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Does open fasciotomy contribute to morbidity and mortality after acute lower extremity ischemia and revascularization?
Does open fasciotomy contribute to morbidity and mortality after acute lower extremity ischernia and revascularization? Daniel S. Rush, M D , a Scott B. Frame, M D , b Richard M. Bell, M D , a Eugene E. Berg, M D , c Morris D. Kerstein, M D , b and James L. Haynes, M D (
Columbia, S.C., and New Orleans, La. A retrospective review was undertaken of 127 lower extremity fasciotomies performed for compartment syndrome after acute ischemia and revascularization in 73 patients with vascular trauma and 49 patients with arterial occlusive disease. One hun&red twelve (88%) fasciotomies were performed early (at the time of revascularization); 15 (12%) were delayed because of late compartment syndrome diagnosis. Ninety-four (77%) patients had more than one accepted indication for fasciotomy. Double-incision fasciotomy was used in 98 (77%) extremities, single-incision fasciotomy was used in 19 (15%), and fasciotomy-fibulectomy was used in 10 (8%). Fasciotomies were dosed in 88 (69%) patients an average of 14 days after surgery. Seven patients needed multiple skin grafting procedures or myocutaneous flaps to close the wound; none compromised limb salvage. Five other patients had minor wound infections that resolved. Functional status returned to preoperative levels by the time of discharge from the hospital in 59 (48%) patients. Thirty-one (24%) patients had residual lower extremity disability related to delayed union of the fracture (five), chronic neuropathy (20), leg swelling (one), or ischemic nonhealing fasciotomy wounds (three); two patients had unrelated disabilities. Fourteen (11%) amputations were required for refractory limb ischemia; two (1.6%) were required for wet gangrene of the foot, which infected the fasciotomy site; the others had open noninfected incisions. Eighteen (15 %) patients died of cardiopulmonary failure or multisystem failure or both, without fasciotomy-related problems. Open fasciotomy for compartment syndrome after acute lower extremity ischemia and revascularization was associated with an increased risk of minor wound morbidity. However, limb loss and death resulted from persistent ischemia and underlying systemic disease processes or injuries, but not from open fasciotomy wound complications. (J VAsc SURG 1989;10:343-50.)
Postischemic compartment syndrome (CS) may follow lower extremity revascularization from either vascular trauma (VT) or arterial occlusive disease (AOD). l'z Fasciotomy is the accepted method of treatment for CS. ~3 Delay in performance of fasciotomy until after the clinical appearance of CS risks additional injury to nerve and muscle already compromised by ischemia? -3 Furthermore, sustained compartmental hypertension ultimately results in irFrom the Departmentsof Surgery'and Orthopaedics,cUniversity of South Carolina School of Medicine, Columbia, S,C., and the Departmentof Surgery,bTulaneUniversitySchoolof Medicine, New Orleans, La. Presented at the ThirteenthAnnualMeetingof the SouthernAssociation for Vascular Surgery, Key West, Fla., Jan. 25-28, 1989. Reprint requests: Daniel S. Rush, MD, Department of Surgery, Universityof South Carolina School of Medicine, Two Richland Medical Park, Suite 402, Columbia, SC 29203. 24/6/14338
reversible neurologic injury, myonecrosis, and the much-feared Volkrnann's ischemic contracture. 1"2 Traditional teaching has so emphasized the morbid consequences of inadequately treated CS that surgeons are usually unwilling to withhold fasciotomy in high-risk clinical situations. Unfortunately, no absolute clinical indications for fasciotomy exist? -3 To achieve therapeutic benefit, fasciotomy is often performed empirically or prophylacticaUy based on clinical assessment. 4,5 Recent technical developments for direct measurement of compartment pressure have not resolved this issue? 3'6 Debate continues regarding the significance of compartment pressure measurements and the need for fasciotomy.6-~° Early fasciotomy has been cited as a major factor contributing to limb salvage and preservation of fimction, especially in VT. 4'5'11"14 However, if injudiciously applied, fasciotomy may have its own mor343
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Table I. Clinical indications for lower extremity fasciotomy in 73 patients with vascular trauma and compartment syndrome Indication for fasciotomy
No. (%)
Popliteal injury Fracture or dislocation Peripheral neurologic deficit Prolonged ischemia (>6 hr) Extensive soft tissue injuq, Arteriovenous injury Distal leg swellingor edema Compamnent tenseness Preadmission hypotension
37 (51%) 37 (51%) 31 (42%) 29 (40%) 26 (36%) 23 (32%) 23 (32%)
Table II. Clinical indications for ~ower extremity fasdotomy in 49 patients with arterial occlusive disease and compartment syndrome Indicationfor fasciotomy
No. (%)
Prolonged ischemia (>6 hr) Peripheral neurologicdeficit Distal leg swellingor edema Compartment tenseness
46 (94%) 28 (57%) 12 (24%) 9 (18%)
15 (21%)
10 (14%)
bidity by exposure of susceptible muscle and deep tissues to the nosocomial environment. 6,8 Blaisdell 8 has taken issue with the concept of fasciotomy for revascularization syndrome and stated that it is rarely indicated. From this viewpoint, "liberal" use of fasciotomy may unnecessarily expose patients to an increased risk of complications from wound infection.8 Concern about infection associated with open fasciotomy incisions has been raised elsewhere. 1,5~6'15-17 Anecdotal reports indicate that infections at the fasciotomy site have resulted in leg amputation. 18,~9Patman and Thompson 4 reported that complications after fasciotomy were related to the underlying cause necessitating the procedure. Other authors report little or no additional morbidity and mortality associated with the aggressive use of fasciotomy in accepted situations.5,n, I4 Therefore the most controversial aspects of fasciotomy continue to be its clinical appropriateness and potential to cause morbidity. 7'17a9The literature provides little data to settle these controversies. Meaningful conclusions are difficult to derive from previous studies because patient inclusion criteria and reporting formats are highly variable. The purpose of this study was to evaluate the morbid consequences of open fasciotomy incisions in a large series of patients at high risk for CS after acute lower extremity ischemia and subsequent revascularization. PATIENTS
Clinical results of 73 patients with VT and 49 patients with AOD who required lower extremity fasciotomies for CS after ischemia and revascularization were retrospectively reviewed. All patients were treated during the past 10 years (i979 to 1989) and were identified from records of the vascular surgery services at the Tulane University School of Medicine, the University of South Carolina School of Medicine, and their affiliated hospitals.
