Lower Leg Lateral Chronic Exertional Compartment Syndrome: Prospective Surgical Treatment Outcomes for Isolated or Combined Lateral Fasciotomy.

BACKGROUND: Chronic exertional compartment syndrome involving the lower leg lateral compartment (lat-CECS) seldom occurs isolated but is usually combined with CECS of the anterior (ant-CECS) or deep posterior compartment (dp-CECS). Patient characteristics in lat-CECS and outcome after surgery are largely unknown. The aim of this prospective case series was to describe patient characteristics and symptoms and to report on outcome following a fasciotomy. METHODS: All patients diagnosed with lat-CECS based on exertional lateral lower leg symptoms and elevated intracompartmental pressure (ICP) measurements according to the Pedowitz criteria (ICP ≥ 15 mm Hg at rest, and/or ≥30 mm Hg after 1 minute, and/or ≥20 mm Hg 5 minutes after exercise) were eligible for this study. A standard intake questionnaire scoring symptom patterns was completed by all patients. Patients who were operated for lat-CECS were asked to complete a 3-month and 12-month postoperative questionnaire scoring symptoms and surgical outcome. Patients with a history of CECS surgery, recent lower leg trauma, or peripheral neurovascular disease were excluded. RESULTS: A total of 881 patients with possible lower leg CECS completed an intake questionnaire and 88 (10%) were diagnosed with lat-CECS according to the Pedowitz criteria (isolated lat-CECS n = 10; lat/ant CECS n = 54, lat/ant/dp CECS n = 19, lat/dp CECS n = 5). Severe pain during exercise and moderate tightness during rest were frequently reported. A group of 28 patients (49 legs; isolated lat-CECS n = 2; lat/ant CECS n = 22, lat/ant/dp CECS n = 3, lat/dp CECS n = 1) was analyzed after fasciotomy. Complications were minor (wound infection requiring antibiotics, n = 3; temporary complex regional pain syndrome with spontaneous recovery, n = 1). Superficial peroneal nerve damage was not observed. One year after surgery, 64% rated outcome as excellent or good, whereas 71% had resumed sports activities. CONCLUSION: One in 10 patients with anterolateral exertional lower leg pain evaluated in a tertiary referral center met diagnostic criteria for lat-CECS. Pain and tightness were present during exertion and were often reported occurring during rest and at night. In this series, we found fasciotomy-either an isolated (lateral) or a multiple (combined with anterior and/or deep posterior) compartment fasciotomy-is safe and beneficial in most patients. LEVEL OF EVIDENCE: Level IV, case series.

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.

Role of Repeat Muscle Compartment Pressure Measurements in Chronic Exertional Compartment Syndrome of the Lower Leg.

BACKGROUND: The diagnostic gold standard for diagnosing chronic exertional compartment syndrome (CECS) is a dynamic intracompartmental pressure (ICP) measurement of the muscle. The potential role of a repeat ICP (re-ICP) measurement in patients with persistent lower leg symptoms after surgical decompression or with ongoing symptoms after an earlier normal ICP is unknown. PURPOSE: To study whether re-ICP measurements in patients with persistent CECS-like symptoms of the lower leg may contribute to the diagnosis of CECS after both surgical decompression and a previously normal ICP measurement. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Charts of patients who underwent re-ICP measurement of lower leg compartments (anterior [ant], deep posterior [dp], and/or lateral [lat] compartments) between 2001 and 2013 were retrospectively studied. CECS was diagnosed on the basis of generally accepted cutoff pressures for newly onset CECS (Pedowitz criteria: ICP at rest ≥15 mmHg, ≥30 mmHg after 1 minute, or ≥20 mmHg 5 minutes after a provocative test). Factors predicting recurrent CECS after surgery or after a previously normal ICP measurement were analyzed. RESULTS: A total of 1714 ICP measurements were taken in 1513 patients with suspected CECS over a 13-year observation period. In all, 201 (12%) tests were re-ICP measurements for persistent lower leg symptoms. Based on the proposed ICP cutoff values, CECS recurrence was diagnosed in 16 of 62 previously operated compartments (recurrence rate, 26%; 53 patients [64% female]; median age, 24 years; age range, 15-78 years). Recurrence rates were not different among the 3 lower leg CECS compartments (ant-CECS, 17%; dp-CECS, 33%; lat-CECS, 30%; χ2 = 1.928, P = .381). Sex (χ2 = 0.058, P = .810), age (U = 378, z = 1.840, P = .066), bilaterality (χ2 = 0.019, P = .889), and prefasciotomy ICP did not predict recurrence. Re-ICP measurements evaluating 20 compartments with previously normal ICP measurements (15 patients [53% female]; mean age, 31 ± 10 years) detected CECS in 3 compartments (15%, all ant-CECS). CONCLUSION: Previous fasciotomy for lower leg CECS or previously normal muscle pressure (ICP) do not rule out CECS as a cause of persisting lower leg symptoms. Repeat ICP measurement may have a potential role in the evaluation of patients with persistent lower leg complaints. However, other reasons for lower leg exertional pain must always be considered prior to secondary surgery.

