The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 88, Issue 4

Scientific Articles | April 01, 2006

Functional Outcome After Acute Compartment Syndrome of the Thigh

Kai Mithoefer, MD¹; David W. Lhowe, MD²; Mark S. Vrahas, MD²; Daniel T. Altman, MD³; Vanessa Erens, DPT⁴; Gregory T. Altman, MD³

¹ Harvard Vanguard Orthopedics and Sports Medicine, Brigham and Women's Hospital, 230 Worcester Street, Wellesley, MA 02481. E-mail address for K. Mithoefer: kmithoefer@partners.org
² Department of Orthopedic Surgery, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114
³ Allegheny General Hospital, 1307 Federal Street, 2nd Floor, Pittsburgh, PA 15212
⁴ Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215

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The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at Brigham and Women's Hospital, Massachusetts General Hospital, and Beth Israel Deaconess Medical Center, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2006 Apr 01;88(4):729-737. doi: 10.2106/JBJS.E.00336

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Abstract

Background: Acute compartment syndrome of the thigh is an uncommon condition that is associated with a high rate of morbidity. Because of its rarity, limited information is available on the long-term functional outcome for patients with this condition and the factors that affect the clinical result.

Methods: Eighteen patients with acute compartment syndrome of the thigh were evaluated at an average of sixty-two months after treatment. Functional outcome was evaluated by means of physical examination, isokinetic thigh-muscle testing, and validated functional outcome scores.

Results: Long-term functional deficits were present in eight patients, and only five patients had full recovery of thigh-muscle strength. The persistent dysfunction was reflected in worse overall functional outcome scores. High injury severity scores, ipsilateral femoral fracture, prolonged intervals to decompression, the presence of myonecrosis at the time of fasciotomy, and an age of more than thirty years were associated with increased long-term functional deficits, persistent thigh-muscle weakness, and worse functional outcome scores.

Conclusions: Acute compartment syndrome of the thigh is often associated with considerable long-term morbidity. Several factors can affect the functional outcome, and knowledge of these factors can help in the development of a more effective clinical management strategy to reduce long-term morbidity.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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Acute compartment syndrome of the thigh is being reported with increasing frequency, but information in the literature remains largely limited to small series and individual case reports. Schwartz at al. described seventeen patients who had acute compartment syndrome of the thigh after trauma and reported a short-term morbidity of 78% and an associated mortality rate of 47%¹. In contrast, some individual reports have demonstrated good functional recovery after acute compartment syndrome of the thigh^2-4. Because of its rarity and clinical variability, no information is available on the functional outcome following this potentially devastating condition. Because of the lack of outcome data, little information is available on the factors that influence clinical outcome. As a result, the treatment of acute compartment syndrome of the thigh is still not clearly established^4,5.

Previous studies have suggested that the clinical spectrum of compartment syndrome of the thigh may be comparable with that of compartment syndrome in other anatomic regions^1,5. Factors that have been found to affect the clinical results in other anatomic regions include compartment pressure, the duration of tissue pressure elevation, and associated injuries^5-7. We hypothesized that these factors also may affect the clinical outcome after acute compartment syndrome of the thigh. To investigate this hypothesis, we assessed functional outcome in a large cohort of patients with acute compartment syndrome of the thigh on the basis of a combination of clinical examination, isokinetic thigh-muscle testing, and validated functional outcome questionnaires. The association of the results with demographic and clinical data was then analyzed to identify factors that can affect the clinical outcome after acute compartment syndrome of the thigh.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

The study was approved by the institutional review board, and all patients signed an informed consent form before participation. Previously described methods were used to locate patients for follow-up⁸. Retrospective analysis of the hospital charts identified twenty-seven patients who had been managed for acute compartment syndrome of the thigh between January 1990 and December 2000. Of the twenty-seven patients, three had died from multiple trauma during the initial hospitalization and one had died from unrelated causes during the interval until follow-up. All patients with an injury severity score of >12 (two patients), an ipsilateral tibial fracture (one patient), contralateral leg injuries (one patient), insufficient documentation (two patients), or less than twelve months of follow-up after the injury (one patient) were excluded; some patients met more than one of these exclusion criteria. In patients with an ipsilateral femoral fracture, radiographic evidence of healing was required for inclusion in the study. Eighteen of the surviving twenty-three patients with acute compartment syndrome of the thigh were included in the study on the basis of these criteria. Seventeen of these eighteen patients were male. The average age (and standard deviation) was 37 ± 4 years (range, eighteen to seventy-two years), and the average duration of follow-up after the injury was 62 ± 8 months (range, fourteen to 122 months).

