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Technical note
Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: A new technique J. Pierrart a,∗,1 , P. Croutzet b , T. Gregory a , E.H. Masmejean a a Service de chirurgie de la main, du membre supérieur et des nerfs périphériques, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75908 Paris cedex 15, France b Clinique de l’Union, boulevard de Ratalens, 31240 Saint-Jean, France
a r t i c l e
i n f o
Article history: Received 4 December 2009 Accepted 11 March 2015 Keywords: Chronic compartment syndrome Minimally invasive surgery KnifeLight Endoscopic
a b s t r a c t Introduction: Fasciotomy is the usual treatment for chronic exertional compartment syndrome of the lower limb. For esthetic reasons, minimally invasive techniques have been developed but can generate complications. Herein, we report the use of the KnifeLight during minimally invasive anterior and lateral compartment release in view of reducing these complications, within a feasibility study. Material and methods: This study was conducted on four cadavers (eight legs) and then an athletic patient (two legs). Results: The technique was carried out on all cases with no complications. The patient’s result was excellent. Discussion: The KnifeLight can be used to perform a fasciotomy of the leg’s anterior and lateral compartments. It seems to provide the operator with additional safety compared to other minimally invasive techniques. Conclusion: This is a simple, reliable, and reproducible technique that deserves to be better known. © 2015 Published by Elsevier Masson SAS.
1. Introduction Chronic exertional compartment syndrome of the lower limb is a pathology frequently found in athletes [1]. Treatment is surgical compartment decompression through fasciotomy. The original technique is identical to the technique used for acute compartment syndrome, with a long medial incision for the fasciotomy of the posterior compartments and a long lateral incision for the anterior and lateral compartments. In 1983, Rorabeck et al. [2] were the first to describe a minimally invasive technique with two short lateral incisions for the anterior and lateral compartments and two short medial incisions for the posterior compartments, using Metzenbaum scissors to resect the fascia. In a review of 209 cases, Turnispeed et al. demonstrated a higher complication rate
∗ Corresponding author. Service de chirurgie de la main, du membre supérieur et des nerfs périphériques, université Paris-Descartes, faculté de médecine, hôpital européen Georges-Pompidou (HEGP), Sorbonne Paris Cité, Assistance publique–Hôpitaux de Paris (AP–HP), 20, rue Leblanc, 75908 Paris cedex 15, France. Tel.: +33 1560 92661. E-mail address: [email protected] (J. Pierrart). 1 http://www.chirurgiedelamain.eu.
with the open minimally invasive technique, with nerve lesions, most particularly on the lateral side of the leg [3]. They found 3% sensory nerve lesions in the “minimally invasive” group versus 0% in the “open surgery” group. Other authors have also reported these complications [4]. The esthetic advantage of the minimally invasive approach is clear; nevertheless, these complications are inacceptable. Improvements in the minimally invasive techniques are required. Endoscopic techniques have been developed in view of reducing these complications while increasing favorable results [5–8]. Release of the median nerve via a minimally invasive approach has been achieved using a KnifeLight for subcutaneous resection of the retinaculum of the flexors [9,10]. Our team has described a technique using this instrument to perform subcutaneous fasciotomies in cases of compartment syndromes in the forearm with good results [11]. We find this technique to be simple, reliable, and reproducible. To our knowledge, there are no studies in the literature that have reported the use of the KnifeLight on the leg. Our objective was to conduct a feasibility study on the use of the KnifeLight for subcutaneous fasciotomies of the anterior and lateral compartments of the leg.
http://dx.doi.org/10.1016/j.otsr.2015.03.018 1877-0568/© 2015 Published by Elsevier Masson SAS.
Please cite this article in press as: Pierrart J, et al. Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: A new technique. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.03.018
G Model
ARTICLE IN PRESS
OTSR-1240; No. of Pages 3
J. Pierrart et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
2
Fig. 1. KnifeLight® .
