Regional anesthesia or patient-controlled analgesia and compartment syndrome in orthopedic surgical procedures: a systematic review

Figures & data

Table 1 Literature search methods and results for a systematic review of RA or PCA and CS

Number of search results
Database	Platform	Date of search	Date limits	Other limits	Total references
PubMed	NLM	April 8, 2014	1980–2014	English, age of the study participants: ≥13 years	136
CINAHL	EBSCO	April 16, 2014	1980–2014	English, age of the study participants: ≥13 years	30
Scopus	Elsevier	April 28, 2014	1980–2014	English, cannot limit for the age of the study participants in this database	114
Scopusa	Elsevier	May 27, 2014	1980–2014	English, cannot limit for the age of the study participants in this database	414
PubMed	NLM	November 21, 2014	1980–2014	English, did not limit for the age of the study participants	217
CINAHL	EBSCO	November 21, 2014	1980–2014	English, did not limit for the age of the study participants	56
Scopus	Elsevier	December 12, 2014	2014	English, cannot limit for the age of the study participants in this database	21
PubMed	NLM	December 12, 2014	2014	English, did not limit for the age of the study participants	9
CINAHL	EBSCO	December 12, 2014	2014	English, did not limit for the age of the study participants	5
Total					1,002

Topic-specific search terms
Concept	Controlled vocabulary	Keywords
CS	CSs (MeSH)	Compartment Syndrome
	Anterior CS (MeSH)	Syndrome, Compartment Syndromes, Compartment
	Ischemic contracture (MeSH)	Syndrome, Anterior Compartment Syndromes, Anterior Compartment Anterior Tibial Syndrome Syndrome, Anterior Tibial Syndromes, Anterior Tibial Volkmann’s Contracture
RA	Anesthesia, regional (MeSH)	Anaesthesia, Regional
	Anesthesia, conduction (MeSH)	Regional Anesthesia
	Anesthesia, epidural (MeSH)	Regional Anaesthesia
	Anesthesia, spinal (MeSH)	Anaesthesia, Conduction
	Anesthesia, local (MeSH)	Conduction Anesthesia
	Nerve block (MeSH)	Conduction Anaesthesia
	Autonomic nerve block (MeSH)	Anaesthesia, Epidural
	Analgesia (MeSH)	Epidural Anesthesia
	Audioanalgesia (MeSH)	Epidural Anaesthesia
	Diffuse noxious inhibitory control (MeSH)	Anaesthesia, Spinal Spinal Anesthesia
	Neuroleptanalgesia (MeSH)	Spinal Anaesthesia
	Transcutaneous electric nerve	Anaesthesia, Local
	Stimulation (MeSH)	Local Anesthesia
	Electroacupuncture (MeSH)	Local Anaesthesia Nerve Block Catheter Block Bier Block Peripheral Nerve Block Peripheral Nerve Blockade Femoral Nerve Block Brachial Plexus Block Paravertebral Block Sciatic Nerve Block Popliteal Nerve Block Postoperative Anesthesia Postoperative Anaesthesia Anesthesia, Postoperative Anaesthesia, Postoperative Postoperative Analgesia Analgesia, Postoperative Epidural IV PCA Intravenous PCA Intravenous Patient Controlled Analgesia^* Patient Controlled Analgesia Patient Controlled Anesthesia Patient Controlled Anaesthesia IV Sedation Intravenous Sedation Narcotic Opioid Morphine Dilaudid Fentanyl Ropivacaine Bupivacaine Lidocaine Analgesias Anesthesia, Infiltration Infiltration Anesthesia Anaesthesia, Infiltration Infiltration Anaesthesia

