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Shankar DS, Vasavada KD, Gillinov LA, Kirschner N, Mojica ES, Blaeser AM, Borowski LE, Jazrawi LM, Cardone DA. Female patients have greater improvement in pain symptoms and physical activity after fasciotomy for treatment of chronic exertional compartment syndrome of the lower leg. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38690978 DOI: 10.1002/ksa.12223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/28/2024] [Accepted: 04/09/2024] [Indexed: 05/03/2024]
Abstract
PURPOSE The purpose of this study was to identify sex differences in postoperative outcomes and return-to-sport rates after fasciotomy for treatment of chronic exertional compartment syndrome (CECS) of the lower leg. It was hypothesised that male CECS patients would have a higher rate of return to sport than female CECS patients. METHODS A retrospective cohort study was conducted involving patients who underwent primary fasciotomy of one to four leg compartments for treatment of CECS at a single centre from 2010 to 2020. Each affected leg was treated as a separate subject. Postoperative outcomes included CECS pain frequency and severity, return to sport and Tegner activity level. Multivariable regression was used to determine if sex was an independent predictor of outcomes after adjusting for demographic and clinical covariates. p < 0.05 were considered significant. RESULTS Eighty-one legs (44 M, 37 F) of 47 unique patients (34 of whom had bilateral symptoms) were included with a mean follow-up time of 51.5 ± 31.4 months. Male subjects were older (p < 0.001) and had higher body mass index (p < 0.001) compared to female subjects. Most subjects (84.0%) underwent two- or four-compartment fasciotomies. Female sex was found to be predictive of lower overall postoperative pain severity (p = 0.007), higher odds of return to sport (p = 0.04) and higher postoperative Tegner score (p = 0.005). However, female sex was not predictive of postoperative pain frequency, odds of reoperation or odds of return to sport to at least the presymptomatic level (all p < 0.05). CONCLUSION Female sex is independently predictive of reduced overall pain severity, higher odds of return to sport and higher postoperative improvement in Tegner score following fasciotomy for treatment of lower-limb CECS. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Dhruv S Shankar
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Kinjal D Vasavada
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Lauren A Gillinov
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Noah Kirschner
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Edward S Mojica
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Anna M Blaeser
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Lauren E Borowski
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Dennis A Cardone
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
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2
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Gawel RJ, Kemler BR, Coladonato C, Freedman KB. Rehabilitation and return to activity criteria after operative management of chronic exertional compartment syndrome of the leg: a systematic review. PHYSICIAN SPORTSMED 2024; 52:125-133. [PMID: 37191583 DOI: 10.1080/00913847.2023.2214192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/11/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVES Endurance athletes with chronic exertional compartment syndrome (CECS) frequently require fasciotomy to return to activity, but there are no existing comprehensive evidence-based rehabilitation guidelines. We aimed to summarize rehabilitation protocols and return to activity criteria after CECS surgery. METHODS Through a systematic literature review, we identified 27 articles that explicitly defined physician-imposed restrictions or guidelines for patients to resume athletic activities following CECS surgery. RESULTS Common rehabilitation parameters included running restrictions (51.9%), postoperative leg compression (48.1%), immediate postoperative ambulation (44.4%), and early range of motion exercises (37.0%). Most studies (70.4%) reported return to activity timelines, but few (11.1%) utilized subjective criteria for guiding return to activity. No studies utilized objective functional criteria. CONCLUSIONS Rehabilitation and return to activity guidelines after CECS surgery remain poorly defined, and further investigation is needed to develop such guidelines that will enable endurance athletes to safely return to activities and minimize recurrence.
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Affiliation(s)
- Richard J Gawel
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Bryson R Kemler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Carlo Coladonato
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Kevin B Freedman
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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3
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Rothman R, Berke C, Jivanelli B, Casey E, Cheng J. Sex and gender differences in lower limb chronic exertional compartment syndrome: a systematic review. PHYSICIAN SPORTSMED 2024; 52:1-11. [PMID: 36698053 DOI: 10.1080/00913847.2023.2173489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 01/23/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Chronic exertional compartment syndrome (CECS) is a cause of exertional leg pain and has been reported in varying frequencies in males and females. Currently, it is unclear whether there are significant sex and gender differences in lower-limb CECS. Delineating sex and gender differences is vital in determining the causes of CECS and best treatments. This systematic review aimed to determine the sex/gender distribution of CECS and to assess for sex and gender differences in CECS diagnosis and outcomes. METHODS PubMed (Medline), Cochrane Library, and EMBASE databases were searched for studies that were published from January 2000-March 2022 and reported lower-limb CECS data in males and/or females. Data on CECS diagnosis (intracompartmental pressures) and outcomes (e.g. post-surgical return-to-sport, need for re-operation) with sex/gender breakdowns were extracted. The sex/gender distribution of CECS and prevalence of CECS by sex/gender were calculated. RESULTS Forty-one studies were included in the systematic review; there were 27 retrospective reviews, 8 prospective studies, and 6 retrospective studies with prospective follow-ups. Thirty studies involved surgical populations. Sex/gender distribution of CECS was calculated using data from 24 studies; 51% were female. Prevalence of CECS was available in five studies and ranged widely for males (54%-73%) and females (43%-65%). Intracompartmental pressure data varied by sex/gender. Male athletes were more likely than female athletes to return to sport following surgery for CECS, but variations in all other post-surgical outcomes were observed between sexes and genders in the general population. CONCLUSION Females represented 51% of the patients who were diagnosed with CECS among studies. Most CECS diagnosis and outcomes data varied by sex/gender, except for post-surgical outcomes data in athletes, which demonstrated that males had higher rates of return to sport than females. Future studies are needed to examine factors contributing to sex and gender differences in CECS diagnosis and outcomes.
