scholarly journals Predictors of Improvement After Fasciotomy for Treatment of Chronic Exertional Compartment Syndrome of the Lower Extremity

2021 ◽  
pp. 194173812098410
Author(s):  
John J. Mangan ◽  
Ryan G. Rogero ◽  
Daniel J. Fuchs ◽  
Steven M. Raikin
Keyword(s):  
Linear Regression ◽  
Lower Extremity ◽  
Multiple Linear Regression ◽  
Compartment Syndrome ◽  
Functional Improvement ◽  
Posterior Compartment ◽  
Chronic Exertional Compartment Syndrome ◽  
Exertional Compartment Syndrome ◽  
Patient Variables ◽  
Sporting Activities

Background: Previous studies have demonstrated the effectiveness of lower extremity fasciotomies in treating chronic exertional compartment syndrome (CECS). However, not all patients have demonstrated the same level of symptom improvement. Hypothesis: Specific patient variables will lead to enhanced functional improvement after fasciotomy for CECS of the lower extremity. Study Design: Case series. Level of Evidence: Level 4. Methods: A review of patients undergoing fasciotomy of the lower extremity for treatment of CECS by a single surgeon from 2009 to 2017 was performed. Pre- and postoperative measures of Foot and Ankle Ability Measure–Sports subscale (FAAM–Sports), FAAM–Sports Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) for pain during sporting activities were collected at a minimum of 12 months postoperatively. The primary outcomes of change in FAAM-Sports, FAAM-Sports SANE, and VAS during sporting activities were calculated by taking the difference of post- and preoperative scores. Generalized multiple linear regression analyses was performed to determine independent predictors of functional and pain improvement. Results: A total of 61 patients (58% response rate) who underwent 65 procedures were included in this study, with postoperative outcome measures obtained at mean duration of 57.9 months (range, 12-115 months) after surgery. Patients had a mean ± SD improvement in FAAM-Sports of 40.4 ± 22.3 points ( P < 0.001), improvement in FAAM-Sports SANE of 57.3 ± 31.6 points ( P < 0.001), and reduction of VAS pain of 56.4 ± 31.8 points ( P < 0.001). Multiple linear regression analysis revealed deep posterior compartment involvement, younger age, a history of depression, and male sex to be significant independent predictors of enhanced improvement after fasciotomy. Conclusion: Fasciotomy is an effective treatment of CECS, with our study identifying certain patient variables leading to greater functional improvement. Clinical Relevance: Male patients, younger patients, patients with depression, and patients with deep posterior compartment involvement may serve to benefit more with fasciotomies for treatment of CECS.

scholarly journals Predictors of Improvement in Patient Outcomes after Fasciotomy for Chronic Exertional Compartment Syndrome of the Lower Leg

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0005
Author(s):  
John J. Mangan ◽  
Ryan G. Rogero ◽  
Daniel Corr ◽  
Daniel J. Fuchs ◽  
Joseph T. O’Neil ◽  
...  
Keyword(s):  
Independent Predictor ◽  
Lower Leg ◽  
Compartment Pressure ◽  
Posterior Compartment ◽  
Chronic Exertional Compartment Syndrome ◽  
Exertional Compartment Syndrome ◽  
History Of ◽  
Patient Variables ◽  
Sporting Activities ◽  
History Of Depression

