The impact of fasciotomy on inpatient outcomes in lower leg fracture management

Lower extremity fractures—one of the most common fractures observed in trauma patients [1]—are closely associated with increased morbidity due to severe soft tissue involvement and mortality, especially in elderly people [2]. The reasons for such fractures are manifold, ranging from sports injuries, falls from a height, and road traffic accidents to low-energy trauma [3].

Compartment syndrome of the lower limb manifests most frequently in the lower leg and is often, but not exclusively, associated with high-energy injuries [4]. It may also develop secondarily following surgical fracture treatment involving excessive postoperative swelling.

Depending on the interval between the onset of compartment syndrome and successful compartment release through fasciotomy, poor functional outcome may be the consequence of increased rates of complications, e.g., surgical site infection, nonunion, loss of vital muscles following muscle fibrosis, or even necrosis [5]. Independent from this, postoperative complications can not all be ascribed to the fasciotomy itself, it is rather a multifactorial pathogenesis. Evidently, an early diagnosis of compartment syndrome is crucial for the prevention of adverse events. In this context, the literature shows that the age of the patient is a significant predictive parameter for the outcome of lower extremity fractures with concomitant compartment syndrome. As such, incipient or manifest compartment syndrome can be assessed as the harbinger of a problematic clinical course in treating lower leg fractures [6].

To the best of our knowledge, available data on the in-hospital outcomes of patients undergoing fasciotomy for lower extremity fracture treatment are scarce. Addressing this gap, the aim of this study was to evaluate the extent to which compartment syndrome is a significant predictor of in-hospital complications and length of stay for lower extremity fractures, as recorded by a nationwide quality management tool.

The current study retrospectively analyzed the data of lower leg fracture patients with and without fasciotomy obtained from the prospective surgical registry of the working group for quality assurance in surgery (“Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie” or AQC). The AQC is a voluntary association of physicians in Switzerland formed with the aim of evaluating the in-hospital outcomes of surgical patients. More than 80 Swiss surgical departments, representing 85% of all such departments in Switzerland, contribute the clinical data of hospitalized patients to the AQC. Having been active for more than 25 years, the tool comprises about 2 million anonymized cases with the purpose of ensuring surgical quality in Switzerland [7]. Notably, according to the authorization requirements of the local cantonal ethical review board (Zurich, Switzerland), no institutional review board approval was required to utilize this data.

The goal of the present study was to investigate the extent to which compartment syndrome of the lower leg in conjunction with a lower leg fracture impacts the essential parameters of primary in-hospital stay and the clinical course of treatment. One of the main findings of our cohort study was that around 6% of patients with lower leg fractures undergo fasciotomy. Furthermore, the patient being male, of a younger age, having a notable presence of comorbidities, and a complete fracture of the lower leg were identified as relevant predictors of the need to undergo fasciotomy. Moreover, patients with fasciotomy were found to have experienced three times more operations, two times longer duration of hospital stay, and seven times as many complications than those who did not undergo the procedure. With regard to in-house complications, a higher ASA score was identified as the most significant predictor.

In high-energy and complex trauma, the need for fasciotomy in the lower leg could increase to 50% [10]. A frequency of 5.8%, as observed in our study, points to the fact that both low- and high-energy trauma cases were considered, which reflects the distinct character of this cohort study based on a nationwide database comprising 85% of all Swiss hospitals performing acute trauma surgery.

Consistent with Park et al., this study confirmed that patients with fasciotomies are mostly young men, which underlines the fact that young males are more frequently involved in high-energy trauma than elderly people [11]. Correspondingly, the high number of patients with complete lower leg fractures needing fasciotomy indicates that the amount of energy involved in the trauma strongly correlates with the need for fasciotomy. Interestingly, higher degrees of comorbidities, as reflected by ASA classes III and IV—usually observed in the elderly population—were associated with a higher rate of compartment release. This may be linked to the findings in the literature that claim elderly patients may develop compartment syndrome as a result of their intake of oral anticoagulants, such as Apixaban [12].

