Developing an in-vivo physiological porcine model of inducing acute atraumatic compartment syndrome towards a non-invasive diagnosis using shear wave elastography

Compartment syndrome (CS) is a pathological event caused by elevated intracompartmental pressure (ICP); however, changes from the onset of inducing atraumatic CS remained unclear. The study aimed to investigate the physiological changes in a newly developed in vivo porcine acute atraumatic CS model. CS was induced by ischemia–reperfusion injury in the left hind leg of fourteen pigs divided into an echogenicity group (EG) and a shear wave elastography group (SEG). Echogenicity was measured in EG, and shear elastic modulus (SEM) was measured in SEG seven times before, at the onset of inducing CS, and every 30 min after the onset over eight hours. Simultaneously, ICP, blood pressure, and muscle perfusion pressure (MPP) were also measured in both groups. Our results indicate that SEM of the experimental leg in SEG significantly increased as CS developed compared to the control leg (p = 0.027), but no statistical difference in the echogenicity in EG was found between the experimental leg and control leg. There were also significant correlations between SEM and ICP (p < 0.001) and ICP and MPP (p < 0.001). Our method and findings can be a basis to develop a non-invasive diagnostic tool using a shear wave elastography for atraumatic CS.

Hand Compartment Syndrome

Compartment syndrome is defined by high pressures in a closed myofascial compartment, which affects initially the muscles and later the nerves and vessels. The hand is rarely affected, but if treated suboptimally, it results to a permanent loss of function. Eleven compartments are included in the hand and wrist. Diagnosis of compartment syndrome of the hand remains challenging. Pain out of proportion of injury and excessive swelling should raise suspicion towards a compartment syndrome. Intracompartmental pressure measurement contributes to the diagnosis, but it is not always reliable. Once the diagnosis of acute compartment syndrome has been made, decompression of all compartments is mandatory, in order to achieve a good outcome. Failing to manage this emergent condition properly leads to a significant hand disability. Our chapter includes the following sections: 1. Introduction. A brief description of the hand compartment syndrome is presented. 2. Anatomy. Special considerations regarding hand compartments are presented, 3. Etiology. 4. Diagnosis. Signs and symptoms are reported, as well as guidelines of the technique of intracompartmental pressure measurement. 5. Treatment. Faciotomies’ indications and operative technique are described in details. 6. Conclusion. Appropriate figures of the clinical image and surgical decompression are presented as well.

Hemodynamic Assay of Hind Limb in Multiple Animal Models

ABSTRACT Introduction Measuring hemodynamic characteristics of injured limbs is paramount to early identification of potentially damaging ischemic conditions, but can often prove difficult attributable to a multitude of factors. Here, we present an in vivo optical imaging technique to characterize pulsatile blood flow quality through the distal extremity in multiple animal models that replicate the signs of distal extremity ischemia. The purpose of this study is to examine the feasibility of the optical imaging technique and relevance to hemodynamic complications such as acute compartment syndrome (ACS) and nonobvious hemorrhage. Materials and Methods In one pig and six mice, three different methods were used to create ischemic conditions in the lower extremity, producing symptoms similar to what is observed in ACS. In each condition, perfusion to the distal extremity was measured with the hemodynamic detection device (HDD; Odin Technologies), an optical assessment tool for perfusion and blood flow quality. Results We observed a profound decrease in extremity perfusion immediately after onset of ischemia in all three models. In the porcine model, the HDD’s measurements demonstrated similar characteristic flow between the various measurement locations. After the tourniquet was applied, the HDD revealed a 95% decrease in normalized perfusion value (npv) while the intracompartmental pressure rose from 5 to 52 mmHg (a 47mmHg increase). After the tourniquet was removed during reperfusion, the normalized blood flow returned to baseline and the intracompartmental pressure dropped from 20 to 6 mmHg in less than 5 minutes. For each mouse, the HDD test leg demonstrated a measurement of 0.97 npv before femoral ligation and 0.05 npv after femoral ligation, an 89% decrease (P &lt; .01) in flow. Pulsed-wave Doppler ultrasound (PWDU) measurements on the test leg had pre-ligation measurement of 0.84 npv and a post-ligation measurement of 0.001 npv, a 99% decrease. These PWDU measurements revealed almost complete stoppage of blood flow during ischemia, followed by a substantial increase after the femoral artery ligation was removed. Conclusions Here, we show that a novel, optics-based sensing system can be used to diagnose and assess ACS in animal models. This technology is comparable to other standards used to monitor ACS and nonobvious hemorrhage and may also be a plausible alternative to prolonged invasive monitoring of patients with sustained extremity trauma.

