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Bridges CS, Taylor TN, Bini T, Ontaneda AM, Coleman RD, Hill JF, Montgomery NI, Shenava VR, Gerow FT. Acute Compartment Syndrome in Pediatric Patients on Extracorporeal Membrane Oxygenation Support. J Pediatr Orthop 2024; 44:e285-e291. [PMID: 38084004 DOI: 10.1097/bpo.0000000000002592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND When acute compartment syndrome (ACS) occurs in pediatric patients requiring venoarterial extracorporeal membrane oxygen (VA ECMO) support, there is little data to guide surgeons on appropriate management. The purpose of this study is to characterize the presentation, diagnosis, timeline, and outcomes of patients who developed this complication. METHODS This is a single-center retrospective case series of children below 19 years old on VA ECMO support who subsequently developed extremity ACS between January 2016 and December 2022. Outcomes included fasciotomy findings, amputation, mortality, and documented function at the last follow-up. RESULTS Of 343 patients on VA ECMO support, 18 (5.2%) were diagnosed with ACS a median 29 hours after starting ECMO. Initial cannulation sites included 8 femoral, 6 neck, and 4 central. Femoral artery cannulation was associated with an increased risk of ACS [odds ratio=6.0 (CI: 2.2 to 15), P <0.0001]. In the hospital, the mortality rate was 56% (10/18). Fourteen (78%) patients received fasciotomies a median of 1.2 hours after ACS diagnosis. Only 4 (29%) patients had all healthy muscles at initial fasciotomy, while 9 (64%) had poor muscular findings in at least 1 compartment. Patients with worse findings at fasciotomy had a significantly longer duration between ischemia onset and ACS diagnosis. Patients required a median of 1.5 additional procedures after fasciotomy, and only 1 (7%) developed a surgical site infection. Of the 7 surviving fasciotomy patients, 2 required amputations, 3 developed an equinus contracture, 1 developed foot drop, and 3 had no ACS-related deficits. Four patients did not receive fasciotomies: 3 were deemed too ill and later died, and 1 was diagnosed too late to benefit. The only surviving nonfasciotomy patient required bilateral amputations. CONCLUSIONS Pediatric ECMO-associated ACS is not exclusive to patients with femoral artery cannulation. The majority of fasciotomy patients were diagnosed with ACS after muscle necrosis had already started. We were unable to definitively conclude whether fasciotomies provide better outcomes. There is a need for increased awareness and earlier recognition of this rare yet potentially devastating complication. LEVEL OF EVIDENCE Level IV-retrospective case series.
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Affiliation(s)
| | | | | | - Andrea M Ontaneda
- Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine
| | - Ryan D Coleman
- Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine
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Micicoi L, Gonzalez JF, Gauci MO, Chabrand P, Machado A, Bronsard N, Micicoi G. Acute compartment syndrome of the lower limbs: Fasciotomy or dermofasciotomy? A cadaver study of compartment pressures. Orthop Traumatol Surg Res 2024; 110:103736. [PMID: 37890523 DOI: 10.1016/j.otsr.2023.103736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Acute compartment syndrome (ACS) of the lower limbs is a function-threatening event usually managed by extended dermofasciotomy. Closure of the skin may be delayed, creating a risk of complications when there is an underlying fracture. Early treatment at the pre-ACS stage might allow isolated fasciotomy with no skin incision. The primary objective of this study was to compare intracompartmental pressure (ICP) changes after fasciotomy and after dermofasciotomy. The secondary objectives were to evaluate potential associations linking the starting ICP to achievement of an ICP below the physiological cut-off of 10mm Hg and to determine whether the ICP changes after fasciotomy and dermofasciotomy varied across muscle compartments. HYPOTHESIS Fasciotomy with no skin incision may not provide a sufficient ICP decrease, depending on the initial ICP value. MATERIAL AND METHODS A previously validated model of cadaver ACS of the lower limbs was used. Saline was injected gradually to raise the ICP to>15mmHg (ICP15), >30mmHg (ICP30), and >50mmHg (ICP50). We studied 70 leg compartments (anterior, lateral, and superficial posterior) in 13 cadavers (mean age, 89.1±4.6years). ICP was monitored continuously. Percutaneous, minimally invasive fasciotomy consisting in one to three 1-cm incisions was performed in each compartment. ICP was measured before and after fasciotomy then after subsequent skin incision. The objective was to decrease the ICP below 10mmHg after fasciotomy or dermofasciotomy. RESULTS Overall, mean ICP was 37.8±19.1mmHg after the injection of 184.0±133.01mL of saline. In the ICP15 group, the mean ICP of 16.1mmHg fell to 1.4mmHg after fasciotomy (ΔF=14.7) and 0.3mmHg after dermofasciotomy (ΔDF=1.1). Corresponding values in the ICP30 group were 33.9mmHg, 4.7mmHg (ΔF=29.2), and 1.2mmHg (ΔDF=3.5); and in the ICP50 group, 63.7mmHg, 17.0mmHg (ΔF=46.7), and 1.2mmHg (ΔDF=15.8). Thus, in the group with initial pressures >50mmHg, the ICP decrease was greater after both procedures, but fasciotomy alone nonetheless failed to achieve physiological values (<10mmHg). The pressure changes were not significantly associated with the compartment involved (anterior, lateral, or superficial posterior) (p<0.05). CONCLUSION Under the conditions of this study, higher baseline ICPs were associated with larger ICP drops after fasciotomy and dermofasciotomy. Nevertheless, when the baseline ICP exceeded 50mmHg, fasciotomy alone failed to decrease the ICP below 10mmHg. Adding a skin incision achieved this goal. LEVEL OF EVIDENCE IV, experimental study.