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Affiliation(s)
- Rachel Rothman
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | - Chandler Berke
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Bridget Jivanelli
- Kim Barrett Memorial Library, Hospital for Special Surgery, New York, NY, USA
| | - Ellen Casey
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | - Jennifer Cheng
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
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4
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Return to Sport Rates and Subjective Outcomes Are Similar After Open or Endoscopically Assisted Compartment Release for Chronic Lower-Extremity Exertional Compartment Syndrome. Arthrosc Sports Med Rehabil 2022; 4:e1953-e1959. [PMID: 36579030 PMCID: PMC9791877 DOI: 10.1016/j.asmr.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 08/14/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose To retrospectively compare return to sport rates and subjective outcomes of patients who underwent open or endoscopic compartment release for the surgical management of chronic exertional compartment syndrome. Methods This was a retrospective review of patients who underwent lower-extremity fasciotomy for chronic exertional compartment syndrome from June 2012 to June 2020. Eligibility included patients 15 to 45 years of age who identified as an athlete and had at least 6 months of follow-up. Fasciotomies for trauma or infection were excluded. One surgeon exclusively performed each type of surgery. Postoperative outcome measures included the Lower Extremity Functional Scale, the Marx Activity Scale, and a return to play survey. Results In total, 24 patients (13 endoscopically assisted fasciotomies, 11 open fasciotomies) had a mean follow-up of 3.8 ± 2.1 years; 19 patients returned to their sporting activity. No significant difference existed between return to play rates (P = .630) or return to play times (P = .351). There were no significant differences between the groups in the Lower Extremity Functional Scale score, Marx Activity Scale score, Single Assessment Numeric Evaluation score, pain score at rest, and during sporting activity. Overall satisfaction rates were found to be significantly greater in the endoscopically assisted fasciotomy group (P = .041). Conclusions In this small sample of heterogenous groups of patients, we found no significant differences in return to sport rates or subjective results after surgery. Patients experienced a high subjective recurrence rate. The endoscopically assisted fasciotomy group reported greater subjective patient satisfaction compared with the open fasciotomy group. Level of Evidence Level III, comparative study, retrospective.
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5
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Symeonidis PD, Stavrou P. Single incision, minimally invasive fasciotomy of the anterior and lateral leg compartments with decompression of the superficial peroneal nerve. Foot Ankle Surg 2022; 28:30-36. [PMID: 33632658 DOI: 10.1016/j.fas.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/28/2020] [Accepted: 01/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a considerable overlap of symptoms between chronic exertional compartment syndrome (CECS) of the anterior and lateral compartments of the lower leg and entrapment neuropathy of the superficial peroneal nerve (SPN). We describe a minimally invasive, single incision surgical technique for release of both the compartments and the SPN in the same setting. The operative technique involves a minimal anterolateral approach at the level where the SPN pierces the subcutaneous fascia. METHODS Nineteen patients were operated with the method and 24 anterolateral compartments (5 cases with bilateral CECS) were released. Anterior and lateral, proximal and distal fasciotomies were performed sequentially with the use of a specific instrument designed for carpal tunnel release (KnifeLight®, Stryker). This is a modification of a fasciotome with an intergrated light source which allows for transillumination of the subcutaneous tissues. The SPN and its main branches with their anatomical variations were explored and decompressed at the same setting. RESULTS Patients who met the inclusion criteria were reviewed at one year postoperatively with a Numeric Analog Pain Scale (NAS) and the Linkert satisfaction scale. There were 5 men and 10 women, aged 35.7 (21-60) years. The NAS scores improved by a mean 6 points (p<0.0001) postoperatively and 86.6% (13/15) of the patients were either satisfied or very satisfied with the operation. There were no intraoperative complications. There were two patients with SPN neuropathy symptoms postoperatively, one of whom required revision surgery. One patient had recurrence of less intense symptoms in the first postoperative year with no need for reoperation. CONCLUSIONS The simultaneous release of the anterolateral compartment of the leg and decompression of the SPN with the described technique was safe and effective. It combined the advantages of a single, minimally invasive approach with the subcutaneous transillumination, and had a high patient satisfaction and a low recurrence rate. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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Affiliation(s)
| | - Peter Stavrou
- Private Practice, 215 Hutt Street, Adelaide, SA, Australia
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6
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de Bruijn JA, van Zantvoort APM, Hundscheid HPH, Hoogeveen AR, van Eerten P, Teijink JAW, Scheltinga MR. Comparison of 2 Fasciotomes for Treatment of Patients With Chronic Exertional Compartment Syndrome of the Anterior Leg. Orthop J Sports Med 2021; 9:23259671211051358. [PMID: 34888390 PMCID: PMC8649103 DOI: 10.1177/23259671211051358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/26/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Chronic exertional compartment syndrome (CECS) of the anterior leg compartment (ant-CECS) is frequently treated with a minimally invasive fasciotomy. Several operative techniques and operative devices exist, but none have been compared in a systematic and randomized manner. Purpose: To compare efficacy, safety, and postoperative pain of a novel operative device (FascioMax fasciotome) with a widely accepted device created by Due and Nordstrand (Due fasciotome) during a minimally invasive fasciotomy for ant-CECS. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Patients with bilateral isolated ant-CECS between October 2013 and April 2018 underwent a minimally invasive fasciotomy using the FascioMax fasciotome in 1 leg and the Due fasciotome in the contralateral leg in a single operative session. Symptom reduction at 3 to 6 months and >1 year, postoperative pain within the first 2 weeks, peri- and postoperative complications, and ability to regain sports were assessed using diaries, physical examination, and timed questionnaires. Results: Included in the study were 50 patients (66% female; median age, 22 years [range, 18-65 years]). No differences between the devices were found in terms of perioperative complications (both had none), minor postoperative complications including hematoma and superficial wound infection (overall complication rate: FascioMax, 8% vs Due, 6%), or reduction of CECS-associated symptoms at rest and during exercise. At long-term follow-up (>1 year), 82% of the patients were able to regain their desired type of sport, and 67% (33/49) were able to exercise at a level that was comparable with or higher than before their CECS-associated symptoms started. Conclusion: Both the FascioMax and the Due performed similarly in terms of efficacy, safety, and levels of pain within the first 2 weeks postoperatively. Registration: NL4274; Netherlands Trial Register.
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Affiliation(s)
- Johan A de Bruijn
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
| | | | | | - Adwin R Hoogeveen
- Department of Sports Medicine, Máxima Medical Center, Veldhoven, the Netherlands
| | - Percy van Eerten
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
| | - Joep A W Teijink
- Department of Surgery, Catherina Hospital, Eindhoven, the Netherlands.,Department of Epidemiology, CAPHRI Research School, Maastricht University, Maastricht, the Netherlands
| | - Marc R Scheltinga
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
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7
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MR diagnosed chronic exertional compartment syndrome successfully treated by endoscopically-assisted fasciotomy. Radiol Case Rep 2021; 16:1378-1383. [PMID: 33897933 PMCID: PMC8055527 DOI: 10.1016/j.radcr.2021.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/06/2021] [Accepted: 03/08/2021] [Indexed: 11/24/2022] Open
Abstract
Chronic exertional compartment syndrome is a subset of compartment syndrome that most frequently affects the lower extremities, often in athletic persons. It is most often characterized by calf pain shortly after the initiation of exercise and resolution of the pain soon after rest. While the pathophysiology is not completely understood, it is believed that compartment a lack of fascial compliance and increased compartment fluid leads to increased pressure, ultimately leading to a reversible ischemic state. Chronic exertional compartment syndrome was once considered a diagnosis of exclusion; however, needle manometry is an invasive way to measure intracompartmental pressure. Similarly, fasciotomy is the treatment of choice but is not without complications. We describe a case of chronic exertional compartment syndrome diagnosed by two-stage MRI and successfully treated by endoscopically-assisted fasciotomy.
