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.

Chronic exertional compartment syndrome in the differential diagnosis of peripheral artery disease in older patients with exercise-induced lower limb pain.

OBJECTIVE: Peripheral artery disease (PAD) and chronic exertional compartment syndrome (CECS) both cause exercise-induced lower limb pain. CECS is mostly described in young individuals and may therefore not be considered in older patients with intermittent claudication. The aim of our study was to identify differences in characteristics and symptomatology between patients with CECS and PAD that may help in recognizing CECS in patients ≥50 years with exercise-induced lower limb pain. METHODS: In this case-control study, patients with CECS ≥50 years were selected from a prospectively followed cohort and compared with a sample of newly diagnosed patients with PAD ≥50 years. A questionnaire assessed frequency and severity of lower limb pain, tightness, cramps, muscle weakness, and altered skin sensation at rest and during exercise. RESULTS: At rest, patients with CECS (n = 43, 42% female, 57 years; range, 50-76 years) reported significantly more pain, tightness, muscle weakness and altered skin sensation (all P < .01) than patients with PAD (n = 41, 39% female, 72 years; range, 51-93 years). Having CECS was associated with a significantly higher combined symptom score at rest (P = .02). During exercise, patients with CECS experienced more tightness, muscle weakness and altered sensation (P < .01), but not pain and cramps (P = .36; P = .70). Exercise-induced complaints occurred much later in patients with CECS than in patients with PAD (15 minutes vs 4 minutes; P < .01). Persistence of pain over 4.5 minutes proved most discriminative for the presence of CECS (sensitivity, 95%; specificity, 54%; positive predictive value, 65%). Exercise cessation completely alleviated complaints in all patients with PAD (n = 41) but not in 73% (n = 29) of the patients with CECS. Ongoing discomfort strongly predicted the presence of CECS (sensitivity, 73%; specificity, 100%; positive predictive value, 100%). CONCLUSIONS: Patients with CECS ≥50 years report a symptom pattern that is different from patients with PAD. These differences may aid vascular surgeons in identifying older patients with CECS.

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.

Superficial Peroneal Nerve Injury Risk During a Semiblind Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg: An Anatomical and Clinical Study.

BACKGROUND:: Up to 8% of patients who underwent a fasciotomy for leg anterior chronic exertional compartment syndrome (ant-CECS) report sensory deficits suggestive of iatrogenic superficial peroneal nerve (SPN) injury. In the current study we aimed to thoroughly assess the risk of SPN injury during a semiblind fasciotomy of the anterior compartment using 2 separate approaches. METHODS:: A modified semiblind fasciotomy of the anterior compartment was performed via a longitudinal 2-cm skin incision 2 cm lateral of the anterior tibial crest halfway along the line fibular head-lateral malleolus both in cadaver legs and in patients with ant-CECS. In the cadaver legs, the skin was removed after the procedure and possible SPN injuries and spatial relationships between the SPN and the opened fascia were studied. Between January 2013 and December 2016, 64 ant-CECS patients who underwent a fasciotomy of the anterior compartment were prospectively followed. Iatrogenic SPN injuries were assessed using questionnaires and physical examinations. RESULTS:: Macroscopic SPN nerve injury was not observed in any of the 9 cadaver legs. In 8 specimens, the SPN was located at least 5 mm posterolateral to the opened fascia. In 1 specimen, an undamaged SPN branch crossed the operative field in a ventral plane. De novo sensory deficits suggestive for iatrogenic SPN injury were not observed in any of the 64 patients (120 legs; 36 females; median age, 22 years) who underwent a fasciotomy of the anterior compartment. CONCLUSION:: The proposed semiblind fasciotomy for treatment of ant-CECS was not associated with SPN injury in either the cadaveric study or our clinical series. LEVEL OF EVIDENCE:: Level IV, case series.

Lower Leg Chronic Exertional Compartment Syndrome in Patients 50 Years of Age and Older.