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Affiliation(s)
- Lolita Micicoi
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France
| | - Jean-François Gonzalez
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France
| | - Marc-Olivier Gauci
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France
| | | | - Axel Machado
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France
| | - Nicolas Bronsard
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France
| | - Grégoire Micicoi
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France.
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Akgun E, Emet A, Sibar K, Çatma FM, Kocyigit IA, Şahin A, Imat E, Adiguzel IF, Fırat A. Risk Factors for Surgical Site Infections Following Fasciotomy in Patients With Acute Compartment Syndrome: A Study on the February 2023 Kahramanmaraş Earthquake. Cureus 2023; 15:e46880. [PMID: 37841991 PMCID: PMC10568196 DOI: 10.7759/cureus.46880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 10/17/2023] Open
Abstract
INTRODUCTION Surgical site infections (SSIs) developing after fasciotomy are difficult to treat, costly, and an important source of mortality and morbidity. This study aimed to determine the risk factors affecting the development of SSI in patients who underwent fasciotomy with the diagnosis of acute compartment syndrome (ACS) within 72 hours after two consecutive earthquakes of 7.7 and 7.6 magnitude that occurred in Kahramanmaraş on February 6, 2023. METHOD A total of 116 patients were retrospectively analyzed. Patients were divided into two groups: those who developed SSI and those who did not. In this study, variables such as basic demographic characteristics, time of fasciotomy, center performing fasciotomy, type of wound closure, affected extremity, concomitant renal failure, hyperbaric oxygen (HBO) therapy, blood creatine kinase (CK) level were examined. RESULTS Of 116 patients, 58 (50%) had SSI. It was statistically observed that patients who underwent treatment with vacuum-assisted closure (VAC), those who underwent primary closure with the shoelace method, those who went into renal failure, and those whose fasciotomy was performed in an earthquake zone had a higher incidence of SSI (p<0.001). Blood CK level above 17.839 seemed to be a risk factor according to receiver operating characteristic (ROC) analysis (P<0.01). Age (p=0.193), gender (p=0.125), fasciotomy time (p=0.843), lower extremity (p=0.234), upper extremity (p=0.806), and HBO treatment (p=0.56) were not associated with SSI. Infection was found to be a significant risk factor for amputation (p<0.001). CONCLUSION The use of VAC as a wound closure technique for SSI after fasciotomy in patients who developed ACS due to the earthquake, the presence of renal failure in the patients, and performing fasciotomy in the earthquake zone were independent risk factors. A blood CK level above 17.839 was also determined as a risk factor, but the confidence interval was found to be low.
