Mini-Open Posterior Compartment Release for Chronic Exertional Compartment Syndrome of the Leg Kyle P. Lavery, M.D., Michael Bernazzani, B.S., Kevin McHale, M.D., William Rossy, M.D., Luke Oh, M.D., and George Theodore, M.D.
Abstract: Chronic exertional compartment syndrome (CECS) is a well-recognized cause of leg pain in endurance athletes. Surgical fasciotomy for posterior leg CECS historically has inferior clinical results compared with anterior and lateral compartment release. Poor surgical technique with inadequate release may contribute to less reliable outcomes. In this Technical Note with accompanying video, we describe a mini-open approach for posterior CECS of the leg.
C
hronic exertional compartment syndrome (CECS) is recognized as a common cause of leg pain in both recreational and competitive athletes. Frequent in running sports, patients typically present with pain, cramping, tightness, and loss of sensation in the distribution of the affected compartment. Symptoms occur after a predictable duration and intensity of exercise and are relieved with rest. These symptoms can be debilitating, resulting in significant lost time from participation and competition. The exact etiology and pathophysiology of CECS remain unclear. Generally, it is accepted that muscle expansion during exercise results in increased pressure in an enclosed fascial compartment, compromising perfusion. Symptoms are thought to result from relative ischemia to muscular and neurologic structures. CECS is differentiated from acute compartment syndrome, a surgical emergency, by its transient nature and reversibility with rest. It is uncertain why some individuals are predisposed to developing symptoms.
From the Division of Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received September 7, 2016; accepted January 18, 2017. Address correspondence to Kyle P. Lavery, M.D., Division of Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, 175 Cambridge Street, 4th Floor, Boston, MA 02114, U.S.A. E-mail: [email protected] Ó 2017 by the Arthroscopy Association of North America 2212-6287/16861/$36.00 http://dx.doi.org/10.1016/j.eats.2017.01.010
Reported in many anatomic locations, CECS most frequently affects the leg and has been described in all four compartments. CECS of the anterior compartment of the leg is most common and best studied, with reports and results of surgical treatment published since the 1950s. The deep posterior compartment is also frequently affected, reported to be involved in up to 40% of cases. Puranen reported the first case series of deep posterior compartment release in 1974.1 While long recognized, CECS of the deep posterior compartment is less well understood and more frequently confused with medial tibial stress syndrome.
Fig 1. The patient is positioned supine on a standard operating table with a nonsterile thigh tourniquet. In this example of a right leg, the extremity is externally rotated at the hip into a figure-of-four position to aid in access to the medial side of the leg. An 8- to 10-cm medial longitudinal incision is made approximately 1 cm posterior to the subcutaneous border of the tibia. The image depicts a right leg in the supine position. (A, anterior; Di, distal; P, posterior; Pr, proximal.)
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Fig 2. A scalpel is used to sharply create a 1-cm longitudinal incision in the fascia overlying the gastrocnemius and soleus muscle bellies. The image depicts a right leg in the supine position. (A, anterior; Di, distal; P, posterior; Pr, proximal.)
Surgical fasciotomy is considered the gold standard and most reliable treatment for CECS. Various open and endoscopic-assisted techniques have been described for both laterally based anterior and lateral compartment release and medially based superficial and deep posterior compartment release.2 Minimally invasive techniques are generally less used for medial release because of a greater potential risk to neurovascular structures. Historically, deep posterior fasciotomy has resulted in consistently poorer surgical results than anterior and lateral release, with success rates reported from 30% to 65%.3 The reason for inferior surgical outcomes is not clear. Several investigators have demonstrated the contribution of a separate fifth fascial compartment or subcompartment for the tibialis posterior muscle, but this has not been universally reproducible or accepted.4,5 Other surgeons have suggested that more unfamiliar anatomy and more difficult dissection in this area frequently result in inadequate release of the compartment.
