Chronic exertional compartment syndrome: the controversial "fifth" compartment of the leg

Minimally Invasive Lower Leg Fasciotomy for Chronic Exertional Compartment Syndrome-How Safe Is It? A Cadaveric Study

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.

Ultrasound-Guided Fasciotomies of the Deep and Superficial Posterior Leg Compartments for Chronic Exertional Compartment Syndrome: A Cadaveric Investigation

BACKGROUND

Chronic exertional compartment syndrome (CECS) is a type of leg pain related to elevated intracompartmental pressure with activity in one or more of the four compartments of the leg. Open fasciotomy is the definitive treatment for CECS but has a reported complication rate of up to 15.7% and return to full activity reported up to 16 weeks. Ultrasound-guided (USG) fasciotomy of the anterior and lateral compartments has been translated into clinical practice.

OBJECTIVE

To determine the safety and feasibility of a USG fasciotomy of the deep posterior compartment (DPC) and superficial compartment (SPC) of the leg in a fresh-frozen cadaveric model.

DESIGN

Prospective, cadaveric laboratory investigation.

SETTING

Procedural skills laboratory at an academic institution.

CADAVERIC COHORT

Ten fresh-frozen cadaveric knee-ankle-foot specimens from five female and five male donors aged 58 to 93 years (mean 77.4 years) with body mass indexes of 18.1 to 33.5 kg/m² (mean 25.1 kg/m² ).

METHODS OR INTERVENTIONS

One experienced operator performed 10 USG DPC and SPC fasciotomies. A clinical anatomist performed dissections of each.

MAIN OUTCOME MEASURES

Achievement of target length and continuity of release was recorded. Target lengths of 10 cm for the superficial posterior compartment (SPC) and 15 cm for the deep posterior compartment (DPC) were established based on previous studies. Tendinous and neurovascular structures were assessed for damage.

RESULTS

No tendon or neurovascular injuries were observed. In the SPC, target length was achieved in 90% and continuous release was observed in 80%. In the DPC, target length was achieved in 60% and continuity observed in 30%.

CONCLUSIONS

These findings suggest that SPC USG fasciotomies using the technique described in this study are feasible, may be safe, and warrant further translational research; however, DPC USG fasciotomies are more challenging and require more technical refinement prior to clinical translation.

Release of the Tibialis Posterior Muscle Osseofascial Sheath Improves Results of Deep Exertional Compartment Syndrome Surgery: A Comparative Analysis and Long-term Results

Background:

Success rates for surgical management of chronic exertional compartment syndrome (CECS) are historically lower with release of the deep posterior compartment compared with isolated anterolateral releases. At our institution, when a deep posterior compartment release is performed, we routinely examine for a separate posterior tibial muscle osseofascial sheath and release it if present.

Purpose:

Within the context of this surgical approach, the aim of the current study was to compare long-term patient satisfaction and activity levels in patients who underwent 2-compartment fasciotomy versus a modified 4-compartment fasciotomy for CECS.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients treated with fasciotomy for lower extremity CECS from 2007 to 2017 were retrospectively identified. In all patients in whom a 4-compartment fasciotomy was indicated, the tibialis posterior muscle was examined for a separate osseofascial sheath, which was released when present. Patients completed a series of validated patient-reported outcome (PRO) surveys, including the Marx activity score, Tegner activity score, 12-Item Short Form Health Survey, and Likert score for patient satisfaction.

Results:

Of the 48 patients who were included in this study, 34 (71%) patients with a total of 52 operative limbs responded and completed PRO surveys. The mean follow-up for the entire cohort was 5.5 ± 2.6 years. Of the 34 patients, 23 (68%) underwent 2-compartment fasciotomy and 11 (32%) underwent 4-compartment fasciotomy. Among the patients in the 4-compartment fasciotomy group, 7 (64%) were found to have a fifth compartment. No significant difference was found in any of the validated PRO measures between patients who had a 2- versus 4-compartment fasciotomy or those who underwent 4-compartment fasciotomy with or without a present fifth compartment. At a mean 5.5-year follow-up, 74% of patients who underwent a 2-compartment release reported good or excellent outcomes compared with 82% of patients who underwent our modified 4-compartment release.

Conclusion:

The current study, which included the longest follow-up on CECS patients in the literature, demonstrated that the addition of a release of the posterior tibial muscle fascia led to no significant difference in PRO measures between patients who underwent a 2- versus 4-compartment fasciotomy, when historically the 2-compartment fasciotomy group has had higher success rates.

