Background: Clinical case series have indicated that 1 or 2-compartment decompression of the anterior or lateral leg may be sufficient for release, but, currently, no cadaveric model has verified that approach. The objective of this study was to investigate the functional relationship between compartments by alternating sequences of infusion and fasciotomy release.
Methods: This study utilized multicompartment sequential pressurization with simultaneous monitoring by continuous pressure sensors to model compartment syndrome in a human cadaver leg. Subsequent sequential release of compartments and continuous streaming of pressure readings permitted unique insights.
Results: A leg model allowed the examination of pressure changes in all 4 compartments as treated with sequential fasciotomies. The successful modeling of lower-leg pressures consistent with compartment syndrome showed that discrepancies relative to accepted concepts were seen when the deep posterior compartment was pressurized in isolation. Also, the release of 1 of the 2 of either the anterior or lateral compartments seems to be sufficient for decompression to acceptable pressure levels.
Conclusions: The deep posterior compartment does not appear to be completely discrete and instead follows the pressurization curve of the posterior muscle group. This indicates that release of the deep posterior compartment may not be needed in all acute compartment syndrome scenarios.
Clinical Relevance: Surgical techniques can be modified for treatment of acute compartment syndrome to avoid large scar lengths, deep dissection, and multiple exposures that could improve patient outcomes.
Background: There remain gaps in knowledge regarding the pathophysiology, initial diagnosis, treatment, and outcome of acute compartment syndrome (ACS). Most reported clinical outcomes are from smaller studies of heterogeneous patients. For a disease associated with a financial burden to society that represents billions of dollars worldwide, the literature does not currently establish baseline diagnostic parameters and risk factors that may serve to predict treatment and outcomes.
Methods: This study looks at a very large cohort of trauma patients obtained from four recent years of the Trauma Quality Programs data from the American College of Surgeons. From 3,924,127 trauma cases – 203,500 patients with tibial fractures were identified and their records examined for demographic information, potential risk factors for compartment syndrome, an associated coded diagnosis of muscle necrosis, and presence of other outcomes associated with compartment syndrome. A recurrent multiple logistic regression model was used to identify factors predictive of fasciotomy. The results were compared to the reported results from the literature to validate the findings.
Results: The rate of fasciotomy treatment for ACS was 4.3% in the cohort of identified patients. The analysis identified several clinical predictors of fasciotomy. Proximal and midshaft tibial fractures (P <0.0001) showed highest increases in the likelihood of ACS. Open fractures were twice (O.R [2.20–2.42]) as likely to have ACS. Having a complex fracture (P<0.0001), substance abuse disorder (P<0.0002), cirrhosis (P = 0.002) or smoking (P<0.0051) all increased the likelihood of ACS. Age decreased the likelihood by 1% per year (OR= [0.99–0.993]). Crush and penetrating injuries showed an important increase in the likelihood of ACS (O.R of 1.83 and 1.37 respectively). Additionally, sex, BMI, cirrhosis, tobacco smoking and fracture pattern as defined by OTA group and OTA subgroup had predictive value on actual myonecrosis. Fasciotomies for open tibial fractures were more likely to uncover significant muscle necrosis compared to closed fractures. Amputation resulted after 5.4% of fasciotomies.
Conclusion: This big data approach shows us that ACS is primarily linked to the extent of soft tissue damage. However, newfound effect of some comorbidities like cirrhosis and hypertension on the risk of ACS imply other mechanisms.
Introduction: Acute compartment syndrome (ACS) is a well-recognized and common emergency. Undiagnosed ACS leads to muscle necrosis, limb contracture, intractable pain, and may even result in amputation.
Methods: Three devices (Synthes, Stryker, and MY01) were compared in a pre-clinical rat abdominal compartment syndrome simulation. Simultaneous measurements of intracompartmental pressures allowed concurrent comparison among all devices.
Results: Large variations from the reference values are seen with the Synthes and Stryker devices. Variances are large in these two devices even under ideal conditions. The MY01 device was the truest indicator of reference pressure in this ACS model (over 600% more accurate).
