Long-term outcome of fasciotomy with partial fasciectomy for chronic exertional compartment syndrome of the lower leg

BACKGROUND: Fasciotomy with partial fasciectomy for compartment syndrome has had good short-term results, but no long-term studies have been performed. HYPOTHESIS: Combining a partial fasciectomy with fasciotomy for compartment syndrome relieves pain and eliminates symptoms in the long term. STUDY DESIGN: Retrospective cohort study. METHODS: A self-administered questionnaire was given to 62 patients at a mean follow-up of 51 months after surgery. RESULTS: Of the 50 patients who underwent a single operation, 60% (30) reported an excellent or good outcome. Average pain and pain-on-running were significantly reduced, although some subjects still reported considerable levels of pain. Fifty-eight percent (36 of 62) were exercising at a lower level than before injury and, of these, 36% (13) cited the return of their compartment syndrome or the development of a different lower leg compartment syndrome as the reason for a reduction in exercise levels. Some subjects indicated early initial improvement followed by subsequent deterioration. CONCLUSION: This surgical technique reduces pain and allows the majority of patients to return to sports; however, patients should be counseled that they may not be able to return to their preinjury level of exercise or remain pain-free.     

Diagnosis of exercise-induced pain in the anterior aspect of the lower leg

Ninety-eight patients with chronic exercise-induced pain in the anterior compartment of the lower leg underwent extensive clinical and laboratory investigations to establish the diagnosis. They all were referred because of a putative chronic compartment syndrome (CCS). Intramuscular pressure was recorded bilaterally during exercise in the anterior tibial muscle in all of them. Conduction-velocity recordings of the deep and superficial peroneal nerves were performed in 29 patients. Other investigations included radiography, plethysmography, and scintigraphy. CCS was diagnosed in 26 of the 98 patients. Other diagnoses included periostitis in 41 patients, compression of the superficial peroneal nerve in 13, and miscellaneous other diagnoses in 18. CCS seems to be an uncommon reason for anterior pain in the lower legs.     

Minimally invasive fasciotomy in chronic exertional compartment syndrome and fascial hernias of the anterior lower leg: short- and long-term results

This study evaluated the efficacy of a minimally invasive percutaneous fasciotomy in chronic exertional compartment syndrome and fascial hernias of the anterior lower leg (N = 118). Approximately one-third of symptomatic legs (n = 41) demonstrated fascial herniation and underwent fasciotomy without compartment pressure measurements via a small percutaneous incision using a fasciotome. Symptomatic legs with an intact fascia (n = 77) received similar operative treatment based on pressure measurements. Relief of symptoms was obtained in all but two patients. Postoperative complications included hematoma (9%), superficial peroneal nerve injury (2%), anterior ankle pain (5%), and recurrence (2%). Most patients (96%) reported unlimited exercise after a mean follow-up of 62 months. However, mild symptoms associated with nerve injury as well as ankle pain persisted (4%). A minimally invasive fasciotomy of the anterior lower leg harboring fascial hernias or a chronic exertional compartment syndrome is effective. Complications such as nerve injury and anterior ankle pain may be related to a too distally performed fasciotomy.     

Intramuscular pressures in exercise-induced lower leg pain

Intramuscular pressures were measured in 12 patients with symptoms of medial tibial syndrome and in 12 patients with chronic anterior compartment syndrome. Measurements were performed with the wick catheter technique simultaneously in the deep posterior and the anterior tibial muscle compartments before, during, and after exercise. In the deep posterior compartment there was no pressure increase during or after exercise as compared to controls in either patient group. However, a significant pressure increase was present in the anterior tibial compartment during and after exercise in the patients with chronic anterior compartment syndrome as compared to normal resting values. The medial tibial syndrome patients demonstrated in the anterior tibial muscle compartment, exercise and post-exercise pressures, which were between those of the healthy controls and the chronic anterior compartment syndrome patients. The so-caLled medial tibial syndrome is probably not a compartment syndrome in the deep posterior muscle compartment. Intramuscular pressure measurement is a valuable tool in diagnosing a chronic compartment syndrome and in selecting patients in whom fasciotomy of the affected compartment is indicated.     

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.     