Mini-Open Posterior Compartment Release for Chronic Exertional Compartment Syndrome of the Leg

Chronic exertional compartment syndrome (CECS) is a well-recognized cause of leg pain in endurance athletes. Surgical fasciotomy for posterior leg CECS historically has inferior clinical results compared with anterior and lateral compartment release. Poor surgical technique with inadequate release may contribute to less reliable outcomes. In this Technical Note with accompanying video, we describe a mini-open approach for posterior CECS of the leg.

Accuracy of Palpation-Guided Catheter Placement for Muscle Pressure Measurements in Suspected Deep Posterior Chronic Exertional Compartment Syndrome of the Lower Leg: A Magnetic Resonance Imaging Study

BACKGROUND

A diagnosis of lower leg deep posterior chronic exertional compartment syndrome (dp-CECS) is made by a dynamic pressure measurement. The insertion of a pressure catheter is guided by anatomic landmarks (freehand) or by ultrasound. The catheter tip is ideally positioned in the tibialis posterior muscle (TP). The accuracy of in vivo catheter placement using lower leg magnetic resonance imaging (MRI) in healthy patients suspected of having dp-CECS has never been studied.

PURPOSE

To analyze whether a freehand catheter insertion results in accurate positioning in the TP as confirmed by MRI in patients with suspected dp-CECS.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Catheters were inserted into central portions of the TP using a standard puncturing technique guided by lower leg anatomic landmarks. After timed muscle pressure measurements during a standard provocative treadmill running test, lower leg MRI scans were obtained and evaluated by 2 skilled radiologists. Catheter tip placement was termed accurate (in the TP), suboptimal (in the deep posterior compartment but outside the TP), or inaccurate (outside the deep posterior compartment).

RESULTS

Between March 2013 and September 2014, a total of 24 patients (8 male, 16 female; mean age, 30 years [range, 18-54 years]) underwent an intracompartmental pressure (ICP) measurement, followed by MRI. Cardinal symptoms were pain during exertion (20% very severe, 53% severe, and 20% moderate) and tightness (29% very severe, 43% severe). Symptoms were bilateral in 74% of patients. Nine of the 24 patients were diagnosed with dp-CECS based on elevated ICPs. Of the 24 patients, catheter tip placement was accurate in 10 (42%), whereas suboptimal placement was achieved in 9 (38%). Five procedures were inaccurate (transition zone between the deep and superficial compartments, n = 3; in the superficial lower leg compartment, n = 2). Signs of a hematoma were found in 38% of the patients, although there were no associated clinical symptoms.

CONCLUSION

Palpation-guided placement of catheters for TP pressure measurements is suboptimal in more than half of the patients with suspected lower leg dp-CECS. Optimizing the pressure catheter tip positioning technique may improve diagnostic accuracy in dp-CECS.

Chronic Exertional Compartment Syndrome in a Healthy Young Man

OBJECTIVE

The purpose of this case report is to describe a patient who presented with symptoms of exercise-induced compartment syndrome and was later referred for bilateral fasciotomy surgery.

CLINICAL FEATURES

A 21-year-old patient presented for chiropractic care with the inability to run due to foot paresthesia and weakness. An exertion test and compartment pressure test diagnosed exercise-induced compartment syndrome. Exertion test and compartment pressure test were used to identify and diagnose exercise-induced compartment syndrome.

INTERVENTION AND OUTCOME

The patient was diagnosed with exercise-induced compartment syndrome. He was treated conservatively and referred for additional testing. The orthopedic surgeon requested that 12 weeks of conservative care be provided prior to testing; treatment consisted of chiropractic care and rehabilitation exercises. Following the 12 weeks of treatment, the patient did not significantly respond to conservative care. A compartment pressure test confirmed the initial diagnosis of exercise-induced compartment syndrome. The patient underwent a unilateral fasciotomy surgery and recovered fully. Following the surgery, the patient returned to the chiropractic clinic with the same presentation in the contralateral leg. The same protocol of management resulted in the same outcome. Two years after surgical intervention, the patient continues to maintain an active lifestyle, able to run 2 to 3 miles per day without any exacerbations or symptomatology.

CONCLUSION

Clinical awareness, a detailed history, and thorough examination with reproduction of symptomatology are necessary to form a proper diagnosis and treatment plan for these patients. Therefore, multidisciplinary medical communication would prove to be the most beneficial approach for the patient.