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8
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Lohrer H, Klein J, Nauck T, Schönberg T. Microdialysis for chronic exertional compartment syndrome: a pilot study. BMC Sports Sci Med Rehabil 2021; 13:21. [PMID: 33673874 PMCID: PMC7934517 DOI: 10.1186/s13102-021-00245-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 02/17/2021] [Indexed: 11/30/2022]
Abstract
Background Diagnosing chronic exertional compartment syndrome (CECS) is still a challenge. An increase in intramuscular pressure during and following exercise is accepted as the diagnostic standard. However, neither the methods used nor the interpretation of the obtained results are sufficiently standardized. Methods In the present pilot study, the metabolic state of CECS patients was investigated using microdialysis. We hypothesized that there was no difference in intramuscular concentrations of glucose, lactate, glutamate, and glycerol before and after exercise (H10) or between patients suffering from CECS and healthy control subjects (H20). This study was designed as an explorative case-control study (level of evidence III). Twelve patients suffering from CECS of the lower leg and six matched asymptomatic control subjects underwent microdialysis in the anterior (n = 7) or deep posterior compartment (n = 11) of the leg. Following ultrasound-guided insertion of the microdialysis catheters, 10-minute fractions of the dialysates were collected first during rest and then following fatigue- or pain-induced discontinuation of exercise. Dialysates were analysed for lactate, glucose, glutamate, and glycerol concentrations 6 × 10 min before and 6 × 10 min after exercise. Results Exercise-induced increases in lactate, glutamate, and glycerol concentrations were detected in both CECS patients and control subjects (all p < 0.001). No differences between CECS patients and control subjects were found by comparing the intramuscular glucose, lactate, glutamate, and glycerol concentrations at rest and following exercise (all p > 0.05). Conclusions We found exercise-induced increases in the lactate, glutamate, and glycerol levels in skeletal muscle. However, the metabolic changes did not differentiate CECS patients from healthy subjects. Trial registration The registration trial number is DRKS00021589 on DRKS. ‘Retrospectively registered’. Date of registration: April 4, 2020.
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Affiliation(s)
- Heinz Lohrer
- ESN - European SportsCare Network, Borsigstrasse 2, 65205, Wiesbaden, Germany. .,Department of Sport and Sport Science, University of Freiburg, Freiburg, Germany.
| | - Jochen Klein
- Institute for Pharmacology and Clinical Pharmacy, Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Tanja Nauck
- ESN - European SportsCare Network, Borsigstrasse 2, 65205, Wiesbaden, Germany
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9
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Broderick JM, Synnott KA, Mulhall KJ. Minimally invasive fasciotomy using a lighted retractor in the treatment of chronic exertional compartment syndrome. J Orthop Surg (Hong Kong) 2020; 28:2309499019892800. [PMID: 31876241 DOI: 10.1177/2309499019892800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Chronic exertional compartment syndrome can be a debilitating cause of lower leg pain that typically affects young, healthy people during a variety of aerobic activities. Conservative management has produced a poor success rate and numerous techniques for surgical decompression have been described. Many of these, however, involve blind fascial dissection which increases the risk of direct nerve injury or insufficient fascial release. We describe a novel technique of mini-open fasciotomy using a lighted retractor which enables direct visualization of the fascia and the superficial peroneal nerve using a single, small incision. By the use of a 3- to 4-cm laterally based incision, a lighted retractor with fiber-optic illumination is introduced into the subcutaneous plane and advanced distally and proximally. The retractor gently elevates the subcutaneous tissues while focusing light directly into the surgical area and a long Metzenbaum scissors is then used to release the fascia under direct vision. Fasciotomy using this technique avoids the risks of blind fascial release and is a straightforward, safe, and effective method for compartment decompression.
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Affiliation(s)
- James M Broderick
- Department of Trauma and Orthopaedics, The Mater Misericordiae University Hospital, Dublin, Ireland
| | - Keith A Synnott
- Department of Trauma and Orthopaedics, The Mater Misericordiae University Hospital, Dublin, Ireland
- The Sports Surgery Clinic, Dublin, Ireland
| | - Kevin J Mulhall
- Department of Trauma and Orthopaedics, The Mater Misericordiae University Hospital, Dublin, Ireland
- The Sports Surgery Clinic, Dublin, Ireland
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10
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Grechenig P, Valsamis EM, Müller T, Gänsslen A, Hohenberger G. Minimally Invasive Lower Leg Fasciotomy for Chronic Exertional Compartment Syndrome-How Safe Is It? A Cadaveric Study. Orthop J Sports Med 2020; 8:2325967120956924. [PMID: 33062761 PMCID: PMC7536378 DOI: 10.1177/2325967120956924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/27/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Chronic exertional compartment syndrome (CECS) is a recognized
clinical diagnosis in running athletes and military recruits.
Minimally invasive fasciotomy techniques have become
increasingly popular, but with varied results and small case
numbers. Although decompression of the anterior and peroneal
compartments has demonstrated a low rate of iatrogenic injury,
little is known about the safety of decompressing the deep
posterior compartment. Purpose: To evaluate the risk of iatrogenic injury when using minimally
invasive techniques to decompress the anterior, peroneal, and
deep posterior compartments of the lower leg. Study Design: Descriptive laboratory study. Methods: A total of 60 lower extremities from 30 adult cadavers were subject
to fasciotomy of the anterior, peroneal, and deep posterior
compartments using a minimally invasive technique. Two common
variations in surgical technique were employed to decompress
each compartment. Anatomical dissection was subsequently carried
out to identify incomplete division of the fascia, muscle
injury, neurovascular injury, and the anatomical relationship of
key neurovascular structures to the incisions. Results: Release of the anterior and peroneal compartments was successful in
all but 2 specimens. There was no injury to the superficial
peroneal nerve or any vessel in any specimen. A transverse
incision crossing the anterior intermuscular septum resulted in
muscle injury in 20% of the cases. Release of the deep posterior
compartment was successful in all but 1 specimen when a
longitudinal skin incision was used, without injury to
neurovascular structures. Compared with a longitudinal incision,
a transverse skin incision resulted in fewer complete releases
of the deep posterior compartment and a significantly higher
rate of injury to the saphenous nerve (16.7%; P
= .052) and long saphenous vein (23.3%; P =
.011). Conclusion: Minimally invasive fasciotomy of the anterior, peroneal, and deep
posterior compartments using longitudinal incisions had a low
rate of iatrogenic injury in a cadaveric model. Complete
compartment release was achieved in 97% to 100% of specimens
when employing this technique. Clinical Relevance: Minimally invasive fasciotomy techniques for CECS have become
increasingly popular with purported low recurrence rates,
improved cosmesis, and faster return to sport. It is important
to determine whether this technique is safe, particularly given
the variable rates of neurovascular injury reported in the
literature.
