Fasciotomy for Exertional Anterior Compartment Syndrome: Is Lateral Compartment Release Necessary?

Fasciotomy for Exertional Anterior Compartment Syndrome: Is Lateral Compartment Release Necessary? – )

Anthony A. Schepsis

The exertional or chronic compartment syndrome is a recognized cause of exercise-induced pain in the lower extremity. Often referred to as a type of shin splint, chronic compartment syndrome is defined as a condition in which exercise elevates intramuscular pressure to a point where ischemic pain occurs.[17] Most investigators believe that the increase in pressure is sufficient to diminish blood flow to the tissues, causing pain and, occasionally, neurologic deficit.[9,11] Nonoperative management of an established chronic anterior compartment syndrome, other than modification of activity, usually does not relieve the symptoms,[19] whereas fasciotomy of the involved compartment has been highly successful in relieving pain and in allowing a return to full activity.[15,19]

The measurement of intracompartmental pressures has been shown to be the best method of confirming the diagnosis of exertional compartmental syndrome.[3,8,11-15] Elevated pressures at rest before exercise, 1 minute after exercise, and 5 minutes after exercise have been shown to be highly diagnostic of exertional compartment syndrome.[12] Mohler et al.[9] have started to investigate near-infrared spectroscopy as a noninvasive diagnostic tool for the evaluation of patients suspected of having chronic anterior compartment syndrome of the leg. They found that patients who had exertional anterior compartment syndrome had greater deoxygenation during exercise and delayed reoxygenation after exercise compared with patients who did not have the syndrome. These findings support the belief that ischemia is the cause of exertional compartment syndrome and suggest a noninvasive diagnostic method for confirming exertional compartment syndrome.

Surgical decompression of the afflicted compartment has been shown to be effective in resolving the symptoms involved with exertional anterior compartment syndrome.[17] Operative decompression of the appropriate compartment is usually indicated, especially after conservative measures have failed. Both the anterior and lateral compartments are routinely released in patients with exertional anterior compartment syndrome.[3,14,15]

We performed this study to compare the efficacy of performing only anterior compartment release with the efficacy of performing both anterior and lateral compartment release for exertional anterior compartment syndrome.

MATERIALS AND METHODS

Between 1991 and 1996, we evaluated 30 legs in 20 patients who had documented exertional anterior compartment syndrome without any suspicion of lateral compartment syndrome. Twenty patients underwent surgical fasciotomy by the senior author (AAS), with 10 of these patients undergoing bilateral releases. We divided the limbs into two categories, those that underwent only anterior compartment fasciotomy and those that underwent both anterior and lateral compartment fasciotomy. We prospectively alternated the patients undergoing unilateral surgery into the two groups.

We suspected exertional anterior compartment syndrome on the basis of the patients’ histories and physical examinations. Initial workup consisted of plain radiographs and, in some cases, a bone scan to rule out a stress fracture or periostitis. The diagnosis of anterior compartment syndrome was confirmed by clinical measurement of resting and postexercise compartment pressures. In none of these patients was there any clinical suspicion of involvement of the lateral compartment. Two patients had been excluded from this study for that reason. None of the patients had any signs of superficial peroneal nerve involvement or entrapment.

Our protocol measured compartment pressures before and at two times after exercise. Since other investigators have shown that compartment pressures vary with the position of the ankle, where dorsiflexion increases compartment pressure, all measurements were done with the ankle at 20 [degrees] of plantar flexion.[5] The Stryker catheter (Stryker Co., Kalamazoo, Michigan) was used in this study. For measuring the anterior compartment pressures, the catheter was placed midway between the anterior tibial crest and the lateral intermuscular septum at the junction of the middle and upper thirds of the leg, with the catheter aimed just proximal into the tibialis anterior muscle. Since none of these patients had any clinical suspicion of lateral compartment syndrome, lateral compartment pressures were not measured.

Patients exercised on an isokinetic machine, alternating between plantar flexion and dorsiflexion, at high speed and low resistance until their symptoms were produced. In patients with symptoms in both legs, we measured the compartmental pressures in one leg and then in the other. If the isokinetic exercise did not reproduce the patients’ symptoms, they ran on a treadmill until the symptoms recurred. We measured static compartment pressures before exercise and 1 and 5 minutes after the cessation of exercise.