BACKGROUND: Lower leg chronic exertional compartment syndrome (CECS) is usually diagnosed in young and athletic individuals. The presence of CECS in older patients has received little attention in the literature, and patient characteristics are unknown. PURPOSE: To determine the prevalence of CECS in older patients (≥50 years) and to assess whether older patients with CECS differ clinically from younger patients with CECS. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All individuals with exercise-induced lower leg pain who visited a referral center for CECS between January 2001 and December 2013 were eligible for analysis. Patients were included if history, physical examination, and dynamic intracompartmental pressure measurement indicated CECS. Characteristics of patients 50 years of age or older were compared with characteristics of patients younger than 50. RESULTS: A total of 698 patients with CECS were included: 98 patients were aged 50 years or older and 600 patients were younger than 50 years. Older individuals more often reported a history of lower leg events or comorbidities (≥50 years, 45% vs <50 years, 25%; P < .01) and unilateral symptoms (≥50 years, 45% vs <50 years, 22%; P < .01). Most older patients (62%) did not participate in sport or only walked or hiked, whereas the same was true of only 7% of the younger population. Pain (≥50 years, 94%; <50 years, 96%) and tightness (≥50 years, 57%; <50 years, 62%) were the predominant symptoms of CECS in both groups. Type of CECS differed significantly (P < .01); the anterior muscle compartment was involved more frequently in older patients (≥50 years, 82% vs <50 years, 59%) and deep flexor muscle CECS was more often diagnosed in younger patients (≥50 years, 26% vs <50 years, 53%). CONCLUSION: In the present population, 1 in 7 patients diagnosed with lower leg CECS was 50 years of age or older. These individuals were less active and had more comorbidities than patients younger than 50 years. Older individuals predominantly have anterior CECS. Clinicians should consider CECS in older individuals with exercise-induced lower leg pain, particularly if it is unilateral.

Factors Predicting Lower Leg Chronic Exertional Compartment Syndrome in a Large Population.

Knowledge about lower leg chronic exertional compartment syndrome (CECS) is largely obtained from highly selected populations. Patient characteristics may therefore not be appropriate for the general population. Our purpose was to describe a heterogeneous population of individuals suspected of lower leg CECS and to identify predictors of CECS. Charts of individuals who were analyzed for exercise-induced lower leg pain in a referral center between 2001 and 2013 were retrospectively studied. Patients were included if history and physical examination were suggestive of CECS and if they had undergone a dynamic intracompartmental pressure measurement. Six hundred ninety-eight of 1411 individuals were diagnosed with CECS in one or more of three lower leg muscle compartments (anterior tibial, deep flexor, lateral). Prevalence of CECS peaked around the age of 20-25 years and decreased thereafter, although a plateau around 50 years was found. Age, gender, bilateral symptoms, previous lower leg pathology, sports (running and skating) and tender muscle compartments were identified as independent predictors of lower leg CECS. The proposed predictive model has moderate discriminative ability (AUC 0.66) and good calibration over the complete range of predicted probabilities. The predictive model, displayed as a nomogram, may aid in selecting individuals requiring an invasive dynamic intracompartmental muscle pressure measurement.

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.

Accuracy of Palpation-Guided Catheter Placement for Muscle Pressure Measurements in Suspected Deep Posterior Chronic Exertional Compartment Syndrome of the Lower Leg: A Magnetic Resonance Imaging Study.

BACKGROUND: A diagnosis of lower leg deep posterior chronic exertional compartment syndrome (dp-CECS) is made by a dynamic pressure measurement. The insertion of a pressure catheter is guided by anatomic landmarks (freehand) or by ultrasound. The catheter tip is ideally positioned in the tibialis posterior muscle (TP). The accuracy of in vivo catheter placement using lower leg magnetic resonance imaging (MRI) in healthy patients suspected of having dp-CECS has never been studied. PURPOSE: To analyze whether a freehand catheter insertion results in accurate positioning in the TP as confirmed by MRI in patients with suspected dp-CECS. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Catheters were inserted into central portions of the TP using a standard puncturing technique guided by lower leg anatomic landmarks. After timed muscle pressure measurements during a standard provocative treadmill running test, lower leg MRI scans were obtained and evaluated by 2 skilled radiologists. Catheter tip placement was termed accurate (in the TP), suboptimal (in the deep posterior compartment but outside the TP), or inaccurate (outside the deep posterior compartment). RESULTS: Between March 2013 and September 2014, a total of 24 patients (8 male, 16 female; mean age, 30 years [range, 18-54 years]) underwent an intracompartmental pressure (ICP) measurement, followed by MRI. Cardinal symptoms were pain during exertion (20% very severe, 53% severe, and 20% moderate) and tightness (29% very severe, 43% severe). Symptoms were bilateral in 74% of patients. Nine of the 24 patients were diagnosed with dp-CECS based on elevated ICPs. Of the 24 patients, catheter tip placement was accurate in 10 (42%), whereas suboptimal placement was achieved in 9 (38%). Five procedures were inaccurate (transition zone between the deep and superficial compartments, n = 3; in the superficial lower leg compartment, n = 2). Signs of a hematoma were found in 38% of the patients, although there were no associated clinical symptoms. CONCLUSION: Palpation-guided placement of catheters for TP pressure measurements is suboptimal in more than half of the patients with suspected lower leg dp-CECS. Optimizing the pressure catheter tip positioning technique may improve diagnostic accuracy in dp-CECS.

