Bilateral Lower Limb Acute Compartment Syndrome Related to Drug Abuse: Two Case Reports

Acute compartment syndrome (ACS) is typically observed in a unilateral limb, whereas bilateral lower limb ACS is rare, and few cases are reported. We report 2 cases of bilateral lower limb ACS induced by drug abuse and prolonged Japanese traditional Seiza position. Case 1 involved a 34-year-old man who developed bilateral lower limb ACS after prolonged Seiza sitting while under the influence of amphetamines. He underwent bilateral fasciotomy but required below-knee amputation due to infection. Case 2 involved a 31-year-old man found unconscious in the Seiza position for 11 hours after a suspected benzodiazepine overdose. Despite fasciotomy, he required staged amputations due to poor wound healing. We believe that prolonged Seiza, a traditional Japanese sitting posture, is a key factor in both cases, leading to severe bilateral ACS. We also point out that bilateral ACS should raise clinical suspicion for drug or alcohol use, as substance-induced unconsciousness is a major contributing factor. These cases tend to involve prolonged compression, increasing the risk of severe tissue damage, delayed diagnosis, and even amputation. Clinicians should consider ACS in cases of substance abuse-related immobilization to enable early diagnosis and treatment for better outcomes.