Abstract
Introduction
Acute compartment syndrome (ACS) of the foot is practically unknown following elective surgeries. Therefore, the purpose of this study is to: 1. investigate the incidence, relative risk (RR) and odds ratio (OD) in relation to the type of foot surgery, 2. to study the benefits of prophylactic decompression of the forefoot on the occurrence of ACS, postoperative pain, hospital stay, additional surgeries and morbidity
Materials and methods
This retrospective study was done in children operated between 2008 and 2022. The feet were divided into group −1 (2008–2018) with no prophylactic decompression of the forefoot and group −2 (2019–2022), with prophylactic decompression of the forefoot at the time of foot surgery. The surgeries performed were divided into 6 types. A single-tailed T-test for unpaired samples was used.
Results
29 feet in 26 children developed ACS in group −1 (1164 feet). 26 feet in 19 children (5.3 %) with ‘risk of ACS’ received a prophylactic decompression in group −2 (482 feet). The overall incidence of ACS in group −1 was 2.49 %, with Talectomy showing the highest relative risk (9.2 %). The mean time to diagnosis was 2.7 days. The pain intensity, duration of hospital stay, additional surgeries and morbidity (42,6 %) were significantly higher in group −1.
Conclusion
Despite the lack of literature on this subject, ACS is a possible complication following a complex elective foot surgery. Rigid foot deformities needing complex corrections are susceptible and therefore, a prophylactic decompression of forefoot is beneficial and reduces morbidity with no complications.
1
Introduction
The acute compartment syndrome (ACS) is a well-known complication following closed limb injuries such as fractures of leg or forearm and crush injuries . It is defined as an increased pressure in a space surrounded by non-expandable structures. . A 2.5 %- 15 % prevalence rate has been reported following diaphyseal fractures of tibia by Mc Queen et al. in adults . It can also occur after reperfusion of an acutely ischaemic limb following arterial anastomosis/ angioplasty (reperfusion injury) . The forearm fractures are the most common cause of ACS in children . Different patho-mechanisms causing an ACS have been described ,, . The age of the patient at the time of injury may also play a role, with older patients being less susceptible to an ACS than children .
The diagnosis of an ACS should be followed by immediate decompression of the involved compartment to prevent irreversible damage, to reduce morbidity and to avoid legal consequences which may be more severe than those for other surgical mistakes . Regional analgesia, polytrauma, paediatric age group, altered consciousness and peripheral nerve injury are said to be the reasons for a missed/delayed diagnosis .
Trauma due to motor-vehicle accidents and fall from height continues to be the leading cause of ACS in the foot ,,,, , with bleeding or oedema being the initiating event . The diagnosis of ACS in the foot may be missed due to lack of suspicion and experience ,, .
Children pose a greater challenge in the diagnosis of ACS than adults . A large review study also identified trauma as the most common cause for ACS in children , of which 4 % of all ACS occurred in the foot. Non-traumatic ACS can occur in children. Livingston et al. described 39 cases of ACS of non-fracture origin , with only 1 case of ACS in the foot. However, its cause was not described. Apart from another case report in adults , no literature exists on ACS of the foot following elective foot surgery neither in adults nor in children. Therefore, the purpose of the study was 1. to describe the incidence, relative risk (RR), Odds Ratio (OR), presenting features and outcomes of an ACS of the foot in children following elective foot surgery, 2. to study the effect of prophylactic foot decompression on the postoperative pain, hospital stay and morbidity following an elective foot surgery. We propose the following hypotheses: 1. the incidence and risk of developing an ACS depends on the type of foot surgery, 2. a prophylactic decompression of the forefoot at the time of foot surgery prevents ACS, reduces the postoperative pain, hospital stay and sequelae.
2
Materials and methods
A retrospective study was done using the hospital database on elective paediatric foot surgeries from January 2008 until April 2022. The study was approved by the ethic committee of Friedrich-Alexander-University, Erlangen-Nürnberg. The inclusion criteria were children and adolescents with foot surgery. ACS of the foot was suspected following an elective foot surgery in the presence of progressive excruciating pain and swelling of the foot not responding to analgesia. The exclusion criterium was post-traumatic ACS of the foot. The data collected from the patient records were; demographics, type of index surgery, time to diagnosis of ACS, post-operative pain (VAS scale), symptoms and signs of ACS, revision surgeries, wound closure, duration of hospital stay and morbidity. Except in children with Myelomeningocele (MMC), all children received a continuous peripheral nerve block with Ropivacaine hydrochloride pump for postoperative pain management, with a possibility of self-administration on-demand. Supplementary intravenous medication and oral analgesics or suppositories were also given in uncontrollable pain. Reporting of severity of pain in children < 7 years and children with MMC, (8 in group −1 and 10 in group −2) was inconsistant due to poor quantification of pain and reliability, and therefore were excluded , .