2. Material and methods 2.1. Material We conducted this study on four cadavers (eight legs) and one 20-year-old athletic patient (competitive tennis player), who had chronic compartment syndrome in both legs with pain in the anterior and lateral compartments. Onset of pain occurred after 10 min of playing and receded 20 min after stopping the sport, with no pain at rest. Measurements of anterior compartment pressure, after exertion, were positive (>30 mmHg [12]) with 43 mmHg on the right and 53 mmHg on the left. 2.2. Methods In the cadavers, minimally invasive fasciotomies were performed and followed secondarily by open exploration to verify that the anterior and lateral compartments were fully opened and that there was no nerve, vessel, or tendon damage. The patient only underwent the minimally invasive surgery. An endoluminal knife (KnifeLight® , Stryker® ) (Fig. 1) was used, comprising a scalpel blade inserted between two thin plastic spatulas and emitting a light supplied by batteries. It was originally designed for carpal tunnel surgery [9,10]. The cadaver surgery was done via the lateral approach of the leg at the junction between the anterior and lateral compartments. The surface landmark was a line extending from the Gerdy tubercle to the tip of the lateral malleolus (Fig. 2) [7]. Two 3-cm skin incisions were made along this line (Fig. 3), one 7 cm under the Gerdy tubercle and the other 10 cm more distal. After the cutaneous incision, the dissection was pursued to the fascia, keeping the superficial veins intact. At the distal skin opening, the superficial fibular nerve was identified and folded back. The intermuscular septum between
Fig. 2. Surface landmarks.
Fig. 3. Two 3-cm incisions were made and the dissection was performed with scissors.
the lateral compartment and the anterior compartment was visualized. The fascia was resected first at the anterior compartment and then at the lateral compartment, using an identical technique. The incision of the anterior compartment fascia was made with a scalpel followed by finger dissection completed with closed blunt scissors (Fig. 3) above the fascia to detach this fascia from the subcutaneous plane and below the fascia to detach it from the muscle structures. The KnifeLight was then introduced with these two thin spatulas on either side of the fascia. It was delicately pushed to resect the muscle fascia, first proximally and then distally. The surgical lamps were then turned off. The resection in the frontal plane was viewed by transillumination and the resection deep to the fascia via the distal cutaneous window (Fig. 4). Once the fasciotomy had been terminated, the fascia of the lateral compartment was resected using the same procedure through the same cutaneous incisions. One patient underwent this surgery in the outpatient setting with spinal anesthesia, in the supine position with a tourniquet at the thigh. He underwent the minimally invasive surgery protocol described above for the cadaver studies. Both legs were operated on the same day. The wound was closed using a subcuticular continuous suture after hemostasis and release of the tourniquet, with placement of a Redon drain. Weightbearing was allowed immediately. Rehabilitation began two weeks later and training at six weeks.
Fig. 4. Three-dimensional verification of the resection.
Please cite this article in press as: Pierrart J, et al. Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: A new technique. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.03.018
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ARTICLE IN PRESS J. Pierrart et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
An open exploration was performed on all cadavers to verify that the anterior and lateral compartments were fully open and that there was no tendon, nerve, or blood vessel damage. The patient was seen after the surgery to check that there were no complications and was seen again on day 1, 15, and 45 and again at 18 months. 