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Chanchi ML, DeJong Lempke AF, Kocher M, Shore B, Meehan W, Willwerth S, Dawkins C, Hunt D, d'Hemecourt P, Stracciolini A, Whitney K. Running Biomechanics and Clinical Features Among Adolescent Athletes With Lower Leg Chronic Exertional Compartment Syndrome. Clin J Sport Med 2024; 34:348-356. [PMID: 38626073 DOI: 10.1097/jsm.0000000000001221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/07/2024] [Indexed: 04/18/2024]
Abstract
OBJECTIVE To compare clinical measures between patients with chronic exertional compartment syndrome (CECS) and healthy controls and evaluate running biomechanics, physical measurements, and exertional intracompartmental (ICP) changes in adolescent athletes with lower leg CECS. DESIGN Cross-sectional case-control study. SETTING Large tertiary care hospital and affiliated injury prevention center. PARTICIPANTS Forty-nine adolescents with CECS (39 F, 10 M; age: 16.9 ± 0.8 years; body mass index (BMI): 23.1 ± 2.9 kg/m 2 ; symptom duration: 8 ± 12 months) were compared with 49 healthy controls (39 F, 10 M; age: 6.9 ± 0.8 years; BMI: 20.4 ± 3.7 kg/m 2 ). INTERVENTIONS All participants underwent gait analyses on a force plate treadmill and clinical lower extremity strength and range of motion testing. Patients with chronic exertional compartment syndrome underwent Stryker monitor ICP testing. MAIN OUTCOME MEASURES Symptoms, menstrual history, and ICP pressures of the patients with CECS using descriptive statistics. Mann-Whitney U and χ 2 analyses were used to compare CECS with healthy patients for demographics, clinical measures, and gait biomechanics continuous and categorical outcomes, respectively. For patients with CECS, multiple linear regressions analyses were used to assess associations between gait biomechanics, lower extremity strength and range of motion, and with ICP measures. RESULTS The CECS group demonstrated higher mass-normalized peak ground reaction force measures (xBW) compared with controls (0.21 ± 0.05 xBW ( P < 0.001) and were more likely to have impact peak at initial contact ( P = 0.04). Menstrual dysfunction was independently associated with higher postexertion ICP (ß = 14.6; P = 0.02). CONCLUSIONS The CECS group demonstrated increased total force magnitude and vertical impact transient peaks. In women with CECS, menstrual dysfunction was independently associated with increased postexertion ICP. These biomechanical and physiological attributes may play a role in the development of CECS.
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Affiliation(s)
- Mayela Leal Chanchi
- Boston Children's Hospital Orthopedics and Sports Medicine, Boston, Massachusetts
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
| | - Alexandra F DeJong Lempke
- Boston Children's Hospital Orthopedics and Sports Medicine, Boston, Massachusetts
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan
| | - Mininder Kocher
- Boston Children's Hospital Orthopedics and Sports Medicine, Boston, Massachusetts
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
| | - Ben Shore
- Boston Children's Hospital Orthopedics and Sports Medicine, Boston, Massachusetts
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
| | - William Meehan
- Boston Children's Hospital Orthopedics and Sports Medicine, Boston, Massachusetts
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
| | - Sarah Willwerth
- Boston Children's Hospital Orthopedics and Sports Medicine, Boston, Massachusetts
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
| | - Corey Dawkins
- Boston Children's Hospital Orthopedics and Sports Medicine, Boston, Massachusetts
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
| | - Danielle Hunt
- Boston Children's Hospital Orthopedics and Sports Medicine, Boston, Massachusetts
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
| | - Pierre d'Hemecourt
- Boston Children's Hospital Orthopedics and Sports Medicine, Boston, Massachusetts
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
| | - Andrea Stracciolini
- Boston Children's Hospital Orthopedics and Sports Medicine, Boston, Massachusetts
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
| | - Kristin Whitney
- Boston Children's Hospital Orthopedics and Sports Medicine, Boston, Massachusetts
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
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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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Lindorsson S, Zhang Q, Brisby H, Rennerfelt K. Intramuscular Pressure and Patient-Reported Outcomes in Patients Surgically Treated for Anterior Chronic Exertional Compartment Syndrome. Orthop J Sports Med 2023; 11:23259671221151088. [PMID: 36846814 PMCID: PMC9947687 DOI: 10.1177/23259671221151088] [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] [Indexed: 03/01/2023] Open
Abstract
