|Year : 2015 | Volume
| Issue : 1 | Page : 58-61
Delayed lower leg compartment syndrome in the uninjured limb following hemilithotomy positioning: Report of three cases, review of the literature, and recommendations for prevention
Medhat Zekry1, Girgis Saad2, James Ramos1, Habib Rahman1, Jamal Almulla2
1 Department of Trauma and Orthopaedics, Heartlands Hospital, Birmingham, UK
2 Rashid Hospital, Trauma Centre, Dubai, UAE
|Date of Web Publication||13-Jun-2016|
Heartlands Hospital, Bordesley Green East, Birmingham, West Midlands B9 5SS
Source of Support: None, Conflict of Interest: None
Compartment syndrome in the uninjured leg as a complication of prolonged positioning in a hemilithotomy position is a serious complication. Prolonged operative time, external compression, and elevation of the sound leg are contributing factors. This is a devastating, but rare complication in the uninjured leg
Keywords: Fracture table, hemilithotomy, leg compartment
|How to cite this article:|
Zekry M, Saad G, Ramos J, Rahman H, Almulla J. Delayed lower leg compartment syndrome in the uninjured limb following hemilithotomy positioning: Report of three cases, review of the literature, and recommendations for prevention. J Orthop Traumatol Rehabil 2015;8:58-61
|How to cite this URL:|
Zekry M, Saad G, Ramos J, Rahman H, Almulla J. Delayed lower leg compartment syndrome in the uninjured limb following hemilithotomy positioning: Report of three cases, review of the literature, and recommendations for prevention. J Orthop Traumatol Rehabil [serial online] 2015 [cited 2019 Nov 14];8:58-61. Available from: http://www.jotr.in/text.asp?2015/8/1/58/183959
| Introduction|| |
Compartment syndrome of the lower leg (anterior, lateral, and posterior) is usually associated with significant trauma. Compartment syndrome in the uninjured leg from prolonged positioning in the hemilithotomy position is a serious complication. Risk factors, theories of pathogenesis, and preventive measures are discussed.
Three cases of intraoperative compartment syndrome of the well leg that was elevated and contralateral to a femoral fracture. In each case, the syndrome was found well after the operative procedure.
The uninjured leg placed in hemilithotomy position on a well-padded calf rest with the hip in approximately 80° flexion, 40° abduction, 30° external rotation. The three cases share long operation time, healthy, and young patient. They started to complain of painful contralateral leg pain 10-18 h after the nailing procedure. It was addressed with immediate fasciotomies. None of the three patients had residual neurologic sequelae from the compartment syndrome.
They were complex femoral fractures and treated and followed up for average 30 months at level 1 trauma center (Rashid Hospital Trauma Centre, Dubai, UAE).
| Patients and Methods|| |
Case number 1
A 28-year-old healthy male was admitted following road traffic accident (pedestrian hit by a car). He sustained a segmental fracture his right femur. No other associated injuries or comorbidity, his body weight was 57 kg. He underwent gamma nail with supplementary wiring 13 h after admission. The procedure lasted 4 h and 25 min. A compartment syndrome of the left side was discovered the next morning based on the suggested clinical picture and operated upon for fasciotomy immediately. Five days later a split-thickness skin grafting (STSG) was performed which healed well. The postoperative period was uneventful, and the patient was discharged after 8 days.
Case number 2
A 39-year-old fit male was admitted following a fall from a 4 m height. He had sustained a comminuted subtrochanteric fracture of his right femur, with no other associated injuries. His body weight was 65 kg. He was operated on 7 h after admission for closed reduction and gamma nailing. The operation lasted 4 h and 50 min. A compartment syndrome of left uninjured side was discovered the following morning based on clinical examination and operated immediately by fasciotomy. After 6 days, STSG was done, and the patient was discharged after 9 days.
Case number 3
A 27-year-old female was admitted following road traffic accident as a driver. She had no associated injuries. Her body weight was 71 kg. She sustained right trochanteric and shaft femur fracture. She was operated on 6 h after admission for closed reduction and gamma nailing. The operation lasted 4 h and 32 min. Compartment syndrome of the uninjured leg was discovered the following morning based on confirmed clinical examination and operated by fasciotomy immediately. After 5 days, STSG was done, and the patient was discharged after 12 days [Figure 1].
|Figure 1: (a-c) Three radiographs of one of the difficult cases included in the study|
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| Discussion|| |
Acute compartment syndrome has been widely reported in legs positioned in the lithotomy position for prolonged general surgical, urologic, and gynecologic procedures.
Meyer and associates, in their study of the intramuscular and blood pressure in leg positioned in lithotomy pointed out that changing from the supine to the calf-supported position significantly increased the intramuscular pressure in the anterior compartment (from 11.6 to 19.4 mm Hg) and in the lateral compartment (from 13.0 to 25.8 mm Hg). Changing from the calf-supported to the heel-supported position significantly decreased intramuscular pressure in the anterior, lateral, and posterior compartments (to 2.8, 3.4, and 1.9 mm Hg, respectively). The mean diastolic blood pressure in the ankle averaged 63.9 mm Hg in the supine position, which significantly decreased to 34.6 mm Hg in the calf-supported position. Changing to the heel-supported position had no significant effect on the diastolic blood pressure in the ankle (mean, 32.8 mm Hg).