Conclusions: The MY01 device was the most accurate device in tracking pressure changes in this rat model of abdominal compartment syndrome.
Objective: To evaluate whether published studies support basing the diagnosis of compartment syndrome of the lower leg on clinical findings, intracompartmental pressure (ICP) monitoring, or both.
Data sources: A PubMed/MEDLINE, Web of Science, and Embase search of the English literature from 1966 to February 2022 was performed. This used “lower extremity” or “leg” or “tibia” and “compartment syndrome” and “pressure” as the subjects. A manual search of the bibliographies was performed and cross-referenced with those used to formulate the American Academy of Orthopaedic Surgeons clinical practice guidelines.
Study selection and extraction: Inclusion criteria were traumatic tibia injuries, presence of data to calculate the sensitivity, specificity, positive and negative predictive values of clinical findings and/or pressure monitoring, and the presence or absence of compartment syndrome as the outcome. A total of 2906 full articles were found, of which 63 were deemed relevant for a detailed review. Seven studies met all eligibility criteria.
Data synthesis: The likelihood ratio form of Bayes theorem was used to assess the discriminatory ability of the clinical findings and ICP monitoring as tests for compartment syndrome. The predictive value for diagnosing acute compartment syndrome was 21% and 29% for the clinical signs and ICP, respectively. When combining both, the probability reached 68%.
Conclusions: The use of ICP monitoring may be helpful when combined with a clinical assessment to increase the sensitivity and specificity of the overall diagnosis. Previously accepted individual inference values should be revisited with new prospective studies to further characterize the statistical value of each clinical finding.
Level of evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Purpose: To investigate the incidence, risk factors, demographics, and association in the analysis of acute compartment syndrome of the forearm.
Methods: A retrospective review of the Trauma Quality Programs data from the American College of Surgeons. This includes 120,556 patients who sustained a forearm fracture from 2015 to 2018 (4 calendar years). The main outcome measurements are fasciotomies performed after sustaining a forearm fracture, thus suggesting acute compartment syndrome.
Results: Fasciotomies were performed in 1.6% of all forearm fractures. Open fractures were 5 times more likely to lead to fasciotomies. Being a male was associated with an increased likelihood of fasciotomies of 64%. Complex fractures (OTA type C) exhibited 74% stronger likelihood of fasciotomies compared to simple fractures. Patients with a history of substance abuse disorder (SAD) were 45% more likely to undergo a fasciotomy compared to patient with no SAD. Multiple other factors were addressed while controlling for cofounders.
Conclusion: This big data analysis provided a holistic perspective on the risk factors, demographics, and clinical association of ACS in the forearm. There is a clear need for a gold standard diagnosis for ACS to provide better care for the patients: whether it is continuous pressure monitoring, validated biomarkers, or other biomarkers. Level of Evidence: III, retrospective database cohort study.
Abstract: A 52-year-old man presented with a bicondylar tibial plateau fracture and acute compartment syndrome. Continuous compartment pressure monitoring was used while the patient was treated with fasciotomies and ap- plication of an external fixator. The intraoperative pressure reading in the anterior compartment decreased from 105 mm Hg to 50 mm Hg after skin and subcutaneous tissue incision. Pressure continued to decrease to 10 mm Hg after all 4 compartments were released. The patient underwent staged open reduction and internal fixation and healed both fracture and fasciotomy incisions without complication. To our knowledge, this is the first report of continuous pressure changes during the different stages of a compartment release. Future studies could expand on use of this technology to gain information on compartment pressures during release and how single release affects pressures in other compartments.
Background: Sensor usage in the classical scientific process has allowed new experimentation in medicine. We report on the design process of a MEMS sensor being used for muscle trauma evaluation in diagnosing acute compartment syndrome (ACS), a medical ailment costing society billions of dollars per year.