Background Chronic exertional compartment syndrome (CECS) causes exercise-induced leg pain. The diagnosis is confirmed by intramuscular pressure (IMP) measurements. Fasciotomy has been demonstrated to be a successful treatment for CECS; however, few studies have examined postoperative IMP and long-term outcomes. Purpose To evaluate long-term outcomes and postoperative IMP in patients surgically treated for anterior CECS, and to identify possible preoperative or postoperative factors associated with overall satisfaction with treatment at follow-up. Study Design Case-control study; Level of evidence, 3. Methods A consecutive series of 209 patients who underwent fasciotomy of the anterior compartment for CECS between 2009 and 2019 and had at least 1 year of follow-up were approached for inclusion. A total of 144 patients (69%), with a follow-up time of 1 to 11.5 years, were ultimately included. All patients underwent preoperative and postoperative 1-minute postexercise IMP measurements of the anterior compartment and completed a questionnaire covering pain and activity parameters at both time points. The follow-up questionnaire included an additional question on overall satisfaction with treatment, and surgical details were collected from the patient's medical records. Results The median IMP was significantly lower at follow-up than at baseline (17 mm Hg [range, 5-91 mm Hg] vs 49 mm Hg [range, 25-130 mm Hg]; P < .001). The overall satisfaction rate was 77%, and 83% reported a decreased pain level. The group of patients who were satisfied with the treatment included more men and had a higher ΔIMP and a lower revision rate (P < .05). Among the 16 patients (11%) who had undergone revision fasciotomies before follow-up, the satisfaction rate was 56%, and 64% reported a decrease in pain level. Conclusion Fasciotomy significantly reduced 1-minute postexercise IMP in patients with CECS and resulted in satisfaction and decreased pain in more than three-quarters of the patients at long-term follow-up. The male sex and a significant decrease in IMP were both positively associated with treatment satisfaction. Patients who underwent revision surgery before the follow-up had lower satisfaction rates and less pain reduction than the overall group.
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Affiliation(s)
- Sophia Lindorsson
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sophia Lindorsson, MD, Sahlgrenska University Hospital,
Ortopedmottagningen Mölndal, 431 80 Mölndal, Sweden (
)
| | - Qiuxia Zhang
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Brisby
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kajsa Rennerfelt
- Department of Orthopedics, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Botulinum Toxin A for Chronic Exertional Compartment Syndrome: A Retrospective Study of 16 Upper- and Lower-Limb Cases. Clin J Sport Med 2022; 32:e436-e440. [PMID: 34282061 DOI: 10.1097/jsm.0000000000000958] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 06/09/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess initial and mid-term efficacy of botulinum toxin A (BoNT-A) injections in patients with chronic exertional compartment syndrome (CECS) in the lower and upper limbs. DESIGN Retrospective monocentric study. SETTING A University Hospital Department of Physical Medicine and Rehabilitation. PATIENTS Sixteen patients with CECS of the lower and upper limbs treated with BoNT-A injections (first-line treatment) were included. INTERVENTIONS, MAIN OUTCOME MEASURES We collected data from a follow-up consultation (initial pain reduction [complete, partial, or ineffective] and specific activities triggering CECS) and a subsequent phone questionnaire (mid-term efficacy, pain recurrence, and adverse effects). RESULTS Sixteen patients were included (median age: 25.5 years), and 68.75% reported initial efficacy (4 partial and 7 complete); 8/16 patients were able to resume the activity that triggered CECS. All the patients with initial partial efficacy had pain recurrence (median time of 2.25 months). Among patients with initial complete efficacy, 57.14% had recurrence (median time of 5 months). Minor adverse effects were observed, but with no functional impact. CONCLUSION In 16 individuals with CECS treated with BoNT-A injections, we observed moderate efficacy without major adverse effects, but an initial improvement was often followed by recurrence, especially among those with partial initial efficacy.
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Trew CAJ, Kocialkowski C, Parsons T, Barton T. Predictors of Positive Outcomes and a Scoring System to Guide Management After Fasciotomy for Chronic Exertional Compartment Syndrome. Orthop J Sports Med 2022; 10:23259671221101328. [PMID: 35722180 PMCID: PMC9201312 DOI: 10.1177/23259671221101328] [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: 02/23/2022] [Accepted: 03/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Chronic exertional compartment syndrome (CECS) of the lower limb usually
responds well to fasciotomy in patients with failed nonoperative treatment.