All patients were at high risk to have acute postischemic CS. Each had a period of severe lower extremity ischemia documented by absence of palpable pedal pulses or Doppler arterial flow, and each required surgical intervention to restore regional perfusion. The decision to perform a fasciotomy was made by the senior surgeon based on a presumptive clinical diagnosis of established or impending CS. All patients had at least one accepted indication for fasciotomy, and 94 (77%) had multiple indications (Tables I and II). When measured, compartment pressures above 20 mm H g were considered supportive of the clinical diagnosis of CS; pressures above 40 mm H g confirmed the diagnosis of CS. 2 All patients were also at high risk to have fasciotomy wound problems. Only cases of open fasciotomy (open incision of skin, fascia, and epimysium) were included. Subcutaneous fhsciotomies or those closed perprimam intentionem were excluded. When the likelihood of CS was recognized before surgery or on restoration of arterial blood flow, fasciotomy was performed early (during the initial surgical procedure). Delayed fasciotomies were performed as a second procedure when CS appeared late or was unrecognized. Each patient was assigned at the time of discharge from the hospital to one of the four following clinical outcome categories: (1) functional--the patient returned to preadmission levels of activity, minor wound problems did not exclude patients from this category; (2) disabled--included patients with any dysfunction or major fasciotomy wound complications, although improvement may have occurred subsequent to discharge from the hospital; (3) amputee; (4) in-hospital deaths. Patients requiring bilateral fasciotomies were categorized according to the worst outcome, not the functional status of the better limb. TECHNICAL RESULTS Fasciotomy techniques were similar for both the patients with VT and those with AOD (Table III). The double-incision, four-compartment fasciotomy
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Fasciotomy--morbidity and mortality 345
Table III. Fasciotomy and wound treatment techniques in 76 fasciotomies for vascular trauma and 51 fasciotomies for arterial occlusive disease Techniques
Vascular ~ trauma (%)
Arterial~- occlusive disease (%)
58 (76%) 10 (13%) 8 (11%)
40 (78%) 9 (18%) 2 (4%)
25 34 2 2 8 5
19 8 0 4 6 14
Fasciotomy Double-incision fasciotomy Single-incision fasciotomy Fasciotomy-fibulectomy Wound treatment Delayed primary closure Split-thickness skin graft Myocutaneous flap Open at discharge Open at amputation Open at death
(33%) (44%) (3%) (3%) (11%) (6%)
(37%) (16%) (8%) (12%) (27%)
~+Seventy-threepatients had 76 fasciotomies for treatment of vascular trauma. ~-Forty-nine patients had 51 fasciotomies for treatment of arterial occlusive disease.
was the preferred method of decompression and was used for 98 (77%) extremities. Selective singlecompartment or single-incision, parafibular (fourcompartment) fasciotomy was used in 19 (15%) extremities. Fasciotomy-fibulectomy was used for 10 (8%) extremities early in the series. Open fasciotomy sites were surgically debrided as necessary and dressed frequently with sterile gauze bandages. Fasciotomy incisions were closed after resolution of muscle edema at an average of 14 days after surgery (range, 3 to 35 days) (Table III). Delayed primary closure of the wound was preferred and often performed at the bedside. Wound severity in the patients in the VT group resulted in a greater dependence on split-thickness skin grafts to close fasciotomy defects. Myocutaneous flaps were used in two patients with VT for complex tissue defects. Fasciotomy incisions were not closed in 30 (25%) patients (33 fasciotomies) bccause of intervcning amputation or death. Fivc (4%) patients (6 fasciotomies) were discharged from the hospital with open fasciotomies under treatment to allow secondary closure. The mean length of hospital stay was 30 days in both patients with VT and those with AOD. Clinical follow-up was available in 55 (61%) of 90 patients with salvaged limbs at an average of 18 months after discharge from the hospital (range 1 to 72 months); no late fasciotomy-related, limbthreatening problems have been identified. CLINICAL RESULTS Patients with vascular trauma Seventy patients with VT underwent unilateral lower extremity fasciotomies; three required bilateral fasciotomies. The mean age was 28 years (range, 10 to 68 years). Sixty-five patients were men and 8 were women (ratio, 8 : 1), Vascular injuries included five
(7%) stab wounds, 42 (57%) gunshot wounds, and 26 (36%) crushing injuries. The level of vascular injury involved the following arteries: one iliac, six femoral, 19 superficial femoral, 36 popliteal, and 11 tibial. The estimated ischemic time between injury and rcstoration of circulation averaged 7 hours (range, 1 to 33 hours). Transportation to the hospital was the major cause of late revascularization. Delay in treatment after admission to the hospital averaged 3 hours (range, 1 to 8 hours), which represented the time required for clinical and arteriographic evaluation and operating room availability. Direct arterial repair or venous repair or both were required in 53 (70%) vascular injuries. No direct vascular repair was required in 23 (30%) injuries. Reduction and stabilization of fractures or dislocations restored arterial flow in 13. The remaining 10 (mostly tibial arteries) had spontaneous resumption of arterial flow after cessation ofvasospasm or decompressive fasciotomy. Sixty-one (84%) patients had more than one accepted indication for lower extremity fasciotomy (Table I). Fasciotomy was performed during the initial surgical procedure in 71 (93%) cases. Five delayed fasciotomies were performed at an average of 16 hours (range, 2 to 48 hours). Direct compartment pressures were obtained in eight extremities, with a mean of 65 mm Hg (range, 20 to 110 mm Hg). Forty (55%) patients returned to functional stares. Thirty-five healed their fasciotomy incisions uneventfully by the time of discharge. Four fasciotomy wounds required multiple skin grafts and one required a myocutaneous flap. Twenty (27%) patients were dysfunctional at discharge from the hospital. Eight patients had chronic sensory neuropathy; five had wealmess from a motor neuropathy. Orthopedic complications included chronic osteomyelitis or nonunion of the fracture in
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Table IV. Causes of amputation after open lower extremity fasciotomy in eight of 73 patients with vascular trauma Fracture
Amputation (days)
Injury
Vessel
SGW GSW SGW
SFA-PFV SFA SFA-SFV
Femur
AKA (5) BKA (23) AKA (10)
SGW MVA MVA MVA MVA
SFA-SFV POP Iliac POP POP
Tibia-fibula Pelvis Tibia-fibula Tibia-fibula
AKA (14) AKA (4) MZA (24) BKA (2) BKA (2)
Indication for amputation Ischemic myonecrosis Ichemic foot necrosis Ischemia, wet foot gangrene with secondary infection of the open fasciotomy Ischemic myonecrosis Foot gas gangrene Ischemic myonecrosis Refractory ischemia Ischemia, crashed leg
SGW, Shotgun wound, GSW, gunshot wound; MVA, motor vehicle accident; SFV, superficial femoral artery.; PFV, profunda femoris vein; SFV, superficial femoral vein; POP, popliteal artery; Days, number of postoperative days before amputation; AKA, above-knee amputation; BKA, below-knee amputation.
