SLR - July 2016 - Colby Carlson

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

Reference: Winkes MB, van Zantvoort AP, de Bruijn JA, Smeets SJ, van der Cruijsen-Raaijmakers M, Hoogeveen AR, Scheltinga MR. Fasciotomy for Deep Posterior Compartment Syndrome in the Lower Leg: A Prospective Study. Am J Sports Med. 2016 May;44(5):1309-16

Scientific Literature Review

Reviewed By: Colby Carlson, DPM
Residency Program: James A. Haley Veteran Affairs Hospital, Tampa, Florida

Podiatric Relevance:
Exercise-induced pain in the posterior part of the leg is common among runners with multiple possible underlying conditions. Chronic exertional compartment syndrome (CECS) is an underdiagnosed syndrome found in young adult recreational runners, elite athletes and military recruits caused by increased intracompartmental pressure (ICP) within a fascial space. Patients report a combination of 5 cardinal symptoms: pain, tightness, cramps, muscle weakness or loss of sensation. The purpose of this study is to report the short- and long-term effects following fasciotomy on pain, tightness and cramps in a prospective cohort of patients with isolated 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.

Methods: This was a case series study design. Between September 2011 and January 2015, pain, tightness, cramps, muscle weakness and diminished sensation were scored on a 5-item verbal rating scale ranging from very severe [5 points] to absent [1 point] in patients with dp-CECS before and after fasciotomy. Patients included reported a history of exercise induced pain along the inner border of the lower leg accompanied by tightness, cramps, weakness, diminished sensation, symptom resolution at rest and elevated ICP immediately after symptom provoking exercise. ICP cutoff points using a slit catheter technique were >15 mmHg at rest, >30mmHg after 1 minute, or >20 mmHg after 5 minutes of provocative exercise. 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 percent; 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 percent). Before surgery, exertional pain was very severe (27 percent) or severe (61 percent). Fasciotomy improved all symptoms, both in the short term (preoperative vs post-operative pain, 4.1 +/- 0.6 vs 2.3 +/- 1.1; P < 0.001) and the long term (pain, 4.2 +/- 0.6 vs 2.7 +/-1.3; P <0.001). 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 percent, good in 29 percent, moderate in 21 percent, fair in 12 percent, and poor in 10 percent of patients. In the long-term, outcomes were similar (excellent, 12 percent; good, 35 percent; moderate, 24 percent; fair, 18 percent; and poor, 12 percent). An unsatisfactory outcome (fair or poor) was often caused by alternative types of CECS (e.g., anterior or lateral CECS) or to medial tibial stress syndrome. Based on their outcome, 76 percent of patients would opt for surgery again. 

Fasciotomy was beneficial in 71 percent of patients with dp-CECS in the lower leg, while 47 percent of study patients experienced a good to excellent outcome.

Conclusions: Outcomes were stable in the long term. Persistent complaints were often caused by other untreated conditions. As a commonly overlooked condition, CECS typically has a delayed diagnosis of 22 months. The diagnosis should be suspected in any athlete who presents with chronic leg pain that worsens with prolonged use and resolves upon cessation. Improved awareness of CECS may result in earlier intervention and higher success rate of therapy.

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