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CASE REPORT Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 4  |  Page : 262-263
Acute compartmental syndrome developing during knee arthroscopy-A case report


Fujairah Hospital, Fujairah, United Arab Emirates

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How to cite this article:
Dinakar B, Kumar A. Acute compartmental syndrome developing during knee arthroscopy-A case report. Indian J Orthop 2005;39:262-3

How to cite this URL:
Dinakar B, Kumar A. Acute compartmental syndrome developing during knee arthroscopy-A case report. Indian J Orthop [serial online] 2005 [cited 2019 Sep 20];39:262-3. Available from: http://www.ijoonline.com/text.asp?2005/39/4/262/36633

   Introduction Top


Compartment Syndromes are challenging in diagnosis and management. It could be acute or chronic in occurrence and due to many causes [1],[2],[3],[4] . It could be iatrogenic. We are reporting a case of acute compartment syndrome that developed during arthroscopic surgery, on the operating table, when the patient was still under general anaesthesia.


   Case report Top


A 19 year aged male patient presented with a complaint of pain in his left knee. He gave a history of having sustained a twisting injury to the left knee joint while playing football three months prior to reporting to the hospital. Initially at the time of injury he was treated with plaster of Paris slab for ten days and it was followed by physiotherapy to his left knee joint. The patient had pain in his left knee joint, there was history of locking of the joint and the medial joint line was tender. McMurray's test was positive and there was laxity involving the anterior cruciate ligament. X-rays of his left knee was normal. The MRI showed a horizontal tear involving the medial meniscus. There was a partial tear involving the ACL. The lateral meniscus and collateral ligaments were normal. The peripheral pulses, both, posterior tibial and dorsalis pedis on the left lower limb were well felt (normal in both the limbs). The clinical diagnosis of a medial meniscal tear and an ACL tear was made. The patient was admitted to the hospital and he underwent arthroscopy of the left knee joint. A tourniquet was applied and the joint was approached through the standard antero-medial and antero-lateral portals. A Dyonics Arthroscope, of 30 degree angle and 4.5mm cannula was used for the surgery. A pressure pump was used for fluid irrigation. There was a bucket handle tear involving the medial meniscus which was excised with an added mid patellar portal. There was a complete tear involving the ACL. On release of the tourniquet, after completion of the procedure, the calf was swollen and felt tight on the left side. The limb was pale and the capillary filling of the toes on the left side was absent. Both the distal pulses, posterior tibial and dorsalis pedis on that side were absent. Pulse oximetry over the second toe on the left side did not record oxygenation. The clinical diagnosis of an acute compartment syndrome was made. We did not record intra-compartment pressures and while the patient was still under general anaesthesia, an emergency fasciotomy was done using a postero-medial approach. There was swelling and tension involving all the four compartments. When the incisions were made, there was visible muscle bulging in all the compartments. The circulation to the extremity returned immediately after decompressing all the compartments. Both the peripheral pulses (dorsalis pedis, posterior tibial) were well felt and the volume of pulse was normal compared to the right side. The wound was left open. The oxygen saturation over the second toe on the left side was 100% oxygenation. The wound was re-inspected at the end of 48 hours. The swelling had decreased and delayed closure of the wound was done. The post-operative course was uneventful and the patient was discharged home 5 days later. He was advised to continue physiotherapy for his knee joint, to wear a knee brace and to avoid contact sports (due to the presence of ACL tear). During the postoperative period, the wound healed by primary intention and there was no neurologic or vascular deficits. The patient is now ambulatory and he is involved in routine activities other than contact sports. He has no pain or locking episodes, but his ACL is lax which in the future may need reconstruction.


   Discussion Top


Compartment syndromes are progressive, self­perpetuating conditions that could lead to neurovascular ischaemia. The causes are numerous like; direct trauma, local perfusion or extravasation of fluids, prolonged pressure over an area, pressure due to splints, acute or chronic sports injury, post surgery, drug abuse, local hematoma due to trauma or due to bleeding conditions, post arthroscopy [5],[6],[7],[8] , presence of aberrant fascia, prolonged usage of leg supports during surgery [9] , knee chest position during surgery and theophylline infusion. This complication can occur during arthroscopy, though it is uncommon, it could be potentially devastating. Though, the fluid extravasation can occur in many patients during arthroscopy (incidence 1.4%), it is serious, only in rare cases. The mechanism is presumed to be due to the leakage of irrigation fluid, through capsular and fascial defects into the muscular compartments of the leg. An inelastic fascial membrane that, does not allow much muscle expansion when significant oedema occurs, covers each muscle group of the leg. This is the main cause for development of compartment syndromes. Any compartment in the leg, (example: anterior, lateral, deep and superficial) or all the compartments could be involved. Rarely compartment syndrome may be due to deep vein thrombosis [4] .

