Chronic exertional compartment syndrome (CECS) of the leg is a pathological condition often related to overuse in subject who engage repetitive physical activities. Fascial release is the mainstay of surgical management. The purpose of this study was to evaluate the results obtained with a double incision decompressive fasciotomy. Eighteen consecutive athletes with a diagnosis of anterior and/or lateral CECS of the leg were operated on with a minimal double incision fascial release after a mean period of 4months after onset of symptoms. In 11 cases (61%) CECS was bilateral. Surgery was performed without tourniquet and active mobilization was starting immediately. Sports activities were resumed gradually at a mean period of 25days. The athletes were followed until 2years. All resumed pre-injury level sports activity. Two patients (18%) of the 11 who underwent to bilateral fasciotomy referred a sensation of leg weakness for an average period of 3months. The surgical technique presented in this paper seems to be a good mean to treat anterior and lateral leg CECS. The use of tourniquet is deconselled to obtain an accurate intraoperative haemostasis so reducing the risk of post-operative haematom

Akiki, A.

Garofalo, R.

Gremion, G.

Moretti, B.

Mouhsine, E.

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IntroductionThe leg chronic exertional compartment syndrome(CECS) is often seen in athletes. It is generally acceptedthat this condition is related to repetitive exertion oroveruse and often interfere with the performances [1, 2].The pathophysiology is related to elevation of intra-muscular pressure, during exercise, to a point that thetissue within the aﬀected compartment becomes tightand painful, thus preventing further activity. The pain,often, disappears within some minutes after rest andthere are usually no permanent sequelae in the aﬀectedtissue. The problem is that, over time, this conditionbecomes more severe, and a raised intra-compartimentalpressure may cause relative ischemia of the involvedmuscles [1, 20]. Some authors [7, 15] had suggested thatactivity induced muscle swelling is restricted by fascialtightness; this theory is used to propose fasciotomy asthe treatment of choice for this condition [3, 5–7, 14, 17,18, 22]. The most commonly aﬀected compartments inthe leg are the anterior followed by the deep posterior,lateral, and rarely the superﬁcial posterior compartment[1, 2, 8]. Diﬀerent techniques have been described forfasciotomy and fasciectomy of the leg, such as open one[5, 6, 8, 12], or two incisions fasciotomy [2, 17, 19],endoscopically assisted one [10, 13] or two [11] incisionsfasciotomy, and fasciectomy [3, 4]. The use of fascioto-my or fasciectomy has been debated, with some authorsperforming fasciotomy with a partial fasciectomy [19]and others [3, 7] advocates fasciectomy only for recur-rent cases when a previous compartment fasciotomy hadfailed. In this paper we describe the open minimalE. MouhsineR. GarofaloB. MorettiG. GremionA. AkikiTwo minimal incision fasciotomy for chronicexertional compartment syndromeof the lower legReceived: 31 March 2004Accepted: 2 November 2004Published online: 18 May 2005 Springer-Verlag 2005Abstract Chronic exertional com-partment syndrome (CECS) of theleg is a pathological condition oftenrelated to overuse in subject whoengage repetitive physical activities.Fascial release is the mainstay ofsurgical management. The purposeof this study was to evaluate theresults obtained with a double inci-sion decompressive fasciotomy.Eighteen consecutive athletes with adiagnosis of anterior and/or lateralCECS of the leg were operated onwith a minimal double incision fas-cial release after a mean period of4 months after onset of symptoms.In 11 cases (61%) CECS was bilat-eral. Surgery was performed withouttourniquet and active mobilizationwas starting immediately. Sportsactivities were resumed gradually ata mean period of 25 days. The ath-letes were followed until 2 years. Allresumed pre-injury level sportsactivity. Two patients (18%) of the11 who underwent to bilateral fas-ciotomy referred a sensation of legweakness for an average period of3 months. The surgical techniquepresented in this paper seems to bea good mean to treat anteriorand lateral leg CECS. The use oftourniquet is deconselled toobtain an accurate intraoperativehaemostasis so reducing the risk ofpost-operative haematoma.Keywords Leg Æ Compartmentsyndrome Æ Exertional Æ FasciotomyDOI 10.1007/s00167-004-0613-6Knee Surg Sports Traumatol Arthrosc(2006) 14: 193–197 SPORTS MEDICINEE. Mouhsine (&) Æ R. GarofaloB. Moretti Æ G. Gremion Æ A. AkikiDepartment of Orthopaedicand Traumatology,OTR-BH 14, CHUV, 1011 Lausanne,SwitzerlandE-mail: Elyazid.Mouhsine@hospvd.chTel.: +41-21-3142791Fax: +41-21-3142800double incision surgical technique to treat leg CECS,and we present the outcome obtained in a serie of 18consecutive athletes.Material and methodIn the period between 1999 and 2002, 18 consecutiveathletes with a clinical diagnosis of leg CECS underwentfasciotomy. The group of patients consisted of ten menand eight women with an average age of 25 years (19–38 years). The type of sport activity causing symptomsare principally jogging, classic dance and foot-ballplaying. Before coming to our institute the athletes weretreated for a mean period of 4 months (1 to 6) with aconservative management consisting in modiﬁcation ofexercise program, stretching, changing