Assessing Outcomes in Individuals Undergoing Fasciotomy for Chronic Exertional Compartment Syndrome of the Leg Nick Pasic, B.H.Sc., M.Sc., M.D. (cand), Dianne Bryant, B.Sc., B.A., M.Sc., Ph.D., Kevin Willits, B.P.E., M.A., M.D., F.R.C.S.C., and David Whitehead, B.Sc., M.B.Ch.B., F.R.A.C.S.
Purpose: The purposes of this study were to evaluate patient-reported outcomes after fasciotomy of the leg for chronic exertional compartment syndrome (CECS) and to determine the rate at which revision surgery was required and the prognostic value of intracompartmental pressure (ICP) testing. Methods: This was a retrospective consecutive case series of patients with CECS who underwent preoperative ICP testing and surgical fasciotomy for treatment of CECS of the leg between September 2001 and January 2012. Results: Of 69 eligible patients, 46 were evaluated at a mean follow-up time of 54.9 months (range, 3.9 to 127.3 months). Forty-two patients met the Pedowitz criteria for CECS diagnosis. Mean score on the Lower Extremity Functional Scale (LEFS) was 70.4 (standard deviation [SD] 11.2) at follow-up and 72.3 (SD 11.2) at the patient-perceived time of best outcome. Best outcome was reported at a mean time of 14.3 months (range, 0.5 to 84 months). Five of 46 (11%) patients required a revision fasciotomy. Thirty-six of 46 (78%) patients reported being either satisfied (n ¼ 14) or very satisfied (n ¼ 22) at follow-up. The Pedowitz criteria were highly sensitive (97%) but not specific (10%) and had a positive predictive value (PPV) of 79%. Conclusions: Functional outcomes after fasciotomy for CECS were favorable. ICP testing was shown to be sensitive but not specific. Revision surgery was required for 5 of the 46 patients (11%). Patient satisfaction rates, return to sport, return to preoperative activity levels, and LEFS scores were all high. This case series confirms that fasciotomy is a safe and effective surgical treatment for CECS. Level of Evidence: Level IV, therapeutic case series.
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hronic exertional compartment syndrome (CECS) is described as an overuse disorder, typically affecting athletic populations. About one in 5 individuals with exercise-induced pain of the lower leg have CECS.1,2 Nearly all cases of CECS occur in one of the 4 compartments of the lower leg (Fig 1),3 but it has been described in the upper extremity as well. Additionally, debate exists as to whether the tibialis posterior can be considered its own compartment independent of
From Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry (N.P., K.W., D.W.) and Faculty of Health Sciences (D.B.), The University of Western Ontario, London, Ontario, Canada. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received March 27, 2014; accepted October 27, 2014. Address correspondence to Nick Pasic, B.H.Sc., M.Sc., M.D., Schulich School of Medicine and Dentistry, The University of Western Ontario, Clinical Skills Building, Rm 3700, London ON, N6A 5C1, Canada. E-mail: pasicnick@ gmail.com. Ó 2015 by the Arthroscopy Association of North America 0749-8063/14259/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.10.018
the deep posterior compartment.4-6 Anterior compartment involvement is most common; 95% of cases are said to occur here. Consequently, it has been given the most attention in the literature.3-5,7 Although the exact pathophysiologic mechanism is unclear, CECS occurs when physical exertion produces substantially elevated intracompartmental pressure (ICP) caused by inelastic compartments.4-6,8 Typically, individuals experience pain within 15 minutes of starting exercise, which subsides within minutes of rest. Since cessation of precipitating activities is the only means of eliminating symptoms nonoperatively, the current practice is to treat patients with CECS surgically by incising the fascia over the problematic compartment and extending that incision over the length of the compartment.4-6,9-11 Making a diagnosis of CECS is primarily based on history, although ICP testing is also used in centers where it is available. Useful clinical findings include exercise-induced leg pain that subsides within minutes of rest, a palpably tight compartment, and occasionally fascial herniations. ICP testing is viewed throughout the
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Fig 1. Compartments of the leg.
literature as the diagnostic test of choice for confirming a suspicion of CECS.4-6,10-12 The most widely used ICP values for diagnosing CECS are the Pedowitz criteria. The Pedowitz criteria state that one or more of the following criteria, in conjunction with appropriate clinical findings, are indicative of a diagnosis of CECS: (1) a pre-exercise pressure of 15 mm Hg or greater, (2) a 1-minute postexercise pressure of 30 mm Hg or greater, or (3) a 5-minute postexercise pressure of 20 mm Hg or greater. Most studies addressing CECS examine the effectiveness of ICP testing or attempt to create sets of diagnostic criteria for CECS; however, no study currently exists that provides a model for predicting an individual’s outcome after fasciotomy. Additionally, no study has been able to establish which ICP value is of greatest diagnostic value. There is ample evidence to support the use of fasciotomy for individuals with CECS.3,5,9,10,13 Most fasciotomies result in positive outcomes, with patients often able to return to or exceed preoperative activity levels, with reduced pain levels reported.3,5,9,10,13 However, not all individuals who undergo fasciotomy experience a return to full activity, and the need for revision surgery is relatively common.3,5,13 The revision rate has been reported as low as 3%13 and as high as 20%,14 although the reasons why fasciotomy fails in these individuals are not yet clear to clinicians.3,13 To date, no study has determined which preoperative factors predispose an individual to fasciotomy failure. The purposes of this study were to evaluate patientreported outcomes after fasciotomy of the leg for
CECS and to determine the rate at which revision surgery was required and the prognostic value of ICP testing. We hypothesized that patients undergoing fasciotomy for CECS would have favorable outcomes after surgery regardless of ICP testing values, because CECS is considered to be a diagnosis of exclusion, with ICP testing often performed to confirm clinical findings suggestive of CECS.
Methods This was a single-center case series involving 46 consecutive patients who underwent ICP testing preoperatively, surgical fasciotomy for treatment of CECS of the lower leg, and retrospective long-term follow-up. The study took place from September 2011 to August 2012, with the fasciotomies performed between September 2001 and January 2012. Patients who underwent ICP testing followed by fasciotomy for treatment of CECS of the lower leg from September 2001 to January 2012 were eligible to participate in this study. Patients were excluded if they were unable to complete the follow-up questionnaires because of comprehension or language barriers. Eligible patients were mailed a letter of information explaining the study. The letter made clear that participation in the study was voluntary and that patients were free to discontinue participation at any time. A user name and password were provided in the letter of information to allow patients to complete the 3 questionnaires on a secure online database. If the patient had not completed the questionnaires online within 1 week of receiving the letter of information in
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Fig 2. Flow of patients through the study.