Set number	Search statement
Search strategy: search term 1 (concept = CS)
1	Compartment Syndromes
2	Compartment Syndrome
3	Ischemic Contracture
4	Anterior Compartment Syndrome
5	Syndrome, Compartment
6	Syndromes, Compartment
7	Syndrome, Anterior Compartment
8	Syndromes, Anterior Compartment
9	Anterior Tibial Syndrome
10	Syndrome, Anterior Tibial
11	Syndromes, Anterior Tibial
12	Volkmann’s Contracture
13	OR/1–12
Search strategy: search term 2 (concept = RA)
14	Regional Anesthesia
15	Regional Anaesthesia
16	Anesthesia, Regional
17	Anaesthesia, Regional
18	Conduction Anesthesia
19	Conduction Anaesthesia
20	Anesthesia, Conduction
21	Anaesthesia, Conduction
22	Spinal Anesthesia
23	Spinal Anaesthesia
24	Anesthesia, Spinal
25	Anaesthesia, Spinal
26	Anesthesia, Epidural
27	Anaesthesia, Epidural
28	Epidural Anesthesia
29	Epidural Anaesthesia
30	Local Anesthesia
31	Local Anaesthesia
32	Anesthesia, Local
33	Anaesthesia, Local
34	Spinal Anesthesia
35	Spinal Anaesthesia
36	Anesthesia, Spinal
37	Anaesthesia, Spinal
38	Postoperative Anesthesia
39	Postoperative Anaesthesia
40	Anesthesia, Postoperative
41	Anaesthesia, Postoperative
42	Infiltration Anesthesia
43	Infiltration Anaesthesia
44	Anesthesia, Infiltration
45	Anaesthesia, Infiltration
46	Analgesia^*
47	Block
48	Audioanalgesia
49	Epidural
50	IV PCA
51	Intravenous PCA
52	Intravenous Patient Controlled Analgesia
53	Patient Controlled Anesthesia
54	Patient Controlled Anaesthesia
55	IV Sedation
56	Intravenous Sedation
57	Diffuse Noxious Inhibitory Control
58	Neuroleptanalgesia
59	Transcutaneous Electric Nerve
60	Simulation
61	Electroacupuncture
62	Narcotic
63	Opioid
64	Morphine
65	Dilaudid
66	Fentanyl
67	Ropivacaine
68	Bupivacaine
69	Lidocaine
70	OR/14–69
71	(13 AND 70)
72	71 AND English language AND 1980–2014 AND Ages ≥13

Notes:

a The Scopus search conducted on April 28, 2014, was with the “Document Search” (basic search) function; this function truncates long strings of search terms. Thus, we reran the search on May 27, 2014, with the “Advanced Search” function, so that there would be no truncation of search terms. After de-duplicating the 1,002 results, there were 475 unique articles. Database conventions: *, truncation; “”, phrase searching; [MeSH], medical subject heading; AND, OR, NOT, Boolean operators. In Scopus, there is no capability to restrict the age of the study participants. In PubMed, the author did not use truncation (via the * symbol), because the use of truncation turns off automatic mapping to MeSH terms.

Abbreviations: CS, compartment syndrome; IV, intravenous; NLM, National Library of Medicine; PCA, patient-controlled analgesia; RA, regional anesthesia.

Figure 1 The process used during a systematic review of the literature to select articles (review, case reports, and research) on RA or PCA and CS.

Abbreviations: CS, compartment syndrome; PCA, patient-controlled analgesia; RA, regional anesthesia.

Table 2 Case reports identified in a systematic review of the literature on RA and CS (23 articles, with 29 cases), 1980 to November 2014

