Ultrasound-Guided Fasciotomy for Chronic Exertional Compartment Syndrome: A Case Report.

Chronic exertional compartment syndrome (CECS) is characterized by an excessive increase in intracompartmental muscle pressures after exercise. Athletes with CECS report pain, pressure, and occasionally neurologic symptoms in the affected compartment during exercise that abates with rest. Although many treatment options have been proposed, athletes often require a fasciotomy to return to unrestricted sports participation. Surgical success rates vary; complications are not uncommon; and after surgery, it usually takes athletes 6 or more weeks to return to unrestricted impact activities. This case report describes a new ultrasound-guided fasciotomy technique for the treatment of anterior leg compartment CECS. The procedure required a 3 mm incision, was performed in the office under local anesthesia, and allowed the athlete to resume running within 1 week of the procedure. Although the preliminary results of this study are promising, further translational research is required before the widespread adoption of this procedure is recommended.

A Novel Non-invasive Method for the Detection of Elevated Intra-compartmental Pressures of the Leg.

Acute Compartment Syndrome is a devastating consequence of musculoskeletal trauma. Currently the diagnosis is based on clinical signs and symptoms, and while adjuncts such as invasive intra-compartmental pressure measurements are often used to corroborate the physical exam findings, there remains no reliable objective test to aid in the decision to perform a decompressive fasciotomy. In a cadaver model of compartment syndrome, an ultrasound (US) based method has been shown to be a reliable measurement of increased intra-compartmental pressure. An absolute pressure of >100 mbar or a difference of 50 mbar in the CFFP between the legs can be considered pathologic. Using an ultrasound transducer, coupled with a pressure sensor, the pressure needed to flatten the superficial fascia of the anterior compartment of lower legs (Compartment Fascia Flattening Pressure [CFFP]) can be measured. The CFFP of the injured leg is compared to the CFFP of the uninjured leg. This US measured index can then serve as an adjunct to the physical exam in evaluating injured lower extremities and assessing the need for decompressive fasciotomy. The advantages of this protocol include: being a non-invasive method and an easily reproducible technique.

Use of standard musculoskeletal ultrasound to determine the need for fasciotomy in an elevated muscle compartment pressure cadaver leg model.

INTRODUCTION: Acute compartment syndrome (ACS) is a limb-threatening condition often associated with leg injury. The only treatment of ACS is fasciotomy with the purpose of reducing muscle compartment pressures (MCP). Patient discomfort and low reliability of invasive MCP measurements, has led to the search for alternative methods. Our goal was to test the feasibility of using ultrasound to diagnose elevated MCP. METHODS: A cadaver model of elevated MCPs was used in 6 cadaver legs. An ultrasound transducer was combined with a pressure sensing transducer to obtain a B-mode image of the anterior compartment, while controlling the amount of pressure applied to the skin. MCP was increased from 0 to 75 mmHg. The width of the anterior compartment (CW) and the pressure needed to flatten the bulging superficial compartment fascia (CFFP) were measured. RESULTS: Both the CW and CFFP showed high correlations to MCP in the individual cadavers. Average CW and CFFP significantly increased between baseline and the first elevated MCP states. Both Inter-observer and intra-observer agreements for the ultrasound measurements were good to excellent. DISCUSSION: Ultrasound indexes showed excellent correlations in compartment pressures, suggesting that there is a potential for the clinical use of this modality in the future.

Patient-Reported Outcomes Following Fasciotomy for Chronic Exertional Compartment Syndrome.