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Affiliation(s)
- Peter Grechenig
- Division of Macroscopic and Clinical Anatomy, Medical University of Graz, Graz, Austria
| | | | - Tom Müller
- Division of Macroscopic and Clinical Anatomy, Medical University of Graz, Graz, Austria
| | - Axel Gänsslen
- Trauma Department, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Gloria Hohenberger
- Department of Orthopaedics and Trauma Surgery, Medical University of Graz, Graz, Austria
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11
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Vogels S, Ritchie ED, van Dongen TTCF, Scheltinga MRM, Zimmermann WO, Hoencamp R. Systematic review of outcome parameters following treatment of chronic exertional compartment syndrome in the lower leg. Scand J Med Sci Sports 2020; 30:1827-1845. [PMID: 32526086 PMCID: PMC7540008 DOI: 10.1111/sms.13747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/25/2020] [Accepted: 06/03/2020] [Indexed: 12/13/2022]
Abstract
Objective Surgery is the gold standard in the management of chronic exertional compartment syndrome (CECS) of the lower extremity, although recent studies also reported success following gait retraining. Outcome parameters are diverse, and reporting is not standardized. The aim of this systematic review was to analyze the current evidence regarding treatment outcome of CECS in the lower leg. Material and Methods A literature search and systematic analysis were performed according to the PRISMA criteria. Studies reporting on outcome following treatment of lower leg CECS were included. Results A total of 68 reports fulfilled study criteria (n =; 3783; age range 12‐70 year; 7:4 male‐to‐female ratio). Conservative interventions such as gait retraining (n =; 2) and botulinum injection (n =; 1) decreased ICP (x- =; 68 mm Hg tox- =; 32 mm Hg) and resulted in a 47% (±42%) rate of satisfaction and a 50% (±45%) rate of return to physical activity. Fasciotomy significantly decreased ICP (x- =; 76 mm Hg to x- =; 24 mm Hg) and was associated with an 85% (±13%) rate of satisfaction and an 80% (±17%) rate of return to activity. Return to activity was significantly more often achieved (P < .01) in surgically treated patients, except in one study favoring gait retraining in army personnel. Conclusion Surgical treatment of CECS in the lower leg results in higher rates of satisfaction and return to activity, compared to conservative treatment. However, the number of studies is limited and the level of evidence is low. Randomized controlled trials with multiple treatment arms and standardized outcome parameters are needed.
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Affiliation(s)
- Sanne Vogels
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewan D Ritchie
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Thijs T C F van Dongen
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
| | | | - Wes O Zimmermann
- Department of Sports Medicine, Royal Netherlands Army, Utrecht, The Netherlands.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Rigo Hoencamp
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands.,Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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12
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Thein R, Tilbor I, Rom E, Herman A, Haviv B, Burstein G, Tenenbaum S. Return to sports after chronic anterior exertional compartment syndrome of the leg: Conservative treatment versus surgery. J Orthop Surg (Hong Kong) 2020; 27:2309499019835651. [PMID: 30909799 DOI: 10.1177/2309499019835651] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM To evaluate whether surgical treatment for anterior chronic exertional compartment syndrome (CECS) of the lower leg will lead to full athletic activity recovery compared to conservative treatment. METHODS Patients diagnosed with anterior CECS of the leg were offered surgical treatment, as surgery considered today to be the mainstay of treatment. Patients unwilling to be treated surgically were treated conservatively. They were followed up, assessing both groups for pain, functional status, and the Tegner sports activity score with comparisons at diagnosis and following treatment. RESULTS Forty-three patients were treated for CECS (31; 72.1% with surgery and 12; 27.9% conservatively) with a mean follow-up of 28.15 (4.16-54.09) months. Reported pain improved at follow-up by 1.59 (0-6) points and by 4.27 ± (0-10) points in the conservatively and the surgically treated patient groups, respectively ( p = 0.014) with a mean change in the Tegner score of 0.09 (-5 to 5) and 3.22 (-4 to 7), respectively ( p = 0.009). Three patients in the conservatively treated group (25% of 12) and 24 patients in the operated group (77.4% of 31) reported full resumption of their pre-diagnosis activity level ( p = 0.001). CONCLUSION This study supports surgery as the treatment of choice for anterior CECS of the leg with differential benefit for fasciotomy in terms of pain and return to pre-diagnosis athletic activity.
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Affiliation(s)
- Ran Thein
- 1 Department of Orthopedic Surgery, Sheba Medical Center, Tel HaShomer, Tel Aviv University, Tel Aviv, Israel
- 2 Department of Orthopedic, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Tilbor
- 1 Department of Orthopedic Surgery, Sheba Medical Center, Tel HaShomer, Tel Aviv University, Tel Aviv, Israel
- 2 Department of Orthopedic, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Rom
- 1 Department of Orthopedic Surgery, Sheba Medical Center, Tel HaShomer, Tel Aviv University, Tel Aviv, Israel
- 2 Department of Orthopedic, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Herman
- 1 Department of Orthopedic Surgery, Sheba Medical Center, Tel HaShomer, Tel Aviv University, Tel Aviv, Israel
- 2 Department of Orthopedic, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barak Haviv
- 2 Department of Orthopedic, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- 3 Arthroscopy and Sports Injuries Unit, Hasharon Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Gideon Burstein
- 1 Department of Orthopedic Surgery, Sheba Medical Center, Tel HaShomer, Tel Aviv University, Tel Aviv, Israel
- 2 Department of Orthopedic, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shay Tenenbaum
- 1 Department of Orthopedic Surgery, Sheba Medical Center, Tel HaShomer, Tel Aviv University, Tel Aviv, Israel
- 2 Department of Orthopedic, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Winkes M, van Eerten P, Scheltinga M. Deep posterior chronic exertional compartment syndrome as a cause of leg pain. Unfallchirurg 2020; 123:3-7. [PMID: 31098648 DOI: 10.1007/s00113-019-0665-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A small proportion of patients with exertional leg pain (ELP) have deep posterior chronic exertional compartment syndrome (dp-CECS). These individuals report pain, tightness and cramps deep in the calf muscles that are elicited by exercise, but may also be present during rest to a lesser extent. Physical examination often reveals painful palpation of the flexor muscles in the area immediately dorsomedial to the tibial bone. Diagnosis is confirmed by intracompartmental pressure testing. Various entities may mimic or coincide with dp-CECS, including medial tibial stress syndrome (MTSS) and popliteal artery entrapment syndrome (PAES). Fasciotomy of multiple flexor muscles is the only treatment that achieves a beneficial outcome. The aim of this overview is to discuss the diagnosis and management of dp-CECS.
