ANZ J. Surg.

2002;

72

: 720–723

ORIGINAL ARTICLE

Original Article

FASCIOTOMY FOR CHRONIC COMPARTMENT SYNDROME IN THE LOWER LIMB

S

TEVEN

C

OOK

AND

G

REG

B

RUCE

No. 3 Combat Support Hospital, Royal Australian Air Force Base Richmond, Richmond, Sydney, New South Wales, Australia

Background

:

The aim of this study was to determine the success of fasciotomy of lower limb compartments with elevated intra-compartment pressure.

Methods

:

The present report is a retrospective cohort study at No. 3 Combat Support Hospital involving a survey and case note reviewof patients who had undergone fasciotomy for compartment syndrome at least 6 months earlier (December 1997–December 2000).

Results

:

Fourteen patients met the inclusion criteria. Eleven reported success with complete resolution of symptoms and return tomilitary fitness levels. Two reported no change and significant residual symptoms. One reported worse symptoms and one requiredre-operation with a successful result.

Conclusion

:

Surgical decompression is the accepted treatment of compartment syndrome as proven by pressure manometry, afterfailure of conservative treatment.

Key words: chronic exercise induced compartment syndrome, fasciotomy, military.

Abbreviations

: 3CSH, No. 3 Combat Support Hospital; ADF, Australian Defence Force; PFT, physical fitness test; RAAF,Royal Australian Air Force.

INTRODUCTION

Service in the Australian Defence Force (ADF) requires a highlevel of physical fitness and appropriate training can involve anincrease in physical activity which may be significantly above arecruit’s accustomed level. This particularly applies during basicrecruit training in the first few weeks after recruitment.

A physical fitness test (PFT) must be passed annually toremain operational and deployable in the Royal Australian AirForce (RAAF). This involves a 2.4-km run in 12 minutes for menand 13 minutes for women with age exemptions, or a 5-km walkin 40 minutes for men or 41 minutes for women. As fitness is amilitary requirement, exercise is a compulsory activity withemphasis on marching, running and upper body strength. This isassociated with a high level of lower limb injury of which shinpain is a common presentation.

‘Shin splints’ are a common complaint among ADF members,particularly recruits. The term describes a symptom, and possiblediagnoses include exercise induced chronic compartment syn-drome, stress fracture (including single cortex stress fracture shownon bone scan), muscle strain, tendonitis and pain referred from theknee.

1

The first diagnosis is the subject of the present paper.Failure of conservative management is followed by investiga-

tion with bone scans and compartment pressure manometry.Proven compartment syndrome with elevated compartmentpressure not responsive to conservative treatment requiresdecompression fasciotomy as the next step.

This study assesses the success of fasciotomy in appropriatecandidates and their relief of pain as the endpoint. Their ability toreturn to military service and pass the fitness test provides aguide. This is not a large series indicating that chrome compart-ment syndrome is not a common condition.

METHODS

The surgical log book was audited from December 1997 toDecember 2000 and 14 candidates were identified. These met theinclusion criteria of undergoing a decompression fasciotomy ofone or more compartments, diagnosis confirmed on combinationof clinical signs and elevated pressures from manometry, opera-tion at No. 3 Combat Support Hospital (3CSH) by a singlesurgeon and a 6-month recovery period.

A survey was sent out to obtain consent and gain informationon symptoms and signs pre- and post-surgery including restric-tions on lifestyle and sports, and to assess possible complicationsand subsequent ability to pass the fitness test and return to mili-tary duties. Twelve of 14 replied to the survey. Two of the 14were unavailable for detailed survey. One was on maternity leaveand one on long-term overseas posting. These two were consultedover the telephone and had a telephone survey and review of theirclinical charts.

Investigation

All subjects had X-rays as a baseline but these were of limitedvalue due to the high false negative rate for stress fractures evenwith serial X-rays. Bone scans were performed to exclude stressfractures due to their higher sensitivity for single cortex or micro-fractures within the trabeculation. The technetium bone scan usedhad a radiation dose of 4880 microsieverts compared to 120microseiverts for three X-rays in a serial study. Natural back-ground radiation per annum is between two to three millisievertsand there is no firm evidence that doses less than 200 milli-sieverts are responsible for malignant disease.

S. Cook

MB BS;

G. Bruce

MB BS, FRACS (Orth).

Correspondence: Dr S. P. Cook, No. 3 Combat Support Hospital, RoyalAustralian Air Force Base Richmond, Richmond, Sydney, New South Wales2755, Australia.Email: drscook@hotmail.com

Accepted for publication 3 June 2002.

FASCIOTOMY FOR CHRONIC COMPARTMENT SYNDROME 721

All subjects had pressure studies of their affected compart-ments by a sports medicine physician using a Stryker needle andforce transducer. Only the affected compartment was tested dueto the discomfort of the procedure and all patients were testedwith the patient lying supine with the hip and knee flexed. This isrelevent as there is variation of normal limits depending on tech-nique and posture of the compartment, that is, a dependent limbwill have a greater resting pressure. The testing of only theaffected compartments was significant in the failed case wherere-operation on all compartments produced a good result.