of shoes, shoeinserts, or local injection of xylocaine in the area ofmaximal tenderness. In eleven cases the symptoms werebilateral and in the remaining seven only unilateral. Inall cases the muscle complex of the anterior compart-ment was involved for a total of 29 legs and in the fourpatients, three of whom complained of bilateral symp-toms, the anterior and the lateral compartments wereinvolved. Finally 36 compartements were released (Ta-ble 1). At clinical examinations, at rest, no gross physi-cal signs were noted, but in eight cases the anteriorcompartment of the leg was ﬁrm on palpation. Neuro-logical examination was normal in all cases.Surgical techniqueThe same senior surgeon (E.M) performed all of the 36fasciotomy. Surgery was performed always without atourniquet. The technique consisted to perform twovertical skin incision of 2 cm length (Fig. 1a) over theanterior compartment. The distance between the 2incisions averaged 15 cm as described by Rorabeck [17].Once the fascia i identiﬁed, the bridge of skin andsubcutaneous tissue between the two incisions is care-fully dissected down to the level of the fascia with glovedTable 1 Patients treated for leg CECSUnilateralsurgeryBilateralsurgeryAnteriorcompartmentsurgery onlyAnterior and lateralcompartmentsurgeryMen 3 7 7 3Women 4 4 7 1Total 7 11 14 4Fig. 1 Technique and sequence of double mini-incision for fasciot-omy. a Two incisions of 2 cm length over the anterior compartmentare performed. b–d After skin incision, a subcutaneous ﬂap isdeveloped with the two gloved ﬁngers. e Anterior and/or lateralfasciotomy is performed under direct vision. The skin and thesubcutaneous ﬂap is easily mobilised with a retractor allowing agood vision. Sometimes, between the two incisions gloved ﬁngerscan be used as scissor to complete fascial release. f Sterile adhesivestrips closed skin incisionsc194ﬁngers both proximally and distally (Fig. 1b–d). Oncethat this subcutaneous ﬂap is developed, it may be easilymobilised with retractors allowing a clear vision of thedeep fascia.The anterior intermuscular septum and the superﬁcialperoneal nerve were identiﬁed through the lower incisionat the point where it pierces the deep fascia, at anaverage of 10–12 cm proximal to the lateral malleolus.Retracting the skin anteriorly and posteriorly, respec-tively the anterior and lateral compartment fascia (seventimes in our series) was divided with scissors under directvisualisation. The fascia is incised at an average of1.0 cm distance from the intermuscular septum(Fig. 1e). In the cases where the visualisation of thefascia between the two incisions was not good enough, agloved ﬁnger was used to complete the release. Practi-cally it avoids nerve damage. The two incisions wereclosed using a superﬁcial subcutaneous biosine 3.0monoﬁlament (Davis and Geck, Danbury, Conneticut)and sterile adhesive strips (Fig. 1f). A ﬁrm bandage wasthen applied from midfoot to the knee. In the postop-erative period, patients remained in bed for 24 h with theoperated leg elevated. Ice was applied. After that,supervised active range of motion exercises and deam-bulation were instituted. Most patients needed to usecrutches for at least 10 days after the operation. Fifteendays postoperatively, the surgical incisions were con-trolled and sports activities were started gradually on amean period of 25 days (21–32) after surgery.The patients were reviewed at 6 weeks, 3 months,6 months, 1 year and 2 years after surgery. At last fol-low-up a self-administered questionnaire of satisfactionwas given. Clinical results were classiﬁed as none (min-imal or no relief), moderate (minimal to signiﬁcant re-lief), good (return to full activity with minimal or nosymptoms). The results are shown in Table 2.DiscussionSurgical fascial release is the mainstay of treatment ofCECS of the leg [3, 7, 12, 15, 17, 18], with report ofimprovement ranging from 65% to 100% [6–8, 11, 15,17, 18, 20]. Our series with double incision fasciotomyshow good results in 100% of patients with an anterioror antero-lateral leg CECS, at 2 years of follow up. Thepattern of recovery from the operation indicated anearly gradual improvement that remained stable withtime.The speciﬁc method for performing fascia release isvariable and various authors have used both a one [5, 8,12] and two incisions [16, 17, 19, 21] techniques; Detmer[7] have suggested three or more incisions for patientswith excessively long legs. Recently, the use of endo-scope has been proposed to assist visualisation of fas-ciotomy with single [10, 13] or double incisions [11]. Thereported complication rate of fascia release, is between4.5% and 13% including nerve injury, infections, post-operative haematoma, recurrence of symptoms second-ary to incomplete release, cosmetically unacceptablescarring, anaesthetic problems, muscle fascia adhesions,swelling, lymphocele or haemorrhage [6–8, 17, 23]. Inour series diﬀerently to another report [6] in any case analtered skin sensation over the fasciotomy site wasfound. So also if,the subcutaneous tissue was under-mined by fascia using gloved ﬁnger, the risk of nervestripping with local denervation of the skin is very low.A transitory weakness was revealed in two patients;this data was also present in another report [19]. Dif-ferently from Slimmon [19], we did not perform fasci-ectomy, but caracteristically the two patients presentingthese symptoms have a bilateral CECS that involvedboth the anterior