Bilateral Gluteal Compartment Syndrome After Total Hip Arthroplasty Under Epidural Anesthesia

doi:10.1016/j.arth.2005.02.007

The Journal of Arthroplasty

Volume 20, Issue 8, December 2005, Pages 1081-1083

https://doi.org/10.1016/j.arth.2005.02.007 Get rights and content

Abstract

The gluteal compartment syndrome is uncommon and is discussed in only a few published case reports. The simultaneous bilateral gluteal compartment syndrome is exceptionally rare and is tackled in only 4 case reports to date. We report a case of bilateral gluteal compartment syndrome after total hip arthroplasty under epidural anesthesia and discuss its management.

Section snippets

Case Report

A 39-year-old man presented with congenital dysplasia requiring right hip arthroplasty. Apart from previous operations to both his hips, his past medical history was unremarkable. His preoperative blood results were within normal limits. A decision to perform the surgery using a combination of epidural anesthesia and general anesthesia was made.

After establishing routine monitoring and intravenous access, an epidural site was located under aseptic precautions at the L3-4 level using a 16-gauge

Discussion

Mubarak et al [1] defined compartment syndrome as a condition with raised pressure in a closed osseofascial compartment. Although mainly applied to tibial compartments, similar consequences can also happen in the gluteal region. The gluteal compartment physiologically consists of 3 isolated units:

•
Gluteus maximus compartment enveloped in its own tough fascia;
•
Gluteus medius-minimus compartment surrounded by gluteal fascia; and
•
Tensor fascia lata compartment and its fibrous envelope.