Category: Sports; Other Introduction/Purpose: Chronic exertional compartment syndrome (CECS) of the lower leg is the result of increased pressure in intramuscular compartments that occurs during repetitive physical activity. Previous studies have demonstrated the effectiveness of lower extremity fasciotomies in treating CECS. However, not all patients have the same level of symptom improvement or ability to return to sport. The purpose of this study was to determine if any independent patient variables were predictive of outcomes following fasciotomy for CECS of the lower leg. Methods: A retrospective review of patients undergoing fasciotomy of the lower leg for treatment of CECS by a single fellowship-trained orthopaedic surgeon from 2009 to 2017 was performed. All patients had a diagnosis confirmed by pre- and post-exercise compartment pressure testing using the Pedowitz criteria. Patients that underwent a fasciotomy for trauma, infection, or an acute pathologic process or underwent revision fasciotomy were excluded. Preoperative measures of Foot and Ankle Ability Measure-Sport subscale (FAAM-Sport), FAAM-Sport single assessment numeric evaluation (SANE), and visual analog scale (VAS) for pain during sporting activities were collected. Patients with at least 12 months of follow-up were included. The primary outcomes of change (delta, Δ) in FAAM-Sport, FAAM-Sport SANE, and VAS during sporting activities were calculated. To determine significant predictors of outcomes, a generalized multivariate linear regression model developed based on univariate analysis and clinical experience was used. Statistical significance was set at p<0.05. Results: In total, 61 patients underwent 65 procedures, with outcome measures obtained on average 57.9 (range, 12-115) months postoperatively. Median age was 22, median BMI was 24.4, and 59.0% of the cohort was female. Of the 65 fasciotomies, 39 (60.0%) were simultaneous bilateral, 6 procedures (9.2%) performed on 3 patients were staged bilateral, and 18 (27.7%) were unilateral. There were 16 four-compartment fasciotomies performed (24.6%), while 49 (75.4%) involved 2 compartments. Twenty- two procedures involved deep posterior compartment pressures meeting the Pedowitz criteria. Patients had mean (+- standard deviation) improvement in FAAM-Sport of 40.4 +- 22.3 points (p<0.001), improvement in FAAM-Sport SANE of 57.3 +- 31.6 (p<0.001), and reduction of VAS pain of 56.4 +- 31.8 (p<0.001). Multivariate linear regression results are listed in Table 1. Conclusion:: Fasciotomy is an effective treatment of CECS, with our study identifying certain patient variables leading to greater improvement. Independent predictors of improvement of FAAM-Sport SANE following surgery included younger age, history of depression, and male sex. A history of depression was an independent predictor of greater VAS pain reduction following fasciotomy. Patients with deep posterior compartment pressure testing meeting the Pedowitz criteria was an independent predictor of increased improvement in FAAM-Sport. To our knowledge, this is the first study to investigate and identify independent patient variables predictive of greater functional improvement following fasciotomy for CECS. [Table: see text]

scholarly journals Mini-Open Posterior Compartment Release for Chronic Exertional Compartment Syndrome of the Leg

2017 ◽  
Vol 6 (3) ◽  
pp. e649-e653 ◽  
Author(s):  
Kyle P. Lavery ◽  
Michael Bernazzani ◽  
Kevin McHale ◽  
William Rossy ◽  
Luke Oh ◽  
...  
Keyword(s):  
Compartment Syndrome ◽  
Posterior Compartment ◽  
Chronic Exertional Compartment Syndrome ◽  
Exertional Compartment Syndrome ◽  
Mini Open

Patient-Reported Outcomes Following Fasciotomy for Chronic Exertional Compartment Syndrome

2018 ◽  
Vol 11 (5) ◽  
pp. 471-477 ◽  
Author(s):  
Jacqueline M. Maher ◽  
Emily M. Brook ◽  
Christopher Chiodo ◽  
Jeremy Smith ◽  
Eric M. Bluman ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Compartment Syndrome ◽  
Patient Reported Outcomes ◽  
Case Series ◽  
Lower Extremity Function ◽  
Five Dimensions ◽  
Chronic Exertional Compartment Syndrome ◽  
Patient Reported ◽  
Exertional Compartment Syndrome

Background. Lower extremity chronic exertional compartment syndrome (CECS) can negatively affect exercise and activity and may require operative intervention to release the fascia. Few studies have evaluated or compared patient-reported outcomes for bilateral versus single-leg staged fasciotomy and number of compartments released. Methods. A total of 27 eligible patients who underwent a fasciotomy procedure for CECS at a single institution were identified. A retrospective review of the medical record was performed, and individuals were contacted by phone to collect patient-reported outcomes, including ability to return to desired exercise level, postoperative expectation assessment, European Quality of Life—Five Dimensions, and the Foot and Ankle Ability Measure sports subscale. Results. A total of 21 patients were available for follow-up (average follow-up 36.9 months). The average single numeric assessment evaluation of lower-extremity function in sport was 87.5% in those who underwent a simultaneous bilateral fasciotomy (n = 10), 94% in those who had a staged unilateral fasciotomy (n = 5), and 74% in those who underwent an isolated single-leg fasciotomy. In all, 91% (n = 10) of patients who had all 4 compartments released intra-operatively were able to return to their desired exercise level versus 66.7% (n = 6) of those who did not have all 4 compartments released. Conclusion. The patient-reported outcomes of a staged unilateral fasciotomy and simultaneous bilateral fasciotomy for CECS are similar. Those who did not have all 4 compartments released reported worse outcomes. Further research should be conducted on the short-term outcomes and cost-effectiveness of a bilateral versus staged fasciotomy procedure. Levels of Evidence: Level IV: Case series

scholarly journals Release of Tibialis Posterior Muscle Osseofascial Sheath for Chronic Exertional Compartment Syndrome Leads to Improved Outcomes