five patients. One patient with a severe head injury and another with paraplegia from spinal cord injury were classified as disabled; neither had fasciotomyrelated impairment. Four patients classified as dysfunctional had recurrent superficial cellulitis; one required multiple skin graftings and a myocutaneous flap. These wound problems resolved and were not associated with residual morbidity. Eight (11%) patients required amputation; three amputations were performed below the knee and five above the knee (Table IV). Four amputations followed penetrating superficial femoral artery trauma accompanied by extensive soft tissue damage; venous injury was present in three and the femur fractured in one. The other four patients requiring amputation experienced trauma as a result of vehicular accidents and had extensive soft tissue damage; two amputations followed blunt popliteal artery trauma accompanied by tibia-fibula fractures, and the other two resulted from severe injuries that crushed the lower extremities. The need for early amputation (within 5 days of injury) was evident in four limbs and was performed before a fasciotomy wound problem could develop. The remaining four limbs were amputated from 10 to 24 days after initial treatment without fasciotomy wound complications. Seven amputations healed primarily; one below-knee amputation required revision. One patient with crushed legs underwent bilateral four-compartment fasciotomies; the nonamputated extremity was salvaged by popliteal artery repair and remained functional. In all cases amputation resulted from persistent or refractory limb ischemia combined with osseousmyocutaneous injury-. In one patient with an above-knee amputation, an ischemic foot infection with wet gangrene
progressed to secondarily involve the open fasciotomy site. No primary fasciotomy wound infections resulted in amputation. Five (7%) patients died; all had massive crushing injuries. As a group they were older (mean age, 44 years; range, 29 to 68 years). Three died of acute cardiac complications within 3 days of hospitalization; their open fasciotomy wounds were clean. Two experienced multisystem organ failure and died after surgery at 65 and 94 days, respectively. The fasciotomy incision healed in the first patient. The second patient underwent above-knee amputation for refractory limb ischemia 2 months before death; the fasciotomy site at that time was still open but not infected. No deaths from VT could be attributed to fasciotomy wound complications. Patients with arterial occlusive disease
The 49 patients with AOD underwent 47 unilateral and two bilateral lower extremity fasciotomies. Their average age was 61 years (range, 35 to 78 years); 33 were men and 16 were women (ratio, 2:1). The estimated ischemia time before revascularization averaged 22 hours (range, 2 hours to greater than 1 week). Causes of the ischemic event included 19 (39%) patients with arterial embolism, 10 (20%) with arterial thrombosis, and 18 (37%) with graft thrombosis. Two (4%) patients had prolonged ischemia (greater than 10 hours) during complicated aortic reconstructions: one reconstruction followed an elective suprarcnal aortic aneurysmectomy, which also required femoral-popliteal bypass grafting for acute intraoperative limb ischemia; the other following a complex extraanatomic reconstruo tion for a ruptured infected aortic graft. Direct lower
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Fasciotomy--morbidity and mortality 347
Table V. Causes of amputation after open lower extremity fasciotomy in six of 49 patients with arterial occlusive disease Cause
Amputation (days)
Thromboembolism Thromboembolism
AKA (3) AKA (30)
Arterial thrombosis Graft thrombosis Graft thrombosis Graft thrombosis
AKA (21) AKA (2) BKA (8) BKA (34)
Indicationfor amputation Recurrent arterial thrombosis, refractory ischemia Persistent ischemia, wet foot gangrene with secondary infection of the open fasciotomy Ischemic myonecrosis Referactory ischemia Ischemic myonecrosis Refractory ischem~a
AKA, Above-knee amputation; BICA, below-knee amputation; days, number of postoperative days before amputation.
Table VI. Causes of death after open lower extremity fasciotomy in 13 of 49 patients with arterial occlusive disease Cause Thromboembolism Thromboembolism Thromboembolism Arterial thrombosis Arterial thrombosis Prolonged operation (> 10 hr) Thromboembolism Thromboembolism Thromboembofism Arterial thrombosis Arterial thrombosis Graft thrombosis Graft thrombosis
Amputation (days)
Death (days)
AKA (4) AKA (10) AKA (12) AKA (4) M ~ (15) AKA (3) AKA (15)
Multisystem organ failure (4) Cardiac (5) Multisystem organ failure (6) Cardiac (1) Cardiac (3) Multisystem organ failure (3) Pulmonary embofism (41) Cardiac (26) Sepsis (47) Cardiac (13) Cardiac (43) Multisystem organ failure (96) Sepsis (45)
Days, Number of postoperative days before amputation or death; AKA, above-knee amputation.
extremity revascularization was required for all 49 patients with AOD. Thrombectomy or embolectomy were performed in 36 (73%) patients, and arterial bypass grafting was performed in 13 (27%). Clinical indications for fasciotomy in the patients in the AOD group are listed in Table II. Thirty-three (67%) patients had more than one accepted indication for fasciotomy. Thirty-nine (76%) fasciotomies were performed at the time of the revascularization procedure. Delayed fasciotomies were performed in 12 (23%) patients at an average of 32 hours (range, 11 to 72 hours) after revascularization. Compartment pressures were measured in three patients and averaged 55 nun Hg (range, 40 to 65 m m Hg), all of which confirmed the clinical impression. Nineteen (39%) patients returned to their preoperative functional status. Two patients had minor fasciotomy wound problems; one required multiple skin graftings and the other had wound drainage that resolved with topical care. Eleven (22%) patients were chronically disabled; three had residual ischemic sensory neuropathy, four
had motor neuropathy, and one had leg swelling. Three patients had nonhealing fasciotomy incisions attributed to chronic ischemia. Two required belowknec amputations for rest pain (6 and I8 months later, respectively) despite subsequent bypass grafting attempts; their fasciotomy wounds were clean but did not heal. The last patient has remained ambulatory with fasciotomy wounds that are still healing after 2 years of follow-up. Six (12%) patients with AOD were discharged from the hospital with amputations; two were below the knee and four above the knee (Table V). All amputations were performed for refractory ischemia with myonecrosis. One patient with wet gangrene of the foot had infection of the fasciotomy site as a result and required above-knee amputation. Three amputations were performed early (within the first week of hospitalization) and the remaining two at 21 to 34 days; respectively; no fasciotomy wounds had clinical evidence of infection. Thirteen (27%) patients with AOD died (Table VI). The cause of death was cardiopulmonary in
348
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Rush et M.
seven patients and sepsis/multisystem organ failure in six. Six patients died within the first week of hospitalization, and all had noninfected open fasiotomy sites. Seven patients underwent early above-knee amputations for refractory limb ischemia and died weeks or months later. No deaths could be attributed to fasciotomy wound complications.