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Affiliation(s)
- Michiel Winkes
- Máxima Medical Center, De Run 4600, P.O. Box 7777, 5500 MB, Veldhoven, The Netherlands
| | - Percy van Eerten
- Máxima Medical Center, De Run 4600, P.O. Box 7777, 5500 MB, Veldhoven, The Netherlands
| | - Marc Scheltinga
- Máxima Medical Center, De Run 4600, P.O. Box 7777, 5500 MB, Veldhoven, The Netherlands.
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[Deep posterior chronic exertional compartment syndrome as a cause of leg pain-German version]. Unfallchirurg 2019; 122:834-839. [PMID: 31690985 DOI: 10.1007/s00113-019-0664-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A small proportion of patients with exertional leg pain (ELP) have deep posterior chronic exertional compartment syndrome (dp-CECS). These individuals report pain, tightness and cramps deep in the calf muscles that are elicited by exercise, but may also be present during rest to a lesser extent. Physical examination often reveals painful palpation of the flexor muscles in the area immediately dorsomedial to the tibial bone. Diagnosis is confirmed by intracompartmental pressure testing. Various entities may mimic or coincide with dp-CECS, including medial tibial stress syndrome (MTSS) and popliteal artery entrapment syndrome (PAES). Fasciotomy of multiple flexor muscles is the only treatment that achieves a beneficial outcome. The aim of this overview is to discuss the diagnosis and management of dp-CECS.
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15
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Buerba RA, Fretes NF, Devana SK, Beck JJ. Chronic exertional compartment syndrome: current management strategies. Open Access J Sports Med 2019; 10:71-79. [PMID: 31213933 PMCID: PMC6537460 DOI: 10.2147/oajsm.s168368] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/23/2019] [Indexed: 11/23/2022] Open
Abstract
Chronic exertional compartment syndrome (CECS) is an underdiagnosed condition that causes lower and upper extremity pain in certain at-risk populations. Lower-extremity CECS is most often observed in running athletes and marching military members. Upper-extremity CECS is most commonly seen in rowers and professional motorcyclists. Although early outcome research on CECS has been based mostly on adult male patients, there has been an increase in the number of studies in pediatric and adolescent patient populations, particularly in females. Evaluation of CECS must include a thorough history and physical exam to rule out other causes of exertional leg pain, but differential diagnosis must remain high on the list. Needle manometry can be used to confirm diagnosis of CECS by measuring intracompartmental pressure. Operative treatment of CECS with fasciotomy has been shown to be effective in resolution of CECS, and new surgical techniques are being developed. In the pediatric population, endoscopy-assisted compartment release has provided high success rates with low complication rates. Nonoperative management of CECS is more commonly described in the literature, and consists of cessation of activities, altering foot-strike pattern, physical therapy, taping, and injections of botulinum toxin A. Nonetheless, larger samples and a more diverse population are needed to better understand the outcomes of nonoperative management. There have been fewer studies on upper-extremity CECS, given its rarity. Success has been found in the treatment of upper-extremity CECS with open fasciotomy, but more studies are needed to understand the efficacy of minimally invasive techniques in the upper extremity. Further research also needs to be done to understand why a large portion (approximately 20%) of the patient population does not experience full resolution of symptoms after fasciotomy.
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Affiliation(s)
- Rafael A Buerba
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nickolas F Fretes
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sai K Devana
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jennifer J Beck
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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de Bruijn JA, van Zantvoort APM, Hundscheid HPH, Hoogeveen AR, Teijink JAW, Scheltinga MR. Superficial Peroneal Nerve Injury Risk During a Semiblind Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg: An Anatomical and Clinical Study. Foot Ankle Int 2019; 40:343-351. [PMID: 30466306 DOI: 10.1177/1071100718811632] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Up to 8% of patients who underwent a fasciotomy for leg anterior chronic exertional compartment syndrome (ant-CECS) report sensory deficits suggestive of iatrogenic superficial peroneal nerve (SPN) injury. In the current study we aimed to thoroughly assess the risk of SPN injury during a semiblind fasciotomy of the anterior compartment using 2 separate approaches. METHODS: A modified semiblind fasciotomy of the anterior compartment was performed via a longitudinal 2-cm skin incision 2 cm lateral of the anterior tibial crest halfway along the line fibular head-lateral malleolus both in cadaver legs and in patients with ant-CECS. In the cadaver legs, the skin was removed after the procedure and possible SPN injuries and spatial relationships between the SPN and the opened fascia were studied. Between January 2013 and December 2016, 64 ant-CECS patients who underwent a fasciotomy of the anterior compartment were prospectively followed. Iatrogenic SPN injuries were assessed using questionnaires and physical examinations. RESULTS: Macroscopic SPN nerve injury was not observed in any of the 9 cadaver legs. In 8 specimens, the SPN was located at least 5 mm posterolateral to the opened fascia. In 1 specimen, an undamaged SPN branch crossed the operative field in a ventral plane. De novo sensory deficits suggestive for iatrogenic SPN injury were not observed in any of the 64 patients (120 legs; 36 females; median age, 22 years) who underwent a fasciotomy of the anterior compartment. CONCLUSION: The proposed semiblind fasciotomy for treatment of ant-CECS was not associated with SPN injury in either the cadaveric study or our clinical series. LEVEL OF EVIDENCE: Level IV, case series.
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Affiliation(s)
- Johan A de Bruijn
- 1 Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
| | | | | | - Adwin R Hoogeveen
- 2 Department of Sports Medicine, Máxima Medical Center, Veldhoven, the Netherlands
| | - Joep A W Teijink
- 3 Department of Surgery, Catherina Hospital, Eindhoven, the Netherlands.,4 Department of Epidemiology, CAPHRI Research School, Maastricht University, Maastricht, the Netherlands
| | - Marc R Scheltinga
- 1 Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
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Lohrer H, Malliaropoulos N, Korakakis V, Padhiar N. Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies. PHYSICIAN SPORTSMED 2019; 47:47-59. [PMID: 30345867 DOI: 10.1080/00913847.2018.1537861] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'. We aimed to review clinical entities that come under the umbrella term 'Exercise-induced leg pain' (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.
