The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 78, Issue 4

Articles | April 01, 1996

Compartment Syndromes Associated with Postoperative Epidural Analgesia. A Case Report*

CHARLES PRICE, M.D.†; JOHN RIBEIRO, M.D.‡; TODD KINNEBREW, M.D.§, ORLANDO, FLORIDA

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Investigation performed at the Orlando Regional Medical Center, Orlando

J Bone Joint Surg Am, 1996 Apr 01;78(4):597-9

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Extract

Compartment syndrome of the thigh is a rare complication that has been reported as a result of trauma, prolonged compression, and vascular injury^{1-3,8,11,20,27}; however, it has not been reported after an elective osteotomy of the femur, to our knowledge. We describe the case of a patient in whom compartment syndromes of the thigh and leg developed after corrective osteotomies of the distal part of the femur and proximal part of the tibia. Similar osteotomies had been performed on the contralateral lower extremity fourteen weeks previously, and no complications had developed. The only modification during the second procedure was the use of epidural analgesia for the relief of postoperative pain. We believe that postoperative epidural analgesia may obscure the symptoms of compartment syndrome²²; therefore, patients who are so managed should be monitored very carefully.

Figures in this Article

Introduction

Introduction | Case Report | Discussion | References

Compartment syndrome is a condition in which increased pressure within a closed compartment reduces the level of capillary perfusion to less than that required for the viability of tissues^14,17,26. The exact prevalence of compartment syndrome of the leg after an elective osteotomy is unknown. Steel et al., in 1971, reported neurological changes due to ischemia in nine of forty-six children who had had a proximal tibial osteotomy, but none of the complications were recognized as a compartment syndrome. Morrissy and Ballard, in 1987, reported two transient peroneal palsies and no vascular complications or compartment syndromes in seventy-four children who had had a proximal tibial osteotomy. It should be noted that all seventy-four children also had had a simultaneous subcutaneous fasciotomy of the anterior compartment. Several authors have reported compartment syndrome as a complication of tibial osteotomy^{9,17,19,22,24}. Mubarak and Carroll, in 1979, reported on fifty-five children in whom an ischemic contracture developed; the contracture was related to trauma, vascular occlusion, compression injury, or hemorrhage in forty-nine patients and was secondary to an elective operation on the tibia in six.

We report the case of a patient in whom compartment syndromes of the thigh and leg developed after osteotomies had been performed to correct femoral and tibial deformities associated with hypophosphatemic rickets. The possible relationship between compartment syndrome and postoperative epidural analgesia will be discussed.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Pediatric Orthopedics, Orlando Regional Medical Center, 1414 South Kuhl Avenue, Orlando, Florida 32856.

‡Department of Orthopaedics, 3024, 12021 South Wilmington Avenue, Los Angeles, California 90059.

§4660 Riverside Park Boulevard, Macon, Georgia 31210.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Pediatric Orthopedics, Orlando Regional Medical Center, 1414 South Kuhl Avenue, Orlando, Florida 32856.

‡Department of Orthopaedics, 3024, 12021 South Wilmington Avenue, Los Angeles, California 90059.

§4660 Riverside Park Boulevard, Macon, Georgia 31210.

Case Report

Introduction | Case Report | Discussion | References

A sixteen-year-old boy who had hypophosphatemic rickets was examined at our institution because of bilateral genu varum. Bilateral corrective osteotomies had been performed when the patient was six years old, but the deformities had recurred. As both femora and tibiae were involved, we elected to correct the deformities on the right side first and those on the left side in a second operation. A previously described technique was utilized¹⁸.

Transverse opening-wedge osteotomies of the distal part of the right femur and proximal part of the right tibia were performed after the application of external fixators. The gain in length was less than one centimeter, and there did not appear to be any soft-tissue tension at the time of the correction. Narcotic medications were used to control postoperative pain. Correction was maintained with use of external fixators until there was evidence of union at the osteotomy sites. The postoperative course was uneventful, and there were no complications.