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.

Isolated Chronic Exertional Compartment Syndrome of the Lateral Lower Leg: A Case Series.

BACKGROUND: Exercise-induced lower leg pain may be caused by chronic exertional compartment syndrome (CECS). The anterior (ant-CECS) or deep posterior compartment (dp-CECS) is usually affected. Knowledge regarding CECS of the lateral compartment (lat-CECS) is limited. PURPOSE: To describe demographic characteristics and symptoms in a consecutive series of patients with isolated CECS of the lateral compartment of the leg. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Since 2001, patients undergoing dynamic intracompartmental pressure (ICP) measurements for suspected CECS in a single institution were prospectively monitored. Individuals with a history possibly associated with lat-CECS and elevated ICP measurements (Pedowitz criteria) were identified. Exclusion criteria were concomitant ipsilateral ant-CECS/dp-CECS, acute compartment syndrome, recent significant trauma, peroneal nerve entrapment, or vascular claudication. RESULTS: During an 11-year time period, a total of 26 patients with isolated lat-CECS fulfilled study criteria (15 females; median age, 21 years; range, 14-48 years). Frequently identified provocative sports were running (n = 4), walking (n = 4), field hockey (n = 3), soccer (n = 3), and volleyball (n = 2). Exercise-induced lateral lower leg pain (92%) and tightness (42%) were often reported. The syndrome was bilateral in almost two-thirds (62%, n = 16). Delay in diagnosis averaged 24 months (range, 2 months to 10 years). CONCLUSION: Young patients with exercise-induced pain in the lateral portions of the lower leg may suffer from isolated CECS of the lateral compartment. ICP measurements in the lateral compartment in these patients are recommended.

Is surgery effective for deep posterior compartment syndrome of the leg? A systematic review.

BACKGROUND: Results of surgery for lower leg deep posterior chronic exertional compartment syndrome (dp-CECS) are inferior compared to other types of CECS. Factors influencing suboptimal surgical results are unknown. The purpose of this systematic review was to provide a critical analysis of the existing literature on the surgical management of dp-CECS aimed at identifying parameters determining surgical results. METHODS: A literature search was performed using Pubmed, EMBASE, MEDLINE and CINAHL (EBSCO). Studies including surgical results for dp-CECS were systematically reviewed. RESULTS: 7 studies of level III evidence reporting on a total of 131 patients met inclusion criteria (>5 patients, reporting intracompartmental pressures (ICP), clearly stating postoperative outcome). Only four studies strictly adhered to predefined ICP criteria. Cutoff ICP levels varied widely among the 7 studies. Surgical procedures ranged from a superficial crural fasciotomy to multiple fasciotomies of various deep posterior compartments. No single surgical procedure proved superior. Prolonged high ICP levels following provocation were associated with postoperative success. Success rates after fasciotomy were modest ranging from 30% to 65%. Risk factors for failure of surgery were not identified. CONCLUSIONS: The quality of studies reporting on surgery for dp-CECS is poor. Prospective, controlled or randomised studies are lacking. Diagnostic criteria and surgical techniques are diverse. As functional results of current management regimes are disappointing, future studies of dp-CECS should focus on optimising diagnostic criteria and standardisation of treatment modalities.

Compartment pressure curves predict surgical outcome in chronic deep posterior compartment syndrome.

BACKGROUND: Results of surgery for chronic exertional compartment syndrome (CECS) of the lower leg deep posterior compartment are inferior compared with other types of CECS. Factors predicting success after surgery are unknown. PURPOSE: To study the prognostic value of preoperative compartmental pressure curves in patients receiving surgery for deep posterior compartment CECS. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Intracompartmental pressures (ICPs) of patients with deep posterior lower leg CECS were obtained at 4 time points (ie, before, immediately after, and 1 and 5 minutes after a standard exercise challenge test). Area under the 4-point pressure curve was calculated. Patients received a questionnaire investigating residual symptoms after surgery. RESULTS: A complete data set was available for 52 patients (men, n = 23; age, 33 ± 14 years). They rated their 3-month postoperative clinical outcome as excellent (14%), good (38%), fair (35%), or poor (13%). Outcome at 3 months was related to the area under the preoperative 4-point pressure curve (excellent, 127 ± 28; good, 113 ± 25; fair, 100 ± 22; and poor, 88 ± 15; P = .005; odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01-1.08). At the long-term follow-up (39 ± 24 months), all 5 cardinal symptoms (pain, tight feeling, cramps, weakness, and diminished sensibility) were greatly attenuated (P < .001) in the successfully operated group. Long-term success was 48%. Delay in diagnosis was related to poor outcome (P = .04). Correlations between pressures/area under the 4-point pressure curve and long-term outcome were not significant, however. CONCLUSION: Preoperative measured intracompartmental pressures obtained in rest and after a standard exercise test may predict success of surgery for deep posterior compartment CECS of the lower limb. Further standardizing of preoperative pressure protocols may confirm that compartmental pressure analysis has diagnostic as well as predictive properties.

