Compartment syndrome of the foot associated with a delayed presentation of acute limb ischemia Neal R. Barshes, MD, MPH, George Pisimisis, MD, and Panos Kougias, MD, Houston, Tex Compartment syndrome of the leg is a well-recognized complication known to follow urgent revascularization done for acute limb ischemia, but compartment syndrome of the foot has not been reported after the ischemia-reperfusion sequence. Herein we report a case of foot fasciotomy done for compartment syndrome that occurred after urgent revascularization. We suggest that foot fasciotomies should be considered in particular circumstances of acute lower leg ischemia, such as infrapopliteal thromboembolic events, prolonged ischemia, and persistent or worsening foot symptoms that follow revascularization and calf fasciotomies. (J Vasc Surg 2015;-:1-4.)
Compartment syndrome is a complication known to follow urgent revascularization done for acute limb ischemia and is widely recognized to occur in the leg, forearm, and hand compartments as a result of the ischemiareperfusion sequence.1,2 Compartment syndrome of the foot has been described only in the setting of trauma3 but has not been reported after the ischemia-reperfusion that occurs in the setting of acute limb ischemia. Herein we report a case of fasciotomy of the foot done for compartment syndrome that occurred after urgent revascularization. Written informed consent for the use of photography for publication was obtained from the patient. Consistent with our institution’s policy on case reporting, Institutional Review Board approval was not obtained. CASE REPORT An 80-year-old man presented to our hospital. He previously had no limitations in walking. He had a known history of diabetes mellitus, atrial fibrillation, congestive heart failure (ejection fraction of 40%45%), and stage 2 chronic kidney disease. Before admission, he noted the acute onset of left foot pain, weakness, and decreased sensation. Noticing some initial (although limited) improvement, he assumed the symptoms would resolve. He therefore sought medical attention only 10 days after the initial onset of the symptoms because he experienced a lack of resolution that severely impaired his walking ability. At the time of this delayed presentation, the left foot was notable for pallor. Objective weakness and sensory impairment From the Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/ Michael E. DeBakey Veterans Affairs Medical Center. Author conflict of interest: none. Reprint requests: Neal R. Barshes, MD, MPH, Assistant Professor of Surgery, Division of Vascular and Endovascular Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd (OCL 112), Houston, TX 77030 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2015.01.043
were noted in the foot and calf. Venous waveforms were noted at the level of the ankle, but no arterial signals could be found with a continuous-wave Doppler probe. Fogarty catheter thromboembolectomy was performed through the common femoral and distal popliteal arteries; soft, dark red-appearing thrombus was retrieved from the common femoral, proximal superficial femoral, deep femoral, and distal popliteal arteries. The catheter did not pass through the distal superficial femoral artery/proximal popliteal artery or through the posterior tibial or peroneal arteries. To ensure adequate revascularization, a femoropopliteal bypass was done using polytetrafluoroethylene tunneled in an anatomic fashion. A two-incision, four-compartment leg fasciotomy was performed to the level of the distal calf. Completion angiography demonstrated in-line flow through the bypass, the anterior tibial artery, and the dorsalis pedis artery in the foot. Early after this initial operation, his leg and foot symptoms had improved, but they worsened significantly again by day 3. The patient had reported severe and progressively worsening pain in the dorsum of the foot. Examination was notable for only mild swelling of the dorsum of the foot (Fig 1) but significant tenderness. Pain and limited range of motion were noted with passive movement of the toes and ankle. He did not have significant calf swelling or tenderness. He was urgently returned to the operating room. The fasciotomy incisions in the anterior and medial compartments were extended to near the level of the extensor retinaculum tendon of the ankle. A five-incision foot fasciotomy4,5 (Fig 1) was performed to open and to inspect 9 of the 10 compartments of the foot (all except the calcaneal compartment). The dorsal, lateral, and several interosseus compartments had significant soft tissue swelling as noted. The muscles in the interosseous compartments were pale and edematous but contracted with electrocautery. The muscle of the medial and both central compartments appeared viable. The patient’s left lower extremity function improved significantly after this operation. Specifically, pain during active and passive movement was significantly decreased. Both sensation and strength improved significantly. He was able to ambulate with a four-point walker before discharge on postoperative day 17. He received negative pressure wound therapy dressings for the calf wounds and gauze dressings for the foot wounds. He has been seen at regular intervals in our outpatient clinic. The sensation in his left foot improved to near baseline. Strength and range of motion also further improved. All foot incisions
1
2 Barshes et al
JOURNAL OF VASCULAR SURGERY --- 2015
Fig 1. Five incisions used to release 9 of the 10 compartments of the left foot. These consist of two incisions on the dorsum of the foot (parallel to the second and fourth metatarsals; left panel) to release the dorsal compartment and four interosseous compartments; one on the plantar aspect of the foot (parallel to the third metatarsal; middle panel) to release the superficial and deep central compartments; and one incision each on the medial and lateral aspects of the forefoot (parallel to the glabrous skin borders of first and fifth metatarsals; upper and lower right panels) to release the medial and lateral compartments, respectively.