Fig 3. (A) A long, blunt Metzenbaum scissor is introduced into the fascial rent aiming distally. (B) The scissor is gently advanced distally, bluntly separating the fascia from the underlying muscle bellies and tendons. (C, D) Using a push-cut technique, the fascia is slowly incised distally to the level of the ankle. All images depict a right leg in the supine position. (A, anterior; Di, distal; P, posterior; Pr, proximal.)
MINI-OPEN POSTERIOR COMPARTMENT RELEASE
Fig 4. The proximal fascia is then incised in a similar fashion. The image depicts a right leg in the supine position. (A, anterior; Di, distal; P, posterior; Pr, proximal.)
In this Technical Note with accompanying video (Video 1), we describe our preferred technique for deep and superficial posterior compartment fasciotomy for CECS of the leg. We use a mini-open approach that we feel optimizes visualization, ensures adequacy of release, and minimizes risk to neurovascular structures.
Surgical Technique The patient is positioned supine on a standard operating table with a nonsterile thigh tourniquet. The lower extremity is prepped and sterilely draped in standard surgical fashion. Prior to incision, the leg is exsanguinated and the tourniquet inflated to create a bloodless field. The posterior release is often accompanied by an anterolateral release that can be performed prior to or after the posterior portion of the procedure.
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The extremity can be externally rotated at the hip into a figure-of-four position to aid in access to the medial side of the leg (Fig 1). We utilize a small central incision to perform complete compartment releases both proximally and distally. An 8- to 10-cm medial longitudinal incision is made approximately 1 cm posterior to the subcutaneous border of the tibia. The subcutaneous tissue is bluntly dissected to the level of the fascia using Metzenbaum scissors to avoid injury to the saphenous neurovascular bundle, which is often encountered crossing the field. The nerve and vein are carefully mobilized for visualization. Small venous branches can be coagulated to aid in mobilization and retraction. Large skin flaps are developed using blunt finger dissection to expose the investing muscular fascia. The superficial posterior compartment release is carried out first. A scalpel is used to sharply create a 1-cm longitudinal rent in the fascia overlying the gastrocnemius and soleus muscle bellies (Fig 2). A blunt Metzenbaum scissor is slid distally deep to the fascia to free it from the underlying musculotendinous structures. Using a push-cut technique, the fascia is released distally to the level of the ankle (Fig 3) The fascia is then released proximally in similar fashion (Fig 4). Next, attention is given to the more challenging deep posterior compartment release. The saphenous neurovascular bundle is retracted posteriorly, and the tibia is palpated. Using electrocautery, the fascia and subperiosteal tissues are released directly off its posterior border (Fig 5A). This is carefully continued until muscle is encountered (Fig 5B). The flexor digitorum longus muscle has a broad origin on the posteromedial surface of the tibia and is the first muscle belly encountered in the deep compartment at the level of
Fig 5. (A) Retracting the saphenous neurovascular bundle posteriorly, the fascia and subperiosteal tissues are incised from the posteromedial tibia using electrocautery. (B) The flexor digitorum longus is the first muscle belly encountered medially in the deep posterior compartment. The images depict a right leg in the supine position. (A, anterior; Di, distal; FDL, flexor digitorum longus; P, posterior; Pr, proximal; S, saphenous neurovascular bundle; T, tibia.)
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Fig 6. (A) Subperiosteal dissection is carried out proximally and distally from the tibial border to ensure complete deep posterior compartment release. (B) The superficial posterior compartment release is visualized as the saphenous neurovascular bundle is retracted anteriorly. The images depict a right leg in the supine position. (A, anterior; Di, distal; P, posterior; Pr, proximal; S, saphenous neurovascular bundle; T, tibia.)
