Ischemic contracture of the foot and ankle: principles of management and prevention

Free functional muscle transfer for lower extremity reconstruction

BACKGROUND

Free functional muscle transfer is a reconstructive strategy for the reconstruction of lost muscle units in the lower extremity after oncologic resection, trauma, compartment syndrome, or severe nerve injuries. Under appropriate circumstances, free functional muscle transfer may be the only suitable reconstructive option. This article reviews the underlying principles of free functional muscle transfer, its application to lower extremity reconstruction, appropriate patient selection, and surgical techniques.

METHODS

The underlying principles of free functional muscle transfer, its application to lower extremity reconstruction, appropriate patient selection, and surgical techniques are presented. Commonly used donor muscles appropriate for each type of functional defect are discussed. A review of recent publications on free functional muscle transfer in the lower extremity was also performed.

RESULTS

Good functional recovery with a Medical Research Council grade of up to 4/5 and full range of motion can be attained with free functional muscle transfer. Clinical outcomes and specific parameters for published case series in lower extremity free functional muscle transfer are presented and an illustrative case.

CONCLUSION

Free functional muscle transfer is a suitable treatment for the appropriate patient to restore essential functions and potentially regain ambulation. However, additional published clinical outcomes are needed and represent a major area for further investigation.

Compartment Syndrome of the Foot

Foot compartment syndrome is an uncommon condition that should be recognized by all orthopedic surgeons. The clinical presentation is often less clear than other limb compartment syndromes and requires high clinical suspicion with a low threshold for direct measurement of compartment pressure. Controversy exists regarding the number of anatomic compartments and the most effective treatment. Both acute surgical intervention and delayed management can result in significant morbidity and long-term sequelae.

Tendon Transfers and Their Role in Cavus Foot Deformity

Management of the cavus foot is a difficult task for the foot and ankle surgeon. Tendon transfers have been a longstanding accepted treatment for the flexible cavus foot. Performing tendon transfers requires an in-depth understanding of the patient's medical history, factors leading to the development of deformity, as well as the deforming forces contributing to the deformity. Evaluation of the patient for rigid, progressive, and/or spastic deformities is critical to avoid postoperative complications. Educating the patient on postoperative rehabilitation, potential complications, and postoperative expectations is essential to ensure appropriate surgical outcomes.

Neurologic Conditions Associated with Cavus Foot Deformity

The cavus foot deformity is an often less understood deformity within the spectrum of foot and ankle conditions. The hallmark concern is the possibility of an underlying neurologic or neuromuscular disorder. Although a proportion of these deformities are idiopathic, a significant majority do correlate with an underlying disorder. The appropriate evaluation of this deformity, in coordination within the multidisciplinary scope of health care, allows for a timely diagnosis and understanding of the patient's condition. We provide an abbreviated survey of possible underlying etiologies for the patient with the cavus foot deformity as a reference to the foot and ankle surgeon.

Compartment Syndrome of the Foot: An Evidence-Based Review

Compartment syndrome of the foot (CSF) is a surgical emergency, with high risk of morbidity and poor outcome, including persistent neurologic deficits or amputation. Uncertainty remains regarding surgical approaches, pressure monitoring values, and the extent of surgical treatment. This review provides a summary of the current knowledge and reports evidence-based diagnostic and therapeutic management options for CSF. Articles describing CSF were identified from MEDLINE, PubMed, and Cochrane databases up until February 2018. Experimental and original articles, systematic and nonsystematic reviews, case reports, and book chapters, independent of their level of evidence, were included. Crush injuries are the leading cause of CSF, but CSF can present after fractures of the tarsal or metatarsal bones and dislocations of the Lisfranc or Chopart joints. CSF is often associated with persistent neurologic deficits, claw toes, amputations, and skin healing problems. Diagnosis is made after accurate clinical evaluation combined with intracompartmental pressure monitoring. A threshold value of <20 mmHg difference between the diastolic blood pressure and the intracompartmental pressure is considered diagnostic. Management consists of surgery, whereby 2 dorsal incisions are combined with a medioplantar incision to the calcaneal compartment. The calcaneal compartment can serve as an "indicator compartment," as the highest-pressure values can regularly be measured within this compartment. Appropriately powered studies of CSF are necessary to further evaluate and compare diagnostic and therapeutic options.

