missed positional gluteal compartment syndrome in an obese

CASE REPORT Open Access

Missed positional gluteal compartmentsyndrome in an obese patient after footsurgery: a case reportRami Khalifa1, Madison R. Craft2, Aaron J. Wey1, Ahmed M. Thabet1 and Amr Abdelgawad3*

Abstract

Background: Gluteal compartment syndrome is an uncommon condition and can be difficult to diagnose. It hasbeen diagnosed after trauma, vascular injury, infection, surgical positioning, and prolonged immobilization fromdrug or alcohol intoxication. The diagnosis is based on clinical findings and, in most cases, recognizing thesesymptoms and making a diagnosis early is critical to a complete recovery.

Case presentation: A 53-year-old male who underwent left foot surgery had severe pain to his contralateral hipand posterior gluteal compartment radiating to the right lower extremity immediately postoperative. He waspositioned supine with a “bump” placed under his right hip to externally rotate his operative leg during thesurgery. Due to the patient’s complex past medical history, a presumptive diagnosis of a herniated disc and/orcompression of the sciatic nerve was made as a cause for the patient’s pain. This resulted in a misdiagnosis periodof 36 h until the patient was diagnosed with unilateral gluteal compartment syndrome. Performing a fasciotomywas decided against due to the increased risk of complications. The patient was treated with administration of IVfluids and closely monitored. On post-op day 6, the patient was discharged. At three months post-op, the patientwas walking without a limp and he had no changes in his peripheral neurologic examination compared to hispreoperative baseline.

Conclusion: Gluteal compartment syndrome is a surgical emergency that must be considered postoperativelyespecially in obese patients with prolonged operation times who experience acute buttock pain. The use ofpositional bars or “bumps” in the gluteal area should be used with caution and raise awareness of this complicationafter orthopedic surgeries.

Keywords: Gluteal compartment syndrome, Compartment syndrome, Buttock pain, Post-operative complication

BackgroundCompartment syndrome in the gluteal area is a rare andoften unrecognized syndrome. Trauma, vascular injury, in-fection, surgical positioning, and prolonged immobilizationfrom drug or alcohol intoxication are the most commoncauses of gluteal compartment syndrome [1–4]. Early

recognition and treatment can help to prevent long termcomplications such as residual sciatic nerve problems orrenal failure from rhabdomyolysis [5, 6].A systemic review of gluteal compartment syndrome

found that 50% of the gluteal compartment syndromecases were due to prolonged immobilization after al-cohol or other drugs intoxication or after long surgi-cal interventions such as total hip or kneearthroplasty or procedures with complications thatprolong OR time [7]. The lithotomy and lateral de-cubitus positions are commonly used for orthopedic

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* Correspondence: [email protected] of Orthopedic Surgery, Maimonides Medical Center,Maimonides Bone and Joint Center, 6010 Bay Parkway, Brooklyn, NY 11204,USAFull list of author information is available at the end of the article

Khalifa et al. Patient Safety in Surgery (2020) 14:35 https://doi.org/10.1186/s13037-020-00260-8

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procedures and have been associated with glutealcompartment syndrome [8, 9]. Risk factors such asobesity in addition to extended operative time andpatient positioning should warrant suspicion of glutealcompartment syndrome when symptoms arise. Thisarticle will describe a case of missed gluteal compart-ment syndrome that followed contralateral foot sur-gery. The report includes a literature review forpositional gluteal compartment syndrome cases fol-lowing orthopedic surgeries. We only indicated casesthat occurred following orthopedic surgeries not per-formed in the pelvis/hip area so that the post-operative gluteal compartment syndrome is due to pa-tient “positioning” and not due to “local trauma bythe surgery”.

Case presentationPre-operative historyA 53-year-old male with diabetes mellitus and docu-mented peripheral neuropathy presented with left footpain and deformity. He had a previous Lisfranc injurytreated with open reduction and internal fixation threeyears before presentation. The fixation construct failedand the patient developed Charcot arthropathy of themidfoot (Fig. 1). He also presented with stage III poster-ior tibial tendon insufficiency with a rigid hindfoot val-gus deformity and forefoot abduction. The patient wasindicated for hardware removal, medial column arthrod-esis, and subtalar arthrodesis to correct the flatfoot de-formity and a triple hemisection Achilles tenotomy forEquinus deformity. Past surgical history included lumbarspine decompression and fusion a few years prior. Thepatient had a weight of 149 kg and a height of 188 cmresulting in a BMI of 42.