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0003
Author(s):  
Adam Boissonneault ◽  
Taylor Bellamy ◽  
Sameh Labib
Keyword(s):  
Patient Satisfaction ◽  
Lower Extremity ◽  
Compartment Syndrome ◽  
Surgical Management ◽  
Activity Level ◽  
Tibialis Posterior ◽  
Success Rates ◽  
Chronic Exertional Compartment Syndrome ◽  
Exertional Compartment Syndrome

Category: Sports Introduction/Purpose: Success rates for surgical management of chronic exertional compartment syndrome (CECS) in the lower extremity are influenced by the leg compartment involved. A failure rate of 40-50% has been associated with release of the deep posterior compartment, which has historically been associated with significantly worse outcomes than isolated anterolateral releases. The tibialis posterior muscle often resides in a separate osseofascial sheath, the so-called “fifth compartment.” At our institution, when a deep posterior release is performed, we routinely examine for this fifth compartment and release it if present. Within the context of this surgical approach, the aim of the current study was to compare long-term patient satisfaction and activity levels in those that underwent 2-versus 4-compartment fasciotomy for CECS. Methods: Our study reports on 48 limbs from 31 patients associated with a consecutive series that presented to a single institution for surgical management of lower extremity CECS from 2007-2016. The mean (standard deviation) follow-up was 65 (+/- 28) months. All patients underwent pre-operative intramuscular compartment pressure testing for CECS diagnosis. All surgeries were performed by a single surgeon. In all patients in which 4-compartment fasciotomy was indicated, the tibialis posterior muscle was examined for a separate osseofascial sheath. This sheath was released when present. The presence or absence of the sheath was always dictated in the operative note. Patient satisfaction outcomes were assessed with a Likert scale (excellent, good, fair, or poor). Current activity level was assessed via Marx and Tegner activity scores. Results: Of the 48 limbs, 29 limbs received 2-compartment anterolateral releases only and 19 limbs received 4-compartment fasciotomies. Of those that received 4-compartment fasciotomies, 13 (68%) were found to have a separate osseofascial sheath surrounding the tibialis posterior muscle. At a mean 5-year follow-up interval, 77% of the total cohort rated their outcome as good or excellent. Among the 4-comparment fasciotomy sub-cohort, 79% of patients rated their outcome as good or excellent. Among the entire cohort, there were no revision surgeries performed. The overall mean Tegner and Marx activity scores were 6 and 11 respectively. There was no significant difference in mean outcome scores between those that had 2-versus 4-compartment fasciotomies. Conclusion: Our study illustrates that 1) a separate osseofascial sheath exists around the tibialis posterior muscle in the majority of cases and 2) if this fifth compartment is consistently examined for and released, patients can achieve equivalent success rates and return to a similarly high activity level as those that undergo 2-compartment fasciotomy for CECS. Our study demonstrates superior results for 4-compartment release and includes the longest mean follow-up time for CECS patients in the literature.

scholarly journals Surgical Management of Chronic Exertional Compartment Syndrome of the Lower Extremity: Outcome Analysis and Return to Sport

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0005
Author(s):  
John J. Mangan ◽  
Ryan Rogero ◽  
Daniel J. Fuchs ◽  
Steven M. Raikin
Keyword(s):  
Regression Analysis ◽  
Lower Extremity ◽  
Compartment Syndrome ◽  
Patient Reported Outcomes ◽  
Return To Sport ◽  
Outcome Analysis ◽  
Young Athletes ◽  
Chronic Exertional Compartment Syndrome ◽  
Patient Reported ◽  
Exertional Compartment Syndrome