BACKGROUND: Lower extremity chronic exertional compartment syndrome (CECS) can negatively affect exercise and activity and may require operative intervention to release the fascia. Few studies have evaluated or compared patient-reported outcomes for bilateral versus single-leg staged fasciotomy and number of compartments released. METHODS: A total of 27 eligible patients who underwent a fasciotomy procedure for CECS at a single institution were identified. A retrospective review of the medical record was performed, and individuals were contacted by phone to collect patient-reported outcomes, including ability to return to desired exercise level, postoperative expectation assessment, European Quality of Life-Five Dimensions, and the Foot and Ankle Ability Measure sports subscale. RESULTS: A total of 21 patients were available for follow-up (average follow-up 36.9 months). The average single numeric assessment evaluation of lower-extremity function in sport was 87.5% in those who underwent a simultaneous bilateral fasciotomy (n = 10), 94% in those who had a staged unilateral fasciotomy (n = 5), and 74% in those who underwent an isolated single-leg fasciotomy. In all, 91% (n = 10) of patients who had all 4 compartments released intra-operatively were able to return to their desired exercise level versus 66.7% (n = 6) of those who did not have all 4 compartments released. CONCLUSION: The patient-reported outcomes of a staged unilateral fasciotomy and simultaneous bilateral fasciotomy for CECS are similar. Those who did not have all 4 compartments released reported worse outcomes. Further research should be conducted on the short-term outcomes and cost-effectiveness of a bilateral versus staged fasciotomy procedure. LEVELS OF EVIDENCE: Level IV: Case series.

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

INTRODUCTION: Compression 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 METHODS: The 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. RESULTS: The 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. CONCLUSION: Compression 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.

Acute Compartment Syndrome of the Leg.

INTRODUCTION: Acute compartment syndrome (ACS) is well known among orthopaedic surgeons. The timely diagnosis and management of ACS is crucial to avoiding its sequelae, including renal failure, ischemic contractures, and limb loss. Despite its relative importance, ACS poses a challenge to many residents and clinicians as diagnosis relies largely on clinical judgment. METHODS: Timely diagnosis and thorough compartment release are essential to optimizing outcomes in ACS. This video highlights a clinical case in which compartment syndrome of the leg was considered, diagnosed, and surgically managed. RESULTS: This video will present the indications for compartment release and a video-guided demonstration of compartment checks using an arterial line transducer, a 4-compartment fasciotomy with 2 incisions, and temporizing vessel loop closure. CONCLUSIONS: Compartment syndrome can be a devastating complication of common fractures. It is essential that orthopaedic practitioners understand the immediacy of intervention. We have a responsibility to provide timely, accurate diagnosis along with expedient surgical management.

[Intra-articulair tibial Plateau Fractures]. / Intraartikuläre Tibiakopffrakturen.

Tibial plateau fractures are complex articular injuries, especially if caused by high energy. For adequate treatment a decidedly clinical and radiographic diagnostic is required. The three-column-concept has proven as excellent surgical planningstool in this complex trauma. By (1) precisely considering the specific characteristics of the fracture, (2) careful treatment of soft-tissue envelope and (3) choosing the right treatment strategy, a good functional outcome can be achieved.

Ultrasound-Guided Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg.

Chronic exertional compartment syndrome is characterized by exertional pain and elevated intracompartmental pressures affecting the leg in physically active young people. In patients who have failed conservative measures, fasciotomy is the treatment of choice. This study presents a new method for performing fasciotomy using high-resolution ultrasound (US) guidance and reports on the clinical outcomes in a group of these patients. Over a 3-year period, 7 consecutive patients with a total of 9 involved legs presented clinically with anterior compartment chronic exertional compartment syndrome, which was confirmed by intracompartmental pressure measurements before and after exercise. After a US examination, fasciotomy under US guidance was performed. Preoperative and postoperative pain and activity levels were assessed as well as number of days needed to "return to play." All patients had a decrease in pain, and all except 1 returned to presymptomatic exercise levels with a median return to play of 35 days.

Computed tomography angiography and magnetic resonance imaging performance of acute segmental single compartment syndrome following an Achilles tendon repair: A case report and literature review.