Objectives: Modeling the disease with scientific process allows a more complete understanding of the disease. The goal was to formulate a hypothesis that could be tested to aid in making the diagnosis of ACS accurately.
Methods: Scientific process was observed throughout the disease modelling process. Background information was improved and clarified, new pre-clinical models were designed and verified, a hypothesis built on pressure measurement with MEMS sensors was carried out, and the testing of the model as verified against previous clinical data was accomplished.
Results: Scientific process resulted in hypothesis generation around the relationship of intracompartmental pressure measurement and the disease process and therapy. This resulted in new understanding of ACS, accurate modeling, and sensor. Design resulting in a MEMS device that has an extremely high sensitivity and specificity (over 99%) in treating and diagnosing the disease.
Conclusion: MEMS sensor technology defines the new gold standard of implanting a sensor in a muscle compartment that allows accurate diagnosis of ACS with continuous trends in pressure.
Case: A 34-year-old man had an injury which resulted in pilon fracture and acute compartment syndrome of his forefoot. The case report describes the use of a novel minimally invasive dorsal approach for decompression of the lateral, central, medial, and interosseous compartments. The release was performed through multiple small incisions on the dorsal foot. The patient had complete relief with normal function of all muscle groups at 6 weeks and is now 18 months after surgery. He has returned to full activity.
Conclusion: The successful decompression of the forefoot compartments through a percutaneous approach avoided known complications of muscle death, toe clawing, and secondary surgeries.
Case: The American Academy of Orthopaedic Surgeons has recently identified continuous intracompartmental pressure monitoring as 1 of the few means to assist in ruling out acute compartment syndrome (ACS). There are very few methods that allow this measurement. This manuscript describes the use of a new digital monitoring system for ACS in 3 patients. This minimally invasive device, the MY01 (NXTSENS, Montreal, Canada) is capable of continuously and precisely measuring variations in intracompartmental pressure.
Conclusion: MY01 detected the occurrence of ACS at early stage and expedited the timing of surgery for 2 patients. This tool also objectively excluded a suspected diagnosis of ACS in a medically comorbid patient, obviating the need for unnecessary fasciotomies and potential complications.
Background: Acute compartment syndrome of the foot is a controversial topic. Release of the foot has been seen as complicated because of large incisions and postoperative morbidity, and there has been debate over whether this procedure is actually effective for releasing all areas of increased pressure. New sensor technology affords the opportunity to advance our understanding of acute compartment syndrome of the foot and its treatment. The purpose of the present study was to determine whether percutaneous decompression could be performed for the treatment of compartment syndrome in a forefoot model.
Methods: The present study utilized a validated continuous pressure sensor to model compartment syndrome in human cadaveric feet. We utilized a pressure-controlled saline solution infusion system to induce increased pressure. A novel percutaneous release of the forefoot was investigated to assess its efficacy in achieving decompression.
Results: For all cadaveric specimens, continuous pressure monitoring was accomplished with use of a continuous pressure sensor. There were 4 discrete compartment areas that could be reliably pressurized in all feet. The average baseline, pressurized, and post-release pressures (and standard deviations) were 4.5 ± 2.9, 43.8 ± 7.7, and 9.5 ± 3.6 mm Hg, respectively. Percutaneous decompression produced a significant decrease in pressure in all 4 compartments (p < 0.05).
Conclusions: With use of continuous compartment pressure monitoring, 4 consistent areas were established as discrete compartments in the foot. All 4 compartments were pressurized with a standard pump system. With use of 2 small dorsal incisions, all 4 compartments were successfully released, with no injuries identified in the cutaneous nerve branches, extensor tendons, or arteries. These results have strong implications for the future of modeling compartment syndrome as well as for guiding clinical studies.
Clinical Relevance: A reproducible and accurate method of continuous pressure monitoring of foot compartments after trauma is needed (1) to reliably identify patients who are likely to benefit from compartment release and (2) to help avoid missed or evolving cases of acute compartment syndrome. In addition, a reproducible method for percutaneous compartment release that minimizes collateral structural damage and the need for secondary surgical procedures is needed.