There were 15 limbs in group 1, those that received anterior compartment release only. There were 15 limbs in group 2, those that received both anterior and lateral compartment releases. Overall, there were 12 women and 8 men, all of whom were athletes involved in running sports. The ages of the patients ranged from 16 to 37 years, with an average age of 23. The average duration of symptoms in group 1 was 12 months (range, 4 to 30) and in group 2 was 15 months (range, 4 to 30). The average compartment pressures in both groups are listed in Table 1. The mean follow-up was 2.2 years with a range of I to 3.5 years.

TABLE 1 Comparison of Anterior Compartment Pressures in Groups 1 and 2

Average resting Average postexercise pressure

Group pressure (mm Hg) (mm Hg)

After 1 minute After 5 minutes

1 17.1 34.0 25.0

2 16.5 36.5 25.3

Overall 16.8 35.3 25.2

Five of the patients who underwent unilateral-limb surgery were in group 1 and five were in group 2. All of the patients who underwent bilateral-limb surgery had an anterior compartment release on one leg and both an anterior and a lateral compartment release on the other.

Once exertional anterior compartment syndrome was diagnosed on the basis of the patients’ histories and physical examinations and then confirmed by compartment pressure measurements, nonoperative treatment options were limited to restriction or modification of activities. Most of the patients in this study had been referred to our department after failure of nonoperative measures. The long duration of symptoms and previous failure of other nonoperative options indicated the need for operative intervention.

Surgical decompression was performed by a method similar to that described by Fronek et al.[3] and Mubarak and Owen,[11] in which a single 4- to 5-cm vertical incision is made halfway between the anterior tibial crest and the fibula in the midportion of the leg. The incision was made to the fascia, identifying the lateral intermuscular septum. A horizontal incision was then made in the fascia, and, using large right-angle retractors, the fascia was undermined proximally and distally. In cases where only a fasciotomy of the anterior compartment was to be performed, 12-inch fasciotomy scissors were used to release the anterior compartment. If both the anterior and lateral compartments were to be released, fasciotomy of both compartments was performed. The skin was then closed and a compressive dressing was applied.

Postoperative management was similar in both patient groups. Immediate range of motion exercises for the ankle and knee and weightbearing as tolerated were instituted. A compressive dressing was used for approximately 72 hours after surgery. The patients usually discontinued the use of their crutches within 3 to 5 days after surgery, and stretching and strengthening exercises were then begun. A full return to activity was guided by each patient’s response to the surgery.

RESULTS

The evaluation of the success of the patients’ surgery was based on their ability to return to their athletic activities without significant symptoms. This was assessed by a subjective questionnaire (Fig. 1) and by a visual analog pain scale on which the patients estimated the magnitude of their pain at its worst in the recovery room, 6 hours after surgery, on days 1, 2, and 3 after surgery, and at 1, 2, and 3 weeks after surgery. We also evaluated objective criteria such as strength, range of motion of surrounding joints, palpable tenderness, and atrophy.

Figure 1. The subjective questionnaire used in this study.

1. What activity did you participate in when your symptoms began?

2. If you are a runner: How many miles were you running per week at the time you first experienced your symptoms? If you are not a runner: How long was your training session at the time you first experienced your symptoms?

3. At what level of participation were you?

recreational athlete –, club athlete (compete in local/regional events) –, competitive athlete (compete in intercollegiate/scholastic national events) —

4. At what point of the season did you first notice your symptoms?

preseason –, early season –, (within 1st or 2nd month), mid to late season —

5. How did the symptoms affect you?

unable to participate –, able to participate but at a decreased level of performance –, able to participate at same level of performance but with pain —

6. Subjectively, how would you describe your level of activity once your symptoms began?

excellent –, good –, fair –, poor —

7. Which symptoms affected your performance? (you may check more than one symptom)

pain –, paresthesia (numbness) –, tingling –, muscle weakness –, other (describe) —

8. At what point in your training did you experience your symptoms(s)?

prior to beginning your activity –, [is less than] than 15 minutes –, 15-30 minutes –, 30-60 minutes –, [is greater than] 60 minutes —

9. Which nonoperative treatment(s) did you receive?

rest–, ice –, medications –, physical therapy –, ultrasound –, other (describe) —

10. What was the time interval between onset of symptoms to surgery?

0-3 months –,3-6 months –, 6-12 months –, 1-2 years –, [is greater than] than 2 years —

11. Subjectively, how would you rate the success of your surgery?

excellent –, good –, fair –, poor —

12. How long after surgery were you able to make a full return to your sport?

Sport — Time – Exact # weeks — # days —

Comments: —

How long after surgery were you able to start running? # weeks — # days —

13. Subjectively, what is your postoperative level of activity?

excellent –, good –, fair –, poor —

14. How many years from your surgery are you?

15. Have any of your symptoms recurred? Yes –, No —

16. Which symptoms have recurred?

pain –, paresthesia (numbness) — tingling –, muscle weakness –, other (described) —

