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Leg Compartment Release - Single Incision Approach

Preoperative Patient Care

A

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • assess lower extremity compartments
  • document distal neurovascular status
  • check for associated orthopedic injuries

2

Interpret basic imaging studies

  • biplanar radiographs of the leg

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • staples/sutures removed
  • start range of motion exercises
  • diagnose and management of early complications
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
B

Advanced Evaluation and Management

1

Prioritizes the needs of the polytrauma patient

  • timing of long bone fixation
  • works with consulting

2

Complex wound management and debridement

  • understanding need for consultation for flap coverage

3

Capable of treating complications both intraoperatively and post-operatively

  • manages post operative infection
C

Preoperative H & P

1

Perform focused orthopedic exam

  • assess lower extremity compartments
  • document distal neurovascular status

2

Order basic imaging studies

  • need biplanar radiographs of entire tibia/fibula, knee, and ankle

3

Perform operative consent

  • describe complications of surgery including
  • scarring
  • injury to the superficial peroneal nerve

Operative Techniques

E

Preoperative Plan

1

Execute surgical walkthrough

  • describe key steps of the procedure to the attending verbally prior to the start of the case
  • describe potential complications and the steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • curved mayo scissors

2

Room setup and equipment

  • standard OR table

3

Patient positioning

  • patient supine
G

Perifibular Approach

1

Mark the incision halfway between the fibula and the crest of the tibia

  • make a 10 cm incision dircelty over the midportion of the fibula
  • retract the skin anteriorly
H

Anterior and Lateral Compartment Release

1

Incise the anterior fascia

  • release the fascia of the anterior and lateral compartment longitudinally in a proximal and distal direction
  • retract the skin posteriorly
I

Superficial Posterior Compartment Release

1

Incise the lateral fascia

  • release the fascia that overlies the lateral head of the gastrocnemius
  • incise the fascia over the superficial posterior compartment for a distance of 15 cm
  • evaluate the color, consistency, contractility and capillary refill
J

Deep Posterior Compartment Release

1

Expose and release the deep posterior compartment

  • retract the anterior and lateral compartments anteriorly and the superficial posterior compartment posteriorly
  • release the soleal bridge from the fibula
  • identify the fascia over the FHL

2

Incise the fascia over the FHL

3

Retract the gastrocsoleus complex posterior

  • retract the FHL laterally
  • this exposes the posterior tibial artery, tibial nerve and peroneal artery that is overlying the tibialis posterior
K

FHL Release

1

Perform release

  • incise the fascia around the tibialis posterior and the interval between the muscle and the origins of the flexor hallucis longus is widened if it is constrictive
L

Wound Closure

1

Place negative pressure dressings

2

Place in splint with the ankle in neutral

  • this prevents equinus contracture

3

Return to OR in 48-96 hours for additional wound debridement

4

Return to OR in 5-7 days for primary wound closure

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • serial compartment checks x 24 hours
  • advance diet as tolerated
  • pain control
  • wound management
  • return to the OR in 48-96 hours for repeat compartment check and wound debridement
  • foley out when ambulating
  • check appropriate labs
  • antibiotics
  • prescribe DVT prophyhlaxis

2

Physical therapy

  • nonweightbearing

3

Appropriate medical management and medical consultation

4

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up in 2 weeks
  • wound care
R

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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