Clinical Journal of Sport Medicine – BinkandBoo

Symptom scores (mean; standard error; *P

The percentage of patients not experiencing pain reduction during rest was 13% (FU3) and 22% (FU12), while it was 13% (FU3) and 8% (FU12) during exercise.

Three months postoperatively, changes in symptom scores of patients with unilateral CECS or bilateral CECS were not different. After 1 year, however, the unilateral group showed lower scores of tightness during rest compared with the bilateral group (unilateral group N = 26, bilateral group N = 37; P

Success Rate and Return to Sports

Three and 12 months postoperatively, success was reported by 56% and 48%, respectively. Three months after surgery, 63% had returned to sports of whom 25% returned to their preinjury level. Twelve months after surgery, 80% of the patients sported again with 28% returning to full sports.

Factors Determining Surgical Outcome

Univariate analysis demonstrated that not 1 of the preselected factors age, level of sports, symptom duration, ICP 1 minute after provocation, surgeon, or compartments was related to either success rate, complications, reduction in pain (during rest and exercise), or reduction in tightness during exercise.

However, a high 1-minute ICP value was associated with a lower chance of tightness reduction during rest (OR = 0.923 (0.866–0.985), P = 0.016). In addition, young age (OR = 0.937 (0.888–0.989), P = 0.018) and sporting on a local competitive level versus social level (OR = 4.500 (1.069–18.945), P = 0.040) were related with a higher odds of returning to sports. Moreover, a long symptom duration (>36 months OR = 0.189 (0.043–0.831), P = 0.027) was associated with a lower chance of a return to full sports.

Multivariate analysis illustrated that the surgical technique used by surgeon B resulted in a lower probability of a return to sports compared with surgeon A (OR = 0.116 (0.020–0.670), P = 0.016). Furthermore, patients with >36 months symptoms had a lower odds of returning to full sports (OR = 0.214 (0.047–0.968), P = 0.045).

Postoperative Complications

All patients were operated in a day care setting. Severe complications (excessive bleeding requiring reoperation, nerve damage, readmission) were not observed. Minor complications within 2 weeks after surgery were localized hematoma (24%, no surgery required) and wound infection (as reported by 17% of patients; half of them received antibiotics as judged by a general practitioner). Two patients reported transient edema, requiring 6 to 12 weeks of compressive stockings.

DISCUSSION

The present prospective study evaluated effectiveness of a dp-CECS fasciotomy. Approximately half of the patients considered their surgery as successful. Symptoms frequency and intensity dropped by more than 50%. At 3 months postoperatively, 3 of 5 patients had returned to sports, while 4 of 5 patients sported again 12 months after the operation. A long symptom duration (>36 months) was associated with a lower chance of returning to full sports. Interestingly, operative technique was also important as a flexor hallucis muscle fasciotomy conferred higher rate of return to sports.

The success rate of this study (48%–56%) is relatively poor, but in line with the literature.^{^2,8} Compared with superior success rates of a study of Winkes who found a 71% success rate in patients with isolated dp-CECS, success rates are lower in populations with combined pathologies as reported by this study.^⁷

The definition of success is crucial when comparing study results. At present, not 1 uniform classification of success is standardly adopted. For instance, some studies used 4 categories (excellent, good, fair, poor)^{^2,26} with 1 categorized “fair” as successful^² and 1 not,^²⁶ while others chose 5 different categories of success (excellent, good, moderate, fair, poor).^{^7,23} The scoring of success in this study changed from a 5-item to a 7-item scale as the standard questionnaire was updated in 2020. Although these categories were aligned, a lack of uniform end points, both within the study and compared with other studies, might bias outcomes. A consistent classification that is generally accepted is of great importance to facilitate future data comparison.

Diagnosing CECS is notoriously bothersome but pain and tightness are considered cardinal. Unfortunately, a standardized system of symptom documentation is currently lacking hindering comparison among studies. Treatment efficacy is reported as residual symptoms using questionnaires or rating scales.^{^6,7} This study used a drop in symptoms as a parameter of success as suggested.^⁷ Interestingly, this effect was already attained after 3 months and stabilized during the following months. These findings will aid physicians and patients in the preoperative counseling process.