Chronic exercise-induced pain in the anterior aspect of the lower leg. An overview of diagnosis

Clinical examination following an exercise test that elicits the symptoms of lower leg pain is most helpful in diagnosing the causes. Location of swelling, pain, impaired muscle function and impaired nerve function should all be analysed. History and clinical signs alone are insufficient to establish the diagnosis of chronic anterior compartment syndrome, and for this reason intramuscular pressure recordings have an important role in diagnosis. Different techniques for pressure recording and different pressure parameters are reviewed. Muscle relaxation pressure during exercise and intramuscular pressure at rest after exercise are the best parameters to study. Fasciotomy relieves pain in between 60% and 100% of patients. Closure of a fascial defect is never indicated, because it decreases the compartment size and may precipitate an acute compartment syndrome. Recording of nerve conduction velocity is a helpful complement in the diagnosis and evaluation of superficial peroneal nerve compression. Decompression by local fasciectomy and fasciotomy of the lateral compartment gives good results in more than 50% of patients. The value of periostitis as a clinical sign and the possibility of chronic pain following eccentric exercise are discussed.     

Chronic deep posterior compartment syndrome of the leg in athletes: postoperative results of fasciotomy

The present study evaluates the efficacy of two treatment regimens in individuals possibly suffering from chronic exercise induced compartment syndrome (CECS) of the deep posterior compartment of the leg. We hypothesised that the current method of fasciotomy of the deep posterior compartment of the leg is a procedure with a limited success rate. Dynamic intra-compartmental pressure measurements were applied to 46 patients that had symptomatology of a posterior CECS. Only those patients that met predefined pressure criteria, the "high-pressure group" (27 patients), were offered surgical treatment in the form of fasciotomy. The other 19 patients, "low-pressure group", received conservative treatment, consisting of inlays and physiotherapy. In addition, these patients were examined more closely in order to exclude different pathology. Efficacy of both approaches was evaluated by a questionnaire after a mean three-year follow-up. Fifty-two percent of the high-pressure group judged their operation successful, whereas 48 % did not. The majority of the low-pressure group (84 %) was free of symptoms, after conservative treatment as well as following treatment of other pathology. The present study shows that the success rate of patients surgically treated for posterior CECS is relatively low (52 %). The established cut-off points for the compartment pressure to deselect patients for an operation are justified based on the long-term success rate of the low-pressure group.     

Revision surgery for exertional anterior compartment syndrome of the lower leg: technique, findings, and results

BACKGROUND: Recurrent symptoms or failure after fasciotomy for exertional anterior compartment syndrome is not uncommon. HYPOTHESIS: Symptoms from high compartment pressures can be secondary to involvement of the entire compartment or to localized constrictions from postsurgical fibrosis, as well as to entrapment of the superficial peroneal nerve. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eighteen patients who underwent revision surgery for exertional anterior compartment syndrome were available for follow-up. All were athletes who had either a failure or a recurrence of symptoms at a mean of 23.5 months (range, 8-54 months) after the index fasciotomy. Pressure measurements using a slit catheter at rest, at 1 minute postexercise, and at 5 minutes postexercise were performed in 2 places within the compartment: in the area of the previous incision and in the proximal muscle belly of the tibialis anterior. Surgical technique consisted of a 2-incision approach with partial fasciectomy, exploration and decompression of the superficial peroneal nerve, and excision of all fibrotic tissue. An objective examination and a comprehensive subjective questionnaire previously described were performed at a mean follow-up of 42 months (range, 22-67 months). RESULTS: Sixty percent of patients had abnormal pressures only in a localized area, whereas 40% had high pressures throughout the compartment. Eight of 18 (44%) patients had symptoms, signs, and surgical findings of entrapment of the superficial peroneal nerve. At follow-up, 72% of patients had a satisfactory outcome (5 excellent, 8 good), and 28% had an unsatisfactory outcome for intense running sports (4 fair, 1 poor), although 3 patients with the fair results reported improvement with low-level activity. All 8 patients with documented peroneal nerve entrapment had a satisfactory outcome. CONCLUSION: Symptoms from high pressures can be secondary to involvement of the entire compartment or localized to a certain area from postsurgical fibrosis. Pressure measurements should be performed in at least 2 separate areas.     

Ultrasound measurement of the anterior leg compartment

Eight male subjects, weighing 65 to 83 kg and between 22 and 34 years of age, were measured for depth changes in the anterior leg compartment at rest and following treadmill running and weighted dorsiflexion exercises. Measurements were obtained from ultrasound scans at two points on the leg. The results showed no significant differences in the compartment's depth between rest and treadmill exercise, while significant changes were noted between rest and dorsiflexion exercises. These results suggest that the anterior leg muscles were maximally functioning during the dorsiflexion exercises, but not during the treadmill exercises. It is concluded that the ultrasound can be used to detect depth changes, and hence volume changes, in muscle compartments and may have potential use in combination with other techniques as a noninvasive diagnostic tool in assessing changes in a muscle compartment.     