The index surgery was defined as the surgical correction or a part of it, performed to correct the main component/s of the foot deformity and were classified into; soft-tissue surgeries (tendon lengthening, shortening transfers and capsulotomies), osteotomies (were further classified into hindfoot, midfoot and forefoot osteotomies), arthrodesis (subtalar arthrodesis and midtarsal/ triple arthrodesis), talectomy and arthroereisis. Additional surgeries such as tendon transfers, other osteotomies performed together with the index surgery were also documented but were not further evaluated. For example, if a Cole’s Osteotomy, a supramalleolar osteotomy and Jones Procedure was performed, then Cole was considered as index surgery as it would have the maximum impact on the cavus foot. Similarly, if 2- or 3-level osteotomies were performed as in the correction of a flatfoot, then the osteotomy having the maximum impact on restoring the anatomy of the subtalar and talonavicular joint was taken as index surgery.
The compartment pressures were measured, and ACS was diagnosed until 2019 with a Stryker® device, after which this device was no longer available in European market. Thereafter, the diagnosis ACS was made from 2019 clinically based on the symptoms of break-through pain. The time to the diagnosis of ACS was from the end of the index surgery was documented.
3
Surgical decompression technique
The surgical decompression of the forefoot was done after the diagnosis of ACS in group −1 and prophylactically in group −2 at the time of index surgery. Two incisions placed on the dorsum of the forefoot overlying the shafts of the 2nd and the 4th metatarsals ( Fig. 1 ). The deep fascia was incised, the extensor tendons were retracted, and all interosseous spaces were opened bluntly using a curved mosquito clamp. In addition, the medial, plantar and the lateral compartments were opened bluntly through the same 2 incisions. The primary surgical wounds were reopened when the tension was seen to endanger the skin and covered temporarily with Epigard® (Biovision GmbH, Ilmenau, Germany). Successive wound closure was done between 4th– 12th day using running skin sutures or with full-thickness skin graft and the children were discharged with a circular plaster cast.
Showing the dorsal incisions of decompression used in all the cases in this series. Note the severe swelling of the subcutaneous tissues and the tissue fluid combined with blood oozing from the wounds. The child received a talecotomy for a severe stiff residual clubfoot deformity due to arthrogryposis multiplex congenita.
4
Statistical analysis
The relative risk (RR) and Odds Ratio (OR) of developing ACS was calculated for the type of surgery. In addition, single-tailed T-test for unpaired samples was done to compare age, pain, additional surgeries, hospital stay and morbidity between groups. The significance was set a p < 0.05.
5
Results
A total of 1646 elective foot surgeries were performed between 2008 and 2022. Of these, 1164 were done from 2008 to 2018 (Group −1), in those the decompression of the foot compartments was done following the diagnosis of ACS. Group −2 consisted of 482 elective foot surgeries operated between 2019– 2022. We observed in group −1, a high incidence of ACS in rigid foot deformities following talectomy, Cole midfoot osteotomy or Arthrodesis. Therefore, a prophylactic forefoot decompression at the time of index surgery in 26 rigid foot deformities (5.39 %) requiring one of the above 3 surgeries in group −2 (which were considered as ‘at risk of ACS’), as mentioned in the methods section of the paper. It is our standard practice to operate all the feet under pneumatic tourniquet.
ACS occurred in 29 feet in 26 children in group −1 ( Fig. 2 ) in the postoperative period. Male: female ratio was 17:9, right:left:bilateral ratio was 15:8:3 (6 feet). Group −2 consisted of 26 feet in 19 children ( Table 1 ). Male:female ratio was 11:8. Right:left:bilateral ratio was 9:3:7 (14 feet) The age of the children was not statistically different (p < 0.106) between groups. The demographics, primary medical diagnoses, type of the foot deformity, and index surgery of the children in both groups are presented in Table 1 . Table 2 presents the details of surgery, symptoms and diagnosis of ACS in Group −1.
2a, Showing swelling of the right foot following a Lambrinudi triple arthrodesis for a residual clubfoot deformity in a child with arthrogryposis congenita. Note the tension of the skin between the skin sutures and the skin is tethered between the k-wires. The left non-operated foot is presented for comparison. 2b, Showing extensive swelling of the entire foot following talectomy for a severe congenital clubfoot in a child with arthrogryposis congenita in an another 6- year old child.