The diagnosis of acute compartment syndrome of the thigh was based on the diagnostic criteria previously described for acute compartment syndrome^6,7. Diagnostic symptoms included thigh pain out of proportion to the injury, severe swelling and induration of the involved compartment, increased thigh circumference, pain with passive stretch, weakness of the involved thigh muscles, or sensory or motor deficits in the anatomic distribution of the nerves contained in the involved compartment (Table I). A tense, severely painful thigh was present at the time of the initial presentation in eighteen patients, and pain with passive stretch was present in eleven patients. Sensory deficits were found in thirteen patients and variably included the saphenous, anterior femoral cutaneous, obturator, peroneal, and tibial nerve distributions. Motor deficits involving the quadriceps, extensor hallucis longus, and gastrocnemius-soleus muscles initially were present in nine patients. Because of their nonspecific diagnostic value, decreased or absent distal pulses in the involved extremity were not used as a diagnostic sign. While the sensitivity of individual symptoms can be low, the combination of three diagnostic symptoms has been shown to correctly diagnose compartment syndrome in 93% of cases⁹. Each patient in the study had three or more of these clinical symptoms. Acute compartment syndrome of the thigh was diagnosed by the treating surgeon on the basis of the documented diagnostic clinical symptoms and supplemented by the measurement of intracompartmental pressures. Compartment pressures were documented in all patients with use of a handheld monitoring device (Stryker, Kalamazoo, Michigan) but had only an adjunctive role in the diagnosis. In thirteen patients, more than one pressure measurement was documented at different time-points and the mean pressure values for each compartment were used for calculations. Compartment pressures were available in the anterior compartment (all patients), the posterior compartment (twelve patients), and the medial compartment (four patients). The average pressure was 70 ± 4 mm Hg in the anterior compartment, 55 ± 8 mm Hg in the posterior compartment, and 34 ± 7 mm Hg in the medial compartment. The measured compartment pressures ranged from 12 to 120 mm Hg, including the values for involved and uninvolved compartments. All patients had at least one thigh compartment with a pressure of >50 mm Hg. The average difference between diastolic blood pressure and compartment pressure (that is, the average differential pressure [?P]) was 32 ± 5 mm Hg (range, 0 to 68 mm Hg).

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TABLE I Compartment-Specific Diagnostic Criteria of Acute Compartment Syndrome of the Thigh

Thigh Compartment	Clinical Symptoms
Anterior compartment
Pain with passive stretch	Passive knee flexion with hip in extension
Motor deficit	Knee extension
Sensory deficit	Lateral, intermediate, and medial thigh (femoral nerve cutaneous branches), medial calf and foot (saphenous nerve)
Posterior compartment
Pain with passive stretch	Passive knee extension with hip in flexion
Motor deficit	Knee flexion, plantar flexion (sciatic tibial branch), dorsiflexion, great toe extension (peroneal branch)
Sensory deficit	Plantar foot (tibial branch), dorsal foot and first web space (peroneal branch)
Medial compartment
Pain with passive stretch	Passive hip abduction with knee in extension
Motor deficit	Hip adduction
Sensory deficit	Proximal-medial thigh (obturator nerve cutaneous branch)

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TABLE I Compartment-Specific Diagnostic Criteria of Acute Compartment Syndrome of the Thigh

Thigh Compartment	Clinical Symptoms
Anterior compartment
Pain with passive stretch	Passive knee flexion with hip in extension
Motor deficit	Knee extension
Sensory deficit	Lateral, intermediate, and medial thigh (femoral nerve cutaneous branches), medial calf and foot (saphenous nerve)
Posterior compartment
Pain with passive stretch	Passive knee extension with hip in flexion
Motor deficit	Knee flexion, plantar flexion (sciatic tibial branch), dorsiflexion, great toe extension (peroneal branch)
Sensory deficit	Plantar foot (tibial branch), dorsal foot and first web space (peroneal branch)
Medial compartment
Pain with passive stretch	Passive hip abduction with knee in extension
Motor deficit	Hip adduction
Sensory deficit	Proximal-medial thigh (obturator nerve cutaneous branch)

The compartment syndrome had resulted from contusion in eight patients, motor vehicle trauma in seven, and penetrating trauma, femoral artery injury, or isolated thigh compression in one patient each. Twelve patients had involvement of the left thigh and six had involvement of the right thigh, with fifteen patients having involvement of the dominant side. The average injury severity score was 5.4 ± 1 points (range, 1 to 12 points). A closed ipsilateral femoral fracture was present in seven patients. Creatine-phosphokinase levels were elevated to an average of 14,891 ± 5969 mU/mL (range, 297 to 84,840 mU/mL). All patients were managed with fasciotomy. Surgical decompression was performed in the anterior compartment (eighteen patients), posterior compartment (eighteen patients), and medial compartment (four patients). The time from injury to surgical decompression, as determined from prehospital records, emergency room notes, and operative records, averaged 10.2 ± 1.8 hours (range, two to thirty-six hours). Intraoperatively, edematous but viable muscle was observed in twelve cases and myonecrosis was present in six. For the seven femoral fractures, stabilization was achieved by means of reamed intramedullary nailing in six patients and plate fixation in one.