Operative techniqueIn the OR, the patient was positioned supine on a regu-lar operating table with a “bump” made of rolled up twosheets was placed under his right hip to externally rotatehis operative leg. A left thigh tourniquet was placed andinflated to 350 mmHg for 120 min. No epidural or re-gional block was used. The duration of surgery was 3 hand 53min. The procedure was performed in the follow-ing sequences 1) Complex hard ware removal (brokenimplant), 2) Precutaneous Achilles tendon lengthening,3) Fusion of the 1st metatarsal with the medial cunei-form, 4) Fusion of the medial cuneiform with navicularbone, 5) Fusion of the navicular with the talus, 6) Fusionof the subtalar joint 96(Fig. 2). The procedure went un-eventful. The patient was extubated and tolerated theprocedure during surgery very well.

Postoperative day (POD) 0In the immediate postoperative period, the patient com-plained of 10/10 pain to the right (contralateral) hip andposterior gluteal compartment radiating to the rightlower extremity. The patient was more comfortable withthe bed at 45 compared to lying flat. An emergent CTscan was obtained to rule out a fracture of the femoralneck or proximal femur and it was negative and did notshow any other abnormality around the pelvis area. Dueto his prior history of lumbar spine surgery, degenerativechanges in the lower lumbar spine with marked narrow-ing of disc space, and sclerosis of endplates and osteo-phytes were seen on CT, a presumptive diagnosis of aherniated disc and/or compression of the sciatic nervewas made. An urgent MRI was also ordered that night;however, the patient was unable to lay supine due topain and the only way to obtain the MRI was underanesthesia. Due to his recent prolonged surgery, a

Fig. 1 preoperative Radiographs showing failure of the fixation construct and the patient developed Charcot arthropathy of the midfoot

Khalifa et al. Patient Safety in Surgery (2020) 14:35 of 10

decision was reached not to anesthetize the patient asecond time for the MRI. The provisional diagnosis ofradicular pain and sciatica was the prevailing diagnosisat that time. Please note that the diagnosis of the glutealcompartment syndrome was missed on the day of sur-gery. The patient experienced uncontrolled pain thenight after surgery that did not respond to narcotic painmedication. He stated that the pain in his right lowerback and buttocks was more severe than the pain in hisleft ankle from recent surgery.

POD 1On POD 1, the patient continued to complain of radicu-lar pain in the right L5, S1, and sciatic nerve distribu-tion. On physical exam, he had grade 5/5 motor powerstrength with ankle dorsiflexion, plantar flexion, Exten-sor Hallucis longus, Flexor Hallucis Longus, knee exten-sion, and knee flexion. The sensation was normal in theL1 to S1 nerve distribution. Dorsalis pedis and posteriortibialis pulses were palpable and symmetric in the leftfoot. The palpation of the right gluteal compartmentwas tense. The patient was also much more comfortablelaying at 45° than supine in the bed. He was sent for anMRI of the lumbar spine and right hip. The MRI did notshow a lumbar disc herniation but did reveal increasedsignal in the gluteal compartment (gluteus maximus,medius, and minimus) on the right side (Fig. 3).

POD 2–3Systemic blood work obtained on POD 2 included an el-evated creatine kinase at 49,688 and a BUN/Cr at 44/1.5.The patient was treated with IV fluids and diagnosedwith right gluteal compartment syndrome. Due to theprolonged misdiagnosis in the first 36 h post-op, the de-cision was made not to decompress the gluteal

compartment to avoid operating on possibly necrosedmuscle which would increase the risk for massive infec-tion or significant fibrosis.