The number of patients with dp-CECS who return to sports is relatively high in this study. One review described a 50% to 100% return to activity rate.^¹⁶ This study found percentages (63%–80%) that are similar with values after an ant-CECS fasciotomy.^¹⁹ In contrast to a review reporting a 50% to 100% returning to full sports rate, this study revealed a lower return to full sports rate (25%–28%).^¹⁶ This percentage is in line with rates found in patients with isolated dp-CECS (29%).^⁷ One other study found that 60% could eventually do sports at a high level.^⁹ Discrepancies are likely related to different follow-up lengths.^{^9,16} Another possible reason is a different case mix as symptom duration before diagnosis is much longer in this study (42 vs 16 months).

As expected, this study found that a delay in diagnosis had an adverse impact on the effectiveness of dp-CECS surgery. Earlier research also concluded that a long delay before a dp-CECS surgery predicts an unsuccessful response.^{^9,27} Causes of a protracted period are the extended list of alternative diagnoses. Moreover, the pivotal role of ICP measurements is progressively controversial. According to most research, levels of ICP do not influence surgical outcome.^{^2,7} However, 1 study suggested that levels of ICP predicted success.^⁸ We could not confirm this relation although an association with persistent tightness, which is in line with our expectation, was determined. Because levels of ICP were associated with just 1 of 8 predetermined outcome measures, its central role in the diagnostic approach of dp-CECS may be questioned. Consistent with the literature and our expectations, this study also observed that patients having more than 36 months of symptoms had a lower chance of returning to full sports. These data illustrate the current unawareness and insufficient knowledge levels of athletes, coaches, and physicians regarding dp-CECS.

The lower leg deep flexor compartment contains 3 separate muscles with own fascias. Which of the 3 contributes most to the inappropriately high muscle compartment pressure is unknown. Various methods for a deep posterior compartment release were proposed.^{^15,17} This study found that outcome is optimal if a fasciotomy of a flexor hallucis muscle is included. Whether the posterior tibial muscle also standardly requires a fasciotomy in dp-CECS is unknown but is advised.

Major strengths of this study are its prospective character minimizing recall bias and its substantial volume. A strength is also the inclusion of a range of predefined factors possibly related to outcome because most previous research considered only 1 variable. A limitation is a lack of a control group that classifies the study as a cohort study.^²⁸ Future research should consider a design with a control group. For example, the surgical technique could be randomized across patients. The number of patients with an outcome per variable was occasionally too small for a multivariate analysis. As a consequence, the interpretation of its results must be taken with caution. The elected categorization of success may possibly have been too strict because just 1 in 2 patients considered the surgery as successful, whereas 4 out of 5 patients returned to sports.

In conclusion, a dp-CECS fasciotomy reduced levels of cardinal symptoms including pain and tightness by approximately 50%. Twelve months postoperatively, half of patients considered the effect as successful, and 4 of 5 patients had returned to sports. However, the return to full sports rate was low for which a long symptom duration was found as predictor. Factors associated with a beneficial outcome are a relatively low muscle compartmental pressure, opening the flexor hallucis muscle fascia and a short symptom duration (

ACKNOWLEDGMENTS

The support of Stichting Stimuleren Sportgeneeskunde ZOB, The Netherlands for this study is highly acknowledged.

References

1. Reinking MF. Exercise related leg pain (ERLP): a review of the literature. N Am J Sports Phys Ther. 2007;2:170–180.

2. van Zoest WJ, Hoogeveen AR, Scheltinga MR, et al. Chronic deep posterior compartment syndrome of the leg in athletes: postoperative results of fasciotomy. Int J Sports Med. 2008;29:419–423.

3. Tucker AK. Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskelet Med. 2010;3:32–37.

4. Vogels S, Ritchie ED, van Dongen T, et al. Systematic review of outcome parameters following treatment of chronic exertional compartment syndrome in the lower leg. Scand J Med Sci Sports. 2020;30:1827–1845.

5. Davis DE, Raikin S, Garras DN, et al. Characteristics of patients with chronic exertional compartment syndrome. Foot Ankle Int. 2013;34:1349–1354.

6. Maher JM, Brook EM, Chiodo C, et al. Patient-reported outcomes following fasciotomy for chronic exertional compartment syndrome. Foot Ankle Spec. 2018;11:471–477.

