Managing missed lower extremity compartment syndrome in the physiologically stable patient: A systematic review and lessons from a level I trauma center.

Background: Decompressing an acute lower extremity compartment syndrome salvages muscle and nerve and preserves limb function. However reperfusion of ischemic tissue causes a systemic insult that can be life-threatening. Hence, the management of missed acute lower limb compartment syndrome remains controversial. The aim of this study was to evaluate the literature and, together with our own experience from a level 1 trauma centre, clarify the management of missed compartment syndrome in the physiologically stable patient. Methods: Pubmed, EMBASE, MEDLINE, the Cochrane database of systematic reviews and the Cochrane central register of controlled trials was searched. Studies were evaluated using the GRADE methodology. In addition, our trauma database was searched (2005-May 2015) for additional cases and a multidisciplinary case note review was conducted for all cases identified. This study was registered prospectively on the PROSPERO database (CRD42015026098). Results: Our systematic review yielded 9 studies, including one case-controlled study, 3 case series and 5 case reports with a total of 57 patients and 64 limbs. Overall study quality was "very low" with the exception of the case-controlled study which was "low". Delayed compartment decompression (6-120 hours) resulted in amputation rates of 5 of 24, 8 of 19, 4 of 5 and 2 of 3 limbs. Two patients died of complications associated with late compartment decompression. One compartment syndrome of the buttock was managed non-operatively. Most surviving limbs exhibited functional deficits. Additionally, our experience comprised 10 cases. Of the 6 who underwent compartment decompression the burden of subsequent morbidity included 3 amputations (one above knee), 2 complete foot drops and one episode of severe sepsis. As this experience mirrored the poor outcomes reported in the literature, we managed the 4 most recent cases non-operatively. All remain ambulant with incomplete foot drops or limb weakness. Conclusion: Surgical decompression of missed acute lower limb compartment syndrome yields an early physiological insult and a high late amputation rate. Managing selected cases non-operatively may result in less early morbidity and yield superior long term results but the evidence remains sparse and of poor quality. Level of evidence: Systematic review, level II. Source of funding: none (C) 2016 Lippincott Williams & Wilkins, Inc.

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