Acute CS of the lower leg is not widely reported, but its potential complications can develop after fractures, crush injury, or traumatic injury. Long-term devastating complications are known to seriously impede the mobility of the patients and the quality of life. CS related disabilities and even death were reported if the diagnoses and treatments were seriously delayed [11, 12].
All eight patients in this study suffered severe CS due to different traumatic injuries. They all had bone fractures and nerve injuries of various extents, damaged vascular and necrotic muscles, as well as severe clubfoot on their affected legs. Even after fasciotomy and other surgical treatment at local hospitals, they still experienced severe tissue dysfunctions and foot deformities, which required further wound treatment and multiple surgeries to achieve anatomical and functional recovery. In this study, we combined a series of treatments that covered every course of CS development and achieved satisfactory clinical outcomes in all patients.
The increase of compartment pressure induces CS, eventually leading to ischemic necrosis of muscles and nerves [13, 14]. Skeletal muscle is the dominant calf tissue and is most vulnerable to ischemia . Labber et al. reported that 3, 4 and 5 h of ischemia led to necrosis in 2, 30 and 90% of leg muscles, respectively . Conventional treatment after the detection of CS is immediate fasciotomy to reduce tension.
For CS patients with high-impact injuries caused by earthquakes, Huang et al. reported that more wound infections and amputations were associated with fasciotomy . It was believed that as high as 15–25% of systemic complications were related to fasciotomy for CS patients with vascular damages on the lower extremity . However, Faber et al. compared and analyzed the complications and efficacy of 612 cases of fasciotomy within (the early group) and after (the late group) 8 h following vascular restorations. The results indicated that the risks of amputations and infections in the early group were effectively lowered and the hospitalization duration was shortened in the early group compared to the late group . Therefore, fasciotomy carried out long after the onset of CS may initiate undesired complications, which emphasizes the importance of early diagnosis and fasciotomy of CS.
In this study, six patients had fasciotomy 12–24 h after their affected legs got swollen (early group), while one patient had fasciotomy 2 days after the detection of CS and another patient was not diagnosed as CS at local hospital and received no fasciotomy (late group). Before fasciotomy, six patients in early group had necrotic anterior and outer lateral leg muscles, while two other patients in late group had necrotic muscles all over their affected legs except for gastrocnemius. Our clinical findings suggest that muscle necrosis could have been effectively prevented by early diagnosis as well as a timely fasciotomy.
Systemic support is beneficial to mitigate inflammatory reactions resulting from ischemic reperfusion, prevent organ complications, and improve the tolerance to surgery . Both necrotic muscle tissues and their catabolic products could activate endogenous coagulate system and release inflammatory mediators . All patients in this study had wound debridement 2–4 times to remove necrotic tissues. Suturing or skin grafting was applied to close the wounds. We speculate that these procedures largely contribute to satisfactory clinical outcomes. No systemic inflammatory response, infection or secondary organ damage was found throughout the course of treatment.
For patients with mild clubfoot, orthopedic braces are effective. In other cases, patients receive corrective surgeries, such as peroneus longus, brevis or posterior tibial muscle tendon displacement. In addition, arthrolysis on the rear side of ankle, including incision of posterior capsule film and Achilles tendon lengthening, could ease the deformity. At our hospital, most of the patients with acute CS had worn orthopedic braces during hospitalization. After being discharged from the hospital, the patients continued wearing the braces for another 3–6 months, allowing them to gradually resume daily walking and exercises. For those who had drop foot, similar programs of soft tissue treatment were carried out within 6 months after the closure of their wounds, which enabled them to walk and exercise.
Notably, in this study patients with severe complications all experienced at least one of secondary horseshoe ankle, metatarsophalangeal joint dislocation, foot varus and claw toes, which were too severe to be corrected simply via soft tissue treatment. Osteotomy fusion could restore clubfoot almost completely with high success rate and low recurrence . However, this procedure is invasive, involving tarsal bone amputation and downsizing affected feet . Furthermore, CS patients usually suffer vascular injuries and impaired soft tissues. All these concerns need to be taken into consideration before planning osteotomy fusion . On the contrary, Ilizarov external frame is relatively noninvasive and less affected by impaired soft tissues, and facilitates tissue regeneration. As a result, deformed foot and ankle could be rearranged to normal position to correct the clubfoot [5,6,7].
In this study we summarized our experiences of managing eight patients with serious complications of acute CS. The sample size is relatively small, which is a limitation of this study. Further studies that enroll more patients with serious complications of acute CS are necessary.