Objectives: Acute compartment syndrome is a devastating condition associated with lasting consequences or even death if not treated in a timely fashion. Current preclinical modeling is inadequate. Ideally a model should mimic human disease. There should be a trauma-induced reperfusion or direct muscle event that causes gradual increased pressure and is amenable to release with fasciotomy. We have attempted to reproduce this mechanism and outcome in a porcine model.
Methods: Anterior tibial musculature was injured with vascular occlusion plus exterior tourniquet crush or direct intracompartmental crush through balloon inflation. The injury was maintained for over 5 hours. At that time, the tourniquet or balloon was removed. The injuries were continuously monitored with an intramuscular continuous pressure sensor. Pressure changes were recorded and after 2 hours of postinjury observation, a fasciotomy was performed for the muscle compartment.
Results: Pressures were brought to 100 mm Hg during the injury phase. During the two-hour observation period, the balloon catheter technique achieved an average pressure of 25.1 6 SD 8.8 mm Hg with a maximum reading of 38.2 mm Hg and minimum reading of 14.1 mm Hg. During this same period, the ischemia-reperfusion + direct crush technique achieved an average pressure of 33.7 6 SD 7.3 mm Hg, with a maximum reading of 43.5 mm Hg and minimum reading of 23.5 mm Hg. Average pressure post-fasciotomy for the balloon catheter technique was 2.4 6 SD 2.5 mm Hg; and for the crush technique, average value post-fasciotomy was 4.9 6 SD 3.7 mm Hg—both representing a return to physiologic levels.
Conclusion: This is the first preclinical model that shows the same response to injury and treatment as is observed in human physiology.
Objective: Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy.
Methods: Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers’ responses.
Results: The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency.
Conclusion: This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.
Acute compartment syndrome (ACS) in the foot is a challenging diagnosis and can lead to significant disabilities to patients. The present study aims to investigate the incidence, risk factors, demographics and association in the analysis of acute compartment syndrome (ACS) of the foot. We performed a retrospective review of the Trauma Quality Programs data from the American College of Surgeons including 70,525 patients who sustained a fracture of the foot from 2015 to 2018 (4 calendar years). Fasciotomies were performed in 0.7% of all foot fractures. Open fractures, crush injuries and multiple foot fractures were the strongest predictors of fasciotomies, with odds ratios of 2.38, 2.38 and 2.33 respectively. Being a male was associated with an increased likelihood of fasciotomies of 64% (p < .0001 O.R. = [1.42-1.90]), while a dislocation in the foot increased likelihood of fasciotomies by 48% (p = .0008 O.R. = [1.18-1.86]). Trauma centre level III had higher rate of fasciotomy than Tertiary Trauma centers. Multiple other factors were addressed while controlling for cofounders. This big data analysis provided information not previously reported on the risk factors, demographics, and clinical association of ACS in the foot.
Digital health principles are starting to be evident in medicine. Orthopaedic trauma surgery is also being impacted —indirectly by all other improvements in the health ecosystem but also in particular efforts aimed at trauma surgery. Data acquisition is changing how evidence is gathered and utilized. Sensors are the pen and paper of the next wave of data acquisition. Sensors are gathering wide arrays of information to facilitate digital health relevance and adoption. Early adaption of sensor technology by the nonlegacy health environment is what has made sensor-driven data acquisition so palatable to the normal health care system. As it applies to orthopaedic trauma, current sensor-driven diagnostics and surveillance are nowhere near as developed as in the larger medical community. Digital health is being explored for health care records, data acquisition in diagnostics and rehabilitation, wellness to health care translation, intraoperative monitoring, surgical technique improvement, as well as some early-stage projects in long- term monitoring with implantable devices. The internet of things is the next digital wave that will undoubtedly affect medicine and orthopaedics. Internet of things (loT) devices are now being used to enable remote health monitoring and emergency notification systems. This article reviews current and future concepts in digital health that will impact trauma care.