Current Concepts In Treating Chronic Exertional Compartment Syndrome

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A Historical Perspective On The Emergence Of Chronic Exertional Compartment Syndrome

In regard to chronic exertional compartment syndrome, Voght and Severin originally referred to the condition as march gangrene in 1943.1 They noted that march gangrene occurred in fit young soldiers who were undergoing training.

   Cerumen and colleagues described the condition again in 1944.2 They discussed the assumption that the condition was due to the cumulative affects of multiple microtrauma rather than a single injury. These authors noted the condition “ … stimulated a march fracture and could be called march myositis. This in fact was a misnomer since the pathology was not that of inflammation of muscle but of infarction.”2

   Physicians reported diagnosing the condition in the lower extremities, most often the anterior tibial compartment, with signs and symptoms of pain, swelling and local heat. When physicians utilized electronic diagnostic testing, the muscle showed no symptoms. There was often evidence of peripheral nerve injury and an inability for the patient to move her digits. Patients have also experienced numbness in the first interdigital space of the foot.

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66
Author(s): 
Robert J. Duggan, DPM, FACFAS

   I then ask the patient to exercise either in the office or outside the office with a short run. Then I redo this test on both legs. The affected leg in most cases will have as much as a 50 percent decrease in the sphygmomanometer measurement of mmHg when the patient reports perceived pain in comparison with the unaffected side. Further research is warranted to correlate these measurements with preoperative intracompartmental pressure measurements or near-infrared spectroscopy measurements.

   A delay in identifying CECS can lead to local tissue necrosis and permanent changes to both the musculoskeletal component and the neurologic component of the lower leg.4

Weighing Conservative Versus Surgical Treatment

Treatment for CECS focuses on decreasing pain and limiting any chronic tissue damage to the fascial compartment that is involved. Physical therapy and modalities geared toward decreasing inflammation seem to be of some value in those patients who have mild symptoms. When it comes to patients with persistent CECS, symptoms will limit activity enough that these patients will seek additional pain relief in the form of surgical intervention.

   For those patients failing conservative care, surgeons have used several approaches for fascial decompression. In the early history of this condition, treatment was in most cases an open fasciotomy of the compartment involved.5 More recent reports are focusing on incisional fascial decompression of the involved compartments with a significant shift toward the use of endoscopic techniques.3,6,7 These procedures have been very effective in decreasing symptomatology as well as shortening the postoperative time to healing.

   A large portion of the patients presenting with chronic exertional compartment syndrome have involvement in the anterior or anterior-lateral lower leg compartment. There have been significant advances in the surgical treatment of these two compartments with the use of endoscopic procedures, which we have used in my practice with good success. Research has shown that the procedure described by Stein and Sennett is safe and effective.7

Step-By-Step Surgical Insights

Prep and drape the affected lower leg in the usual manner. Place a pneumatic tourniquet at the thigh and set it for the appropriate level for hemostasis. Place the surgical incision 5 cm lateral to the crest of the tibia and 12.5 cm proximal from the distal aspect of the fibula. The incision is approximately 2 to 3 cm in length and the surgeon deepens it to expose the fascia. Make a linear incision in the fascia below the skin incision. Using a switching stick from the arthroscopy instrumentation, make a tunnel and move proximal to accommodate long Metzenbaum scissors.

   Introduce the arthroscopy camera subcutaneously and as the camera moves proximally, use it to visualize the fasciotomy. This allows for direct arthroscopic visualization of the fascial incision, the perforating vessels, the underlying musculature and the portions of the peroneal nerve that may be presenting to the wound area. Then free the switching stick, remove the arthroscopic camera and free the fascia distally. This completes the procedure.

   Withdraw the instrumentation, place simple sutures in the skin and apply a wound dressing. Apply a bandage of half-stretch Coban (3M) over the compartment from distal to proximal to create a mild compression dressing. Follow-up occurs between three and five days postoperatively. The patient is able to actively dorsiflex and plantarflex to toleration but with no weightbearing on the affected side for the first three to five days. The patient then slowly progresses to full activity as tolerated.

What The Literature Says About Subcutaneous Fasciotomies

Several authors have reported excellent or good results in the majority of their patients who have undergone subcutaneous fasciotomies.8-10 In those patients with less than excellent results, hematoma was the most common postoperative complication.

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