The results of fasciotomy in the management of chronic exertional compartment syndrome

Twenty-five patients with well-documented clinical history and elevated tissue pressures were subjected to surgical fasciotomy of the respective compartment (anterior, 13; anterior and posterior, 4; deep posterior, 8). The indications for surgery were resting pressures in excess of 15 mmHg and elevated postexercise pressure measurements with delayed normalization. Twenty-two patients were satisfied with the procedure and were able to return to athletics. There were three failures, all of whom had decompression of the deep posterior compartment. This study has demonstrated that fasciotomy of the anterior compartment, when done with the correct indications, gives excellent relief of chronic anterior leg pain. It is recommended that fasciotomy of the deep posterior compartment include a formal release of the tibialis posterior at the time of decompression.     

Posteromedial pain in the lower leg

Intramuscular pressure was recorded in 28 patients with exercise-induced posteromedial pain in the lower leg. Pressure was recorded simultaneously in the posterior tibial muscle and in the flexor digitorum muscle during an exercise test and at rest after exercise. This study shows that intramuscular pressures during exercise and the time period for normalization of the pressure at rest after exercise were within normal limits. The result of pressure recording depends on which muscle in the deep posterior compartment is investigated and on the type of work performed. This article describes some of the difficulties associated with pressure recording in the deep posterior compartment. Chronic compartment syndrome in the deep posterior compartment as a reason for pain in the posteromedial part of the lower leg could not be demonstrated.     

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.     

Indications and results of fasciotomy in vascular injuries of the lower extremities

Aim of this study was to re-evaluate the indications for fasciotomy in war vascular injuries of the lower extremities. Retrospective and partially prospective analysis of 31 patients with surgical revascularisation performed during 1999 was done. Fasciotomy has been used as a prophylactic measure against development of Compartment Syndrome (CSy) in three out of ten patients within the first group where ischemia time was less than six hours before the time of repair. The second group, where ischemia time was longer than six hours before the time of repair, prophylactic fasciotomy (measured compartmental pressure lower than 30 mmHg) was performed in 8 patients. In 13 patients with already developed CSy fasciotomy was performed as the delayed treatment (measured compartmental pressure higher than 30 mmHg). Neither one of patients from the first group developed CSy. All patients who developed CSy had necrosis of neuromuscular tissues at the time of surgery. Musculectomy was required in five and limb amputation in six patients. The conclusion of this study is that when the ischemia time is less than six hours before the time of repair fasciotomy is not necessary. When the period from injury to the revascularisation is longer than six hours the prophylactic fasciotomy is recommended.     

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.     

Diagnostic imaging in athletes with chronic lower leg pain

OBJECTIVE: Our purpose is to describe the imaging features in athletes with chronic lower leg pain, emphasizing the role of MRI and CT, which are the diagnostic tools with the highest sensitivity and specificity in the differential diagnosis of lower leg pain. Moreover, a diagnostic algorithm in patients with chronic lower leg pain is proposed. CONCLUSION: Plain radiography has a low sensitivity but may reveal tibial stress fractures, bone tumors, and soft-tissue calcification. CT and MRI may be useful to better evaluate the abnormalities shown by plain radiography.     

Lower leg pain. Diagnosis and treatment of compartment syndromes and other pain syndromes of the leg

Leg pain in athletes has many aetiologies. The clinician must strive to specifically define the clinical problem in order to administer the appropriate treatment for the athlete's condition. Clinical conditions in the leg causing symptoms in athletes include chronic exertional compartment syndrome (CECC), tendinitis, medial tibial stress syndrome, stress fractures, fascial defects, musculotendinous junction disruptions (tennis leg), popliteal artery entrapment syndrome, effort-induced venous thrombosis and nerve entrapment. Appropriate diagnostic studies are needed to allow accurate diagnosis. A work-up might include radiographs, bone scans and compartment pressure measurement. Many of these conditions relate to overuse and training errors. Conservative measures including rest, activity modification and rehabilitation will permit a gradual return to participation in sports. Some problems such as CECC, popliteal artery entrapment syndrome and nerve entrapment may require surgical intervention to allow the resolution of symptoms. Clinicians should be familiar with the range of problems causing leg pain in order to prescribe specific treatment for each athlete.