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Wed Sep 6 17:41:33 BST 2006

Having ran into this problem on two separate occasions
(once for an elderly APR and another time for a 17
year old girl free fibular graft to the hip for AVN) I
don't think that perioperative pressure monitoring
would be of benefit.  

The compartment syndrome occurs when the legs are
lowered out of the stirrups and reperfusion occurs. 
If you compress the calves perioperatively (in my
experience) they almost NEVER are firm.  Once you
lower them, they get plump.  As far as I'm concerned,
even in the unconscious patient, the best marker for
fasciotomy in cases of suspected compartment syndrome
is physical exam.  Regret is rare for a surgeon who
fasciotomizes early when the exam suggests it. 

What works is good positioning on Allen stirrups with
attention to keeping joint angles as ergonomic as
possible and neurotically padding problem areas. 

Ben Reynolds, PA-C
Pittsburgh, PA

--- johan.malmgren at vgregion.se wrote:

---------------------------------
List! 
Would be grateful for some input although a bit off
topic. 
20 y/o boy reoperated upon yesterday with a
urethroplasty, buccal graft. Otherwise healthy, I'd
guess 1.85 cm/85 kg. 
At earlier similar operation it had been noted a
tendency for decubitus, so everybody took extra
precautions. Operation lasted some 15 hours, under
which the legs were lowered a couple of times, and I
even think a nurse massaged them. BP was steady as a
rock the entire time, no need for inotropic drugs. 
Still develops bilateral compartment-syndrome and was
bilat fasciotomied later same night.

The discussion today was of course prevention, and the
question raised was if we should routinely have ortho
come and measure pressure perioperatively during these
kind of operations. (I guess the same would apply for
some robotic-surgery operations were the patient
almost hangs upside down) On the other hand, as far as
I know, that would tell us when to open his legs and
in an elective case like this, that already seems "too
late".
Any ideas? Would be happy to hear what your local
routines tells about this!

/Johan Malmgren
MD, Anaesthesia and Critical Care/Trauma
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OT: Compartment prevention perioperatively