Rev. bras. ortop. vol.50 número4

rev bras ortop.2015;50(4):478–481

w w w . r b o . o r g . b r

Case

Report

Compartment

syndrome

after

total

knee

arthroplasty:

regarding

a

clinical

case

夽

Ana

Alexandra

da

Costa

Pinheiro

_,

_Pedro

_Miguel

_Dantas

_Costa

_Marques,

Pedro

Miguel

Gomes

Sá,

Carolina

Fernandes

Oliveira,

Bruno

Pombo

Ferreira

da

Silva,

Cristina

Maria

Varino

de

Sousa

UnidadeLocaldeSaúdedoAltoMinho,VianadoCastelo,Portugal

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r

t

i

c

l

e

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n

f

o

Articlehistory: Received23June2014 Accepted18August2014 Availableonline10July2015

Keywords: Kneearthroplasty Knee

Postoperativecomplications

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Althoughcompartmentsyndromeisararecomplicationoftotalkneearthroplasty,itisone ofthemostdevastatingcomplications.Itisdefinedasasituationofincreasedpressure withinaclosedosteofascialspacethatimpairsthecirculationandthefunctioningofthe tissuesinsidethisspace,therebyleadingtoischemiaandtissuedysfunction.Here,aclinical caseofapatientwhowasfollowedupinorthopedicoutpatientconsultationsduetoright gonarthrosisispresented.Thepatienthadahistoryofarthroscopicmeniscectomyand pre-sentedkneeflexionof10◦_{beforetheoperation,whichconsistedoftotalarthroplastyofthe} rightknee.Theoperationseemedtobefreefromintercurrences,butthepatientevolved withcompartmentsyndromeoftheipsilaterallegaftertheoperation.Sincecompartment syndromeisatruesurgicalemergency,earlyrecognitionandtreatmentofthiscondition throughfasciotomyiscrucialinordertoavoidamputation,limbdysfunction,kidneyfailure anddeath.However,itmaybedifficulttomakethediagnosisandcasesmaynotbe recog-nizedifthecauseofcompartmentsyndromeisunusualorifthepatientisunderepidural analgesiaand/orperipheralnerveblock,whichthuscamouflagesthemainwarningsign, i.e.disproportionalpain.Inaddition,edemaofthelimbthatunderwenttheinterventionis commonaftertotalkneearthroplastyoperations.Thisstudypresentsareviewofthe liter-atureandsignalsthatthepossiblerarityofcasesisprobablyduetofailuretorecognizethis conditioninatimelymannerandtoplacingthesepatientsinotherdiagnosticgroupsthat arelesslikely,suchasneuropraxiacausedbyusingatourniquetorperipheralnerveinjury. ©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

夽

WorkperformedintheOrthopedicsandTraumatologyService,UnidadeLocaldeSaúdedoAltoMinho,VianadoCastelo,Portugal. ∗ _{Correspondingauthor.}

E-mail:ana.alexandra.pinheiro@gmail.com(A.A.d.C.Pinheiro). http://dx.doi.org/10.1016/j.rboe.2015.06.017

rev bras ortop.2015;50(4):478–481

479

Síndrome

de

compartimento

após

artroplastia

total

do

joelho:

a

propósito

de

um

caso

clínico

Palavras-chave: Artroplastiadojoelho Joelho

Complicac¸õespós-operatórias

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e

s

u

m

o

Apesardeasíndromedecompartimentoserumacomplicac¸ãoraradaartroplastiatotaldo joelho,essaconstituiumadascomplicac¸õesmaisdevastadoras.Asíndromede comparti-mentodefine-secomooaumentodapressãodentrodeumespac¸oosteofascialfechadoque comprometeacirculac¸ãoeafunc¸ãodostecidosdentrodesseespac¸oeconduzàisquemia eàdisfunc¸ãotecidular.Osautoresapresentamumcasoclínicodepacienteseguidaem consultaexternadeortopediaporgonartrosedireita,comantecedentesdemeniscectomia artroscópicaecomflexãode10◦_{dojoelhopré-operatório,quefoisubmetidaaartroplastia} totaldojoelhodireito.Acirurgiaaparentementedecorreusemintercorrênciase o pós-operatórioevoluiucomsíndromedecompartimentodapernaipsilateral.Sendoasíndrome decompartimentoumaemergênciacirúrgica,oseureconhecimentoetratamentoprecoce pormeiodefasciotomiaséfulcralparaevitaraamputac¸ão,disfunc¸ãodomembro, insufi-ciênciarenalemorte.Noentanto,odiagnósticopodeserdifícilenãoreconhecidoperante umacausaincomumdesíndromedecompartimento.Quandoopacienteestásob anal-gesiaepidurale/oubloqueionervosoperiférico,camufladessemodooprincipalsinalde alarme,adordesproporcional.Alémdisso,oedemadomembrointervencionadoécomum nopós-operatóriodeartroplastiatotaldojoelho.Osautoresrevêmaliteraturaealertam queapossívelraridadederelatosdecasossedevaaomaisprovávelnãoreconhecimento precocedessaidentidadeeaoenquadramentodessesdoentesemoutrosgrupos diagnós-ticosetiologicamentemenosprováveis,comoneuropraxiaporusodegarroteoulesãode nervosperiféricos.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Compartment syndrome is defined as increased pressure insideaclosedosteofascialspacethatcompromisesthe cir-culationandthefunctioningofthetissueswithinthisspace, therebyleadingtoischemiaandtissuedysfunction.1–3_Itisa

severecomplicationthatrequiresdecompressionfasciotomy inordertopreventtissuenecrosis.

Correctearly diagnosis ofthis entity isvery important, becausedelayindiagnosingitistheonlycauseoftreatment failure.Thediagnosisisessentiallyclinical,bymeansof anam-nesis and physicalexamination, and is confirmedthrough measuringthepressureofthecompartment(s).4–9

Case

report

Thepatientwasa65-year-oldwomanwithahistoryof right-sidearthroscopicinternalmeniscectomy,whichwasfollowed upthrough orthopedicoutpatientconsultationsbecause of right-sidethree-compartmentgonarthrosis.Beforethe oper-ation,shepresentedsevereright-kneestiffness,withflexion of20◦_{andmaximumflexionoflessthan90}◦_.

Thepatientunderwentright-sidetotalkneearthroplasty (TKA)underlocoregionalanesthesiawithsubarachnoidblock, whichwasperformedinaccordancewithdescriptionsinthe orthopedic literature and seemed to follow an uneventful course.Thedurationoftheoperationwas2handanepidural

catheterwasimplantedtodeliverropivacainefor postopera-tiveanalgesia.Onthefirstdayaftertheoperation,thepatient presentedneurologicalalterationssuchashypoesthesiaand limitationofthemobilityoftherightankleandfoot.Forthis reason,theepiduralanalgesiawassuspendedandthe ban-dagingoftheoperativewoundwaschanged,althoughithad not presentedabnormaltension. Therightlower limb had presentedgoodperipheralperfusionandthepatienthadnot madeanycomplaintsaboutpainduetotheanalgesia.Because ofthesuspicionofacentrallesion,magneticresonance imag-ing(MRI)wasperformedonthelumbosacralspineasamatter ofurgencyafterremovalofthecatheter,soastoscreenforan epiduralhematomaoralumbarnerveinjury,butthefindings were normal.Nonetheless,administrationofanalgesia was startedparenterally.

480

Fig.1–Carewiththebandagingofthefasciotomysites

demonstratedthepresenceofnecrosisofthemusclesof

theanteriorandlateralcompartmentsoftherightleg.

Consequently,progressivemuscledebridementwas

performed.

therightlowerlimbwasobservedandfasciectomyofthefour compartmentsoftheright legwas performed.Thepatient underwenturgentcomputedtomographyangiographyonthe rightlowerlimb,whichhadnormalfindingsanddidnotshow any vascular lesions or space-occupying lesions. The care takenwiththebandagingofthefasciotomysitesshowedthat therewasnecrosisofthemusclesoftheanteriorandlateral compartmentsoftherightleg,andthereforeprogressive mus-cledebridementwasperformed(Figs.1–3).

Suturingofthe fasciotomysiteswas doneprogressively andnoskingraftswerenecessary.

Onthedayofhospitaldischarge,thepatientcontinuedto beasymptomatic inthe rightknee and presentedmobility of0–90◦_{,withoutsignificantinflammatorysigns.Shedidnot}

presentanyextensionstrengthintheankleandtoes,andhad slightdorsiflexionintheankleandsecondtofifthtoesofthe rightfoot.Shereportedhavingparesthesiaonthelateralface

Fig.2–Progressivemuscledebridementandcarewiththe

bandagingofthefasciotomysitesoverthecourseofthe

operation.