Nonatherosclerotic PAD: Approach to Exertional Pain in the Lower Extremities

Atherosclerotic peripheral artery disease is the most common cause of intermittent claudication. Nonatherosclerotic peripheral artery disease is a heterogeneous collection of diseases affecting the extracoronary arteries which is not due to atherosclerosis. These diseases include, but are not limited to, popliteal artery entrapment syndrome, cystic adventitial disease, external iliac endofibrosis, and thromboangiitis obliterans. Due to its relatively low prevalence, nonatherosclerotic peripheral artery disease may be misdiagnosed leading to the mismanagement of potentially treatable conditions. The proper and timely diagnosis of these conditions is paramount to the prevention of adverse outcomes as treatments widely vary. The diagnostic approach to patients presenting with intermittent claudication must take into account both atherosclerotic as well as nonatherosclerotic causes of peripheral artery disease making the differential vital to clinical practice.

Functional Popliteal Artery Entrapment Syndrome: Poorly Understood and Frequently Missed? A Review of Clinical Features, Appropriate Investigations, and Treatment Options

Functional popliteal artery entrapment syndrome (PAES) is an important and possibly underrecognized cause of exertional leg pain (ELP). As it is poorly understood, it is at risk of misdiagnosis and mismanagement. The features indicative of PAES are outlined, as it can share features with other causes of ELP. Investigating functional PAES is also fraught with potential problems and if it is performed incorrectly, it can result in false negative and false positive findings. A review of the current vascular investigations is provided, highlighting some of the limitations standard tests have in determining functional PAES. Once a clinical suspicion for PAES is satisfied, it is necessary to further distinguish the subcategories of anatomical and functional entrapment and the group of asymptomatic occluders. When definitive entrapment is confirmed, it is important to identify the level of entrapment so that precise intervention can be performed. Treatment strategies for functional PAES are discussed, including the possibility of a new, less invasive intervention of guided Botulinum toxin injection at the level of entrapment as an alternative to vascular surgery.

[Chronic compartmental syndrome. a review of 234 patients]

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.

[Acute lower leg compartment syndrome]

OBJECTIVE

Decompression of all four muscle compartments of the lower leg to normalize tissue pressure and prevent permanent neuromuscular dysfunction.

INDICATIONS

Incipient compartment syndrome (characterized by excessive pain, muscle pain on extension, tensely swollen and shiny skin, and Δp>30 mmHg without neuromuscular deficit) and no clinical improvement after conservative treatment and/or acute compartment syndrome (symptoms as for incipient compartment syndrome with neuromuscular deficit and Δp<30 mmHg).

CONTRAINDICATIONS

None. There is some dispute about indications and timing of fasciotomy and necrectomy when the need for dermatofasciotomy is recognized late (e.g. intubated intensive care patients).

SURGICAL TECHNIQUE

In unilateral compartment release as described by Matsen, the lateral compartment is decompressed first through a parafibular approach. After identification of the anterior and superficial posterior compartments by transverse incision of the fasciae, these muscles are also decompressed longitudinally. Finally, the deep posterior compartment beneath the lateral compartment is decompressed. In bilateral dermatofasciotomy, the fasciae of the anterior and lateral compartments are incised through a proximal anterolateral approach and the superficial and deep posterior compartments through a distal dorsomedial approach.

POSTOPERATIVE MANAGEMENT

Synthetic skin substitute or vacuum-assisted wound closure until definitive closure by secondary suture or mesh grafting after about 5 days. Patient mobilization generally depends on the concomitant bone injury.

RESULTS

During the period from October 2001 to November 2008, 37 dermatofasciotomies were performed at our hospital to treat acute posttraumatic compartment syndrome. On the day of dismissal, symptoms of neuromuscular dysfunction after acute compartment syndrome had not disappeared completely in 5 patients. One patient received intermittent dialysis for acute kidney failure after crush syndrome. There were perioperative complications in a total of 6 patients: iatrogenic neurotomy (n=1), hematoma requiring revision (n=2), deep wound infection (n=2), and superficial disturbed wound healing (n=1).

Missed posterior deep, inferior subcompartment syndrome in a patient with an ankle fracture: a case report

Deep posterior compartment syndrome is an extremely rare complication of ankle fracture and the few reported cases in the literature show that it is usually diagnosed late. Anterior and deep posterior compartment syndromes have been described with variable manifestations according to the compartment affected. We present a case of deep posterior compartment syndrome isolated to the disputed distal "subcompartment" of the leg, which had a very subtle and late presentation and was missed. The diagnosis of compartment syndrome was confirmed on MRI scan. Subsequently the patient developed a flexor hallucis longus muscle contracture that was managed nonoperatively.