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Affiliation(s)
- Heinz Lohrer
- a European SportsCare Network (ESN) - Zentrum für Sportorthopädie , Wiesbaden-Nordenstadt , Germany
| | | | - Vasileios Korakakis
- c Department of Rehabilitation , Aspetar, Orthopaedic and Sports Medicine Hospital , Doha , Qatar
| | - Nat Padhiar
- d William Harvey Research Institute, Centre for Sports & Exercise Medicine , Queen Mary University of London , London , UK
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Dai AZ, Zacchilli M, Jejurikar N, Pham H, Jazrawi L. Open 4-Compartment Fasciotomy for Chronic Exertional Compartment Syndrome of the Leg. Arthrosc Tech 2017; 6:e2191-e2201. [PMID: 29349018 PMCID: PMC5766428 DOI: 10.1016/j.eats.2017.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 08/07/2017] [Indexed: 02/03/2023] Open
Abstract
Chronic exertional compartment syndrome (CECS) is a significant source of lower extremity pain and morbidity in the athletic population. Although endoscopic techniques have been introduced, open fasciotomy remains the mainstay of surgical treatment because of the paucity of evidence in support of an endoscopic approach. The literature on surgical management of CECS is mixed, and overall success rates are modest at best. Optimizing surgical technique, including prevention of neurovascular injury and wound complications, can make a significant impact on the clinical outcome. Here we present our surgical technique, including pearls and pitfalls, for open 4-compartment fasciotomy for treatment of chronic exertional compartment syndrome.
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Affiliation(s)
- Amos Z. Dai
- Address correspondence to Amos Z. Dai, B.S., NYU Hospital for Joint Diseases, 301 E 17th Street, Suite 1500, New York, NY 10003, U.S.A.NYU Hospital for Joint Diseases301 E 17th Street, Suite 1500New YorkNY10003U.S.A.
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Vajapey S, Miller TL. Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome: a review of current literature. PHYSICIAN SPORTSMED 2017; 45:391-398. [PMID: 28952402 DOI: 10.1080/00913847.2017.1384289] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chronic exertional compartment syndrome (CECS) is a rare condition that usually affects distance runners and other running athletes. It is characterized by pain and pressure in one or multiple muscle compartments with repetitive physical activity. Reduction in pain typically occurs with cessation of activity. Evaluation of CECS consists of a thorough history of patient symptoms and ruling out of other causes of symptoms. Post-exercise pressure measurements can help confirm the diagnosis when symptoms are consistent and imaging evaluation negative for other causes. Non-operative treatment is a viable option for hindfoot runners and patients with anterior compartment syndrome of the leg. Limited-incision fasciotomy has been shown to be the most effective treatment and remains the gold standard for treatment. Minimal-incision open fasciotomy and endoscopic fasciotomy have surgical outcomes similar to wide-open fasciotomy. Military patients treated with fasciotomy have higher failure rates compared to civilians. Pediatric patients have similar outcomes compared to adults.
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Affiliation(s)
- Sravya Vajapey
- a Wexner Medical Center, Orthopaedics , Ohio State University , Columbus , OH , USA
| | - Timothy L Miller
- a Wexner Medical Center, Orthopaedics , Ohio State University , Columbus , OH , USA
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20
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Endoscopic Fasciotomy of the Superficial and Deep Posterior Compartments of the Leg. Arthrosc Tech 2017; 6:e711-e715. [PMID: 28706822 PMCID: PMC5495649 DOI: 10.1016/j.eats.2017.01.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 01/30/2017] [Indexed: 02/03/2023] Open
Abstract
Chronic exertional compartment syndrome is a rare cause of lower leg pain incurred during sports activities and typically affects young athletes who need to return to their activity level as quickly as possible. Nonoperative treatments are often unsuccessful and fasciotomy of the involved compartment is the treatment of choice. Endoscopically assisted release of the anterior and deep compartments is proven to be safe and effective. Endoscopically assisted deep posterior compartment release via an incision 1 to 3 cm behind the medial tibial border has high risk of injury to the great saphenous and perforating veins and the saphenous nerve. The purpose of this Technical Note is to describe the details of endoscopic fasciotomy of the superficial and deep posterior compartments of the leg. The operative field of this approach is away from the saphenous vein and nerve. Moreover, the tibial insertion of the soleus muscle does not need to be released to gain access to the proximal part of the deep posterior compartment.
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Drexler M, Rutenberg TF, Rozen N, Warschawski Y, Rath E, Chechik O, Rachevsky G, Morag G. Single minimal incision fasciotomy for the treatment of chronic exertional compartment syndrome: outcomes and complications. Arch Orthop Trauma Surg 2017; 137:73-79. [PMID: 27670876 DOI: 10.1007/s00402-016-2569-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Chronic exertional compartment syndrome (CECS) is a common injury in young athletes, causing pain in the involved leg compartment during strenuous exercise. The gold standard treatment is fasciotomy, but most of the reports on its effectiveness include relatively small cohorts and relatively short follow-up periods. This study reports the long-term results of a large cohort of young athletes who underwent single-incision fasciotomy for CECS. MATERIALS AND METHODS This a retrospective case-series study. All patients treated by fasciotomies performed for CECS between 2007 and 2011, in a tertiary medical institution. CECS was diagnosed following history taking and clinical evaluation, and confirmed by compartment pressure measurements. Ninety-five legs that underwent single-incision subcutaneous fasciotomy were included. Data on the numerical analog scale (NAS), Tegner activity score, and quality-of-life (QOL) as measured via the short form-12 (SF-12) were retrieved from all patients preoperatively and at the end of follow-up. RESULTS The average time to diagnosis was 22 months and the mean follow-up was 50.1 months. Sixty-three legs underwent anterior compartment fasciotomy (an additional 30 legs also underwent lateral compartment release), and two legs underwent lateral and peroneal compartment releases. The average change in Tegner score was an improvement of 14.6 points. Similarly, the patients reported a significant improvement in the SF-12 and NAS scores. Satisfaction rates were high (average 75.5 %). The main complications were wound infection (2 patients) and nerve injuries (4 patients). Eight patients had recurrence. CONCLUSION Single-incision fasciotomy leads to long-term improvement in the activity level and QOL of patients with CECS.
