Download compartment syndrome of the buttock following a total

COMPARTMENT SYNDROME OF THE BUTTOCK FOLLOWING A TOTAL
HIP REPLACEMENT : A CASE REPORT. J ARTHRO- PLASTY 11(5): 609-10, 1996.
V.S.Pai, D'Ortho, M.S (Orth), Dip. National Board (Orth), M.Ch (Orth)
Memorial Hospital
Omahu Road
Hastingsc
New Zealand
presentation was described in the
INTRODUCTION
literature3 .
An
elevation
of
the
interstitial
pressure in a closed osseofascial
CASE REPORT
compartment results in compartment
syndrome 7. This may be caused by a
A sixty-eight-year-old woman with
decrease in compartment volume or an
degenerative arthrosis of her right hip
increase in compartment contents.
underwent a Biomet cementless hip
The gluteal compartment syndrome is
replacement in December 1994.
rare. Because the gluteal region has a
hip joint was exposed through a
large volume,
this compartment
posterior approach and the short
requires a massive increase in content
external rotators were divided at the
to cause a compartment syndrome.
greater trochanter. The upper border
Also,
blend
of the quadratus femoris was divided
anatomically with the muscles of the
with a diathermy for further exposure.
thigh, allowing extravasation of blood
The operation
this
compartment
outside the compartmental envelope
12
.
The
proceeded without
apparent intraoperative complications.
There was no excessive bleeding
during
the
procedure
and
This case report is of a patient whose
intraoperatively the patient did not
medial circumflex femoral artery was
exhibit any abnormal drop in blood
severed during a total hip replacement
pressure. In the recovery room, she
through a posterior approach leading
was alert and felt well.
to compartment syndrome of the
buttock.
Although
this
clinical
On the second postoperative night,
presentation has not been described as
the patient had a sharp pain in the right
compartment syndrome,
thigh, which was noted to be swollen.
one similar
She complained of paraesthesia of the
replacement).
The surgical wound
right leg, corresponding to the sensory
was opened.
The skin, which was
distribution
under extreme tension, spread widely
of
the
sciatic nerve.
However , neurological assessment did
when the incision was made.
not reveal any deficit. he was given
gluteus maximus initially appeared
morphine but this failed to relieve her
gray, but appeared viable. A large
pain which increased over the next
haematoma (1.5 litres of clotted blood)
four hours.
was located deep to the gluteus
maximus
was decompressed.
The
The
At the time of assessment , the blood
haematoma extended into the thigh
pressure was 126/84 millimetres of
deep to the deep fascia up to its upper
mercury. The pulse remained between
two thirds.
68 and 72 per minute. The right
regained a healthy, red colour and
lower limb revealed marked swelling
were contractile to stimulation.
and ecchymosis of the right buttock
muscle debridement was performed.
and thigh. Any movement of the right
Bleeding vessels were identified at the
hip caused excruciating pain in that
lower border of the quadratus femoris
area.
and were ligated. There was bruising
There
was
decreasing
The gluteal muscles
No
the
of the sciatic nerve but no evidence of
distribution of the sciatic nerve as the
intraneural haemorrhage. The wound
patient could no longer dorsiflex the
was closed primarily.
ankle or toes.
There was complete
needed a total of five units of packed
loss of sensation over the entire foot
red blood cells while she was in
and lateral aspect of the calf. Knee
hospital.
extension was present but painful.
function of the anterior and posterior
neurological
function
in
The patient
In the recovery room,
tibial muscles was noted, and three
An emergency decompression carried
days later there was improvement in
out (within 20 hrs of the total hip
the function of the extensor and
peroneal muscles.
Thereafter, there
1
(superior gluteal
rupture),
following
vascular injury
was rapid return of nerve function.
artery
Six months after operation the patient
intramedullary fixation
had regained full motor control and the
coagulopathy
sensation was normal.
common cause for an increase in the
DISCUSSION
The diagnosis of a compartment
9
.
12
and
with
Bleeding is a
contents of
compartment.
Various
mechanisms
causing
vascular
complications
the
following
total
hip
syndrome involves a high index
arthroplasty have been well described
suspicion.
8,11
This syndrome is better
.
In a posterior approach to the hip
described by the 4"S"s - Severe pain
joint , branches of the
(out of proportion to the clinical
circumflex femoral artery can be
situation),
damaged when the upper part of the
Stretch
pain,
Sensory
abnormalities and Swollen & tense
quadratus
muscle10.
Severe "break through"
Inadvertent laceration of the artery
pain resistant to analgesics is usually
may cause massive haemorrhage if
the earliest symptom of compartment
unrecognised,
syndrome6
various
context of elderly patients who are
techniques of measuring compartment
often receiving deep vein thrombosis
pressures
prophylaxis with anticoagulant drugs.
.
have
Although
been
developed,
femoris
medial
is
divided.
particularly
bleeding
in
can
the
controversy exists over definition of
Troublesome
be
compartment syndromes on the basis
prevented bny meticulous surgery and
of a specific tissue pressure5 .
if a
vessel is divided, haemostasis
must be achieved.
This syndrome in the gluteal region
Sciatic
nerve
palsy
following
and thigh although not common, has
subgluteal haematoma formation after
been reported earlier with
prophylactic
or
anticoagulation
has
fractures
12,13
femur
, soft tissue contusion
4
,
therapeutic
been
well
3,9
However, direct
compartment syndrome of the buttock.
damage to medial circumflex femoral
J Bone Joint Surg 72A:134-137, 1990.
artery causing compartment syndrome
2. Evanski PM, Waugh TR: Gluteal
of the hip and sciatic paralysis is rare.
Compartment Syndrome: Case report.
The present case report resembles case
J. Trauma, 17: 323-324, 1977
documented
3
reported
.
by
Fleming3
,
who
3.
Fleming
RE,
Michelsen
CB,
discussed five cases of sciatic paresis
Stinchfield FE: Sciatic Paralysis - A
which developed as the result of
complication of bleeding following hip
haemorrhage following hip surgery.
surgery. J Bone Joint Surg 61-A:37-39
4. Gorman PW, McAndrew MP: Acute
Pain on passive stretching of the
anterior compartment syndrome of the
muscles in the posterior compartment
thigh following contusion. A case
is tested for by extending the knee
report and review of literature. J
while holding the hip in flexion.
Ortho. Trauma. 1: 68-70, 1987
Severe buttock pain, marked swelling
5.
in the thigh and a distal sciatic neural
Compartment syndrome of the lower
deficit in the lower limb of a patient
extremity. Ortho. Clin: 25, 677-684,
who has had hip surgery are evidence
1994.
of
6. Matsen FA, Winquist RA, Krugmire
a compartment syndrome of the
Gulli
Jr,
B,
et
Templeman
al:
buttock. Early recognition and prompt
RB
surgical decompression is suggested to
management
prevent irreversible damage.
syndromes. J Bone Joint Surg 62A:
of
Diagnosis
D:
and
compartmental
286-291,1980
7. Mubarak SJ, Owen CA, Hargens
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Zurcher R: The mechanisms of severe
ACKNOWLEDGMENT
arterial injury in surgery of the hip
joint.
Clin. Orthop. 141,122-132,
The author is grateful to Dr. Peter
1979.
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