Functional Outcomes After the Surgical Management of Isolated Anterolateral Leg Chronic Exertional Compartment Syndrome

Chronic exertional compartment syndrome is frequently diagnosed through static compartment pressure measurements and managed with fasciotomy: A systematic review

OBJECTIVES

Chronic exertional compartment syndrome (CECS) can be diagnosed either clinically or with intra-compartmental pressure monitor measurements and can be treated surgically or conservatively.

METHODS

A systematic review was performed on diagnostic and treatment modalities for CECS. Included studies were those that reported both their specific diagnostic modality and treatment regimens. Both surgical and conservative treatment strategies were considered. Demographic variables, diagnostic modalities, patient satisfaction and return to sport, the number of surgical incisions used for the anterior compartment fasciotomy, and the specific conservative treatment regimens were also recorded. Diagnostic modalities were grouped into one of three groups: 1) static compartment pressure monitor, 2) dynamic pressure monitoring, and 3) strictly clinical diagnosis.

RESULTS

The literature search identified 373 studies, of which 29 were included for final analysis. In total, there were 1270 total patients. Twenty-four studies used static compartment pressure monitors, 5 studies used dynamic pressure monitors and 2 studies used a strictly clinical diagnosis. Surgical management with fasciotomy was performed in 25 studies with a total of 1018 patients, while conservative management was used in 252 patients in 9 studies (5 studies included surgical and conservative treatments). Among surgical studies, 15 used a single-incision technique for anterior compartment fasciotomy, while 6 used a 2-incision technique. The reported satisfaction after fasciotomy was 42-94% while the return to sport was 26-100%. The reported return to sport in conservative management studies was 25-35%.

CONCLUSION

This systematic review found that the majority of clinical reports utilize static compartment pressure measurements to diagnose CECS, with fewer studies using dynamic intra-compartment pressure monitors. Additionally, surgical fasciotomy using a single-incision technique was the most common treatment strategy for anterior compartment CECC, with some studies reporting success with the two-incision technique.

STUDY DESIGN

Systematic review, level 4.

Measuring Intracompartmental Pressures in the Lower Leg: Assessing the Use of Unilateral Measurements in Patients with Bilateral Symptoms

The purpose of the present study was to evaluate whether unilateral intracompartmental pressure (ICP) measurements correctly represent the contralateral ICP value in patients suspected to have bilateral chronic exertional compartment syndrome (CECS) in the anterior compartment of the leg.

METHODS

A retrospective cohort study was performed that included military service members who had been referred to a secondary care department for bilateral anterolateral exercise-related leg pain. The obtained ICP values were utilized to assess 2 possible measurement strategies to perform unilateral ICP measurements: the right-leg strategy (i.e., always testing the right leg) and the most-symptomatic-leg strategy (i.e., always testing the most symptomatic). The diagnostic cutoff value for CECS in this cohort was 35 mmHg in the first minute after provocation. Four outcome categories were created to describe the pressure classification of the second leg if only 1 leg would have been measured: correct (category 1: both values ≥35 mmHg; category 2: both values <35 mmHg) or incorrect (category 3: measured leg, ≥35 mmHg and contralateral leg, <35 mmHg; category 4: measured leg, <35 mmHg and contralateral leg, ≥35 mmHg).

RESULTS

A total of 442 patients (884 legs) were included. In 88% of patients, the unilateral value would have correctly diagnosed the other symptomatic leg, whereas in 12% of patients, the contralateral leg would have been diagnosed incorrectly. The right-leg strategy had a slightly smaller proportion of cases in which the contralateral leg would have been incorrectly diagnosed (7% compared with 8% for the most symptomatic leg strategy). In 89% of the 390 patients in categories 1 and 2, the ICP values deviated by >5 mmHg from the 35-mmHg cutoff value compared with 40% of the 52 patients in categories 3 and 4.

CONCLUSIONS

In military service members with bilateral chronic anterolateral exertional pain, a unilateral ICP measurement seems to be justified, especially among those with pressure values >5 mmHg above or below the diagnostic cutoff value. When a unilateral pressure measurement is within 5 mmHg above or below the cutoff value, a bilateral ICP measurement may be warranted.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predicting surgical outcomes for chronic exertional compartment syndrome using a machine learning framework with embedded trust by interrogation strategies

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.

Comparison of 2 Fasciotomes for Treatment of Patients With Chronic Exertional Compartment Syndrome of the Anterior Leg

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.

Outcome following mini-open lower limb fasciotomy for chronic exertional compartment syndrome

Purpose

The aim of this study was to report outcomes following mini-open lower limb fasciotomy (MLLF) in active adults with chronic exertional compartment syndrome (CECS).

