Fasciotomy for Exertional Compartment Syndrome—Cutting Edge?

Abstract & Commentary

Synopsis: Fasciotomy reduces pain and allows most athletes to return to sports, but often they are not pain-free and may not return to their preinjury level of sports activity.

Source: Slimmon D, et al. Am J Sports Med. 2002;30:581-588.

Chronic exertional compartment syndrome is a relatively common exercise-related injury of the lower leg in young athletes. Increased intramuscular pressures are believed to be the etiology of this syndrome, and measurement of compartment pressures are an essential part of the diagnostic work-up. Although short-term success has been reported for this procedure, there have been no long-term independent results published regarding the outcome of these procedures.

A total of 62 of 140 patients who had fasciotomies for chronic exertional compartment syndrome over a 5-year period responded to a questionnaire sent by Slimmon and colleagues. The surgical technique involved release of the fascia and removal of a strip of fascia and/or periosteum overlying the affected compartment. Follow-up was done at an average of 51 months (just over 4 years) with a range of 24-107 months. Good-to-excellent results were reported in 60% (37/62) of patients. Pain was recorded on a 10-point visual analog scale with low scores signifying less pain. Pain improvement was related to compartments involved/released with the best results in patients who had posterior releases (8.2 pre-op to 1.3 at follow-up) and the worst results in patients who had anterior and posterior releases (9.1 pre-op to 5.1 at follow-up). Exercise levels improved following compartment releases, with 74% reporting a return to preinjury levels at some point. At final follow-up, however, the number of patients who returned to preinjury levels declined to 42%. Patients with anterior compartment fasciotomies had more pain and problems than those with posterior fasciotomies. The duration of preoperative symptoms was important in the anterior compartment releases with delays over 12 months associated with worse results.

Comment by Mark D. Miller, MD

This study has several flaws, namely, it is retrospective and was based on questionnaires with only a 44% recruitment rate. Nevertheless, it does represent one of the only reports of intermediate to long-term results of fasciotomies for exertional compartment syndrome. Slimmon et al reported less than encouraging results, especially in patients with anterior compartment releases. They suggest several reasons for this including difficulty in making the diagnosis, secondary delayed effects of surgery (such as scarring), and possibly intrinsic structural defects.

This report is interesting because it reflects my own clinical practice. Rarely is compartment release for exertional compartment syndrome a "home run." We need to counsel our patients of that fact. I perform only a few of these procedures a year, and sometimes dread seeing these patients back in clinic postoperatively. I cannot imagine what the Slimmon’s clinic must be like after performing 260 of these procedures through 1997! The message is clear: Proceed with caution, and don’t promise great results.

Dr. Miller, Associate Professor, UVA Health System, Department of Orthopaedic Surgery, Charlottesville, VA, is Associate Editor of Sports Medicine Reports.