Complications Associated With Intermittent Pneumatic
Elisabeth A. Lachmann, MD, Jack L. Rook, MD, Richard Tunkel, MD, Willibald Nagler, MD
ABSTRACT. Lachmann EA, Rook JL, Tunkel R, Nagler \V. Complications associated with intermittent pneumatic
compression. Arch Phys Med Rehabil I992;73:482-5.
• The intermittent pneumatic compression device (1PCD) is prophylaxis for prevention of deep-venous thrombosis
(DVT). This pneumatic leg sleeve has been used extensively in high-risk surgical patients, without complication. We
describe two cases, one with peroneal neuropathy and the other with compartment syndrome, associated with IPCD use
during surgery. Case I involves a patient with pancreatic cancer and weight loss who developed bilateral peroneal nerve
palsies during surgery. Case 2 involves a patient with bladder cancer who developed lower leg compartment syndrome
during prolonged surgery in the lithotomy position. These cases are unusual for several reasons. First, patients wearing
IPCDs during surgery are at increased risk of neurovascular compression. Second, significant weight loss may predispose
the peroneal nerve to injury from intermittent compression garments. Third, patients undergoing surgery in the
lithotomy position are at risk of compartment syndrome. Therefore, physicians may wish to use another method of DVT
prophylaxis in surgical patients with cancer or significant weight loss, or those who are undergoing procedures in the
© 1992 by the American Congress of Rehabilitation Medicine, and the American Academy of Physical Medicine and
KEY M ORDS: Compartment syndromes: Compression: Peroneal nerve: Postoperative complications
Deep-venous thrombosis (DVT) and pulmonary embolism
(PE) are causes of morbidity and mortality in hospitalized
patients. Prophylaxis to prevent DVT formation include
anticoagulation and physical methods such as the
intermittent pneumatic compression device (IPCD). In high-
risk surgical patients, the use of anticoagulants may be
contraindicated: whereas, physical methods have been proven
The most common side effects of IPCD use are discom-
fort, warmth, and sweating beneath the vinyl leg sleeves.4
Complications associated with a related pneumatic com-
pression device, the sequential pneumatic compression de-
vice (SPCD), have been reported. These complications in-
clude peroneal nerve palsy and pressure necrosis of the
thigh.5-6 Neither of these complications lias been associated
with IPCD use.
We describe the first reported cases of bilateral peroneal
neuropathy and compartment syndrome associated with
IPCD use during surgery. In the first case, a patient with
cancer and significant weight loss developed peroneal nerve
From ihe Department of Rehabilitation Medicine. The New York Hospital-Cornell
Medical Center (Drs. Lachmann. Tunkel. and Nagler. New York); and the Department
of Rehabilitation Medicine. Capron Rehabilitation Center/Penrose Hospital (Dr.
Rook). Colorado Springs. CO.
Submitted for publication March 12. 1991. Accepted in revised form June II.
No commercial party having a direct or indirect interest in the subject matter of this
article has conferred or will confer a benefit upon the authors or upon any organization
with which the authors are associated.
Reprint requests to Elisabeth A. Lachmann. MD. Department of Rehabilitation
Medicine. Box 142. The New York Hospital-Cornell Medical Center. 525 East 68th
Street. New York. NY 1 002 1.
•c> 1992 by the American Congress of Rehabilitation Medicine and the American
Academy ol Physical Medicine and Rehabilitation
palsies postoperatively. Compression neuropathies due to
weight loss alone are not uncommon, especially those in-
volving the common peroneal nerve (CPN) at the fibular
head.7-8 Case 2 involves a patient with cancer who developed
lower leg compartment syndrome after prolonged surgery in
the lithotomy position. Patients undergoing surgery in the
lithotomy position are at risk of limb compression and
subsequent compartment syndrome.9-10 Therefore, IPCDs
should be used with caution in surgical patients with cancer,
peripheral neuropathy, or weight loss or those undergoing
procedures in the lithotomy position; other methods of DVT
prophylaxis should be considered.