Normal compartment pressures at rest were between 0 and4 mmHg with 15 mmHg regarded as diagnostic for compartmentsyndrome. A post-exercise reading of greater than 30 mmHgwas highly indicative of compartment syndrome and greater than40 mmHg was diagnostic.

Pre-surgical treatment

All subjects except one had physiotherapy involving an assess-ment, deep tissue massage, stretching and ultrasound. Patientswith mainly anterior compartment symptoms were started on astretching programme of tibialis anterior. None of the patientsimproved with a 3-month physiotherapy programme. Nine usedorthotics, involving mainly arch supports, and alterations weremade to footwear without success.

Surgical technique

Disappointing results following decompression of chronic com-partment syndrome can be due to a number of factors. Accuratediagnosis is important, especially identification of the number ofcompartments involved and the elimination of alternative path-ology. Poor results following surgery can be due to woundhaematoma, infection, delayed healing, post-operative muscleadhesion and weakness, inadequate decompression or damage tocutaneous nerves.

An identical surgical technique was used for each compart-ment decompressed. The only variation between patients was theselection of compartments decompressed. Decompression wasperformed through conventional skin incisions with anterolateralincision for anterior and lateral compartments and a postero-medial incision for superficial and deep posterior compartments.

Several steps were taken to protect against haematoma forma-tion. Exsanguinating tourniquets were not used, all wounds weredrained, local anaesthetic and adrenaline were injected backthrough the drains at the end of the operation, pressure dressingswere applied and the patient was kept on bed rest and with thelegs elevated for 48 h post-operatively. Deep vein thrombosisprophylaxis was vigorous calf exercise.

The procedure was not done ‘blind’ or percutaneously. A5-cm length incision allowed clear vision between subcutane-ous tissue and deep fascia. Use of a Deaver or Langenbackretractor ensured adequate decompression proximally and dis-tally and also protection of cutaneous nerves. There was clearvision of decompressed muscle and further resection of fasciaor separation of fascia from muscle was performed if decom-pression was inadequate.

The wound was closed using 4–0 Prolene interrupted suturesof the skin only and all wounds were injected with local anaes-thetic and adrenaline and were drained with a small bore lowpressure suction drain. No prophylactic antibiotics were used.

The compression dressings were changed to compression tubi-grip within the first 10 days. This technique prevents haematomaand allows early healing of wounds.

All patients rested in bed with their legs elevated for at least48 h and were then mobilized by physiotherapy to prevent scar-ring and recurrence of symptoms. The average stay in hospitalwas 3.5 days.

Material

This paper studies the treatment and progress of 14 patients whohad decompression of chronic compartment syndrome of the legat 3CSH, RAAF Richmond over a 3-year period. There were 13RAAF members and one army member. Ten were men and fourwere women with an average age of 27 years (range 22–38). Onlyfour had developed symptoms at recruit training, with the othersdeveloping symptoms subsequently. None had symptoms prior torecruitment.

All complained of pain after exercise and the expression ‘shinsplints’ was frequently used. Less frequent symptoms were swell-ing, tightness or sensory changes. There were varying tolerancesto exercise and also varying rates of recovery on cessation ofexercise. Each patient, with one exception, stopped all sport andrecreational physical activity. Only four failed the PFT but theothers passed with considerable discomfort and determination topersist with the test despite the severity of the symptoms. Mostwalked the test whereas their preference was to run.

The average duration of symptoms was 5 years and 3 months(range 6 months–10 years). Eight patients had had symptoms formore than 5 years. All were coping with difficulty and four wereclassified as non-deployable after failure of the PFT.

All patients except one had bilateral symptoms and bilateralsurgery (see Table 1).

RESULTS

The patients were reviewed on average at 37 months post surgery(range 11–90 months). Eleven of the 14 (78.5%) patients des-cribed complete relief from the symptoms and were very satisfiedwith the operation. Three reported no improvement with onepatient describing no change and the other two patients statingthat they were worse after the operation. The 11 cases with com-plete relief described no pain, full function and participation in allsports and physical recreation of choice.

Two of the three surgical failures were unable to attempt thePFT and have been medically discharged from the RAAF, withthe other patient able to complete the PFT in pain. The other 11have passed the PFT and are fully deployable. Significantly twoof the 11 successful cases had previously failed the PFT and arenow able to pass the test pain-free. The PFT test can be used as aguide only, as 10 out of 14 patients were able to pass the test inpain before the surgery and 12 out of 14 could pass post surgeryincluding one with initially unsuccessful surgery. All of thosewho had complete relief from symptoms reported improvementof times for the run component of the PFT.

One patient with a poor result only had the anterior segmentdecompressed and subsequent pressure studies demonstratedthat four compartment decompression was necessary. This wasoffered but the patient elected to not have the surgery. There wasno apparent reason for the poor result in the other two patients,one of whom had bilateral anterior compartment decompressionand the other bilateral four compartment decompression.

722 COOK AND BRUCE

One patient with a good result after four compartment decom-pression had a relapse of symptoms in the left leg and the uni-lateral compartment decompression was repeated with completerelief of symptoms.

All wounds healed rapidly without early complications such ashaematoma or infection.

