A. Mahajan1, D. L. Teodorescu3,4, E. Lagazzi2 1Neurological Institute of Thailand, Department Of Neurosurgery, Bangkok, BANGKOK, Thailand 2Massachusetts General Hospital, Division Of Trauma, Emergency Surgery, And Surgical Critical Care, Boston, MA, USA 3Massachusetts Institute Of Technology, D-Lab, Cambridge, MA, USA 4Cedars-Sinai Medical Center, Los Angeles, CA, USA
Introduction:
Compartment syndrome (CS) is a major post-injury complication, leading to mortality, disability, infection, and amputation. Comprehensive literature on global fasciotomy trends and post-CS remains limited. This scoping review aims to elucidate current global practices and outcomes following fasciotomy due to CS.
Methods:
A search was conducted on MEDLINE, CINAHL, Web of Science, and PubMed up to 17th August 2023. Included primary studies detailed fasciotomy for both threatened or established CS status, and reported infectious outcomes following fasciotomy. Excluded studies were animal or in vitro studies. Our search string included terms such as 'trauma,' 'emergency,' 'fasciotomy,' 'compartment syndrome,' and various infection-related terms. A standardized form was employed capturing data on study resource setting (high-income country (HIC) vs low-middle income country (LMIC)), patient demographics, etiology, indication, timing of fasciotomy, method of closure, infection rates and management, complications, and follow-up duration. Given the heterogeneity in presentation and reporting, qualitative analysis was pursued.
Results:
From 2,286 articles, 24 met the inclusion criteria, accounting for 1,903 fasciotomies. The most common cause was crush syndrome following earthquakes (n=584, 32.5%), with a majority of fasciotomies performed on the lower limb (n=363, 70.76%). Mean (range) infection rate post-fasciotomy was 28.4% (0%-100%), with mortality at 4.6% (0%-35%) and amputation rates at 5.52% (0%-25%). Infections strongly correlated with initial injury severity, especially when extensive soft tissue involvement was present. The rate of primary closure vs secondary closure rates varied by resource settings with HICs often using primary closure (59% vs 8%), and LMICs using secondary closure (32% vs 63%). A significant correlation was noted between early fasciotomy (mean 5.6 hours post-trauma) and improved outcomes such as reduced muscle excision, amputations, and minimized blood product administration when compared to delayed fasciotomy (mean 26.2 hours post-trauma). Very early (<12 hours) and prophylactic fasciotomies recorded the highest infection rates. Delay in functional activity leading to worsening disability as a result of initial fasciotomy must be a consideration in decision making. Ensuring stringent post-fasciotomy wound care stands out as a potent strategy to minimize infection, sepsis and mortality.
Conclusion:
The surge in global trauma emphasizes the need for standardized fasciotomy approaches and research. Our clinical workflow demonstrates the first global resource that can be used to guide evidence-based fasciotomy practice. Our findings highlight the disparities in care across resource settings, emphasizing the importance of resource allocation. Considering the significant post-trauma long-term disability, it is vital to explore fasciotomy's potential as a global surgical bellwether procedure.