Methods

From 2013–2018, 38 consecutive patients (mean age 31 years [16–60], 71% [n = 27/38] male) underwent MLLF. There were 21 unilateral procedures, 10 simultaneous bilateral and 7 staged bilateral. There were 22 anterior fasciotomies, five posterior and 11 four-compartment. Early complications were determined from medical records of 37/38 patients (97%) at a mean of four months (1–19). Patient-reported outcomes (including EuroQol scores [EQ-5D/EQ-VAS], return to sport and satisfaction) were obtained via postal survey from 27/38 respondents (71%) at a mean of 3.7 years (0.3–6.4).

Results

Complications occurred in 16% (n = 6/37): superficial infection (11%, n = 4/37), deep infection (3%, n = 1/37) and wound dehiscence (3%, n = 1/37). Eight per cent (n = 3/37) required revision fasciotomy for recurrent leg pain. At longer-term follow-up, 30% (n = 8/27) were asymptomatic and another 56% (n = 15/27) reported improved symptoms. The mean pain score improved from 6.1 to 2.5 during normal activity and 9.1 to 4.7 during sport (both p < 0.001). The mean EQ-5D was 0.781 (0.130–1) and EQ-VAS 77 (33–95). Of 25 patients playing sport preoperatively, 64% (n = 16/25) returned, 75% (n = 12/16) reporting improved exercise tolerance. Seventy-four per cent (n = 20/27) were satisfied and 81% (n = 22/27) would recommend the procedure.

Conclusion

MLLF is safe and effective for active adults with CECS. The revision rate is low, and although recurrent symptoms are common most achieve symptomatic improvement, with reduced activity-related leg pain and good health-related quality of life. The majority return to sport and are satisfied with their outcome.

Systematic review of outcome parameters following treatment of chronic exertional compartment syndrome in the lower leg

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.

Outcomes of Surgically Treated Chronic Exertional Compartment Syndrome in Runners

BACKGROUND

Chronic exertional compartment syndrome (CECS) is primarily seen in running athletes. Previous outcomes of surgical treatment with fasciotomy have suggested moderate pain relief, but evidence is lacking regarding postoperative return to running.

HYPOTHESIS

Running athletes with limiting symptoms of CECS will show high rates of return to running after fasciotomy.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

Running athletes treated with fasciotomy for CECS at a single institution were identified using a surgical database and asked to complete a questionnaire designed to assess postoperative pain, activity level, return to running, running distances, overall satisfaction, and rate of revision fasciotomy.

RESULTS

A total of 43 runners met the inclusion criteria, and 32 runners completed outcomes questionnaires at a mean postoperative follow-up of 66 months. In total, 27 of these 32 patients (84%) returned to sport(s) after fasciotomy. However, 9 (28%) of these patients pursued nonrunning sports, 5 (16%) due to recurrent pain with running. Of the 18 patients who returned to running sports (56%), the mean weekly running distance decreased postoperatively. Recurrence of symptoms was reported in 6 patients (19%), 4 of whom had returned to running and 2 of whom had been unable to return to sports. All of these 6 patients elected to undergo revision fasciotomy surgery. Twenty-five (78.1%) patients reported being satisfied with their procedure. In the overall cohort, the mean visual analog scale scores for pain during activities/sports decreased from 7.9 preoperatively to 1.7 postoperatively.

CONCLUSION

Fasciotomy for CECS in runners may provide significant improvement in pain and satisfaction in over three-quarters of patients and return to sports in 84% of patients. However, only 56% returned to competitive running activity, with a subset (19%) developing recurrent symptoms resulting in revision surgery.

CLINICAL RELEVANCE

Fasciotomy has been shown to decrease pain in most patients with CECS. This study provides outcomes in running athletes after fasciotomy for CECS with regard to return to sports, maintenance of sports performance, and rates of revision surgery.

Chronic Lower Leg Pain in Athletes: Overview of Presentation and Management

BACKGROUND

Athletes with chronic lower leg pain present a diagnostic challenge for clinicians due to the differential diagnoses that must be considered.

PURPOSE/QUESTIONS

We aimed to review the literature for studies on the diagnosis and management of chronic lower leg pain in athletes.

METHODS

A literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The PubMed, Scopus, and Cochrane library databases were searched, and articles that examined chronic lower leg pain in athletes were considered for review. Two independent reviewers conducted the search utilizing pertinent Boolean operations.

RESULTS

Following two independent database searches, 275 articles were considered for initial review. After the inclusion and exclusion criteria were applied, 88 were included in the final review. These studies show that the most common causes of lower leg pain in athletes include medial tibial stress syndrome, chronic exertional compartment syndrome, tibial stress fractures, nerve entrapments, lower leg tendinopathies, and popliteal artery entrapment syndrome. Less frequently encountered causes include saphenous nerve entrapment and tendinopathy of the popliteus. Conservative management is the mainstay of care for the majority of cases of chronic lower leg pain; however, surgical intervention may be necessary.