Careful history taking and compartment pressure testing are both required to
accurately diagnose CECS. Purposes: To evaluate patients with CECS after fasciotomy to establish predictive
criteria of positive outcomes and to develop a scoring system to aid
clinicians in their management of such patients. Study Design: Case-control study; Level of evidence, 3. Methods: We reviewed data from 28 patients who underwent fasciotomy between 2017 and
2019. All patients had undergone preoperative dynamic intracompartmental
pressure (ICP) monitoring. For each patient, subjective preoperative and
postoperative pain scores were gained via a questionnaire. The point
biserial and Pearson correlation coefficients were used to calculate the
association between multiple diagnostic criteria and a reduction in visual
analog scale (VAS) pain scores after fasciotomy. Results: A reduction in VAS pain scores was strongly correlated with a peak ICP >40
mm Hg (r = 0.71; P = .0007) and an area
under the receiver operating characteristic curve for an intraexercise ICP
>22,000 mm Hg·s2 (r = 0.76;
P = .0002). A moderate correlation was found between a
history of CECS pain (r = 0.61; P = .005),
a duration of symptoms of <30 minutes after stopping exercise
(r = 0.60; P = .006), and a gradient
in the intraexercise ICP >10 mm Hg (r = 0.60;
P = .006). When combined into an objective, weighted
scoring system (2 points for factors with r > 0.7; 1
point for r = 0.5-0.7), a score of ≥4 points (of 7) had a
strong correlation (r = 0.85; P <
.00001) with postoperative improvement in the VAS pain score. Linear
regression of this score demonstrated a good fit (R2 = 0.61; P < .0001), indicating a degree of
predictive power. Conclusion: We identified diagnostic criteria in the history and examination of patients
with CECS that can be used to help predict positive outcomes after
fasciotomy. We propose a scoring system to aid clinicians in their
management of such patients. We recommend taking these results forward in
prospective trials to test the efficacy of predictive scoring.
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Affiliation(s)
| | | | - Tom Parsons
- Trauma and Orthopaedic Department, Royal United Hospitals, Bath, UK
| | - Tristan Barton
- Trauma and Orthopaedic Department, Royal United Hospitals, Bath, UK
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Andrew H, Georgina C, Phillipa T, Alexander B. Predicting surgical outcomes for chronic exertional compartment syndrome using a machine learning framework with embedded trust by interrogation strategies. Sci Rep 2021; 11:24281. [PMID: 34931008 PMCID: PMC8688508 DOI: 10.1038/s41598-021-03825-4] [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: 09/06/2021] [Accepted: 12/03/2021] [Indexed: 11/26/2022] Open
Abstract
Chronic exertional compartment syndrome (CECS) is a condition occurring most frequently in the lower limbs and often requires corrective surgery to alleviate symptoms. Amongst military personnel, the success rates of this surgery can be as low as 20%, presenting a challenge in determining whether surgery is worthwhile. In this study, the data of 132 fasciotomies for CECS was analysed and using combinatorial feature selection methods, coupled with input from clinicians, identified a set of key clinical features contributing to the occupational outcomes of surgery. Features were utilised to develop a machine learning model for predicting return-to-work outcomes 12-months post-surgery. An AUC of 0.85 ± 0.08 was achieved using a linear-SVM, trained using 6 features (height, mean arterial pressure, pre-surgical score on the exercise-induced leg pain questionnaire, time from initial presentation to surgery, and whether a patient had received a prior surgery for CECS). To facilitate trust and transparency, interrogation strategies were used to identify reasons why certain patients were misclassified, using instance hardness measures. Model interrogation revealed that patient difficulty was associated with an overlap in the clinical characteristics of surgical outcomes, which was best handled by XGBoost and SVM-based models. The methodology was compiled into a machine learning framework, termed AITIA, which can be applied to other clinical problems. AITIA extends the typical machine learning pipeline, integrating the proposed interrogation strategy, allowing to user to reason and decide whether to trust the developed model based on the sensibility of its decision-making.
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Affiliation(s)
- Houston Andrew
- School of Computer Science, Loughborough University, Loughborough, LE11 3TU, UK. .,Academic Department of Military Rehabilitation, Defence Medical Services, Loughborough, LE12 5QW, UK.
| | - Cosma Georgina
- School of Computer Science, Loughborough University, Loughborough, LE11 3TU, UK
| | - Turner Phillipa
- Centre for Lower-Limbs Rehabilitation, Defence Medical Services, Loughborough, LE12 5QW, UK
| | - Bennett Alexander
- Academic Department of Military Rehabilitation, Defence Medical Services, Loughborough, LE12 5QW, UK.,Imperial College London, National Heart and Lung Institute, London, SW7 2BU, UK.,School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU, UK
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