the mail, a telephone interview was conducted by a member of the research team. Compartment pressure measurement of the most symptomatic compartment was undertaken for all 69 eligible patients (50 anterior, 0 lateral, 19 deep posterior, and 0 superficial posterior) using the Synthes Compartmental Pressure Monitoring System (DePuy Synthes, West Chester, PA). First, the patient was placed supine with the ankle relaxed. Three to 4 mL of 1% lidocaine was used to anesthetize the local tissue superficially. Next, a 14-gauge intravenous cannula was inserted into the compartment. The angle at which the needle was inserted varied depending on the compartment being tested; an angle of 30 to the tibia is ideal for measurements of pressure within the anterior compartment, and an angle of 45 to the tibia and skin is ideal for pressure measurements within the deep posterior compartment. The trocar was removed, the probe was inserted through the cannula into the compartment, and the cannula was retracted to expose the tip of the probe. To confirm that the probe was properly inserted into the compartment, light pressure was applied to the compartment; if the probe was properly inserted, the pressure reading increased simultaneously with the applied force. Once the probe was appropriately adjusted, the patient’s baseline (resting) pressure was recorded. The probe was then taped against the patient’s leg, and a stocking was
applied to the lower leg to cover the insertion site and bandage. Patients then ran on an inclined treadmill until their symptoms were reproduced or they became too symptomatic to continue. Typically this took 10 to 15 minutes. Patients were asked to reproduce symptoms to at least an 8 of 10 on a self-reported pain score, with 10 of 10 serving to represent symptoms at their worst. On completing the treadmill exercise, patients were quickly returned to the supine position and the 1minute postexercise pressure was recorded. Additional pressure measurements were obtained at 5, 10, 15, and 20 minutes after exercise, after which the cannula was removed. If symptoms were present over both the medial and lateral aspects of the tibia, a 4-compartment fasciotomy was performed. Fasciotomies were performed in a fashion similar to the technique described by Rorabeck et al.15 Patients were asked to complete a total of 3 questionnaires: a 20-item standardized return-to-sport and satisfaction questionnaire created for this study (Appendix 1, available at www.arthroscopyjournal.org) and 2 versions of the 20-item Lower Extremity Functional Scale (LEFS). The first was to represent the patient’s current functional outcome (Appendix 2, available at www.arthroscopyjournal.org) and the second was to represent the patient’s self-perceived time of best outcome (Appendix 3, available at www. arthroscopyjournal.org). The return-to-sport and
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Table 1. Patient Demographics Characteristics Sex, number female (% female) Mean age at surgery, yr, mean SD (range) Length of symptoms before surgery, mo, mean SD (range) Bilateral surgery, number yes (% yes) Compartment tested Anterior Deep posterior Affected compartments, no. of legs Anterior Lateral Superficial posterior Deep posterior Precipitating activity Running Basketball Prolonged standing Other Self-reported pain score, mean SD Length of follow-up, mo, mean, (range)
satisfaction questionnaire was used to obtain patientreported satisfaction and return-to-sport rates, as well as time to best outcome.
Results Of the 89 patients screened for this study, 20 were ineligible, 10 were unable to be contacted (contact information was not updated), and 13 could not be contacted (unable to reach patient). Patients were deemed ineligible because they did not undergo ICP testing (n ¼ 11), had an acute compartment syndrome (n ¼ 5), had a compartment syndrome somewhere other than the lower leg (n ¼ 2), or were deceased (n ¼ 2) (Fig 2). Beginning in April 2012 until May 2012, 69 patients were recruited to participate in this study. Forty-six patients completed all 3 follow-up questionnaires. Five patients had values missing from their ICP testing. Forty-four patients had ICP testing that allowed them to be classified using the Pedowitz criteria. Forty-two patients were considered to have CECS when the Pedowitz criteria were applied. Our sample had an even distribution of male patients (50%) and female patients (50%), with a mean age of 30 years (SD 13.0) at surgery. Thirty-eight patients (83%) had bilateral surgery, 5 (11%) had only surgery of the right leg, and the remaining 3 (6%) had left leg
Eligible and Completed Questionnaires (n ¼ 46) 23 (50%) 30 13.0 (16-57) 47.5 53.8 (0-252) 38 (83%) 35 11 80 80 42 42 19 1 3 24 8.1 1.2 54.9 (3.9-127.3)
fasciotomy only. The precipitating activity was primarily running (19 patients), and the average length of time of symptoms before surgery was 47.5 months (SD 53.8) (range, 0 to 252 months) (Table 1). At the time of follow-up, the mean LEFS score was 70.4 (SD 11.2), although the mean LEFS score for the patient-perceived time of best outcome was 72.3 (SD 11.2). The mean for the time of best outcome was at 14.3 months (SD 17.7) (range, 0.5 to 84 months) after surgery. At the time of follow-up, 5 of the 46 patients (11%) had required a revision surgery for their CECS (Table 2). Revision surgery consisted of a fasciotomy with fasciectomy to remove a window of fascia from the revised compartment in a method similar to that described by Slimmon et al.14 Consequently, this subgroup was analyzed separately. At the time of follow-up, the average LEFS score in these 5 patients was not significantly different from that in the other 41 patients. At the time of follow-up, 35 of 46 (76%) patients reported they were (or would have been) able to return to their chosen sport after fasciotomy. Additionally, 29 of these 35 patients reported they were (or would have been) able to return to their preoperative activity levels. At the time of follow-up, 76% of all patients included in the study (35 of 46) (76%) reported that their expectations were met after surgery. Forty of 46 (87%)
Table 2. Outcomes Outcomes Patients requiring revision fasciotomy Patients able to return to sport/preoperative activity levels Patients satisfied with outcome
Proportion of Patients (%) 5 of 46 (11) Sport: 35 of 46 (76) Activity: 29 of 35 (83) 36 of 46 (78%)
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FASCIOTOMY FOR CECS OF THE LEG Table 3. Case Summaries: ICP Testing and Outcomes
Case No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Total N
P rest, mm Hg 26 25 31 4 19 e 17 29 22 15 23 13 21 12 32 21 12 7 25 20 15 13 17 19 25 16 3 16 17 22 e 26 12 18 23 12 20 19 16 6 15 14 7 16 16 12 44
P 1, mm Hg 119 50 103 e 65 e 25 109 55 28 120 40 35 25 43 60 71 34 128 34 52 70 58 67 74 58 40 32 84 46 e 70 45 39 59 60 60 115 19 98 34 37 65 49 29 21 43
P 5, mm Hg 80 30 e 5 34 e 24 90 33 19 107 23 28 17 e 38 41 21 80 25 41 59 31 53 40 40 21 26 58 26 e 43 35 44 58 41 38 102 15 79 24 32 39 41 28 20 42
Time of Best Outcome, mo 0.50 6.00 44.00 24.00 12.00 3.00 4.00 5.00 2.00 7.00 3.00 28.00 12.00 3.00 2.00 1.00 12.00 6.00 1.00 3.00 24.00 12.00 3.00 18.00 27.00 84.00 72.00 6.00 12.00 14.00 7.00 6.00 6.00 8.00 12.00 12.00 46.00 6.00 4.00 12.00 7.00 5.00 41.00 24.00 6.00 3.00 46
LEFS Score at Time of Best Outcome (min ¼ 0, max ¼ 80) 69.00 47.00 79.00 78.00 80.00 80.00 78.00 56.00 80.00 76.00 80.00 73.00 74.00 68.00 80.00 80.00 71.00 65.00 80.00 66.00 76.00 77.00 80.00 79.00 80.00 72.00 63.00 66.00 80.00 80.00 77.00 80.00 80.00 69.00 59.00 64.00 46.00 80.00 38.00 78.00 80.00 80.00 68.00 76.00 72.00 65.00 46
Length of Follow-up, mo 11.00 11.39 44.08 112.68 85.81 12.91 13.33 20.69 7.39 69.12 50.00 35.31 92.58 38.63 3.90 22.99 42.41 76.97 26.64 64.39 123.62 81.21 124.35 127.34 34.75 96.03 69.22 79.14 95.76 15.07 20.89 95.34 99.25 24.64 86.50 76.35 46.02 30.12 37.02 25.78 36.10 54.53 42.54 92.41 25.06 42.31 46
LEFS at Time of Follow-up (min ¼ 0, max ¼ 80) 69.00 45.00 79.00 78.00 80.00 71.00 78.00 56.00 80.00 76.00 80.00 64.00 74.00 68.00 80.00 80.00 71.00 67.00 80.00 66.00 77.00 76.00 80.00 79.00 64.00 65.00 63.00 39.00 80.00 80.00 70.00 80.00 80.00 66.00 59.00 64.00 46.00 80.00 38.00 78.00 80.00 80.00 68.00 67.00 73.00 65.00 46
“Overall, after the surgery you were:” Very satisfied Satisfied Satisfied Very satisfied Very satisfied Satisfied Very satisfied Uncertain Very satisfied Very satisfied Satisfied Uncertain Dissatisfied Uncertain Very satisfied Very satisfied Satisfied Uncertain Very satisfied Very satisfied Satisfied Very satisfied Very satisfied Satisfied Very satisfied Satisfied Dissatisfied Very satisfied Very satisfied Very satisfied Satisfied Very satisfied Very satisfied Dissatisfied Satisfied Dissatisfied Satisfied Very satisfied Satisfied Very satisfied Satisfied Very satisfied Satisfied Uncertain Very satisfied Uncertain 46
P1, postexercise pressure at 1 minute; P5, postexercise pressure at 5 minutes.