The potential morbidity of lower extremity fasciotomy has been a subject of considerable recent debate. ~62° At issue is whether the potential limbsalvaging benefit of fasciotomy in the treatment of CS is outweighed by the possible infectious consequences of open leg wounds in patients already at risk for limb loss and death. We sought to resolve this issue by studying the postoperative morbidity and mortality of a large series of patients with VT and AOD who were at high risk because they had open fasciotomy incisions. All patients in this study had clinical evidence of CS and met or exceeded standard surgical indications for fasciotomy previously reported. 2'4'sa4Additionally, all patients had a period of acute lower cxtremity ischemia, which required surgical intervention to reestablish circulation. The aggressive use of fasciotomy in conjunction with a rcvascularization procedure remains controversial. ~'6-8'~7 An aura of urgency surrounds fasciotomy decision making, since delay may potentiate the risk of limb dysfunction from neuromuscular compromise. ~,2a6 Furthermore, patients undergoing vascular surgery may be at risk for the late appearance of a CS as a result of a reperfusion phenomenon? Some authors have stated that the diagnosis of CS can reliably be made from preoperative signs and symptoms. 4'~'n'14'2° In our cxperience clinical manifestations of an impending CS are nonspecific and frequently indistinguishable from the signs and symptoms of extensive limb trauma or severe limbthreatening arterial insufficiency. Given these uncertainties, fasciotomy is often used empirically or prophylactically when there is high risk for CS. ~- Aggressive use of fasciotomy can be justified under such circumstances only if its consequences have an acceptably low morbidity and mortality. Unfommately, the use ofintercompartment pressure monitoring has not darified the indications for fasciotomy. 1,2,6,9,11 Questions remain concerning the variability of human tolerances to compartment hypertension and the need for surgical decompression. v3 For these reasons direct compartment pres-
sure measurement has thus far fotmd limited acceptance in either elective or emergency vascular situations, s,~,~3,14'2°Measurable increases in lower extremity compartment pressures occur after elective aortic and infrainguinal arterial reconstructions, yet the need for fasciotomy after routine vascular operations is rare. <6,m'21,= Only one patient in our series (less than I%) needed fasciotomy after an elective operation. The need for fasciotomy was clinically apparent in all of our patients and supported by compartment pressure determination in all cases measured. In our opinion clinical context, accepted indications, and compartment pressure measurement when necessary are the best determinants for fasciotomy in patients with VT and AOD. Fasciotomy has been associated with an increased risk of wound problems. ~ Fortunately, superficial wound infections in our series were minor and resolved with proper attention. Chronic, nonhealing fasciotomy wounds remained stable for long time periods without infection in three of our patients with AOD. Anecdotal reports indicate that fasciotomy wound infections can result in leg amputation, although contributing factors such as persistent ischemia or distal gangrenous changes were not discussed. 18,19 Spread of infection from the foot to the fasciotomy site contributed to above-knee amputation in two of our patients. The 12% incidence of amputation in our patients is comparable to amputation rates reported elsewhere in patients undergoing vascular surgery who require fasciotomy.4,s'14 No limb loss was attributable to morbidity related to primary open fasciotomy in our patients, Persistent or refractory limb-threatening ischemia was the major factor responsible for amputation in this and other studies. 4,s,14,29 Fasciotomy has been performed as an adjunctive procedure in 19% to 80% of reported patients with VT undergoing lower extremity arterial repair. 14,20,23-28Patients having popliteal, arteriovenous, and blunt lower extremity trauma require fasciotomy more frequently than do patients with isolated, penetrating vascular injuries, n-la,24,2s Although they had open fasciotomies, no amputations or deaths occurred in any of our patients with isolated, penetrating trauma, including popliteal injuries. The severity of associated injury (including the extent of soft tissue damage, fractures, and duration of ischemia) continues to be the major factor contributing to limb loss and death in patients with lower extremity VW. 1I'14'23'24"26 All amputations in our patients
~References 4, 5, 11, 12, 14, 17.
~References 6, 8, 16, 17, 19, 20.
DISCUSSION
Volume 10 Number 3 September 1989
with VT were associated with ischemia and complex injuries and were not related to open fasciotomy complications. Likewise, all posttraumatic deaths in our series followed crushing injuries. Death occurred either early before fasciotomy complications could develop or long after amputation had been performed for refractory ischemia. Successful treatment of injuries in which lower extremities were crushed remains an unsolved clinical problem carrying high rates of morbidity and mortality irrespective of the use of fasciotomy. 2429 Early amputation of severely injured limbs instead of attempted limb salvage has been suggested as a means of increasing patient survival. 29,30 Information regarding the outcome of fasciotomy in patients revascularized after acute ischemia from AOD is somewhat sparse. <5"31Our data suggest that lower extremity fasciotomy adds little additional risk of morbidity beyond that of the attempted revascularization for acute limb-threatening ischemia itself. 31,32 Blaisdell et al. 33 reported a 7.5% mortality and two-thirds limb-salvage rate in patients with acute thromboembolism treated by systemic heparinization, selective revascularization, and early amputation when needed; the use of fasciotomy was specifically avoided. The 27% mortality in our patients with AOD was similar to mortality rates from other series reviewed in the above study. 33 Considering the source of ischemia and attendant medical problems, the risk of amputation and death in patients at high risk appears related to the primary decision for surgical revascularization, rather than to the performance of fasciotomy afterward, a2"aa In this series of patients undergoing vascular surgery who had clinical evidence of CS, open lower extremity fasciotomies were performed with little additional morbidity and mortality. Fasciotomy remains an effective procedure to maximize postischemic tissue viability and fimction in the presence of compartment hypertension. Open fasciotomy did subject extremities to an increased risk of wound problems. In our experience, superficial wound complications were minor and resolved with proper attention. Nonhealing fasciotomy incisions were maintained without risk of serious infection and did not prevent subsequent attempts at revascularization. The major enemy of limb salvage after fasciotomy was ischemia. Deaths resulted from cardiopulmonary or multisystem organ failure and occurred either early before development of fasciotomy problems or long after amputation had been performed. In conclusion, the reputed morbidity and mortality of fasciotomy are the result of refractory ischemia and underlying
Fasciotomy--morbidity and mortality 349
medical problems or associated injuries and not the • procedure itself. Fasciotomy should not be withheld when clinically indicated for fear that this effective ancillary procedure will adversely affect limb salvage and patient survival. The authors express their appreciation to Pam N o i ~ o for manuscript preparation.
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changes during and after revascularization of the femoral arteries in humans. World J Surg 1983;7:646-52. Qvarfordt PG, Christenson JT, Eld6f B, Ohlin P. Intramuscular pressure after revascularization of the popliteal artery in severe ischemia. Br J Surg 1983;70:539-41. Pasch AR, Bishara RA, Lim LT, Meyer JP,Schuler IJ, Flanigan DP. Optimal limb salvage in penetrating civilian vascular tramna. J VASCSURG 1986;3:189-95. Jaggers RC, Feliciano DV, Mattox KL, Graham JM, DeBakey ME. Injury to popliteal vessels. Arch Surg 1982; 117:657-61. Wagner WH, Calkins ER, Weaver FA, Goodwin JA, Myles RA, Yellin AE. Blunt popliteal artery trauma: one hundred consecutive injuries. J VASCSURG 1988;7:736-43. Weaver FA, Rosenthal RE, Waterhouse G, Adkins RB. Combined skeletal and vascular injuries of the lower extremities. Am Surg 1984;50:189-97. Snyder WH III. Vascular injuries near the knee: an updated series mad overview of the problem. Surgery 1982;91:502-6.
