OTA 2006 Posters

Scientific Poster #73 Basic Science

Evaluation of Pressure Drop in Induced Compartment Syndrome
after Treatment with Standard Fasciotomy or Pie Crusting:
A Cadaveric Study
Mark J. Anders, MD (n); Dov A. Bader, MD (n); Matthew J. Harris (n); William M. Mihalko, MD (n);
University at Buffalo, State University of New York, Buffalo, New York, USA

Purpose: In order to aid in the closure of fascia during open reduction and internal fixation procedures for tibial plateau fractures, the senior author of this study has employed the technique of pie crusting in a number of patients. None of these patients went on to develop a compartment syndrome. The standard treatment for a patient diagnosed with acute compartment syndrome is a timely fasciotomy. However, it has been suggested that there is a functional relationship between fascia, muscle tension, and pressure. Decreased dorsiflexion strength as well as muscle herniation have been reported after treatment with standard fasciotomy. These observations formed the basis for our study: to evaluate the role of pie crusting to help in the management of soft tissues to allow closure of the fascia in an at-risk patient. Our pie crusting technique consists of stab incisions in line with the fascial fibers and spaced approximately 1 cm apart in the superior-inferior and medial-lateral directions, with care taken to avoid the peroneal nerve.

Methods: Eight lower extremity specimens were harvested by performing a midfemur cut. A 1-cm skin incision was made one third of the way distally from the tibial tubercle to the anterior ankle joint line, over the midportion of the anterior compartment but not in line with future fasciotomy. The fascia was identified and a 14-gauge catheter was introduced into the anterior compartment. The skin was then closed with simple sutures. The 14-gauge catheter was connected to an infusion pump. Two 5-mm skin incisions were then made, each 5 cm away from the 14-gauge catheter, one proximally and one distally to introduce a slit catheter once the fascia was identified; the skin was then closed with simple sutures. Infusing 10-cc increments of normal saline solution into the compartment increased the compartment pressure. Pressure and volume were monitored and recorded after each increment. Average compartment pressures were determined by averaging the readings of the first and second pressure transducers. A standard 20- to 25-cm skin incision was made to expose the compartmental fascia. The fascia was then randomized to a standard fasciotomy or initial pie crusting, followed by a fasciotomy. After the fascia was treated and the pressure equilibrated, the change in pressure was then recorded. The initial skin incision was then fully sutured and the same technique used for the remaining compartment of each limb.

Results: A total of 16 compartments from eight limbs were tested. The average preincision compartment pressure was 101 mmHg ± 15.7. Ten compartments underwent pie crusting with an average total percent reduction of 62.8% ± 12.2. Fasciotomy alone was performed on six compartments with an average total percent reduction of 98.5% ± 3.3. In the ten compartments that initially underwent pie crusting, a standard fasciotomy was later performed with an additional average percent reduction of 35.5% ± 11.4. The initial pie crusting followed by subsequent fasciotomy yielded an average total combined percent reduction of 98.3% ± 4.1.

Conclusion/Significance: Overall, pie crusting reduces compartmental pressure by 62.8%, inferior to standard fasciotomy. Pie crusting remains a possible adjunct treatment to facilitate closure of the fascia and may help in the management of soft tissues in an at-risk patient.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
· 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.