3. Results For the cadaver study, the fasciotomy of the lateral and anterior compartment was complete in all cases. No vein, nerve or tendon lesions were found during exploration. The patient who underwent this technique is very satisfied: pain has completely disappeared and he resumed tennis six weeks after surgery. No complications were found. At 18 months after the operation, he has presented no recurrence of pain. 4. Discussion We have shown that use of the KnifeLight in minimally invasive surgery for chronic compartment syndrome in the lower limb is feasible for fasciotomy of these two compartments, i.e., anterior and lateral. In cadavers, fasciotomy of the anterior and lateral compartments was complete in all cases and no vein or nerve lesions were observed. The patient was cured and presented no complications. In a review of 209 cases, Turnispeed et al. demonstrated a higher complication rate for the minimally invasive technique than for the open technique [3]. Nerve damage was more frequent with the minimally invasive technique (3% versus 0% for the open technique), most particularly on the lateral side of the leg. The superficial fibular nerve can be damaged where it perforates the muscle fascia, whose position varies from one individual to another. The risk of injuring it is therefore major in the distal third of the leg. No damage to this nerve was noted in our cadaver study. The KnifeLight is usually used for carpal tunnel surgery [10]. It improves subcutaneous visualization of the reticulum resection and increases the operation’s safety. As for its use in the leg, its transillumination makes it easier to control the direction of the fascial resection in all three dimensions and thus improves the surgery’s safety. This could reduce potential nerve damage. Moreover, since vein damage can be responsible for hematoma, if exsanguination of the limb is not complete, the veins are visible through the skin because of the knife’s light. This provides better visibility and it is thus easier to avoid them. This technique is also used in our department for chronic forearm compartment syndromes [11] and we are equally satisfied with the results. Endoscopic assistance proposed by other authors [5,7,8] would also reduce the risks of this surgery
3
and seems to be an elegant solution. However, our technique has the advantage of being simple, both in terms of patient installation and the necessary material, and the cost remains acceptable. Endoscopy presents the disadvantage of requiring greater logistics (arthroscopy tower). The contribution of the KnifeLight in minimally invasive lateral and anterior compartment fasciotomy surgery of the leg seems relevant and warrants being better known. This technique is simple, effective, and reproducible. A study on a larger series would be useful to confirm the results reported herein. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Tucker AK. Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskelet Med 2010;3:32–7, http://dx.doi.org/10.1007/s12178-010-9065-4. [2] Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. J Bone Joint Surg Am 1983;65: 1245–51. [3] Turnipseed W, Detmer DE, Girdley F. Chronic compartment syndrome. An unusual cause for claudication. Ann Surg 1989;210:557–62. [4] 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 Off J Can Acad Sport Med 2000;10:176–84. [5] Hutchinson MR, Bederka B, Kopplin M. Anatomic structures at risk during minimal-incision endoscopically assisted fascial compartment releases in the leg. Am J Sports Med 2003;31:764–9. [6] Knight JR, Daniels M, Robertson W. Endoscopic compartment release for chronic exertional compartment syndrome. Arthrosc Tech 2013;2:e187–90, http://dx.doi.org/10.1016/j.eats.2013.02.002. [7] Leversedge FJ, Casey PJ, Seiler JG, Xerogeanes JW. Endoscopically assisted fasciotomy: description of technique and in vitro assessment of lower-leg compartment decompression. Am J Sports Med 2002;30:272–8. [8] Lohrer H, Nauck T. Endoscopically assisted release for exertional compartment syndromes of the lower leg. Arch Orthop Trauma Surg 2007;127:827–34, http://dx.doi.org/10.1007/s00402-006-0269-4. [9] Cellocco P, Rossi C, El Boustany S, Di Tanna GL, Costanzo G. Minimally invasive carpal tunnel release. Orthop Clin North Am 2009;40, http://dx.doi.org/10.1016/j.ocl.2009.06.002, 441–8, vii. [10] Wallach F, Vercoutère M, Chassat R, Masmejean EH. Libération du nerf médian au canal carpien par technique mini-invasive non endoscopique. In: Fontaine C, Livernaux P, Masmejean E, editors. CECM. Montpellier: Sauramps Ed.; 2008, 339–44, n.d. [11] Croutzet P, Chassat R, Masmejean EH. Mini-invasive surgery for chronic exertional compartment syndrome of the forearm: a new technique. Tech Hand Up Extrem Surg 2009;13:137–40, http://dx.doi.org/10.1097/ BTH.0b013e3181aa9193. [12] Brewer RB, Gregory AJM. Chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment. Sports Health 2012;4:121–7, http://dx.doi.org/10.1177/1941738111426115.