ant the lateral compartment.The good outcome in term of symptoms improve-ment in our series is probably related to three factors:ﬁrst, the compartment involved, second, the surgicaltechnique used, and third, the time of preoperativesymptoms duration.In literature, the most of reports has showed a betterlong term outcome for antero-lateral compared withposterior compartment decompression [1, 3, 4, 6,–8, 11,17, 18, 20]. In fact, the reported success for anterior andlateral compartment decompression surgery varies be-tween 65% and 100% [6–8, 11, 15, 17, 18, 20], while forthe posterior compartment the percentage is between50% and 75% [1, 3, 4, 8, 17–19].About surgical technique, a some variety is reportedin literature. A study performed on cadaver specimen[10] concluded that neither techniques, endoscopic orpercutaneous, was without risk of nerve injury, but asingle incision endoscopically assisted fascial release ofthe anterior and the lateral compartments showed alower risk of peroneal nerve injury. This nerve is mostfrequently at risk at the junction of the middle anddistal thirds of the calf, where it pierces the fascia at anaverage distance of 10–12 cm proximal to the lateralmalleolus and begins to head more obliquely andanteriorly. The technique of two vertical incisions asproposed by Rorabeck [17], allows in our advice toperform a complete anterior and lateral fascial releasewithout taking major risks. Undermining the skin andthe subcutaneous tissue is a very important step thatallows a decompression of compartments under directTable 2 Clinical resultsSurgical complications 0Resumed sports activities 18Neurological impairment 0Reoperation 0Transitory sensation of weakness of leg (< 3 months) 2195control, after that the anterior intermuscular septumand the superﬁcial peroneal nerve are identiﬁed. Usingtwo retractors during surgery is possible to performfascial release respect the two incisions at the proximaland distal margins of the compartments with scissors.Only a little area of 1.5–2 cm, located between the twoincisions can remain blind, and in this area the glovedﬁnger of the surgeon is used as scissors, thus reducingthe risk of nerve damage. Diﬀerently to the originaldescription of Rorabeck [17], we do not use a tourni-quet during surgery in order to better control haemo-stasis. This surgical step is very important because apostoperative haematoma may lead to drainingwounds, delayed recovery and potential infection.Moreover various authors [3, 4, 9, 17] have proposedan early mobilisation of the knee and the ankle andwalking on the aﬀected limb after surgery to preventexcessive scarring and adhesions. This was the protocoladapted in our department. In case of postoperativehaematoma formation, this would compromise themobilisation protocol and thus leading to poor resultsdue to scarring, adhesions, stiﬀness and pain.The duration of preoperative symptoms is anotherimportant point. In our series, no-one patient presentedduration longer than 7 months. Slimmon [19] haveshowed that the duration of preoperative symptomsaﬀected signiﬁcantly the proportion of satisfactory re-sults in patients with an isolated anterior compartmentsurgery, suggesting a time more than 12 months afterthe onset of symptoms associated with poor results. Thisargument stresses the necessity to perform early thediagnosis of CECS. So when a trainer or a sports doctorface an athlete with leg pain responding to physiother-apy or to activity modiﬁcation, a CECS should be ex-cluded.Although this series presents limitations related to theretrospective series, some points of strength are present:in fact, it was a consecutive series, in which the operationwas performed by a single senior surgeon. Moreover, theoutcomes at the follow up was evaluated by a indepen-dent reviewer who did not participate to any of thesurgeries through a self-administered questionnaire ofsatisfaction.In conclusion, minimal open double incision fasciot-omy seems to be a viable surgical method to treatanterior and lateral CECS of the leg. This techniqueallows a good surgical site visualisation minimising therisks of incomplete compartment release and soft tissueinjury. The surgery should be performed without atourniquet, so a good haemostasis can be carried out, toavoid postoperative haematoma, and thus lowering riskof scarring or adhesions.References1. Allen MJ, Barnes MR (1986) Exercisepain in the lower leg. Chronic com-partment syndrome and medial tibialsyndrome. J Bone Joint Surg Br68(5):818–8232. Balduini FC, Shenton DW, O’ConnorKH, Heppenstall RB (1993) Chronicexertional compartment syndrome:correlation of compartment pressureand muscle ischemia utilizing 31P-NMR spectroscopy. Clin Sports Med12(1):151–1653. Bell S (1986) Repeat compartmentdecompression with partial fasciectomy.J Bone Joint Surg Br 68(5):815–8174. Black KP, Schultz TK, Cheung NL(1990) Compartment syndromes inathletes. Clin Sports Med 9(2):471–4875. Blackmann PG (2000) A review ofchronic exertional compartment syn-drome in the lower leg. Med Sci SportsExerc 32 (3 Suppl):S4–S106. Cook S, Bruce G (2002) Fasciotomy forchronic compartment syndrome in thelower limb. 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Two minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg

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Two minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg

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