Diagnosis and Treatment of Acute Compartment Syndrome

The onset of acute compartment syndrome is something of great concern to the emergency room physician, trauma surgeon, and podiatric foot and ankle surgeon.  It is something that is routinely screened for an any lower extremity trauma.

The muscles of the foot and leg are divided into compartments, each of which is separated by a layer of fascia.  This dividing fascia is tough and restricting, and does not allow for much expansion of the tissues within the compartment.  Normally this is a good thing, as it helps separate and organize the muscle compartments of the foot and leg.  However, when the volume of the compartment expands following injury, these bands of tissue help to restrict the fluid, creating an increase in the compartmental pressure.  This increase in pressure can cause damage to the muscles, nerves, and vessels within the compartment, and can lead to tissue death if not addressed properly. 

Signs and symptoms of acute compartment pressure include intense pain out of proportion for the given injury, numbness or tingling in the toes, loss of function of the toes or an inability to move them, and coolness to touch caused by decreased blood flow.  Later in the development of compartment syndrome, pulses may be absent and the toes may turn white in color. 

The diagnosis of compartment syndrome is largely based on the history and physical findings, but a device called a wick catheter may be used to confirm the diagnosis.  This is an instrument that is mainly composed of a needle attached to a pressure gauge, which acts to measure the compartmental pressure.  The normal pressure reading for a muscular compartment should be between 0 and 10 mmHg.  Pressures between 10-20mmHg are closely monitored, as they may continue to increase.  Pressures above 30mmHg are considered diagnostic of compartment syndrome in most cases. 

Once the diagnosis of compartment syndrome is made, the patient must be taken to surgery right away.  A delay in surgical treatment may result in irreversible muscle and tissue damage.  Surgery for compartment syndrome involves releasing the fascia between compartments to relieve the pressure.  This procedure is known as a fasciotomy. 

There are four muscle compartments in the leg to release; the superficial and deep posterior compartments, the lateral compartment, and the anterior compartment.  In the foot, there are also four main compartments; the medial, lateral, central, and interosseous.  Some references will divide the central compartment into a superficial, deep, and calcaneal compartment, and also consider each of the interosseous compartments their own separate compartment.  When acute compartment syndrome is diagnosed, both the leg and foot compartments will oftentimes be opened together. 

The incision sites are kept open, and local wound care is performed to keep the sites clean and prevent infection.  Compartment syndrome will generally keep a patient in the hospital for at least several days, while their condition can be monitored.  Any other injuries must also be addressed.  

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

New Drug for the Treatment of Gout

This Tuesday, a federal advisory committee recommended the approval of Krystexxa, a new drug that has been in development by Savient Pharmaceuticals. In clinical trials, the drug has shown to be an effective treatment for gout.

The committee recommended the approval by a landslide 14-1 vote. The drug now must be approved by the Federal Drug Administration (FDA) before Savient can begin producing, distributing, and marketing the drug. In the past, the FDA has been known to follow the advice of the advisory committees. If Krystexxa is approved, it will be the second drug for the treatment of gout approved this year, after 40 years without innovation in this particular area. Uloric, which is manufactured by Takeda Pharmaceutical, was approved for use in February.

Gout, which is a form of arthritis, is caused by a buildup of uric acid in the body. This uric acid can then be deposited in the joints. The deposits are known as tophi. The big toe is particularly susceptible to this searing pain caused by tophi, but other joints, including joints in the hands and elbows can also be affected.

The uric acid that builds up in the body is commonly associated with diet, as it is a metabolism defect. Foods such as alcohol (especially beer), red meat, and some seafood are commonly associated with gout. For this reason, gout has often been referred to as the “disease of the kings”, as these foods were historically only available to the wealthy. However, these foods have become more and more accessible to a larger percentage of the population, making gout more common, and less known as a disease of the rich. Increased incidence of gout has sparked a new interest in the medical research community.

Krystexxa is a form of uricase, an enzyme responsible for degrading uric acid in the body. The drug works by attacking the tophi, and helping to dissolve the deposits. In clinical trials, about forty-percent of patients saw significant improvement while taking the drug. Some patients reported that the tophi dissolved completely, and that they were able to walk and use their hands again without pain.

There are some side-effects that have been reported with the use of Krystexxa, including an increase in the prevalence of cardiovascular complications and allergic reactions. Committee members state that it is unclear whether the increase in cardiovascular conditions, however, is due to the drug or due to chance, based on the small trial size. The FDA, nevertheless, is expected to approve the drug, as the striking benefits for patients with chronic gout outweigh the side-effects.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com