POD 4–6The patient was observed and treated without surgicaldecompression. His pain decreased gradually on eachpost-op day moving forward. Creatine kinase trendeddown to 12,064 on POD 5, and to 6702 on POD 6. HisBUN/Cr improved to 25/1.0 on POD 6. After walkingwith physical therapy, the patient was discharged homeon POD 6. At three months post-op, the patient waswalking without a limp, had no proximal weakness, and

Fig. 2 postoperative radiographs showing fusion of left foot medial column joints and the subtalar joint

Fig. 3 Patient’s MRI postoperatively of the lumbosacral regiondemonstrating hyperintense signaling from the right gluteal muscles(white arrows), please notice the difference between it and thenormal left gluteal muscles (black arrows)


had no changes in his peripheral neurologic examinationcompared to his preoperative baseline.

Discharge protocolNon-weight-bearing to left lower extremity and weight-bearing as tolerated to the right lower extremity. Phys-ical therapy was scheduled to improve muscle recoveryand regain strength. The patient was given forms withinformation on diabetic foot care, pain medicine instruc-tions, walker use, fall prevention, and home safety. Out-patient clinic visits were scheduled every two weeks tomonitor the patient’s recovery.

DiscussionGluteal compartment syndrome is a rare condition thatmainly occurs after trauma directly to the gluteal area orprolonged immobilization with pressure on the glutealregion after intoxication or prolonged surgery [2–4, 10,11]. Acute pelvic trauma can cause gluteal compartmentsyndrome due to local swelling from the injury thatcompromises vascular structures within a closed fascialspace [1, 11, 12]. Postoperative gluteal compartmentsyndrome can occur due to local surgical trauma wherestructures have been incised and manipulated leading toedema; however, most cases of postoperative glutealcompartment syndrome affect the non-operative ana-tomical site due to prolonged immobilization andpressure.A detailed literature review was performed to identify

cases of positional gluteal compartment after orthopedicprocedures. Cases due to direct trauma, vascular causes(e.g. injury to the gluteal vessels), intoxication, or thosefollowing non-orthopedic surgeries were excluded. Weconsidered spinal procedures and extremity microsur-gery among orthopedic surgeries. Cases of gluteal com-partment syndrome following operative intervention onthe ipsilateral hip (e.g. total hip arthroplasty) were con-sidered “local trauma” and were excluded from this re-port. One article described bilateral gluteal compartmentsyndrome after total hip arthroplasty [13], we only in-cluded the contralateral side in the review as the ipsilat-eral side was considered local trauma. Thirteen caseseries/ case reports were included. Table 1 shows the de-tails of the included papers/ cases. All studies wereretrospective case reports [6, 10–17]. The average agewas 53.2 years old, with most cases (84.6%) being malesand the average BMI was 33.7 (from the studies that re-corded BMI). The average operation time was 3 h.Six patients were positioned supine during surgery;

two of the cases used lithotomy position; three caseswith lateral positioning during hip surgeries had glutealcompartment syndrome develop on the lower side thatpatient laid on. There were two cases after lumbar de-compression surgeries. In these two cases, the patients

were positioned in the knee-chest/elbow position with“buttock support”. In our case, the procedure was per-formed in the supine position with elevation of the rightside of the body with a “bump” under the right glutealarea to keep the left lower limb externally rotated. Theuse of a “bump” as well as the use of buttocks supportsshould be considered as a possible cause of gluteal com-partment syndrome due to constant increased localizedpressure.Previous studies have found that major risk factors for

gluteal compartment syndrome include obesity, pro-longed operative time, and epidural anesthesia [3, 11,18]. Our patient had a morbidly obese BMI of 42. Thisstudy’s literature review had patients with an averageBMI of 33.7 indicating moderate obesity. This seems tobe a factor contributing to the development of glutealcompartment syndrome due to elevated pressure fromthe increased patient weights and from prolonged sur-geries that are typically associated with more obese pa-tients. These cases require a lower threshold forsuspicion postoperatively.Nine patients in our review had epidural anesthesia

used for the operation and/or postoperatively. It hasbeen mentioned in the literature that epidural analgesiamay predispose susceptible patients to gluteal compart-ment syndrome [12, 17]. In our case, the patient under-went the surgery under general anesthesia that why hehad a severe pain shortly postoperative, this may supportthe use of general anesthesia in certain surgical interven-tions, which have the high risk of the position relatedcompartment syndrome.The most common clinical signs for gluteal compart-