Functional Outcome Evaluation

All eighteen patients completed the Short Musculoskeletal Function Assessment questionnaire (SMFA)¹⁰ and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) (version 1.0)¹¹. The SMFA questionnaire recently has been validated for traumatic conditions and provides a disability index and bother index score, with lower scores representing better function. Four patients were not available for follow-up examinations, including two patients with contusions, one patient with a femoral fracture secondary to motor-vehicle trauma, and one patient with penetrating trauma. Fourteen of the eighteen patients were available for follow-up clinical examination and isokinetic thigh-muscle testing. Six of these patients had experienced an ipsilateral femoral fracture. Patients with and without a femoral fracture were not different in terms of age (r = 0.395, p = 0.105), compartment pressure (r = 0.147, p = 0.574), etiology (r = 0.532, p = 0.078), time from injury to follow-up (r = 0.279, p = 0.261), or time to decompression (r = 0.272, p = 0.276), but the presence of a femoral fracture was correlated with the prevalence of myonecrosis (r = 0.645, p < 0.01). Followup clinical examination included goniometric analysis of range of motion of the knee, measurement of thigh circumference 12 cm proximal to the superior pole of the patella, evaluation of sensory and motor function, gait analysis, and evaluation for patellofemoral pain. The presence of decreased knee range of motion, permanent muscle weakness, persistent sensory deficits, patellofemoral pain, or a limp was defined as a long-term functional deficit. The use of analgesics or supportive devices also was recorded. Radiographs were made and reviewed for evidence of myositis ossificans.

Isokinetic Thigh-Muscle Testing

Isokinetic testing of concentric muscular strength in the thigh was performed with an isokinetic dynamometer (Lido-Active, Loredan Biomedical, Sacramento, California) according to previously described principles¹² and was supervised by an independent physical therapist (V.E.) who was experienced in isokinetic muscle testing and was unaware of the patient's clinical history. After gravity correction, the patients were allowed five to ten submaximal contractions at each test speed for familiarization and warm-up. The uninvolved extremity was tested first. Each subject performed five flexions and extensions as forcefully as possible at a fixed speed of 90° per second to measure voluntary maximum torque output. The peak torques of knee extension and flexion were used to evaluate maximum strength. After a standardized period of rest, the patients then performed twenty consecutive extensions and flexions at 240° per second in order to evaluate endurance. The results for the involved extremity were compared with those for the uninvolved, contralateral side. The quadriceps-hamstring ratio was calculated to identify persistent reciprocal thigh-muscle imbalance. No testing of the adductor compartment was performed. To identify any predictors of clinical outcome, the results of clinical follow-up examinations, isokinetic testing, and validated outcome scores were related to the demographic and clinical data obtained from the medical records.

Statistical Analysis

Statistical analysis was performed with use of SPSS software (version 11.0; SPSS, Chicago, Illinois). Intergroup and intragroup comparisons between parameters were tested with the t test and the paired t test, respectively. Differences between variable proportions were evaluated with chi-square analysis. For testing relationships between variables, correlation analysis was used. The level of significance was set at p < 0.05.

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Fig. 1: Graph illustrating the difference of SF-36 outcome scores in the presence (black) and absence (gray) of ipsilateral femoral fracture, delayed fasciotomy, an age of more than thirty years, or myonecrosis in patients with acute compartment syndrome of the thigh (^*p < 0.05, ^**p < 0.01).

Results

Materials and Methods | Results | Discussion | Appendix | References

Four patients had a persistent limp, and three regularly used supportive devices. Only one patient admitted to frequent analgesic use. Bulging of the thigh muscle through the persistent fascial defect was noted in all patients but was not described as symptomatic. Muscle-wasting at the time of follow-up was present in six patients and averaged 2.5 ± 0.6 cm (range, 1 to 4 cm). Decreased knee flexion was present in four of fourteen patients, with an average loss of 27° ± 6° (range, 15° to 40°). Patellofemoral pain was reported by five patients and was more frequent in patients with persistent muscle-wasting (p < 0.01). Myositis ossificans was observed in six patients. None of these patients had had an associated head injury. Persistent sensory deficits were present in six patients and were located in the saphenous nerve distribution in five patients and in the superficial and deep peroneal nerve distributions in one. Persistent palsy of the gastrocnemius-soleus musculature was observed in one patient and in the peroneals and extensor hallucis longus in another.