A RETROSPECTIVE STUDY OF 16 CASES OF ACUTE COMPARTMENT SYNDROME FOLLOWING SNAKEBITE

Acute compartment syndrome after snakebite is considered to be quite rare and there is still a lot of controversy in regard to its diagnosis and management as it has been reported by the little available medical literature on the topic. It is in this context that our series assumes importance as we report our experience relating to management and outcome of 16 consecutive cases of compartment syndrome from snakebites. A 15-year retrospective study was conducted on all adult patients with compartment syndrome following snakebites, who were admitted between April 2005 and December 2019 in our institution. Due to non-availability of equipment to measure intracompartmental pressure, the diagnosis of compartment syndrome was based on clinical judgment. There were 10 (62.5%) male and 6 (37.5%) female, with a mean age of 32.1 ± 7.8 years. Bite site was mostly in the lower limbs (62.5%). Based on clinical severity, 2 (12.5%), 10 (62.5%) and 4 (25%) patients were classified into classes I, II, and III, respectively. FAV-Afrique® antivenom was administered to 12 (75%) patients in doses ranging from 1 to 5 vials by patients. Fasciotomy was performed in all cases and the median time from admission to surgery was 5.8 hours (range: 4– 9hours). The mean hospital stay was 16 days and follow-up of patients has shown good results: normal limb function was regained in all cases. In summary, acute compartment syndrome following snakebite is not rare in our context and must be treated by performing early fasciotomy without any delay after diagnosis.

Schwannoma of Tibial Nerve; Diagnosis and Management: A Rare Case Report With Brief Review of Literature

Introduction: Schwannomas are benign, encapsulated, silent, and usually solitary tumors originating from Schwann cells of the peripheral nerve sheath. Tibial nerve Schwannomas are very rare hence we are reporting this case for the better understanding of this unusual clinical entity. Case Presentation: A 53-year-old male patient, truck- driver by occupation, arrived to our Plastic Surgery Department complaining of swelling, pain and paresthesia in the upper part of his right leg. These symptoms were present for about 8 months and were more apparent at the end of the day. There was no evidence of any other medical comorbidity like peripheral vascular disease. There was no history of prior traumatic events related to right lower limb. Thorough clinical examination and MRI supported the diagnosis of a benign peripheral nerve tumor and patient was treated by microsurgical excision of the lesion which completely relieved the patient’s symptoms. Discussion: Mechanical compression caused by the space occupying lesion resulted in aggravation of symptoms. Classical burning/shooting pain and paresthesia often manifested by nerve sheath tumors. An increase in intracompartmental pressure resulted in pressure over nerve which consequently led to episodic pattern of neurological symptoms (diurnal variation in pain and paresthesia). Microsurgical excision of the tumor cured the symptoms completely and again patient was able to resume his regular day- to- day activities without any discomfort. Conclusion: We describe a rare case of a patient with an unusual tibial nerve Schwannoma clinical presentation. Microsurgical excision of the space occupying lesion preserving the nerve fascicles play an important role in achieving the good post- surgical outcome. Medical literature on this topic is scarce hence this case report intends to add further data about such pathological conditions

Ultrasound-Guided Proximal and Distal Tarsal Decompression: An Analysis of Pressures in the Tarsal, Medial Plantar, and Lateral Plantar Tunnels

Objectives. To analyze the reliability of measurements of tarsal tunnel and medial and lateral plantar tunnel pressures before and after ultrasound-guided release. Measurements taken were guided by ultrasound to improve reliability. This novel approach may help surgeons make surgical decisions. The second objective was to confirm that decompression using ultrasound-guided surgery as previously described by the authors is technically effective, reducing pressure to the tarsal and medial and lateral plantar tunnels. Methods. The study included 23 patients with symptoms compatible with idiopathic tarsal tunnel syndrome (TTS). The first step was to measure intracompartmental pressure of the tarsal tunnel, medial plantar tunnel, and lateral plantar tunnel preoperatively. The second step was ultrasound-guided decompression of the tibial nerve and its branches. Subsequently, pressure was measured again immediately after decompression in the 3 tunnels. Results. After surgery, the mean values significantly dropped to normal values. This represents a validation of effective decompression of the tibial nerve and its branches in TTS with ultra–minimally invasive surgery. Conclusions. The ultrasound-guided surgical technique to release the tibial nerve and its branches is effective, significantly reducing pressure in the tunnels and, thereby, decompressing the nerves. Level of evidence: Level IV

Historic cohort: outcome of chronic exertional compartment syndrome-suspected patients

IntroductionExercise-related leg pain (ERLP) may be caused by chronic exertional compartment syndrome (CECS), occurring mainly in athletes and military recruits. In military populations, the effectiveness of surgical treatment in CECS is debated. The purpose of this study is to assess the outcome of surgical treatment for CECS in Alrijne Hospital (the Netherlands), a civilian hospital with supraregional referral function.MethodsA historic cohort study was performed on patients with ERLP who were suspected for CECS and were referred for intracompartmental pressure measurement (ICPM) from 2013 to 2017 (n=160). Patient demographics, ICPM and survey response were analysed.ResultsThe mean delay before visitation was 29.0±30.3 months. When comparing surgical-treated patients with CECS with conservative-treated patients with ERLP, surgical-treated patients were more satisfied, reported better recovery towards former level of performance (2.8±2.0 vs 3.9±1.7 and 2.5±1.6 vs 3.2±1.4 on a 7-point Likert scale, respectively) and better subjective injury status (79.3±22.6 vs 63.5±27.4 using the Single Assessment Numeric Evaluation score). Treatment satisfaction was 75.0% in surgical-treated CECS versus 51.4% in conservative-treated ERLP.ConclusionCivilian patients report improved functional outcomes after fasciotomy for CECS. Future research should focus on non-invasive diagnostic options and methods to determine which treatment is the most appropriate for each individual patient.