ment syndrome included pain in the gluteal region(92.3%), non-compressible tense swelling of the buttocksarea with possible erythema (84.6%), pain that did notimprove with analgesics (53.8%), pain elicited with pas-sive range of motion of the hip (38.5%), and sensory/motor nerve dysfunction with the sciatic nerve distribu-tion (38.5%). Four patients experienced foot drop(30.8%). Out of the 13 cases, only one was diagnosedbased on measuring compartmental pressures and theother 12 were based on clinical findings and patientsymptoms. All the published cases were treated with afasciotomy. In our case, the gluteal and back of the thighpain was the first and the main symptom of our casewhich developed immediately postoperatively, inaddition to tense gluteal region on the physicalexamination.The symptoms and signs of gluteal compartment syn-

drome can be aided by labs and imaging to rule outother causes of the presenting symptoms. Creatine kin-ase and potassium levels are often elevated due tomuscle ischemia [19]. Thus, given the large muscle massinvolved, it is likely that a rise in CK may be one of the


Table

1Theliteraturereview

summary

Article/Autho

rsPa

tien

tCha

racteristics

(BMI,

morbidities,

obesity,

weight,

height)

Surgery

perform

edan

dduration

Typeof

anesthesia

Position

ing

during

surgery

The

ipsilateralo

rco

ntralateral

side

Dialysis

Signs

andsymptoms

that

lead

tothe

diagno

sis

Trea

tmen

tTimeafter

surgery

fasciotomy

was

perform

ed

Long

term

effects

(com

plete

reco

very,

persisten

tpain)

Sarw

arU,2

017

[11]:

Postop

erative

gluteal

compartm

ent

synd

rome

follo

wing

microsurgical

free

-flapha

ndreco

nstruc

tion

51yo

FPM

H:d

iabe

tes,

obesity,

hype

rten

sion

,GERD

Microsurgical

free-flapfor

hand

-8h

Gen

eral

anesthesia

Supine

Con

tralateral

(leftbu

ttocks)

No

Unrem

ittingpain

with

radiationdo

wnthe

posteriorthighandleg.

Restless

andwrithing

inthebe

dun

ableto

get

comfortable.Localized

tend

erne

ss.Passive

movem

ent,extension,

flexion

,abd

uctio

n,and

addu

ction,worsene

dthepain.A

ctive

extensionandabdu

ction

ofthehipwereweak.

Clinicaldiagno

sis

Fasciotomy.A

lumbarep

idural

provided

much

reliefof

sciatica

type

pain.Itwas

removed

after2

day

3hpo

st-op.

Sciatica-type

pain

persistedalon

gtherig

htleg/foot

aftersurgery,

butthepatient

madea

completerecovery

Krysa

J,20

02[14]:G

luteal

compartm

ent

synd

rome

follo

wingPC

Lrepair

31yo

MPC

Lrepair-1h

n/a

Mod

ified

litho

tomy

Con

tralateral

No

Increasing

pain

inhis

contralateralb

uttocks

despite

strong

eranalge

sia.Exacerbated

bypassivemuscle

stretching

.The

gluteal

region

was

swollen,

tense,andtend

er.

Neuro/vascularno

rmal.

Intracom

paremtneal

pressure

58mmHgwhile

diastolic

pressure

at40

fasciotomy

24hpo

st-

opUne

ventfulrecovery

with

none

urolog

ical

sequ

elae

Ostee

n,20

12[15]:B

ilateral

gluteal

compartm

ent

synd

rome

follo

wingrigh

ttotalk

nee

revision

52yo

MPM

H:

obesity,H

TN,

HLD

Revision

TKA-

3h20

min

Com

bine

dspinal-

epidural

Supine

Bilateral

No

Agitatio

n,severe

distress

from

bilateralb

uttock

pain.Left-side

dbu

ttock

numbn

ess.R/Lgluteal

region

tense,hard,and

erythe

matou

s.CPK/LFTs

elevated

.Nopassive

movem

enttoleratio

n.Clinicaldiagno

sis

Fasciotomy.