Not surprisingly, the duration of surgery in the case of patients with fasciotomy was significantly longer compared to cases without fasciotomy, which aligns with the finding that prolonged operating time is probably a marker of technical difficulty and lengthened exposure of the wound. Such circumstances, in conjunction with more severe soft tissue trauma, are more likely to lead to higher rates of postoperative infections [13]. This might explain the significantly higher rates of antibiotic use by patients undergoing fasciotomy during their hospital stay. Furthermore, this could be linked to longer in-hospital stays observed for patients after fasciotomy, as confirmed by other researchers [14]. In the present study, primary in-hospital stay by patients following fasciotomy was twice as long compared to those who did not undergo the procedure. Moreover, a surgical intervention rate of almost four surgeries in the case of fasciotomy indicates that a larger number of such patients required more than a secondary operation for soft tissue closure, e.g., serial debridement, step-wise approximation of the fasciotomy wound, or conversion from external to internal fixation. Data about the conversion of fixations may be derived from the primary rate of the use of external fixators, which was twice as high for the group with fasciotomy (23%) compared to the group without it (12%).

This is, in particular, relevant especially from the logistical view of clinics, which are confronted with concurrent problems like bed shortage to be able to expect a higher effort with patients of the fasciotomy group.

There are many factors that increase the likelihood for fasciotomy [15]. Combined plateau-shaft fractures, presence of fibula fracture, Schatzker VI fractures, OTA/AO 41-C2, and 41-C3 fractures were predictive in the literature of acute compartment syndrome [16, 17]. However, our cohort lacked detailed fracture classifications.

Saiz et al. showed that multiple comorbidities, including smoking, drug use, and alcohol use, were associated with an increased risk of having a fasciotomy. This may be due to these patients having decreased sensorium, which can make the diagnosis of an acute compartment syndrome diagnosis difficult; it may also be from vasoconstriction of smaller vessels; this leads to decreased perfusion and earlier myonecrosis [18]. A similar effect may be caused by state of shock on admission as a cause of more swelling. Our dataset was limited and did not offer in-depth insights into patients’ medical history, comorbidities, or the specific circumstances surrounding their conditions upon admission to the hospital.

Furthermore, complication rates were found to be significantly higher in the case of fasciotomy—found in almost every second patient who underwent the procedure—compared to cases without fasciotomy. Consequently, in-depth knowledge of the predictors of complications arising from fasciotomy may be crucial for prevention and early control. The current study observed a high ASA class to be the most crucial predictor, apart from young and, in general, healthy male patients with relevant comorbidities, of a high-risk cohort in terms of developing complications. The literature also emphasizes that significantly higher ASA scores and, in turn, detection of more comorbidities represents an increased risk factor for having a fasciotomy [19].

However, while employing the AQC database to collect and interpret data has its advantages, this methodology also suffers from a few inherent weaknesses. One of the most significant advantages of utilizing this extant database is the availability of a large amount of data from all levels of hospitals across Switzerland, accounting for a majority of the patients treated from January 2012 to December 2022. However, a major limitation of this dataset is that it registers only primary in-hospital data. As a result, no data on long-term effects, functional and final outcomes, or late complications that arose after the patients’ discharge from the hospital could be accounted for in this study. In addition to that the AQC database did not allow to further differentiate the specific in-hospital complications like surgery specific associated events or injuries to veins and nerves.

Furthermore, a potential bias in this study could be distortion of data by physicians based on their interpretation of the questions in the AQC datasheet. For example, the current study found a significantly high complication rate in patients treated with fasciotomies. Although this is consistent with the findings reported in the literature [20], the compartment syndrome itself might already be registered as a complication.

Consistent with previous findings reported in the literature, this study analyzed a large volume of data encompassing 11 years from a nationwide quality assessment tool to confirm that patients who underwent fasciotomies after a fracture to their lower leg were mostly young men with comparatively more comorbidities who underwent longer operations and frequently developed complications, as well as had a longer primary stay at the hospital. Most importantly, a higher ASA class was identified as the only predictor of complications.

However, since the findings of this study are drawn from primary in-hospital observations, further research should analyze long-term complications and functional outcomes as the next step in evaluating the long-term validity of the predictors identified in this study.