Table 1
Demographics, primary medical diagnoses, type of the foot deformity, index surgery, measurement of compartment syndrome and morbidity of the children in both groups.
| Group– 1 | Group– 2 | |
|---|---|---|
| Number of feet operated | 1164 | 428 |
| Number of Children | 26 (with ACS) | 19 (at risk for ACS) |
| Number of Feet | 29 |
26
(with prophylactic decompression) |
| Number of Foot Compartment Syndromes | 29 | 0 |
| Number of Children | 26 | 19 |
| Male | 17 | 11 |
| Female | 9 | 8 |
| Age | 11.1 (SD±5.16) | 9.0 (SD±7) years |
| Side | ||
| Right | 15 | 9 |
| Left | 8 | 3 |
| Bilateral | 3 | 7 |
| Primary Diagnosis | 26 Children (with ACS) | 19 Children (at risk for ACS) |
| Idiopathic clubfoot | 11 | 0 |
| AMC | 7 | 11 |
| MMC | 2 | 0 |
| HSMN | 3 | 2 |
| Cerebral Palsy | 1 | 2 |
| Syndrome | 2 | 2 |
| Muscle Dystrophy | 0 | 2 |
| Foot Deformity | ||
| Recurrent Clubfoot | 16 | 15 |
| Rigid flatfoot (overcorrected clubfoot) | 8 | 4 |
| Pes Cavus | 2 | 5 |
| Neurogenic/Myogenic clubfoot | 1 | 1 |
| Equinus | 2 | 1 |
| Type of surgery causing ACS | ||
| Cole midfoot osteotomy | 8 | 6 |
| Arthrodesis | 15 | 8 |
| Talectomy | 5 | 9 |
| Soft-tissue surgery | 1 | 3 |
| Arthroereisis | 0 | 0 |
| Subtalar Arthrodesis | 0 | 0 |
| Measurement of Compartment Pressures | ||
| Yes | 19 | 0 |
| No | 10 | 0 |
| Morbidity | 17 Feet | 3 Feet |
| Amputations | 2 | 0 |
| Skin-grafting | 5 | 3 |
| Secondary wound healing | 2 | 0 |
| Loss of correction | 6 | 0 |
| Claw toes | 1 | 0 |
| Hypo-/Hyperesthesia | 1 | 0 |
Table 2
Presenting the list of patients and their details including the outcomes in whom an acute compartment syndrome of the foot was diagnosed. Yellow colour filled boxes are bilateral ACS (3 children).
| Sex | Age @ Sx | Side | Dx | FD | Sx | PA | Day until Dx | Symptoms | Skin Necorsis | Wound Deh. | CP | No. of add. Sx | Problems | Skingrafting | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Norm. = 1, Abs. = 2, Hyper = 3 | Yes = 1, No = 2 | Yes = 1, No = 2 | Yes = 1, No = 2 | Yes = 1, No = 2 | Present= 1, Absent = 2 | Yes = 1, No = 2 | Yes = 1, No = 2 | |||||||||||||||
| Cole | Talectomy | Arthrodesis | PTR | Yes = 1, No = 2 | Sensation. | Pain | Perfusion | Blisters | Swelling | Motorik | ||||||||||||
| M | 13,7 | L | Idiop. | OCCF | Y | Y | 3 | 2 | 1 | 1 | 2 | 2 | 1 | 2 | 2 | N/m | 1 | Claw toes, Hyperesthesie Foot Sole | Tendon lengthening | |||
| M | 17,5 | R | Idiop. | OCCF | Y | Y | 5 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | N/m | 4 | 1st Ray Resection | Vac-Dressing | |||
| F | 6,5 | R | Synd. | RCF | Y | Y | 3 | 3 | 1 | 1 | 1 | 1 | 2 | 1 | 1 | N/m | 10 | Loss of correction, Severe complex foot deformity | Skin grafting | |||
| M | 4,8 | L | AMC | RCF | Y | Y | 6 | 1 | 1 | 1 | 1 | 1 | 1 | 2 | 1 | N/m | 1 | None | None | |||
| M | 5,0 | R | AMC | RCF | Y | Y | 1 | 2 | 1 | 1 | 1 | 1 | 1 | 2 | 2 | 31 | 2 | None | None | |||
