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Recurrent Lower-Extremity Compartment Syndrome after Four-Compartment Fasciotomy Secondary to Acute Limb Ischemia
Case Report Recurrent Lower-Extremity Compartment Syndrome after Four-Compartment Fasciotomy Secondary to Acute Limb Ischemia Ashwini P. Kerkar, Alik Farber, Jeffrey A. Kalish, and Jeffrey J. Siracuse, Boston, Massachusetts
Lower-extremity compartment syndrome is a limb-threatening event necessitating emergent treatment using fasciotomy. Recurrent compartment syndrome is rare and has only been reported after trauma and in conjunction with underlying connective tissue disorders. In this report, we present a case of recurrent lower-extremity compartment syndrome caused by ischemiaereperfusion injury, in a patient previously treated with adequate 4-compartment fasciotomies. As such, this is the first reported case of recurrent compartment syndrome in the setting of ischemiaereperfusion injury that required treatment with 4-compartment fasciotomies on both occasions. This case demonstrates that fasciotomy is not protective against the development of recurrent compartment syndrome due to ischemiaereperfusion injury and that patients at high risk require monitoring.
Lowereextremity compartment syndrome can occur after reperfusion of a limb when it has been exposed to prolonged ischemia. Diagnosis is usually made using history and physical examination, with compartment pressures measured in an adjunctive fashion in cases where the clinical examination is equivocal.1 Definitive treatment is an expeditious fasciotomy of the affected compartments and assessment of the muscle for viability. Timely diagnosis and treatment are critical in preventing permanent disability.2,3 Causes of compartment syndrome can be classified as either those that decrease the volumetric size of the compartment (bandages, casts, burns, or
Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, MA. Correspondence to: Jeffrey J. Siracuse, MD, Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Surgery, 732 Harrison Avenue, Boston, MA 02118, USA; E-mail: [email protected] Ann Vasc Surg 2015; -: 1–2 http://dx.doi.org/10.1016/j.avsg.2015.06.092 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: February 23, 2015; manuscript accepted: June 21, 2015; published online: ---.
tight fascia closure) or those that increase the size of the compartment (edema due to injury, reperfusion, spasm, and hemorrhage).4 Recurrent compartment syndrome after prior fasciotomy is rare and has not been reported for compartment syndrome secondary to ischemia.5e7 Published cases involve patients presenting with a connective tissue disorder, viral myositis, and trauma.5e8 Recurrent compartment syndrome has only been reported a few times and each case has been unique. Clinicians may be unaware that this can occur and may be falsely reassured by a prior fasciotomy. Here, we present a case of recurrent compartment syndrome secondary to ischemiaereperfusion injury, requiring repeat 4-compartment fasciotomies within the same year.
CASE REPORT A 54-year-old man with a history of smoking and peripheral vascular disease presented to Boston Medical Center with severe pain in his right lower extremity. On examination, the extremity was found to be cool, with loss of both sensory and motor function of the foot. Eight months prior, he had presented with acute limb ischemia of the 1
2 Case Report
same extremity, and at that time underwent open thrombectomy of the superficial femoral artery, calf 4-compartment fasciotomies, and patch angioplasty of the common femoral artery. The fasciotomies were performed using a lateral and medial calf incision; the anterior, lateral, superficial posterior and deep posterior compartments were widely opened using long Metzenbaum scissors. Skin and fasciotomy incisions spanned from 5-cm distal to the patella proximally, to 3 cm above the malleoli distally. The skin was left open. After 5 days, the lateral incision was closed primarily, and the medial incision required split-thickness skin grafting. He had regained all function of the limb at the time and was discharged home. During this current presentation, an angiogram showed occluded popliteal, peroneal, anterior tibial, and posterior tibial arteries. Tissue Plasminogen Activator was administered through a lysis catheter overnight. The next day an angiogram showed that inline flow to the foot was restored. Balloon angioplasty of the popliteal artery was performed for stenosis. Overnight, the patient developed severe calf pain. Pressures in the 4 leg compartments were measured to be 54, 45, 53 and 67 mm Hg in the anterior, lateral, superficial posterior and deep posterior compartments, respectively. The patient was taken urgently to the operating room where a 4-compartment fasciotomy was performed through previous sites. The muscles were edematous, but viable. After fasciotomy, his pain improved, and his foot regained full function. A vacuum assisted closure device was placed to aid in closure, and the incisions were covered with split-thickness skin grafts 15 days later. The patient was then discharged home and has recovered well.