healed by secondary intent within 2 months. Massive swelling of the foot persisted for about 2 months but was improved by the third month (Fig 2). He has been offered split-thickness skin grafting to re-epithelialize small residual calf wounds but has refused. He remains fully ambulatory with use of a cane and returned to his part-time work as a construction supervisor. He remained well at last follow-up 5 months after surgery.
DISCUSSION Compartment syndrome is a well-recognized complication of the ischemia-reperfusion sequence that follows revascularization for acute limb ischemia. Vascular surgeons are familiar with the recognition and management of compartment syndrome of the calf. Compartment syndrome of the hand and the importance of fasciotomy incisions there have long been recognized to follow ischemiareperfusion.1,2 Despite being analogous to compartment syndrome of the hand, compartment syndrome of the foot has been reported only after various forms of trauma3,6,7 and never in the setting of acute limb ischemia. The natural history of untreated or unrecognized foot compartment syndrome is poor, resulting in Volkmann ischemic contractures and significantly impaired foot
function.8 After performing detailed late follow-up evaluations (average of approximately 2 years after the initial injury), Rosenthal et al9 identified untreated traumarelated compartment syndrome in 10% of a group of patients with calcaneal fractures. Persistent complications of untreated compartment syndrome in the foot included persistent pain (both with activity and at rest), impaired sensation, muscle atrophy, and claw toe deformity. Grading of residual foot function was significantly worse in patients who had untreated foot compartment syndrome than in those who did not.9 On the basis of the clinical presentation after revascularization with calf fasciotomy incisions and the significant swelling seen in the dorsal and lateral compartments of the foot on foot fasciotomy, the patient described here seems to have had clear evidence of compartment syndrome in the dorsal and lateral compartments. The incisions achieved complete secondary wound closure with local wound care only, with the plantar and medial incisions (those without significant swelling) healing the fastest. Ten compartments of the foot have been described (Fig 3). These are the medial compartment, the lateral compartment, the superficial and deep central
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Barshes et al 3
Fig 2. Massive swelling of the dorsal compartment of the foot after dorsal fasciotomy incisions persisted for nearly 2 months but was improved by the third month.
Fig 3. Compartments of the foot as viewed from a coronal section through the proximal forefoot (left) and from the plantar aspect of the foot (right).
compartments, the dorsal compartment, the calcaneal compartment, and four interosseus compartments.5,10 These compartments can be accessed through five “safe” incisions intended to minimize disruption of the cutaneous blood supply.11,12 We have used these same fasciotomy incisions in other patients with advanced cyanosis or early skin necrosis in the foot to assess the viability of foot musculature before revascularization for similar delayed presentations. Foot infections have also long been known to track along the compartments of the foot.13,14 Like other groups,15,16 we often use compartmental anatomy and similar fasciotomy-type incisions to effectively drain foot abscesses in patients with diabetes or peripheral arterial disease.
Because the consequences of untreated compartment syndrome of the foot are significant and risks of fasciotomy seem limited, foot fasciotomy incisions should be considered when the suspicion of foot compartment syndrome exists after limb revascularization, especially in the following settings: patients with acute thromboembolic events affecting the distal (crural or infracrural) arteries; patients presenting with a significant delay after the onset of symptoms of acute limb ischemia; and patients who have worsening or persistent foot pain or function despite four-compartment fasciotomy of the calf. Attempts to use a needle to measure compartment pressures would be challenging because of the small size of the multiple compartments in the foot; we therefore recommend proceeding with the performance
JOURNAL OF VASCULAR SURGERY --- 2015
4 Barshes et al
of foot fasciotomy incisions in conjunction with a foot and ankle orthopedic surgeon or other surgeons familiar with the compartmental anatomy of the foot. The authors acknowledge Scott Holmes for the medical illustrations provided in this manuscript. REFERENCES 1. Rowland SA. Fasciotomy: the treatment of compartment syndrome. In: Green DP, Hotchkiss RN, Pederson WC, editors. Green’s operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999. p. 689-710. 2. Botte MJ. Compartment syndrome and ischemic contracture. In: Berger RA, Weiss AP, editors. Hand surgery. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 1555-614. 3. Dodd A, Le I. Foot compartment syndrome: diagnosis and management. J Am Acad Orthop Surg 2013;21:657-64. 4. Myerson MS. Experimental decompression of the fascial compartments of the footdthe basis for fasciotomy in acute compartment syndromes. Foot Ankle 1988;8:308-14. 5. Manoli A 2nd, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle 1990;10:267-75. 6. Thakur NA, McDonnell M, Got CJ, Arcand N, Spratt KF, DiGiovanni CW. Injury patterns causing isolated foot compartment syndrome. J Bone Joint Surg Am 2012;94:1030-5. 7. Dumbre Patil S, Dumbre Patil V, Abane S, Luthra R, Ranaware A. Acute compartment syndrome of the foot due to infection after local
8.