| M | 15,6 | L | Idiop. | OCCF | Y | Y | 2 | 2 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | N/m | 4 | Necrosisi of Tendoachillis due to skin necrosis leading to Weakness of plantar flexion | Skin grafting | |||
| F | 5,4 | R | AMC | RCF | Y | N | 2 | 3 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 34 | 2 | None | Skin grafting | |||
| F | 14,5 | L | Idiop. | OCCF | Y | Y | 3 | 3 | 1 | 1 | 2 | 1 | 1 | 2 | 2 | 46 | 1 | None | None | |||
| F | 15,3 | R | HSMN | PC | Y | Y | 2 | 2 | 1 | 1 | 1 | 1 | 1 | 2 | 2 | 40 | 1 | None | None | |||
| M | 13,6 | L | HSMN | PC | Y | Y | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2 | 2 | 40 | 2 | None | None | |||
| M | 8,0 | R | AMC | RCF | Y | Y | 5 | 1 | 1 | 1 | 1 | 1 | 1 | 2 | 2 | 64 | 2 | Loss of correction, Recurrent CF | None | |||
| F | 15,4 | L | Idiop. | OCCF | Y | y | 2 | 3 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | N/m | * | Hyperesthesie of the Sole | Secondary Healing | |||
| M | 11,3 | R | Idiop. | Equinus | Y | Y | 2 | 2 | 1 | 2 | 1 | 1 | 1 | 1 | 1 | N/m | 2 | None | Secondary Healing | |||
| M | 6,0 | R | AMC | RCF | Y | Y | 3 | 2 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | N/m | 1 | Loss of correction | None | |||
| M | 16,8 | L | Idiop. | OCCF | Y | Y | 3 | 1 | 1 | 1 | 1 | 1 | 1 | 2 | 2 | 48 | 3 | None | None | |||
| M | 10,8 | R | Idiop. | RCF | Y | Y | 2 | 1 | 1 | 1 | 1 | 1 | 1 | 2 | 2 | 46 | 1 | None | None | |||
| M | 8,9 | L | Idiop. | OCCF | Y | Y | 2 | 1 | 1 | 1 | 1 | 1 | 1 | 2 | 1 | 44 | 2 | None | Vac-Dressing | |||
| M | 9,5 | R | Idiop. | OCCF | Y | Y | 2 | 2 | 1 | 1 | 1 | 1 | 1 | 2 | 1 | 54 | 1 | None | Vac-Dressing | |||
| M | 5,6 | R | MMC | RCF | Y | N | 3 | 2 | 2 | 1 | 1 | 1 | 1 | 2 | 2 | 54 | 2 | None | None | |||
| M | 5,6 | L | MMC | RCF | Y | N | 3 | 2 | 2 | 1 | 1 | 1 | 1 | 2 | 2 | 60 | 2 | None | None | |||
| F | 23,0 | R | Idiop. | RCF | Y | Y | 7 | 2 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | N/m | 1 | Loss of correction | Secondary Healing | |||
| F | 12,8 | R | TSCP | NCF | Y | Y | 2 | 1 | 1 | 1 | 1 | 1 | 1 | 2 | 2 | 40 | 2 | Loss of correction | Rev.Surgery | |||
| F | 4,2 | R | MMC | RCF | Y | N | 3 | 2 | 2 | 1 | 1 | 1 | 1 | 2 | 2 | 43 | 2 | None | None | |||
| F | 4,2 | L | MMC | RCF | Y | N | 3 | 2 | 2 | 1 | 1 | 1 | 1 | 2 | 2 | 57 | 3 | None | None | |||
| M | 16,0 | R | AMC | RCF | Y | Y | 3 | 2 | 1 | 1 | 1 | 1 | 1 | 1 | 2 | 50 | 5 | 1st Ray Amputation, Forefoot Prosthesis | None | |||
| F | 15,7 | R | AMC | RCF | y | y | 2 | 2 | 1 | 1 | 1 | 1 | 2 | 1 | 1 | 75 | 6 | None | Skin grafting | |||
| M | 7,0 | R | AMC | RCF | Y | Y | 2 | 2 | 1 | 1 | 1 | 1 | 2 | 2 | 2 | 58 | 1 | None | None | |||
| F | 16,7 | R | Synd. | Equinus | Y | Y | 1 | 2 | 1 | 1 | 1 | 1 | 2 | 2 | 2 | 56 | 2 | None | None | |||
| M | 5,0 | L | AMC | RCF | y | Y | 3 | 2 | 1 | 1 | 1 | 1 | 2 | 1 | 1 | Nm | 1 | Hyperesthesie Foot Sole | None | |||
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