Discontinued

simvastatin

POD

4.Vancom

ycin

+Zo

synPO

D2

POD2

Nosign

sof

necrosis

durin

gfasciotomy;

discharged

5days

after

fasciotomywith

none

urode

ficits

orresidu

alpain

inthegluteal

region

Pach

eco;

2001

[12],G

luteal

compartm

ent

synd

romeafter

TKAwith

epidural

postoperative

analgesia

47yo

MPM

H:

obesity,H

TNBM

I:41.66

TKA-2hand

15min

Epidural

Supine

Bilateral

No

Back

pain

anddifficulty

infinding

acomfortable

positio

n.Pyrexia

(38.4°C).sw

ollen,tend

er,

andpainfulb

uttocks.

Not

relievedby

non-

opioid

analge

sia.Com

-partmen

tpressure

Fasciotomies

44hpo

st-

opGoo

drecovery

Discharge

d9days

after

admission

;one

year

later,complaine

dof

gluteald

iscomforton

sitting


Table


summary(Con

tinued)

Article/Autho

rsPa

tien

tCha

racteristics

(BMI,

morbidities,

obesity,

weight,

height)

Surgery

perform

edan

dduration

Typeof

anesthesia

Position

ing

during

surgery

The

ipsilateralo

rco

ntralateral

side

Dialysis

Signs

andsymptoms

that

lead

tothe

diagno

sis

Trea

tmen

tTimeafter

surgery

fasciotomy

was

perform

ed

Long

term

effects

(com

plete

reco

very,

persisten

tpain)

Case1

results

wereat

thebo

r-de

rline

uppe

rlim

it,clin-

icallydiagno

sed

Case2

71yo

Mweigh

t:81

kgBM

I:26.44

TKA(righ

t)-2h

25min

Epidural

Supine

ipsilateral

No

Righ

tfoot

drop

was

noticed

abou

t4.5hafter

theep

iduralanesthesia

hadbe

endiscon

tinued.

Exam

inationshow

edloss

ofsensationin

the

distrib

utionof

therig

htsciatic

nervewith

noactivemovem

entof

the

ankle(fo

otdrop

).Sw

ellingandtend

erne

ssof

therig

htbu

ttockand

skin

intherig

htgluteal

area

wereindu

ratedand

discolored

.The

serum

levelsof

urea

and

creatin

inewereelevated

.Clinicaldiagno

sis

Fasciotomy,

sciatic

nerve

neurolysis.The

necroticmuscle

was

excisedfro

mbe

neaththe

fascialata

and

from

vastus

lateralis

and

rectus

femoris

47.5h

postop

Nochange

inmotor

orsensoryfunctio

ndistal

toknee;nerve

cond

uctio

nstud

ies

show

edabno

rmalities

inthesciatic

nerve.

Inability

toob

tain

sensoryor

motor

respon

sesin

the

common

perone

aland

posteriortib

ialn

erves.

Rudolph,

2011

,[16],B

ilateral

gluteal

compartm

ent

synd

romean

dseve

rerhab

dom

yolysis

afterlumbar

spinesurgery

65yo

Mhe

ight

178cm

,weigh

t124kg,BMI39.1

PHM:O

besity,

DM2,HTN

bilateral

decompression

L3-L5–4h

endo

trache

alanesthesia

Knee-che

stpo

sitio

ncushione

dbar

supp

ortin

gthebu

ttocks

andsoftside

supp

orts

againstthe

femoral

trochanters

Bilateral

Yes

Pain

inthebu

ttocks

had

increased.

Oliguriawith

darken

edurine.Severe

stiffne

ss,ten

derness,and

painfulswellingof

glutealm

uscles

onbo

thside

s.Sciatic

nervepalsy

was

absent.C

reatine

phosph

okinase(CPK)

levelat91,000

IU/l

(normal30–240

IU/l).

Clinicaldiagno

sis.

Fasciotomy,

Hem

odialysis

despite

the

aggressive

fluid

replacem

ent

7hpo

st-op

Thepatient

requ

iredfive

coursesof

hemod

ialysis.

