Surgical Management of Chronic Exertional Compartment Syndrome of the Lower Extremity: Outcome Analysis and Return to Sport

Abstract

Category: Sports Introduction/Purpose: Chronic exertional compartment syndrome (CECS) occurs as the result of increasing pressure in a closed muscular compartment, typically in the leg, as the result of repetitive activity. Physiologic changes in myofibril size during exercise increase muscle volume leading to higher compartmental pressures, which can result in neurologic and vascular changes. CECS has been estimated to cause 27%-33% of exertional leg pain and frequently leads to a decrease in athletic training and competition. CECS affects males and females equally but is especially common in young athletes, particularly competitive runners, as well as soccer, field hockey and lacrosse players and in military personnel. The purpose of this study is to evaluate patient- reported outcomes and return to sport (RTS) after open fasciotomy for lower extremity CECS. Methods: A retrospective review of patients that underwent lower extremity fasciotomy for CECS by a single surgeon was performed. All patients had a diagnosis confirmed by pre- and post-exercise compartment pressure testing. Two-incision technique was used with lateral and anterior compartments released through a lateral incision, while deep and superficial posterior compartments were released through a medial approach when indicated. Patients that underwent a fasciotomy for trauma, infection, or an acute pathologic process were excluded. Patient outcome measures were recorded for each patient including the Foot and Ankle Ability Measure-Sport subscale (FAAM-Sport), FAAM-Sport Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale (VAS) for pain. A novel RTS questionnaire was designed and implemented. Patient demographic information was included. Outcome analysis was performed using Student’s t-test and chi-square testing. RTS was compared using Mann-Whitney U testing, and regression analysis was used to identify independent risk factors for failure to RTS. Results: 59 patients that underwent 63 procedures were included. Average age was 26.6 years (range, 15-55), 59.3% were female, and average follow-up was 58.8 months (range, 12-115). 37 patients underwent simultaneous bilateral fasciotomies, 8 had staged bilateral fasciotomies and 18 underwent unilateral fasciotomy. Four-compartment fasciotomy was performed 14 times and 49 fasciotomies involved one or two compartments. Significant postoperative improvement was seen in the FAAM-Sport, Sport SANE and the VAS for pain compared to preoperative scores (p<0.001). Overall 93.2% (55/59) of patients were able to return to sport, 78.1% (43/55) returned to the same level of sport, and 21.9% (12/54) returned to a lower level of competition. Bivariate regression analysis demonstrated that higher preoperative BMI (p=0.049) was associated with a lower likelihood of return to sport. Conclusion: CECS is a relatively common problem seen in young athletes and can cause significant change in athletic participation and ability. This cohort of patients who underwent lower extremity fasciotomies for CECS is larger than any previously published. This study demonstrates that lower extremity fasciotomy for CECS results in improvement of patient-reported outcomes and returns athletes back to competition at a high rate.