Diagnosis and treatment of acute extremity compartment syndrome

Acute compartment syndrome of the extremities is well known, but diagnosis can be challenging. Ineffective treatment can have devastating consequences, such as permanent dysaesthesia, ischaemic contractures, muscle dysfunction, loss of limb, and even loss of life. Despite many studies, there is no consensus about the way in which acute extremity compartment syndromes should be diagnosed. Many surgeons suggest continuous monitoring of intracompartmental pressure for all patients who have high-risk extremity injuries, whereas others suggest aggressive surgical intervention if acute compartment syndrome is even suspected. Although surgical fasciotomy might reduce intracompartmental pressure, this procedure also carries the risk of long-term complications. In this paper in The Lancet Series about emergency surgery we summarise the available data on acute extremity compartment syndrome of the upper and lower extremities in adults and children, discuss the underlying pathophysiology, and propose a clinical guideline based on the available data.

Combined medial column primary arthrodesis, middle column open reduction internal fixation, and lateral column pinning for treatment of Lisfranc fracture-dislocation injuries

Lisfranc fracture-dislocation can be a devastating injury with significant long-term sequelae, including degenerative joint disease, progressive arch collapse, and chronic pain that can be potentiated if not effectively treated. We present a case to demonstrate our preferred surgical approach, consisting of combined medial column primary arthrodesis, middle column open reduction internal fixation, and lateral column pinning, with the primary goal of minimizing common long-term complications associated with Lisfranc injuries. We present the case of a typical patient treated according to this combined surgical approach to highlight our patient selection criteria, rationale, surgical technique, and operative pearls. A 36-year-old male who had sustained a homolateral Lisfranc fracture-dislocation injury after falling from a height initially underwent fasciotomy for foot compartment syndrome. The subsequent repair 16 days later involved primary first tarsometatarsal joint fusion, open reduction internal fixation of the second and third tarsometatarsal joints, and temporary pinning of the fourth and fifth tarsometatarsal joints. He progressed well postoperatively, exhibiting an American College of Foot and Ankle Surgeons forefoot score of 90 of 100 at 1 year after surgery with no need for subsequent treatment. Lisfranc fracture-dislocations often exhibit primary dislocation to the medial column and are conducive to arthrodesis to stabilize the tarsometatarsal complex. The middle column frequently involves comminuted intra-articular fractures and will often benefit from less dissection required for open reduction internal fixation instead of primary fusion. We propose that this surgical approach is a viable alternative technique for primary treatment of Lisfranc fracture-dislocation injuries.

Foot compartment syndrome: diagnosis and management

Although uncommon, foot compartment syndrome (FCS) is a distinct clinical entity that typically results from high-energy fractures and crush injuries. In the literature, the reported number of anatomic compartments in the foot has ranged from 3 to 10, and the clinical relevance of these compartments has recently been investigated. Diagnosis of FCS can be challenging because the signs and symptoms are less reliable indicators than those of compartment syndrome in other areas of the body. This may lead to a delay in diagnosis. The role of fasciotomy in management of FCS has been debated, but no high-level evidence exists to guide decision making. Nevertheless, emergent fasciotomy is commonly recommended with the goal of preventing chronic pain and deformity. Surgical intervention may also be necessary for the correction of secondary deformity.

Injury patterns causing isolated foot compartment syndrome

BACKGROUND

The true incidence and primary predictors of foot compartment syndrome remain controversial. Our aim was to better define the overall incidence of foot compartment syndrome in relation to the frequency and location of various foot injuries. We hypothesized that (1) the incidence would increase in proportion to the number of anatomic locations of injury, (2) the incidence would be higher in association with hindfoot and crush injuries compared with any other injury categories, and (3) not only would the incidence associated with calcaneal fractures be lower than the often quoted 10% but foot compartment syndrome would also be fairly uncommon after such fractures.

METHODS

The National Trauma Data Bank was used to identify patients who had undergone a fasciotomy for the treatment of isolated foot compartment syndrome. Strict inclusion and exclusion criteria were used to identify only patients with foot injuries who had undergone fasciotomy for foot compartment syndrome.

RESULTS

Three hundred and sixty-four patients with an isolated foot compartment syndrome were identified. The highest incidence of foot compartment syndrome was seen in association with a crush mechanism combined with a forefoot injury (18%, nineteen of 106), followed by an isolated crush injury (14%, twenty-three of 162). Only 1% (thirty-two) of 2481 patients with an isolated calcaneal fracture underwent fasciotomy. An increase in the number of anatomic locations of injury did not appear to correspond to an increased incidence of foot compartment syndrome.

CONCLUSION

Our results demonstrate that injuries involving a crush mechanism, either in isolation or in combination with a forefoot injury, should raise suspicion about the possibility that a foot compartment syndrome will develop.

