How To Diagnose And Treat Chronic Exertional Compartment Syndrome
- Volume 22 - Issue 6 - June 2009
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Why Fasciotomy Is The Gold Standard
The first approach to treatment is conservative care. Conservative options include modification of activity, prolonged rest, anti-inflammatory drugs, stretching, bracing, massage, orthotics, diuretics and physiotherapy.1,7 The literature notes the majority of these conservative modalities tend to be less effective in alleviating exertion-induced pain.
The second option and mainstay of treatment is the fasciotomy. Common techniques include open fasciotomy, subcutaneous release and endoscopically assisted fasciotomy.6 Fasciotomy is generally reserved for recurrent episodes of CECS. Studies have shown that endoscopically assisted fascial release reduces the risk of superficial peroneal nerve injury in comparison to blind percutaneous release.10
In Hutchinson’s study of percutaneous versus endoscopically assisted fasciotomy, four of six specimens undergoing the percutaneous procedure had complete transection of the superficial peroneal nerve.10 Detmer et al., found that 90 percent of the 70 patients treated with subcutaneous fasciotomy had significant improvement.2 Verleisdonk and colleagues had a similar success rate of 87 percent for 53 patients treated with fasciotomy.9
Potential complications of fasciotomy include infection, nerve injury, recurrence secondary to incomplete release, cosmetically unacceptable scarring, muscle fascia adhesions and postoperative hematoma.10
How To Perform An Endoscopically Assisted Fasciotomy For Anterior/Lateral CECS
Prep the left leg and drape it in normal sterile fashion. After performing Esmarch exsanguination, inflate a thigh tourniquet to 300 mmHg to maintain hemostasis. Make a 2 cm vertical incision, the center of which is 12 cm proximal to the lateral malleolus and 5 cm lateral to the tibial crest. Dissect down to the fascia.
Place a 30-degree endoscope into the incision and identify the anatomy within the fascial incision. Then place Metzenbaum scissors into the incision. Under endoscopic visualization, use the scissors to release the fascia both proximally and distally until you can perform a complete fasciotomy. Take care to visualize and protect the superficial peroneal nerve throughout the entire procedure.
It is not uncommon to perform both an anterior and lateral compartment release at the same time. Incise the anterior compartment fascia sharply and insert the endoscope. Using the same technique one would employ with the lateral compartment, incise the anterior compartment fascia under endoscopic visualization proximally and distally. Then irrigate the incision and deflate the tourniquet. After confirming hemostasis, close the incision in a running subcuticular pattern.
Pertinent Postoperative Pearls
The literature describes varying postoperative protocols following fasciotomy. Patients should elevate the extremity for the first 48 to 72 hours to prevent edema. We advocate non-weightbearing for two weeks. One would subsequently emphasize protected weightbearing in a fracture boot and the initiation of formal physical therapy.
At four weeks postoperatively, patients may ambulate in regular shoe gear and resume their normal daily activities. Some high performance athletes may return to training regiments as soon as eight to 10 weeks postoperatively if tolerated.
Chronic exertional compartment syndrome is an activity-induced pathological elevation of tissue pressures within an osteofascial envelope that results in debilitating symptoms of pain and neurological dysfunction. The etiology of this process is unclear but it appears to be a combination of vascular, neurological and muscular sequelae.6 The diagnosis is often difficult due to the differential diagnoses that involve the neurological, vascular and musculoskeletal systems. A high level of clinical suspicion, a thorough history and measurement of the intracompartmental pressures can help accurately diagnose CECS.