Isokinetic testing, performed at a mean of 62 ± 8 months after the acute compartment syndrome of the thigh, showed that average quadriceps and hamstring strength and endurance were decreased relative to those in the contralateral, uninjured limb (Table II). Nine patients had not recovered full thigh-muscle strength, with eight patients having persistent thigh-muscle imbalance (average quadriceps-hamstring ratio, 1.3 ± 0.1).

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TABLE II Isokinetic Testing Results in Patients with Acute Compartment Syndrome of the Thigh

Isokinetic Parameters	Average	Patients With Long-Term Functional Deficit	Patients Without Long-Term Functional No Deficit
Strength (90°/s)^*
Quadriceps	72 ± 12	48 ± 15	97 ± 16†
Hamstring	52 ± 8	36 ± 10	67 ± 11
Endurance (240°/s)^*
Quadriceps	86 ± 12	76 ± 16	104 ± 12
Hamstring	74 ± 11	81 ± 12	95 ± 9
Quadriceps-hamstring ratio
Involved limb	1.3 ± 0.1	1.2 ± 0.2	1.5 ± 0.1
Uninvolved limb	1.9 ± 0.1†	1.8 ± 0.1†	1.9 ± 0.2

The values are expressed as a percentage of the value for the contralateral thighp < 0.05

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TABLE II Isokinetic Testing Results in Patients with Acute Compartment Syndrome of the Thigh

Isokinetic Parameters	Average	Patients With Long-Term Functional Deficit	Patients Without Long-Term Functional No Deficit
Strength (90°/s)^*
Quadriceps	72 ± 12	48 ± 15	97 ± 16†
Hamstring	52 ± 8	36 ± 10	67 ± 11
Endurance (240°/s)^*
Quadriceps	86 ± 12	76 ± 16	104 ± 12
Hamstring	74 ± 11	81 ± 12	95 ± 9
Quadriceps-hamstring ratio
Involved limb	1.3 ± 0.1	1.2 ± 0.2	1.5 ± 0.1
Uninvolved limb	1.9 ± 0.1†	1.8 ± 0.1†	1.9 ± 0.2

The values are expressed as a percentage of the value for the contralateral thighp < 0.05

Short Musculoskeletal Function Assessment (SMFA) scores demonstrated an average disability index of 25 ± 5.6 (range, 0 to 71) and an average bother index of 30 ± 6.6 (range, 0 to 88). The average SF-36 scores are shown in the Appendix. Better SF-36 and SMFA scores were associated with greater quadriceps strength at the time of follow-up (Table III).

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TABLE III Correlation of Outcome Scores with Clinical Parameters

	Pearson Correlation Coefficient (r)
	SF-36 Physical Component Score	SMFA Disability Index	SMFA Bother Index
Injury severity score	—0.630^*	0.583†	0.597^*
Age	—0.710‡	0.656^*	0.547†
Serum creatine-phosphokinase	—0.202	0.224	0.057
Compartment pressure	—0.132	0.190	0.148
Differential pressure	0.135	—0.138	—0.148
Time to fasciotomy	—0.568†	0.418§	0.639^*
Isokinetic quadriceps strength	0.702^*	—0.850‡	—0.587†

p < 0.01p < 0.05p < 0.001p = 0.08

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TABLE III Correlation of Outcome Scores with Clinical Parameters

	Pearson Correlation Coefficient (r)
	SF-36 Physical Component Score	SMFA Disability Index	SMFA Bother Index
Injury severity score	—0.630^*	0.583†	0.597^*
Age	—0.710‡	0.656^*	0.547†
Serum creatine-phosphokinase	—0.202	0.224	0.057
Compartment pressure	—0.132	0.190	0.148
Differential pressure	0.135	—0.138	—0.148
Time to fasciotomy	—0.568†	0.418§	0.639^*
Isokinetic quadriceps strength	0.702^*	—0.850‡	—0.587†

p < 0.01p < 0.05p < 0.001p = 0.08

Several factors were found to be associated with the prevalence of long-term functional deficits, isokinetic thigh-muscle weakness, and outcome scores after thigh compartment syndrome. Patients younger than thirty years of age had a lower prevalence of myositis ossificans (p < 0.05) and had significantly better outcome scores than older patients did (Figs. 1 and 2). In fact, younger age correlated with better outcome scores (Table III).

Injury severity scores in patients with long-term functional deficits were higher than those in patients without deficits (8.9 ± 1.1 compared with 1.5 ± 0.5; p < 0.001). Higher injury severity scores also were observed in patients with muscle-wasting (8.7 ± 1.7 compared with 2.7 ± 1.0; p < 0.01) and were associated with decreased quadriceps strength (r = -0.594, p < 0.05) and worse SF-36 and SMFA scores (Table III).