patients indicated that, knowing what they know now, they would have chosen to undergo the fasciotomy. Forty-two of 46 (91%) patients responded that they would recommend fasciotomy for someone else with CECS. Finally, 36 of 46 (78%) patients reported being either satisfied (n ¼ 14) or very satisfied (n ¼ 22) with the outcome at the time of follow-up (Table 3). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the
Pedowitz criteria were assessed using a patient-reported outcome of satisfied or very satisfied as the surrogate gold standard for diagnosis of CECS. The results were as follows: sensitivity ¼ 97% (33 of 34), specificity ¼ 10% (1 of 10), PPV ¼ 79% (33 of 42), and NPV ¼ 50% (1 of 2).
Discussion The outcomes of patients who had deep posterior compartment involvement as part of their fasciotomy
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were unique to our study. The predominant viewpoint in the CECS literature is that these patients will fare significantly worse than will those with only anterolateral compartment involvement. However, our results showed no appreciable differences between the 2 groups with respect to outcome (LEFS score or satisfaction measures), length of time that patients were symptomatic before surgery, or the time at which patients experienced their best outcome after surgery. Furthermore, these 2 groups had similar preoperative demographics, leading us to believe that patients with CECS with deep posterior compartment involvement fare better than is reported in the literature. A similar claim is made in a study by Slimmon et al.14 Explanations for this discrepancy between our results and the prevailing view on CECS could stem from surgeon expertise with the fasciotomy technique; it is well established that a deep posterior compartment release is a more difficult procedure than an anterior or lateral compartment release because of the complex anatomy, poor visualization, and presence of subdivisions, or potential fifth compartment, within the deep posterior compartment. Although ICP testing is considered the gold standard for diagnosis, there is some controversy as to which ICP measurements are of greatest diagnostic importance. Some advocate for the use of a resting baseline ICP measurement,6,12,16,17 whereas others believe that ICP testing should be used only to determine the time it takes pressure to return to baseline levels.3,6,7,9,10,18 Additionally, CECS is a unique entity in that, unlike an anterior cruciate ligament tear or fracture, no diagnostic tool can definitely establish its presence, or absence, in a patient. In 2004, Verleisdonk et al.7 evaluated ICP values in individuals with CECS before and after surgical fasciotomy. Pressure values were collected at rest, immediately after exercise, and 5 minutes after exercise. After fasciotomy, statistically significant reductions in pressure were found immediately after and 5 minutes after exercise but not at rest. Thus, the authors concluded that a diagnosis of CECS should be made using exercise-related pressures rather than baseline pressures. Similarly, Howard et al.3 retrospectively evaluated outcomes in individuals who underwent ICP testing followed by fasciotomy for CECS. The authors found no statistically significant association between percentage of pain relief after surgery and the immediate postexercise pressure value.3 A 1990 study by Pedowitz et al.12 established ICP values that most clinicians have used for diagnostic purposes the past 2 decades. In their study, 120 patients suspected of having CECS underwent ICP testing. Seventy-five individuals were classified as not having CECS and 45 were considered to have CECS. Two
standard deviations were added to the mean pressures in individuals without CECS at baseline, 1-minute after exercise, and 5 minutes after exercise to create the Pedowitz criteria. Pedowitz et al. reasoned that by adding 2 SD to the mean ICP values of individuals without CECS, there should be less than a 5% chance of a false-positive diagnosis. When we evaluated the sensitivity, specificity, PPV, and NPV, we used a satisfactory result at the time of follow-up to retroactively confirm a diagnosis of CECS. A similar method had been used previously by van den Brand et al.19 when evaluating the utility of ICP testing. Our results show that the Pedowitz criteria have very low specificity and high specificity and offer a moderate PPV. It is worthwhile noting that these results were obtained using a patient population in which CECS was expected, a method known to increase sensitivity, specificity, and PPV. The high sensitivity and low specificity suggest that ICP testing is best suited as a screening test for CECS. Further analysis with a patient population facing diagnostic uncertainty would provide a better understanding of the true sensitivity, specificity, PPV, and NPV. Strengths of this study include its sample size. Complete follow-up on 46 patients after fasciotomy is a modest number for a CECS study. In addition, this is the first study to use the validated LEFS to measure outcome in this patient population. This analysis provided a more comprehensive understanding of patient satisfaction rates, revision surgery rates, and the utility of ICP testing in CECS. Another strength of our study was the standardization of both the ICP testing procedure and the surgical technique. All the ICP testing was performed at one site by one of 2 clinicians (T.J., K.W.) following a standard procedure with the same equipment, thereby reducing the variability from multiple raters or measurement techniques. Also, 42 of the 46 surgical procedures were performed by the same surgeon (K.W.), reducing the opportunity for the results to be influenced by surgical technique or variability in surgeon expertise. Limitations The primary limitation of this study was that it was retrospective. Fasciotomies were performed as early as 2001in the patients contacted. Another limitation of our study was the inherent variability and error related to compartment pressure measurement; occasionally a patient will register a tremendously high pressure value that is not consistent with physical findings. Finally, because there is no true gold standard for confirming the presence of CECS, we used patient satisfaction with the procedure at the time of follow-up as confirmation of a diagnosis of CECS, a method that is known to increase the sensitivity, specificity, and PPV.
