The role of prophylactic fasciotomy and medical treatment in limb ischemia and revascularization

Multiple studies have demonstrated that muscle poorly tolerates ischemia. When the ischemic state is unduly prolonged, the successfully replanted or revascularized limb undergoes deleterious biochemical reactions that cascade to vessel intimal damage, increased vessel permeability, and lowering of pH. The resultant tissue edema leads to increasing compartment pressures, which not only impede the recovery of function, but also can lead to irreversible muscle necrosis, increased risk of infection, and sepsis if not reversed in a timely fashion. The development of compartment syndrome jeopardizes not only the injured limb, but life itself secondary to the biochemical toxins produced by the ischemic extremity. A thorough understanding of the biochemistry of ischemia and reperfusion provides insight into the role of fasciotomy in the replanted or revascularized extremity. The scientific basis for fasciotomy in the revascularized or replanted limb is discussed as well as the potential 'protective' role of pharmacologic agents in ischemic and reperfusion injury.