28. Phifer TJ, GerlockAJ Jr, Vekovius WA~Pdch NM, McDonaM JC. Amputation risk factors in concomitant superficial femoral artery and vein injuries. Am Surg 1984;199:241-3. 29. Seller JG, Richardson JD. Amputation after extremi~ trauma. Am J Surg i986;152:260-4. 30. Adinolfi MF, Hardin WD Jr, O'ConneH RC, Kerstein MD. Amputation after vascular trauma in civilians. South Med J 1983;76:1241-3. 31. Kendrick J, Thompson BW, Read RC, Campbell GS, Walls RC, Casali RE. Arterial embolectomy in the leg: results in a referral hospital. Am J Surg 1981;I42:739-43. 32. Rolland PY, Baliga KP,Rice JC, Kerstein MD, Lower limb embolus: a near-lethal disease after age 75 years. South Med I 1989;82:178-81. 33. Blaisdell FW, Steele M, Allen RE. Management of acute lower extremiD, arterial ischemia due to embohsm and thrombosis. Surgery 1978;84:822-34.
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Columbia, S.C., and New Orleans, La. A retrospective review was undertaken of 127 lower extremity fasciotomies performed for compartment syndrome after acute ischemia and revascularization in 73 patients with vascular trauma and 49 patients with arterial occlusive disease. One hun&red twelve (88%) fasciotomies were performed early (at the time of revascularization); 15 (12%) were delayed because of late compartment syndrome diagnosis. Ninety-four (77%) patients had more than one accepted indication for fasciotomy. Double-incision fasciotomy was used in 98 (77%) extremities, single-incision fasciotomy was used in 19 (15%), and fasciotomy-fibulectomy was used in 10 (8%). Fasciotomies were dosed in 88 (69%) patients an average of 14 days after surgery. Seven patients needed multiple skin grafting procedures or myocutaneous flaps to close the wound; none compromised limb salvage. Five other patients had minor wound infections that resolved. Functional status returned to preoperative levels by the time of discharge from the hospital in 59 (48%) patients. Thirty-one (24%) patients had residual lower extremity disability related to delayed union of the fracture (five), chronic neuropathy (20), leg swelling (one), or ischemic nonhealing fasciotomy wounds (three); two patients had unrelated disabilities. Fourteen (11%) amputations were required for refractory limb ischemia; two (1.6%) were required for wet gangrene of the foot, which infected the fasciotomy site; the others had open noninfected incisions. Eighteen (15 %) patients died of cardiopulmonary failure or multisystem failure or both, without fasciotomy-related problems. Open fasciotomy for compartment syndrome after acute lower extremity ischemia and revascularization was associated with an increased risk of minor wound morbidity. However, limb loss and death resulted from persistent ischemia and underlying systemic disease processes or injuries, but not from open fasciotomy wound complications. (J VAsc SURG 1989;10:343-50.)
Postischemic compartment syndrome (CS) may follow lower extremity revascularization from either vascular trauma (VT) or arterial occlusive disease (AOD). l'z Fasciotomy is the accepted method of treatment for CS. ~3 Delay in performance of fasciotomy until after the clinical appearance of CS risks additional injury to nerve and muscle already compromised by ischemia? -3 Furthermore, sustained compartmental hypertension ultimately results in irFrom the Departmentsof Surgery'and Orthopaedics,cUniversity of South Carolina School of Medicine, Columbia, S,C., and the Departmentof Surgery,bTulaneUniversitySchoolof Medicine, New Orleans, La. Presented at the ThirteenthAnnualMeetingof the SouthernAssociation for Vascular Surgery, Key West, Fla., Jan. 25-28, 1989. Reprint requests: Daniel S. Rush, MD, Department of Surgery, Universityof South Carolina School of Medicine, Two Richland Medical Park, Suite 402, Columbia, SC 29203. 24/6/14338
reversible neurologic injury, myonecrosis, and the much-feared Volkrnann's ischemic contracture. 1"2 Traditional teaching has so emphasized the morbid consequences of inadequately treated CS that surgeons are usually unwilling to withhold fasciotomy in high-risk clinical situations. Unfortunately, no absolute clinical indications for fasciotomy exist? -3 To achieve therapeutic benefit, fasciotomy is often performed empirically or prophylacticaUy based on clinical assessment. 4,5 Recent technical developments for direct measurement of compartment pressure have not resolved this issue? 3'6 Debate continues regarding the significance of compartment pressure measurements and the need for fasciotomy.6-~° Early fasciotomy has been cited as a major factor contributing to limb salvage and preservation of fimction, especially in VT. 4'5'11"14 However, if injudiciously applied, fasciotomy may have its own mor343
journat of VASCULAR SURGERY
344. Rush tt al.
Table I. Clinical indications for lower extremity fasciotomy in 73 patients with vascular trauma and compartment syndrome Indication for fasciotomy
No. (%)
Popliteal injury Fracture or dislocation Peripheral neurologic deficit Prolonged ischemia (>6 hr) Extensive soft tissue injuq, Arteriovenous injury Distal leg swellingor edema Compamnent tenseness Preadmission hypotension
37 (51%) 37 (51%) 31 (42%) 29 (40%) 26 (36%) 23 (32%) 23 (32%)
Table II. Clinical indications for ~ower extremity fasdotomy in 49 patients with arterial occlusive disease and compartment syndrome Indicationfor fasciotomy
No. (%)
Prolonged ischemia (>6 hr) Peripheral neurologicdeficit Distal leg swellingor edema Compartment tenseness
46 (94%) 28 (57%) 12 (24%) 9 (18%)
15 (21%)
10 (14%)
bidity by exposure of susceptible muscle and deep tissues to the nosocomial environment. 6,8 Blaisdell 8 has taken issue with the concept of fasciotomy for revascularization syndrome and stated that it is rarely indicated. From this viewpoint, "liberal" use of fasciotomy may unnecessarily expose patients to an increased risk of complications from wound infection.8 Concern about infection associated with open fasciotomy incisions has been raised elsewhere. 1,5~6'15-17 Anecdotal reports indicate that infections at the fasciotomy site have resulted in leg amputation. 18,~9Patman and Thompson 4 reported that complications after fasciotomy were related to the underlying cause necessitating the procedure. Other authors report little or no additional morbidity and mortality associated with the aggressive use of fasciotomy in accepted situations.5,n, I4 Therefore the most controversial aspects of fasciotomy continue to be its clinical appropriateness and potential to cause morbidity. 7'17a9The literature provides little data to settle these controversies. Meaningful conclusions are difficult to derive from previous studies because patient inclusion criteria and reporting formats are highly variable. The purpose of this study was to evaluate the morbid consequences of open fasciotomy incisions in a large series of patients at high risk for CS after acute lower extremity ischemia and subsequent revascularization. PATIENTS
Clinical results of 73 patients with VT and 49 patients with AOD who required lower extremity fasciotomies for CS after ischemia and revascularization were retrospectively reviewed. All patients were treated during the past 10 years (i979 to 1989) and were identified from records of the vascular surgery services at the Tulane University School of Medicine, the University of South Carolina School of Medicine, and their affiliated hospitals.