the midleg. Continued dissection laterally will reveal the tibialis posterior muscle. The tibial nerve and posterior tibial vessels lie between and posterior to the muscle bellies of the flexor digitorum longus and tibialis posterior. As a result, the posterior neurovascular bundle is protected if the dissection is carried out subperiosteally. Subperiosteal dissection is continued both proximally and distally. Digital examination is carried out to free any residual adhesions and ensure adequate compartment release (Fig 6). The wound is copiously irrigated, and meticulous hemostasis is achieved with electrocautery to limit the risk of postoperative hematoma. The subcutaneous tissues and skin are closed in layers, and a sterile dressing is applied. The patient is permitted to bear weight as tolerated when pain allows. Immediate knee
Table 1. Pearls and Pitfalls Pearls Perform a careful workup, including history, physical examination, imaging, and compartment pressure measurements to ensure the correct diagnosis and define the compartments involved. Carefully identify and protect the saphenous neurovascular bundle to prevent postoperative hematoma and neurologic injury. To decompress the deep posterior compartment, dissect subperiosteally from the posteromedial border of the tibia. The posterior tibial neurovascular bundle is posterior to the flexor digitorum and tibialis posterior musculature and will be protected. Pitfalls Failure to make the correct diagnosis or define the compartments involved. Failure to identify and protect the saphenous neurovascular bundle, resulting in iatrogenic injury. Inadequate visualization, resulting in inadequate compartment release.
and ankle range of motion is encouraged to decrease swelling and limit postoperative stiffness.
Discussion CECS is one of the most common causes of leg pain in endurance athletes, often resulting in debilitating symptoms and missed time from participation and competition. Often unresponsive to conservative treatment, surgical fasciotomy is recognized as the most reliable treatment of CECS. While CECS is more frequent in the anterior compartment of the leg, the deep posterior compartment is often affected in isolation or in combination with the anterior and lateral compartments. It is well recognized that the results of fasciotomy for deep posterior CECS are generally inferior to anterior and lateral release. Winkes et al. conducted a recent systematic review of the published results of fasciotomy for deep posterior exertional compartment syndrome.3 Seven studies (131 patients) met the criteria and were included in this systematic review, all consisting of level 3 evidence.6-12 Success rates in the analyzed studies ranged from only 30% to 65%. In 2016, Winkes et al. published the first prospective study of patients who underwent fasciotomy for isolated deep posterior compartment syndrome.13 Forty-two patients (64 legs) were evaluated at a mean Table 2. Advantages and Disadvantages Advantages Optimal anatomic visualization Identification and protection of neurovascular structures Direct visualization and palpation of complete compartment release Disadvantages Poorer cosmesis Potential for increased infection and wound healing problems
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follow-up of 26 months. A minority of patients experienced subjectively excellent (12%) or good (35%) results, with 30% rated as fair or poor. Only 29% returned to their previous level of sporting activity. The reason for less predictable outcomes after the surgical treatment of deep posterior CECS is unclear. Causes may be attributed to improper diagnosis, treatment, or both. The differential for leg pain in the athlete is broad. Etiologies may include musculotendinous, vascular (popliteal artery entrapment syndrome, vascular insufficiency), and bony (stress fracture, medial tibial stress syndrome) causes, in addition to rare infectious or oncologic conditions. Additionally, the clinical presentation of deep posterior CECS can be vague, often consisting of nonspecific pain or cramping. The extensive differential diagnosis combined with an often nebulous presentation, lack of physical findings, and unreliable objective diagnostic testing results in the increased potential for misdiagnosis or unrecognized concomitant pathology. There is also a lack of consistency among surgical techniques for the treatment of posterior CECS, with numerous open and endoscopic-assisted techniques described. Some investigators have also advocated for the specific release of controversial subcompartments.4,5 Regardless of technique, it is clear that posterior fasciotomy presents a more challenging surgical dissection than anterior and lateral releases. Unfamiliarity with the anatomy and the potential risk to deep neurovascular structures may result in inadequate compartment release. In this Technical Note with accompanying video, we describe our preferred approach for deep and superficial posterior compartment fasciotomy for CECS of the leg (Table 1). Past investigators have advocated more minimally invasive and endoscopic-assisted techniques, citing improved cosmesis, decreased rates of infection and wound healing problems, and the potential for expedited recovery. Despite these potential advantages, we use a mini-open technique that we feel optimizes visualization. Through this additional exposure, the anatomy can be clearly defined to ensure adequate compartment release and minimizes the potential for iatrogenic injury and complications (Table 2).