Ipsilateral femoral fracture was associated with long-term functional deficits in every patient, while deficits were present in only two patients with isolated thigh compartment syndrome (p < 0.05). Quadriceps and hamstring strength was significantly lower in patients with a femoral fracture than in patients without a femoral fracture (Fig. 3), and thigh-muscle imbalance was more profound in patients with a femoral fracture than in those without a femoral fracture (average quadriceps-hamstring ratio, 1.1 ± 0.1; p < 0.05). This finding was consistent with a higher prevalence of muscle-wasting in patients with a femoral fracture (p < 0.05). In addition, patellofemoral pain was more frequent in patients with an ipsilateral femoral fracture (p < 0.05). Importantly, the presence of a femoral fracture was associated with significantly worse functional outcome scores (Figs. 1 and 2).

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Fig. 2: Graph illustrating the Short Musculoskeletal Function Assessment (SFMA) disability index (black and blue bars) and bother index (white and yellow bars) in patients with acute compartment syndrome of the thigh in the presence (black and white bars) and absence (blue and yellow bars) of ipsilateral femoral fracture, delayed fasciotomy, an age of more than thirty years, or myonecrosis. Lower values reflect better clinical function (^*p < 0.05, +p < 0.01).

Long-term functional deficits occurred more frequently in patients with evidence of myonecrosis at the time of fasciotomy (p < 0.05) (Fig. 4), and the average creatine-phosphokinase level in patients with myonecrosis was higher than that in patients without myonecrosis (34,116 ± 17,297 compared with 6882 ± 2873 mU/mL; p < 0.05). Intraoperative evidence of myonecrosis was associated with decreased quadriceps strength (Fig. 3) and persistent thigh-muscle imbalance (p < 0.05).

Seven patients in whom the interval to decompression had been more than eight hours had long-term functional deficits, compared with only one patient in whom the interval had been shorter (p < 0.05) (Fig. 4). In patients with high compartment pressures (>70 mm Hg), long-term functional deficits were already observed after even shorter pressure durations of six hours (p < 0.05). Patients in whom the time to decompression had been more than eight hours had significantly more frequent muscle-wasting (p < 0.05), lower quadriceps strength (p < 0.01) (Fig. 3), and worse SF-36 and SMFA scores than did patients with a shorter time to decompression (Figs. 1 and 2, Table III).

With the numbers available, no significant association was found between the absolute compartment pressure or the differential pressure (the difference between diastolic blood pressure and compartment pressure) and functional outcome scores, thigh-muscle strength, or the prevalence of long-term deficits (Table III). However, a differential pressure of <30 mm Hg was associated with a significant increase in myonecrosis (p < 0.05).

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Fig. 3: Graph illustrating concentric quadriceps strength 62 ± 8 months after acute compartment syndrome of the thigh in the presence (black) and absence (gray) of ipsilateral femoral fracture, delayed fasciotomy, an age of more than thirty years, or myonecrosis. The values are expressed as percentages of the value for the uninjured, contralateral extremity (^*p < 0.05).

Discussion

Materials and Methods | Results | Discussion | Appendix | References

In contrast to the leg, limited experience exists with acute compartment syndrome of the thigh^1,4,5. To date, we are aware of only two studies involving more than ten patients with this condition^1,5. Both of those studies described the spectrum of acute compartment syndrome of the thigh but provided little information on long-term function after acute compartment syndrome of the thigh or the factors that influence the clinical outcome. This lack of knowledge stands in direct contrast to the substantial morbidity and mortality that have been described for this clinical entity¹. Because of the absence of outcome data, the clinical treatment of thigh compartment syndrome is still debated^1,4,5. The present study provides the first specific information on clinical outcome in patients with this condition, and we have demonstrated that 64% of patients did not recover full thigh-muscle strength and that 57% had long-term functional deficits, which was reflected in worse functional outcome scores at a mean of sixty-two months after the injury. These data confirm the serious nature of this orthopaedic emergency and emphasize the need for more effective treatment.

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Fig. 4: Graph illustrating the prevalence of long-term functional deficits after acute compartment syndrome of the thigh in the presence (black) and absence (gray) of ipsilateral femoral fracture, delayed fasciotomy, an age of more than thirty years, or myonecrosis (^*p < 0.05).

The shortcomings of the present study included the limited number of patients, the lack of a control group, and the retrospective patient analysis. However, because of the rarity of acute compartment syndrome of the thigh, large prospective and controlled studies of this condition are difficult to achieve. Despite these limitations, we were able to identify several factors that were associated with functional outcome after acute compartment syndrome of the thigh.