DISCUSSION In this case, both presentations of compartment syndrome were related to reperfusion injury after a period of ischemia. The first occurred after the leg was revascularized using open thrombectomy whereas the second occurred after endovascular revascularization using percutaneous thrombolysis. Reperfusion leads to compartment syndrome through the introduction of free oxygen radicals, neutrophils and endothelial factors that were collected during the period of ischemia.9 These interact with lipids on cell membranes leading to an increase in capillary permeability.10 This results in edema and increased pressure in the compartment. If pressures rise above 35 mm Hg then the injuries may become irreversible.1 A case of recurrent compartment syndrome, secondary to ischemiaereperfusion injury, has not been previously described. It has, however, been described in patients with underlying connective tissue disease and in cases secondary to trauma. A
Annals of Vascular Surgery
patient with an unclassified connective tissue disorder that displayed some features of EhlerseDanlos syndrome was reported to have had an estimated 60e70 fasciotomies performed within a span of 10 years.7 In another case, a 34-year-old man developed compartment syndrome, requiring lateral compartment fasciotomies of the same leg, twice in the same year, 2 years after he had a 4compartment fasciotomy for acute compartment secondary to a closed injury of the leg. In both instances of his recurrent lateral compartment syndrome, no cause was identified.3 The only reported repeat calf 4-compartment fasciotomy is in a female soccer player.6 Her first fasciotomy was for an acute episode of exerciseinduced compartment syndrome, and her second was for compartment syndrome secondary to intramedullary nailing of a broken tibia.6 In this case, the patient suffered a repeat compartment syndrome although his calf fascia has been widely opened previously and 1 of the 2 skin incisions required closure with a skin graft. A secondary compartment developed despite these anatomic changes suggesting that a compartment syndrome can recur after ischemiaereperfusion when edematous muscle can be constrained by skin alone. This has been observed in other types of compartment syndrome, with skin closure only, such as abdominal compartment syndrome.3 Recurrent compartment syndrome is rare, with no cases reported due ischemiaereperfusion injury and only 1 case reported requiring repeat 4compartment fasciotomies. Our case demonstrates that prior fasciotomy of all 4 compartments of the leg is not protective for repeat compartment syndrome for any compartments. Patients with subsequent ischemic events have to be examined with a high level of suspicion if they have symptoms consistent with compartment syndrome. In conclusion, this is the first reported case to demonstrate that recurrent compartment syndrome can occur in cases with ischemiaereperfusion injury. Clinicians need to have a high level of suspicion for compartment syndrome in the appropriate clinical situation even if the patient has had a prior 4-compartment fasciotomy. REFERENCES 1. Arat o E, K€ urthy M, Sı´nay L, et al. Pathology and diagnostic options of lower limb compartment syndrome. Clin Hemorheol Microcirc 2009;41:1e8. 2. Farber A, Tan T, Hamburg NM, et al. Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: a review of the National Trauma Data Bank. Injury 2012;43:1486e91.
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No.
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2015
3. Tremblay LN, Feliciano DV, Schmidt J, et al. Skin only or silo closure in the critically ill patient with an open abdomen. Am J Surg 2001;182:670e5. 4. Masquelet AC. Acute compartment syndrome of the leg: pressure measurement and fasciotomy. Orthop Traumatol Surg Res 2010;96:913e7. 5. Chokshi BV, Lee S, Wolfe SW. Recurrent compartment syndrome of the hand: a case report. J Hand Surg Am 1998;23: 66e9. 6. Gaskill TR, Zura R, Aldridge JM III. Recurrent compartment syndrome: 2 cases and a review of the literature. Am J Orthop (Belle Mead NJ) 2010;39:141e3.
Case Report 3
7. Barajas BD, Sun A, Rimoin DL, et al. Recurrent compartment syndrome in a patient with clinical features of a connective tissue disorder. Am J Med Genet A 2013;161A: 1442e6. 8. Slobogean BL, Reilly CW, Alvarez CM. Recurrent viralinduced compartment syndrome. Pediatr Emerg Care 2011;27:660e2. 9. Widgerow AD. Ischemia-reperfusion injury: influencing the microcirculatory and cellular environment. Ann Plast Surg 2014;72:253e60. 10. Gourgiotis S, Villias C, Germanos S, et al. Acute limb compartment syndrome: a review. J Surg Educ 2007;64:178e86.
