Two minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg

Chronic exertional compartment syndrome (CECS) of the leg is a pathological condition often related to overuse in subject who engage repetitive physical activities. Fascial release is the mainstay of surgical management. The purpose of this study was to evaluate the results obtained with a double incision decompressive fasciotomy. Eighteen consecutive athletes with a diagnosis of anterior and/or lateral CECS of the leg were operated on with a minimal double incision fascial release after a mean period of 4 months after onset of symptoms. In 11 cases (61%) CECS was bilateral. Surgery was performed without tourniquet and active mobilization was starting immediately. Sports activities were resumed gradually at a mean period of 25 days. The athletes were followed until 2 years. All resumed pre-injury level sports activity. Two patients (18%) of the 11 who underwent to bilateral fasciotomy referred a sensation of leg weakness for an average period of 3 months. The surgical technique presented in this paper seems to be a good mean to treat anterior and lateral leg CECS. The use of tourniquet is deconselled to obtain an accurate intraoperative haemostasis so reducing the risk of post-operative haematoma.     

Evaluation,diagnosis, and treatment of chronic exertional compartment syndrome: a review of current literature

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.     

Chronic exertional compartment syndrome of the forearm

Chronic exertional compartment syndrome (CECS) is an overuse injury characterized by increased intracompartmental pressure during exercise. CECS has been described in the foot, thigh, and trunk, but 95% of cases occur in the lower leg. Interestingly, CECS may also affect the upper extremities and has been best described in the forearms. Unfortunately, due to the rarity of this condition, there is no consensus regarding its diagnosis and treatment. This review seeks to discuss the prevalence, etiology, diagnosis, and treatment of CECS of the forearms, which has been described in the literature.     

A technique for arthroscopic fasciotomy for the chronic exertional tibialis anterior compartment syndrome

Chronic exertional anterior compartment syndrome (CECS) is a condition that causes pain over the front of the shin bone that usually occurs in physically active people, especially runners. It may require sometimes an immediate fasciotomy. A longitudinal incision just over the fibula has used as surgical treatment bad cosmetic appearance. Although nowadays mini surgical incisions are preferred. The aim of this study to evaluate a simple fasciotomy technique with a minimal incision by using arthroscope. Nine legs of six patients that diagnosed as CECS has underwent fasciotomy operation with a 1 cm incision. Complaints had disappeared after operation. The mean follow-up time is 2 years. The results were good all of the patients and they never experienced exertional pain episodes. The arthroscopic assisted mini incisional fasciotomy technique has advantage such as early rehabilitation and good cosmetic appearance.     

Chronic exertional compartment syndrome of the lower extremities: improved screening using a novel dual birdcage coil and in-scanner exercise protocol

Objective The purpose of this study was to design and evaluate an MRI screening protocol for chronic exertional compartment syndrome (CECS) of the lower legs using an in-scanner exercise protocol and novel dual birdcage coil design for improved imaging. Materials and methods Coil and phantom studies: a custom-made dual birdcage coil designed for this protocol was evaluated for uniformity and signal-to-noise ratio (SNR) compared with a conventional phased-array receive-only torso coil and the body coil. Phantom and normal subject studies were performed to confirm coil performance. In-vivo studies: eight unaffected subjects and 42 patients with lower extremity symptoms suggestive of CECS were imaged with the dual birdcage coil and an in-scanner exercise protocol which included imaging at rest, during isometric resisted dorsi flexion, at rest (recovery), during isometric resisted plantar flexion and, again, at rest. Of 42 patients, 14 had confirmed CECS and 28 had lower extremity anomalies attributable to other causes. Ratios of relative T2-weighted signal intensities were calculated for exercise and recovery images compared to baseline after processing of images, including re-registration for motion, smoothing and segmentation to remove bone and pulsation artifacts from blood vessels. Results Receiver operating characteristic (ROC) analysis showed a threshold for the ratio of relative T2-weighted signal intensity of 1.54 to have a sensitivity of 96%, specificity of 90% and accuracy of 96% for CECS. Patients with CECS had their peak ratio of signal intensity compared with baseline during the first recovery period after isometric dorsi flexion, whereas unaffected subjects and patients with other causes of exercise-induced lower extremity pain reached their peak values during exercise (P < 0.001). Conclusion We have developed the first in-scanner MRI exercise protocol for the assessment of patients with suspected CECS. The technique shows high accuracy, sensitivity and specificity for diagnosis in this small cohort of patients with CECS. Further study may allow this non-invasive test to be used as a triage tool for invasive intracompartmental pressure measurements in patients with suspected CECS.     