Ipsilateral femoral fracture in patients with acute compartment syndrome of the thigh resulted in significantly worse functional outcome scores, decreased thigh-muscle strength, and a higher rate of long-term functional deficits. Fracture may be of critical importance as it implies a very high-energy injury. Previous authors have pointed out the increased prevalence of myonecrosis in patients with concomitant femoral fracture as compared with those with isolated acute compartment syndrome of the thigh⁵. The previously described energy-dependent microscopic and macroscopic muscle-fiber disruption, infiltrative muscle-bleeding, and marked microcirculatory impairment after blunt muscle trauma could explain the higher rate of myonecrosis, persistent thigh atrophy, muscle weakness, and contracture after compartment syndrome associated with an ipsilateral femoral fracture^13-16. Permanent quadriceps impairment has been reported in as many as 39% of patients with femoral fracture without compartment syndrome and is thought to be related to the amount of muscle damage caused by the initial displacement of the fracture^17-20. Compared with these age and severity-matched historic controls, 83% of patients with combined femoral fracture and acute compartment syndrome of the thigh had persistent thigh-muscle weakness in our study. This finding suggests that compartment syndrome of the thigh and femoral fracture may act synergistically to augment muscular injury. Persistent muscle weakness offers a plausible explanation for the worse functional outcome scores in this group of patients as well, and the resultant overload of the skeleton may be responsible for the high rate of patellofemoral symptoms observed in patients with concomitant femoral fracture²¹.

Myonecrosis at the time of fasciotomy was associated with higher long-term functional deficits and persistent thigh-muscle dysfunction. Myonecrosis in patients with acute compartment syndrome results from skeletal muscle ischemia caused by impairment of intramuscular microcirculation by both trauma and increased compartment pressures, leading to irreversible muscle degeneration^15,22,23. The present study demonstrates that development of irreversible myoneural damage in association with acute compartment syndrome of the thigh has important long-term functional implications and emphasizes the importance of a preventative treatment strategy. In contrast with the observational approach proposed by some authors⁴, a proactive diagnostic approach and swift surgical decompression should be exercised to avoid severe long-term dysfunction^24-26.

Myositis ossificans has been reported in 43% of patients with compartment syndrome of the thigh but in only 9% of patients with quadriceps contusions^1,5,27. Previous studies have indicated that myositis ossificans is related to injury severity²⁷, which is consistent with the higher rates of myositis ossificans in patients with myonecrosis and ipsilateral femoral fracture in our study. While myositis ossificans has been described in 30% to 36% of patients with femoral fractures that are treated with reamed intramedullary nailing, it is frequently limited to the hip abductors and is thought to be caused by debris from reaming^28,29. While the prevalence of myositis ossificans was considerable in our patients with compartment syndrome of the thigh, we were unable to demonstrate that myositis ossificans had a significant effect on long-term outcome in our patients.

Absolute compartment pressure or differential pressure (the difference between diastolic blood pressure and compartment pressure) alone did not affect the outcome of acute compartment syndrome of the thigh in our study. Absolute compartment pressure also did not affect the outcome following tibial fracture in patients with a differential pressure of >30 mm Hg³⁰. Compartment pressures of 30 mm Hg^26,31 or 45 mm Hg⁶ or a differential pressure of <30 mm Hg³² have been shown to cause myonecrosis and have been proposed as indicators for fasciotomy. However, the use of generalized pressure thresholds is still controversial and may be of limited value because ischemic muscle tolerance can be influenced by multiple factors, such as the amount of tissue trauma^15,33, associated neurologic dysfunction³⁴, compartment pressure^7,23,25, differential pressure^35-37, pressure duration³⁷, the presence of a previous ischemic insult^26,36, anatomic variations^25,38, muscle energy metabolism³⁹, the autoregulatory capacity of muscle microcirculation^15,33, and systemic adrenergic response⁴⁰. The multifactorial variability of ischemic muscle tolerance in each individual patient would explain our inability to detect a pressure threshold or effect of differential pressure and compartment pressure on functional outcome. While an absolute pressure threshold remains to be established for the thigh, our study demonstrated that pressures of >70 mm Hg call for expedited surgical decompression. The increased prevalence of myonecrosis in our patients with a differential pressure of <30 mm Hg suggests that differential pressure may be a more useful clinical indicator for fasciotomy in the thigh than absolute intracompartmental pressure is. Larger, prospective studies specifically designed to address this issue may be able to identify a critical pressure threshold in the human thigh.