Category: Sports Introduction/Purpose: Chronic exertional compartment syndrome (CECS) occurs as the result of increasing pressure in a closed muscular compartment, typically in the leg, as the result of repetitive activity. Physiologic changes in myofibril size during exercise increase muscle volume leading to higher compartmental pressures, which can result in neurologic and vascular changes. CECS has been estimated to cause 27%-33% of exertional leg pain and frequently leads to a decrease in athletic training and competition. CECS affects males and females equally but is especially common in young athletes, particularly competitive runners, as well as soccer, field hockey and lacrosse players and in military personnel. The purpose of this study is to evaluate patient- reported outcomes and return to sport (RTS) after open fasciotomy for lower extremity CECS. Methods: A retrospective review of patients that underwent lower extremity fasciotomy for CECS by a single surgeon was performed. All patients had a diagnosis confirmed by pre- and post-exercise compartment pressure testing. Two-incision technique was used with lateral and anterior compartments released through a lateral incision, while deep and superficial posterior compartments were released through a medial approach when indicated. Patients that underwent a fasciotomy for trauma, infection, or an acute pathologic process were excluded. Patient outcome measures were recorded for each patient including the Foot and Ankle Ability Measure-Sport subscale (FAAM-Sport), FAAM-Sport Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale (VAS) for pain. A novel RTS questionnaire was designed and implemented. Patient demographic information was included. Outcome analysis was performed using Student’s t-test and chi-square testing. RTS was compared using Mann-Whitney U testing, and regression analysis was used to identify independent risk factors for failure to RTS. Results: 59 patients that underwent 63 procedures were included. Average age was 26.6 years (range, 15-55), 59.3% were female, and average follow-up was 58.8 months (range, 12-115). 37 patients underwent simultaneous bilateral fasciotomies, 8 had staged bilateral fasciotomies and 18 underwent unilateral fasciotomy. Four-compartment fasciotomy was performed 14 times and 49 fasciotomies involved one or two compartments. Significant postoperative improvement was seen in the FAAM-Sport, Sport SANE and the VAS for pain compared to preoperative scores (p<0.001). Overall 93.2% (55/59) of patients were able to return to sport, 78.1% (43/55) returned to the same level of sport, and 21.9% (12/54) returned to a lower level of competition. Bivariate regression analysis demonstrated that higher preoperative BMI (p=0.049) was associated with a lower likelihood of return to sport. Conclusion: CECS is a relatively common problem seen in young athletes and can cause significant change in athletic participation and ability. This cohort of patients who underwent lower extremity fasciotomies for CECS is larger than any previously published. This study demonstrates that lower extremity fasciotomy for CECS results in improvement of patient-reported outcomes and returns athletes back to competition at a high rate.

scholarly journals A Retrospective Chart Review to Examine Intra-Compartment Pressures and Post-Operative Outcomes of Chronic Exertional Compartment Syndrome

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0014
Author(s):  
Jacob Brower ◽  
David M. Shuster ◽  
Nicholas A. Cheney ◽  
Brian C. Clark
Keyword(s):  
Lower Extremity ◽  
Compartment Syndrome ◽  
Blood Supply ◽  
Surgical Outcomes ◽  
Positive Trend ◽  
Chronic Exertional Compartment Syndrome ◽  
Post Operative Pain ◽  
Exertional Compartment Syndrome ◽  
Compartment Pressures ◽  
Pain Improvement

Category: Other Introduction/Purpose: Chronic exertional compartment syndrome (CECS) is defined as reversible, insufficient blood supply to a fascial compartment’s contents. Patients with this condition have abnormally elevated pressures within specific fascial compartments, causing decreased blood flow to that area. This temporary loss of blood supply produces a feeling of tightness in the affected muscles, pain, and possibly local paresthesia. Surgical treatment involves a fasciotomy, which releases the implicated compartment’s fascia. This procedure creates additional space for muscle expansion and more adequate blood supply to the appropriate tissues.The purpose of this study is to review the surgical outcomes of patients diagnosed with lower extremity CECS whom received a fasciotomy, assessing correlations between resting intramuscular compartment pressures and surgical outcomes. Methods: A retrospective chart analysis was performed of the senior author’s patients between January 1st, 2013 and June 30th, 2019. Patients included in this study presented with symptoms consistent with lower extremity CECS and had the diagnosis confirmed, either unilaterally or bilaterally, via the resting intramuscular pressure cutoff (>=15 mmHg) outlined by the Pedowitz criteria. These patients subsequently received fasciotomies for the syndrome. Results: Out of the 37 patients included in this study, 30 (81.1%) reported improvement in their post-operative pain scores. There was a trend (P > 0.1523) between resting intra-compartment pressures and post-operative pain improvement. Conclusion: Our study suggests a positive trend between higher resting intra-compartment pressures and post-operative pain improvement. Due to the limited number of study participants, no correlations could be determined. However, this data is significant because it demonstrates the importance of the Pedowitz diagnostic criteria, as it is the first study showing a relationship between the resting pressure criteria and surgical outcomes. Further research is necessary to determine if there is a correlation between higher intramuscular pressures and positive surgical outcomes.

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