Case report	Procedure	Age (years); sex; weight	RA	Medications at the time of diagnosis	Signs/symptoms	Treatment	Did RA mask CS?	Monitoring
Traumatic orthopedic procedures
Aguirre et al^Citation3	Open repositioning of a complex distal right humerus fracture	47; female; not available	Infraclavicular nerve block catheter	Continuous 0.3% ropivacaine at 6 mL/h for an unreported length of time. An additional 20 mL bolus of 0.5% ropivacaine was administered at the time when patient developed increasing pain	Severe pain	Fasciotomy	No	Physical examination and compartment pressure measurement of 40 mmHg
Azam et al^Citation67	Surgical stabilization of bilateral femur fractures and both bone right leg fractures	32; male; not available	Epidural analgesia	3 mg morphine in 10 mL normal saline every 12 hours	Four hours after the removal of epidural catheter, patient started complaining of progressive pain unrelieved by appropriate oral analgesic. Clinical examination revealed swollen compartment of leg with altered sensorium and significant pain on passive stretching. Extension of toe and dorsiflexion of ankle was remarkably absent. Dorsalis pedis was not palpable and posterior tibial artery was doubtful. Nail bed circulation was present	Fasciotomy	Yes	Physical examination and compartment pressure measurement (unknown)
Hyder et al^Citation66	Closed fracture of tibial shaft with intramedullary nailing	28; male; not available	Triple nerve block (femoral, obturator, lateral cutaneous nerve of thigh)	0.5% bupivacaine	Postoperatively, the patient had altered sensation in the foot and leg. At 48 hours postoperatively, these symptoms persisted, and the patient was unable to actively extend the big toe	Fasciotomy	Yes	Physical examination and compartment pressure measurement of 108 mmHg
Morrow et al^Citation36	Intramedullary nailing of the tibia	18; male; not available	Epidural anesthesia	Initial bolus of 50 μg fentanyl and 50 mg bupivacaine, and epidural fentanyl (10 μg/mL) and bupivacaine (2 mg/mL) at 4 mL/h employed overnight	At 13 hours postoperatively, the patient experienced total anesthesia and paresis of the left leg. Left calf muscle turgidity was observed	Fasciotomy	Yes	Physical examination and compartment pressure measurement of 70 mmHg
Patillo et al^Citation75	Closed reduction in pilon fracture with application of an external fixator spanning	19; male; not available	Epidural anesthesia	Not available	48 hours after the initial injury, the patient awoke with severe right leg pain that was poorly controlled with both epidural and oral narcotic pain medication, also severe pain with passive range of motion of the great toe and some mild paresthesias over the dorsum of the foot. Capillary refill throughout the foot was <3 seconds on each examination	Fasciotomy	No	Physical examination and compartment pressure monitoring (peaked at 48 mmHg)
Uzel and Steinmann^Citation68	Closed femoral fracture internal fixation using an intramedullary rod	26; male; 66 kg	Femoral nerve block	Single injection with 20 mL 0.75% ropivacaine hydrochloride	Patient complained of unusually severe pain. The anterior thigh compartment was very taut, and there was no sensorimotor or vascular deficit	Fasciotomy	Yes	Physical examination and compartment pressure measurement of 54 mmHg
Elective total joint arthroplasties
Bezwada et al^Citation20	Bilateral consecutive TKA for tricompartmental osteoarthritis of both knees	60; male; not available	Epidural anesthesia	Bupivacaine and fentanyl	Reduced strength and active movement of the right foot, numbness, edema, and ecchymoses	Fasciotomy	Unclear	Compartment pressure monitoring (peaked at 30 mmHg)
Haggis et al^Citation32	Revision of left TKA	69; female; not available	Epidural anesthesia	Not available	Edema (no pain)	Fasciotomy	Yes	Physical examination
Haggis et al^Citation32	Right TKA in a patient with the history of chronic osteomyelitis of right femur and tibia, septic arthritis of right knee	53; male; not available	Epidural anesthesia	Not available	Pain, coldness, pulselessness, edema	Fasciotomy	Yes	Physical examination
Haggis et al^Citation32	Right TKA in a patient with valgus osteoarthritis	48; female; not available	Epidural anesthesia	Not available	Swelling, foot drop	Fasciotomy	Yes	Physical examination
Haggis et al^Citation32	Right TKA in a patient with epiphyseal dysplasia. Right knee arthrodesis (before 16 years). This was a conversion to TKA	39; female; not available	Epidural anesthesia	Not available	Pain, pulselessness, edema	Fasciotomy	Yes	Physical examination
Haggis et al^Citation32	Left TKA	49; female; not available	Epidural anesthesia	Not available	Pain, foot drop	Fasciotomy	Yes	Physical examination and compartment pressure monitoring (peaked at 94 mmHg)
Haggis et al^Citation32	Right TKA	61; male; not available	Epidural anesthesia	Not available	Pain, paralysis, paresthesia, edema	Fasciotomy	Yes	Physical examination
Hailer^Citation35	TKA	43; female; not available	Epidural anesthesia	Epidural infusion of ropivacaine and sufentanil, later IV ketobemidone	Loss of active toe extension, pain, pulselessness, edema	Fasciotomy	Yes	Physical examination
Kort et al^Citation76	TKA	44; female; BMI, 39 kg/m^2	Epidural anesthesia	0.125% bupivacaine at a rate of 8 mL/h	The peripheral pulses were not palpable on the operated leg, but the capillary refill was normal. Approximately 12 hours postoperatively, the patient complained of pain and swelling in the left leg. There were normal neurologic findings, and the capillary refill was also normal. The pain was worsened by passive stretch of the involved muscles	Fasciotomy	No	Physical Examination