Please cite this article in press as: Pierrart J, et al. Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: A new technique. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.03.018
ARTICLE IN PRESS
OTSR-1240; No. of Pages 3
Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Technical note
Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: A new technique J. Pierrart a,∗,1 , P. Croutzet b , T. Gregory a , E.H. Masmejean a a Service de chirurgie de la main, du membre supérieur et des nerfs périphériques, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75908 Paris cedex 15, France b Clinique de l’Union, boulevard de Ratalens, 31240 Saint-Jean, France
a r t i c l e
i n f o
Article history: Received 4 December 2009 Accepted 11 March 2015 Keywords: Chronic compartment syndrome Minimally invasive surgery KnifeLight Endoscopic
a b s t r a c t Introduction: Fasciotomy is the usual treatment for chronic exertional compartment syndrome of the lower limb. For esthetic reasons, minimally invasive techniques have been developed but can generate complications. Herein, we report the use of the KnifeLight during minimally invasive anterior and lateral compartment release in view of reducing these complications, within a feasibility study. Material and methods: This study was conducted on four cadavers (eight legs) and then an athletic patient (two legs). Results: The technique was carried out on all cases with no complications. The patient’s result was excellent. Discussion: The KnifeLight can be used to perform a fasciotomy of the leg’s anterior and lateral compartments. It seems to provide the operator with additional safety compared to other minimally invasive techniques. Conclusion: This is a simple, reliable, and reproducible technique that deserves to be better known. © 2015 Published by Elsevier Masson SAS.
1. Introduction Chronic exertional compartment syndrome of the lower limb is a pathology frequently found in athletes [1]. Treatment is surgical compartment decompression through fasciotomy. The original technique is identical to the technique used for acute compartment syndrome, with a long medial incision for the fasciotomy of the posterior compartments and a long lateral incision for the anterior and lateral compartments. In 1983, Rorabeck et al. [2] were the first to describe a minimally invasive technique with two short lateral incisions for the anterior and lateral compartments and two short medial incisions for the posterior compartments, using Metzenbaum scissors to resect the fascia. In a review of 209 cases, Turnispeed et al. demonstrated a higher complication rate
∗ Corresponding author. Service de chirurgie de la main, du membre supérieur et des nerfs périphériques, université Paris-Descartes, faculté de médecine, hôpital européen Georges-Pompidou (HEGP), Sorbonne Paris Cité, Assistance publique–Hôpitaux de Paris (AP–HP), 20, rue Leblanc, 75908 Paris cedex 15, France. Tel.: +33 1560 92661. E-mail address: [email protected] (J. Pierrart). 1 http://www.chirurgiedelamain.eu.
with the open minimally invasive technique, with nerve lesions, most particularly on the lateral side of the leg [3]. They found 3% sensory nerve lesions in the “minimally invasive” group versus 0% in the “open surgery” group. Other authors have also reported these complications [4]. The esthetic advantage of the minimally invasive approach is clear; nevertheless, these complications are inacceptable. Improvements in the minimally invasive techniques are required. Endoscopic techniques have been developed in view of reducing these complications while increasing favorable results [5–8]. Release of the median nerve via a minimally invasive approach has been achieved using a KnifeLight for subcutaneous resection of the retinaculum of the flexors [9,10]. Our team has described a technique using this instrument to perform subcutaneous fasciotomies in cases of compartment syndromes in the forearm with good results [11]. We find this technique to be simple, reliable, and reproducible. To our knowledge, there are no studies in the literature that have reported the use of the KnifeLight on the leg. Our objective was to conduct a feasibility study on the use of the KnifeLight for subcutaneous fasciotomies of the anterior and lateral compartments of the leg.
http://dx.doi.org/10.1016/j.otsr.2015.03.018 1877-0568/© 2015 Published by Elsevier Masson SAS.
Please cite this article in press as: Pierrart J, et al. Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: A new technique. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.03.018
G Model
ARTICLE IN PRESS
OTSR-1240; No. of Pages 3
J. Pierrart et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
2
Fig. 1. KnifeLight® .
