TRAUMA 2023, Nov, 20 | 12:00 am

Step-by-Step Surgical Techniques for Leg Compartment Syndrome: Single vs Two-Incision Approach

Learn about Leg Compartment Syndrome Surgery through detailed, interactive, step-by-step guides with pre-operative and post-operative care instructions using single and two-incision approach.">

Preoperative Patient Care

Learn about the pre-op evaluation and management, and order basic imaging studies to begin surgical procedures. Have a comprehensive admission plan for the perioperative inpatient management and prescribe physical therapy for the inpatient. Complete surgical consent process and describe complications of surgery to patients.

Operative Techniques

Execute surgical walkthrough and prepare the room with surgical instrumentation and patient positioning. Learn the Perifibular Approach with the Single-incision approach, and Superficial Anterolateral Incision with the Two-incision approach. Follow surgical procedures to release Anterior and Lateral Compartments, Superficial and Deep Compartment, and Flexor Hallucis Longus Release. Finally, learn to Close Wounds and place the patient in a supportive splint.

Postoperative Patient Care

Discuss postoperative planning and make arrangements for outpatient treatment. Have a follow-up plan with wound checks, diagnostic tests, prescribing pain medications, returning to the OR for additional wound debridement, and initiating physical therapy. Know to recognize early and late complications in the patients to make necessary changes to the plan.

Disclaimer

This blog post is for informational purposes only and should not be used as a substitute for professional medical advice. Consult a healthcare provider for diagnosis and treatment recommendations.

Learn about leg compartment syndrome and the step-by-step surgical techniques of the single and two incision approaches. Get pre-operative patient care, operative techniques, and postoperative patient care.

Single Incision Approach

Preoperative Patient Care

A. Outpatient Evaluation and Management

  1. Obtains focused history and performs focused exam
    • assess lower extremity compartments
    • document distal neurovascular status
    • check for associated orthopedic injuries
  2. Interpret basic imaging studies
    • biplanar radiographs of the leg
  3. Makes informed decision to proceed with operative treatment
    • describes accepted indications and contraindications for surgical intervention
  4. Provides post-operative management and rehabilitation
    • postop: 2-3 week postoperative visit
    • wound check
    • staples/sutures removed
    • start range of motion exercises
    • diagnose and management of early complications
    • postop: ~ 3 month postoperative visit
    • diagnosis and management of late complications
    • postop: 1 year postoperative visit

B. Advanced Evaluation and Management

  1. Prioritizes the needs of the polytrauma patient
    • timing of long bone fixation
    • works with consulting
  2. Complex wound management and debridement
    • understanding need for consultation for flap coverage
  3. Capable of treating complications both intraoperatively and post-operatively
    • manages post operative infection

C. Preoperative H & P

  1. Perform focused orthopedic exam
    • assess lower extremity compartments
    • document distal neurovascular status
  2. Order basic imaging studies
    • need biplanar radiographs of entire tibia/fibula, knee, and ankle
  3. Perform operative consent
    • describe complications of surgery including scarring and injury to the superficial peroneal nerve

Operative Techniques

E. Preoperative Plan

  1. Execute surgical walkthrough
    • describe key steps of the procedure to the attending verbally prior to the start of the case
    • describe potential complications and the steps to avoid them

F. Room Preparation

  1. Surgical instrumentation
    • curved mayo scissors
  2. Room setup and equipment
    • standard OR table
  3. Patient positioning
    • patient supine

G. Perifibular Approach

  1. Mark the incision halfway between the fibula and the crest of the tibia
    • make a 10 cm incision dircelty over the midportion of the fibula
    • retract the skin anteriorly

H. Anterior and Lateral Compartment Release

  1. Incise the anterior fascia
    • release the fascia of the anterior and lateral compartment longitudinally in a proximal and distal direction
    • retract the skin posteriorly

I. Superficial Posterior Compartment Release

  1. Incise the lateral fascia
    • release the fascia that overlies the lateral head of the gastrocnemius
    • incise the fascia over the superficial posterior compartment for a distance of 15 cm
    • evaluate the color, consistency, contractility and capillary refill

J. Deep Posterior Compartment Release

  1. Expose and release the deep posterior compartment
    • retract the anterior and lateral compartments anteriorly and the superficial posterior compartment posteriorly
    • release the soleal bridge from the fibula
    • identify the fascia over the FHL
  2. Incise the fascia over the FHL
  3. Retract the gastrocsoleus complex posterior
    • retract the FHL laterally
    • this exposes the posterior tibial artery, tibial nerve and peroneal artery that is overlying the tibialis posterior