Case I. A 65-year-old man with atherosclerotic heart disease
and hypertension was admitted with a one-month history of an-
orexia, painless jaundice, 20-pound weight loss, and recently diag-
nosed non-insulin-dependent diabetes mellitus. Abdominal CT
scan revealed a mass at the head of the pancreas. Preoperative
physical examination revealed no clinical evidence of peripheral
neuropathy. Surgical stockings and IPCDs were applied preopera-
tively for DVT prophylaxis. The patient underwent a subtotal
pancreatectomy. with biopsy demonstrating poorly differentiated
Postoperatively. the patient complained of numbness and
weakness of both lower legs. On examination, distal pulses were
present and the legs were warm with good capillary refill. Sensation
was decreased over the anterolateral legs and dorsum of the feet.
Motor testing revealed absence of ankle dorsiflexion and
eversion. He ambulated with a bilateral steppage gait that im-
proved with use of ankle-foot orthoses and a rolling walker.
Electrodiagnostic studies 14 days after surgery demonstrated
bilateral peroneal neuropathies with slowed motor nerve conduc-
Arch Phys Med Rehabil Vol 73. May 1992
COMPLICATIONS OF PNEUMATIC COMPRESSION, Lachmann
lion of the CPN across the fibular head. An EMG revealed dener-
vation of the tibialis anterior, peroneus longus, and extensor hallu-cis
longus, with the short head of the biceps femoris spared
bilaterally. During the next three months, there was clinical evi-
dence of partial resolution of the nerve injury with increased
strength of ankle dorsiflexion (3/5), eversion, and great toe extension
(2/5). He required a cane and bilateral posterior leaf-spring
orthoses until his death three months later.
Case 2. A 67-year-old man with recurrent transitional-cell car-
cinoma of the bladder was admitted for palliative treatment. Pre-
operative physical examination revealed no focal neurologic deficits
and normal gait. Surgical stockings and IPCDs were applied
preoperatively for DVT prophylaxis. The patient underwent radical
cystectomy and ileal neobladder substitution, and he was in the
lithotomy position for eight hours during the procedure.
Postoperatively. he complained of lower leg pain and paresthe-
sias. Physical examination revealed a tight, swollen lower right leg.
Distal pulses were present, as well as capillary refill. Sensation was
decreased over the anterolateral leg and dorsum of the foot. Motor
testing revealed calf pain with passive ankle dorsiflexion and plantar
flexion, and weakness of active ankle dorsiflexion and great toe
extension. Compartment pressures of the lower leg were as fol-
lows: anterior, 52mmHg: lateral, 58mmHg; superficial posterior,
55mmHg and deep posterior, SOmmHg.
Acute compartment syndrome was diagnosed. A four-compart-
ment fasciotomy was performed, and multiple skin grafts were
necessary to close the fasciotomy wound. The patient refused elec-
trodiagnostic studies postoperatively. At discharge two weeks
later, the patient had normal (5/5) dorsiflexion and great toe ex-
tension, as well as normal gait.
Pneumatic compression devices were developed during
the 1970s as an alternative to anticoagulation for DVT pre-
vention. Use of IPCDs reduces the incidence of DVT for-
mation by 50% or more, and it is the prophylaxis of choice
when low-dose heparin (LDH) is either contraindicated or
Surgical patients with malignancies require DVT pro-
phylaxis because of high embolic risk. The high incidence
of DVT formation may be due to coagulability properties of
the malignancy or increase blood viscosity from dehy-
dration.4 One third of patients with pancreatic carcinomas
develop venous thromboembolisms.14 Use of IPCDs in
cancer patients undergoing surgery may reduce postoperative
DVT formation by 90%.15
An IPCD consists of a pair of double-walled, vinyl pneu-
matic sleeves, placed around the calves and connected to a
compressor that inflates and deflates the garments (fig 1).
Compressions last 12 seconds per minute, with inflation
pressure of 40mmHg. The leg sleeves (12 to 16 inches long)
extend distally from the inferior border of the patella. They
are applied preoperatively and are worn during surgery;
they are removed once the patient begins walking.
