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      Male sex, height, weight, and body mass index can increase external pressure to calf region using knee-crutch-type leg holder system in lithotomy position

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          Abstract

          Background

          Well-leg compartment syndrome (WLCS) is one of the catastrophic complications related to prolonged surgical procedures performed in the lithotomy position, using a knee-crutch-type leg holder (KCLH) system, to support the popliteal fossae and calf regions. Obesity has been implicated as a risk factor in the lithotomy position-related WLCS during surgery. In the present study, we investigated the relationship between the external pressure (EP) applied to the calf region using a KCLH system in the lithotomy position and selected physical characteristics.

          Methods

          Twenty-one young, healthy volunteers (21.4±0.5 years of age, eleven males and ten females) participated in this study. The KCLH system used was Knee Crutch ®. We assessed four types of EPs applied to the calf region: box pressure, peak box pressure, contact pressure, and peak contact pressure, using pressure-distribution measurement system (BIG-MAT ®). Relationships between these four EPs to the calf regions of both lower legs and a series of physical characteristics (sex, height, weight, and body mass index [BMI]) were analyzed.

          Results

          All four EPs applied to the bilateral calf regions were higher in males than in females. For all subjects, significant positive correlations were observed between all four EPs and height, weight, and BMI.

          Conclusion

          EP applied to the calf region is higher in males than in females when the subject is supported by a KCLH system in the lithotomy position. In addition, EP increases with the increase in height, weight, and BMI. Therefore, male sex, height, weight, and BMI may contribute to the risk of inducing WLCS.

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          Most cited references 42

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          Diagnosis and management of compartmental syndromes.

          Patients at risk for compartmental syndromes challenge both the diagnostic and the therapeutic abilities of the physician. Suboptimum results may be due to delays in diagnosis and treatment, to incomplete surgical decompression, and to difficulties in the management of the limb after decompression. Although careful clinical assessment permits the diagnosis of a compartmental syndrome in most patients, we have found measurement of tissue pressure and direct nerve stimulation to be helpful for resolving ambiguous or equivocal cases. In our experience, the four-compartment parafibular approach to the leg and the ulnar approach to the volar compartments of the forearm provide efficient and complete decompression of potentially involved compartments. The skeletal stabilization of fractures associated with compartmental syndromes may facilitate management of the limb after surgical decompression.
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            Compartment monitoring in tibial fractures. The pressure threshold for decompression.

            We made a prospective study of 116 patients with tibial diaphyseal fractures who had continuous monitoring of anterior compartment pressure for 24 hours. Three patients had acute compartment syndrome (2.6%). In the first 12 hours of monitoring, 53 patients had absolute pressures over 30 mmHg and 30 had pressures over 40 mmHg, with four higher than 50 mmHg. Only one patient had a differential pressure (diastolic minus compartment pressure) of less than 30 mmHg; he had a fasciotomy. In the second 12-hour period 28 patients had absolute pressures over 30 mmHg and seven over 40 mmHg. Only two had differential pressures of less than 30 mmHg; they had fasciotomies. None of our 116 patients had any sequelae of the compartment syndrome at their latest review at least six months after injury. A threshold for decompression of 30 mmHg would have indicated that 50 patients (43%) would have required fasciotomy, and at a 40 mmHg threshold 27 (23%) would have been considered for an unnecessary fasciotomy. In our series, the use of a differential pressure of 30 mmHg as a threshold for fasciotomy led to no missed cases of acute compartment syndrome. We recommended that decompression should be performed if the differential pressure level drops to under 30 mmHg.
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              Lower limb (well leg) compartment syndrome after urological pelvic surgery.

              Well leg compartment syndrome (WLCS) is being seen more frequently as the complexity and duration of pelvic urological surgery increases, ie reconstruction/radical cancer surgery. The etiology of WLCS is multifactorial and prevention should form the mainstay of treatment. With significant morbidity and mortality, in particular lower limb morbidity secondary to fasciotomy wounds and long-term neurological sequelae, all urologists should be aware of this iatrogenic complication and how to prevent or treat it when it occurs. A retrospective review of the world literature using MEDLINE was performed from 1966 to 2002, searching for lower limb compartment syndrome (well leg compartment syndrome), and its association with the lithotomy position and pelvic surgery. Although WLCS is not commonly reported in the urological literature, it has significant morbidity and mortality. The incidence of WLCS is probably under reported due to failed diagnosis or misdiagnosis. With increased awareness the incidence of this iatrogenic complication may be minimized or avoided altogether. Because the lithotomy position is one of the most common positions used in urology, it is mandatory for urologists to be familiar with the complications associated with it. If this complication is recognized early, prompt treatment decreases morbidity and mortality. Minimizing the risk of WLCS will leave urologists less open to litigation, which may follow this significant iatrogenic complication.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2016
                25 February 2016
                : 12
                : 305-312
                Affiliations
                [1 ]Department of Anesthesiology and Pain Medicine, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo
                [2 ]Faculty of Health and Welfare Science, Okayama Prefectural University, Soja-shi, Okayama, Japan
                Author notes
                Correspondence: Ju Mizuno, Department of Anesthesiology and Pain Medicine, Juntendo University Faculty of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan, Tel +81 3 3813 3111, Fax +81 3 5689 3820, Email mizuno_ju8@ 123456yahoo.co.jp
                Article
                tcrm-12-305
                10.2147/TCRM.S86934
                4772916
                26955278
                © 2016 Mizuno and Takahashi. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Original Research

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