Osteotomies of the left femur and tibia were performed fourteen weeks later. These procedures were similar to those on the right side in that the same technique was used, the same attending physician and resident performed the operations, and a tourniquet was not used on the lower extremity. After the operation on the left side, however, an epidural catheter was inserted, and fentanyl was administered for the control of postoperative pain in accordance with the protocol established by the anesthesiologist. The patient received no other supplemental analgesia. This protocol provided excellent analgesia, and the patient was comfortable in the early postoperative period. Eighteen hours after the operation, however, he was uncomfortable and had slight numbness in the leg but did not request supplemental medication for the relief of pain. He was able to move the left ankle and foot. The thigh appeared to be swollen, and the skin was shiny and tense. The pressures in the anterior and posterior compartments were sixty-four and thirty-two millimeters of mercury (8.53 and 4.27 kilopascals), respectively. Pressures of less than thirty millimeters of mercury (4.00 kilopascals) are acceptable^1,14,17,26. Because the compartment pressures were so high, fasciotomies of the thigh were performed through a lateral incision. The pressures in the anterior, lateral, posterior, and deep posterior compartments of the leg were sixty-eight, forty-eight, forty, and forty millimeters of mercury (9.06, 6.40, 5.33, and 5.33 kilopascals), respectively. The compartments of the leg also were released through a single lateral incision.

Five to ten cubic centimeters of consolidated hematoma was found at each osteotomy site. The muscles in all compartments were pale, and they bulged through the fascia when released. After the fasciotomies, the muscles responded to electrical stimulation and no longer were as pale as they had been before the fasciotomies. The pressure in all compartments was less than fifteen millimeters of mercury (2.00 kilopascals) after the fasciotomies. A small area of necrotic muscle was noted in the deep posterior compartment of the leg and was debrided. The histopathological findings were suggestive of ischemic myonecrosis.

One week later, the incision in the thigh was closed primarily. The incision in the leg required split-thickness skin-grafting. The patient had no neurological sequelae, and all wounds healed uneventfully. At the two-year follow-up examination, the patient had no residual sequelae from the compartment syndromes and was functioning normally without any symptoms.

Discussion

Introduction | Case Report | Discussion | References

Although compartment syndromes after simultaneous osteotomies of the femur and tibia are uncommon, surgeons should be aware of the potential for this complication. Since compartment syndrome of the thigh is itself very rare, it is not difficult for the diagnosis to be missed.

Although no conclusions regarding the etiology of compartment syndrome can or should be made on the basis of the isolated episode described in the present report, we believe that the use of epidural analgesia could have contributed to the development of this complication in our patient. Iaquinto et al. reported an increased prevalence of neurological complications in patients who had been managed with continuous epidural analgesia after tibial fractures compared with that in a similar group of patients who had been managed with oral analgesia.

Previous authors have suggested that epidurally administered local anesthetics increase blood flow secondary to a sympathetic blockade^5,7,23,25; such an increase may contribute to a rise in intracompartmental pressure. Terry et al. used electromagnetic flow-probes in blood vessels and demonstrated increased peripheral blood flow before and after operative sympathectomy. Weber et al. reported that the injection of bupivacaine through an epidural catheter successfully restored blood flow to a free muscle flap after a transient loss of arterial pulsation. Cousins and Wright demonstrated increased blood flow to grafts after epidural anesthesia⁶. Modig et al. suggested that increased blood flow may contribute to a decreased risk of thromboembolic disease after operations on the hip in which epidural anesthesia was used.

In contrast, epidurally administered opioids do not abolish the normal vasoconstrictor response^4,7,10,13,28. Liao et al. demonstrated that the epidural administration of morphine did not alter the reflex vasoconstriction secondary to hypotension (which had been induced by means of intravenous administration of acetylcholine) or the reflex vasodilation secondary to hypertension (which had been induced by means of intravenous administration of norepinephrine). Cousins and Glynn noted a normal vasoconstrictor response after the application of ice, but they observed small but consistent increases in blood flow, with the patient at rest, after the epidural administration of meperidine⁵. Those authors suggested that reduced afferent nociceptive input to the sympathetic nervous system contributes to the transient hypotension observed after the epidural administration of meperidine. This phenomenon was thought to be due to a direct effect of meperidine on the peripheral vasculature. Another possibility is that an indirect sympathetic blockade may have occurred in the central nervous system. Our patient received only fentanyl through an epidural catheter, and therefore a sympathetic blockade should not have occurred. However, it is possible that the epidural administration of fentanyl may have increased the blood flow with the patient at rest in a manner similar to that of meperidine.