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Additionally, analysis showed that the LEFS scores did not have a standard normal distribution; scores were skewed toward the upper (higher functioning) boundary of 80, with 14 patients scoring a perfect 80 of 80 at the time of follow-up. In contrast, the ICP values did have a standard normal distribution. Thus, the ceiling effect noted in the distribution of LEFS scores means that we have to assume the 14 individuals with a score of 80 experienced identical outcomes when in reality some likely fared better than the LEFS was able to reflect. However, there is no questionnaire or outcome measure that has been validated specifically for the CECS population. Furthermore, if our model were used in a prospective study, it may be useful to collect a baseline LEFS score before fasciotomy, because the effect of surgery on functional change could then be directly assessed.
Conclusions Functional outcomes after fasciotomy for CECS were favorable. ICP testing was shown to be sensitive but not specific. Revision surgery was required for 5 of the 46 patients (11%). Patient satisfaction rates, return to sport, return to preoperative activity levels, and LEFS scores were all high. This case series confirms that fasciotomy is a safe and effective surgical treatment for CECS.
References 1. Qvarfordt P, Christenson JT, Eklof B, Ohlin P, Saltin B. Intramuscular pressure, muscle blood flow, and skeletal muscle metabolism in chronic anterior tibial compartment syndrome. Clin Orthop 1983;179:284-290. 2. Styf J. Diagnosis of exercise-induced pain in the anterior aspect of the lower leg. Am J Sports Med 1988;16:165-169. 3. Howard JL, Mohtadi NG, Wiley JP. Evaluation of outcomes in patients following surgical treatment of chronic exertional compartment syndrome in the leg. Clin J Sport Med 2000;10:176-184. 4. Bong MR, Polatsch DB, Jazrawi LM, Rokito AS. Chronic exertional compartment syndrome: Diagnosis and management. Bull Hosp Jt Dis 2005;62:77-84. 5. Blackman PG. A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc 2000;32:S4-S10 (suppl 2). 6. Brennan FH Jr, Kane SF. Diagnosis, treatment options, and rehabilitation of chronic lower leg exertional
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compartment syndrome. Curr Sports Med Rep 2003;2: 247-250. Verleisdonk EJ, Schmitz RF, van der Werken C. Longterm results of fasciotomy of the anterior compartment in patients with exercise-induced pain in the lower leg. Int J Sports Med 2004;25:224-229. Edmundsson D, Toolanen G, Sojka P. Chronic compartment syndrome also affects nonathletic subjects: A prospective study of 63 cases with exercise-induced lower leg pain. Acta Orthop 2007;78:136-142. Garcia-Mata S, Hidalgo-Ovejero A, Martinez-Grande M. Chronic exertional compartment syndrome of the legs in adolescents. J Pediatr Orthop 2001;21:328-334. Schepsis AA, Lynch G. Exertional compartment syndromes of the lower extremity. Curr Opin Rheumatol 1996;8:143-147. Tucker AK. Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskelet Med 2010;3:32-37. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 1990;18:35-40. Detmer D, Sharpe K, Sufit R, Girdley F. Chronic compartment syndrome: Diagnosis, management, and outcomes. Am J Sports Med 1985;13:162-170. Slimmon D, Bennell K, Brukner P, Crossley K, Bell SN. Long-term outcome of fasciotomy with partial fasciectomy for chronic exertional compartment syndrome of the lower leg. Am J Sports Med 2002;30:581-588. Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. J Bone Joint Surg Am 1983;65:1245-1251. Rorabeck CH, Fowler PJ, Nott L. The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med 1988;16:224-227. Rorabeck CH, Bourne RB, Fowler PJ, Finlay JB, Nott L. The role of tissue pressure measurement in diagnosing chronic anterior compartment syndrome. Am J Sports Med 1988;16:143-146. Amendola A, Rorabeck CH, Vellett D, Vezina W, Rutt B, Nott L. The use of magnetic resonance imaging in exertional compartment syndromes. Am J Sports Med 1990;18: 29-34. van den Brand JG, Nelson T, Verleisdonk EJ, van der Werken C. The diagnostic value of intracompartmental pressure measurement, magnetic resonance imaging, and near-infrared spectroscopy in chronic exertional compartment syndrome: A prospective study in 50 patients. Am J Sports Med 2005;33:699-704.
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Appendix 1. Return to Sport and Satisfaction Survey
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Appendix 2 Lower Extremity Functional Scale for Current Health Status Lower Extremity Functional Scale (LEFS)dCurrent Health Status We are interested in knowing whether you are currently having any difficulty at all with the activities listed below because of your previous lower limb problem. Please provide an answer for each activity. Today, do you or would you have any difficulty at all with:
1. Any of your usual work, housework, or school activities 2. Your usual hobbies, recreational or sport activities 3. Getting into or out of the bath 4. Walking between rooms 5. Putting on your shoes or socks 6. Squatting 7. Lifting an object, like a bag of groceries, from the floor 8. Performing light activities around your home 9. Performing heavy activities around your home 10. Getting into or out of a car 11. Walking 2 blocks 12. Walking a mile 13. Going up or down 10 stairs (about 1 flight of stairs) 14. Standing for 1 hour 15. Sitting for 1 hour 16. Running on even ground 17. Running on uneven ground 18. Making sharp turns while running fast 19. Hopping 20. Rolling over in bed
Extreme Difficulty or Unable to Perform B
Quite a Bit of Difficulty B
Moderate Difficulty B
A Little Bit Of Difficulty B
No Difficulty B
B
B
B
B
B
B B B B B
B B B B B
B B B B B
B B B B B
B B B B B
B B B B B B
B B B B B B
B B B B B B
B B B B B B
B B B B B B
B B B B B B B
B B B B B B B
B B B B B B B
B B B B B B B
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Appendix 3 Lower Extremity Functional Scale for Best Outcome Lower Extremity Functional Scale (LEFS)dBest Outcome We are interested in knowing whether at your best outcome after surgery you would have experienced any difficulty at all with the activities listed below because of your lower limb problem. Please provide an answer for each activity. At your best outcome after surgery, would you have experienced any difficulty at all with:
1. Any of your usual work, housework, or school activities 2. Your usual hobbies, recreational or sport activities 3. Getting into or out of the bath 4. Walking between rooms 5. Putting on your shoes or socks 6. Squatting 7. Lifting an object, like a bag of groceries, from the floor 8. Performing light activities around your home 9. Performing heavy activities around your home 10. Getting into or out of a car 11. Walking 2 blocks 12. Walking a mile 13. Going up or down 10 stairs (about 1 flight of stairs) 14. Standing for 1 hour 15. Sitting for 1 hour 16. Running on even ground 17. Running on uneven ground 18. Making sharp turns while running fast 19. Hopping 20. Rolling over in bed
Extreme Difficulty or Unable to Perform B
Quite a Bit of Difficulty B
Moderate Difficulty B
A Little Bit Of Difficulty B
No Difficulty B
B
B
B
B
B
B B B B B
B B B B B
B B B B B
B B B B B
B B B B B
B B B B B B
B B B B B B
B B B B B B
B B B B B B
B B B B B B
B B B B B B B
B B B B B B B
B B B B B B B
B B B B B B B
B B B B B B B
Purpose: The purposes of this study were to evaluate patient-reported outcomes after fasciotomy of the leg for chronic exertional compartment syndrome (CECS) and to determine the rate at which revision surgery was required and the prognostic value of intracompartmental pressure (ICP) testing. Methods: This was a retrospective consecutive case series of patients with CECS who underwent preoperative ICP testing and surgical fasciotomy for treatment of CECS of the leg between September 2001 and January 2012. Results: Of 69 eligible patients, 46 were evaluated at a mean follow-up time of 54.9 months (range, 3.9 to 127.3 months). Forty-two patients met the Pedowitz criteria for CECS diagnosis. Mean score on the Lower Extremity Functional Scale (LEFS) was 70.4 (standard deviation [SD] 11.2) at follow-up and 72.3 (SD 11.2) at the patient-perceived time of best outcome. Best outcome was reported at a mean time of 14.3 months (range, 0.5 to 84 months). Five of 46 (11%) patients required a revision fasciotomy. Thirty-six of 46 (78%) patients reported being either satisfied (n ¼ 14) or very satisfied (n ¼ 22) at follow-up. The Pedowitz criteria were highly sensitive (97%) but not specific (10%) and had a positive predictive value (PPV) of 79%. Conclusions: Functional outcomes after fasciotomy for CECS were favorable. ICP testing was shown to be sensitive but not specific. Revision surgery was required for 5 of the 46 patients (11%). Patient satisfaction rates, return to sport, return to preoperative activity levels, and LEFS scores were all high. This case series confirms that fasciotomy is a safe and effective surgical treatment for CECS. Level of Evidence: Level IV, therapeutic case series.