Long-term results of surgical decompression of chronic exertional compartment syndrome of the forearm in motocross racers.

BACKGROUND: Chronic exertional compartment syndrome (CECS) is occasionally observed in the forearm flexor muscles of motocross racers. Long-term results of fasciectomy and fasciotomy for this syndrome are scarce. PURPOSE: To study the long-term effects of 2 surgical techniques for forearm flexor CECS. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A database of patients with forearm CECS who underwent surgery was analyzed. Long-term pain reduction (visual analog scale [VAS], 0-100) and efficacy were evaluated using a questionnaire. RESULTS: Data of 24 motocross racers were available for analysis. Intracompartmental pressures during rest, during provocation, and after 1 and 5 minutes of provocation were 15 ± 4, 78 ± 24, 29 ± 10, and 25 ± 7 mm Hg, respectively. Painful sensations in the forearm were reduced from 53 to 7 (median VAS; P < .001). Both fasciectomy (n = 14) and fasciotomy (n = 10) were equally effective. More than 95% (23/24) of the patients were satisfied with the postoperative result after 5 ± 2 years' follow-up. CONCLUSION: Surgical fasciotomy and fasciectomy of the forearm flexor compartment are equally successful in motocross racers suffering from forearm CECS.

Assessment of the effects of physical training in patients with chronic heart failure: the utility of effort-independent exercise variables.

Traditionally, the effects of physical training in patients with chronic heart failure (CHF) are evaluated by changes in peak oxygen uptake (peak VO(2)). The assessment of peak VO(2), however, is highly dependent on the patients' motivation. The aim of the present study was to evaluate the clinical utility of effort-independent exercise variables for detecting training effects in CHF patients. In a prospective controlled trial, patients with stable CHF were allocated to an intervention group (N = 30), performing a 12-week combined cycle interval and muscle resistance training program, or a control group (N = 18) that was matched for age, gender, body composition and left ventricular ejection fraction. The following effort-independent exercise variables were evaluated: the ventilatory anaerobic threshold (VAT), oxygen uptake efficiency slope (OUES), the V(E)/VCO(2) slope and the time constant of VO(2) kinetics during recovery from submaximal constant-load exercise (tau-rec). In addition to post-training increases in peak VO(2) and peak V(E), the intervention group showed significant within and between-group improvements in VAT, OUES and tau-rec. There were no significant differences between relative improvements of the effort-independent exercise variables in the intervention group. In contrast with VAT, which could not be determined in 9% of the patients, OUES and tau-rec were determined successfully in all patients. Therefore, we conclude that OUES and tau-rec are useful in clinical practice for the assessment of training effects in CHF patients, especially in cases of poor subject effort during symptom-limited exercise testing or when patients are unable to reach a maximal exercise level.

Evaluation of two methods for continuous cardiac output assessment during exercise in chronic heart failure patients.

The purpose of this study was to evaluate the accuracy of two techniques for the continuous assessment of cardiac output in patients with chronic heart failure (CHF): a radial artery pulse contour analysis method that uses an indicator dilution method for calibration (LiDCO) and an impedance cardiography technique (Physioflow), using the Fick method as a reference. Ten male CHF patients (New York Heart Association class II-III) were included. At rest, cardiac output values obtained by LiDCO and Physioflow were compared with those of the direct Fick method. During exercise, the continuous Fick method was used as a reference. Exercise, performed on a cycle ergometer in upright position, consisted of two constant-load tests at 30% and 80% of the ventilatory threshold and a symptom-limited maximal test. Both at rest and during exercise LiDCO showed good agreement with reference values [bias +/- limits of agreement (LOA), -1% +/- 28% and 2% +/- 28%, respectively]. In contrast, Physioflow overestimated reference values both at rest and during exercise (bias +/- LOA, 48% +/- 60% and 48% +/- 52%, respectively). Exercise-related within-patient changes of cardiac output, expressed as a percent change, showed for both techniques clinically acceptable agreement with reference values (bias +/- LOA: 2% +/- 26% for LiDCO, and -2% +/- 36% for Physioflow, respectively). In conclusion, although the limits of agreement with the Fick method are pretty broad, LiDCO provides accurate measurements of cardiac output during rest and exercise in CHF patients. Although Physioflow overestimates cardiac output, this method may still be useful to estimate relative changes during exercise.