2. Material and methods 2.1. Material We conducted this study on four cadavers (eight legs) and one 20-year-old athletic patient (competitive tennis player), who had chronic compartment syndrome in both legs with pain in the anterior and lateral compartments. Onset of pain occurred after 10 min of playing and receded 20 min after stopping the sport, with no pain at rest. Measurements of anterior compartment pressure, after exertion, were positive (>30 mmHg [12]) with 43 mmHg on the right and 53 mmHg on the left. 2.2. Methods In the cadavers, minimally invasive fasciotomies were performed and followed secondarily by open exploration to verify that the anterior and lateral compartments were fully opened and that there was no nerve, vessel, or tendon damage. The patient only underwent the minimally invasive surgery. An endoluminal knife (KnifeLight® , Stryker® ) (Fig. 1) was used, comprising a scalpel blade inserted between two thin plastic spatulas and emitting a light supplied by batteries. It was originally designed for carpal tunnel surgery [9,10]. The cadaver surgery was done via the lateral approach of the leg at the junction between the anterior and lateral compartments. The surface landmark was a line extending from the Gerdy tubercle to the tip of the lateral malleolus (Fig. 2) [7]. Two 3-cm skin incisions were made along this line (Fig. 3), one 7 cm under the Gerdy tubercle and the other 10 cm more distal. After the cutaneous incision, the dissection was pursued to the fascia, keeping the superficial veins intact. At the distal skin opening, the superficial fibular nerve was identified and folded back. The intermuscular septum between
Fig. 2. Surface landmarks.
Fig. 3. Two 3-cm incisions were made and the dissection was performed with scissors.
the lateral compartment and the anterior compartment was visualized. The fascia was resected first at the anterior compartment and then at the lateral compartment, using an identical technique. The incision of the anterior compartment fascia was made with a scalpel followed by finger dissection completed with closed blunt scissors (Fig. 3) above the fascia to detach this fascia from the subcutaneous plane and below the fascia to detach it from the muscle structures. The KnifeLight was then introduced with these two thin spatulas on either side of the fascia. It was delicately pushed to resect the muscle fascia, first proximally and then distally. The surgical lamps were then turned off. The resection in the frontal plane was viewed by transillumination and the resection deep to the fascia via the distal cutaneous window (Fig. 4). Once the fasciotomy had been terminated, the fascia of the lateral compartment was resected using the same procedure through the same cutaneous incisions. One patient underwent this surgery in the outpatient setting with spinal anesthesia, in the supine position with a tourniquet at the thigh. He underwent the minimally invasive surgery protocol described above for the cadaver studies. Both legs were operated on the same day. The wound was closed using a subcuticular continuous suture after hemostasis and release of the tourniquet, with placement of a Redon drain. Weightbearing was allowed immediately. Rehabilitation began two weeks later and training at six weeks.
Fig. 4. Three-dimensional verification of the resection.
