Fifty-one patients with a mean age of 43years (6-76) were included. Of these, 41 (80%) had a selective fasciotomy. There was no missed compartment syndrome. One patient had a reoperation 8h after primary selective fasciotomy due to ACS of the superficial and deep flexor compartment. The anterior compartment had to be released in all patients. In 67%, the release of 2 compartments was sufficient. Six patients had postoperative sensomotoric deficits at discharge with full recovery during follow-up. Selective fasciotomy is feasible and seems to be safe. Future comparative studies will have to focus on possible benefits of this less invasive treatment.

Compression sonography for non-invasive measurement of lower leg compartment pressure in an animal model

IntroductionCompression ultrasound is a non-invasive technique allowing for qualitative visualization and quantitative measurements of mechanical tissue properties. In acute compartment syndrome (ACS), cadaver studies have proven that the intra-compartmental pressure (ICP) measured by compression sonography correlates with the ICP measured invasively. This study aimed to evaluate compression sonography for compartment pressure measurements in an animal model. Material and methodsThe pressure in the anterior tibial compartment of 6 domestic pig legs was increased from baseline to 40mmHg in 5mmHg steps. Using compression sonography, the compartment diameter was measured without external pressure and during manual application of five levels of external pressure. The elasticity ratio (ER) was computed as the ratio of the compartment diameter with and without external pressure.At 40mmHg of external pressure the ERs at different ICP levels were compared using repeated ANOVA measurements. Post-hoc comparisons evaluated the lowest detectable ICP fulfilling the definition of ACS (ICP≥30mmHg) by starting from each pressure below 30mmHg (baseline, 20mmHg and 25mmHg, respectively). Receiver operator characteristic analyses defined ER limits with appropriate sensitivity and specificity to detect ACS. ResultsThe ER increased from 79.0% at baseline ICP to 89.3% at 40mmHg ICP. The ER at baseline and at 20mmHg ICP significantly differed from the ER at 30mmHg ICP (p=0.007 and 0.002, respectively); the ER at 25mmHg ICP significantly differed from the ER at 40mmHg ICP (p=0.001).An ER less than 87.1% had a sensitivity of 94.4% and a specificity of 88.9% to proper diagnosis of ACS. ConclusionCompression sonography might offer a non-invasive technique to guide treatment in cases of uncertain acute compartment syndrome. Further studies are needed to collect elasticity ratio data in humans and to clinically validate compression sonography for compartment pressure measurements.

Accuracy of Palpation-Guided Catheter Placement for Muscle Pressure Measurements in Suspected Deep Posterior Chronic Exertional Compartment Syndrome of the Lower Leg

Background: A diagnosis of lower leg deep posterior chronic exertional compartment syndrome (dp-CECS) is made by a dynamic pressure measurement. The insertion of a pressure catheter is guided by anatomic landmarks (freehand) or by ultrasound. The catheter tip is ideally positioned in the tibialis posterior muscle (TP). The accuracy of in vivo catheter placement using lower leg magnetic resonance imaging (MRI) in healthy patients suspected of having dp-CECS has never been studied. Purpose: To analyze whether a freehand catheter insertion results in accurate positioning in the TP as confirmed by MRI in patients with suspected dp-CECS. Study Design: Case series; Level of evidence, 4. Methods: Catheters were inserted into central portions of the TP using a standard puncturing technique guided by lower leg anatomic landmarks. After timed muscle pressure measurements during a standard provocative treadmill running test, lower leg MRI scans were obtained and evaluated by 2 skilled radiologists. Catheter tip placement was termed accurate (in the TP), suboptimal (in the deep posterior compartment but outside the TP), or inaccurate (outside the deep posterior compartment). Results: Between March 2013 and September 2014, a total of 24 patients (8 male, 16 female; mean age, 30 years [range, 18-54 years]) underwent an intracompartmental pressure (ICP) measurement, followed by MRI. Cardinal symptoms were pain during exertion (20% very severe, 53% severe, and 20% moderate) and tightness (29% very severe, 43% severe). Symptoms were bilateral in 74% of patients. Nine of the 24 patients were diagnosed with dp-CECS based on elevated ICPs. Of the 24 patients, catheter tip placement was accurate in 10 (42%), whereas suboptimal placement was achieved in 9 (38%). Five procedures were inaccurate (transition zone between the deep and superficial compartments, n = 3; in the superficial lower leg compartment, n = 2). Signs of a hematoma were found in 38% of the patients, although there were no associated clinical symptoms. Conclusion: Palpation-guided placement of catheters for TP pressure measurements is suboptimal in more than half of the patients with suspected lower leg dp-CECS. Optimizing the pressure catheter tip positioning technique may improve diagnostic accuracy in dp-CECS.

Acute Lower Leg Compartment Syndrome: A Rare Complication following CABG.

Compartment syndrome of lower legs following coronary artery bypass grafting is a rare complication which results from a combination of local and systemic factors. Early recognition is vital for good outcome. The case discussed describes this rare complication of CABG resulting in long term disability.

A case of bilateral lower leg compartment syndrome required operation

A case of bilateral lower leg compartment syndrome required operation

Introduction: Goodness and Human Life.

