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Scientific Articles   |    
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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    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 Thigh”. 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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