Acute compartment syndrome of the lower extremity is a serious postinjury complication that requires emergency treatment. Early diagnosis is of paramount importance for a good outcome. Four muscle compartments in the calf (anterior, lateral, deep posterior, and superficial posterior) may be individually or collectively affected. Acute segmental single-compartment syndrome is an extremely rare condition characterized by high pressure in a single compartment space with threatening of the segmental tissue viability. In this case report, we describe a young man with Achilles tendon rupture who complained of postoperative pain in the anterior tibial region. Emergent computed tomography angiography and magnetic resonance imaging revealed local muscle edema. Segmental anterior compartment syndrome was diagnosed and fasciotomy was performed.

Measurement of compartment elasticity using pressure related ultrasound: a method to identify patients with potential compartment syndrome.

PURPOSE OF THE STUDY Decision-making in treatment of an acute compartment syndrome is based on clinical assessment, supported by invasive monitoring. Thus, evolving compartment syndrome may require repeated pressure measurements. In suspected cases of potential compartment syndromes clinical assessment alone seems to be unreliable. The objective of this study was to investigate the feasibility of a non-invasive application estimating whole compartmental elasticity by ultrasound, which may improve accuracy of diagnostics. MATERIAL AND METHODS In an in-vitro model, using an artificial container simulating dimensions of the human anterior tibial compartment, intracompartmental pressures (p) were raised subsequently up to 80 mm Hg by infusion of saline solution. The compartmental depth (mm) in the cross-section view was measured before and after manual probe compression (100 mm Hg) upon the surface resulting in a linear compartmental displacement (Δd). This was repeated at rising compartmental pressures. The resulting displacements were related to the corresponding intra-compartmental pressures simulated in our model. A hypothesized relationship between pressures related compartmental displacement and the elasticity at elevated compartment pressures was investigated. RESULTS With rising compartmental pressures, a non-linear, reciprocal proportional relation between the displacement (mm) and the intra-compartmental pressure (mm Hg) occurred. The Pearson's coefficient showed a high correlation (r2 = -0.960). The intraobserver reliability value kappa resulted in a statistically high reliability (κ = 0.840). The inter-observer value indicated a fair reliability (κ = 0.640). CONCLUSIONS Our model reveals that a strong correlation between compartmental strain displacements assessed by ultrasound and the intra-compartmental pressure changes occurs. Further studies are required to prove whether this assessment is transferable to human muscle tissue. Determining the complete compartmental elasticity by ultrasound enhancement, this application may improve detection of early signs of potential compartment syndrome. Key words: compartment syndrome, intra-compartmental pressure, non-invasive diagnostic, elasticity measurement, elastography.

The thickness of the anterior compartment does not indicate compartment syndrome in acutely traumatised legs?

BACKGROUND: The study was conducted to achieve early detection of increased compartment pressure by comparing the changes between the thickness and pressure within the musculofascial compartments after lower leg injury. METHODS: We included cases of a lower-leg fracture between January and December 2007. Bilateral lower leg compartment pressure and thickness were measured before the surgery and post-anaesthesia, and the surgery was performed within 12 h after the initial trauma. The intracompartment pressure (ICP) was measured with a Wick catheter pressure monitor. The thickness (width) of the anterior compartment of lower leg was measured using ultrasound. RESULTS: All data were measured within 4-6h of the injury. The average thickness in injured legs versus uninjured was 30 mm (15-46 mm) versus 20.4 mm (13-30 mm), P<0.001. The average intracompartment pressure (ICP) in injured leg versus uninjured was 45.3 mmHg (26-80 mmHg) versus 17.5 mmHg (15-20 mmHg), P<0.001. The thickness and ICP were significantly increased for injured lower legs compared to the uninjured legs, but the increase in ICP did not show a significant relationship with the change in thickness of the injured lower leg. CONCLUSION: In this study, the results of ICP and thickness changes of injury lower leg compared with uninjured leg revealed no statistically significant correlation. Some injuries showed a high ICP with only mild changes in thickness, while some showed a high ICP with significant changes. Although ultrasound has many advantages for the evaluation of soft tissue changes after trauma, this study revealed that thickness changes are not a predicable parameter for determining pressure on the acute fracture of lower leg.