Fig.3–Suturingofthefasciotomysiteswasperformed

progressivelyandnoskingraftswerenecessary.

ofthelowerlegandhypoesthesiaontheheel,internalfaceof thefootandfirstandsecondtoesoftherightfoot.Because shewaswalkingwithahangingfoot,ananti-equinussplint wasprescribed.Onthe40thpostoperativeday,thepatientwas walkingwiththeaidofaframeandwasusingasplint.Shewas advisedtoundergorehabilitationatacontinuingcareunit, withintensivephysiotherapy.Twomonthsaftertheoperation, shewasstillhavingphysiotherapyandcontinuedtopresent adeficitofdorsiflexioninherrightfoot,withswellingofthe posteriormusclesofthelowerleg,andwasusingasplintto stabilizehergait.Shewasbeingfollowedupasan orthope-dicsoutpatient,withimprovementofright-kneejointrange ofmotionandwalkingwithcrutches(Figs.4and5).

Fig.4–Twomonthsaftertheoperation,thepatientwas

stillundergoingphysiotherapyandthedeficitsof

dorsiflexionintherightfootremained,withswellingofthe

rev bras ortop.2015;50(4):478–481

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Fig.5–Anti-equinussplintprescribedbecausethepatient

waswalkingwithahangingfoot.

Discussion

Compartmentsyndromecandevelopsilentlyoverthe post-operativeperiod. Itsdiagnosis is essentiallyclinical and is characterizedbyincessantpainbeyondtheexpectedlevelfor theunderlyinginjuryandbytheneedformoreanalgesiathan whatwouldbeexpectedforthisinjuryorsurgery.

Whencompartmentsyndromeoccurssubsequentto“low risk” surgery such as TKA, delayed diagnosis is common andmayleadtodramaticconsequencesduetoirreversible ischemia of the nerves and muscle tissue.10 _{Hence, early}

diagnosisand treatmentofcompartmentsyndromeisvery important.

Theroleoffasciotomyincasesofcompartmentsyndrome diagnosedatalatestage(morethan8haftertheoperation) isquestionable,sincetheneuromusculardeficitsthatbecome establishedareonlyrarelyrecoveredafterfasciotomy.11_Even

ifcompartmentsyndromeissuspectedatastageinwhich fas-ciotomymaybelate,asoccurredinthecasedescribedhere, salvageofthecompartmentshouldbeattempted.Increased pain, despitethe use of analgesicmedication,is the main warning sign for compartment syndrome. Epidural block, which excludespain as anindicator ofcompartment syn-drome,togetherwithalowdegreeofsuspicion,maycreatea disastrouscombination.Whenlocalepiduralanestheticsare used,itisessentialthattheintensityoftheblockshouldbe appropriatefortheexpectedintensityofpain,without induc-ingmotorblock.12_{However,theanalgesiashouldnotbetaken}

tobethecause,butonlyafactorinthedelayinthediagnosis.13

Thediagnosisinthiscasewascomplicatedbecauseofthe mechanismoftheassociatedinjuryandbecauseofthe post-operativeanalgesia.TKAisararecauseofacutecompartment syndromeinthe calfmusclesand only11caseshavebeen describedintheliterature.7 _{Althoughsurgeonsgenerallydo}

notliketopublishtheircomplications,itisimportantforus

todothis,soastoalertthescientificcommunityregarding theexistenceofcompartmentsyndromeandsothatall sur-geonsknowhowtodiagnoseitandtreatitearlyon.Forthis reason,wepresentedararecaseofcompartmentsyndromein thelowerleg(littlereportedintheliterature)thatdeveloped afterTKAhadbeenperformed.

Compartmentsyndromeconstitutesasurgicalemergency. Recognitionandearlytreatmentofthisentitybymeansof fas-ciotomyispivotalforavoidingamputation,limbdysfunction, kidneyfailureanddeath.

Nevertheless,thediagnosismaybedifficulttomakeand maynotberecognizedinthelightofanuncommoncauseof compartmentsyndromeandwhenthepatientisunder anal-gesia.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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