Revision Surgery for Recurrent Exertional Anterior Compartment Syndrome of the Lower Leg: Findings, Technique, and Results
Authors:
Mark S. Fitzgerald MD, Boston University Medical Center, Boston, MA
Anthony A. Schepsis MD, Boston
University Medical Center, Boston, MA
Objective: Recurrent symptoms following fasciotomy for exertional anterior compartment syndrome (EACS) is not uncommon. We present a series of patients that underwent revision surgery and our results at minimum two year follow-up.Methods: Between 1997 and 2001, 22 patients underwent revision surgery for EACS. 18 were available for follow-up. There were 13 females and 5 males, with a mean age of 25. All were athletes that had either a failure or a recurrence of symptoms at mean of 23.5 months (range 8-54 months) after the index fasciotomy. Pressure measurements using a slit catheter at rest, 1 and 5 minutes post-exercise was performed in 2 separate locations; in the area of the previous incision and in the proximal muscle belly of the tibialis anterior. Pressure criteria as described by Pedowitz were utilized. Surgical technique consisted of a 2 incision approach with partial fasciectomy (removal of a 1 cm longitudinal strip of fascia from both the anterior and lateral compartments), exploration and decompression of the superficial peroneal nerve, excision of all fibrotic tissue, injection of a small amount of steroid in the tissues surrounding the nerve when it was involved, and closure with minimal non absorbable suture. An objective exam and a comprehensive subjective questionnaire previously described were performed at a mean follow-up of 42 months (23 – 67).Results: 60% of patients had abnormal pressures only in a localized area, while 40% had high pressures throughout the compartment. 8 of 18 (44%) had symptoms, signs, and surgical findings of entrapment of the superficial peroneal nerve. At follow-up, 72% of patients had a satisfactory outcome (5 excellent, 8 good) and 28% had an unsatisfactory outcome for intense running sports (4 fair, one poor), although 3 of the fair results reported improvement with low level activity. All 8 patients with documented peroneal nerve entrapment had a satisfactory outcome.
Figure 1
Criteria for classification of results:
Conclusions: Revision surgery for EACS does not have as good an outcome as primary surgery, however most will benefit from the aggressive surgical approach described. Symptoms from high pressures can be secondary to involvement of the entire compartment or localized to a certain area from post-surgical fibrosis. Pressure measurements should be performed in at least 2 separate areas. Superficial peroneal nerve entrapment is common and should always be recognized and addressed.References:
Schepsis A, Martini D, Corbett M: Surgical Management
of Exertional Compartment Syndrome of the Lower Leg. AM J Sports Med
21:811-817, 1993.
Slimmon, D, et al: Long-Term Outcome of Fasciotomy
with Partial Fasciectomy for Chronic Exertional Compartment Syndrome of the
Lower Leg. AM J Sports Med 30:581-588(2002).
Pedowitz RA, Hargens AR, Murbarak SJ: Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 18(1):35-40, 1990.