17. Have you had any further surgery? Yes –, No —

18. If yes, what was the nature of the surgery?

19. Overall, were you pleased with your surgery? Yes –, No —

20. Other comments.

The results were categorized as excellent, good, fair, and poor, according to the results of the subjective questionnaire (Table 2). Excellent and good were satisfactory outcomes, but fair and poor were unsatisfactory results. Overall, there was a 90% satisfactory outcome (27 of 30 limbs in the overall group) with 13 excellent, 14 good, 2 fair, and 1 poor result. Statistical analysis was performed using the two-tailed t-test.

TABLE 2

Criteria for Classification of Results

Result Criteria

Excellent No pain during or after exercise

No limitation of duration and extent of exercise

Patient considers him/herself “cured”

Good Minimal discomfort or soreness during/after exercise

No limitation of duration and extent of exercise

Significantly improved

Glad to have had surgery

Fair Pain with running/exercise or afterward

Still has limitations

Recurrence of symptoms

Only slight improvement

Poor Unchanged or worse

Complications

Anterior Compartment Fasciotomy

In group 1, there was a 93% satisfactory outcome (14 of 15 limbs) with 8 excellent, 6 good, and I fair result. The average time to the full return to their respective sports was 8.1 weeks (range, 5 to 11) for the five patients who had surgery on only one limb. The unsatisfactory outcome was the result of complaints of persistent pain and swelling. Further workup including pressure measurements of both the anterior and lateral compartments was nondiagnostic.

Anterior and Lateral Compartment Fasciotomy

In group 2, there was an 87% satisfactory outcome (13 of 15 limbs) with 5 excellent, 8 good, 1 fair, and 1 poor result. The average time to the full return to their respective sports was 11.4 weeks (range, 7 to 14) for the five patients who had surgery on only one limb. One of the unsatisfactory outcomes was due to persistent deep calf pain while running. Repeat compartment pressures of both the anterior and posterior compartments were nondiagnostic. The other unsatisfactory outcome was in a patient who post-operatively developed hypesthesia over the sensory distribution of the intermediate cutaneous branch of the superficial peroneal nerve, with a positive Tinel’s sign. The patient subjectively had some resolution after two steroid injections but still complained of neuritic pain. We believed this was related to the lateral compartment release.

There were no differences in the objective criteria of strength, range of motion of the ankle and knee joints, palpable tenderness, and atrophy. However, there was a statistically significant difference (P = 0.015) in the time until full return to sports (8.1 week in group 1 versus 11.4 weeks in group 2) among the patients who had surgery in only one limb.

Bilateral-Surgery Patients

Among the 10 patients who underwent bilateral fasciotomies, with one leg undergoing anterior compartment release only and the other leg undergoing both anterior compartment release and lateral compartment release, there were no statistical differences in terms of postoperative pain between the two operated sides. Overall, full return to sports was 12.2 weeks (range, 6 to 14). We asked each of these patients which leg seemed to recover more quickly. Seven patients believed that the leg that had had only anterior compartment release recovered more quickly and three patients noted no difference. It was not possible to quantify the results in these cases nor draw any statistical or scientific conclusions.

DISCUSSION

Exertional anterior compartment syndrome can be debilitating to the highly trained athlete. The symptoms of exertional compartment syndrome are often a result of inadequate tissue oxygenation secondary to decreased venous return and insufficient perfusion of muscle tissue caused by increased compartmental pressures during exercise. The increased compartmental pressures are often a result of an initial increase in perfusion, which causes as much as a 20% increase in muscle weight. In addition, muscle fibers can swell to 20 times their resting size.[3] However, since the anterior compartment is a confined space, the volume of the blood and fibers increases the pressure in accordance with Laplace’s law.[18] Once an appropriate diagnosis is made, fasciotomy has proven to provide effective treatment that allows athletes to return to their previous activities.[2,15,17] Conservative treatment often involves decreasing or completely avoiding the physical activity that produces the symptoms, such as running, basketball, and lacrosse. The differential diagnosis includes stress fracture, stress reaction, periostitis, peripheral nerve entrapment syndromes, claudication from pop-liteal artery entrapment, and medial tibial syndrome (the last two usually with deep posterior compartment syndrome).[16]

The diagnosis of anterior compartment syndrome can usually be suspected by the patient’s history, but the clinical physical examination at rest is not sufficient in making the diagnosis. The measurement of compartment pressures before and after exercise is extremely reliable as a basis for the diagnosis.[7] Anterior compartment pressures are easier to measure than posterior compartment pressures because the tibialis anterior muscle is readily palpable in the proximal third of the leg.