Endoscopically assisted release for exertional compartment syndromes of the lower leg

BACKGROUND

Endoscopic treatment of intractable chronic anterior and lateral exertional compartment syndromes of the lower leg in athletes is reported anecdotically only in six patients.

HYPOTHESIS

H(0) = There is no difference between preoperative and postoperative status after endoscopic release of chronic exertional compartment syndromes of the lower leg.

STUDY DESIGN

Case series; level of evidence, 4.

METHODS

We developed a minimally invasive, endoscopically assisted technique for release of chronic exertional compartment syndromes of the lower leg. All patients were investigated by telephone interview 47 months (range 5 months-7 years) after surgery.

RESULTS

This investigation comprises release of 19 deep posterior, 16 anterior, and 3 lateral compartments in 17 athletes. No complications were seen following endoscopic anterior and lateral compartment decompression, while two patients following deep posterior compartment release underwent open revision surgery due to hemorrhage. Initial endoscopic surgery in these two patients was performed under tourniquet. There were no postoperative complications due to vascular injuries in all further patients who were operated without tourniquet. Ten patients returned to previous sport activity. At follow-up, results were good or excellent in 10 out of 17 patients. Visual analogue pain scale ranged from 5 to 9 (mean 7.4) before surgery and from 1 to 8 (mean 2.4) at follow up (P = 0.0005).

CONCLUSIONS

This study confirms feasibility of endoscopic release for chronic exertional compartment syndromes of the lower leg on a larger scale. At least for the deep posterior compartment its safety and effectiveness cannot be recommended without stint as results are inferior as compared to data obtained from literature for open surgery. To avoid vascular complications, especially during deep posterior compartment fasciotomy it is most important to perform the procedure without tourniquet.

Anatomical variations within the deep posterior compartment of the leg and important clinical consequences

The management of musculoskeletal conditions makes up a large part of a sports medicine practitioner's practice. A thorough knowledge of anatomy is an essential component of the armament necessary to decipher the large number of potential conditions that may confront these practitioners. To cloud the issue further, anatomical variations may be present, such as supernumerary muscles, thickened fascial bands or variant courses of nerves and blood vessels, which can themselves manifest as acute or chronic conditions that lead to significant morbidity or limitation of activity. There are a number of contentious areas within the literature surrounding the anatomy of the leg, particularly involving the deep posterior compartment. Conditions such as chronic exertional compartment syndrome, tibial periostitis (shin splints), peripheral nerve entrapment and tarsal tunnel syndrome may all be affected by subtle anatomical variations. This paper primarily focuses on the deep posterior compartment of the leg and uses the gross dissection of cadaveric specimens to describe definitively the anatomy of the deep posterior compartment. Variant fascial attachments of flexor digitorum longus are documented and potential clinical sequelae such as chronic exertional compartment syndrome and tarsal tunnel syndrome are discussed.

Le syndrome de loge d'effort

OBJECTIVES

To review the literature on chronic exertional compartment syndrome.

METHODS

We searched the Medline database with use of the keys words compartment syndrome, exertional, chronic, pressure, and fasciotomy.

RESULTS

Exertional compartment syndrome is characterized by pain on exertion, which recedes at rest, and by excessive increase in compartment intramuscular pressure. Intramuscular pressure measurement is the reference diagnostic tool, but it has not been standardized or evaluated. Pressure observed during the first 5 min after exertion stops is more often used in diagnosis. The first studies of noninvasive investigations (magnetic resonance imaging, thallium single-photon emission tomographic imaging, near infrared spectroscopy) revealed their inadequate diagnostic value. The pathophysiological features of exertional compartment syndrome remain unclear: increased muscle bulk, fascia thickness and stiffness, stimulation of fascial sensory stretch-receptors, poor venous return, micromuscular injuries, and small clinical myopathic abnormalities. Treatment includes decreased sport activity or fasciotomy with partial fasciectomy. Several authors have used endoscopically assisted fasciotomy, which retrospective studies have shown to be successful. Long-term outcome studies could investigate the persistence of exertional minor pain and recurrence of the compartment syndrome with this treatment.

CONCLUSION

Further studies are required to understand the physiopathology, standardize the intramuscular pressure test and evaluate the pressure threshold values, evaluate noninvasive investigations and specify the long-term outcome of fasciotomy.