SLR - October 2019 - Donald Cohen
Surgical Management of Acute Compartment Syndrome and Sequential Complications
Reference: Du, W., Hu, X., Shen, Y., & Teng, X. (2019). Surgical Management of Acute Compartment Syndrome and Sequential Complications. BMC Musculoskeletal Disorders, 20(1). doi: 10.1186/s12891-019-2476-5
Scientific Literature Review
Reviewed By: Donald Cohen, DPM
Residency Program: St. Vincent Hospital – Worcester, MA
Podiatric Relevance: Acute compartment syndrome (CS) results from increasing compartmental pressures, directly affecting muscles and innervation following acute injury. CS may arise following traumatic injuries, revascularization, use of tourniquets or tight splinting. While the diagnosis is uncommon, it tends to affect the lower extremities – most often the anterior compartment of the leg. Failure to recognize CS in a timely fashion can lead to permanent damage to muscle and nervous tissue. The damage to these tissues can lead to a systemic inflammatory reaction which may result in organ failure and death.
Because CS most commonly affects the lower extremities, it clearly concerns podiatric clinicians. The extent of tissue damage is time-sensitive; meaning, early treatment leads to better prognosis. Delay in treatment can lead to severe fibrosis affecting musculature balance, often leading to clubfoot, claw toe and cavovarus deformities. CS is an imperative diagnosis podiatric clinicians do not want to miss.
The study performed by Du et al. aims to improve surgical management of acute CS. They discuss several methods for treatment options of acute CS, reporting the outcomes of 46 patients.
Methods: Forty-six patients were studied between January 2008 and December 2012 with lower leg CS. These patients were admitted to the hospital for a fasciotomy and post-operative wound management. Eight of the 46 patients were deemed to have severe complications resulting from CS, and were the subjects for the study. The age ranged from 20-60 years with a mean of 37 years, seven males and one female. The follow-up time was three to five years.
Once hemodynamically stable, the patients underwent fasciotomy, and either skin graft placement or primary closure. The patients all wore foot drop corrective braces until they could be placed in an Ilizarov external frame for clubfoot correction. Orthopedic surgeons then placed patients into the Ilizarov external fixator. Some patients underwent ankle arthrodesis. Claw toe deformities were corrected with arthroplasty and flexor lengthening.
Results: Six of the eight patients had a fasciotomy performed within 12-24 hours (early group), one patient within 48 hours (late group), and the last did not undergo fasciotomy as they were not diagnosed with CS at another hospital. The early group was found to have necrosis of the anterior and superficial lateral leg muscles. The late group, however, had necrosis found in every compartment, sparing the gastrocnemius muscles.
All patients underwent two to four debridements, and those with severe deformity were corrected through the use of Ilizarov external fixator or ankle arthrodesis. No amputations were reported after a three to five year follow-up; however, two neuropathic foot ulcers were reported. Patient satisfaction and ability to resume ambulation and daily activities were noted in all eight patients following treatment.
Conclusions: Acute CS is a serious condition which may lead to systemic inflammation or death. Early recognition and prompt fasciotomy are key for improved prognosis. Other therapies combined with fasciotomy like bracing, external fixation and further surgery may be necessary to achieve a functional foot and ankle, and return to normal activity.