The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome: a pilot study.

OBJECTIVE: To test the hypothesis that patients with chronic exertional compartment syndrome (CECS) of the anterior leg compartment have an increased anterior compartment thickness (ACT) compared with control subjects after exertion using ultrasound. DESIGN: Prospective comparison study. SETTING: Diagnostic imaging department of a tertiary care hospital. PATIENTS: Four patients with CECS and 9 control subjects. INTERVENTIONS: Patients with CECS and control subjects ran on a treadmill for up to 10 minutes. Anterior compartment thickness (both groups) and anterior compartment pressure (CECS patients) were measured before exertion and at scheduled intervals after exertion. MAIN OUTCOME MEASURES: Anterior compartment thickness, percentage change in ACT from rest, and compartment pressure. RESULTS: Anterior compartment pressures were diagnostic of CECS using the modified Pedowitz criteria in patients with CECS. Mean percentage change in ACT from rest in patients with CECS versus control subjects at 0.5 minutes was 21.3% versus 6.32% [95% confidence interval (CI), 6.92-35.6 and 0.094-12.5, respectively; P = 0.011]; at 2.5 minutes, it was 24.6% versus 4.22% (95% CI, 10.7-38.5 and -1.85-10.3, respectively; P = 0.003); and at 4.5 minutes, it was 24.9% versus 5.08% (95% CI, 14.3-35.5 and -0.813-11.0, respectively; P = 0.003). Mean ACT in patients with CECS versus control subjects significantly increased after exertion (P = 0.003) at 0.5 minutes, 2.5 minutes, and 4.5 minutes. CONCLUSIONS: Ultrasonography reveals a significant increase in ACT in patients with CECS of the anterior leg compartment. Further studies are warranted to validate these findings with the goal of developing anterior leg compartment CECS ultrasound diagnostic criteria and exploring the role of using ultrasound to diagnose CECS in other compartments.

[Bilateral leg compartment syndrome due to severe myonecrosis caused by inappropriate use of simvastatin]. / Syndrome de compression des loges bilatéral des membres inférieurs et myonécrose sévère due à l'usage inapproprié de la simvastatine.

Bilateral leg compartment syndrome due to myonecrosis caused by inappropriate use of statins is a rare but potentially fatal complication of this lipid lowering medication. We report a case of a 39-year-old woman who presented with suspicious critical lower limb ischemia. Subsequently, bilateral leg compartment syndrome and myonecrosis developed. The primary cause of myonecrosis was due to misuse of simvastatin mistaken by the patient for a weight-reducing drug. Urgent fasciotomies were performed and the patient underwent urgent renal replacement therapy with continuous hemodialysis for acute renal failure due to myoglobinuria. After this complex treatment, the patient was discharged. She almost fully recovered with only a residual paresis of the left fibular nerve. According to literature, this is a unique case of bilateral compartment syndrome and myonecrosis with acute renal failure due to statin overdose leading to acute renal failure and bilateral fasciotomy.

Anterior tibial compartment syndrome due to the pyomyositis in a patient with rheumatoid arthritis. A case report.

Anterior tibial compartment syndrome was developed due to pyomyositis in a 33-year-old male patient with rheumatoid arthritis while receiving steroid therapy during the follow-up period. The preoperative physical examination, laboratory findings, MRI images, intraoperative observation and postoperative histopathological examinations confirmed the association with pyomyositis. The surgical drainage and antibiotic treatment were effective, and in the follow-up period, neuromuscular dysfunctions disappeared completely within 6 months. The patient has been asymptomatic for 4 years of follow-up. To date, anterior tibial compartment syndrome due to pyomyositis in a case with rheumatoid arthritis has not been reported.