Lower-extremity compartment syndrome is a limb-threatening event necessitating emergent treatment using fasciotomy. Recurrent compartment syndrome is rare and has only been reported after trauma and in conjunction with underlying connective tissue disorders. In this report, we present a case of recurrent lower-extremity compartment syndrome caused by ischemiaereperfusion injury, in a patient previously treated with adequate 4-compartment fasciotomies. As such, this is the first reported case of recurrent compartment syndrome in the setting of ischemiaereperfusion injury that required treatment with 4-compartment fasciotomies on both occasions. This case demonstrates that fasciotomy is not protective against the development of recurrent compartment syndrome due to ischemiaereperfusion injury and that patients at high risk require monitoring.
Lowereextremity compartment syndrome can occur after reperfusion of a limb when it has been exposed to prolonged ischemia. Diagnosis is usually made using history and physical examination, with compartment pressures measured in an adjunctive fashion in cases where the clinical examination is equivocal.1 Definitive treatment is an expeditious fasciotomy of the affected compartments and assessment of the muscle for viability. Timely diagnosis and treatment are critical in preventing permanent disability.2,3 Causes of compartment syndrome can be classified as either those that decrease the volumetric size of the compartment (bandages, casts, burns, or
Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, MA. Correspondence to: Jeffrey J. Siracuse, MD, Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Surgery, 732 Harrison Avenue, Boston, MA 02118, USA; E-mail: [email protected] Ann Vasc Surg 2015; -: 1–2 http://dx.doi.org/10.1016/j.avsg.2015.06.092 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: February 23, 2015; manuscript accepted: June 21, 2015; published online: ---.
tight fascia closure) or those that increase the size of the compartment (edema due to injury, reperfusion, spasm, and hemorrhage).4 Recurrent compartment syndrome after prior fasciotomy is rare and has not been reported for compartment syndrome secondary to ischemia.5e7 Published cases involve patients presenting with a connective tissue disorder, viral myositis, and trauma.5e8 Recurrent compartment syndrome has only been reported a few times and each case has been unique. Clinicians may be unaware that this can occur and may be falsely reassured by a prior fasciotomy. Here, we present a case of recurrent compartment syndrome secondary to ischemiaereperfusion injury, requiring repeat 4-compartment fasciotomies within the same year.
CASE REPORT A 54-year-old man with a history of smoking and peripheral vascular disease presented to Boston Medical Center with severe pain in his right lower extremity. On examination, the extremity was found to be cool, with loss of both sensory and motor function of the foot. Eight months prior, he had presented with acute limb ischemia of the 1
2 Case Report
same extremity, and at that time underwent open thrombectomy of the superficial femoral artery, calf 4-compartment fasciotomies, and patch angioplasty of the common femoral artery. The fasciotomies were performed using a lateral and medial calf incision; the anterior, lateral, superficial posterior and deep posterior compartments were widely opened using long Metzenbaum scissors. Skin and fasciotomy incisions spanned from 5-cm distal to the patella proximally, to 3 cm above the malleoli distally. The skin was left open. After 5 days, the lateral incision was closed primarily, and the medial incision required split-thickness skin grafting. He had regained all function of the limb at the time and was discharged home. During this current presentation, an angiogram showed occluded popliteal, peroneal, anterior tibial, and posterior tibial arteries. Tissue Plasminogen Activator was administered through a lysis catheter overnight. The next day an angiogram showed that inline flow to the foot was restored. Balloon angioplasty of the popliteal artery was performed for stenosis. Overnight, the patient developed severe calf pain. Pressures in the 4 leg compartments were measured to be 54, 45, 53 and 67 mm Hg in the anterior, lateral, superficial posterior and deep posterior compartments, respectively. The patient was taken urgently to the operating room where a 4-compartment fasciotomy was performed through previous sites. The muscles were edematous, but viable. After fasciotomy, his pain improved, and his foot regained full function. A vacuum assisted closure device was placed to aid in closure, and the incisions were covered with split-thickness skin grafts 15 days later. The patient was then discharged home and has recovered well.
