Predicting factors of muscle necrosis in acute compartment syndrome of the lower extremity

Sharri J Mortensen; Dafang Zhang; Amin Mohamadi; Jamie Collins; Michael J Weaver; Ara Nazarian; Arvind G von Keudell

doi:10.1016/j.injury.2019.11.022

Predicting factors of muscle necrosis in acute compartment syndrome of the lower extremity

Injury. 2020 Feb;51(2):522-526. doi: 10.1016/j.injury.2019.11.022. Epub 2019 Nov 16.

Authors

Sharri J Mortensen¹, Dafang Zhang², Amin Mohamadi³, Jamie Collins⁴, Michael J Weaver⁵, Ara Nazarian⁶, Arvind G von Keudell⁵

Affiliations

¹ Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States. Electronic address: smortens@bidmc.harvard.edu.
² Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
³ Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
⁴ Orthopedic and Arthritis Center for Outcome Research, Brigham and Women's Hospital, Boston, MA, United States.
⁵ Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, United States.
⁶ Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, United States; Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia.

PMID: 31767373
DOI: 10.1016/j.injury.2019.11.022

Abstract

Background: Acute physiologic compartment syndrome (ACS) is a disorder of increased intra-compartmental pressure leading to decreased tissue perfusion and muscle necrosis. Tissue ischemia can result in irreversible muscle and nerve injury and requires urgent fasciotomy. The aim of this study was to determine the factors associated with the presence of necrotic muscle in patients undergoing leg fasciotomy.

Methods: This is a retrospective cohort study of all patients undergoing fasciotomies for ACS of the leg at two level 1 trauma centers from 2000 to 2015. We found 1,028 patients who underwent leg fasciotomies. We excluded ACS at other sites than the leg, the index fasciotomy performed at an outside institution, prophylactic fasciotomy with no clinical signs of ACS, and patients with inadequate medical records. A total of 357 patients were included in the final analysis. We used bivariate analysis to assess which explanatory variables are associated with the main outcome measure, the presence of necrotic muscle at fasciotomy. We used multivariable regression analysis to determine association accounting for any confounding.

Results: Of 357 cases of ACS of the leg, 14.6% of patients presented with an open fracture and 21.3% of patients were multiply injured. Overall, 14.3% of cases had muscle necrosis at the time of fasciotomy. Fifty-nine percent of patients with necrotic muscle required more than 3 debridements. Open fracture was the only statistically significant predictor of muscle necrosis (OR=2.8). Crush injury (OR=3.1) and soft tissue injuries (OR=2.8) were at an increased odds of necrotic muscle, but only marginally significant.

Conclusion: ACS is a potentially limb threatening condition often associated with poor outcomes, particularly when the diagnosis is delayed. Patients with open fracture have a three-fold increase in odds of necrotic muscle at the time of fasciotomy.

Keywords: ACS; Acute compartment syndrome; Lower extremity; Muscle necrosis; Myonecrosis.

MeSH terms

Adult
Compartment Syndromes / complications*
Compartment Syndromes / surgery*
Debridement / methods
Fasciotomy / methods
Female
Fractures, Open / complications*
Fractures, Open / epidemiology
Humans
Lower Extremity / injuries*
Male
Middle Aged
Muscles / blood supply
Muscles / pathology
Necrosis / etiology
Necrosis / surgery
Retrospective Studies
Soft Tissue Injuries / complications*
Soft Tissue Injuries / epidemiology
Time Factors
Treatment Outcome