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Affiliation(s)
- Erkan Akgun
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Abdulsamet Emet
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Kemal Sibar
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Faruk M Çatma
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | | | - Ali Şahin
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Emrah Imat
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | | | - Ahmet Fırat
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
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Obuh OO, Esomu EJO, Sydney RO. Suturing Dermatotraction Techniques in Closing Fasciotomy Wounds: A Systematic Review. Cureus 2023; 15:e37550. [PMID: 37197103 PMCID: PMC10184723 DOI: 10.7759/cureus.37550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 05/19/2023] Open
Abstract
A surgical patient post-fasciotomy presents a challenge to restore the cover of the muscle groups, and the use of the suturing dermatotraction techniques presents a cheap and easy means of native cover. This systematic review of case series and case-control study explored the trend of this technique, including duration of delayed primary wound closure, complications, and failure rates. A literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted on Medline, Embase, and Cumulative Index of Nursing and Allied Health Literature (CINAHL), yielding a combined total of 820 articles between 1946 and June 18, 2022. Human studies with suturing dermatotraction techniques were included. Sixteen (16) studies reviewed met the criteria. The basic anatomy of the dermatotraction technique involves an anchor point on the skin, a material for traction, and a suture pattern. The shoelace technique was the predominant suture pattern, with staples as skin anchor material/method and silastic vessel loops as traction sling used by 11 studies. Modifications of this method included the use of intradermal Prolene sutures and pediatric catheters. The shortest duration for skin apposition was two days, and the longest was 113 days. Complications were comparable to that of surgical wounds and thus may not be attributable to the technique itself. Studies reviewed showed that superficial and early complications were more likely than deep or delayed complications. Negative pressure wound therapy (NPWT) and skin graft salvaged a few failed closures in two studies. There are varying practices of tightening rates with reports ranging from daily to every 72 hours. The rate of tightening and disease burden may account for the wide range of reported delayed primary closure. Most of the studies reviewed closed fasciotomy wounds with this technique within an average of <10 days. It is relatively cheaper, carries a low morbidity burden, and has multiple reported success in the closure of fasciotomy wounds in this review and thus should have an increased adoption as a first approach in managing fasciotomy wounds, especially in low-income countries.
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Affiliation(s)
- Otomi O Obuh
- Plastic and Reconstructive Surgery, Surgery Interest Group of Africa, Lagos, NGA
- Surgery, Imperial College Healthcare NHS Trust, London, GBR
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Lui TH, Wong WB, Pan X. Bruise over the palm. BMJ 2022; 378:e071151. [PMID: 36137600 DOI: 10.1136/bmj-2022-071151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Tun Hing Lui
- Department of Orthopaedics and Traumatology, North District Hospital, Sheung Shui, NT, Hong Kong SAR, China
- Shenzhen University, Shenzhen, China
| | | | - Xiaohua Pan
- Department of Trauma and Orthopedics, Second Affiliated Hospital of Shenzhen University & Affiliated Baoan Hospital of Shenzhen, Southern Medical University, The 8th People's Hospital of Shenzhen, Shenzhen, Guangdong 518101, China
- Guangdong Provincial Engineering Research Center of Wound Repair and Regenerative Medicine, Guangdong Provincial Academician Workstation of Wound Repair and Regenerative Medicine, China
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Novak M, Penhaker M, Raska P, Pleva L, Schmidt M. Extremity compartment syndrome: A review with a focus on non-invasive methods of diagnosis. Front Bioeng Biotechnol 2022; 10:801586. [PMID: 35923576 PMCID: PMC9340208 DOI: 10.3389/fbioe.2022.801586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
The article deals with an overview of acute extremity compartment syndrome with a focus on the option of non-invasive detection of the syndrome. Acute extremity compartment syndrome (ECS) is an urgent complication that occurs most often in fractures or high-energy injuries. There is still no reliable method for detecting ECS. The only objective measurement method used in clinical practice is an invasive measurement of intramuscular pressure (IMP). The purpose of this paper is to summarize the current state of research into non-invasive measurement methods that could allow simple and reliable continuous monitoring of patients at risk of developing ECS. Clinical trials are currently underway to verify the suitability of the most studied method, near-infrared spectroscopy (NIRS), which is a method for measuring the local oxygenation of muscle compartments. Less explored methods include the use of ultrasound, ultrasound elastography, bioimpedance measurements, and quantitative tissue hardness measurements. Finding a suitable method for continuous non-invasive monitoring of the syndrome would greatly improve the quality of care for patients at risk. ECS must be diagnosed quickly and accurately to prevent irreversible tissue damage that can occur within hours of syndrome onset and may even warrant amputation if neglected.
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Affiliation(s)
- Martin Novak
- Trauma Surgery Clinic, University Hospital Ostrava, Ostrava, Czechia
| | - Marek Penhaker
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB—Technical University of Ostrava, Ostrava, Czechia
| | - Pavel Raska
- Department of Occupational and Process Safety, Faculty of Safety Engineering, VSB—Technical University of Ostrava, Ostrava, Czechia
| | - Leopold Pleva
- Trauma Surgery Clinic, University Hospital Ostrava, Ostrava, Czechia
| | - Martin Schmidt
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB—Technical University of Ostrava, Ostrava, Czechia
- *Correspondence: Martin Schmidt,
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