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Affiliation(s)
- Michael Drexler
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - T Frenkel Rutenberg
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - N Rozen
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Warschawski
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Rath
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Chechik
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G Rachevsky
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G Morag
- Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Surgical Management for Chronic Exertional Compartment Syndrome of the Leg: A Systematic Review of the Literature. Arthroscopy 2016; 32:1478-86. [PMID: 27020462 DOI: 10.1016/j.arthro.2016.01.069] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 01/27/2016] [Accepted: 01/29/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To review published literature to characterize the at-risk demographic, operative indications, surgical techniques, functional outcomes, and reoperation and complication rates after operative management of chronic exertional compartment syndrome (CECS) of the lower leg. METHODS We searched PubMed, Embase, Cochrane Database, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) through February 1, 2015, using the terms "chronic exertional" and/or "exercise induced compartment syndrome." The inclusion criteria were studies of Level I to IV evidence in English, published in 1970 or later, involving human subjects, reporting clinical outcomes of operative management of CECS of the lower leg, including at least 5 patients, and having follow-up of at least 80% and 6 months. RESULTS Among the 204 original articles, 24 primary studies with 1,596 patients met the inclusion criteria. The mean age was 26.6 years (standard deviation, 8.9 years), and the majority of patients were male patients (70%). The total study population mostly comprised military service members (54%) and athletes (29%). Of the athletes, 83% were recreational; 9% were college level; and 8% were either national, international, or professional. The most commonly involved compartment was the anterior compartment (51%; 95% confidence interval [CI], 48.6% to 52.3%), followed by lateral (33%; 95% CI, 31.4% to 34.9%), deep posterior (13%), and superficial posterior (3%). The cumulative posterior involvement rate was 16% (95% CI, 15.1% to 17.8%). Mean follow-up was 48.8 months (standard deviation, 22.1 months; 95% CI, 47.1 to 50.5 months). Six percent underwent revision surgery. The overall complication rate was 13% (due to postoperative neurologic dysfunction, infection, and so on). CONCLUSIONS Primary operative management of lower-extremity CECS was successful in approximately two-thirds of all young athletic patients, and 84% were satisfied with their surgical outcomes at short- to mid-term follow-up. Open fasciotomy remains the predominant surgical technique, although its comparative efficacy relative to newer endoscopic or other minimally invasive techniques is not currently known. These data may be used to guide the orthopaedic community on accurate preoperative counseling and benchmark patient outcomes for future quality-improvement initiatives. LEVEL OF EVIDENCE Level IV, systematic review (studies ranging from Level I to Level IV).
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Balius R, Bong DA, Ardèvol J, Pedret C, Codina D, Dalmau A. Ultrasound-Guided Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:823-829. [PMID: 26960800 DOI: 10.7863/ultra.15.04058] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Chronic exertional compartment syndrome is characterized by exertional pain and elevated intracompartmental pressures affecting the leg in physically active young people. In patients who have failed conservative measures, fasciotomy is the treatment of choice. This study presents a new method for performing fasciotomy using high-resolution ultrasound (US) guidance and reports on the clinical outcomes in a group of these patients. Over a 3-year period, 7 consecutive patients with a total of 9 involved legs presented clinically with anterior compartment chronic exertional compartment syndrome, which was confirmed by intracompartmental pressure measurements before and after exercise. After a US examination, fasciotomy under US guidance was performed. Preoperative and postoperative pain and activity levels were assessed as well as number of days needed to “return to play.” All patients had a decrease in pain, and all except 1 returned to presymptomatic exercise levels with a median return to play of 35 days.
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Lohrer H, Nauck T, Lohrer L. Endoscopic-assisted Release of Lower Leg Chronic Exertional Compartment Syndromes. Sports Med Arthrosc Rev 2016; 24:19-23. [DOI: 10.1097/jsa.0000000000000106] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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de Bruijn JA, van Zantvoort APM, Winkes MB, Raaymakers L, van der Cruijsen-Raaijmakers M, Hoogeveen AR, Scheltinga MR. Feasibility and Safety of an Operative Tool for Anterior Chronic Exertional Compartment Syndrome Treatment. Foot Ankle Int 2015. [PMID: 26219908 DOI: 10.1177/1071100715596081] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Operative management of chronic exertional compartment syndrome of the tibialis anterior muscle compartment (ant-CECS) usually involves the use of a fasciotome. Collateral tissue damage such as hematoma and nerve damage may occur during the procedure. The current report assessed the feasibility and safety of an alternative tool for the operative management of ant-CECS. METHODS The system had a speculum-like hollow tube that was inserted via a 2-cm skin incision and allowed for the protected advancement of a fasciotome. The device was tested in patients with bilateral ant-CECS. Symptoms were prospectively scored before and after surgery using a 5-category verbal rating scale (VRS). Fourteen patients (age 26 ± 10 years) were analyzed. Complications and operative efficacy were determined using physical examination and questionnaires after 21 (range = 16-25) months. RESULTS Technical operative success rate was 100% (28/28 legs). Operation time was 10 ± 2 minutes per leg (range = 6-14). Perioperative complications were not observed. One superficial wound infection was treated nonoperatively. Significant reductions in pain (-2.2 ± 1.1 on 5-point VRS, P < .001), tightness (-1.9 ± 1.6, P = .01), cramps (-1.4 ± 1.6, P = .009), muscle weakness (-1.6 ± 1.2, P < .001), and altered sensibility (-1.3 ± 1.4, P = .005) were registered 21 months postoperatively. CONCLUSION This fasciotome was simple to use and allowed for a safe fasciotomy in patients with leg ant-CECS. A randomized controlled trial comparing the present device with a widely used fasciotome was under way at the time of writing of this study.
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Affiliation(s)
- Johan A de Bruijn
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
| | | | - Michiel B Winkes
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
| | - Leo Raaymakers
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
| | | | - Adwin R Hoogeveen
- Department of Sports Medicine, Máxima Medical Center, Veldhoven, the Netherlands
| | - Marc R Scheltinga
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands CARIM Research School, Maastricht University, Maastricht, the Netherlands
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Pierrart J, Croutzet P, Gregory T, Masmejean EH. Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: a new technique. Orthop Traumatol Surg Res 2015; 101:633-5. [PMID: 26047755 DOI: 10.1016/j.otsr.2015.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 02/12/2015] [Accepted: 03/11/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Fasciotomy is the usual treatment for chronic exertional compartment syndrome of the lower limb. For esthetic reasons, minimally invasive techniques have been developed but can generate complications. Herein, we report the use of the KnifeLight during minimally invasive anterior and lateral compartment release in view of reducing these complications, within a feasibility study. MATERIAL AND METHODS This study was conducted on four cadavers (eight legs) and then an athletic patient (two legs). RESULTS The technique was carried out on all cases with no complications. The patient's result was excellent. DISCUSSION The KnifeLight can be used to perform a fasciotomy of the leg's anterior and lateral compartments. It seems to provide the operator with additional safety compared to other minimally invasive techniques. CONCLUSION This is a simple, reliable, and reproducible technique that deserves to be better known.
