Fasciotomy, Chronic Venous Insufficiency, and the Calf Muscle Pump

Abstract

To test the hypothesis that fasciotomy may impair the function of the calf muscle pump, which in turn could result in the development of chronic venous insufficiency. Design: A cohort study of patients with a history of lower extremity fasciotomy. Setting: An urban trauma center. Patients: Seventeen of the 83 patients identified through trauma, vascular, and/or orthopedic registries consented to participation in this study. Interventions: Participating patients completed a study questionnaire, and then underwent a complete vascular examination, including air plethysmographic (APG) assessment. Patients with a history of venous injuries were also studied with color flow duplex venous imaging. Main Outcome Measures: Function of the calf muscle pump as measured by APG, and evidence of chronic venous insufficiency as measured by APG, findings on clinical examination, and by venous ultrasonography. Results: Seventeen patients completed the study, including 8 with a history of vascular injuries, 6 with old fractures, and 3 who had undergone fasciotomy for soft tissue infections. The time from injury to examination ranged from 5 months to 20 years. Eight patients had signs or symptoms of venous insufficiency, the severity of which appeared to be time dependent. The APG data showed significant mean differences between fasciotomy and control extremities in ejection fraction (PϽ.001) and residual volume fraction (PϽ.001), both measures of calf muscle pump function. There were no significant changes in venous filling index, a measure of venous reflux, or in outflow fraction, which correlates with venous obstruction. There were no differences in APG variables between patients with vascular injuries vs those with orthopedic or soft tissue injuries. Conclusions: Lower extremity fasciotomy impairs longterm calf muscle pump function, as measured by APG, in patients with and without vascular injuries. These patients are at risk for the long-term development of chronic venous insufficiency following lower extremity trauma.

A Critical Reappraisal of Indications for Fasciotomy After Extremity Vascular Trauma

“…Furthermore, the concept that fasciotomy is without functional impairment of the limb during the long-term has recently been questioned. In a recent report, Bermudez and associates 26 followed up 17 patients with fasciotomy for a period of 6 months to 20 years. The extremities were studied with air plethysmography, comparing the contralateral limb as a control.…”

Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: A review of the National Trauma Data Bank

“…Proponents of prophylactic, or early fasciotomy, suggest that development of ECS and its associated complications can be avoided (2–4,7,12,14,16). Detractors point out that fasciotomies have associated short (16–18) and long-term (19–21) complications and that that their prophylactic use is unnecessary (15,18,22). …”

Compartment Syndrome in the Setting of Vascular Injury

“…25 Similar results were also identified in trauma patients who underwent fasciotomy. 26 Fasciotomy wounds are disfiguring if they are not closed in a delayed primary fashion. Studies have shown that patients who undergo split thickness skin grafting are upset by their cosmetic wounds.…”