Four-Compartment Fasciotomy for Chronic Exertional Compartment Syndrome

Abstract

Background:

Chronic exertional compartment syndrome (CECS) is characterized by pain related to exercise that resolves with a period of rest. Along with these symptoms, CECS is commonly diagnosed based on an increase in intercompartmental pressure during exercise. A negative magnetic resonance imaging (MRI) is helpful to rule out commonly presenting symptoms. While fasciotomy remains the gold standard for patients who require more than conservative treatment, sex-specific outcome data require further investigation.

Indications:

This case presents a 17-year-old female adolescent with a 2-year history of bilateral calf pain, burning, and foot tingling after 15 minutes of exertion during soccer games that resolved with rest. Several nonoperative interventions, such as footwear modifications and inserts, failed to provide relief. MRI ruled out a stress fracture, and intercompartment pressure testing demonstrated elevated postexercise pressures in all 4 compartments bilaterally, confirming the indication for bilateral 4-compartment fasciotomy.

Technique Description:

With the patient in a supine position and without a regional block or tourniquet, both legs were prepped and draped for full exposure. Anatomical landmarks were marked for lateral and medial approaches. Limited (4 cm) longitudinal incisions allowed sequential release of anterior, lateral, superficial posterior, and deep posterior compartments using a combination of blunt dissection, careful nerve identification, and push-cut technique with Metzenbaum scissors, with careful consideration and protection of nerves. Finger palpation was frequently utilized to ensure the completion of the fasciotomies. Wounds were irrigated, closed with nylon sutures, and dressed with sterile coverings and transparent dressings.

Results:

The patient returned to sports (RTS) within 3 months of surgery and has remained asymptomatic. Based on the literature, operative CECS patients can expect to RTS within 6 to 12 weeks. However, large-cohort data indicate variable sex-specific outcomes, with some studies showing lower RTS rates in females (75%) compared to males (97%), despite lower reported postoperative pain severity in women.

Discussion/Conclusion:

After attempted nonoperative intervention, bilateral 4-compartment fasciotomy utilizing the technique demonstrated is an effective surgical option for adolescent females with CECS. Given the conflicting literature on sex-based outcomes, further prospective, sex-inclusive research is warranted to clarify prognostic factors and optimize rehabilitation protocols for female athletes.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

Background And Indications

This is a 17-year-old female who has had bilateral calf pain for about 2 years with no traumatic event. Symptoms included burning and foot tingling after 15 minutes of exertion that resolved after a period of rest. Shoe modifications and inserts have not provided much relief.

Clinical examination was fairly normal, and the magnetic resonance imaging (MRI) ruled out a stress fracture and was otherwise normal. As such, we moved forward with compartment testing, which demonstrated elevated compartment pressures after exertion bilaterally in all 4 compartments as per the Pedowitz criteria.

In general, chronic exertional compartment syndrome (CECS) can present similarly to the diagnoses listed here. They were ruled out for this specific patient. She was indicated for bilateral 4-compartment fasciotomy.

Technique Description

The patient is positioned supine on the operating table, and no regional block is given to allow for assessment of the nerve after the procedure.

Both lower extremities are prepped and draped in standard fashion to allow full-length exposure. No tourniquet is used.

Anatomical landmarks are outlined, demarcating the lateral malleolus and fibular head. Then, a mark is made 10 cm proximal to the tip of the lateral malleolus. At this level, another mark is made halfway between the tibial crest and the fibula, and a 4-cm longitudinal incision is marked.

The proximal lateral incision should be made so that the surgeon's fingers can easily reach the distal incision. This can be planned by positioning one's finger at the distal incision and confirming it will reach the proximal incision. Once this has been determined, then a 4-cm longitudinal incision is marked in line with the distal incision, halfway between the tibia and the fibula.

The medial incision will be used for the superficial and deep posterior compartment fasciotomies. The incision is marked one fingerbreadth medial to the tibia crest. A 4-cm longitudinal incision is marked at this level.

We start with the distal lateral incision. Careful hemostasis is performed. Dissection is carried down with a blunt Metzenbaum scissor and finger dissection to release all adhesions. The superficial peroneal nerve descends in the lateral compartment of the leg between the fibularis longus and brevis muscles and the extensor digitorum longus muscle. In the distal third of the leg, the nerve pierces the deep fascia and becomes cutaneous. At the distal incision level, it is easily identified. The nerve should be carefully dissected.