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Affiliation(s)
- J Pierrart
- Service de chirurgie de la main, du membre supérieur et des nerfs périphériques, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75908 Paris cedex 15, France.
| | - P Croutzet
- Clinique de l'Union, boulevard de Ratalens, 31240 Saint-Jean, France
| | - T Gregory
- Service de chirurgie de la main, du membre supérieur et des nerfs périphériques, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75908 Paris cedex 15, France
| | - E H Masmejean
- Service de chirurgie de la main, du membre supérieur et des nerfs périphériques, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75908 Paris cedex 15, France
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Mathis JE, Schwartz BE, Lester JD, Kim WJ, Watson JN, Hutchinson MR. Effect of lower extremity fasciotomy length on intracompartmental pressure in an animal model of compartment syndrome: the importance of achieving a minimum of 90% fascial release. Am J Sports Med 2015; 43:75-8. [PMID: 25361856 DOI: 10.1177/0363546514554601] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been an increase in minimally invasive surgery for chronic exertional compartment syndrome (CECS), despite the potential for incomplete compartment release and iatrogenic injuries. To our knowledge, no study has examined the effect of the length of fascial release on compartment pressures. PURPOSE/HYPOTHESIS The purpose was to explain the high failure rate seen in fascial release for CECS by evaluating the effect of fasciotomy length on intracompartmental pressures. We hypothesized that complete fascial release would need to be performed to return pressures to baseline levels. STUDY DESIGN Controlled laboratory study. METHODS Five male swine (10 lower extremities) were anesthetized. A slit catheter, connected to a pressure monitor, was inserted into the anterior compartment and a solution containing 5% swine albumin was injected into the compartment until the compartment pressure was >25 mm Hg for 10 minutes. Pressures were measured at rest, after the injection, and after each 10% incremental fasciotomy release. RESULTS The mean resting intracompartmental pressure was 3.2 mm Hg (range, 0-6 mm Hg), which increased after the injection to a mean of 37 mm Hg (range, 26-67 mm Hg). After complete fasciotomy, the mean pressure was 1.1 mm Hg (range, 0-4 mm Hg). There was a strong negative correlation (r=-0.693) between fasciotomy length and intracompartmental pressure. In 90% of the specimens, the pressures were <15 mm Hg after 80% fascial release, and after 90% release, all pressures were ≤8 mm Hg. CONCLUSION This study demonstrates a strong correlation between fasciotomy length and a reduction in intracompartmental pressures in a swine model. Our study suggests that 90% fascial release may represent a possible watershed zone, returning the intracompartmental pressure to a value at or near baseline values. CLINICAL RELEVANCE The results suggest that even in cases with near complete fascial release, intracompartmental pressures may decrease enough to provide symptomatic relief and avoid possible iatrogenic injuries associated with percutaneous release. It is unknown whether the swine model may adequately translate to the clinical setting; thus, recommendations should be taken with caution, and future studies should be performed to examine the correlation in a human model.
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Affiliation(s)
- James E Mathis
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Brian E Schwartz
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jonathan D Lester
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Walter J Kim
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jonathan N Watson
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mark R Hutchinson
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Dunn JC, Waterman BR. Chronic Exertional Compartment Syndrome of the Leg in the Military. Clin Sports Med 2014; 33:693-705. [DOI: 10.1016/j.csm.2014.06.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Winkes MB, Hoogeveen AR, Scheltinga MR. Is surgery effective for deep posterior compartment syndrome of the leg? A systematic review. Br J Sports Med 2013; 48:1592-8. [DOI: 10.1136/bjsports-2013-092518] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Knight JR, Daniels M, Robertson W. Endoscopic compartment release for chronic exertional compartment syndrome. Arthrosc Tech 2013; 2:e187-90. [PMID: 23875149 PMCID: PMC3716236 DOI: 10.1016/j.eats.2013.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Accepted: 02/08/2013] [Indexed: 02/03/2023] Open
Abstract
Exertional compartment syndrome of the leg is a condition that can cause chronic debilitating pain in active persons during a variety of aerobic activities. Nonoperative treatments using stretching protocols and activity modifications are often unsuccessful, and thus several operative strategies have been used to treat this condition. A novel technique for endoscopically assisted fasciotomy for chronic exertional compartment syndrome is described. By use of a small laterally based incision and an arthroscope, polydioxanone sutures are passed percutaneously along the anterior and lateral compartments with the Spectrum suture-shuttling device (ConMed Linvatec, Largo, FL). These sutures are used to retract the skin and subcutaneous tissues over the respective compartments. This method allows excellent visualization of the intercompartmental septum, the superficial peroneal nerve, and all perforating vessels. The anterior and lateral compartments can be safely and completely released with this minimally invasive approach. The patient is allowed to return to full activity at 6 weeks postoperatively, because of the decreased soft-tissue disruption.
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Affiliation(s)
- Justin R. Knight
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
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Pierret C, Tourtier JP, Blin E, L Bonnevie, Garcin JM, Duverger V. [Chronic compartmental syndrome. a review of 234 patients]. ACTA ACUST UNITED AC 2011; 36:254-60. [PMID: 21742450 DOI: 10.1016/j.jmv.2011.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 05/26/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Diagnosis of chronic compartment syndrome of the lower leg, which occurs in a young and athletic population, is often delayed. We studied postoperative outcomes after fasciotomy in patients with compartment syndrome in order to identify specific postoperative complications. Long-term functional outcomes were also evaluated. METHODS All patients with a diagnosis of chronic exercise-related compartment syndrome of the lower leg who underwent surgery from January 1985 to August 2009 were studied prospectively. The type of compartment and whether surgery was uni or bilateral was recorded. One year after surgery, patients completed a questionnaire to evaluate their functional outcome. RESULTS Two hundred and thirty-six compartment procedures were performed in 234 patients. Only one compartment (constantly the superficial posterior compartment) was treated in 56/236 (23.7%) procedures. Two compartments (anterior and lateral) were involved in 90/236 procedures (38.1%). Three compartments (anterolateral and superficial posterior) were noted in 74/236 procedures (31.4%) and four compartments (anterolateral and superficial and deep posterior) were described in 6.8%. Involvement of the deep posterior compartment was always associated with another compartment. Surgery was bilateral in 70% of patients. The questionnaire response rate was 65%. The success rate of fasciotomy was 68.4% and a significant improvement was reported by 23.9% of responders; outcome was unsatisfactory for 7.7%. CONCLUSIONS The diagnostic criteria used to confirm chronic exercise-related compartment syndrome of the lower leg were based on the compartment pressure measurement after exercise. In this study, all patients underwent fasciotomy. The surgical technique was standardized. Outcomes have been satisfactory with few surgical complications.
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Affiliation(s)
- C Pierret
- Service de chirurgie vasculaire, hôpital d'instruction des armées du Val-de-Grâce, Paris cedex, France.
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Lohrer H. Chronic exertional compartment syndrome. Letter to the editor. Am J Sports Med 2010; 38:NP1; author reply NP1-2. [PMID: 21123837 DOI: 10.1177/0363546510388597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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