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References 1. Puranen J. The medial tibial syndrome: exercise ischaemia in the medial fascial compartment of the leg. J Bone Joint Surg Br 1974;56:712-715. 2. Wittstein J, Moorman CT 3rd, Levin LS. Endoscopic compartment release for chronic exertional compartment syndrome: surgical technique and results. Am J Sports Med 2010;38:1661-1666. 3. 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. 4. Davey JR, Rorabeck CH, Fowler PJ. The tibialis posterior muscle compartment. An unrecognized cause of exertional compartment syndrome. Am J Sports Med 1984;12: 391-397. 5. Hislop M, Tierney P, Murray P. Chronic exertional compartment syndrome: the controversial “fifth” compartment of the leg. Am J Sports Med 2003;31:770776. 6. Pedowitz RA, Hargens A, Mubarak S. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 1990;18:35-40. 7. Winkes MB, Hoogeveen A, Houterman S. Compartment pressure curves predict surgical outcome in chronic deep posterior compartment syndrome. Am J Sports Med 2012;40:1899-1905. 8. 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 817. 9. Biedert RM, Marti B. Intracompartmental pressure before and after fasciotomy in runners with chronic deep posterior compartment syndrome. Int J Sports Med 1997;18: 381-386. 10. Rorabeck CH. Exertional tibialis posterior compartment syndrome. Clin Orthop Relat Res 1986;208:61-64. 11. Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. J Bone Joint Surg Am 1983;65:1245-1251. 12. van Zoest WJ, Hoogeveen A, Scheltinga M. Chronic deep posterior compartment syndrome of the leg in athletes: postoperative results of fasciotomy. Int J Sports Med 2008;29:419-423. 13. Winkes MB, van Zantvoort A, de Bruijn J. Fasciotomy for deep posterior compartment syndrome in the lower leg: a prospective study. Am J Sports Med 2016;44:1309-1316.
Abstract: Chronic exertional compartment syndrome (CECS) is a well-recognized cause of leg pain in endurance athletes. Surgical fasciotomy for posterior leg CECS historically has inferior clinical results compared with anterior and lateral compartment release. Poor surgical technique with inadequate release may contribute to less reliable outcomes. In this Technical Note with accompanying video, we describe a mini-open approach for posterior CECS of the leg.
C
hronic exertional compartment syndrome (CECS) is recognized as a common cause of leg pain in both recreational and competitive athletes. Frequent in running sports, patients typically present with pain, cramping, tightness, and loss of sensation in the distribution of the affected compartment. Symptoms occur after a predictable duration and intensity of exercise and are relieved with rest. These symptoms can be debilitating, resulting in significant lost time from participation and competition. The exact etiology and pathophysiology of CECS remain unclear. Generally, it is accepted that muscle expansion during exercise results in increased pressure in an enclosed fascial compartment, compromising perfusion. Symptoms are thought to result from relative ischemia to muscular and neurologic structures. CECS is differentiated from acute compartment syndrome, a surgical emergency, by its transient nature and reversibility with rest. It is uncertain why some individuals are predisposed to developing symptoms.
From the Division of Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received September 7, 2016; accepted January 18, 2017. Address correspondence to Kyle P. Lavery, M.D., Division of Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, 175 Cambridge Street, 4th Floor, Boston, MA 02114, U.S.A. E-mail: [email protected] Ó 2017 by the Arthroscopy Association of North America 2212-6287/16861/$36.00 http://dx.doi.org/10.1016/j.eats.2017.01.010
Reported in many anatomic locations, CECS most frequently affects the leg and has been described in all four compartments. CECS of the anterior compartment of the leg is most common and best studied, with reports and results of surgical treatment published since the 1950s. The deep posterior compartment is also frequently affected, reported to be involved in up to 40% of cases. Puranen reported the first case series of deep posterior compartment release in 1974.1 While long recognized, CECS of the deep posterior compartment is less well understood and more frequently confused with medial tibial stress syndrome.