Reproducibility of onset and recovery oxygen uptake kinetics in moderately impaired patients with chronic heart failure.

Oxygen (O2) kinetics reflect the ability to adapt to or recover from exercise that is indicative of daily life. In patients with chronic heart failure (CHF), parameters of O2 kinetics have shown to be useful for clinical purposes like grading of functional impairment and assessment of prognosis. This study compared the goodness of fit and reproducibility of previously described methods to assess O2 kinetics in these patients. Nineteen CHF patients, New York Heart Association class II-III, performed two constant-load tests on a cycle ergometer at 50% of the maximum workload. Time constants of O2 onset- and recovery kinetics (tau) were calculated by mono-exponential modeling with four different sampling intervals (5 and 10 s, 5 and 8 breaths). The goodness of fit was expressed as the coefficient of determination (R2). Onset kinetics were also evaluated by the mean response time (MRT). Considering O2 onset kinetics, tau showed a significant inverse correlation with peak- VO2 (R = -0.88, using 10 s sampling intervals). The limits of agreement of both tau and MRT, however, were not clinically acceptable. O2 recovery kinetics yielded better reproducibility and goodness of fit. Using the most optimal sampling interval (5 breaths), a change of at least 13 s in tau is needed to exceed normal test-to-test variations. In conclusion, O2 recovery kinetics are more reproducible for clinical purposes than O2 onset kinetics in moderately impaired patients with CHF. It should be recognized that this observation cannot be assumed to be generalizable to more severely impaired CHF patients.

Sports-related flow limitations in the iliac arteries in endurance athletes: aetiology, diagnosis, treatment and future developments.

Approximately one in five top-level cyclists will develop sports-related flow limitations in the iliac arteries. These flow limitations may be caused by a vascular lumen narrowing due to endofibrotic thickening of the intima and/or by kinking of the vessels. In some athletes, extreme vessel length contributes to this kinking. Endofibrotic thickening is a result of a repetitive vessel damage due to haemodynamic and mechanical stress. Atherosclerotic intimal thickening is seldom encountered in these young athletes. This type of sports-related flow limitation shows no relationship with the classical risk factors for atherosclerosis like smoking, hypercholesterolaemia or family predisposition for arterial diseases. The patient's history is paramount for diagnosis. If an athlete reports typical claudication-like complaints in a leg at maximal effort, which disappear quickly at rest, approximately two out of three will have a flow limitation in the iliac artery. In current (sports) medical practice, this diagnosis is often missed, since a vascular cause is not expected in this healthy athletic population. Even if suspected, the routinely available diagnostic tests often appear insufficient. Definite diagnosis can be made by a combination of the patient's history and special designed tests consisting of a maximal cycle ergometer test with ankle blood pressure measurements and/or an echo-Doppler examination with provocative manoeuvres like hip flexion and exercise. Conservative treatment consists of diminishing or even completely stopping the provocative sports activity. If conservative treatment is insufficient or deemed unacceptable, surgical treatment might be considered. As surgery needs to be tailored to the underlying lesions, a detailed analysis before surgery is necessary. Standard clinical tests, used for visualising atherosclerotic diseases, are inadequate to identify and quantify the causes of flow limitations. Echo-Doppler examination and magnetic resonance angiography with both flexed and extended hips have been proven to be adequate tools. In particular, overprojection and eccentric location of the lesions seriously limit the usefulness of a two-dimensional technique like digital subtraction angiography. In the early stages, when kinking has not yet led to intimal thickening or excessive lengthening, simple surgical release of the iliac artery is effective. However, for patients with excessive vessel lengths or extensive endofibrotic thickening, a vascular reconstruction may be necessary. A major drawback of these interventions is that long-term effects and complications are unknown. As both the diagnostic methods and the treatments for this type of flow limitation differ substantially from routine vascular procedures, these patients should be examined in specialised research centres with appropriate diagnostic tools and medical experience.