Biomechanical differences between cases with chronic exertional compartment syndrome and asymptomatic controls during walking and marching gait

Chronic exertional compartment syndrome is a significant problem in military populations that may be caused by specific military activities. This study aimed to investigate the kinematic and kinetic differences in military cases with chronic exertional compartment syndrome and asymptomatic controls.20 males with symptoms of chronic exertional compartment syndrome of the anterior compartment and 20 asymptomatic controls were studied. Three-dimensional lower limb kinematics and kinetics were compared during walking and marching.Cases were significantly shorter in stature and took a relatively longer stride in relation to leg length than controls. All kinematic differences identified were at the ankle. Cases demonstrated increased ankle plantarflexion from mid-stance to toe-off. Cases also demonstrated less ankle inversion at the end of stance and early swing phases. Lower ankle inversion moments were observed during mid-stance.The anthropometric and biomechanical differences demonstrated provide a plausible mechanism for the development of chronic exertional compartment syndrome in this population. The shorter stature in combination with the relatively longer stride length observed in cases may result in an increased demand on the anterior compartment musculature during ambulation. The results of this study, together with clinical insights and the literature suggest that the suppression of the walk-to-run stimulus during group marches may play a significant role in the development of chronic exertional compartment syndrome within a military population. The differences in joint angles and moments also suggest an impairment of the muscular control of ankle joint function, such as a reduced effectiveness of tibialis anterior. It is unclear whether this is a cause or consequence of chronic exertional compartment syndrome.     

The effect of gender on intramuscular pressure in patients with chronic exertional compartment syndrome of the lower leg

This study aimed to compare intramuscular pressure (IMP) in all four compartments of the lower leg between men and women in patients with suspected chronic exertional compartment syndrome (CECS), and to assess possible effects of gender in relation to covariation factors. A consecutive series of patients with exertional leg pain (n = 962, median age 27 years, 56.2% women) underwent IMP measurements between 2009 and 2019. The CECS diagnosis was confirmed (n = 491, 48% women) or ruled out (n = 471, 65% women) based on the patient's history, clinical examination, and IMP measurements. IMP values of the compartments were compared between genders. A multiple linear regression analysis was performed for IMP in the anterior and lateral compartments, where the number of patients was large enough to investigate the possible impact of other factors such as height, age, and duration of pain. Among those with a confirmed CECS diagnosis, one-minute post-exercise IMP was significantly lower in women than in men for all four muscle compartments: anterior (median [range] mmHg 44 [24–120] vs. 50 [24–130]), lateral (35 [20–89] vs. 40 [26–106]), deep posterior (31 [25–36] vs. 34 [24–53]), and superficial posterior (32 [27–39] vs. 37 [22–54]). In the multiple regression analysis, gender differences remained significant in the anterior compartment but not the lateral compartment, where only height remained a significant predictor of IMP. Gender should be considered when using cut-off values for IMP in diagnosing CECS, especially for the anterior compartment.     

Pathophysiology and diagnosis of chronic compartment syndrome

Chronic compartment syndrome (CCS) should be considered in the differential diagnosis of exertional leg pain. Currently, the pathophysiology of CCS and the mechanisms of pain production are not completely understood. It may be difficult to differentiate CCS from other etiologies of leg pain based on the history and physical examination. Objective diagnosis of CCS is facilitated by direct measurements of intramuscular pressure before, during, and after exercise. This article reviews current understanding of the pathophysiology and diagnosis of CCS.     

Evaluation of Tc-99m-tetrofosmin single-photon emission computed tomography for detection of chronic exertional compartment syndrome of the leg

Chronic exertional compartment syndrome (CECS) of the leg is a common, painful condition related to exercise and associated with increased muscle compartment pressure (CP). Invasive methods are currently the method of choice for diagnosing the condition. We investigated the use of Tc-99m-tetrofosmin perfusion single-photon emission computed tomography (SPECT) as a diagnostic tool compared with the gold standard, muscle CP measurement. In 14 subjects perfusion SPECT and CP were measured before and immediately after exercise leading to pain in the lower legs. Six subjects had increased pressures indicating the presence of CECS. In three (50%) of these muscular hypoperfusion was observed by perfusion SPECT. In eight subjects with normal CPs SPECT suggested muscular hypoperfusion. Because of the low diagnostic rates, sensitivity 50% and specificity 63%, Tc-99m-tetrofosmin perfusion SPECT seems not to be a useful method for diagnosing CECS.     