Fasciotomy for Deep Posterior Compartment Syndrome in the Lower Leg: A Prospective Study.

BACKGROUND: Patients with exercise-induced lower leg pain may suffer from deep posterior chronic exertional compartment syndrome (dp-CECS). Current evidence for the efficacy of surgery is based on retrospective studies. Effects of fasciotomy on symptoms associated with dp-CECS have not been systematically studied, and reasons for unsuccessful surgery are unknown. PURPOSE: To report the short- and long-term effects of fasciotomy on pain, tightness, and cramps in a prospective cohort of patients with isolated dp-CECS. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between September 2011 and January 2015, pain, tightness, cramps, muscle weakness, and diminished sensation were scored (5-item verbal rating scale ranging from very severe [5 points] to absent [1 point]) in patients with dp-CECS before and after fasciotomy. Outcomes were graded as excellent, good, moderate, fair, or poor. Fair and poor cases were again analyzed during a follow-up visit in the outpatient department. RESULTS: Forty-four patients underwent surgery for isolated dp-CECS. Short-term follow-up (median, 4 months; range, 3-7 months) was complete in 42 of the 44 patients (95%; median patient age, 23 years; 23 male; 64 operated legs). Long-term follow-up (median, 27 months; range, 12-42 months) was complete in 34 of 37 eligible patients (92%). Before surgery, exertional pain was very severe (27%) or severe (61%). Fasciotomy improved all symptoms, both in the short term (preoperative vs postoperative pain, 4.1 ± 0.6 vs 2.3 ± 1.1; P < .001) and the long term (pain, 4.2 ± 0.6 vs 2.7 ± 1.3; P < .001). Levels of tightness, cramps, muscle weakness, and diminished sensation demonstrated similar significant improvements. Short- and long-term symptom scores did not differ. The short-term outcome was excellent in 29%, good in 29%, moderate in 21%, fair in 12%, and poor in 10% of patients. In the long term, outcomes were similar (excellent, 12%; good, 35%; moderate, 24%; fair, 18%; and poor, 12%). An unsatisfactory outcome (fair or poor) was often caused by alternative types of CECS (eg, anterior or lateral CECS) or to medial tibial stress syndrome. Based on their outcome, 76% of patients would opt for surgery again. CONCLUSION: Fasciotomy was beneficial in 71% of patients with dp-CECS in the lower leg; 47% of study patients experienced a good to excellent outcome. Outcomes were stable in the long term. Persistent complaints were often caused by other untreated conditions.

Feasibility and Safety of an Operative Tool for Anterior Chronic Exertional Compartment Syndrome Treatment.

BACKGROUND: Operative management of chronic exertional compartment syndrome of the tibialis anterior muscle compartment (ant-CECS) usually involves the use of a fasciotome. Collateral tissue damage such as hematoma and nerve damage may occur during the procedure. The current report assessed the feasibility and safety of an alternative tool for the operative management of ant-CECS. METHODS: The system had a speculum-like hollow tube that was inserted via a 2-cm skin incision and allowed for the protected advancement of a fasciotome. The device was tested in patients with bilateral ant-CECS. Symptoms were prospectively scored before and after surgery using a 5-category verbal rating scale (VRS). Fourteen patients (age 26 ± 10 years) were analyzed. Complications and operative efficacy were determined using physical examination and questionnaires after 21 (range = 16-25) months. RESULTS: Technical operative success rate was 100% (28/28 legs). Operation time was 10 ± 2 minutes per leg (range = 6-14). Perioperative complications were not observed. One superficial wound infection was treated nonoperatively. Significant reductions in pain (-2.2 ± 1.1 on 5-point VRS, P < .001), tightness (-1.9 ± 1.6, P = .01), cramps (-1.4 ± 1.6, P = .009), muscle weakness (-1.6 ± 1.2, P < .001), and altered sensibility (-1.3 ± 1.4, P = .005) were registered 21 months postoperatively. CONCLUSION: This fasciotome was simple to use and allowed for a safe fasciotomy in patients with leg ant-CECS. A randomized controlled trial comparing the present device with a widely used fasciotome was under way at the time of writing of this study.