CONCLUSIONS

Multiple conditions may result in lower leg pain in athletes. A focused clinical history and physical examination supplemented with appropriate imaging studies can guide clinicians in diagnosis and management. We provide a table to aid in the differential diagnosis of chronic leg pain in the athlete.

Isolated Lateral Chronic Exertional Compartment Syndrome of the Leg: A New Entity?

Background:

Chronic exertional compartment syndrome (CECS) mostly occurs in the anterior or deep posterior compartments (ant-CECS and dp-CECS, respectively) of the leg. It is generally accepted that CECS of the third or lateral compartment (lat-CECS) always occurs together with ant-CECS. However, whether exertional leg pain (ELP) can be caused by an isolated form of lat-CECS is unknown.

Purpose:

To determine the existence of isolated lat-CECS and study whether history taking and a physical examination aid in discriminating between different subtypes of CECS.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients were eligible for this single-center study, conducted between January 2013 and February 2018, if they reported anterolateral ELP and completed a questionnaire scoring the frequency and intensity of pain, tightness, cramps, muscle weakness, and paresthesia during rest and exercise. They were asked to mark areas of altered foot skin sensation, if present, on a drawing. All patients underwent a dynamic intracompartmental pressure (ICP) measurement of the anterior and lateral compartments simultaneously. The diagnosis of CECS was confirmed by elevated ICP (Pedowitz criteria). There were 3 patient groups: (1) isolated ant-CECS with elevated ICP in the anterior compartment and normal ICP in the lateral compartment, (2) isolated lat-CECS with elevated ICP in the lateral compartment but normal ICP in the anterior compartment, and (3) ant-/lat-CECS with elevated ICP in both the anterior and lateral compartments.

Results:

A total of 73 patients with anterolateral ELP fulfilled study criteria (isolated ant-CECS: n = 26; isolated lat-CECS: n = 5; ant-/lat-CECS: n = 42). Group differences were not observed regarding age (isolated ant-CECS: median, 26 years [range, 13-68 years]; isolated lat-CECS: median, 20 years [range, 17-63 years]; ant-/lat-CECS: median, 28 years [range, 17-57 years]; χ² (2) = 0.466; P = .79), sex (isolated ant-CECS: 50% male; isolated lat-CECS: 40% male; ant-/lat-CECS: 62% male; P = .49), or bilateral symptoms (isolated ant-CECS: 54%; isolated lat-CECS: 80%; ant-/lat-CECS: 69%; P = .40). However, cramps at rest were present in a portion of the patients with isolated ant-CECS (38%) and ant-/lat-CECS (57%) but not in those with isolated lat-CECS (P = .032). Patient drawings of altered foot skin sensation did not contribute to the diagnosis (P = .92). ICP values after provocation were all lower in patients with isolated ant-CECS and isolated lat-CECS compared with those with ant-/lat-CECS (P < .05).

Conclusion:

Seven percent of patients with CECS and anterolateral ELP who had symptoms due to isolated lat-CECS in the presence of normal muscle pressure in the anterior compartment.

[Chronic exertional compartment syndrome as a cause of anterolateral leg pain-German version]

Exercise-induced leg pain (ELP) and tightness may be caused by a chronic exertional compartment syndrome (CECS). Although CECS can develop in any muscle compartment, most individuals suffer from an anterior tibial muscle CECS (ant-CECS). Typically, a patient with ant-CECS experiences discomfort toward the end of sports activity or in the hours thereafter. Physical examination may reveal tenderness upon palpation of the anterior tibial muscle belly. The gold standard diagnostic tool is a dynamic intracompartmental pressure (ICP) measurement demonstrating elevated muscle tissue pressures. Duplex analysis and imaging may be indicated for exclusion of concomitant entities such as entrapment of the popliteal artery or nerves. Conservative treatments including modification of the patient's running technique can be successful. A fasciotomy must be considered in recalcitrant cases. Residual or recurrent disease may necessitate partial removal of the fascia. The aim of this overview is to discuss the management of CECS in the anterolateral portion of the leg.

Risk factors for complications following decompression of non-traumatic compartment syndrome

Purpose

To investigate the rate of and risk factors for complications following non-traumatic compartment syndrome decompression.

Methods

The National Surgical Quality Improvement Program database was queried from 2006 to 2016 for non-traumatic compartment syndrome diagnosis codes. Multivariate analysis was performed to identify risk factors for 30-day complications and hospital readmissions.

Results

Overall complication, major complication, minor complication, and hospital readmission rates were 4.5%, 2.5%, 2.3%, and 2.0%, respectively. Active smoking was identified as a risk factor for post-operative complication (95%CI 1.19-9.24).

Conclusion

The complication profile of non-traumatic compartment syndrome decompression is higher than that of traditional elective orthopaedic surgery.

Level of evidence

IV.