Then, the proximal lateral incision is made, and hemostasis is ensured. Dissection is carried down to the fascia, and again, finger dissection is used to release any superficial adhesions. With both distal and proximal lateral approaches completed, the surgeon places their finger in the proximal and distal incisions to make sure the tips of the fingers meet. Similarly, the finger should be able to reach the fibular head through the proximal incision. Again, take time to release all adhesions with finger dissection.

At the distal incision, the fascia of the anterior compartment is identified. A 15-blade is used to make a small transverse incision. Then, a long, blunt Metzenbaum scissor is used and should first be placed over the fascia and be directed toward the surgeon's fingertip to familiarize itself with the direction of the fasciotomy, and utilizing a push-cut technique, the scissors are slid proximally toward the tip of the surgeon's finger.

Then, a small incision is made on the lateral compartment fascia, and similar steps are performed. Again, when performing the fasciotomy, keep the tip of the scissors away from the nerve.

Here you can see the anterior compartment fasciotomy being extended distally. The scissors are first slid over the fascia, then under it. It is important to place only the tip of the scissors on the fascia rent and direct the cut toward the surgeon's finger, which is positioned at the anterior margin of the lateral malleolus. Similarly, the fascia of the lateral compartment is then released distally. First, slide the scissors under the fascia, then over it, and finally release the fascia, aiming toward the tip of the finger positioned at the lateral malleolus, keeping the scissors tip directed away from the nerve.

We then released the mid-third fascia, beginning with the anterior compartment. A 15-blade is used to make a small transverse incision. The surgeon's finger should be placed on the distal incision and directed proximally. One should be able to feel the previously performed fascia release. The scissors first slide over the fascia toward the surgeon's fingertip, then slide under the fascia. Once the direction is practiced, the scissors tip is placed on the fascia, and the scissors are slid, releasing the fascia until it meets the surgeon's finger. At this time, one can feel that both fasciotomies are completed.

The mid-third lateral compartment release is performed following the same steps: small incision with a knife, then scissors over the fascia, then under the fascia, and finally opening the fascia. With both fingers through the incisions, the surgeon can confirm complete release of the fascia.

Lastly, the proximal third of the leg is addressed. Starting with the anterior compartment, the scissors are slid over the fascia, then under the fascia. One should keep the fingertip at the anterior margin of the fibular head. The scissors are slightly opened, and the tip is slid proximally to release the fascia of the anterior compartment. The same steps are repeated to release the lateral compartment fascia proximally, with the scissors tip directed toward the fibular head.

At this time, with both anterior and lateral compartments fully released, we proceeded to release the posterior compartments.

The medial incision is performed, and hemostasis is ensured. Subcutaneous finger dissection is done to release all adhesions. The saphenous vein can be easily identified and shown here.

A 15-blade is used to make a small transverse incision on the superficial fascia overlying the gastrocnemius and soleus muscles. The scissors are then slid over and then under the fascia. The tip is slightly opened, and utilizing a push-cut technique, the scissors are slid proximally to release the fascia, with the scissors directed toward the surgeon's fingertip positioned at the proximal aspect of the medial tibia. The same process is repeated distally to complete the release of the superficial posterior compartment. The tips of the scissors are directed away from the vein.

The medial surface of the tibia is then palpated, and an electrocautery is used to release the fascia and subperiosteum tissues from the posterior aspect of the tibia. This is continued until the muscle is identified. Then, a key elevator is used to release the deep muscles from the tibia. The posterior neurovascular structures are safe if the dissection is kept subperiosteally. This is performed proximally and distally until adequate release is achieved. Before closure, be sure to evaluate and protect the nerve.

The wounds are copiously irrigated, and incisions are closed with nylon and simple sutures. Local anesthetic is injected for postoperative pain control, and sterile dressings are applied with a gauze and transparent medical dressing.

Results

Postoperative care and complications are detailed below, and the patient returned to sport in full within 11 weeks of surgery. She has been asymptomatic since.

Discussion/Conclusion

Outcomes for female patients with CECS of the lower leg are presented here. In the literature, there exist varied results. In small cohort studies, some demonstrate that males have a higher RTS, whereas others show that this is true for females.^1,2

Still, in larger cohorts, female sex independently predicted lower postoperative pain severity.^3,4

However, a systematic review of 27 papers found RTS rates of 97% among males and 75% among females. ⁵

More research is necessary to further explore the relationship between sex, treatment, and outcomes.