The criteria for defining exertional compartment syndrome were those proposed by Pedowitz et al.,[12] which require one or more of the following: a resting pressure of greater than or equal to 15 mm Hg, a 1-minute postexercise pressure of greater than or equal to 30 mm Hg, and a 5-minute postexercise pressure of greater than or equal to 20 mm Hg (95% confidence level). A previous study at our center confirmed these pressure criteria as diagnostic for exertional compartment syndromes.[17] All patients met the requirements of exertional anterior compartment syndrome by pressure measurements at rest and after symptoms had been reproduced with exercise. It is noteworthy that there were no symptoms referable to the lateral compartment during or after exercise.

In addition to a visual analog scale for postoperative pain management, the patients filled out a subjective questionnaire that allowed their outcomes to be classified as excellent, good, fair, and poor. Only excellent and good were deemed satisfactory outcomes. In group 1, there was a 93% satisfactory outcome (14 of 15 limbs), and, in group 2, there was an 87% satisfactory outcome (13 of 15 limbs). There was no statistically significant difference in postoperative pain between the two groups, including patients who had had bilateral surgery. However, the patients who had had only an anterior fasciotomy in unilateral surgery fully returned to sports 3.3 weeks sooner than the patients who had had both anterior and lateral fasciotomies in unilateral surgery (at 8.1 weeks and 11.4 weeks, respectively; P = 0.015).

Rorabeck et al.[14,15] have alluded to the importance of postoperative management of fasciotomy patients. Active range of motion exercises with weightbearing as tolerated should be instituted immediately after surgery. Crutches may be used for the first few postoperative days, but patients should be encouraged to walk without assistance.

In our study, we excluded patients who had any suspicion of lateral compartment involvement. Other studies have shown that in patients who have only lateral compartment syndrome, a single lateral compartment fasciotomy effectively relieved their symptoms. In a case report by Goodman,[6] isolated lateral compartment syndrome was identified and treated surgically with isolated lateral compartment release. The patient proceeded to have a good result and the gait was normal. Blasier et al.[1] report two cases of isolated “march-induced” peroneal compartment syndrome. In both cases, the patients had pain and tenderness over the lateral aspect of their legs. The patients’ peroneal compartments were found to be tense to palpation, and the patients had pain with passive inversion. Resting pressures were completely indicative of lateral compartment syndrome. The patients underwent isolated lateral compartment fasciotomy with alleviation of their symptoms and no residual weakness.

We also excluded from this study any cases of anterior compartment syndrome associated with a fascial hernia. This was because in such cases it is recommended that both compartments be released, since fascial hernias occur around the exit of the superficial peroneal nerve from the lateral compartment and usually extend across both the anterior and lateral compartments.

As seen in our study, patients with isolated anterior compartment syndrome and no clinical suspicion of lateral compartment syndrome had a 93% overall satisfactory outcome with only the release of the anterior compartment as compared with an 87% overall satisfactory outcome in patients who had fasciotomy of both the anterior and lateral compartments. Also, the single-compartment fasciotomy patients seemed to benefit from a more rapid full return to sports without the potential additional morbidity of a lateral compartment fasciotomy, such as damage to the medial or intermediate dorsal cutaneous branches of the superficial peroneal nerve. Furthermore, Garfin et al.[4] and Mozan and Keagy[10] found that in athletes with exertional compartment syndrome pain, the pain due to elevated compartment pressures and ischemia limited the athletes’ ability to perform. In these same athletes, the functional capacity of the tibialis anterior muscle was increased after fasciotomy. Garfin et al. concluded that fasciotomy normalized the muscle-relaxation pressure during exercise. However, these authors also describe an animal model where fascial release decreased muscle force as well as the muscle contraction pressure of normal, unaffected compartments. Thus, fasciotomy of a compartment without elevated pressures would only decrease the work that could be generated by that compartment, and it therefore does not seem logical to release the fascia in a compartment that is unaffected.

Detmer et al.[2] have described increased fascial thickness, exuberant scar formation over the fasciotomized muscle, and muscle abnormalities as potential factors that can lead to an unsatisfactory outcome. Permanent impairment of the myofascial unit before fasciotomy is another possible cause of less optimal long-term outcome.