K. FHL Release

  1. Perform release
  2. Incise the fascia around the tibialis posterior and the interval between the muscle and the origins of the flexor hallucis longus is widened if it is constrictive

L. Wound Closure

  1. Place negative pressure dressings
  2. Place in splint with the ankle in neutral
    • this prevents equinus contracture
  3. Return to OR in 48-96 hours for additional wound debridement
  4. Return to OR in 5-7 days for primary wound closure

Postoperative Patient Care

O. Perioperative Inpatient Management

  1. Write comprehensive admission orders
    • serial compartment checks x 24 hours
    • advance diet as tolerated
    • pain control
    • wound management
    • return to the OR in 48-96 hours for repeat compartment check and wound debridement
    • foley out when ambulating
    • check appropriate labs
    • antibiotics
    • prescribe DVT prophyhlaxis
  2. Physical therapy
    • nonweightbearing
  3. Appropriate medical management and medical consultation
  4. Discharges patient appropriately
    • pain meds
    • outpatient PT
    • schedule follow up in 2 weeks
    • wound care

R. Complex Patient Care

  1. Develops unique, complex post-operative management plans

Two Incision Approach

This approach follows similar pre-operative patient care and postoperative patient care as the single incision approach. The operative techniques are different and are listed below.

Operative Techniques

E. Preoperative Plan

  1. Execute surgical walkthrough
    • describe key steps of the procedure to the attending verbally prior to the start of the case
    • describe potential complications and the steps to avoid them

F. Room Preparation

  1. Surgical instrumentation
    • curved mayo scissors
  2. Room setup and equipment
    • standard OR table
  3. Patient positioning
    • patient supine

G. Superficial Anterolateral Incision

  1. Mark the incision halfway between the fibula and the crest of the tibia
    • make the incision directly over the anterolateral intermuscular septum
    • extend the incision 15 to 20 cm distally
  2. Identify the superficial peroneal nerve
    • the nerve is 10 to 12 cm proximal to the tip of the lateral malleolus

H. Anterior Compartment Release through Anterolateral Incision

  1. Incise the anterior fascia
    • localize the intermuscular septum at the proximal end of the wound
    • make a short transverse incision anterior to the intermuscular septum
    • the transverse incision should be long enough to fit the tip of curved mayo scissors for the fasciotomy
  2. Perform the fasciotomy
    • run the scissors cephalad and caudally
  3. Assess the musculature of the anterior compartment
    • evaluate the color, consistency, contractility and capillary refill

I. Lateral Compartment Release through Anterolateral Incision

  1. Incise the lateral fascia
    • localize the intermuscular septum at the proximal end of the wound
    • make a short transverse incision posterior to the intermuscular septum
    • the incision should be long enough to fit the tip of curved mayo scissors for the fasciotomy
  2. Perform the fasciotomy
    • run the scissors cephalad and caudally
  3. Assess the musculature of the lateral compartment
    • evaluate the color, consistency, contractility and capillary refill

J. Superficial and Deep Compartment Release

  1. Mark the incision 2 cm medial to the posterior border of the tibia
    • make an anteriormedial incision 2 cm medial to the posterior medial border of the tibia
    • make incision 15-20 cm distally
    • retract the saphenous vein and nerve anteriorly
  2. Perform fasciotomy
    • incise the fascia directly under the incision for a short distance
    • place the tip of the curved mayo scissors into the incision
    • direct the mayo scissors cephalad and caudally
    • this decompresses the superficial posterior compartment
  3. Assess the musculature of the superficial posterior compartment
  4. Release the deep posterior compartment
    • release the fascia distally and run mayo scissors proximally through and under the soleus bridge
    • release the the soleus attachment to the tibia more than half way
    • release the fascia over the posterior tibia muscle
  5. Assess the musculature of the deep compartment

K. Superficial Compartment Release through the Anteromedial Incision

  1. Perform fasciotomy
    • incise the fascia directly under the incision for a short distance
    • place the tip of the curved mayo scissors into the incision
    • direct the mayo scissors cephalad and caudally
    • this decompresses the superficial posterior compartment
  2. Assess the musculature of the superficial compartment

L. Deep Compartment Release through Anteromedial Incision

  1. Release the deep posterior compartment
    • release the fascia distally and run mayo scissors proximally
    • continue release through and under the soleus bridge
    • release the the soleus attachment to the tibia more than half way
  2. Assess the musculature of the deep compartment

N. Wound Closure

  1. Place negative pressure dressings
  2. Place in splint with the ankle in neutral
    • this prevents equinus contracture
  3. Return to OR in 48-96 hours for additional wound debridement
  4. Return to OR in 5-7 days for primary wound closure