9.
10.
11.
12. 13. 14. 15. 16.
hydrocortisone injection: a case report [published online ahead of print May 14, 2014]. J Foot Ankle Surg doi: 10.1053/j.jfas.2014.02.020. Santi MD, Botte MJ. Volkmann’s ischemic contracture of the foot and ankle: evaluation and treatment of established deformity. Foot Ankle Int 1995;16:368-77. Rosenthal R, Tenenbaum S, Thein R, Steinberg EL, Luger E, Chechik O. Sequelae of underdiagnosed foot compartment syndrome after calcaneal fractures. J Foot Ankle Surg 2013;52:158-61. Reach JS Jr, Amrami KK, Felmlee JP, Stanley DW, Alcorn JM, Turner NS, et al. Anatomic compartments of the foot: a 3-Tesla magnetic resonance imaging study. Clin Anat 2007;20:201-8. Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg 2006;117(Suppl):261S-93S. Clemens MW, Attinger CE. Functional reconstruction of the diabetic foot. Semin Plast Surg 2010;24:43-56. Grodinsky M. A study of the fascial spaces of the foot and their bearing on infections. Surg Gynecol Obstet 1929;29:737-51. Grodinsky M. Foot infections of peridigital origin: routes of spread and methods of treatment. Ann Surg 1931;94:274-85. Rauwerda JA. Foot debridement: anatomic knowledge is mandatory. Diabetes Metab Res Rev 2000;16(Suppl 1):S23-6. Aragón-Sánchez J, Lázaro-Martínez JL, Pulido-Duque J, Maynar M. From the diabetic foot ulcer and beyond: how do foot infections spread in patients with diabetes? Diabet Foot Ankle 2012;3.
Submitted Oct 22, 2014; accepted Jan 26, 2015.
Compartment syndrome is a complication known to follow urgent revascularization done for acute limb ischemia and is widely recognized to occur in the leg, forearm, and hand compartments as a result of the ischemiareperfusion sequence.1,2 Compartment syndrome of the foot has been described only in the setting of trauma3 but has not been reported after the ischemia-reperfusion that occurs in the setting of acute limb ischemia. Herein we report a case of fasciotomy of the foot done for compartment syndrome that occurred after urgent revascularization. Written informed consent for the use of photography for publication was obtained from the patient. Consistent with our institution’s policy on case reporting, Institutional Review Board approval was not obtained. CASE REPORT An 80-year-old man presented to our hospital. He previously had no limitations in walking. He had a known history of diabetes mellitus, atrial fibrillation, congestive heart failure (ejection fraction of 40%45%), and stage 2 chronic kidney disease. Before admission, he noted the acute onset of left foot pain, weakness, and decreased sensation. Noticing some initial (although limited) improvement, he assumed the symptoms would resolve. He therefore sought medical attention only 10 days after the initial onset of the symptoms because he experienced a lack of resolution that severely impaired his walking ability. At the time of this delayed presentation, the left foot was notable for pallor. Objective weakness and sensory impairment From the Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/ Michael E. DeBakey Veterans Affairs Medical Center. Author conflict of interest: none. Reprint requests: Neal R. Barshes, MD, MPH, Assistant Professor of Surgery, Division of Vascular and Endovascular Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd (OCL 112), Houston, TX 77030 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2015.01.043
were noted in the foot and calf. Venous waveforms were noted at the level of the ankle, but no arterial signals could be found with a continuous-wave Doppler probe. Fogarty catheter thromboembolectomy was performed through the common femoral and distal popliteal arteries; soft, dark red-appearing thrombus was retrieved from the common femoral, proximal superficial femoral, deep femoral, and distal popliteal arteries. The catheter did not pass through the distal superficial femoral artery/proximal popliteal artery or through the posterior tibial or peroneal arteries. To ensure adequate revascularization, a femoropopliteal bypass was done using polytetrafluoroethylene tunneled in an anatomic fashion. A two-incision, four-compartment leg fasciotomy was performed to the level of the distal calf. Completion angiography demonstrated in-line flow through the bypass, the anterior tibial artery, and the dorsalis pedis artery in the foot. Early after this initial operation, his leg and foot symptoms had improved, but they worsened significantly again by day 3. The patient had reported severe and progressively worsening pain in the dorsum of the foot. Examination was notable for only mild swelling of the dorsum of the foot (Fig 1) but significant tenderness. Pain and limited range of motion were noted with