The evaluation and treatment ofexertional compartment syndrome

Exertional compartment syndrome (ECS) is becoming increasingly recognized as a cause of exercise-induced legpain in the athletic population. Unfortunately, the pathophysiology is not clearly understood. The use of 31P-NMR has shown that ischemia is not a significant component of ECS because it is in the acute syndrome. A primary diagnosis can be made after a thorough history and physical examination. In a young patient with leg pain that is only exercise induced, reproducible and associated with a normal physical examination, a diagnosis of ECS is likely and does not need to be a diagnosis of exclusion. Confirmation with intracompartmental pressure measurement still remains the gold standard before further management. Nonoperative management is usually ineffective and fasciotomies of the affected leg(s) and compartment is the recommended treatment in the symptomatic patient. At our center, the use of a two-incision anterior and lateral compartment release, and a one-incision posterior compartment release has been very successful in returning athletes symptom free to their sporting level.     

Acute exertional compartment syndrome of the paraspinal musculature

BackgroundAcute exertional compartment syndrome of the paraspinal musculature is rarely reported. Only 24 cases have been recorded in the surgical literature since it was first described by Carr et al. in 1985. Supportive management is recommended in the literature but equipoise remains regarding whether to observe the patient only, or perform a lumbar fasciotomy.Materials and MethodsA 21 year old man presented to our hospital following progressively worsening lower back pain after a bout of deadlifting exercises. On presentation he had severe local pain, with tense and enlarged paraspinal muscles. An MRI demonstrated enlarged paraspinal musculature with increased T2 signal bilaterally.ResultsThe patient was treated with topical ice, bed rest, anti-inflammatory agents and hydration. The patient made a full recovery within days.ConclusionCompartment syndrome of the paraspinal muscles is a rare, but serious cause of acute back pain. Non operative treatment was successful in this case and suggests that fasciotomy is not necessary for all such patients.     

Near infrared spectroscopy:A noninvasive technique for diagnosing exertional compartment syndrome

Dual-wave near infrared spectroscopy provides a valuable noninvasive means for monitoring intramuscular oxygen content and potentially for diagnosing exertional compartment syndrome (ECS). The optical technique exploits the difference in optical absorption spectra between oxygenated and deoxygenated states of hemoglobin and myoglobin. By calculating the arithmetic difference between the two absorption spectra, a continuous assessment of tissue oxygenation is generated, which is independent of the overall perfusion state of the muscle. Near-infrared spectroscopy has been used to diagnose ECS in the anterior compartment of the lower leg with exercise in subjects with simulated ECS and in patients with confirmed ECS. In both cases, tissue oxygen decreased significantly within the first minute of exercise compared with healthy control subjects. Also, recovery times after exercise were two and six times as long for simulated ECS and actual ECS, respectively, as compared with healthy controls. These investigations document that near infrared spectroscopy is a unique method for noninvasively monitoring active in vivo metabolic processes of deep tissue and, therefore, holds promise for research and diagnoses of disorders involving upper and lower extremities.     

Intramuscular pressure recording in the assessment of patients with suspected chronic compartment syndrome

This report presents results from intramuscular pressure recordings in 181 consecutive patients. All patients were suspected on clinical grounds of suffering from chronic compartment syndrome (CCS). The diagnostic criterion used in this study was an intramuscular pressure exceeding 30 mmHg immediately postexercise. Most of the pressure studies were made with the micro-capillary infusion technique. CCS in the anterior tibial compartment was diagnosed in 36 of 165 patients with anterior or anterolateral exercise-induced pain. Regarding measurements in other lower-leg compartments, CCS was diagnosed in only one patient in the superficial posterior compartment. CCS was more commonly found in men than in women. It is concluded that, even in highly selected cases, CCS is a rather uncommon cause of exercise-induced pain, predominantly found in the anterior tibial compartment     

小腿骨筋膜间隔综合征的诊治与延误分析

目的 探讨小腿骨筋膜间隔综合征的成因、鉴别特征、早期诊治方法，并分析诊治延误原因。方法 本组男41例，女22例；年龄7—58岁，平均35岁。其中闭合性骨折44例，开放性骨折11例，单纯软组织挫伤8例。致伤原因：交通伤38例，机械绞窄伤9例，高处坠落伤7例，辗压伤5例，砸伤4例。伤后1h～8d入院。18例因各种原因导致延误诊治，其中伤后14例8—12h，4例转入院时已超过24h。密切观察临床症状和特征，及时应用Whiteside针刺测压装置监测，多普勒超声血流探测仪或彩超检查。确诊后即时切开减压33例，保守治疗后减压30例。结果 及时减压组优良率约91％（30／33），保守后减压组优良率约47％（14／30）（x^2=11．79，P〈0．01）。随访10个月～10年，平均3年，其中1例后期形成慢性窦道骨髓炎，1例骨不连接再次植骨加内固定而治愈，6例截肢后安装义肢，足下垂、轻度膝、踝关节僵硬7例，站立及行走乏力4例；44例血液循环及下肢功能恢复良好。结论 早期诊断、严密观察、及时切开减压是治疗骨筋膜间隔综合征的重要措施。