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Original paper
A pilot study of surgical telementoring for leg fasciotomy
  1. Max Talbot1,2,
  2. E J Harvey1,
  3. G K Berry1,
  4. R Reindl3,
  5. H Tien2,4,
  6. D J Stinner5,6 and
  7. G Slobogean2,7
  8. Compartment Release in Austere Locations (CORAL) Collaborators
    1. 1 Department of Surgery, McGill University, Montréal, Quebec, Canada
    2. 2 Royal Canadian Medical Service, Canadian Armed Forces, Canada
    3. 3 McGill University - Department of Surgery, Montréal, Quebec, Canada
    4. 4 Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
    5. 5 Centre for Blast Injury Studies, Imperial College London, London, UK
    6. 6 US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
    7. 7 R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
    1. Correspondence to LCol Max Talbot, Canadian Forces Trauma Training Center (East), 6363 Notre-Dame Est Bldg 20. Montréal H1N 3V9, Canada

    Abstract

    Introduction Acute extremity compartment syndrome requires rapid decompression. In remote locations, distance, weather and logistics may delay the evacuation of patients with extremity trauma beyond the desired timeline for compartment release. The aim of this study was to establish the feasibility of performing telementored surgery for leg compartment release and to identify methodological issues relevant for future research.

    Methods Three anaethetists and one critical care physician were recruited as operators. They were directed to perform a two-incision leg fasciotomy on a Thiel-embalmed cadaver under the guidance of a remotely located orthopaedic surgeon. The operating physician and the surgeon (mentor) were connected through software that allows for real-time supervision and the use of a virtual pointer overlaid onto the surgical field. Two experienced orthopaedic traumatologists independently assessed the adequacy of compartment decompression and the presence of iatrogenic complications.

    Results 14 of 16 compartments (in four leg specimens) were felt to have been completely released. The first evaluator considered that the deep posterior compartment was incompletely released in two specimens. The second evaluator considered that the superficial posterior compartment was incompletely released in two specimens. The only complication was a large laceration of the soleus muscle that occurred during a period of blurred video signal attributed to a drop in bandwidth.

    Conclusions This study suggests that surgical telementoring may enable physicians to safely perform two-incision leg fasciotomy in remote environments. This could improve the chances of limb salvage when compartment syndrome occurs far from surgical care. We found interobserver variation in the assessment of compartment release, which should be considered in the design of future research protocols.

    • trauma management
    • telemedicine

    https://doi.org/10.1136/jramc-2017-000817

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      Footnotes

      • Contributors MT, EJH, GKB, RR, HT and GS contributed to study design. MT, EJH, GKB, RR, HT and GS and DS contributed to data analysis and interpretation. MT wrote the manuscript. EJH, GKB, RR, HT, DS and GS ciritcally reviewed the manuscript.

      • Funding This study was self-funded. The cadavers were accessed during the Royal Canadian Medical Service’s Advanced Military Trauma Resuscitation Program. The investigators received after sale customer support from Innovative Imaging Technologies Inc.

      • Competing interests Outside the submitted work: MT is a member of the Society of Military Orthopaedic Surgeons’ Board of Directors and of the Orthopaedic Trauma Association’s Military Committee. EJH is a co-founder of NTXSens, a biomedical company. GS received personal fees from Zimmer Biomet and grants from PCORI and the Department of Defence. GKB was a surgical educator for Stryker Inc.

      • Ethics approval McGill University Faculty of Medicine.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Collaborators Compartment Release in Austere Location (CORAL) Collaborators: Max Talbot; Edward J Harvey; Gregory K Berry; Rudolph Reindl; Homer Tien; Daniel J Stinner; Gerard Slobogean; Paul A Martineau; Valerie Weagle; Marie-Julie Levesque; Joanne Schmid; Wang-Chun Ip; Leilani Doyle; Chris Berger; Stephen Crummey; Mathieu Couillard.

      • Correction notice This article has been corrected since it was published Online First. Dr Rudolph Reindl has been reinstated in the author list after being removing by accident during editing.