Atraumatic compartment syndrome of the foot in a 15-year-old female

Compartment syndrome is a surgical emergency that usually occurs as a sequel to high-energy trauma. We report an uncommon presentation of atraumatic compartment syndrome of the right foot involving the abductor hallucis muscle. A 15-year-old female presented with pain and mild swelling of the right foot after taking part in a school sports activity. Compartment syndrome was diagnosed, >2 months of conservative treatment failed to improve her symptoms, and surgical release and debridement were performed. Our clinical experience demonstrates that compartment syndrome of the foot may occur after mild sports activity in physically inactive children.

Compartment syndrome: a review of the literature

Compartment syndrome is a rare but severe complication of lower extremity trauma. This article provides an extensive review of the literature, including incidence, physical examination findings, pathophysiology, compartment pressure evaluation, and surgical decompression techniques. Most of the recent compartment syndrome literature shows case reports of atypical causes of this limb-threatening disorder. Although the emphasis of this article is traumatic compartment syndrome, recent literature on chronic lower extremity compartment syndrome, secondary to exercise or activity, is also discussed.

Acute compartment syndrome of the foot following fixation of a pilon variant ankle fracture

Acute traumatic compartment syndrome of the foot is a serious potential complication after fractures, crush injuries, or reperfusion injury after vascular repair. Foot compartment syndrome in association with injuries to the ankle is rare. This article presents a case of acute compartment syndrome of the foot following open reduction and internal fixation of an ankle fracture. A 16-year-old girl presented after sustaining a left ankle injury. Radiographs demonstrated a length-stable posterior and lateral malleolar ankle fracture. Initial treatment consisted of a bulky splint and crutches pending the improvement of her swelling. Over the course of a week, the soft tissue environment of the distal lower extremity improved, and the patient underwent open reduction and internal fixation of both her fibula and distal tibia through 2 approaches. Approximately 2 hours from the completion of surgery, the patient reported worsening pain over the medial aspect of her foot and into her calcaneus. Physical examination of the foot demonstrated a swollen and tense abductor hallicus and heel pad. Posterior tibial and dorsalis pedis pulses were palpable and her sensation was intact throughout her foot. Emergently, fasciotomy of both compartments was performed through a medial incision. Postoperatively, the patient reported immediate pain relief. At 18-month follow-up, she reported no pain and had returned to all of her preinjury athletic activities.

Management of long-term sequelae of compartment syndrome involving the foot and ankle

BACKGROUND

Lower leg compartment syndrome can lead to severe sequelae affecting patient autonomy. Ischemic muscle fibrosis and retraction result in foot and ankle deformities ranging from claw toes to complex multiplanar dislocations with soft tissue impairment requiring amputation. Although these deformities have been reported in relation to compartment syndrome, they have rarely been discussed specifically in the light of a long term follow up.

MATERIALS AND METHODS

Between 1981 and 2006, 151 patients were treated in our hospital for compartment syndrome of the lower limb. Ten of them later required further surgery to treat sequelae on the foot and ankle and were followed up prospectively. Personal data and surgical events were recorded, as well as potential risk factors for sequelae and functional outcome. The data was analyzed and compared to that available in previous literature. We analyzed and describe the different surgical procedures available for the management of this condition including arthroscopic ankle arthrodesis which could be a less invasive and efficient technique in mild equinus deformities.

RESULTS

All ten patients were diagnosed late for compartment syndrome. The anterior and lateral compartments were most often involved but rarely accounted for late sequelae. The deep posterior compartment seems to be the key element in generating after effects. Functional results were good in eight patients. Two required amputation after failed secondary surgery.

CONCLUSION

The late, post-compartment syndrome affecting the foot and ankle can be treated efficiently provided surgery is performed acurately, taking into account the multiplanar deformity. However, the best treatment for this condition remains prevention.

Tibial compartment syndrome and the cavovarus foot

Compartment syndrome of the leg is an orthopedic emergency that requires a high index of suspicion for diagnosis and a low threshold for surgical management to prevent devastating complications. Where the clinical findings are subtle, continuous monitoring of compartment pressures, with clinical correlation, is the key to diagnosis. Surgical management should include decompression of all four compartments and early rehabilitation to prevent ischemic contracture. If contracture develops, it may cause varying degrees of equinocavovarus deformity of the foot and ankle. Appropriate evaluation and careful surgical planning that considers all components of this complex deformity are essential for obtaining good clinical results.

