Well-leg compartment syndrome after orthopedic surgery in the hemi-lithotomy position: a three-case series and literature review

Well-leg compartment syndrome (WLCS) is an acute compartment syndrome developing in an uninjured limb, classically associated with lithotomy or hemi-lithotomy positioning. We report three cases of WLCS following femoral fixation performed on a traction table with the contralateral limb positioned in hemi-lithotomy and review previously reported orthopedic and trauma-related cases. Diagnostic, treatment, and prevention recommendations are derived from the most recent available literature. Most reported orthopedic cases occur after femoral intramedullary nailing. Reported risk factors include prolonged continuous elevation (≥4 h), increased body mass-index, head-down tilt, hypovolemia, forced ankle dorsiflexion, calf-supported positioning, intraoperative hypotension, and increased external pressure. WLCS appears to be largely preventable. Diagnosis is primarily clinical, and fasciotomy should not be delayed. When indicated, two-incision, four-compartment decompression remains the recommended approach, whereas selective fasciotomy is discouraged.