In patients with unilateral exertional anterior compartment syndrome, those treated surgically by isolated anterior compartment fasciotomy had a shorter recovery period than did patients who had release of both the anterior and lateral compartments. We realize that the difference is small, the numbers are small, and the return to sport somewhat subjective, but the important point is that patients who had isolated anterior compartment fasciotomy enjoyed the same success level as patients who had release of both the anterior and lateral compartments and less potential morbidity, such as that seen in the dual-compartment release patients who had unsatisfactory results. The majority of the patients who underwent bilateral surgery seemed to recover more quickly on the side that had only an anterior compartment release, but no scientific or statistical conclusions could be drawn from this observation. However, the level of success was not different in these patients. We believe that lateral compartment fasciotomy in addition to anterior compartment release is unnecessary in patients who have only signs and symptoms consistent with exertional anterior compartment syndrome.

REFERENCES

[1.] Blasier D, Barry RJ, Weaver T: Forced march-induced peroneal compartment syndrome. A report of two cases. Clin Orthop 284: 189-192, 1992

[2.] Detmer DE, Sharpe K, Sufit RL, et al: Chronic compartment syndrome: Diagnosis, management, and outcomes. Am J Sports Med 13: 162-170, 1985

[3.] Fronek J, Mubarak S J, Hargens AR, et al: Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop 220: 217-227, 1987

[4.] Garfin SR, Tipton CM, Mubarak S J, et al: Role of fascia in maintenance of muscle tension and pressure. J Appl Physiol 51: 317-320, 1981

[5.] Gershuni DH, Yaru NC, Hargens AR, et al: Ankle and knee position as a factor modifying intracompartmental pressure in the human leg. J Bone Joint Surg 66A: 1415-1420, 1984

[6.] Goodman MJ: Isolated lateral-compartment syndrome. Report of a case. J Bone Joint Surg 62A: 834, 1980

[7.] Kirkebo A, Wishes A: Regional tissue fluid pressure in rat calf muscle during sustained contraction or stretch. Acta Physiol Scand 114: 551-556, 1982

[8.] Matsen FA III, Rorabeck CH: Compartment syndromes. Instr Course Lect 38: 463-472, 1989

[9.] Mohler LR, Styf JR, Pedowitz RA, et al: Intramuscular deoxygenation during exercise in patients who have chronic anterior compartment syndrome of the leg. J Bone Joint Surg 79A: 844-849, 1997

[10.] Mozan LC, Keagy RD: Muscle relationships in functional fascia. A preliminary study. Clin Orthop 67: 225-230, 1969

[11.] Mubarak SJ, Owen CA: Double-incision fasciotomy of the leg for decompression in compartment syndromes. J Bone Joint Surg 59A: 184-187, 1977

[12.] Pedowitz RA, Hargens AR, Mubarak SJ, et al: Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 18: 35-40, 1990

[13.] Rorabeck CH, Bourne RB, Fowler PJ, et al: The role of tissue pressure measurement in diagnosing chronic anterior compartment syndrome. Am J Sports Med 16: 143-146, 1988

[14.] Rorabeck CH, Bourne RB, Fowler P J: The surgical treatment of exertional compartment syndrome in athletes. J Bone Joint Surg 65A: 1245-1251, 1983

[15.] Rorabeck CH, Fowler PJ, Nott L: The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med 16: 224-227, 1988

[16.] Schepsis AA, Lynch G: Exertional compartment syndromes of the lower extremity. Curr Opin Rheumatol 8: 143-147, 1996

[17.] Schepsis AA, Martini D, Corbett M: Surgical management of exertional compartment syndrome of the lower leg. Long-term followup. Am J Sports Med 21:811-817, 1993

[18.] Sejersted OM, Hargens AR: Regional pressure and nutrition of skeletal muscle during isometric contraction, in Hargens AR (ed): Tissue Nutrition and Viability. New York, Springer-Verlag, 1986

[19.] Styf JR, Korner LM: Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy. J Bone Joint Surg 88A: 1338-1347, 1986

Anthony A. Schepsis,([dagger]) MD, Sanjitpal S. Gill, and Timothy A. Foster, MD

From the Department of Orthopaedic Surgery, Boston Medical Center, Boston, Massachusetts

(*) Presented at the interim meeting of the AOSSM, New Orleans, Louisiana, March 1998.

([dagger]) Address correspondence and reprint requests to Anthony Schepsis, MD, Director, Sports Medicine and Arthroscopy Services, Department of Orthopaedic Surgery, Boston Medical Center, 720 Harrison Avenue, DOB 808, Boston, MA 02118

No author or related institution has received any financial benefit from research in this study.3

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