Con

tinuedto

have

pain

andwas

discharged

depe

nden

ton

awhe

elchairdu

eto

mod

erateglutealp

ain

andbilateral

insufficien

cyof

gluteal

muscles

Polacek,

2009

[6]:Gluteal

compartm

ent

synd

romeafter

lumbar

laminectomy

65yo

MBM

I38,

PMH:obe

sity,

CKD

III,D

M2,

HTN

Lumbar

laminectomy

Elbo

w-4h

Inhalatio

nanesthesia

Theelbo

w-

knee

positio

nwith

side

and

buttock

supp

ort

Leftgluteal

compartmen

tYes

Increasing

pain

inbo

thglutealreg

ions,

espe

ciallyon

theleft

side

.The

pain

didno

trespon

dto

analge

sic

treatm

ent.Bo

thgluteal

region

swereabno

rmally

firm

andpainful.Bo

thfeet

hadde

creased

capillary

fillingandfelt

Fasciotomy;

Necrotic

partsof

gluteusmuscles

wereremoved

27hpo

st-

opDischarge

d12

days

after

theinitialop

eration

(doe

sn’tsayho

wthe

patient

was

doingor

ifwalking

)


Table


summary(Con

tinued)

Article/Autho

rsPa

tien

tCha

racteristics

(BMI,

morbidities,

obesity,

weight,

height)

Surgery

perform

edan

dduration

Typeof

anesthesia

Position

ing

during

surgery

The

ipsilateralo

rco

ntralateral

side

Dialysis

Signs

andsymptoms

that

lead

tothe

diagno

sis

Trea

tmen

tTimeafter

surgery

fasciotomy

was

perform

ed

Long

term

effects

(com

plete

reco

very,

persisten

tpain)

cold.Palpablepu

lsation

was

foun

din

thearteria

dorsalispe

dis(ADP)

and

arteria

tibialis

posterior

(ATP),verifiedby

Dop

pler

ultrasou

nd.N

oabno

rmalne

urolog

ical

finding

swereno

ted.

Clinicaldiagno

sis

Somayaji,20

05[13]:B

ilateral

gluteal

compartm

ent

synd

romeafter

THAun

der

epidural

anesthesia

39yo

MCon

genitalH

ipDysplasia

THA-2h

Epidural&

gene

ral

anesthesia

Leftlateral

positio

nBilateral

No

Severe

pain

and

discom

fortin

both

buttocks

8/10.

Con

tinuedto

worsen

andde

velope

dblisters

inbo

thbu

ttocks

durin

gthenigh

t(secon

d-nigh

tpo

stop

).Bilateralsciatic

nervepalsy.Pedalp

ulses

inbo

thlim

bs.Sen

satio

nandpo

wer

inbo

thlower

limbs

failedto

return

tono

rmal24

haftercessationof

epiduralanalge

sia.

Elevated

creatin

ine

kinase

(31,000).C

linical

diagno

sis.

Fasciotomywith

debridem

entof

necrotictissue

50hpo

st-

opFull-thicknessskin

grafts

appliedbilaterally,w

alks

with

awalking

stickwith

minim

alabdu

ctionand

weakexternalrotatio

n(the

articledo

esn’tstate

ifweaknessin

both

side

sor

oneside

)

Kum

arV,2

007

[10]:G

luteal

compartm

ent

synd

rome

follo

wingjoint

arthroplasty

under

epidural

anesthesia:4

cases

Case1

46yo

F101kg,

BMI:38

PMH:

obesity

Ltotalkne

earthroplasty

-2

h

Epidural

Supine

ipsilateral

No

Pain

intheleftbu

ttock.

Tense,tend

ersw

elling

butno

abno

rmal

neurolog

icalfinding

s.Clinicaldiagno

sis.

Fasciotomy

48hpo

st-

opCom

pleterecovery

Case2

71yo

Mweigh

t:94

kg;BMI:28

LeftTH

A-2h

20min

epidural

Righ

tlateral

positio

ncontralateral

No

Severe

right

buttock

pain.Firm

,ten

se,ten

der

swellingwith

erythe

ma

overlyingtherig

htbu

ttock.Clinical

diagno

sis.