All patients were at high risk to have acute postischemic CS. Each had a period of severe lower extremity ischemia documented by absence of palpable pedal pulses or Doppler arterial flow, and each required surgical intervention to restore regional perfusion. The decision to perform a fasciotomy was made by the senior surgeon based on a presumptive clinical diagnosis of established or impending CS. All patients had at least one accepted indication for fasciotomy, and 94 (77%) had multiple indications (Tables I and II). When measured, compartment pressures above 20 mm H g were considered supportive of the clinical diagnosis of CS; pressures above 40 mm H g confirmed the diagnosis of CS. 2 All patients were also at high risk to have fasciotomy wound problems. Only cases of open fasciotomy (open incision of skin, fascia, and epimysium) were included. Subcutaneous fhsciotomies or those closed perprimam intentionem were excluded. When the likelihood of CS was recognized before surgery or on restoration of arterial blood flow, fasciotomy was performed early (during the initial surgical procedure). Delayed fasciotomies were performed as a second procedure when CS appeared late or was unrecognized. Each patient was assigned at the time of discharge from the hospital to one of the four following clinical outcome categories: (1) functional--the patient returned to preadmission levels of activity, minor wound problems did not exclude patients from this category; (2) disabled--included patients with any dysfunction or major fasciotomy wound complications, although improvement may have occurred subsequent to discharge from the hospital; (3) amputee; (4) in-hospital deaths. Patients requiring bilateral fasciotomies were categorized according to the worst outcome, not the functional status of the better limb. TECHNICAL RESULTS Fasciotomy techniques were similar for both the patients with VT and those with AOD (Table III). The double-incision, four-compartment fasciotomy
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Fasciotomy--morbidity and mortality 345
Table III. Fasciotomy and wound treatment techniques in 76 fasciotomies for vascular trauma and 51 fasciotomies for arterial occlusive disease Techniques
Vascular ~ trauma (%)
Arterial~- occlusive disease (%)
58 (76%) 10 (13%) 8 (11%)
40 (78%) 9 (18%) 2 (4%)
25 34 2 2 8 5
19 8 0 4 6 14
Fasciotomy Double-incision fasciotomy Single-incision fasciotomy Fasciotomy-fibulectomy Wound treatment Delayed primary closure Split-thickness skin graft Myocutaneous flap Open at discharge Open at amputation Open at death
(33%) (44%) (3%) (3%) (11%) (6%)
(37%) (16%) (8%) (12%) (27%)
~+Seventy-threepatients had 76 fasciotomies for treatment of vascular trauma. ~-Forty-nine patients had 51 fasciotomies for treatment of arterial occlusive disease.
was the preferred method of decompression and was used for 98 (77%) extremities. Selective singlecompartment or single-incision, parafibular (fourcompartment) fasciotomy was used in 19 (15%) extremities. Fasciotomy-fibulectomy was used for 10 (8%) extremities early in the series. Open fasciotomy sites were surgically debrided as necessary and dressed frequently with sterile gauze bandages. Fasciotomy incisions were closed after resolution of muscle edema at an average of 14 days after surgery (range, 3 to 35 days) (Table III). Delayed primary closure of the wound was preferred and often performed at the bedside. Wound severity in the patients in the VT group resulted in a greater dependence on split-thickness skin grafts to close fasciotomy defects. Myocutaneous flaps were used in two patients with VT for complex tissue defects. Fasciotomy incisions were not closed in 30 (25%) patients (33 fasciotomies) bccause of intervcning amputation or death. Fivc (4%) patients (6 fasciotomies) were discharged from the hospital with open fasciotomies under treatment to allow secondary closure. The mean length of hospital stay was 30 days in both patients with VT and those with AOD. Clinical follow-up was available in 55 (61%) of 90 patients with salvaged limbs at an average of 18 months after discharge from the hospital (range 1 to 72 months); no late fasciotomy-related, limbthreatening problems have been identified. CLINICAL RESULTS Patients with vascular trauma Seventy patients with VT underwent unilateral lower extremity fasciotomies; three required bilateral fasciotomies. The mean age was 28 years (range, 10 to 68 years). Sixty-five patients were men and 8 were women (ratio, 8 : 1), Vascular injuries included five
(7%) stab wounds, 42 (57%) gunshot wounds, and 26 (36%) crushing injuries. The level of vascular injury involved the following arteries: one iliac, six femoral, 19 superficial femoral, 36 popliteal, and 11 tibial. The estimated ischemic time between injury and rcstoration of circulation averaged 7 hours (range, 1 to 33 hours). Transportation to the hospital was the major cause of late revascularization. Delay in treatment after admission to the hospital averaged 3 hours (range, 1 to 8 hours), which represented the time required for clinical and arteriographic evaluation and operating room availability. Direct arterial repair or venous repair or both were required in 53 (70%) vascular injuries. No direct vascular repair was required in 23 (30%) injuries. Reduction and stabilization of fractures or dislocations restored arterial flow in 13. The remaining 10 (mostly tibial arteries) had spontaneous resumption of arterial flow after cessation ofvasospasm or decompressive fasciotomy. Sixty-one (84%) patients had more than one accepted indication for lower extremity fasciotomy (Table I). Fasciotomy was performed during the initial surgical procedure in 71 (93%) cases. Five delayed fasciotomies were performed at an average of 16 hours (range, 2 to 48 hours). Direct compartment pressures were obtained in eight extremities, with a mean of 65 mm Hg (range, 20 to 110 mm Hg). Forty (55%) patients returned to functional stares. Thirty-five healed their fasciotomy incisions uneventfully by the time of discharge. Four fasciotomy wounds required multiple skin grafts and one required a myocutaneous flap. Twenty (27%) patients were dysfunctional at discharge from the hospital. Eight patients had chronic sensory neuropathy; five had wealmess from a motor neuropathy. Orthopedic complications included chronic osteomyelitis or nonunion of the fracture in
346
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Table IV. Causes of amputation after open lower extremity fasciotomy in eight of 73 patients with vascular trauma Fracture
Amputation (days)
Injury
Vessel
SGW GSW SGW
SFA-PFV SFA SFA-SFV
Femur
AKA (5) BKA (23) AKA (10)
SGW MVA MVA MVA MVA
SFA-SFV POP Iliac POP POP
Tibia-fibula Pelvis Tibia-fibula Tibia-fibula
AKA (14) AKA (4) MZA (24) BKA (2) BKA (2)
Indication for amputation Ischemic myonecrosis Ichemic foot necrosis Ischemia, wet foot gangrene with secondary infection of the open fasciotomy Ischemic myonecrosis Foot gas gangrene Ischemic myonecrosis Refractory ischemia Ischemia, crashed leg
SGW, Shotgun wound, GSW, gunshot wound; MVA, motor vehicle accident; SFV, superficial femoral artery.; PFV, profunda femoris vein; SFV, superficial femoral vein; POP, popliteal artery; Days, number of postoperative days before amputation; AKA, above-knee amputation; BKA, below-knee amputation.