passive movement of the toes and ankle. He did not have significant calf swelling or tenderness. He was urgently returned to the operating room. The fasciotomy incisions in the anterior and medial compartments were extended to near the level of the extensor retinaculum tendon of the ankle. A five-incision foot fasciotomy4,5 (Fig 1) was performed to open and to inspect 9 of the 10 compartments of the foot (all except the calcaneal compartment). The dorsal, lateral, and several interosseus compartments had significant soft tissue swelling as noted. The muscles in the interosseous compartments were pale and edematous but contracted with electrocautery. The muscle of the medial and both central compartments appeared viable. The patient’s left lower extremity function improved significantly after this operation. Specifically, pain during active and passive movement was significantly decreased. Both sensation and strength improved significantly. He was able to ambulate with a four-point walker before discharge on postoperative day 17. He received negative pressure wound therapy dressings for the calf wounds and gauze dressings for the foot wounds. He has been seen at regular intervals in our outpatient clinic. The sensation in his left foot improved to near baseline. Strength and range of motion also further improved. All foot incisions
1
2 Barshes et al
JOURNAL OF VASCULAR SURGERY --- 2015
Fig 1. Five incisions used to release 9 of the 10 compartments of the left foot. These consist of two incisions on the dorsum of the foot (parallel to the second and fourth metatarsals; left panel) to release the dorsal compartment and four interosseous compartments; one on the plantar aspect of the foot (parallel to the third metatarsal; middle panel) to release the superficial and deep central compartments; and one incision each on the medial and lateral aspects of the forefoot (parallel to the glabrous skin borders of first and fifth metatarsals; upper and lower right panels) to release the medial and lateral compartments, respectively.
healed by secondary intent within 2 months. Massive swelling of the foot persisted for about 2 months but was improved by the third month (Fig 2). He has been offered split-thickness skin grafting to re-epithelialize small residual calf wounds but has refused. He remains fully ambulatory with use of a cane and returned to his part-time work as a construction supervisor. He remained well at last follow-up 5 months after surgery.
DISCUSSION Compartment syndrome is a well-recognized complication of the ischemia-reperfusion sequence that follows revascularization for acute limb ischemia. Vascular surgeons are familiar with the recognition and management of compartment syndrome of the calf. Compartment syndrome of the hand and the importance of fasciotomy incisions there have long been recognized to follow ischemiareperfusion.1,2 Despite being analogous to compartment syndrome of the hand, compartment syndrome of the foot has been reported only after various forms of trauma3,6,7 and never in the setting of acute limb ischemia. The natural history of untreated or unrecognized foot compartment syndrome is poor, resulting in Volkmann ischemic contractures and significantly impaired foot
function.8 After performing detailed late follow-up evaluations (average of approximately 2 years after the initial injury), Rosenthal et al9 identified untreated traumarelated compartment syndrome in 10% of a group of patients with calcaneal fractures. Persistent complications of untreated compartment syndrome in the foot included persistent pain (both with activity and at rest), impaired sensation, muscle atrophy, and claw toe deformity. Grading of residual foot function was significantly worse in patients who had untreated foot compartment syndrome than in those who did not.9 On the basis of the clinical presentation after revascularization with calf fasciotomy incisions and the significant swelling seen in the dorsal and lateral compartments of the foot on foot fasciotomy, the patient described here seems to have had clear evidence of compartment syndrome in the dorsal and lateral compartments. The incisions achieved complete secondary wound closure with local wound care only, with the plantar and medial incisions (those without significant swelling) healing the fastest. Ten compartments of the foot have been described (Fig 3). These are the medial compartment, the lateral compartment, the superficial and deep central
JOURNAL OF VASCULAR SURGERY Volume -, Number -
Barshes et al 3
Fig 2. Massive swelling of the dorsal compartment of the foot after dorsal fasciotomy incisions persisted for nearly 2 months but was improved by the third month.