Fig 1. The patient is positioned supine on a standard operating table with a nonsterile thigh tourniquet. In this example of a right leg, the extremity is externally rotated at the hip into a figure-of-four position to aid in access to the medial side of the leg. An 8- to 10-cm medial longitudinal incision is made approximately 1 cm posterior to the subcutaneous border of the tibia. The image depicts a right leg in the supine position. (A, anterior; Di, distal; P, posterior; Pr, proximal.)
Arthroscopy Techniques, Vol 6, No 3 (June), 2017: pp e649-e653
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Fig 2. A scalpel is used to sharply create a 1-cm longitudinal incision in the fascia overlying the gastrocnemius and soleus muscle bellies. The image depicts a right leg in the supine position. (A, anterior; Di, distal; P, posterior; Pr, proximal.)
Surgical fasciotomy is considered the gold standard and most reliable treatment for CECS. Various open and endoscopic-assisted techniques have been described for both laterally based anterior and lateral compartment release and medially based superficial and deep posterior compartment release.2 Minimally invasive techniques are generally less used for medial release because of a greater potential risk to neurovascular structures. Historically, deep posterior fasciotomy has resulted in consistently poorer surgical results than anterior and lateral release, with success rates reported from 30% to 65%.3 The reason for inferior surgical outcomes is not clear. Several investigators have demonstrated the contribution of a separate fifth fascial compartment or subcompartment for the tibialis posterior muscle, but this has not been universally reproducible or accepted.4,5 Other surgeons have suggested that more unfamiliar anatomy and more difficult dissection in this area frequently result in inadequate release of the compartment.
Fig 3. (A) A long, blunt Metzenbaum scissor is introduced into the fascial rent aiming distally. (B) The scissor is gently advanced distally, bluntly separating the fascia from the underlying muscle bellies and tendons. (C, D) Using a push-cut technique, the fascia is slowly incised distally to the level of the ankle. All images depict a right leg in the supine position. (A, anterior; Di, distal; P, posterior; Pr, proximal.)
MINI-OPEN POSTERIOR COMPARTMENT RELEASE
Fig 4. The proximal fascia is then incised in a similar fashion. The image depicts a right leg in the supine position. (A, anterior; Di, distal; P, posterior; Pr, proximal.)
In this Technical Note with accompanying video (Video 1), we describe our preferred technique for deep and superficial posterior compartment fasciotomy for CECS of the leg. We use a mini-open approach that we feel optimizes visualization, ensures adequacy of release, and minimizes risk to neurovascular structures.
Surgical Technique The patient is positioned supine on a standard operating table with a nonsterile thigh tourniquet. The lower extremity is prepped and sterilely draped in standard surgical fashion. Prior to incision, the leg is exsanguinated and the tourniquet inflated to create a bloodless field. The posterior release is often accompanied by an anterolateral release that can be performed prior to or after the posterior portion of the procedure.