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hronic exertional compartment syndrome (CECS) is described as an overuse disorder, typically affecting athletic populations. About one in 5 individuals with exercise-induced pain of the lower leg have CECS.1,2 Nearly all cases of CECS occur in one of the 4 compartments of the lower leg (Fig 1),3 but it has been described in the upper extremity as well. Additionally, debate exists as to whether the tibialis posterior can be considered its own compartment independent of
From Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry (N.P., K.W., D.W.) and Faculty of Health Sciences (D.B.), The University of Western Ontario, London, Ontario, Canada. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received March 27, 2014; accepted October 27, 2014. Address correspondence to Nick Pasic, B.H.Sc., M.Sc., M.D., Schulich School of Medicine and Dentistry, The University of Western Ontario, Clinical Skills Building, Rm 3700, London ON, N6A 5C1, Canada. E-mail: pasicnick@ gmail.com. Ó 2015 by the Arthroscopy Association of North America 0749-8063/14259/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.10.018
the deep posterior compartment.4-6 Anterior compartment involvement is most common; 95% of cases are said to occur here. Consequently, it has been given the most attention in the literature.3-5,7 Although the exact pathophysiologic mechanism is unclear, CECS occurs when physical exertion produces substantially elevated intracompartmental pressure (ICP) caused by inelastic compartments.4-6,8 Typically, individuals experience pain within 15 minutes of starting exercise, which subsides within minutes of rest. Since cessation of precipitating activities is the only means of eliminating symptoms nonoperatively, the current practice is to treat patients with CECS surgically by incising the fascia over the problematic compartment and extending that incision over the length of the compartment.4-6,9-11 Making a diagnosis of CECS is primarily based on history, although ICP testing is also used in centers where it is available. Useful clinical findings include exercise-induced leg pain that subsides within minutes of rest, a palpably tight compartment, and occasionally fascial herniations. ICP testing is viewed throughout the
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Fig 1. Compartments of the leg.
literature as the diagnostic test of choice for confirming a suspicion of CECS.4-6,10-12 The most widely used ICP values for diagnosing CECS are the Pedowitz criteria. The Pedowitz criteria state that one or more of the following criteria, in conjunction with appropriate clinical findings, are indicative of a diagnosis of CECS: (1) a pre-exercise pressure of 15 mm Hg or greater, (2) a 1-minute postexercise pressure of 30 mm Hg or greater, or (3) a 5-minute postexercise pressure of 20 mm Hg or greater. Most studies addressing CECS examine the effectiveness of ICP testing or attempt to create sets of diagnostic criteria for CECS; however, no study currently exists that provides a model for predicting an individual’s outcome after fasciotomy. Additionally, no study has been able to establish which ICP value is of greatest diagnostic value. There is ample evidence to support the use of fasciotomy for individuals with CECS.3,5,9,10,13 Most fasciotomies result in positive outcomes, with patients often able to return to or exceed preoperative activity levels, with reduced pain levels reported.3,5,9,10,13 However, not all individuals who undergo fasciotomy experience a return to full activity, and the need for revision surgery is relatively common.3,5,13 The revision rate has been reported as low as 3%13 and as high as 20%,14 although the reasons why fasciotomy fails in these individuals are not yet clear to clinicians.3,13 To date, no study has determined which preoperative factors predispose an individual to fasciotomy failure. The purposes of this study were to evaluate patientreported outcomes after fasciotomy of the leg for
CECS and to determine the rate at which revision surgery was required and the prognostic value of ICP testing. We hypothesized that patients undergoing fasciotomy for CECS would have favorable outcomes after surgery regardless of ICP testing values, because CECS is considered to be a diagnosis of exclusion, with ICP testing often performed to confirm clinical findings suggestive of CECS.
Methods This was a single-center case series involving 46 consecutive patients who underwent ICP testing preoperatively, surgical fasciotomy for treatment of CECS of the lower leg, and retrospective long-term follow-up. The study took place from September 2011 to August 2012, with the fasciotomies performed between September 2001 and January 2012. Patients who underwent ICP testing followed by fasciotomy for treatment of CECS of the lower leg from September 2001 to January 2012 were eligible to participate in this study. Patients were excluded if they were unable to complete the follow-up questionnaires because of comprehension or language barriers. Eligible patients were mailed a letter of information explaining the study. The letter made clear that participation in the study was voluntary and that patients were free to discontinue participation at any time. A user name and password were provided in the letter of information to allow patients to complete the 3 questionnaires on a secure online database. If the patient had not completed the questionnaires online within 1 week of receiving the letter of information in
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Fig 2. Flow of patients through the study.
