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.
When performing this procedure, the surgeon must pay special attention to the superficial peroneal nerve because of the risk for muscle injury and excessive bleeding. Post-op management of the patient and wound is similar to any other type of open fasciotomy and one must monitor the patient’s gradual return back to activity as well as local healing of the leg wound and the patient’s general health.
Dr. Duggan is an Attending Physician with the Florida Hospital East Orlando Residency Training Program in Orlando, Fla. He is a Fellow of the American College of Foot and Ankle Surgeons.