Fasciotomy

44hpo

st-

opCom

pleterecovery


Table


summary(Con

tinued)

Article/Autho

rsPa

tien

tCha

racteristics

(BMI,

morbidities,

obesity,

weight,

height)

Surgery

perform

edan

dduration

Typeof

anesthesia

Position

ing

during

surgery

The

ipsilateralo

rco

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[17]:G

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signs of compartment syndrome. In our patient, the cre-atine kinase level was not recorded until POD 2 and wasmarkedly elevated (more than 49,000). This high valueindicated that significant tissue damage had already oc-curred. Earlier measurements of CK could have sup-ported the diagnosis of gluteal compartment syndrome.In the literature review, two cases out of the 13 (15.4%)required dialysis due to renal affection by the circulatingmyoglobin from the muscle injury.Our literature review revealed that the more time that

elapses until fasciotomy, the worse outcome for the pa-tient. All the published cases were treated with a fasciot-omy. The average time after surgery to fasciotomy was33.5 h. The patients that did not achieve a complete re-covery had fasciotomies performed a minimum of 44 hafter surgery. Thus, the diagnosis of gluteal compart-ment syndrome must be made promptly to treat as soonas possible and to achieve a better likelihood of acomplete recovery. In many cases, due to the rarity ofthe condition, the masking of the symptoms from epi-dural anesthesia or more relevant issues from the pri-mary surgery, the diagnosis may be delayed.In our case, the diagnosis of position gluteal compart-

ment syndrome was missed for the first 36 h as the pa-tient was assumed to have radicular symptoms due topossible lumbar spine etiology. Once the diagnosis wasconfirmed, due to existing literature expressing morecomplications with late fasciotomies and fear of operat-ing on necrosed muscle which carries a high incidenceof infection, it was decided that a fasciotomy would notbe performed [20]. Fortunately, the patient completelyrecovered with no sequelae from the compartment syn-drome. This article should not be interpreted, by anymeans, as a message that we encourage managing thesecases nonoperatively. It is simply a description of thecourse of the disease in our patient. In our literature re-view, Eight of the patient (61.5%) achieved a completerecovery while five patients (38.5%) had persistent symp-toms including gluteal discomfort with pressure (2/13,15.4%), sciatic nerve sensory or motor dysfunction (1/13,7.6%), and gluteal muscles weakness with Trendelenburgsign (3/13, 23%) (One patient had 2 long term sequalae).

ConclusionGluteal compartment syndrome is a surgical emergencythat must be considered postoperatively especially inobese patients with prolonged operation times who ex-perience acute buttock pain. The use of positional barsor “bumps” in the gluteal area should be used with cau-tion and raise awareness of this complication afterorthopedic surgeries.

AbbreviationsMRI: Magnetic Resonance Imaging.; BMI: Body Mass Index; POD: Post-Operative Day; CK: Creatine Kinase; BUN/Cr: Blood Urea Nitrogen/Creatinine

AcknowledgementsNone.

Authors’ contributionsRK: drafted manuscript, helped in data collection (articles of glutealcompartment syndrome assessment). MC: did most of the data collection(articles of gluteal compartment syndrome assessment) and analysis of thedata and the Table. AW: did the description of the case and helped with thediscussion. AT: planned the study design, reviewed the manuscript. AA:wrote the manuscript, reviewed the data of the table, finalized thesubmission and supervised all the other authors. All authors read andapproved the manuscript.

FundingNo funding was obtained for this research.This research did not receive any funds. We would like to ask for waiver/discount for the APCs as there is no secured funds for the publications’ fees.

Availability of data and materialsAll materials (consent, pictures, labs) are available for review if needed.

Ethics approval and consent to participateWritten informed consent was obtained by the patient featured in this article forpublication of the case report including accompanying images and protectedhealth data. The consent is available for review by the editor-in-chief uponrequest.Texas Tech University Health Science Centers of El Paso Institutional BoardReview (IRB) consider all “case reports” as waived from obtaining approval solong consent was obtained from the patient.

Consent for publicationA consent to publish was obtained from the patient himself.

Competing interestsThe authors declare that they have no competing interests.

Author details1Department of Orthopedic Surgery, Paul L. Foster School of Medicine, TexasTech University Health Sciences Center, El Paso, TX 79905, USA. 2Paul L.Foster School of Medicine, Texas Tech University Health Sciences Center, ElPaso, TX 79905, USA. 3Department of Orthopedic Surgery, MaimonidesMedical Center, Maimonides Bone and Joint Center, 6010 Bay Parkway,Brooklyn, NY 11204, USA.

Received: 29 April 2020 Accepted: 8 September 2020

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missed positional gluteal compartment syndrome in an obese

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