the mail, a telephone interview was conducted by a member of the research team. Compartment pressure measurement of the most symptomatic compartment was undertaken for all 69 eligible patients (50 anterior, 0 lateral, 19 deep posterior, and 0 superficial posterior) using the Synthes Compartmental Pressure Monitoring System (DePuy Synthes, West Chester, PA). First, the patient was placed supine with the ankle relaxed. Three to 4 mL of 1% lidocaine was used to anesthetize the local tissue superficially. Next, a 14-gauge intravenous cannula was inserted into the compartment. The angle at which the needle was inserted varied depending on the compartment being tested; an angle of 30 to the tibia is ideal for measurements of pressure within the anterior compartment, and an angle of 45 to the tibia and skin is ideal for pressure measurements within the deep posterior compartment. The trocar was removed, the probe was inserted through the cannula into the compartment, and the cannula was retracted to expose the tip of the probe. To confirm that the probe was properly inserted into the compartment, light pressure was applied to the compartment; if the probe was properly inserted, the pressure reading increased simultaneously with the applied force. Once the probe was appropriately adjusted, the patient’s baseline (resting) pressure was recorded. The probe was then taped against the patient’s leg, and a stocking was
applied to the lower leg to cover the insertion site and bandage. Patients then ran on an inclined treadmill until their symptoms were reproduced or they became too symptomatic to continue. Typically this took 10 to 15 minutes. Patients were asked to reproduce symptoms to at least an 8 of 10 on a self-reported pain score, with 10 of 10 serving to represent symptoms at their worst. On completing the treadmill exercise, patients were quickly returned to the supine position and the 1minute postexercise pressure was recorded. Additional pressure measurements were obtained at 5, 10, 15, and 20 minutes after exercise, after which the cannula was removed. If symptoms were present over both the medial and lateral aspects of the tibia, a 4-compartment fasciotomy was performed. Fasciotomies were performed in a fashion similar to the technique described by Rorabeck et al.15 Patients were asked to complete a total of 3 questionnaires: a 20-item standardized return-to-sport and satisfaction questionnaire created for this study (Appendix 1, available at www.arthroscopyjournal.org) and 2 versions of the 20-item Lower Extremity Functional Scale (LEFS). The first was to represent the patient’s current functional outcome (Appendix 2, available at www.arthroscopyjournal.org) and the second was to represent the patient’s self-perceived time of best outcome (Appendix 3, available at www. arthroscopyjournal.org). The return-to-sport and
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Table 1. Patient Demographics Characteristics Sex, number female (% female) Mean age at surgery, yr, mean SD (range) Length of symptoms before surgery, mo, mean SD (range) Bilateral surgery, number yes (% yes) Compartment tested Anterior Deep posterior Affected compartments, no. of legs Anterior Lateral Superficial posterior Deep posterior Precipitating activity Running Basketball Prolonged standing Other Self-reported pain score, mean SD Length of follow-up, mo, mean, (range)
satisfaction questionnaire was used to obtain patientreported satisfaction and return-to-sport rates, as well as time to best outcome.
Results Of the 89 patients screened for this study, 20 were ineligible, 10 were unable to be contacted (contact information was not updated), and 13 could not be contacted (unable to reach patient). Patients were deemed ineligible because they did not undergo ICP testing (n ¼ 11), had an acute compartment syndrome (n ¼ 5), had a compartment syndrome somewhere other than the lower leg (n ¼ 2), or were deceased (n ¼ 2) (Fig 2). Beginning in April 2012 until May 2012, 69 patients were recruited to participate in this study. Forty-six patients completed all 3 follow-up questionnaires. Five patients had values missing from their ICP testing. Forty-four patients had ICP testing that allowed them to be classified using the Pedowitz criteria. Forty-two patients were considered to have CECS when the Pedowitz criteria were applied. Our sample had an even distribution of male patients (50%) and female patients (50%), with a mean age of 30 years (SD 13.0) at surgery. Thirty-eight patients (83%) had bilateral surgery, 5 (11%) had only surgery of the right leg, and the remaining 3 (6%) had left leg
Eligible and Completed Questionnaires (n ¼ 46) 23 (50%) 30 13.0 (16-57) 47.5 53.8 (0-252) 38 (83%) 35 11 80 80 42 42 19 1 3 24 8.1 1.2 54.9 (3.9-127.3)
fasciotomy only. The precipitating activity was primarily running (19 patients), and the average length of time of symptoms before surgery was 47.5 months (SD 53.8) (range, 0 to 252 months) (Table 1). At the time of follow-up, the mean LEFS score was 70.4 (SD 11.2), although the mean LEFS score for the patient-perceived time of best outcome was 72.3 (SD 11.2). The mean for the time of best outcome was at 14.3 months (SD 17.7) (range, 0.5 to 84 months) after surgery. At the time of follow-up, 5 of the 46 patients (11%) had required a revision surgery for their CECS (Table 2). Revision surgery consisted of a fasciotomy with fasciectomy to remove a window of fascia from the revised compartment in a method similar to that described by Slimmon et al.14 Consequently, this subgroup was analyzed separately. At the time of follow-up, the average LEFS score in these 5 patients was not significantly different from that in the other 41 patients. At the time of follow-up, 35 of 46 (76%) patients reported they were (or would have been) able to return to their chosen sport after fasciotomy. Additionally, 29 of these 35 patients reported they were (or would have been) able to return to their preoperative activity levels. At the time of follow-up, 76% of all patients included in the study (35 of 46) (76%) reported that their expectations were met after surgery. Forty of 46 (87%)
Table 2. Outcomes Outcomes Patients requiring revision fasciotomy Patients able to return to sport/preoperative activity levels Patients satisfied with outcome
Proportion of Patients (%) 5 of 46 (11) Sport: 35 of 46 (76) Activity: 29 of 35 (83) 36 of 46 (78%)
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FASCIOTOMY FOR CECS OF THE LEG Table 3. Case Summaries: ICP Testing and Outcomes
Case No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Total N
P rest, mm Hg 26 25 31 4 19 e 17 29 22 15 23 13 21 12 32 21 12 7 25 20 15 13 17 19 25 16 3 16 17 22 e 26 12 18 23 12 20 19 16 6 15 14 7 16 16 12 44
P 1, mm Hg 119 50 103 e 65 e 25 109 55 28 120 40 35 25 43 60 71 34 128 34 52 70 58 67 74 58 40 32 84 46 e 70 45 39 59 60 60 115 19 98 34 37 65 49 29 21 43
P 5, mm Hg 80 30 e 5 34 e 24 90 33 19 107 23 28 17 e 38 41 21 80 25 41 59 31 53 40 40 21 26 58 26 e 43 35 44 58 41 38 102 15 79 24 32 39 41 28 20 42
Time of Best Outcome, mo 0.50 6.00 44.00 24.00 12.00 3.00 4.00 5.00 2.00 7.00 3.00 28.00 12.00 3.00 2.00 1.00 12.00 6.00 1.00 3.00 24.00 12.00 3.00 18.00 27.00 84.00 72.00 6.00 12.00 14.00 7.00 6.00 6.00 8.00 12.00 12.00 46.00 6.00 4.00 12.00 7.00 5.00 41.00 24.00 6.00 3.00 46
LEFS Score at Time of Best Outcome (min ¼ 0, max ¼ 80) 69.00 47.00 79.00 78.00 80.00 80.00 78.00 56.00 80.00 76.00 80.00 73.00 74.00 68.00 80.00 80.00 71.00 65.00 80.00 66.00 76.00 77.00 80.00 79.00 80.00 72.00 63.00 66.00 80.00 80.00 77.00 80.00 80.00 69.00 59.00 64.00 46.00 80.00 38.00 78.00 80.00 80.00 68.00 76.00 72.00 65.00 46
Length of Follow-up, mo 11.00 11.39 44.08 112.68 85.81 12.91 13.33 20.69 7.39 69.12 50.00 35.31 92.58 38.63 3.90 22.99 42.41 76.97 26.64 64.39 123.62 81.21 124.35 127.34 34.75 96.03 69.22 79.14 95.76 15.07 20.89 95.34 99.25 24.64 86.50 76.35 46.02 30.12 37.02 25.78 36.10 54.53 42.54 92.41 25.06 42.31 46
LEFS at Time of Follow-up (min ¼ 0, max ¼ 80) 69.00 45.00 79.00 78.00 80.00 71.00 78.00 56.00 80.00 76.00 80.00 64.00 74.00 68.00 80.00 80.00 71.00 67.00 80.00 66.00 77.00 76.00 80.00 79.00 64.00 65.00 63.00 39.00 80.00 80.00 70.00 80.00 80.00 66.00 59.00 64.00 46.00 80.00 38.00 78.00 80.00 80.00 68.00 67.00 73.00 65.00 46
“Overall, after the surgery you were:” Very satisfied Satisfied Satisfied Very satisfied Very satisfied Satisfied Very satisfied Uncertain Very satisfied Very satisfied Satisfied Uncertain Dissatisfied Uncertain Very satisfied Very satisfied Satisfied Uncertain Very satisfied Very satisfied Satisfied Very satisfied Very satisfied Satisfied Very satisfied Satisfied Dissatisfied Very satisfied Very satisfied Very satisfied Satisfied Very satisfied Very satisfied Dissatisfied Satisfied Dissatisfied Satisfied Very satisfied Satisfied Very satisfied Satisfied Very satisfied Satisfied Uncertain Very satisfied Uncertain 46
P1, postexercise pressure at 1 minute; P5, postexercise pressure at 5 minutes.