five patients. One patient with a severe head injury and another with paraplegia from spinal cord injury were classified as disabled; neither had fasciotomyrelated impairment. Four patients classified as dysfunctional had recurrent superficial cellulitis; one required multiple skin graftings and a myocutaneous flap. These wound problems resolved and were not associated with residual morbidity. Eight (11%) patients required amputation; three amputations were performed below the knee and five above the knee (Table IV). Four amputations followed penetrating superficial femoral artery trauma accompanied by extensive soft tissue damage; venous injury was present in three and the femur fractured in one. The other four patients requiring amputation experienced trauma as a result of vehicular accidents and had extensive soft tissue damage; two amputations followed blunt popliteal artery trauma accompanied by tibia-fibula fractures, and the other two resulted from severe injuries that crushed the lower extremities. The need for early amputation (within 5 days of injury) was evident in four limbs and was performed before a fasciotomy wound problem could develop. The remaining four limbs were amputated from 10 to 24 days after initial treatment without fasciotomy wound complications. Seven amputations healed primarily; one below-knee amputation required revision. One patient with crushed legs underwent bilateral four-compartment fasciotomies; the nonamputated extremity was salvaged by popliteal artery repair and remained functional. In all cases amputation resulted from persistent or refractory limb ischemia combined with osseousmyocutaneous injury-. In one patient with an above-knee amputation, an ischemic foot infection with wet gangrene
progressed to secondarily involve the open fasciotomy site. No primary fasciotomy wound infections resulted in amputation. Five (7%) patients died; all had massive crushing injuries. As a group they were older (mean age, 44 years; range, 29 to 68 years). Three died of acute cardiac complications within 3 days of hospitalization; their open fasciotomy wounds were clean. Two experienced multisystem organ failure and died after surgery at 65 and 94 days, respectively. The fasciotomy incision healed in the first patient. The second patient underwent above-knee amputation for refractory limb ischemia 2 months before death; the fasciotomy site at that time was still open but not infected. No deaths from VT could be attributed to fasciotomy wound complications. Patients with arterial occlusive disease
The 49 patients with AOD underwent 47 unilateral and two bilateral lower extremity fasciotomies. Their average age was 61 years (range, 35 to 78 years); 33 were men and 16 were women (ratio, 2:1). The estimated ischemia time before revascularization averaged 22 hours (range, 2 hours to greater than 1 week). Causes of the ischemic event included 19 (39%) patients with arterial embolism, 10 (20%) with arterial thrombosis, and 18 (37%) with graft thrombosis. Two (4%) patients had prolonged ischemia (greater than 10 hours) during complicated aortic reconstructions: one reconstruction followed an elective suprarcnal aortic aneurysmectomy, which also required femoral-popliteal bypass grafting for acute intraoperative limb ischemia; the other following a complex extraanatomic reconstruo tion for a ruptured infected aortic graft. Direct lower
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Fasciotomy--morbidity and mortality 347
Table V. Causes of amputation after open lower extremity fasciotomy in six of 49 patients with arterial occlusive disease Cause
Amputation (days)
Thromboembolism Thromboembolism
AKA (3) AKA (30)
Arterial thrombosis Graft thrombosis Graft thrombosis Graft thrombosis
AKA (21) AKA (2) BKA (8) BKA (34)
Indicationfor amputation Recurrent arterial thrombosis, refractory ischemia Persistent ischemia, wet foot gangrene with secondary infection of the open fasciotomy Ischemic myonecrosis Referactory ischemia Ischemic myonecrosis Refractory ischem~a
AKA, Above-knee amputation; BICA, below-knee amputation; days, number of postoperative days before amputation.
Table VI. Causes of death after open lower extremity fasciotomy in 13 of 49 patients with arterial occlusive disease Cause Thromboembolism Thromboembolism Thromboembolism Arterial thrombosis Arterial thrombosis Prolonged operation (> 10 hr) Thromboembolism Thromboembolism Thromboembofism Arterial thrombosis Arterial thrombosis Graft thrombosis Graft thrombosis
Amputation (days)
Death (days)
AKA (4) AKA (10) AKA (12) AKA (4) M ~ (15) AKA (3) AKA (15)
Multisystem organ failure (4) Cardiac (5) Multisystem organ failure (6) Cardiac (1) Cardiac (3) Multisystem organ failure (3) Pulmonary embofism (41) Cardiac (26) Sepsis (47) Cardiac (13) Cardiac (43) Multisystem organ failure (96) Sepsis (45)
Days, Number of postoperative days before amputation or death; AKA, above-knee amputation.
extremity revascularization was required for all 49 patients with AOD. Thrombectomy or embolectomy were performed in 36 (73%) patients, and arterial bypass grafting was performed in 13 (27%). Clinical indications for fasciotomy in the patients in the AOD group are listed in Table II. Thirty-three (67%) patients had more than one accepted indication for fasciotomy. Thirty-nine (76%) fasciotomies were performed at the time of the revascularization procedure. Delayed fasciotomies were performed in 12 (23%) patients at an average of 32 hours (range, 11 to 72 hours) after revascularization. Compartment pressures were measured in three patients and averaged 55 nun Hg (range, 40 to 65 m m Hg), all of which confirmed the clinical impression. Nineteen (39%) patients returned to their preoperative functional status. Two patients had minor fasciotomy wound problems; one required multiple skin graftings and the other had wound drainage that resolved with topical care. Eleven (22%) patients were chronically disabled; three had residual ischemic sensory neuropathy, four
had motor neuropathy, and one had leg swelling. Three patients had nonhealing fasciotomy incisions attributed to chronic ischemia. Two required belowknec amputations for rest pain (6 and I8 months later, respectively) despite subsequent bypass grafting attempts; their fasciotomy wounds were clean but did not heal. The last patient has remained ambulatory with fasciotomy wounds that are still healing after 2 years of follow-up. Six (12%) patients with AOD were discharged from the hospital with amputations; two were below the knee and four above the knee (Table V). All amputations were performed for refractory ischemia with myonecrosis. One patient with wet gangrene of the foot had infection of the fasciotomy site as a result and required above-knee amputation. Three amputations were performed early (within the first week of hospitalization) and the remaining two at 21 to 34 days; respectively; no fasciotomy wounds had clinical evidence of infection. Thirteen (27%) patients with AOD died (Table VI). The cause of death was cardiopulmonary in
348
Journal of VASCULAR SURGERY
Rush et M.
seven patients and sepsis/multisystem organ failure in six. Six patients died within the first week of hospitalization, and all had noninfected open fasiotomy sites. Seven patients underwent early above-knee amputations for refractory limb ischemia and died weeks or months later. No deaths could be attributed to fasciotomy wound complications.