LaReau et al^Citation79	TKA	73; male; not available	Femoral nerve block	30 mL of 0.375% bupivacaine with epinephrine at a concentration of 1:400,000	On the evening of postoperative day 1, nursing reported increasing pain and difficulty with the range of motion	Fasciotomy	Unclear	Physical examination and compartment pressure monitoring (as high as 50 mmHg)
Nicholl et al^Citation69	Revision total hip arthroplasty	65; male; not available	Epidural anesthesia	Epidural morphine infusion	At 24 hours postoperatively, the patient complained of pain in the left lower shin, which was swollen and tender. Active and passive movements of the ankle and toes produced some discomfort. At 72 hours postoperatively, the leg was more swollen, tense, and painful, with paresthesia in the foot	Fasciotomy	Yes	Physical examination and compartment pressure monitoring (peaked at >32 mmHg)
Noorpuri et al^Citation70	Revision arthroplasty of the forefoot	37; female; not available	Ankle block	Ankle block was performed to the sural, saphenous, anterior, and posterior tibial nerves using 30 mL 0.25% bupivacaine	Breakthrough pain, edema, paresthesia, altered sensation, delayed capillary refill, reduced active movement of toes, exaggerated pain with passive motion	Fasciotomy	Yes	None
Tang and Chiu^Citation71	TKA	62; female; not available	Epidural anesthesia	Continuous 0.125% bupivacaine at the rate of 8 mL/h	On postoperative day 2, the capillary return of right toes diminished. Toes were also swollen	Fasciotomy	Yes	Physical examination and compartment pressure measurement (peaked at 80 mmHg)
Other elective orthopedic procedures
Addison et al^Citation72	Extensive resection of osteosarcoma and closure of the anterolateral thigh flap	25; male; not available	Epidural anesthesia	Not available	On the third postoperative day, the donor site wound margins were noted to be blistering, tense, and moist. The patient was noted to have a mildly swollen right leg, but no associated pain or skin changes	Operative debridement	Yes	Physical examination
Addison et al^Citation72	Resection of osteosarcoma and closure of the anterolateral thigh flap	38; male; not available	Epidural anesthesia	Not available	Five days after the procedure, the patient was noted to have some blistering and marginal necrosis of the thigh wound edges, but with no increase in pain. Over the next few days, the wound edges slowly worsened	Operative debridement	Yes	Physical examination
Chidambaran et al^Citation77	Left knee multi-ligamentous reconstruction	16; male; BMI, 35 kg/m^2	Femoral and sciatic nerve block	Postoperative analgesia with 0.2% ropivacaine	On postoperative day I, patient developed loss of ankle dorsiflexion, cola-colored urine and increased CPK	Physical therapy and forced alkaline dieresis	No	Thigh compartment pressure was high but did not warrant fasciotomy
Cometa et al^Citation33	Patient with Blount's disease underwent elective distal femur and proximal tibial osteotomy	15; male; 150 kg	Continuous femoral and sciatic nerve blocks	Femoral and sciatic nerve catheter infusions of 0.2% ropivacaine at 10 mL/h, decreased to 5 mL/h in femoral nerve catheter and 10 mL/h in sciatic nerve catheter	At >48 hours postoperatively, patient experienced pain (refractory to nerve blocks and IV opioids) that intensified with passive movement, edema, limitation in active movement of the foot, and weakness	Fasciotomy	No	Physical examination and compartment pressure monitoring (peaked at >30 mmHg)
Dunwoody et al^Citation78	Innominate triple osteotomy for developmental dysplasia of the left hip	14; male; 60 kg	Lumbar epidural anesthesia	Epidural infusion of fentanyl (1 μg/kg per hour) and bupivacaine (0.1 %; 0.2 mg/kg per hour)	At 30 hours postoperatively, patient experienced exquisite pain with foot inversion and eversion, weak active dorsiflexion and plantar flexion of the toes, and weak ankle movement	Fasciotomy	No	Physical examination and compartment pressure monitoring (peaked at 45 mmHg)
Kucera and Boezaart^Citation51	Right lateral ankle ligament reconstruction for ankle instability	29; male; 85 kg	Single-injection sciatic and femoral nerve blocks	30 mL 0.5% ropivacaine sciatic; 20 mL 0.75% ropivacaine femoral	Pain, erythema	Cast removal	No	Physical examination
Price et al^Citation73	Left simultaneous corrective osteotomies of the femur and tibia	16; male; not available	Epidural anesthesia	Fentanyl	Paresthesia, swelling, tense and shiny skin	Fasciotomy	Yes	Physical examination and compartment pressure monitoring (peaked at 68 mmHg)
Seybold and Busconi^Citation74	Scapular fasciocutaneous-free flap grafting for a non-healed ulcer of the medial heel	18; male; not available	Epidural anesthesia	Not available	12 hours postoperatively, the patient's right anterior thigh was obviously swollen. 2 hours later, he experienced discomfort in his thigh and exquisite pain with active and passive flexion of the thigh	Fasciotomy	Yes	Physical examination and compartment pressure monitoring (peaked at 40 mmHg)
Strecker et al^Citation65	Osteocutaneous-free fibula transfer from right leg	45; male; not available	Epidural anesthesia	Continuous bupivacaine 0.125% at the rate of 10 mL/h	Dull pain improved by releasing bandage, dysesthesia, swelling, pain out of proportion to that expected from the procedure	Fasciotomy	Yes	Physical examination
Walker étal^Citation41	Left calcaneal lengthening osteotomy and percutaneous Achilles tendon lengthening	19; female; 79 kg	Popliteal catheter and a single-injection saphenous nerve block at the mid-femur level	Popliteal catheter and single-injection saphenous nerve block in popliteal catheter: Initial bolus of 5 mL bupivacaine given, continuous infusion of ropivacaine 0.2% at 8 mL/h. In saphenous block, 5 mL bupivacaine 0.5% with 1:200,000 epinephrine; infusion turned down to 6 mL/h next day	Pain, tightness, decreased sensation	Cast splitting and use of a spacer	No	Physical examination