patients indicated that, knowing what they know now, they would have chosen to undergo the fasciotomy. Forty-two of 46 (91%) patients responded that they would recommend fasciotomy for someone else with CECS. Finally, 36 of 46 (78%) patients reported being either satisfied (n ¼ 14) or very satisfied (n ¼ 22) with the outcome at the time of follow-up (Table 3). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the
Pedowitz criteria were assessed using a patient-reported outcome of satisfied or very satisfied as the surrogate gold standard for diagnosis of CECS. The results were as follows: sensitivity ¼ 97% (33 of 34), specificity ¼ 10% (1 of 10), PPV ¼ 79% (33 of 42), and NPV ¼ 50% (1 of 2).
Discussion The outcomes of patients who had deep posterior compartment involvement as part of their fasciotomy
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were unique to our study. The predominant viewpoint in the CECS literature is that these patients will fare significantly worse than will those with only anterolateral compartment involvement. However, our results showed no appreciable differences between the 2 groups with respect to outcome (LEFS score or satisfaction measures), length of time that patients were symptomatic before surgery, or the time at which patients experienced their best outcome after surgery. Furthermore, these 2 groups had similar preoperative demographics, leading us to believe that patients with CECS with deep posterior compartment involvement fare better than is reported in the literature. A similar claim is made in a study by Slimmon et al.14 Explanations for this discrepancy between our results and the prevailing view on CECS could stem from surgeon expertise with the fasciotomy technique; it is well established that a deep posterior compartment release is a more difficult procedure than an anterior or lateral compartment release because of the complex anatomy, poor visualization, and presence of subdivisions, or potential fifth compartment, within the deep posterior compartment. Although ICP testing is considered the gold standard for diagnosis, there is some controversy as to which ICP measurements are of greatest diagnostic importance. Some advocate for the use of a resting baseline ICP measurement,6,12,16,17 whereas others believe that ICP testing should be used only to determine the time it takes pressure to return to baseline levels.3,6,7,9,10,18 Additionally, CECS is a unique entity in that, unlike an anterior cruciate ligament tear or fracture, no diagnostic tool can definitely establish its presence, or absence, in a patient. In 2004, Verleisdonk et al.7 evaluated ICP values in individuals with CECS before and after surgical fasciotomy. Pressure values were collected at rest, immediately after exercise, and 5 minutes after exercise. After fasciotomy, statistically significant reductions in pressure were found immediately after and 5 minutes after exercise but not at rest. Thus, the authors concluded that a diagnosis of CECS should be made using exercise-related pressures rather than baseline pressures. Similarly, Howard et al.3 retrospectively evaluated outcomes in individuals who underwent ICP testing followed by fasciotomy for CECS. The authors found no statistically significant association between percentage of pain relief after surgery and the immediate postexercise pressure value.3 A 1990 study by Pedowitz et al.12 established ICP values that most clinicians have used for diagnostic purposes the past 2 decades. In their study, 120 patients suspected of having CECS underwent ICP testing. Seventy-five individuals were classified as not having CECS and 45 were considered to have CECS. Two
standard deviations were added to the mean pressures in individuals without CECS at baseline, 1-minute after exercise, and 5 minutes after exercise to create the Pedowitz criteria. Pedowitz et al. reasoned that by adding 2 SD to the mean ICP values of individuals without CECS, there should be less than a 5% chance of a false-positive diagnosis. When we evaluated the sensitivity, specificity, PPV, and NPV, we used a satisfactory result at the time of follow-up to retroactively confirm a diagnosis of CECS. A similar method had been used previously by van den Brand et al.19 when evaluating the utility of ICP testing. Our results show that the Pedowitz criteria have very low specificity and high specificity and offer a moderate PPV. It is worthwhile noting that these results were obtained using a patient population in which CECS was expected, a method known to increase sensitivity, specificity, and PPV. The high sensitivity and low specificity suggest that ICP testing is best suited as a screening test for CECS. Further analysis with a patient population facing diagnostic uncertainty would provide a better understanding of the true sensitivity, specificity, PPV, and NPV. Strengths of this study include its sample size. Complete follow-up on 46 patients after fasciotomy is a modest number for a CECS study. In addition, this is the first study to use the validated LEFS to measure outcome in this patient population. This analysis provided a more comprehensive understanding of patient satisfaction rates, revision surgery rates, and the utility of ICP testing in CECS. Another strength of our study was the standardization of both the ICP testing procedure and the surgical technique. All the ICP testing was performed at one site by one of 2 clinicians (T.J., K.W.) following a standard procedure with the same equipment, thereby reducing the variability from multiple raters or measurement techniques. Also, 42 of the 46 surgical procedures were performed by the same surgeon (K.W.), reducing the opportunity for the results to be influenced by surgical technique or variability in surgeon expertise. Limitations The primary limitation of this study was that it was retrospective. Fasciotomies were performed as early as 2001in the patients contacted. Another limitation of our study was the inherent variability and error related to compartment pressure measurement; occasionally a patient will register a tremendously high pressure value that is not consistent with physical findings. Finally, because there is no true gold standard for confirming the presence of CECS, we used patient satisfaction with the procedure at the time of follow-up as confirmation of a diagnosis of CECS, a method that is known to increase the sensitivity, specificity, and PPV.