The prevalence of compartment syndrome after epidural analgesia is unknown. We are aware of only one other report in the English-language literature in which this complication was described²², but this may be due to the failure of investigators to report unfavorable results. Strecker et al. reported the case of a patient in whom a compartment syndrome was not detected in the early stages because the earliest symptom of pain probably was masked by the epidural analgesia. Those authors recommended caution when epidural infusion is used for patients who are at risk for the development of a compartment syndrome; such patients include those who have been managed with operative procedures on the long bones of the lower extremity. We concur that this potent method of providing analgesia can mask the symptoms of compartment syndrome. Pain, pallor, and pulselessness were absent in our patient, and the paresthesias were attributed to the epidural analgesia. Fortunately, the compartment syndromes were diagnosed before irreversible changes had occurred.

We believe that orthopaedic surgeons should be aware of the possibility of a compartment syndrome after corrective osteotomies of the long bones. Furthermore, when epidural analgesia is used, the surgeon should be aware that the classic symptoms of compartment syndrome may be masked.

References

Introduction | Case Report | Discussion | References

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An, H. S.; Simpson, J. M.; Gale, S.; and |and |Jackson, W. T.: Acute anterior compartment syndrome in the thigh: a case report and review of the literature. J. Orthop. Trauma,1: 180-182, 1987.1180 1987 [PubMed][CrossRef]

Bass, R. R.; Allison, E. J., Jr.; Reines, H. D.; Yeager, J. C.; and |and |Pryor, W. H., Jr.: Thigh compartment syndrome without lower extremity trauma following application of pneumatic antishock trousers. Ann. Emerg. Med,12: 382-384, 1983.12382 1983 [PubMed][CrossRef]

Bromage, P. R.; Camporesi, E.; and |and |Leslie, J.: Epidural narcotics in volunteers: sensitivity to pain and to carbon dioxide. Pain,9: 145-160, 1980.9145 1980 [PubMed][CrossRef]

Cousins, M. J., and Glynn, C. J.: New horizons. In Neural Blockade in Clinical Anesthesia and Management of Pain, pp. 699-719. Edited by M. J. Cousins and P. O. Bridenbaugh. Philadelphia, J. B. Lippincott, 1980.

Cousins, M. J., and |and |Wright, C. J.: Graft, muscle, skin blood flow after epidural block in vascular surgical procedures. Surg., Gynec. and Obstet,133: 59-64, 1971.13359 1971

Cousins, M. J.; Mather, L. E.; Glynn, C. J.; Wilson, P. R.; and |and |Graham, J. R.: Selective spinal analgesia [letter]. Lancet,1: 1141-1142, 1979.11141 1979 [PubMed][CrossRef]

Foster, R. D., and |and |Albright, J. A.: Acute compartment syndrome of the thigh: case report. J. Trauma,30: 108-110, 1990.30108 1990 [PubMed][CrossRef]

Gibson, M. J.; Barnes, M. R.; Allen, M. J.; and |and |Chan, R. N. W.: Weakness of foot dorsiflexion and changes in compartment pressures after tibial osteotomy. J. Bone and Joint Surg,68-B(3): 471-475, 1986.68-B(3)471 1986

Glynn, C. J.; Mather, L. E.; Cousins, M. J.; Graham, J. R.; and |and |Wilson, P. R.: Peridural meperidine in humans: analgesic response, pharmacokinetics, and transmission into CSF. Anesthesiology,55: 520-526, 1981.55520 1981 [PubMed][CrossRef]

Gorman, P. W., and |and |McAndrew, M. P.: Acute anterior compartmental syndrome of the thigh following contusion. A case report and review of the literature. J. Orthop. Trauma,1: 68-70, 1987.168 1987 [PubMed][CrossRef]