A 27 year-old female is admitted with severe lower leg compartment syndrome. A fasciotomy will not be effective, and she needs a below-knee amputation. After explaining this to her, she refuses. Shocked and confused by this refusal, you ask if she understands the consequences. She recapitulates the consequences accurately, namely death, and refuses once more. You ask why, and she indicates that she simply does not want her legs cut off. You know that with advances in prosthetics and surgical amputation she will return to ‘‘baseline’’ or very close to it. Most people working in healthcare will grant that this is a moral dilemma in which two values, benefiting the patient and respecting her autonomy, conflict. It appears as if no matter what you do as a clinician, you will be violating at least one of these values. A previous Special Issue in HEC Forum addressed the value and nature of autonomy. This issue takes up the other pole, the value of human life. The case above is only a dilemma if we assume both that her wishes are valuable and her life and health is valuable. But what is so valuable about human life and health? What is it that ‘‘makes’’ us valuable or should our value be understood as basic and unsourced? How should our understanding of human life inform clinical decisions especially cases where a patient’s autonomy is compromised? Can certain clinical conditions, such as disorders of consciousness, affect or lessen a patient’s value or worth? This special issue aims to address these questions. Before summarizing the contributions, it is important to acuminate our question on human value. A desiderata for understanding the value of human life is that it is a

Interobserver Variability in the Measurement of Lower Leg Compartment Pressures

To determine whether interobserver technical variations and errors in the measurement of compartment pressures may affect measurement accuracy. Four above-knee cadaveric specimens were used to create a consistent model of lower leg compartment syndrome. Thirty-eight physicians examined the limbs and measured 4 compartment pressures using the Intra-Compartmental Pressure Monitor (Stryker Orthopaedics). They were observed for correct assembly and use of the monitor. Measurements obtained were compared with known pressures. Of the total number of compartment measurements, 31% were made using the correct technique, 39% were made with lesser errors in technique, and 30% were made with catastrophic errors. Only 60% of measurements made with the correct technique were within 5 mm Hg of the standard pressure. Accuracy dropped to 42% for measurements taken with small errors in technique and 22% when a catastrophic error was committed. Variations in use of a commercially available pressure monitor exist, and errors are common. Proper use improved accuracy, but even with proper technique, 40% of the measurements were >5 mm Hg from the actual pressure. Based on our data, measurement accuracy with this device should be questioned and viewed within a range. Regular review and education of technique is strongly recommended.

出血性ショックを伴う腹部刺創に対し，IABO併用下のDCS後に下腿コンパートメント症候群を呈した1例(A complicated case of lower leg compartment syndrome after damage control surgery (DCS) with intra–aortic balloon occlusion (IABO) for severe abdominal stab injury under severe hemorrhagic shock)

要旨腹部刺創による出血性ショック症例に対して，大動脈閉塞バルーンカテーテル（intra–aortic balloon occlusion; IABO），Damage Control Surgery（以下DCS）を施行後，下腿コンパートメント症候群（Lower Leg Compartment Syndrome; LLCS）を呈した1例を経験したので報告する。症例は43歳男性で，腹部を刺し倒れているところを発見され，当院に救急搬送された。来院時ショック状態を呈し，腹部超音波検査にてMorison窩に液体貯留を認め，外表上，腹部2ヶ所の刺創より腸管脱出を認めた。初期輸液に反応せず，気管挿管及び，右大腿動脈からIABOを挿入し，濃厚赤血球の急速輸血を開始した。来院から約35分で緊急開腹術を施行した。開腹すると，複数箇所の腸管損傷を認め，刺入創先端は後腹膜に達していた。可及的な腸管切除後，後腹膜部位からの出血のコントロールが困難となり，deadly triadを認めたため，ガーゼパッキングを実施して速やかに閉腹した。初回術後，Intra–abdominal pressure（以下IAP）は最高値40mmHgを示したため，abdominal compartment syndrome（以下ACS）と判断し，術後約24時間でsecond look operationを施行し，腸管吻合を実施した後，閉腹した。その後IAPは16mmHgまで速やかに改善した。しかし初回緊急手術から約48時間後，右下腿の色調変化と，下腿コンパートメント圧の上昇（最大80mmHg）を認めた。血清クレアチニンキナーゼ（CK）は62100IU/Lまで上昇した。右LLCSと診断し，減張切開を行い，速やかにコンパートメント圧は低下した。しかし一部筋壊死を認めたため，術後13日目に，壊死筋部のデブリードマンを要した。術後経過は良好で，第53病日に独歩退院した。本症例におけるLLCSの成因として，IABOやDCSに伴う下腿虚血・還流障害が一因と考えられた。

A case of lower leg compartment syndrome after mowing out of doors

A case of lower leg compartment syndrome after mowing out of doors

Delayed lower leg compartment syndrome in the uninjured limb following hemilithotomy positioning: Report of three cases, review of the literature, and recommendations for prevention

Compartment syndrome in the uninjured leg as a complication of prolonged positioning in a hemilithotomy position is a serious complication. Prolonged operative time, external compression, and elevation of the sound leg are contributing factors. This is a devastating, but rare complication in the uninjured leg

Lower leg compartment syndrome after appendicectomy.

A 10-year-old boy presented with severe left lower leg pain, uncontrolled with increasing analgesia after appendicectomy. A diagnosis of acute compartment syndrome was made after a delayed referral to the orthopaedic service. The patient subsequently underwent an emergency fasciotomy and made a good functional recovery. To the best of our knowledge this is the first reported case of paediatric lower leg compartment syndrome after appendicectomy in the literature. The case report serves to highlight the importance of maintaining a high index of suspicion for compartment syndrome.