This device compresses the lower leg, reproducing the
action of the calf muscles in promoting venous return. Studies
indicate that calf compression stimulates fibrinolysis, and
this action contributes to preventing thrombus formation.16-
'7 Contraindications to IPCD
thrombophlebitis, suspected DVT, congestive heart failure,
pulmonary edema, and leg ischemia due to peripheral vas-
The etiology of the CPN palsy in the first case was multi-
factorial (ie, weight loss, paraneoplastic effects, nutritional
and metabolic deficiencies, and intermittent pneumatic
compression). Loss of tissue and fat around the CPN left it
unprotected at the fibular head. Increased anterior com-
partment pressure from the intermittent compression device
contributed to ischemia of the nerve.
Use of IPCDs caused direct injury to the CPN. During
inflation, the calf sleeve compresses the CPN at the fibular
head, where approximately 4cm of the nerve is covered only
by skin and superficial fascia and is susceptible to injury.18'19
Loss of protective tissue over the fibular head due to weight
loss also contributed to nerve injury.20"24
Pancreatic adenocarcinoma may contribute to the pro-
duction of compression neuropathies through dramatic
weight loss and production of humoral factors that affect
peripheral nerves. Sensorimotor neuropathies have been
associated with pancreatic adenocarcinomas.25 These par-
aneoplastic effects, along with weight loss, render the CPN
prone to compression injury.
In the second case, the etiology of compartment syn-
drome was multifactorial (ie, lithotomy position, prolonged
surgery, and IPCD use). Prolonged surgery in the lithotomy
position has infrequently been associated with the develop-
ment of compartment syndrome.9'10 A compartment syn-
drome occurs when the circulation and function of tissues
within a closed space are compromised by increased pres-
sure.26 Muscles and nerves enclosed in these compartments are
susceptible to injury by this condition. Acute compartment
syndrome caused by a malfunctioning pneumatic-
compression boot has been described.27
External envelopes, such as IPCDs, can hasten compart-
ment syndrome by restricting the volume of the leg com-
partment, thus increasing intracompartmental pressures.28
Direct local muscle pressure from the IPCDs can cause
muscle necrosis and loss of capillary integrity. In the pres-
ence of an intact vascular supply, massive edema results.29-
30 Edema formation in closed compartmental spaces leads to
increased compartmental pressures. A self-perpetuating
edema-ischemia cycle results in myonecrosis and nerve
injury in the compartment.
Compartment syndrome may occur during surgery in the
lithotomy position; additional use of IPCDs during surgery
increases the risk of compression injury. Experiments have
shown that 90% of the external pressure developed by
pneumatic garments is transmitted to the muscular com-
partments.31 The IPCD produces 40mmHg of pressure for 12
seconds every minute; significant necrosis of intracom-
use include acute
Arch Phys Med Rehabil Vol 73, May 1992
Compression site at
fibutar head (common
Superficial peroneal n.
Fig 1—Compression of the common peroneal nerve at the fibular
head (arrow) by an inflated pneumatic leg sleeve.
COMPLICATIONS OF PNEUMATIC COMPRESSION, Lachmann
Fig 2—Cross-section of the middle and distal thirds of the leg,
illustrating the four compartments and their respective nerves.
partmental muscle may be produced at a threshold of
30mmHg during eight hours.32 Therefore, use of IPCDs
during a prolonged surgical procedure in the lithotomy po-
sition predisposes patients to increased tissue pressures and
An acute compartment syndrome may occur in any one
of the four compartments of the lower leg (fig 2), with the
anterior compartment most commonly involved.29 The
CRN divides into the deep and superficial branches. The
deep peroneal nerve courses from the lateral compartment to
the anterior compartment. The superficial peroneal nerve
courses along the anterior intramuscular septum in the
lateral compartment. The deep posterior compartment
contains the tibial nerve. The sural nerve travels in the fascia
of the superficial posterior compartment. Elevated in-
tracompartmental pressures may produce ischemia and sen-
sory or motor deficits in the distribution of any of these
Methods other than conventional pneumatic compression
devices should be used for DVT prophylaxis in surgical
patients with cancer and weight loss; as in the first case. A
CPN palsy can be avoided by using antithromboplastic
agents such as LDH or dextran, or another physical
method. Use of LDH carries the risk of bleeding and hema-
toma formation, and dextran has been associated with con-
gestive heart failure, renal failure, and anaphylaxis.4-33 Both
methods carry significant risks for surgical patients. Physical
methods are preferred and may include continuous passive
motion (CPM) devices, range of motion (ROM) exercises for
the knee and ankle, modified pneumatic compressive
devices, surgical stockings, and electric stimulation of the calf.