The potential morbidity of lower extremity fasciotomy has been a subject of considerable recent debate. ~62° At issue is whether the potential limbsalvaging benefit of fasciotomy in the treatment of CS is outweighed by the possible infectious consequences of open leg wounds in patients already at risk for limb loss and death. We sought to resolve this issue by studying the postoperative morbidity and mortality of a large series of patients with VT and AOD who were at high risk because they had open fasciotomy incisions. All patients in this study had clinical evidence of CS and met or exceeded standard surgical indications for fasciotomy previously reported. 2'4'sa4Additionally, all patients had a period of acute lower cxtremity ischemia, which required surgical intervention to reestablish circulation. The aggressive use of fasciotomy in conjunction with a rcvascularization procedure remains controversial. ~'6-8'~7 An aura of urgency surrounds fasciotomy decision making, since delay may potentiate the risk of limb dysfunction from neuromuscular compromise. ~,2a6 Furthermore, patients undergoing vascular surgery may be at risk for the late appearance of a CS as a result of a reperfusion phenomenon? Some authors have stated that the diagnosis of CS can reliably be made from preoperative signs and symptoms. 4'~'n'14'2° In our cxperience clinical manifestations of an impending CS are nonspecific and frequently indistinguishable from the signs and symptoms of extensive limb trauma or severe limbthreatening arterial insufficiency. Given these uncertainties, fasciotomy is often used empirically or prophylactically when there is high risk for CS. ~- Aggressive use of fasciotomy can be justified under such circumstances only if its consequences have an acceptably low morbidity and mortality. Unfommately, the use ofintercompartment pressure monitoring has not darified the indications for fasciotomy. 1,2,6,9,11 Questions remain concerning the variability of human tolerances to compartment hypertension and the need for surgical decompression. v3 For these reasons direct compartment pres-
sure measurement has thus far fotmd limited acceptance in either elective or emergency vascular situations, s,~,~3,14'2°Measurable increases in lower extremity compartment pressures occur after elective aortic and infrainguinal arterial reconstructions, yet the need for fasciotomy after routine vascular operations is rare. <6,m'21,= Only one patient in our series (less than I%) needed fasciotomy after an elective operation. The need for fasciotomy was clinically apparent in all of our patients and supported by compartment pressure determination in all cases measured. In our opinion clinical context, accepted indications, and compartment pressure measurement when necessary are the best determinants for fasciotomy in patients with VT and AOD. Fasciotomy has been associated with an increased risk of wound problems. ~ Fortunately, superficial wound infections in our series were minor and resolved with proper attention. Chronic, nonhealing fasciotomy wounds remained stable for long time periods without infection in three of our patients with AOD. Anecdotal reports indicate that fasciotomy wound infections can result in leg amputation, although contributing factors such as persistent ischemia or distal gangrenous changes were not discussed. 18,19 Spread of infection from the foot to the fasciotomy site contributed to above-knee amputation in two of our patients. The 12% incidence of amputation in our patients is comparable to amputation rates reported elsewhere in patients undergoing vascular surgery who require fasciotomy.4,s'14 No limb loss was attributable to morbidity related to primary open fasciotomy in our patients, Persistent or refractory limb-threatening ischemia was the major factor responsible for amputation in this and other studies. 4,s,14,29 Fasciotomy has been performed as an adjunctive procedure in 19% to 80% of reported patients with VT undergoing lower extremity arterial repair. 14,20,23-28Patients having popliteal, arteriovenous, and blunt lower extremity trauma require fasciotomy more frequently than do patients with isolated, penetrating vascular injuries, n-la,24,2s Although they had open fasciotomies, no amputations or deaths occurred in any of our patients with isolated, penetrating trauma, including popliteal injuries. The severity of associated injury (including the extent of soft tissue damage, fractures, and duration of ischemia) continues to be the major factor contributing to limb loss and death in patients with lower extremity VW. 1I'14'23'24"26 All amputations in our patients
~References 4, 5, 11, 12, 14, 17.
~References 6, 8, 16, 17, 19, 20.
DISCUSSION
Volume 10 Number 3 September 1989
with VT were associated with ischemia and complex injuries and were not related to open fasciotomy complications. Likewise, all posttraumatic deaths in our series followed crushing injuries. Death occurred either early before fasciotomy complications could develop or long after amputation had been performed for refractory ischemia. Successful treatment of injuries in which lower extremities were crushed remains an unsolved clinical problem carrying high rates of morbidity and mortality irrespective of the use of fasciotomy. 2429 Early amputation of severely injured limbs instead of attempted limb salvage has been suggested as a means of increasing patient survival. 29,30 Information regarding the outcome of fasciotomy in patients revascularized after acute ischemia from AOD is somewhat sparse. <5"31Our data suggest that lower extremity fasciotomy adds little additional risk of morbidity beyond that of the attempted revascularization for acute limb-threatening ischemia itself. 31,32 Blaisdell et al. 33 reported a 7.5% mortality and two-thirds limb-salvage rate in patients with acute thromboembolism treated by systemic heparinization, selective revascularization, and early amputation when needed; the use of fasciotomy was specifically avoided. The 27% mortality in our patients with AOD was similar to mortality rates from other series reviewed in the above study. 33 Considering the source of ischemia and attendant medical problems, the risk of amputation and death in patients at high risk appears related to the primary decision for surgical revascularization, rather than to the performance of fasciotomy afterward, a2"aa In this series of patients undergoing vascular surgery who had clinical evidence of CS, open lower extremity fasciotomies were performed with little additional morbidity and mortality. Fasciotomy remains an effective procedure to maximize postischemic tissue viability and fimction in the presence of compartment hypertension. Open fasciotomy did subject extremities to an increased risk of wound problems. In our experience, superficial wound complications were minor and resolved with proper attention. Nonhealing fasciotomy incisions were maintained without risk of serious infection and did not prevent subsequent attempts at revascularization. The major enemy of limb salvage after fasciotomy was ischemia. Deaths resulted from cardiopulmonary or multisystem organ failure and occurred either early before development of fasciotomy problems or long after amputation had been performed. In conclusion, the reputed morbidity and mortality of fasciotomy are the result of refractory ischemia and underlying
Fasciotomy--morbidity and mortality 349
medical problems or associated injuries and not the • procedure itself. Fasciotomy should not be withheld when clinically indicated for fear that this effective ancillary procedure will adversely affect limb salvage and patient survival. The authors express their appreciation to Pam N o i ~ o for manuscript preparation.
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