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Additionally, analysis showed that the LEFS scores did not have a standard normal distribution; scores were skewed toward the upper (higher functioning) boundary of 80, with 14 patients scoring a perfect 80 of 80 at the time of follow-up. In contrast, the ICP values did have a standard normal distribution. Thus, the ceiling effect noted in the distribution of LEFS scores means that we have to assume the 14 individuals with a score of 80 experienced identical outcomes when in reality some likely fared better than the LEFS was able to reflect. However, there is no questionnaire or outcome measure that has been validated specifically for the CECS population. Furthermore, if our model were used in a prospective study, it may be useful to collect a baseline LEFS score before fasciotomy, because the effect of surgery on functional change could then be directly assessed.
Conclusions Functional outcomes after fasciotomy for CECS were favorable. ICP testing was shown to be sensitive but not specific. Revision surgery was required for 5 of the 46 patients (11%). Patient satisfaction rates, return to sport, return to preoperative activity levels, and LEFS scores were all high. This case series confirms that fasciotomy is a safe and effective surgical treatment for CECS.
References 1. Qvarfordt P, Christenson JT, Eklof B, Ohlin P, Saltin B. Intramuscular pressure, muscle blood flow, and skeletal muscle metabolism in chronic anterior tibial compartment syndrome. Clin Orthop 1983;179:284-290. 2. Styf J. Diagnosis of exercise-induced pain in the anterior aspect of the lower leg. Am J Sports Med 1988;16:165-169. 3. Howard JL, Mohtadi NG, Wiley JP. Evaluation of outcomes in patients following surgical treatment of chronic exertional compartment syndrome in the leg. Clin J Sport Med 2000;10:176-184. 4. Bong MR, Polatsch DB, Jazrawi LM, Rokito AS. Chronic exertional compartment syndrome: Diagnosis and management. Bull Hosp Jt Dis 2005;62:77-84. 5. Blackman PG. A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc 2000;32:S4-S10 (suppl 2). 6. Brennan FH Jr, Kane SF. Diagnosis, treatment options, and rehabilitation of chronic lower leg exertional
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compartment syndrome. Curr Sports Med Rep 2003;2: 247-250. Verleisdonk EJ, Schmitz RF, van der Werken C. Longterm results of fasciotomy of the anterior compartment in patients with exercise-induced pain in the lower leg. Int J Sports Med 2004;25:224-229. Edmundsson D, Toolanen G, Sojka P. Chronic compartment syndrome also affects nonathletic subjects: A prospective study of 63 cases with exercise-induced lower leg pain. Acta Orthop 2007;78:136-142. Garcia-Mata S, Hidalgo-Ovejero A, Martinez-Grande M. Chronic exertional compartment syndrome of the legs in adolescents. J Pediatr Orthop 2001;21:328-334. Schepsis AA, Lynch G. Exertional compartment syndromes of the lower extremity. Curr Opin Rheumatol 1996;8:143-147. Tucker AK. Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskelet Med 2010;3:32-37. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 1990;18:35-40. Detmer D, Sharpe K, Sufit R, Girdley F. Chronic compartment syndrome: Diagnosis, management, and outcomes. Am J Sports Med 1985;13:162-170. Slimmon D, Bennell K, Brukner P, Crossley K, Bell SN. Long-term outcome of fasciotomy with partial fasciectomy for chronic exertional compartment syndrome of the lower leg. Am J Sports Med 2002;30:581-588. Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. J Bone Joint Surg Am 1983;65:1245-1251. Rorabeck CH, Fowler PJ, Nott L. The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med 1988;16:224-227. Rorabeck CH, Bourne RB, Fowler PJ, Finlay JB, Nott L. The role of tissue pressure measurement in diagnosing chronic anterior compartment syndrome. Am J Sports Med 1988;16:143-146. Amendola A, Rorabeck CH, Vellett D, Vezina W, Rutt B, Nott L. The use of magnetic resonance imaging in exertional compartment syndromes. Am J Sports Med 1990;18: 29-34. van den Brand JG, Nelson T, Verleisdonk EJ, van der Werken C. The diagnostic value of intracompartmental pressure measurement, magnetic resonance imaging, and near-infrared spectroscopy in chronic exertional compartment syndrome: A prospective study in 50 patients. Am J Sports Med 2005;33:699-704.
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Appendix 1. Return to Sport and Satisfaction Survey
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Appendix 2 Lower Extremity Functional Scale for Current Health Status Lower Extremity Functional Scale (LEFS)dCurrent Health Status We are interested in knowing whether you are currently having any difficulty at all with the activities listed below because of your previous lower limb problem. Please provide an answer for each activity. Today, do you or would you have any difficulty at all with:
1. Any of your usual work, housework, or school activities 2. Your usual hobbies, recreational or sport activities 3. Getting into or out of the bath 4. Walking between rooms 5. Putting on your shoes or socks 6. Squatting 7. Lifting an object, like a bag of groceries, from the floor 8. Performing light activities around your home 9. Performing heavy activities around your home 10. Getting into or out of a car 11. Walking 2 blocks 12. Walking a mile 13. Going up or down 10 stairs (about 1 flight of stairs) 14. Standing for 1 hour 15. Sitting for 1 hour 16. Running on even ground 17. Running on uneven ground 18. Making sharp turns while running fast 19. Hopping 20. Rolling over in bed
Extreme Difficulty or Unable to Perform B
Quite a Bit of Difficulty B
Moderate Difficulty B
A Little Bit Of Difficulty B
No Difficulty B
B
B
B
B
B
B B B B B
B B B B B
B B B B B
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B B B B B B
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B B B B B B B
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Appendix 3 Lower Extremity Functional Scale for Best Outcome Lower Extremity Functional Scale (LEFS)dBest Outcome We are interested in knowing whether at your best outcome after surgery you would have experienced any difficulty at all with the activities listed below because of your lower limb problem. Please provide an answer for each activity. At your best outcome after surgery, would you have experienced any difficulty at all with:
1. Any of your usual work, housework, or school activities 2. Your usual hobbies, recreational or sport activities 3. Getting into or out of the bath 4. Walking between rooms 5. Putting on your shoes or socks 6. Squatting 7. Lifting an object, like a bag of groceries, from the floor 8. Performing light activities around your home 9. Performing heavy activities around your home 10. Getting into or out of a car 11. Walking 2 blocks 12. Walking a mile 13. Going up or down 10 stairs (about 1 flight of stairs) 14. Standing for 1 hour 15. Sitting for 1 hour 16. Running on even ground 17. Running on uneven ground 18. Making sharp turns while running fast 19. Hopping 20. Rolling over in bed
Extreme Difficulty or Unable to Perform B
Quite a Bit of Difficulty B
Moderate Difficulty B
A Little Bit Of Difficulty B
No Difficulty B
B
B
B
B
B
B B B B B
B B B B B
B B B B B
B B B B B
B B B B B
B B B B B B
B B B B B B
B B B B B B
B B B B B B
B B B B B B
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