Modification of IPCDs and SPCDs, ie, leaving the fibular
head exposed so as not to inflate over it, is the most viable
alternative (fig 3). These modified devices may become the
prophylaxis of choice in patients with weight loss and
cancer and in the general population, since the CPN cannot
be directly injured from compression. However, the effec-
tiveness of modified pneumatic compression devices for
DVT prophylaxis has yet to be proven.
Surgical or thromboembolism-deterrent stockings are
free of side effects and are effective for DVT prophylaxis.34
Arch Phys Med Rehabil Vol 73, May 1992
Electric stimulation of the calf has been shown to be less
effective. However, unaltered pneumatic compression de-
vices are superior to these two methods in preventing DVT
In the second case, acute compartment syndrome may
have been prevented by following certain precautions when
positioning the patient in the lithotomy position. The hips
should not be flexed more than 60° with the horizontal.
Forced adduction or abduction of the foot and stretching of
hip adductor muscles should be avoided. Generous soft
padding should be placed against bony prominences, espe-
cially around the knees and ankles, since the CPN, saphe-
nous nerve, and tibial nerve may also be injured in this
position. Hyperextension of the hips should be avoided.
Personnel in the operating room should avoid leaning objects
of any kind on the patient's extremities.35'36
The safe maximal time for patients in the lithotomy position
is unknown, but compartment syndrome has been reported
after 6 1/2 hours in this position.9-10 When IPCDs are used
for DVT prophylaxis, modification of surgical positioning is
a viable alternative. A leg suspension system may be used
during prolonged procedures in the lithotomy position. This
prevents unnecessary pressure on any portion of the lower
extremity. The legs may be placed on skis and abducted.
Avoidance of the lithotomy position altogether may be
recommended for prolonged surgery to avoid lower
If surgery is to be performed in the lithotomy position
using standard leg holders, other physical methods of DVT
prophylaxis may be considered. This include CPM devices,
surgical or thromboembolism-deterrent stockings, and
electric stimulation of the calf. Postoperative use of IPCDs
may be resumed, since this method has been proven superior
for DVT prophylaxis.'
Intermittent pneumatic compression devices are the pro-
phylaxis of choice for DVT prevention in patients undergo-
Deep peroneal n./
Superficial peroneal n./
Tibial n./deep post,
Fig 3—(upper) modified sequential pneumatic leg sleeve without
compression over the fibular head (arrow); (lower) modified inter-
mittent pneumatic leg sleeve, with uncovered fibular head (arrow).
COMPLICATIONS OF PNEUMATIC COMPRESSION, Lachmann
ing high-risk surgery, including neurosurgery, orthopedic
surgery, and thoracic, abdominal or pelvic surgery for malig-
nancy. However, physicians may wish to use other methods of
DVT prophylaxis in certain surgical patients. Patients with
malignancy and weight loss are at risk of CRN palsy with
IPCD use. Patients undergoing prolonged surgery in the
lithotomy position may develop compartment syndrome
with the use of pneumatic leg sleeves. In these cases,
alternative methods of DVT prophylaxis are necessary.
Physical methods such as modified pneumatic compression
and CPM devices, passive ROM exercises, surgical stock-
ings, and electric stimulation of the calf are viable alterna-
tives. Careful positioning of the patient during surgery may
avoid nerve compression and increased intracompartmen-tal
pressures. Alternative surgical positioning may be necessary.
Acknowledgment: Our thanks, go to Ms. Pauline Thomas, medical illus-
trator. Cornell University Medical College, for her illustrations.
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