DISCUSSION In this case, both presentations of compartment syndrome were related to reperfusion injury after a period of ischemia. The first occurred after the leg was revascularized using open thrombectomy whereas the second occurred after endovascular revascularization using percutaneous thrombolysis. Reperfusion leads to compartment syndrome through the introduction of free oxygen radicals, neutrophils and endothelial factors that were collected during the period of ischemia.9 These interact with lipids on cell membranes leading to an increase in capillary permeability.10 This results in edema and increased pressure in the compartment. If pressures rise above 35 mm Hg then the injuries may become irreversible.1 A case of recurrent compartment syndrome, secondary to ischemiaereperfusion injury, has not been previously described. It has, however, been described in patients with underlying connective tissue disease and in cases secondary to trauma. A
Annals of Vascular Surgery
patient with an unclassified connective tissue disorder that displayed some features of EhlerseDanlos syndrome was reported to have had an estimated 60e70 fasciotomies performed within a span of 10 years.7 In another case, a 34-year-old man developed compartment syndrome, requiring lateral compartment fasciotomies of the same leg, twice in the same year, 2 years after he had a 4compartment fasciotomy for acute compartment secondary to a closed injury of the leg. In both instances of his recurrent lateral compartment syndrome, no cause was identified.3 The only reported repeat calf 4-compartment fasciotomy is in a female soccer player.6 Her first fasciotomy was for an acute episode of exerciseinduced compartment syndrome, and her second was for compartment syndrome secondary to intramedullary nailing of a broken tibia.6 In this case, the patient suffered a repeat compartment syndrome although his calf fascia has been widely opened previously and 1 of the 2 skin incisions required closure with a skin graft. A secondary compartment developed despite these anatomic changes suggesting that a compartment syndrome can recur after ischemiaereperfusion when edematous muscle can be constrained by skin alone. This has been observed in other types of compartment syndrome, with skin closure only, such as abdominal compartment syndrome.3 Recurrent compartment syndrome is rare, with no cases reported due ischemiaereperfusion injury and only 1 case reported requiring repeat 4compartment fasciotomies. Our case demonstrates that prior fasciotomy of all 4 compartments of the leg is not protective for repeat compartment syndrome for any compartments. Patients with subsequent ischemic events have to be examined with a high level of suspicion if they have symptoms consistent with compartment syndrome. In conclusion, this is the first reported case to demonstrate that recurrent compartment syndrome can occur in cases with ischemiaereperfusion injury. Clinicians need to have a high level of suspicion for compartment syndrome in the appropriate clinical situation even if the patient has had a prior 4-compartment fasciotomy. REFERENCES 1. Arat o E, K€ urthy M, Sı´nay L, et al. Pathology and diagnostic options of lower limb compartment syndrome. Clin Hemorheol Microcirc 2009;41:1e8. 2. Farber A, Tan T, Hamburg NM, et al. Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: a review of the National Trauma Data Bank. Injury 2012;43:1486e91.
Vol.
-,
No.
-, -
2015
3. Tremblay LN, Feliciano DV, Schmidt J, et al. Skin only or silo closure in the critically ill patient with an open abdomen. Am J Surg 2001;182:670e5. 4. Masquelet AC. Acute compartment syndrome of the leg: pressure measurement and fasciotomy. Orthop Traumatol Surg Res 2010;96:913e7. 5. Chokshi BV, Lee S, Wolfe SW. Recurrent compartment syndrome of the hand: a case report. J Hand Surg Am 1998;23: 66e9. 6. Gaskill TR, Zura R, Aldridge JM III. Recurrent compartment syndrome: 2 cases and a review of the literature. Am J Orthop (Belle Mead NJ) 2010;39:141e3.
Case Report 3
7. Barajas BD, Sun A, Rimoin DL, et al. Recurrent compartment syndrome in a patient with clinical features of a connective tissue disorder. Am J Med Genet A 2013;161A: 1442e6. 8. Slobogean BL, Reilly CW, Alvarez CM. Recurrent viralinduced compartment syndrome. Pediatr Emerg Care 2011;27:660e2. 9. Widgerow AD. Ischemia-reperfusion injury: influencing the microcirculatory and cellular environment. Ann Plast Surg 2014;72:253e60. 10. Gourgiotis S, Villias C, Germanos S, et al. Acute limb compartment syndrome: a review. J Surg Educ 2007;64:178e86.