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AAOS Now

Published 10/1/2010
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Sally T. Halderman

Early support shapes a career

Grant recipient credits OREF funding for motivating his interest in academic orthopaedics

Frederick A. (Rick) Matsen III, MD, says a series of 1970s grants from the Orthopaedic Research and Education Foundation (OREF) played a key role in shaping his career trajectory.

“I credit OREF with helping steer me toward academic medicine. OREF support gives young physicians a chance to hone skills essential in an academic career—identifying a knowledge gap, posing a research question properly, and gathering solid data that help resolve it,” Dr. Matsen said.

From neurosurgery to orthopaedics
An orthopaedic rotation wasn’t part of the medical school mix for Dr. Matsen at Baylor, University. He was drawn to neurosurgery and, following an internship at Johns Hopkins, he signed on as a clinical associate at the National Institute of Neurological Disorders and Stroke (NINDS). But the reality of the NINDS patient population proved daunting.

“Most of our patients had intractable pain, intractable movement disorders, intractable epilepsy, high-grade brain tumors, and severe vascular malformations,” Dr. Matsen recalled. “It was difficult to make positive changes. So I polled the anesthesiologists on which surgical specialists seemed happiest. Their overwhelming consensus was that orthopaedists had the highest career satisfaction.”

Armed with that information, Dr. Matsen pursued an orthopaedic residency, landing a berth at the University of Washington.

A creative technology transfer
Dr. Matsen’s professional shift didn’t change his passion for diagnostic problem solving. In fact, his 1976 OREF project featured a creative bit of technology transferred from his stint at NINDS. Dr. Matsen and his team adapted monitoring technology commonly used to measure intracranial pressure to explore intracompartmental pressure measurement in the diagnosis of the compartment syndrome.

Compartment syndrome, a potentially devastating loss of circulation to muscles and nerves contained within a fascial compartment, most commonly affects the lower leg. In the uninjured limb, the compartments help the muscles to pump fluid back to the heart. But when the limb is injured, the muscles swell and the pressure builds up within the unyielding fascial envelope, compromising the blood flow to the muscles and nerves within the compartment (Fig. 1).

Compartment syndrome requires timely diagnosis and immediate surgical decompression to avoid irreversible tissue damage. The difficulty is in identifying the patients who need emergency decompression without subjecting those who don’t to unnecessary surgery.

Dr. Matsen theorized that benchmarking a patient’s compartment pressure in the healthy limb and continuously monitoring pressure in the injured limb might help identify a level at which decompression became urgent. The study monitored intracompartmental pressure by measuring the force needed to slowly and steadily infuse a small amount of sterile saline into the muscle.

That 1976 project built on two earlier OREF grants that Dr. Matsen had received to study compartment syndrome in animal models. Those projects helped explode conventional wisdom by demonstrating that cooling doesn’t reduce—and may even increase—swelling, and that raising a limb above the level of the heart actually increases its susceptibility to damage from poor circulation.

The gold standard of care
Dr. Matsen’s work documented that intracompartmental pressure can be monitored, accurately measured, and can help confirm the need for surgical decompression. Pressure measurement can be especially useful in patients who are unable to report their symptoms reliably, including young children and those who are unconscious or impaired.

But Dr. Matsen and his colleagues also concluded that no bright-line critical pressure indicates the threshold for decompression. Patients vary in their tolerance for increased pressure, and the impact depends on whether pressure spikes acutely or remains more modestly elevated over a longer time. Furthermore, pressure measurements may be erroneous. Thus, sound clinical judgment is the gold standard for determining the need for surgical decompression. The most sensitive diagnostic approach remains careful sequential evaluation for the classic constellation of symptoms—disproportionate pain, weakness, loss of feeling, pain on passive stretching, and tension in the fascial boundaries of the compartment.

“Our key result confirmed the value of skilled clinical assessment,” noted Dr. Matsen. “We never set out to introduce a high-tech gizmo that would become the standard of care. That’s important because the day-to-day traumas that can lead to compartment syndrome—skiing accidents, soccer mishaps—don’t always present at major medical centers. But a good orthopaedist has skilled eyes, ears, and fingers. You don’t fall short of the standard of care by failing to monitor intracompartmental pressure. You fall short if you fail to consider the diagnosis when the clinical picture suggests it.”

Sally T. Halderman is a contributing writer for OREF. She can be reached at communications@oref.org