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The extremity can be externally rotated at the hip into a figure-of-four position to aid in access to the medial side of the leg (Fig 1). We utilize a small central incision to perform complete compartment releases both proximally and distally. An 8- to 10-cm medial longitudinal incision is made approximately 1 cm posterior to the subcutaneous border of the tibia. The subcutaneous tissue is bluntly dissected to the level of the fascia using Metzenbaum scissors to avoid injury to the saphenous neurovascular bundle, which is often encountered crossing the field. The nerve and vein are carefully mobilized for visualization. Small venous branches can be coagulated to aid in mobilization and retraction. Large skin flaps are developed using blunt finger dissection to expose the investing muscular fascia. The superficial posterior compartment release is carried out first. A scalpel is used to sharply create a 1-cm longitudinal rent in the fascia overlying the gastrocnemius and soleus muscle bellies (Fig 2). A blunt Metzenbaum scissor is slid distally deep to the fascia to free it from the underlying musculotendinous structures. Using a push-cut technique, the fascia is released distally to the level of the ankle (Fig 3) The fascia is then released proximally in similar fashion (Fig 4). Next, attention is given to the more challenging deep posterior compartment release. The saphenous neurovascular bundle is retracted posteriorly, and the tibia is palpated. Using electrocautery, the fascia and subperiosteal tissues are released directly off its posterior border (Fig 5A). This is carefully continued until muscle is encountered (Fig 5B). The flexor digitorum longus muscle has a broad origin on the posteromedial surface of the tibia and is the first muscle belly encountered in the deep compartment at the level of
Fig 5. (A) Retracting the saphenous neurovascular bundle posteriorly, the fascia and subperiosteal tissues are incised from the posteromedial tibia using electrocautery. (B) The flexor digitorum longus is the first muscle belly encountered medially in the deep posterior compartment. The images depict a right leg in the supine position. (A, anterior; Di, distal; FDL, flexor digitorum longus; P, posterior; Pr, proximal; S, saphenous neurovascular bundle; T, tibia.)
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Fig 6. (A) Subperiosteal dissection is carried out proximally and distally from the tibial border to ensure complete deep posterior compartment release. (B) The superficial posterior compartment release is visualized as the saphenous neurovascular bundle is retracted anteriorly. The images depict a right leg in the supine position. (A, anterior; Di, distal; P, posterior; Pr, proximal; S, saphenous neurovascular bundle; T, tibia.)
the midleg. Continued dissection laterally will reveal the tibialis posterior muscle. The tibial nerve and posterior tibial vessels lie between and posterior to the muscle bellies of the flexor digitorum longus and tibialis posterior. As a result, the posterior neurovascular bundle is protected if the dissection is carried out subperiosteally. Subperiosteal dissection is continued both proximally and distally. Digital examination is carried out to free any residual adhesions and ensure adequate compartment release (Fig 6). The wound is copiously irrigated, and meticulous hemostasis is achieved with electrocautery to limit the risk of postoperative hematoma. The subcutaneous tissues and skin are closed in layers, and a sterile dressing is applied. The patient is permitted to bear weight as tolerated when pain allows. Immediate knee
Table 1. Pearls and Pitfalls Pearls Perform a careful workup, including history, physical examination, imaging, and compartment pressure measurements to ensure the correct diagnosis and define the compartments involved. Carefully identify and protect the saphenous neurovascular bundle to prevent postoperative hematoma and neurologic injury. To decompress the deep posterior compartment, dissect subperiosteally from the posteromedial border of the tibia. The posterior tibial neurovascular bundle is posterior to the flexor digitorum and tibialis posterior musculature and will be protected. Pitfalls Failure to make the correct diagnosis or define the compartments involved. Failure to identify and protect the saphenous neurovascular bundle, resulting in iatrogenic injury. Inadequate visualization, resulting in inadequate compartment release.
and ankle range of motion is encouraged to decrease swelling and limit postoperative stiffness.
