Percutaneous Forefoot Decompression in a Foot Compartment Syndrome Model

Abstract

Background:Acute compartment syndrome of the foot is a controversial topic. Release of the foot has been seen as complicated because of large incisions and postoperative morbidity, and there has been debate over whether this procedure is actually effective for releasing all areas of increased pressure. New sensor technology affords the opportunity to advance our understanding of acute compartment syndrome of the foot and its treatment. The purpose of the present study was to determine whether percutaneous decompression could be performed for the treatment of compartment syndrome in a forefoot model.Methods:The present study utilized a validated continuous pressure sensor to model compartment syndrome in human cadaveric feet. We utilized a pressure-controlled saline solution infusion system to induce increased pressure. A novel percutaneous release of the forefoot was investigated to assess its efficacy in achieving decompression.Results:For all cadaveric specimens, continuous pressure monitoring was accomplished with use of a continuous pressure sensor. There were 4 discrete compartment areas that could be reliably pressurized in all feet. The average baseline, pressurized, and post-release pressures (and standard deviations) were 4.5 ± 2.9, 43.8 ± 7.7, and 9.5 ± 3.6 mm Hg, respectively. Percutaneous decompression produced a significant decrease in pressure in all 4 compartments (p < 0.05).Conclusions:With use of continuous compartment pressure monitoring, 4 consistent areas were established as discrete compartments in the foot. All 4 compartments were pressurized with a standard pump system. With use of 2 small dorsal incisions, all 4 compartments were successfully released, with no injuries identified in the cutaneous nerve branches, extensor tendons, or arteries. These results have strong implications for the future of modeling compartment syndrome as well as for guiding clinical studies.Clinical Relevance:A reproducible and accurate method of continuous pressure monitoring of foot compartments after trauma is needed (1) to reliably identify patients who are likely to benefit from compartment release and (2) to help avoid missed or evolving cases of acute compartment syndrome. In addition, a reproducible method for percutaneous compartment release that minimizes collateral structural damage and the need for secondary surgical procedures is needed.

Minimal Percutaneous Release for Acute Compartment Syndrome of the Foot

“…Work by the current authors 6 has shown that 4 compartments consistently exist in the medial and volar forefoot, with a fifth possible compartment being the more superficial lateral abductor minimi group. This has been validated on a series of cadaver ACS models using ultrasound, sequential compartment pressurization, and the use of multiple pressure monitors 6,7 to determine the presence of physiological compartments. Traditionally, wide surgical releases have been used to accomplish compartment release.…”

“…It is generally accepted that there is a lateral compartment, a superficial central compartment, a medial compartment (sometimes described as 2 compartments with a separate abductor), and an interosseous compartment (described as either 1 continuous compartment or 4 separate compartments) [3][4][5] . Work by the current authors 6 has shown that 4 compartments consistently exist in the medial and volar forefoot, with a fifth possible compartment being the more superficial lateral abductor minimi group. This has been validated on a series of cadaver ACS models using ultrasound, sequential compartment pressurization, and the use of multiple pressure monitors 6,7 to determine the presence of physiological compartments.…”

“…In this case report, percutaneous decompression of the forefoot previously validated on cadaver models 6 was shown to be effective in a clinical case for treatment of forefoot ACS. Although this technique may be effective in forefoot decompression, care must be taken to exclude calcaneal compartment syndrome 11,12 .…”

“…We have applied a minimally invasive technique to a patient with acute compartment syndrome. The advantages of the technique 6 illustrated include a low risk of neurovascular injury, avoidance of the medial incision associated with residual scarring/morbidity, less chance of muscle death/toe clawing, and decreased need for secondary surgeries. Our technique is similar to the accepted approach of Mubarak; however, we were able to accomplish the decompression through smaller proximal incisions 11 .…”