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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 REFERENCES AR, Garetto LP , Akeson WH: Acute 1. Brumback RJ: Traumatic rupture of compartment syndromes: Diagnoses the superior gluteal artery, without and treatment with the aid of the Wick fracture of the pelvis, causing catheter. J. Bone and Joint Surg., 60- report of three cases. J.Bone and Joint A:1091-1095, 1978 Surg. 68 A: 1439-1443, 1986 8. Nachbur B, Meyer RP, Verkala K, 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. Lloyd, Memorial Hospital, 9. Neviaser RJ, Adams JP May GI: help in preparing the manuscript and Complications of Arterial puncture in Mr. anticoagulataed patients. J Bone and photographer, Memorial Hospital for Joint Surg. 58 A, 218-220, 1976 his help. 10. Pai VS: Unrecognised arterial injury of the forearm: Presenting as acute compartment syndrome. NZ Med. J. 108; 368-9, 1995 11.Reiley MA, Bond D, Branick R, Wilson EH: Vascular complications following total hip arthroplasty.. Orthop. 186: 23-28, 1984 12.Schwartz JT Jr, Brumback RJ, Lakatos R, et al: Acute compartment syndrome of the thigh: A specturm of injury. J Bone Joint Surg 71A:392400,1989 13.Tarlow, Hayhurst SD, J, Achterman Ovadia DN: CA, Acute Compartment Syndrome in the thigh complicating fracture of the femur. A Wayne Blair, for their Medical