Please cite this article in press as: Pierrart J, et al. Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: A new technique. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.03.018
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ARTICLE IN PRESS J. Pierrart et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
An open exploration was performed on all cadavers to verify that the anterior and lateral compartments were fully open and that there was no tendon, nerve, or blood vessel damage. The patient was seen after the surgery to check that there were no complications and was seen again on day 1, 15, and 45 and again at 18 months. 3. Results For the cadaver study, the fasciotomy of the lateral and anterior compartment was complete in all cases. No vein, nerve or tendon lesions were found during exploration. The patient who underwent this technique is very satisfied: pain has completely disappeared and he resumed tennis six weeks after surgery. No complications were found. At 18 months after the operation, he has presented no recurrence of pain. 4. Discussion We have shown that use of the KnifeLight in minimally invasive surgery for chronic compartment syndrome in the lower limb is feasible for fasciotomy of these two compartments, i.e., anterior and lateral. In cadavers, fasciotomy of the anterior and lateral compartments was complete in all cases and no vein or nerve lesions were observed. The patient was cured and presented no complications. In a review of 209 cases, Turnispeed et al. demonstrated a higher complication rate for the minimally invasive technique than for the open technique [3]. Nerve damage was more frequent with the minimally invasive technique (3% versus 0% for the open technique), most particularly on the lateral side of the leg. The superficial fibular nerve can be damaged where it perforates the muscle fascia, whose position varies from one individual to another. The risk of injuring it is therefore major in the distal third of the leg. No damage to this nerve was noted in our cadaver study. The KnifeLight is usually used for carpal tunnel surgery [10]. It improves subcutaneous visualization of the reticulum resection and increases the operation’s safety. As for its use in the leg, its transillumination makes it easier to control the direction of the fascial resection in all three dimensions and thus improves the surgery’s safety. This could reduce potential nerve damage. Moreover, since vein damage can be responsible for hematoma, if exsanguination of the limb is not complete, the veins are visible through the skin because of the knife’s light. This provides better visibility and it is thus easier to avoid them. This technique is also used in our department for chronic forearm compartment syndromes [11] and we are equally satisfied with the results. Endoscopic assistance proposed by other authors [5,7,8] would also reduce the risks of this surgery
3
and seems to be an elegant solution. However, our technique has the advantage of being simple, both in terms of patient installation and the necessary material, and the cost remains acceptable. Endoscopy presents the disadvantage of requiring greater logistics (arthroscopy tower). The contribution of the KnifeLight in minimally invasive lateral and anterior compartment fasciotomy surgery of the leg seems relevant and warrants being better known. This technique is simple, effective, and reproducible. A study on a larger series would be useful to confirm the results reported herein. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Tucker AK. Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskelet Med 2010;3:32–7, http://dx.doi.org/10.1007/s12178-010-9065-4. [2] Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. J Bone Joint Surg Am 1983;65: 1245–51. [3] Turnipseed W, Detmer DE, Girdley F. Chronic compartment syndrome. An unusual cause for claudication. Ann Surg 1989;210:557–62. [4] 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 Off J Can Acad Sport Med 2000;10:176–84. [5] Hutchinson MR, Bederka B, Kopplin M. Anatomic structures at risk during minimal-incision endoscopically assisted fascial compartment releases in the leg. Am J Sports Med 2003;31:764–9. [6] Knight JR, Daniels M, Robertson W. Endoscopic compartment release for chronic exertional compartment syndrome. Arthrosc Tech 2013;2:e187–90, http://dx.doi.org/10.1016/j.eats.2013.02.002. [7] Leversedge FJ, Casey PJ, Seiler JG, Xerogeanes JW. Endoscopically assisted fasciotomy: description of technique and in vitro assessment of lower-leg compartment decompression. Am J Sports Med 2002;30:272–8. [8] Lohrer H, Nauck T. Endoscopically assisted release for exertional compartment syndromes of the lower leg. Arch Orthop Trauma Surg 2007;127:827–34, http://dx.doi.org/10.1007/s00402-006-0269-4. [9] Cellocco P, Rossi C, El Boustany S, Di Tanna GL, Costanzo G. Minimally invasive carpal tunnel release. Orthop Clin North Am 2009;40, http://dx.doi.org/10.1016/j.ocl.2009.06.002, 441–8, vii. [10] Wallach F, Vercoutère M, Chassat R, Masmejean EH. Libération du nerf médian au canal carpien par technique mini-invasive non endoscopique. In: Fontaine C, Livernaux P, Masmejean E, editors. CECM. Montpellier: Sauramps Ed.; 2008, 339–44, n.d. [11] Croutzet P, Chassat R, Masmejean EH. Mini-invasive surgery for chronic exertional compartment syndrome of the forearm: a new technique. Tech Hand Up Extrem Surg 2009;13:137–40, http://dx.doi.org/10.1097/ BTH.0b013e3181aa9193. [12] Brewer RB, Gregory AJM. Chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment. Sports Health 2012;4:121–7, http://dx.doi.org/10.1177/1941738111426115.
Please cite this article in press as: Pierrart J, et al. Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: A new technique. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.03.018