Tan et al., in their prospective study to evaluate the relationship between the well leg compartment pressures and time during hemilithotomy position for fracture fixation. The pressure jumped from a baseline of 9.2 to 27.3 mm of mercury (mm Hg) (P< 0.0001). While in the hemilithotomy position, the leg pressure trended slightly upward. Once the leg was taken down, the pressure immediately returned to a near baseline level of 8.1 mm Hg (P< 0.0001). A significant correlation was also found between the body mass index (BMI) and leg pressure (R2 = 0.713; F = 0.002).
A positive correlation between BMI and increased compartment pressure was found, indicating that obesity may be a contributing factor. However, Pfeffer et al. reported that a particular body habitus, that is, slim volunteers with small muscle mass are predisposed to developing compartment syndrome.
Presentation of postoperative compartment syndrome occurs in the setting of a reperfusion injury to a closed osteofascial compartment may be delayed up to 24 h or longer postoperatively as stated by Goldsmith and McCallum.
In our three cases, the patients started to complain next morning (average 13 h).
It has been reported by different specialties adopting the lithotomy position. Moses et al. reported a case following urethroplasty in the dorsolithotomy position.
Kubiak et al. reported four complicated surgical, pediatric patient were kept in lithotomy position for long surgical procedures and developed bilateral compartment in two children, sciatic nerve injury and deep venous thrombosis in the other children.
| Positioning|| |
Anglen and Banovetz, advocate other alternates to avoid hemilithotomy position, would be to use lateral positioning on a fracture table or a regular radiolucent table and to use a femoral distracter as the distracting device followed by reduction and antegrade intramedullary nailing. In cases where the hemilithotomy position cannot be avoided, periodic intraoperative repositioning of the leg is recommended when possible to avoid prolonged pressure on the calf.
Noordin et al., in their experience, they adopt a different position for antegrade intramedullary femoral nailing. Although the lithotomy position is useful and even necessary to the success of some surgical procedures, the patient should be repositioned after 2 h, the maximal time one would use an extremity tourniquet. Often, fluoroscopy is only necessary during certain portions of the case, and the well leg may be returned to a more physiological position in the interval periods. The presence of any predisposing factors, such as peripheral vascular disease, concurrent bony, or soft tissue injury to the contralateral leg (i.e., nonoperative lower extremity), anticipated prolonged surgery and obesity, may require a different positioning approach.
No particular lithotomy suspension equipment including skids, straps, boots, metal or cloth stirrups are immune to this serious complication.
Wu et al. advocate the use of the tilted supine position for different surgical procedures such as plating and nailing a modified patient position for hip fractures that avoids these complications [Figure 2]. A bolster is placed under the affected hip from the iliac crest to the trochanteric area to tilt the pelvis approximately 15° to the opposite side. The tilted supine position allows unobstructed fluoroscopic access for anteroposterior and lateral views of the hip and provides good fluoroscopic images. It is suitable for most patients, and can prevent some complications that can result from the supine and hemilithotomy positions.
|Figure 2: (a) Suggested table positions. (b) Suggested table positions with the easy use of image intensifier. (c) Routine hemilithotomy position|
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| Conclusion|| |
The combination of increased intramuscular pressure due to external compression from the calf support and decreased diastolic pressure resulting from the leg elevation causes a significant decrease in the difference between the diastolic blood pressure and the intramuscular pressure in the hemilithotomy position.
No particular lithotomy suspension equipment is immune to this serious complication. Prolonged operation time, external compression and elevation of the sound leg, increased BMI, are contributing factors to develop compartment syndrome in the well leg during hemilithotomy procedure for hip fracture fixation.
| Recommendations|| |
- After 2 h, the surgeon has to release the sound leg out of the hemolithotomy posture for few minutes, similar to release of tourniquet after 2 h.
- Using alternative positions if the procedure expected to take long-time, for example, traction in extension or tilting position.
- Careful observation of the both legs equally and keep high degree of suspicion after lithotomy position.
- Emergent formal fasciotomy upon discovery of the compartment syndrome.
| Acknowledgement|| |
Mr Steve Hughes FRCS, a senior consultant orthopedics surgeon at Heart of England NHS Foundation trust, Birmingham, UK for his meticulous revision of the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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Meyer RS, White KK, Smith JM, Groppo ER, Mubarak SJ, Hargens AR. Intramuscular and blood pressures in legs positioned in the hemilithotomy position: Clarification of risk factors for well-leg acute compartment syndrome. J Bone Joint Surg Am 2002;84-A:1829-35.
Tan V, Pepe MD, Glaser DL, Seldes RM, Heppenstall RB, Esterhai JL Jr. Well-leg compartment pressures during hemilithotomy position for fracture fixation. J Orthop Trauma 2000;14:157-61.
Pfeffer SD, Halliwill JR, Warner MA. Effects of lithotomy position and external compression on lower leg muscle compartment pressure. Anesthesiology 2001;95:632-6.
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Wu CS, Chen PY, Shih KS, Hou SM. Modified patient position on a fracture table for hip fixation. Orthopedics 2007;30:518-20.
[Figure 1], [Figure 2]