Patients with decompression within eight hours had significantly better outcome scores, significantly greater isokinetic thigh-muscle strength, and a significantly lower prevalence of long-term functional deficits. Similarly, in other studies, early fasciotomy decreased the acute complication rate from 54% to 4% and residual myoneural dysfunction from 92% to 32%⁴¹, with better functional outcome in the leg⁴². Experimental studies have demonstrated that prolonged pressure elevation exacerbates microcirculatory impairment, increases neutrophil-induced reperfusion injury, and markedly depletes intramuscular high-energy phosphates, with resultant irreversible ultrastructural tissue damage^43-45. Those findings are consistent with the increased prevalence of myonecrosis observed in our patients with delayed fasciotomy and could explain the inferior functional outcome in these patients. Our observation that high compartment pressures caused long-term functional deficits even after shorter pressure durations suggests that the pressure level affects the time window until irreversible neuromuscular damage occurs as a result of acute compartment syndrome of the thigh. Pressure duration has been found to be equally important for the development of irreversible myoneural injury in other anatomic areas⁶. Our findings underscore the importance of emergent surgical decompression in the prevention of long-term functional deficits resulting from acute compartment syndrome of the thigh. A proactive treatment approach also may help to minimize the potential medical-legal implications of delayed fasciotomy⁴⁶.

Patients younger than thirty years of age had better functional outcome scores than older patients did. Age also has been shown to predict better outcome in patients with leg compartment syndrome and isolated femoral fracture^17,47. Age-related changes in muscle-fiber composition and a decreased capacity for muscular regeneration in older individuals may explain the effect of age on functional outcome after acute compartment syndrome of the thigh^48-50. Decreased physical activity and socioeconomic factors also may contribute to the decreased function in older patients.

In conclusion, the present study presents the first systematic evaluation of functional outcome after acute compartment syndrome of the thigh. It shows that many patients with this condition present with persistent long-term functional deficits and that early diagnosis and surgical decompression within eight hours is critical in order to prevent the development of irreversible myoneural damage and associated long-term functional deficits. Early diagnosis can be difficult because of the subtle, nonspecific, and variable clinical symptoms of impending compartment syndrome of the thigh. The presence of three or more clinical signs of compartment syndrome establishes the diagnosis of this clinical entity with high probability. Detailed knowledge of the clinical signs of acute compartment syndrome of the thigh combined with a high index of suspicion in patients with thigh injuries will establish an effective preemptive treatment strategy. The particularly poor outcome in patients with an ipsilateral femoral fracture suggests the need for a high index of suspicion and routine monitoring for compartment syndrome in this high-risk population. Older patients with associated injuries also should be monitored more closely. Compartment pressures provide important adjunctive information and should be measured routinely in all high-risk patients. Absolute pressures in excess of 70 mm Hg call for more expedited surgical decompression. Our study indicates that a differential pressure of <30 mm Hg may be a more useful clinical parameter than absolute compartment pressure. However, pressure values should always be interpreted in the clinical context. Because of its relevance for long-term function, specific emphasis should be placed on the rehabilitation of quadriceps strength in patients with compartment syndrome of the thigh.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

A table showing the separate components of the SF-36 outcomes scores is available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ?

References

Materials and Methods | Results | Discussion | Appendix | References

Schwartz JT, Brumback RJ, Lakatos R, Poka A, Bathon GH, Burgess AR. Acute compartment syndrome of the thigh. A spectrum of injury. J Bone Joint Surg Am. 1989;71: 392-400.71392 1989 [PubMed]

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Topics

compartment syndrome ; femoral fractures ; thigh ; fasciotomy ; quadriceps ; muscle necrosis ; thigh muscle

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Kai Mithoefer, M.D.

Posted on June 12, 2006

Dr. Mithoefer et al. reply to Dr. Satpathy

Harvard Vanguard Orthopedics & Sports Medicine, Brigham & Women's Hospital, Boston, MA

We thank Dr. Satpathy for his interest in our study (1). We recognize the high prevalence of knee injuries associated with femur fractures as one of our investigators is also the senior author of an article quoted by Dr. Satpathy (2). However, functional deficits from concomitant knee injuries can be ruled out as a cause of the long-term functional deficits seen in our patients since no patient showed clinical evidence of ligamentous instability or meniscal pathology on the knee examinations routinely performed as part of our follow-up evaluations.

Quadriceps weakness and decreased knee range of motion has been associated with isolated femur fracture in several studies (3-6). However, careful review of the literature on muscle function after femur fracture shows that non-operative treatment including traction, casting, or bracing was used in up to 72% of patients in some of these studies (3). Prolonged muscle weakness and knee stiffness was primarily observed in patients with non-operative treatment and attributed to delayed treatment and muscular rehabilitation.(3, 4). In contrast, fracture fixation with intramedullary rodding and early rehabilitation resulted in minimal limitation of knee motion and quadriceps strength (3-6). Isokinetic testing demonstrated permanent quadriceps weakness in only 27-39% of patients with femur fracture without associated compartment syndrome treated with intramedullary nailing (5, 6). In fact, Staepperts and coworkers reported no significant difference between the intact leg and operated leg treated with intramedullary nailing (5).

