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Observational Study
. 2022 Jan 1;36(Suppl 1):S26-S32.
doi: 10.1097/BOT.0000000000002284.

Defining Incidence of Acute Compartment Syndrome in the Research Setting: A Proposed Method From the PACS Study

Andrew Leroux  1 , Katherine P Frey  2 , Ciprian M Crainiceanu  3 , William T Obremskey  4 , Daniel J Stinner  4 , Michael J Bosse  5 , Madhav A Karunakar  5 , Robert V O'Toole  6 , Eben A Carroll  7 , David J Hak  8 , Roman Hayda  9 , Dana Alkhoury  2 , Andrew H Schmidt  10 ; METRC
Affiliations
Observational Study

Defining Incidence of Acute Compartment Syndrome in the Research Setting: A Proposed Method From the PACS Study

Andrew Leroux et al. J Orthop Trauma. .

Abstract

Objective: To compare the retrospective decision of an expert panel who assessed likelihood of acute compartment syndrome (ACS) in a patient with a high-risk tibia fracture with decision to perform fasciotomy.

Design: Prospective observational study.

Setting: Seven Level 1 trauma centers.

Patients/participants: One hundred eighty-two adults with severe tibia fractures.

Main outcome measurements: Diagnostic performance (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver-operator curve) of an expert panel's assessment of likelihood ACS compared with fasciotomy as the reference diagnostic standard.

Secondary outcomes: The interrater reliability of the expert panel as measured by the Krippendorff alpha. Expert panel consensus was determined using the percent of panelists in the majority group of low (expert panel likelihood of ≤0.3), uncertain (0.3-0.7), or high (>0.7) likelihood of ACS.

Results: Comparing fasciotomy (the diagnostic standard) and the expert panel's assessment as the diagnostic classification (test), the expert panel's determination of uncertain or high likelihood of ACS (threshold >0.3) had a sensitivity of 0.90 (0.70, 0.99), specificity of 0.95 (0.90, 0.98), PPV of 0.70 (0.50, 0.86), and NPV of 0.99 (0.95, 1.00). When a threshold of >0.7 was set as a positive diagnosis, the expert panel assessment had a sensitivity of 0.67 (0.43, 0.85), specificity of 0.98 (0.95, 1.00), PPV of 0.82 (0.57, 0.96), and NPV of 0.96 (0.91, 0.98).

Conclusion: In our study, the retrospective assessment of an expert panel of the likelihood of ACS has good specificity and excellent NPV for fasciotomy, but only low-to-moderate sensitivity and PPV. The discordance between the expert panel-assessed likelihood of ACS and the decision to perform fasciotomy suggests that concern regarding potential diagnostic bias in studies of ACS is warranted.

Level of evidence: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

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Conflict of interest statement

C.M. Crainiceanu is a consultant with Bayer, Johnson and Johnson, and Cytel on methods development for wearable devices in clinical trials. The details of the contracts are disclosed through the Johns Hopkins University eDisclose system and have no direct or apparent relationship with this article. The remaining authors report no conflict of interest.

References

    1. Blair JA, Stoops TK, Doarn MC, et al. Infection and nonunion after fasciotomy for compartment syndrome associated with tibia fractures: a matched cohort comparison. J Orthop Trauma. 2016;30:392–396.
    1. Fitzgerald AM, Gaston P, Wilson Y, et al. Long-term sequelae of fasciotomy wounds. Br J Plast Surg. 2000;53:690–693.
    1. Bermudez K, Knudson MM, Morabito D, et al. Fasciotomy, chronic venous insufficiency, and the calf muscle pump. Arch Surg. 1998;133:1356–1361.
    1. Garfin SR, Tipton CM, Mubarak SJ, et al. Role of fascia in maintenance of muscle tension and pressure. J Appl Physiol Respir Environ Exerc Physiol. 1981;51:317–320.
    1. Reverte MM, Dimitriou R, Kanakaris NK, et al. What is the effect of compartment syndrome and fasciotomies on fracture healing in tibial fractures? Injury. 2011;42:1402–1407.

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