Abbreviations: BMI, body mass index; CPK, creatine phosphokinase; CS, compartment syndrome; IV, intravenous; RA, regional anesthesia; TKA, total knee arthroplasty; h, hour.

Table 3 Case reports identified in a systematic review of the literature on PCA and CS (five articles, with eight cases), 1980 to November 2014

Case report	Procedure	Age (years); sex; weight	Drug(s)	Signs/symptoms	Treatment	PCA masked CS?	Monitoring
Traumatic orthopedic procedures
Harrington et al^Citation40	Isolate, open oblique fracture of mid-shaft of tibia; wound dressed and fracture splinted, then undreamed intramedullary nailing	53; male; 83 kg	PCA syringe pump provided bolus dose of 1 mg with a lock-out duration set at 5 minutes (maximum possible dose of 48 mg morphine in 4-hour period); 131 mg morphine was used over 36 hours postoperatively	Firm and swollen calf	Fasciotomy	Yes	Physical examination and compartment pressure measurement (peaked at 50 mmHg+) in four compartments of the leg, diastolic pressure of 75 mmHg
O’Sullivan et al^Citation38	Intramedullary nailing for closed, displaced mid-shaft fracture of tibia and fibula as well as calcaneal traction	21 ; male; not available	90 mg morphine through PCA (PCA device with 120 mg morphine and 2.5 mg droperidol in 50 mL normal saline; a bolus of 1 mg was available at 5-minute intervals; no background infusion); 75 mg diclofenac intramuscularly administered 12 hours postoperatively; PCA discontinued at 27 hours postoperatively	Numbness in toes, but able to move toes satisfactorily; drowsiness; severe, pounding pain in right leg after discontinuing PCA and pain aggravated by passive dorsiflexion; decreased sensation all over right foot	Fasciotomy; limb amputation	Yes	Not available
Richards et al^Citation35	Closed, reamed intramedullary nailing of tibial shaft fractures	28; male; not available	10 mg of morphine through PCA	Extremely tense calf and obvious foot drop; dorsiflexion of foot and toes produced mild discomfort	Fasciotomy	Yes	Not available
Richards et al^Citation35	Closed, reamed intramedullary nailing	27; male; not available	13 mg morphine through PCA	Increasing inability to move toes; extremely tense calf; altered sensation over dorsum of foot but palpable pulse was noted; compartment pressure reading of 40 mmHg	Fasciotomy	Yes	Physical examination and compartment pressure measurement of 40 mmHg
Richards et al^Citation35	Reamed intramedullary nailing to fix displaced oblique diaphyseal fracture of the tibia	20; male; not available	15 mg morphine on demand through PCA	Altered sensation 16 hours postoperatively over dorsum of the foot; tense and swollen calf with pressure exceeding 50 mmHg	Fasciotomy	Yes	Physical examination and compartment pressure measurement of 50 mmHg
Richards et al^Citation35	Reamed intramedullary nailing to correct oblique displaced diaphyseal tibial fracture	26; male; not available	17 mg morphine through PCA	Tense calf 18 hours postoperatively with altered sensation over the dorsum of the foot	Fasciotomy	Yes	Not available
Elective orthopedic procedures
Bae et al^Citation83	Postoperative/radioulnar osteotomy	14.9; female; not available	Increasing dose of morphine from 1 mg to 2 mg (100% PCA) and increasing frequency of analgesia from every 6 hours to every 4 hours (50%)	Increasing pain and analgesia requirement, pallor, pulselessness, paresthesia, paralysis	Fasciotomy	Unclear	Physical examination
Mai^Citation81	Primary cemented total arthroplasty of the right hip joint	60; male; not available	IV morphine	Acute persistent right hip pain radiating to the right thigh and knee and not relieved with acetaminophen or IV morphine; on examination, the right thigh was markedly edematous and tender without neurovascular impairment	Fasciotomy	Unclear	Compartment pressure measurement of 62 cm H20 (patient BP was 180/90 mmHg)

Abbreviations: BP, blood pressure; CS, compartment syndrome; IV, intravenous; PCA, patient-controlled analgesia.

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