SLR - July 2016 - Khoa Nguyen

Surgical Management for Chronic Exertional Compartment Syndrome of the Leg: A Systematic Review of the Literature

Reference: Campano D, Robaina JA, Kusnezov N, Dunn JC, Waterman BR. Surgical Management for Chronic Exertional Compartment Syndrome of the Leg: A Systematic Review of the Literature. Arthroscopy. 2016 Jul;32(7):1478-86.

Scientific Literature Review

Reviewed By: Khoa Nguyen, DPM
Residency Program: Morristown Medical Center, Atlantic Health System, New Jersey

Podiatric Relevance: This article focuses mainly on the lower-leg compartment syndrome and is incredibly useful for podiatric surgeons to review and evaluate the techniques, functional outcomes and complication rates after operative management of exertional compartment syndrome of the lower leg. The underlying pathology is from transient muscular ischemia and progressive neurovascular dysfunction due to increased intramuscular pressures during exercise. The clinical outcomes of operative management in active individuals are still varied across existing literature. The authors hypothesized that operative management of chronic exertional compartment syndrome (CECS) of the lower leg would offer moderate symptomatic relief but with a significant rate of complications and reoperation among the young athletic demographic.

Method:
A comprehensive literature search of all publications regarding CECS of the lower leg was performed using an Internet-based search beginning with queries of the PubMed, Medline, CINAHL, Cochrane and Embase databases for all articles between January 1, 1970 and March 1, 2015. A total of 204 original articles were isolated for screening. Exclusion criteria consist of 1 or more of the following: animal model or basic science research, acute compartment syndrome, compartments other than the leg, nonsurgical treatment or publication before 1970. The remaining articles were then reviewed for the following inclusion criteria: peer-reviewed clinical studies of Level I to IV evidence, case series including at least 5 patients and clinical follow-up of at least 80% percent and 6 months. Clinical success was defined as 1 or more of the following: good/excellent patient-reported outcome, postoperative patient satisfaction, complete resolution of pain or return to full preoperative levels of activity.

Results: The final review included 24 publications, which comprised 1,596 patients with the weighted average age of 26.6 years. Nearly one-half of the population consisted of military service members, and one-third were specified as athletes. Bilateral involvement was reported in 79 percent of patients in 14 studies. Anterior compartment is most common (50 percent), followed by lateral (33 percent), deep posterior (14 percent), and superficial posterior (3 percent). Nine studies used the Pedowitz criteria to confirm clinical diagnosis of CECS, constituting symptomatic compartment pressure of 15 mm Hg or more before exercise, 30 mm Hg or more at 1 minute after exercise or 20 mm Hg or more at 5 minutes after exercise. Five studies used conventional radiography and bone scans for exclusion diagnosis. Two studies performed vascular test to rule out vascular obstruction. Ninety-four percent of the entire population underwent surgical management, compartment-specific open fasciotomy (86 percent), partial fasciotomy (12 percent) and endoscopic fasciotomy (<2 percent). The defined cumulative success rate was 66 percent. The success rates for specific compartment releases were 86 percent with involvement of the anterior compartment; 90 percent, lateral; 61 percent, deep posterior; 100 percent, superficial posterior. The rate of recurrence of symptoms ranged between 0 percent and 44.7 percent. The overall complication rate was 13 percent, with mostly from neurologic dysfunction such as superficial peroneal neuritis.

Conclusion: The authors found that primary surgical management of CECS of the lower leg showed a cumulative clinical success rate of 66 percent, with a risk of reoperation and complications of 6 percent and 13 percent respectively. Open fasciotomy remains the predominant surgical treatment. After reviewing this article, there are several diagnostic criteria and success rates that would guide podiatric surgeons to accurately diagnose and counsel the patients appropriately for better outcomes in the future. 

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