The compartments of the foot: a 3-tesla magnetic resonance imaging study with clinical correlates for needle pressure testing

BACKGROUND

Reliable measurement of subfascial pressures represents an essential part of compartment syndrome management. To date, there is neither consensus on the number or location of foot compartments, nor a standardized protocol for needle placement. The purpose of this study was to devise a new system using 3-Tesla MRI that assesses the number and location of these compartments.

METHODS

To document the specific location of foot compartments, high resolution 3-Tesla MRI (General Electric, Milwaukee, WI) was coupled with a dedicated transmit-receive high signal-to-noise foot/ankle coil (IGC-Medical Advances, Milwaukee, WI). Individual compartments were highlighted and mapped to T1-weighted MRI. Three-dimensional image analysis allowed standardized needle placement recommendations.

RESULTS

Six feet from healthy volunteers were imaged. From these, ten compartments were described: (1) medial, (2) central superficial, (3) central deep (adductor), (4) lateral, (5-8) interossei, (9) calcaneal, and (10) skin. Optimal needle placement and depth were identified.

CONCLUSIONS

The proposed system allowed us to assess the number and location of foot compartments. Computer image analysis enabled us to define exact points for needle insertion and depth of penetration for accurate pressure monitoring.

Anatomic compartments of the foot: a 3-Tesla magnetic resonance imaging study

There is neither consensus on the number nor agreement on the location of the anatomic compartments of the foot. This project utilized high-resolution magnetic resonance imaging (MRI) to identify foot compartments. The purpose of this study was to devise a new system using 3-Tesla (3T) MRI that assessed the number and location of these compartments. Six feet from healthy volunteers were imaged. From these, 10 compartments were described: (1) medial, (2) calcaneal, (3) lateral, (4) central superficial, (5) central deep (adductor), (6-9) interossei, and (10) skin. The 3T MRI and foot/ankle coil allowed us to assess the number and location of foot compartments.

Lower Limb (Well Leg) Compartment Syndrome After Urological Pelvic Surgery

PURPOSE

Well leg compartment syndrome (WLCS) is being seen more frequently as the complexity and duration of pelvic urological surgery increases, ie reconstruction/radical cancer surgery. The etiology of WLCS is multifactorial and prevention should form the mainstay of treatment. With significant morbidity and mortality, in particular lower limb morbidity secondary to fasciotomy wounds and long-term neurological sequelae, all urologists should be aware of this iatrogenic complication and how to prevent or treat it when it occurs.

MATERIALS AND METHODS

A retrospective review of the world literature using MEDLINE was performed from 1966 to 2002, searching for lower limb compartment syndrome (well leg compartment syndrome), and its association with the lithotomy position and pelvic surgery.

RESULTS

Although WLCS is not commonly reported in the urological literature, it has significant morbidity and mortality. The incidence of WLCS is probably under reported due to failed diagnosis or misdiagnosis. With increased awareness the incidence of this iatrogenic complication may be minimized or avoided altogether.

CONCLUSIONS

Because the lithotomy position is one of the most common positions used in urology, it is mandatory for urologists to be familiar with the complications associated with it. If this complication is recognized early, prompt treatment decreases morbidity and mortality. Minimizing the risk of WLCS will leave urologists less open to litigation, which may follow this significant iatrogenic complication.

Review: acute compartment syndrome of the foot

Foot compartment syndrome is a serious potential complication of foot crush injury, fractures, surgery, and vascular injury. The purpose of this article is to summarize and review the existing literature on this entity. Long-term sequelae of foot compartment syndrome (FCS) include contractures, deformity, weakness, paralysis, and sensory neuropathy. These complications are poorly tolerated, and often necessitate multiple procedures for rehabilitation. Therefore, the threshold for considering compartment syndrome and performing fasciotomy must be low to minimize such outcomes. The existence of nine foot compartments and frequent presence of complicating injuries necessitate multi-stick needle catheterization for direct measurement of compartment pressures. Fasciotomy is indicated when compartment pressure exceeds 30 mmHg, or if compartment pressure is greater than 10-30 mmHg below diastolic pressure. The approaches for compartment decompression generally include two dorsal incisions for access to forefoot compartments, and one medial incision for decompression of the calcaneal, medial, superficial, and lateral compartments.

Foot compartment syndrome

FCS is a recognized clinical entity that has few consistent clinical signs except tense swelling. A high degree of clinical suspicion is necessary to provide appropriate treatment. Invasive direct pressure monitoring is needed to diagnose FCS. High-energy injuries are known to cause FCS, but individual risk factors, such as prolonged venous occlusion and blood dyscrasias, are causative factors.