Sat., 10/6/12 Femur/Tibial Fx/Knee Injuries, PAPER #74, 8:46 am OTA-2012
Compartment Pressure Monitoring for Acute Compartment Syndrome
Margaret M. McQueen, MD; Andrew D. Duckworth, MBChB,BSc (Hons);
Stuart A. Aitken; Charles M. Court-Brown, MD;
Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh,
Edinburgh, Scotland, United Kingdom
Purpose: A delay in the diagnosis of acute compartment syndrome (ACS) has been documented to predict a poor outcome for the patient. A means of predicting the development of ACS could lead to an earlier diagnosis. The first aim of our study was to identify the risk factors associated with the development of ACS. The second aim was to document the sensitivity and specificity of continuous intracompartmental pressure (ICP) monitoring for the diagnosis of ACS.
Methods: From our prospective trauma database we identified all patients who sustained an acute tibial diaphyseal fracture over a 13-year period. A retrospective analysis of 1407 patients was performed to record and analyze the fracture classification, open fractures, treatment, development of ACS, and other patient demographics including smoking, occupation, and socioeconomic deprivation. A diagnosis of ACS was made using clinical signs, with compartment pressure monitoring or a combination of the two. Statistical analysis used univariate and multiple logistic regression analysis. To determine the diagnostic performance characteristics of ICP monitoring we identified all patients who sustained a tibial diaphyseal fracture over a 10-year period. A retrospective analysis of 1184 patients was performed to record and analyze the documented use of continuous ICP monitoring and the need for fasciotomy. A diagnosis of ACS was made if there was escape of muscles at fasciotomy, color change in the muscles or muscle necrosis intraoperatively, or if it was not possible to perform primary closure at 48 hours postfasciotomy. The absence of ACS was confirmed by the absence of neurologic abnormality or contracture at final follow-up.
Results: There were 1388 patients in the primary analysis, with a mean age of 39 years (range, 12-98), and 957 (69%) were male. A total of 160 (11.5%) patients were diagnosed with ACS. Age was strongly predictive for the development of ACS (P <0.001), with the highest prevalence between 12 and 19 years and 20 and 29 years. Male gender, blue collar occupation, sporting injury, fracture classification, and treatment with intramedullary nails also showed an association with the occurrence of ACS (all P <0.05). Occupation (P = 0.01) and implant type (P = 0.004) were the only factors that remained significant after adjusting for age. Following review of 1184 patient records, 979 monitored patients were identified, of whom 850 fit the inclusion criteria with a mean age of 38 years (range, 12-94), and 598 (70.4%) were male (P <0.001). A total of 152 (17.9%) patients underwent fasciotomy for ACS, of whom 141 were considered to have ACS (true positives) and 6 not (false positives). There were five cases where fasciotomy was performed despite a normal monitor reading, with subsequent operative findings consistent with ACS (false negatives). Of the 698 (82.1%) patients who did not have a fasciotomy, 689 had no evidence of any late sequelae of ACS (true negatives) at a mean follow-up of 14 months. Based on our data, we have found the sensitivity of ICP monitoring for suspected ACS to be 94%, with a specificity of 98%, a positive predictive value of 93%, and a negative predictive value of 99%.
Conclusion: This is the largest series documenting the risk factors predictive for the development of ACS following an acute tibial diaphyseal fracture, with youth the strongest predictor. This study is also the first to document the high sensitivity and specificity of continuous ICP monitoring for the diagnosis of ACS following tibial diaphyseal fracture. Based on our findings and the current available literature, we recommend that all patients at risk of ACS should undergo continuous ICP monitoring, with a beneficial reduction in the delay to diagnosis and urgent fasciotomy possible.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.