Fig 3. Compartments of the foot as viewed from a coronal section through the proximal forefoot (left) and from the plantar aspect of the foot (right).
compartments, the dorsal compartment, the calcaneal compartment, and four interosseus compartments.5,10 These compartments can be accessed through five “safe” incisions intended to minimize disruption of the cutaneous blood supply.11,12 We have used these same fasciotomy incisions in other patients with advanced cyanosis or early skin necrosis in the foot to assess the viability of foot musculature before revascularization for similar delayed presentations. Foot infections have also long been known to track along the compartments of the foot.13,14 Like other groups,15,16 we often use compartmental anatomy and similar fasciotomy-type incisions to effectively drain foot abscesses in patients with diabetes or peripheral arterial disease.
Because the consequences of untreated compartment syndrome of the foot are significant and risks of fasciotomy seem limited, foot fasciotomy incisions should be considered when the suspicion of foot compartment syndrome exists after limb revascularization, especially in the following settings: patients with acute thromboembolic events affecting the distal (crural or infracrural) arteries; patients presenting with a significant delay after the onset of symptoms of acute limb ischemia; and patients who have worsening or persistent foot pain or function despite four-compartment fasciotomy of the calf. Attempts to use a needle to measure compartment pressures would be challenging because of the small size of the multiple compartments in the foot; we therefore recommend proceeding with the performance
JOURNAL OF VASCULAR SURGERY --- 2015
4 Barshes et al
of foot fasciotomy incisions in conjunction with a foot and ankle orthopedic surgeon or other surgeons familiar with the compartmental anatomy of the foot. The authors acknowledge Scott Holmes for the medical illustrations provided in this manuscript. REFERENCES 1. Rowland SA. Fasciotomy: the treatment of compartment syndrome. In: Green DP, Hotchkiss RN, Pederson WC, editors. Green’s operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999. p. 689-710. 2. Botte MJ. Compartment syndrome and ischemic contracture. In: Berger RA, Weiss AP, editors. Hand surgery. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 1555-614. 3. Dodd A, Le I. Foot compartment syndrome: diagnosis and management. J Am Acad Orthop Surg 2013;21:657-64. 4. Myerson MS. Experimental decompression of the fascial compartments of the footdthe basis for fasciotomy in acute compartment syndromes. Foot Ankle 1988;8:308-14. 5. Manoli A 2nd, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle 1990;10:267-75. 6. Thakur NA, McDonnell M, Got CJ, Arcand N, Spratt KF, DiGiovanni CW. Injury patterns causing isolated foot compartment syndrome. J Bone Joint Surg Am 2012;94:1030-5. 7. Dumbre Patil S, Dumbre Patil V, Abane S, Luthra R, Ranaware A. Acute compartment syndrome of the foot due to infection after local
8.
9.
10.
11.
12. 13. 14. 15. 16.
hydrocortisone injection: a case report [published online ahead of print May 14, 2014]. J Foot Ankle Surg doi: 10.1053/j.jfas.2014.02.020. Santi MD, Botte MJ. Volkmann’s ischemic contracture of the foot and ankle: evaluation and treatment of established deformity. Foot Ankle Int 1995;16:368-77. Rosenthal R, Tenenbaum S, Thein R, Steinberg EL, Luger E, Chechik O. Sequelae of underdiagnosed foot compartment syndrome after calcaneal fractures. J Foot Ankle Surg 2013;52:158-61. Reach JS Jr, Amrami KK, Felmlee JP, Stanley DW, Alcorn JM, Turner NS, et al. Anatomic compartments of the foot: a 3-Tesla magnetic resonance imaging study. Clin Anat 2007;20:201-8. Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg 2006;117(Suppl):261S-93S. Clemens MW, Attinger CE. Functional reconstruction of the diabetic foot. Semin Plast Surg 2010;24:43-56. Grodinsky M. A study of the fascial spaces of the foot and their bearing on infections. Surg Gynecol Obstet 1929;29:737-51. Grodinsky M. Foot infections of peridigital origin: routes of spread and methods of treatment. Ann Surg 1931;94:274-85. Rauwerda JA. Foot debridement: anatomic knowledge is mandatory. Diabetes Metab Res Rev 2000;16(Suppl 1):S23-6. Aragón-Sánchez J, Lázaro-Martínez JL, Pulido-Duque J, Maynar M. From the diabetic foot ulcer and beyond: how do foot infections spread in patients with diabetes? Diabet Foot Ankle 2012;3.
Submitted Oct 22, 2014; accepted Jan 26, 2015.