7. Winkes MB, van Zantvoort AP, de Bruijn JA, et al. Fasciotomy for deep posterior compartment syndrome in the lower leg: a prospective study. Am J Sports Med. 2016;44:1309–1316.

8. Winkes MB, Hoogeveen AR, Houterman S, et al. Compartment pressure curves predict surgical outcome in chronic deep posterior compartment syndrome. Am J Sports Med. 2012;40:1899–1905.

9. Winkes MB, Hoogeveen AR, Scheltinga MR. Is surgery effective for deep posterior compartment syndrome of the leg? A systematic review. Br J Sports Med. 2014;48:1592–1598.

10. Lavery KP, Bernazzani M, McHale K, et al. Mini-open posterior compartment release for chronic exertional compartment syndrome of the leg. Arthrosc Tech. 2017;6:e649–e653.

11. Pedowitz RA, Hargens AR, Mubarak SJ, et al. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18:35–40.

12. Aweid O, Del Buono A, Malliaras P, et al. Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg. Clin J Sport Med. 2012;22:356–370.

13. Tzortziou V, Maffulli N, Padhiar N. Diagnosis and management of chronic exertional compartment syndrome (CECS) in the United Kingdom. Clin J Sport Med. 2006;16:209–213.

14. Ebraheim NA, Siddiqui S, Raberding C. A single-incision fasciotomy for compartment syndrome of the lower leg. J Orthop Trauma. 2016;30:e252–e255.

15. Campano D, Robaina JA, Kusnezov N, et al. Surgical management for chronic exertional compartment syndrome of the leg: a systematic review of the literature. Arthroscopy. 2016;32:1478–1486.

16. Weiss C, Vogels S, Wee L, et al. Two-compartment or 4-compartment fasciotomy for lower leg chronic exertional compartment syndrome: a systematic review. J Foot Ankle Surg. 2022;61:1124–1133.

17. Bellamy JT, Boissonneault AR, Melquist ME, et al. Release of the tibialis posterior muscle osseofascial sheath improves results of deep exertional compartment syndrome surgery: a comparative analysis and long-term results. Orthop J Sports Med. 2020;8:2325967120942752.

18. Ding A, Machin M, Onida S, et al. A systematic review of fasciotomy in chronic exertional compartment syndrome. J Vasc Surg. 2020;72:1802–1812.

19. Packer JD, Day MS, Nguyen JT, et al. Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome. Am J Sports Med. 2013;41:430–436.

20. Brennan FH Jr, Kane SF. Diagnosis, treatment options, and rehabilitation of chronic lower leg exertional compartment syndrome. Curr Sports Med Rep. 2003;2:247–250.

21. de Bruijn JA, van Zantvoort APM, van Klaveren D, et al. Factors predicting lower leg chronic exertional compartment syndrome in a large population. Int J Sports Med. 2018;39:58–66.

22. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310:2191–2194.

23. Vogels S, Ritchie ED, Hundscheid HP, et al. Chronic exertional compartment syndrome in the leg: comparing surgery to conservative therapy. Int J Sports Med. 2021;42:559–565.

24. de Bruijn JA, van Zantvoort APM, Hundscheid HPH, et al. Comparison of 2 fasciotomes for treatment of patients with chronic exertional compartment syndrome of the anterior leg. Orthop J Sports Med. 2021;9:23259671211051358.

25. van Zantvoort APM, de Bruijn JA, Hundscheid HPH, et al. Fasciotomy for lateral lower-leg chronic exertional compartment syndrome. Int J Sports Med. 2018;39:1081–1087.

26. Schepsis AA, Martini D, Corbett M. Surgical management of exertional compartment syndrome of the lower leg. Long-term followup. Am J Sports Med. 1993;21:811–817; discussion 7.

27. Lohrer H, Nauck T. Endoscopically assisted release for exertional compartment syndromes of the lower leg. Arch Orthop Trauma Surg. 2007;127:827–834.

28. Dekkers OM, Egger M, Altman DG, et al. Distinguishing case series from cohort studies. Ann Intern Med. 2012;156(pt 1):37–40.

Keywords:

cohort study; exercise-induced leg pain; prognostic factors; success rate after surgery