Minimally Invasive Fasciotomy in Chronic Exertional Compartment Syndrome and Fascial Hernias of the Anterior Lower Leg: Short- and Long-Term Results

Military Medicine, May 2006 by de Fijter, Wijand Marnixde, Scheltinga, Marcus Reinoud, Luiting, Martinus G

This study evaluated the efficacy of a minimally invasive percutaneous fasciotomy in chronic exertional compartment syndrome and fascial hernias of the anterior lower leg (N = 118). Approximately one-third of symptomatic legs (n = 41) demonstrated fascial herniation and underwent fasciotomy without compartment pressure measurements via a small percutaneous incision using a fasciotome. Symptomatic legs with an intact fascia (n = 77) received similar operative treatment based on pressure measurements. Relief of symptoms was obtained in all but two patients. Postoperative complications included hematoma (9%), superficial peroneal nerve injury (2%), anterior ankle pain (5%), and recurrence (2%). Most patients (96%) reported unlimited exercise after a mean follow-up of 62 months. However, mild symptoms associated with nerve injury as well as ankle pain persisted (4%). A minimally invasive fasciotomy of the anterior lower leg harboring fascial hernias or a chronic exertional compartment syndrome is effective. Complications such as nerve injury and anterior ankle pain may be related to a too distally performed fasciotomy.

Introduction

A compartment syndrome is defined as a condition in which increased pressure within a confined space compromises tissue circulation and prohibits muscular function.1 The acute form is limb-threatening, requiring emergency surgical treatment. A chronic exertional compartment syndrome (CECS) is usually related to overuse. The majority of CECS occurs in the lower leg,2 and military personnel in particular may be at risk.3,4

A CECS may be present in any compartment but occurs most frequently in the anterior lower leg. Such a CECS may present itself in two different ways. A portion of the patients may complain of a localized pain in the lower leg. At physical examination a fascial defect and protruding muscle may be palpated along the anterior tibial muscle. The presence of such a hernia may be indicative of an abnormal relationship between muscle and its surrounding fascia. Compartmental pressure in these individuals is usually normal but may have been higher before the development of the hernia. However, the vast majority of patients complain of aching or tightness along the anterolateral side of the lower leg during or following exercise, whereas pain gradually subsides after discontinuation.2,5 Physical examination is usually normal although tightness along the tibial muscle may be palpated. In the absence of muscular hernias, pressure measurements may be required to diagnose a CECS in this group of patients. Alien and Barnes6 have proposed a treatment strategy based on these intracompartmental pressure measurements.6

Conservative treatment includes modifying the level of activities, anti-inflammatory agents, and physical therapy.7-10 Incision or partial excision of the fascia surrounding the muscle has been demonstrated to be a most effective treatment modality if conservative measures have failed.5,7,8

The aim of this study was to evaluate a decision-making scheme according to Alien and Barnes and to study immediate and long-term results of a minimally invasive percutaneous fasciotomy of the anterior compartment of the lower leg.

Materials and Methods

Surgical charts of all patients (N = 72; 118 legs) with a characteristic clinical presentation of an anterior CECS that presented over an 8-year time period in our hospital were evaluated retrospectively (Fig. 1). Demographics, results of patient history, and physical examination were tabulated. Patients with a typical history indicative of anterior CECS (lower leg pain following walking >3 months, gradually subsiding after discontinuation, symptomatology located along the anterior aspect of the lower leg), and who had a herniation of a portion of the anterior tibial muscle at physical examination were offered an operation. Symptomatic patients without such hernias were asked to undergo additional compartmental measurements under standardized conditions. These patients were observed while walking on a treadmill for 10 minutes until they experienced symptoms of cramping, burning or aching pain, and tightness of the lower leg. Pressures of the compartment were determined before (P^sub 0^), immediately after (P^sub 10^), and 5 minutes after this exercise (P^sub 15^), as described by Alien and Barnes,6 using a Stryker digital needle and manometer system (Stryker Medical, Eindhoven, The Netherlands; Fig. 2).4 Patients with unilateral CECS underwent pressure measurements of both legs to confirm the diagnosis anterior CECS in the symptomatic as well as to exclude the syndrome in the asymptomatic leg. Pressure measurements in these asymptomatic legs served as control data.

Values of pressure measurements were inserted into a decisionmaking scheme resulting in either conservative or surgical treatment (Fig. 3).6 Conservative therapy included abstinence from long marches, anti-inflammatory drugs, and physical therapy.

Surgical treatment consisted of decompression of the anterior tibial muscle compartment by means of a minimally invasive subcutaneous fasciotomy using a fasciotome as described by Due and Nordstrand;11 Fig. 4). A longitudinal 1-cm skin incision was made one fingerbreadth lateral to the anterior tibial crest halfway of the lower leg. The lower lip of the fasciotome was introduced through a small transverse cut in the crural fascia. While slightly lifting the fascia with the fasciotome, a longitudinal cut was created along the tibial crest in both directions. Toward the knee, the fasciotomy was extended to the tibial origin of the fascia. However, toward the ankle joint, the fasciotome was directed closely along the tibial crest to avoid defects of the superficial peroneal nerve. A mild compressing elastic bandage was applied from the base of the toes to the knee for the first 24 hours. Patients were encouraged to ambulate for at least a 2-hour stretch per day from the first postoperative day to avoid immediate refusion of the fascial blades. This regimen was followed for 3 weeks, and normal exercise schemes were commenced thereafter. The majority of cases (>95%) were operated by a senior military surgeon (M.G.L.).

Follow-up was performed in the outpatient department, once in the immediate postoperative period, and after 1 month. The patient's history was taken and physical examination was carried out for identification of short-term complications. Follow-up in this patient group was complete (100%). Long-term follow-up was obtained in 78% of the patients during a meeting in the outpatient department (81%) or by telephone interview (19%) using a standard set of questions. Differences in pressure values at various time points were analyzed using analysis of variance techniques. Significance was attainted at p