Compartment Syndromes Associated with Postoperative Epidural Analgesia. A Case Report*

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Abstract
Compartment syndrome of the thigh is a rare complication that has been reported as a result of trauma, prolonged compression, and vascular injury [1-3,8,11,20,27]; however, it has not been reported after an elective osteotomy of the femur, to our knowledge. We describe the case of a patient in whom compartment syndromes of the thigh and leg developed after corrective osteotomies of the distal part of the femur and proximal part of the tibia. Similar osteotomies had been performed on the contralateral lower extremity fourteen weeks previously, and no complications had developed. The only modification during the second procedure was the use of epidural analgesia for the relief of postoperative pain. We believe that postoperative epidural analgesia may obscure the symptoms of compartment syndrome [22]; therefore, patients who are so managed should be monitored very carefully. Compartment syndrome is a condition in which increased pressure within a closed compartment reduces the level of capillary perfusion to less than that required for the viability of tissues [14,17,26]. The exact prevalence of compartment syndrome of the leg after an elective osteotomy is unknown. Steel et al., in 1971, reported neurological changes due to ischemia in nine of forty-six children who had had a proximal tibial osteotomy, but none of the complications were recognized as a compartment syndrome. Morrissy and Ballard, in 1987, reported two transient peroneal palsies and no vascular complications or compartment syndromes in seventy-four children who had had a proximal tibial osteotomy. It should be noted that all seventy-four children also had had a simultaneous subcutaneous fasciotomy of the anterior compartment. Several authors have reported compartment syndrome as a complication of tibial osteotomy [9,17,19,22,24]. Mubarak and Carroll, in 1979, reported on fifty-five children in whom an ischemic contracture developed; the contracture was related to trauma, vascular occlusion, compression injury, or hemorrhage in forty-nine patients and was secondary to an elective operation on the tibia in six. We report the case of a patient in whom compartment syndromes of the thigh and leg developed after osteotomies had been performed to correct femoral and tibial deformities associated with hypophosphatemic rickets. The possible relationship between compartment syndrome and postoperative epidural analgesia will be discussed. A sixteen-year-old boy who had hypophosphatemic rickets was examined at our institution because of bilateral genu varum. Bilateral corrective osteotomies had been performed when the patient was six years old, but the deformities had recurred. As both femora and tibiae were involved, we elected to correct the deformities on the right side first and those on the left side in a second operation. A previously described technique was utilized [18]. Transverse opening-wedge osteotomies of the distal part of the right femur and proximal part of the right tibia were performed after the application of external fixators. The gain in length was less than one centimeter, and there did not appear to be any soft-tissue tension at the time of the correction. Narcotic medications were used to control postoperative pain. Correction was maintained with use of external fixators until there was evidence of union at the osteotomy sites. The postoperative course was uneventful, and there were no complications. Osteotomies of the left femur and tibia were performed fourteen weeks later. These procedures were similar to those on the right side in that the same technique was used, the same attending physician and resident performed the operations, and a tourniquet was not used on the lower extremity.