Compartment syndromes should be diagnosed clinically and it may be confirmed by intra-compartment pressure recordings. High index of suspicion is necessary. Bomberg et al described four complications resulting from the use of automated pump arthroscopy in 283 patients [6] . In our case we felt the cause might have been due to a combination of factors like presence of fascial defects and high infusion pressure. During arthroscopy procedure, a close watch should be placed over the infusion pressure and extravasation of fluid and in cases where there is a possibility of extravasation, calf and thigh should be observed and palpated frequently for the tenseness of the compartment. We believe that this complication must be kept in mind during arthroscopy and must be avoided.

When compartment syndromes are suspected, the important immediate measure is wide-splitting of any constricting dressings that have been applied. Surgery is the treatment of choice, which requires long incisions of the skin and fascia, splitting of the retinaculae, excision of necrotic tissue and evacuation of the hematoma. The skin is left open and closed 2-8 days later. The fasciotomy could be done with a single incision, or double incisions. The single incision is over the lateral aspect of fibula, while the double incisions include both lateral and postero-medial incisions. The incisions could be short (4-8cms), or long incisions (15­30cms) [3] . We believe in long longitudinal incisions made over the compartment. Mckenny et al described a mechanical method of fasciotomy wound closure that is effective in 2­4days [10] . Cooper has described a single incision, four compartment fasciotomy of the leg [11] .

Acute compartment syndrome is a possibility during arthroscopic procedures. The cause is due to extravastion of fluid during the procedure. Extravasation may be due the presence of fascial defects, previous knee trauma possibly causing injury to capsule and the ligaments. This may also be due to high pressures in the pressure pump used for fluid irrigation in this case. We feel that the pressure must not exceed 50-60 mm hg during the procedure. Still better, may be the fluid flow should be by gravity alone. This complication should be kept in mind during arthroscopy and if it occurs, it is a serious condition, which needs to be detected promptly and treated immediately by surgery.

Acknowledgements: We acknowledge the help received from Dr. Tariq Khan. FRCS, and Dr. Kavya Dinakar, in preparing this article

 
   References Top

1.Canale ST. Cambell's Operative Orthopedics. 9th edition. Mosby Pub­lication. 1998. 1405-1411.  Back to cited text no. 1    
2. Swain R, Ross D. Lower extremity compartment syndrome. Post­graduate Medicine Online. The McGraw-Hill Company. 2004.  Back to cited text no. 2    
3. Cohen MS,.Garfin SR, Hargens AR, Mubarak SJ. Acute compart­ment syndrome. J Bone Joint Surg (Br).1991;73:287-90.  Back to cited text no. 3    
4. Rahm M, Probe R. Extensive deep venous thrombosis resulting in compartment syndrome. J Bone Joint Surg (Am).1994; 76:1854-1857.  Back to cited text no. 4    
5. Shands PA, Jansson KA. Compartment syndrome of the thigh as a complication of arthroscopy: A case report and review of literature. Medscape Gen Med. (1). 1999.  Back to cited text no. 5    
6. Bomberg BC, Hurley PE, Clark CA, McLaughlin CS. Complication associated with the use of an infusion pump during knee arthroscopy. Arthroscopy. 1992;8(2):224-8.  Back to cited text no. 6    
7. Allum R. Complications of arthroscopy of the knee. J Bone Joint Surg (Br). 2002; 84; 937-945.  Back to cited text no. 7    
8. Belanger M, Fadale P. Compartment syndrome of the leg after arthroscopic examination of a tibial plateau fracture. A case report and review of the literature. Arthroscopy. 1997; 13(5):646-51.  Back to cited text no. 8    
9. Bergqvist D, Bohe M, Ekelund G, Hellsten S et al. Compartment syndrome after prolonged surgery with leg supports. Int J Colorectal Dis.1990; 5(1):1-5.  Back to cited text no. 9    
10. McKenney MG, Nir I, Fee T, Martin L, Lentz K. A simple device for closure of fasciotomy wound. Am J Surg. 1996;172 (3):275-7.  Back to cited text no. 10    
11. Cooper GG. A method of single incision, Four compartment fasciotomy of the leg. Eur J Vasc Surg. 1992;6(6):659-61.  Back to cited text no. 11    

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Correspondence Address:
B Dinakar
P.O. box no 10, Fujairah Hospital, Fujairah
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.36633

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