Iaquinto, J. M.; Thornsberry, R.; and |and |Stevens, D. B.: The use of epidural catheters for post operative pain management in tibial fractures. Orthop. Trans,18: 1159, 1994-1995.181159 1994-1995

Liao, J.-C.; Harrison, P.; Buckley, J. J.; and |and |Takemori, A.: Sympathetic reflexes in morphine vs lidocaine spinal block [abstract]. Anesthesiology,55(3) (Supplement): 148, 1981.55(3) (Supplement)148 1981

Matsen, F. A., III; Krugmire, R. B., Jr.; and |and |King, R. V.: Increased tissue pressure and its effects on muscle oxygenation in level and elevated human limbs. Clin. Orthop,144: 311-320, 1979.144311 1979 [PubMed]

Modig, J.; Borg, T.; Karlstrom, G.; Maripuu, E.; and |and |Sahlstedt, B.: Thromboembolism and total hip replacement: role of epidural and general anesthesia. Anesth. and Analg,62: 174-180, 1983.62174 1983

Morrissy, R. T., and |and |Ballard, R. I.: Osteotomy about the knee in childhood. Orthop. Trans,11: 46-47, 1987.1146 1987

Mubarak, S. J., and |and |Carroll, N. C.: Volkmann's contracture in children: aetiology and prevention. J. Bone and Joint Surg,61-B(3): 285-293, 1979.61-B(3)285 1979

Price, C. T., and Mann, J. W.: Pediatric applications of pin fixators. In Operative Orthopaedics, edited by M. W. Chapman. Ed. 2, pp. 1019-1030. Philadelphia, J. B. Lippincott, 1993.

Rubinovitch, M.; Said, S. E.; Glorieux, F. H.; Cruess, R. L.; and |and |Rogala, E.: Principles and results of corrective lower limb osteotomies for patients with vitamin D-resistant hypophosphatemic rickets. Clin. Orthop,237: 264-270, 1988.237264 1988 [PubMed]

Schwartz, J. T., Jr.; Brumback, R. J.; Lakatos, R.; Poka, A.; Bathon, G. H.; and |and |Burgess, A. R.: Acute compartment syndrome of the thigh. A spectrum of injury. J. Bone and Joint Surg,71-A: 392-400, March 1989.71-A392 1989

Steel, H. H.; Sandrow, R. E.; and |and |Sullivan, P. D.: Complications of tibial osteotomy in children for genu varum or valgum. Evidence that neurological changes are due to ischemia. J. Bone and Joint Surg,53-A: 1629-1635, Dec. 1971.53-A1629 1971

Strecker, W. B.; Wood, M. B.; and |and |Bieber, E. J.: Compartment syndrome masked by epidural anesthesia for postoperative pain. Report of a case. J. Bone and Joint Surg,68-A: 1447-1448, Dec. 1986.68-A1447 1986

Terry, H. J.; Allan, J. S.; and |and |Taylor, G. W.: The effect of adding lumbar sympathectomy to reconstructive arterial surgery in the lower limb. British J. Surg,57: 51-55, 1970.5751 1970 [CrossRef]

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Weber, S.; Bennett, C. R.; and |and |Jones, N. F.: Improvement in blood flow during lower extremity microsurgical free tissue transfer associated with epidural anesthesia. Anesth. and Analg,67: 703-705, 1988.67703 1988

Willis, R. B., and |and |Rorabeck, C. H.: Treatment of compartment syndrome in children. Orthop. Clin. North America,21: 401-412, 1990.21401 1990

Winternitz, W. A., Jr.; Metheny, J. A.; and |and |Wear, L. C.: Acute compartment syndrome of the thigh in sports-related injuries not associated with femoral fractures. Am. J. Sports Med,20: 476-477, 1992.20476 1992 [PubMed][CrossRef]

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Topics

compartment syndrome ; analgesia, epidural ; osteotomy

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CHARLES PRICE, JOHN RIBEIRO, TODD KINNEBREW; Compartment Syndromes Associated with Postoperative Epidural Analgesia. A Case Report*. The Journal of Bone & Joint Surgery. 1996 Apr;78(4):597-9.

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