Since fracture fixation in our study was achieved by intramedullary nailing in all but one patient with a femur fracture, low long-term morbidity would have been predicted. However, compared to the age and severity-matched historic controls, 83% of patients with combined femur fracture and acute thigh compartment syndrome presented with persistent thigh muscle weakness in our study. Therefore, the significant prevalence of functional limitations observed in our patients with combined femur fracture and thigh compartment syndrome cannot be attributed to the femur fracture alone as suggested by Dr. Satpathy, but rather to the associated acute compartment syndrome.

Thus, we conclude that isolated femoral fracture without associated injury does not produce the same level of long-term functional impairment as femur fracture combined with acute thigh compartment syndrome. Rather, the increased prevalence of long- term functional deficits in our study suggests that thigh compartment syndrome and femur fracture act synergistically in augmenting muscular injury and increase the incidence of permanent functional deficits.

References:

1. Mithoefer K, Lhowe DW, Vrahas MS, Altman DT, Erens V, Altman GT. Functional Outcome After Acute Compartment Syndrome of the Thigh. J Bone Joint Surg Am 2006; 88: 729-737

2. Dickson KF, Galland MW, Barrack RL, Neitzschman HR, Harris MB, Myers L, Vrahas MS. Magnetic resonance imaging of the knee after ipsilateral femur fracture.J Orthop Trauma. 2002 Sep;16(8):567-71.

3. Mira AJ, Markley K, Greer RB 3rd. A critical analysis of quadriceps function after femoral shaft fracture in adults. J Bone Joint Surg Am.1980; 62:61 -7. 4. Finsen V, Harnes OB, Nesse O, Benum P. Muscle function after plated and nailed femoral shaft fractures.Injury . 1993;24:531 -4.

5. Stappaerts KH, Broos P, Willocx T, Aelvoet C. Factors determining quadriceps function recovery following femoral shaft fractures. Unfallchirurg.1986; 89:121 -6.

6. Hennrikus WL, Kasser JR, Rand F, Millis MB, Richards KM. The function of the quadriceps muscle after a fracture of the femur in patients who are less than seventeen years old. J Bone Joint Surg Am. 1993;75:508 -13.

Jibanananda Satpathy

Posted on April 25, 2006

Femoral Shaft Fractures Without Acute Compartment Syndrome Can Also Lead to Functional Deficit

Oxford Radcliffe NHS Trust (Horton) UK

To the Editor:

I read with interest the article by Mithoefer, et al, "Functional Outcome after Acute Compartment Syndrome of the Thighâ€. I would note that there are other possible explanations for a residual functional deficit in these patients. For example, six of eight patients with long term functional deficits (Limp, patello-femoral pain, sensory deficit, limited knee ROM and gait) had femur fractures which underwent operative intervention. A fracture of the femoral shaft without thigh compartment syndrome can produce limp or knee pain. There is a high incidence of associated knee injuries with femur shaft fractures that can produce functional deficit(1,2).

Associated shortening following femur fractures can produce limp, and femoral shaft fractures have been associated with weakness of the quadriceps and decreased knee range of motion(3,4,5,6), as has been noted by the author.

It seems logical to conclude that an isolated femoral fracture without the associated complication of a compartment syndrome, could have produced the long term functional deficits reported in this study. Femoral shaft fractures, with or without compartment syndrome, can adversely affect long term functional outcome.

References:

1.Walking AK, Seradge H, Spiegel PG. Injuries to the knee ligaments with fractures of the femur. J Bone Joint Surg Am.1982;64(9):1324-7

2.Dickson KF, Galland MW, Barrack RL, Neitzschman HR, Harris MB, Myers L, Vrahas MS.Magnetic resonance imaging of the knee after ipsilateral femur fracture.J Orthop Trauma. 2002 Sep;16(8):567-71.

3.Mira AJ, Markley K, Greer RB 3rd. A critical analysis of quadriceps function after femoral shaft fracture in adults. J Bone Joint Surg Am.1980; 62:61 -7.

4.Stappaerts KH, Broos P, Willocx T, Aelvoet C. Factors determining quadriceps function recovery following femoral shaft fractures. Unfallchirurg.1986; 89:121 -6.

5.Finsen V, Harnes OB, Nesse O, Benum P. Muscle function after plated and nailed femoral shaft fractures.Injury . 1993;24:531 -4.

6.Hennrikus WL, Kasser JR, Rand F, Millis MB, Richards KM. The function of the quadriceps muscle after a fracture of the femur in patients who are less than seventeen years old. J Bone Joint Surg Am. 1993;75:508 -13.

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Kai Mithoefer, David W. Lhowe, Mark S. Vrahas, Daniel T. Altman, Vanessa Erens, Gregory T. Altman; Functional Outcome After Acute Compartment Syndrome of the Thigh. The Journal of Bone & Joint Surgery. 2006 Apr;88(4):729-737.

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