Dichotomy in Fasciotomy: Practice Patterns Among Trauma/Acute Care Surgeons With Performing Fasciotomy With Peripheral Arterial Repair

Abstract

Introduction: Failure to perform adequate fasciotomy for a presumed or diagnosed compartment syndrome after revascularization of an acutely ischemic limb is a potential cause of preventable limb loss. When required, outcomes are best when fasciotomy is conducted with the initial vascular repair. Despite over 100 years of experience with fasciotomy, the actual indications for its performance among acute care and trauma surgeons performing vascular repairs are unclear. The hypothesis of this study was that there are many principles of fasciotomy that are uniformly accepted by surgeons and that consensus guidelines could be developed.

Methods: A 20-question survey on fasciotomy practice patterns was distributed to trauma and acute care surgeons of a major surgical society which had approved distribution.

Results: The response to the survey was 160/1066 (15 %). 92.5% of respondents were fellowship trained in trauma and acute care surgery, and 74.9% had been in practice for fewer than 10 years. Most respondents (71.9%) stated that they would be influenced to perform a preliminary fasciotomy (fasciotomy conducted prior to planned exploration and arterial repair) based upon specific signs and symptoms consistent with compartment syndrome-including massive swelling (55.6%), elevated compartment pressures (52.5%), delay in transfer >6 hours (47.5%), or obvious distal ischemia (33.1%). 20.6% responded that they would conduct exploration and repair first, regardless of these considerations. Prophylactic fasciotomies (fasciotomy without overt signs of compartment syndrome) would be performed by respondents in the setting of the tense compartment (87.5%), ischemic time >6 hours (88.1%), measurement of elevated compartment pressures (66.9%), and in the setting of large volume resuscitation requirements (31.3%). 69.4% of respondents selectively measure compartment pressures, with nearly three-fourths utilizing a Stryker needle device (72.5%). The most common sequence of repairs following superficial femoral artery injury with a >6-hour limb ischemia was cited as the initial insertion of a shunt, followed by fasciotomy, then vein harvest, and finally interposition repair.

Conclusions: While there is some general consensus on indications for fasciotomy, there is marked heterogeneity in surgeons' opinions on the precise indications in selected scenarios. This is particularly surprising in light of the long history with fasciotomy in association with major arterial repairs and strongly suggests the need for a consensus conference and/or meta-analysis to guide further care.

Keywords: compartment syndrome; fasciotomy; traumatic arterial injury.