The Well Leg Compartment Syndrome in Orthopaedic Surgery – A Case Report with Review

Abstract

Introduction

For the osteosynthetic treatment of fractures of the femur and optimal exposure of the fractured region including radiological fluoroscopy, it is often recommended to carry out positioning on an extension table, with positioning of the contralateral lower limb on a leg holder. It is not uncommon for this to result in peri- and postoperative damage of varying severity as a result of patient positioning. Some cases of damage due to improper positioning can be found in the literature in the context of urological, general and gynaecological surgery. This is often associated with the responsible surgical speciality, which often requires a lithotomy position and thus the bilateral positioning of the healthy lower extremities. The aim of this article is to draw attention to the well leg compartment syndrome (WLCS) of the unaffected side in orthopaedic surgery, by presenting a case of our own and to point out particular risks on the basis of a current literature review, as well as to discuss procedural suggestions for prevention.

Material and Methods

A literature search was carried out using the online medical database “PubMed” (search date 20.02.2025). After entering the search terms “Well leg compartment syndrome AND orthopaedic surgery”, “Well leg compartment syndrome AND orthopaedics” and “Well leg compartment syndrome AND hemilithotomy positioning”, a total of 175 search hits were found. After removal of duplicates and an extended full-text search, a total of 14 case reports were selected and included in the current publication.

Case Report

This report describes a compartment syndrome of the lower leg of the positioned uninjured limb (well leg compartment syndrome, WLCS) in a 63-year-old patient following prolonged emergency intramedullary nail osteosynthesis of a complex femur fracture, with an operating time of 8:12 h.

Results

In the literature, WLCS of the lower leg in orthopaedic surgery is found in most cases after intramedullary nail osteosynthesis of the femur in patients positioned in modified lithotomy. The operating time was over 2 h in most cases. The diagnosis of compartment syndrome was made in a wide time window between immediately postoperatively and up to 3 days after the operation. The treatment of choice in the majority of cases was fasciectomy of all 4 compartments of the lower leg. No statement can be made about other risk factors in the cases presented in the research – due to missing or limited data.

Conclusion

Position-associated acute compartment syndrome in orthopaedic surgery is a rarely described complication. Risk factors include a long operating time, increased BMI, increased blood loss, low intraoperative blood pressure and peripheral vascular disease. The uninjured leg should be correctly positioned in the lithotomy position intraoperatively (90° flexion in hip and knee) and be as little as possible in the case of known risk factors. Regional procedures can also be used safely in high-risk patients, but often obscure the initial diagnosis.

Keywords

lithotomy position - positioning associated compartment syndrome - well-leg-compartment syndrome

Publication History

Received: 20 March 2025

Accepted after revision: 29 October 2025

Article published online:
26 November 2025

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