Discussion CECS is one of the most common causes of leg pain in endurance athletes, often resulting in debilitating symptoms and missed time from participation and competition. Often unresponsive to conservative treatment, surgical fasciotomy is recognized as the most reliable treatment of CECS. While CECS is more frequent in the anterior compartment of the leg, the deep posterior compartment is often affected in isolation or in combination with the anterior and lateral compartments. It is well recognized that the results of fasciotomy for deep posterior CECS are generally inferior to anterior and lateral release. Winkes et al. conducted a recent systematic review of the published results of fasciotomy for deep posterior exertional compartment syndrome.3 Seven studies (131 patients) met the criteria and were included in this systematic review, all consisting of level 3 evidence.6-12 Success rates in the analyzed studies ranged from only 30% to 65%. In 2016, Winkes et al. published the first prospective study of patients who underwent fasciotomy for isolated deep posterior compartment syndrome.13 Forty-two patients (64 legs) were evaluated at a mean Table 2. Advantages and Disadvantages Advantages Optimal anatomic visualization Identification and protection of neurovascular structures Direct visualization and palpation of complete compartment release Disadvantages Poorer cosmesis Potential for increased infection and wound healing problems
MINI-OPEN POSTERIOR COMPARTMENT RELEASE
follow-up of 26 months. A minority of patients experienced subjectively excellent (12%) or good (35%) results, with 30% rated as fair or poor. Only 29% returned to their previous level of sporting activity. The reason for less predictable outcomes after the surgical treatment of deep posterior CECS is unclear. Causes may be attributed to improper diagnosis, treatment, or both. The differential for leg pain in the athlete is broad. Etiologies may include musculotendinous, vascular (popliteal artery entrapment syndrome, vascular insufficiency), and bony (stress fracture, medial tibial stress syndrome) causes, in addition to rare infectious or oncologic conditions. Additionally, the clinical presentation of deep posterior CECS can be vague, often consisting of nonspecific pain or cramping. The extensive differential diagnosis combined with an often nebulous presentation, lack of physical findings, and unreliable objective diagnostic testing results in the increased potential for misdiagnosis or unrecognized concomitant pathology. There is also a lack of consistency among surgical techniques for the treatment of posterior CECS, with numerous open and endoscopic-assisted techniques described. Some investigators have also advocated for the specific release of controversial subcompartments.4,5 Regardless of technique, it is clear that posterior fasciotomy presents a more challenging surgical dissection than anterior and lateral releases. Unfamiliarity with the anatomy and the potential risk to deep neurovascular structures may result in inadequate compartment release. In this Technical Note with accompanying video, we describe our preferred approach for deep and superficial posterior compartment fasciotomy for CECS of the leg (Table 1). Past investigators have advocated more minimally invasive and endoscopic-assisted techniques, citing improved cosmesis, decreased rates of infection and wound healing problems, and the potential for expedited recovery. Despite these potential advantages, we use a mini-open technique that we feel optimizes visualization. Through this additional exposure, the anatomy can be clearly defined to ensure adequate compartment release and minimizes the potential for iatrogenic injury and complications (Table 2).
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References 1. Puranen J. The medial tibial syndrome: exercise ischaemia in the medial fascial compartment of the leg. J Bone Joint Surg Br 1974;56:712-715. 2. Wittstein J, Moorman CT 3rd, Levin LS. Endoscopic compartment release for chronic exertional compartment syndrome: surgical technique and results. Am J Sports Med 2010;38:1661-1666. 3. 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. 4. Davey JR, Rorabeck CH, Fowler PJ. The tibialis posterior muscle compartment. An unrecognized cause of exertional compartment syndrome. Am J Sports Med 1984;12: 391-397. 5. Hislop M, Tierney P, Murray P. Chronic exertional compartment syndrome: the controversial “fifth” compartment of the leg. Am J Sports Med 2003;31:770776. 6. Pedowitz RA, Hargens A, Mubarak S. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 1990;18:35-40. 7. Winkes MB, Hoogeveen A, Houterman S. Compartment pressure curves predict surgical outcome in chronic deep posterior compartment syndrome. Am J Sports Med 2012;40:1899-1905. 8. 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 817. 9. Biedert RM, Marti B. Intracompartmental pressure before and after fasciotomy in runners with chronic deep posterior compartment syndrome. Int J Sports Med 1997;18: 381-386. 10. Rorabeck CH. Exertional tibialis posterior compartment syndrome. Clin Orthop Relat Res 1986;208:61-64. 11. Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. J Bone Joint Surg Am 1983;65:1245-1251. 12. van Zoest WJ, Hoogeveen A, Scheltinga M. Chronic deep posterior compartment syndrome of the leg in athletes: postoperative results of fasciotomy. Int J Sports Med 2008;29:419-423. 13. Winkes MB, van Zantvoort A, de Bruijn J. Fasciotomy for deep posterior compartment syndrome in the lower leg: a prospective study. Am J Sports Med 2016;44:1309-1316.