Three patients complained of long-term altered sensation inskin over the fasciotomy. This was due to stripping of theskin from the fascia with denervation of the local skin. Sig-nificantly none had damage to a cutaneous nerve with nopatients demonstrating neuroma or loss of sensation distal tothe fasciotomy.

No patient had clinical evidence of deep vein thrombosis orother surgical complications, for example, atelectasis, in the post-surgical period.

DISCUSSION

The ADF requires high levels of physical fitness and its membersare trained and monitored to ensure that this level of fitness ismaintained. This training results in an incidence of exercise-related chronic compartment syndrome which appears to begreater than in the average population. The testing and monitor-ing required by the ADF provides the opportunity to assess theresults of treatment of this condition.

The patients studied all initially had unsuccessful conservativetreatment but 11 out of 14 had successful surgical treatment. Thisis comparable with other major studies of surgical decompression.

4

Study of the three unsuccessful cases reveals that one case mayhave been further improved by decompressing all four compart-ments in each leg whereas he only had the anterior segmentdecompressed. One of the other unsuccessful cases also had onlythe anterior compartment decompressed but did not have furtherpressure studies. The third patient had all four compartmentsdecompressed bilaterally. There was no apparent reason for thelack of success in these last two patients.

The incidence of complication and the time for recovery wasno greater after 4 compartment decompression than single com-partment decompression. The results collated are similar to otherresults in the literature.

2,3

In the largest recent review from the University of Calgary,Alberta, Canada, in a series of 62 patients treated for chronic

exertional compartment syndrome 79% were satisfied with theoperation, 6% required re-operation for exercise induced pain,and 13% reported post-operative complications.

4

In another study from University Hospital, London, Ontario,Canada, 25 patients with resting pressures greater than 15 mmHgand elevated post-exercise pressure measurements with delayed nor-malization were treated with fasciotomy; 22 of these patients weresatisfied with procedure and able to return to athletics. The three fail-ures were releases of the posterior compartments. The conclusion ofthis study was fasciotomy of anterior compartment was very success-ful for correct indications and fasciotomy of posterior compartmentshould include a formal release of the tibialis posterior muscle.

5

Styf and Korner from Goteburg, Sweden, in a series of 30 legsin 19 patients reported increase in functional capacity in 18patients (28 legs) and unchanged in one patient (2 legs) who hadthe decompression of superfical peroneal nerve. Two patientsrequired a repeat fasciotomy due to recurrence of symptoms.Intramuscular pressures were normal at rest as well as during andafter exercise 8 months after original fasciotomy or after secondfasciotomy in two legs.

6

Post-fasciotomy compartment pressures were not tested as ameasure of success in our military study as it was seen as anunnecessary invasive test given the successful relief of symptomsand successful exercise testing.

No comparable Australian study was available on literaturereview.

This series has the advantage that it has a consistent surgicaltechnique performed by one surgeon. All had classical symptomsand were fully investigated so that the diagnosis was in no doubt.The surgical technique emphasized avoidance of wound haematomaand early skin healing. This series shows that surgical decompres-sion achieves complete success in at least 75% of patients.

CONCLUSION

Decompressive fasciotomy is effective treatment of compartmentsyndrome after failure of conservative treatment. The diagnosisneeds to be made using pressure manometry of the affected com-partment. In this series relief of symptoms was achieved in 78.5%of cases with no significant early post-operative complications.Two out of 14 were able to pass the fitness test after previousfailure and continue their service in the military.

Table 1.

Fasciotomy results

Age at operation

Sex Compartments undergoing surgery

Clinical Result PFT result Complications

31 years Male Bilateral anterior No improvement Fail. No change No complications38 years Male Bilateral anterior No residual symptoms Pass. Improved No complications27 years Male Bilateral anterolateral No residual symptoms Pass. Improved No complications25 years Male Bilateral anterior No residual symptoms Pass. Improved No complications31 years Male Bilateral anterior No residual symptoms Pass. Improved No complications37 years Male Bilateral anterior No residual symptoms Pass. Improved No complications24 years Female Bilateral 4 compartments No residual symptoms Pass. Improved. Prior fail No complications22 years Female Bilateral anterior No improvement Fail. No change Altered sensation33 years Male Bilateral 4 compartments Symptoms worse Pass. Slower Altered sensation24 years Female Unilateral 4 compartments No residual symptoms Pass. Improved. Prior fail No complications24 years Male Bilateral 4 compartments Improvement but relapse re-operation Pass. Improved No complications27 years Male Bilateral 4 compartments No residual symptoms Pass. Improved Altered sensation24 years Female Bilateral anterior No residual symptoms Pass. Improved No complications38 years Male Bilateral anterior No residual symptoms Pass. Improved No complications

PFT, physical fitness test.

FASCIOTOMY FOR CHRONIC COMPARTMENT SYNDROME 723

ACKNOWLEDGEMENTS

The authors would like to thank Micheal Rayner of Surgical Out-patients, for his help in collection of data for this study, Dr ErnestCroker, Radiologist, for his expert advice on bone scanning, andalso Dr Steinweg, Sports Medicine Physician, for advice on man-ometry for compartment pressures.

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