The

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Measurement of the gluteal compartment pressures: A cadaveric study describing safety and reproducibility of two methods
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Gluteal compartment syndrome is an uncommon entity and physicians may use intracompartmental pressure measurements for confirmation of the clinical diagnosis, or in cases where the physical exam is indeterminate. However, there is a paucity of literature describing a safe and reproducible technique to measure gluteal intracompartmental pressures during the diagnosis of gluteal compartment syndrome. The purpose of this cadaveric study is to evaluate the sole previous technique described in the literature to measure gluteal intracompartmental pressures and provide a modified technique which can be safely and reliably utilized clinically.
A cadaveric study with three phases was performed in 16 gluteal regions in 8 cadavers. In the first phase, the previously described technique was assessed. In the second phase, a modified set of techniques was created and evaluated. In the third phase, inter-user reliability of the modified set of techniques was assessed and calculated using Cohen's ĸ coefficient. In all three phases, methylene blue was injected through pressure monitoring needles into the gluteus maximus (GMax), gluteus medius/minimus (GMM), and the tensor fascia lata (TFL) compartments. Following dissection, rate of successful penetration into each targeted compartment and distance from the neurovascular structures was recorded.
The previously described set of techniques was found to be variable. The modified set of techniques was effective, successfully reaching the GMax, GMM, and TFL compartments in 100%, 100%, and 81% of attempts, respectively. Inter-user reliability was excellent (ĸ = 1) for the techniques to reach both the GMax and GMM compartments, and moderate (ĸ = 0.54) for the technique to reach the TFL compartment. Within the GMax, the pressure monitoring needle was at a mean of 5.4±0.6 cm, 4.1±0.7 cm, 6.4±0.5 cm from the sciatic nerve (SN), superior gluteal nerve (SGN), and inferior gluteal nerve (IGN), respectively. Within the GMM, the pressure monitoring needle was at a mean of 9.7±1.4 cm, 7.4±1.3 cm, 11.1±1.7 cm from the SN, SGN, and IGN, respectively.
The modified set of techniques presented allows the three gluteal compartments to be safely and reproducibly reached to measure intracompartmental pressures during the diagnosis of gluteal compartment syndrome.
Acute Extremity Compartment Syndrome and (Regional): Anesthesia: The Monster Under the Bed
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Citation Excerpt :
Further compounding risk, orthopaedic literature demonstrates that obese patients experience relatively longer perioperative periods of immobility, including increased anesthesia induction time and duration of surgery, when undergoing the same procedure as smaller patients [94,95]. The association between epidural anesthesia and gluteal compartment syndrome has also been previously reported [46,51,62,66]. The motor blockade caused by epidural anesthesia impairs spontaneous postural repositioning to redistribute pressure loads on the gluteal area.
Gluteal compartment syndrome is a rare but devastating condition with limited characterization in the literature. The purpose of our systematic review, case series, and meta-analysis is to synthesize the current literature and provide recommendations on how to prevent gluteal compartment syndrome, identify at-risk patients, and avoid delays in diagnosis and treatment.
International Classification of Disease codes were used to identify patients at our institution. PubMed, MEDLINE, and the Cochrane Library were searched to identify case reports between 1972 and March 1st, 2018. Cases were analyzed based on demographics, etiology, presentation, symptoms, diagnosis, treatment, and outcomes.
139 cases – 13 from our institution and 126 previously published – were included. The most common etiologies were postoperative (41%), prolonged immobilization secondary to substance abuse or loss of consciousness (35%) and trauma (19%). 89% were male, mean age was 45 years (range, 16-74), and mean body mass index was 41 kg/m². Rhabdomyolysis and sciatic neuropathy were identified in 94% and 74% of patients, respectively. Fasciotomy was performed in 80% of patients. Overall, 93% of patients survived. However, 41% of patients suffered prolonged neurologic dysfunction. In patients with an initial neurologic deficit, there was a higher rate of permanent neurological deficit in patients treated medically than those treated surgically (12/14 vs 29/61, p=0.0153), but no statistical difference in mortality (0/14 vs 4/61, p=1). In patients without initial neurologic deficit, there were no statistical differences in rates of permanent neurological deficit (0/7 vs 2/20, p=1) or mortality (0/7 vs 3/20, p=0.545) between those receiving medical or surgical treatment.
Gluteal compartment syndrome is an orthopaedic emergency that may be more prevalent and associated with higher morbidity and mortality than previously recognized. Risk factors may include prolonged surgical duration, immobilization secondary to substance abuse, and pelvic trauma. Intraoperative precautions and postoperative surveillance are recommended in obese patients undergoing prolonged procedures. Fasciotomies improve neurologic outcomes in patients presenting with an initial neurologic deficit. In patients who are neurologically intact on presentation, medical management with neurologic function surveillance may be the optimal initial treatment. Fasciotomies do not impact mortality. Additionally, a treatment algorithm is provided.
Should Regional Anesthesia Be Used for Orthopedic Trauma Patients?
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Orthopedic trauma presents unique challenges for perioperative and acute pain management. Inadequate treatment of acute pain can potentiate stress response and predispose patients to chronic pain syndromes. Although regional anesthesia (RA) is effective for treating pain in this setting, it is often underused for various reasons. In particular, the concern for delaying a diagnosis of acute compartment syndrome (ACS) may influence the decision to use RA. The use of RA in the trauma setting should ultimately take into account a number of important factors including the available resources and personnel, likelihood of ACS, and ability to monitor for ACS postoperatively. When RA is used, techniques may also need to be modified to avoid dense motor and complete sensory blockade that could delay a timely diagnosis of ACS.
Gluteal compartment syndrome after total hip replacement. A presentation of two cases
2013, Revista Espanola de Cirugia Ortopedica y Traumatologia
Numerosas complicaciones posquirúrgicas tras la implantación de una artroplastia total de cadera han sido descritas a lo largo de los años, diferenciándose entre las precoces o postoperatorias inmediatas y las tardías. Presentamos 2 casos de síndrome compartimental glúteo como complicación de la implantación de prótesis total híbrida (vástago cementado y cótilo impactado atornillado) en 2 pacientes de 60 y 68 años respectivamente, en los cuales se diagnosticó y trató el proceso a las 24-48 h de la cirugía. En ambos casos se trataba de prótesis primarias y ninguno de ellos presentaba antecedentes patológicos de interés, siendo estos casos poco frecuentes y, en consecuencia, con escasas publicaciones en la literatura médica.
Many postoperative complications have been described after a total hip arthroplasty, with early and acute, as well as late, complications being reported. Two cases of compartment syndrome of the buttock are described following a hybrid total hip arthroplasty (cemented stem and press-fit and screwed acetabulum) performed on 2 patients of 60 and 68 years old, both diagnosed and treated 24-48 hours after the surgery. Both cases had a primary prosthesis with no previous significant pathological findings. This condition is still rare, and few cases have been described at the medical literature.

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Case ReportBilateral Gluteal Compartment Syndrome After Total Hip Arthroplasty Under Epidural Anesthesia

Abstract

Section snippets

Case Report

Discussion

Injury

J Arthroplasty

Acute compartment syndromes: diagnosis and treatment with the aid of wick catheter

J Bone Joint Surg Am

Bilateral gluteal compartment syndrome

J Trauma

Crush injury to the lower limbs. Treatment of the local injury

J Bone Joint Surg Am

Case Report
Bilateral Gluteal Compartment Syndrome After Total Hip Arthroplasty Under Epidural Anesthesia