539661
research-article2014
FAIXXX10.1177/1071100714539661Foot & Ankle InternationalMcCallum et al
(Original) Clinical Research Article
Return to Duty After Elective Fasciotomy for Chronic Exertional Compartment Syndrome
Foot & Ankle International® 1–5 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714539661 fai.sagepub.com
Jeremy R. McCallum, MD1, Jay B. Cook, MD1, Adam C. Hines, MD1, James S. Shaha, MD1, Jefferson W. Jex, MD2, and Joseph R. Orchowski, MD1
Abstract Background: Civilian literature has reported excellent outcomes after elective fasciotomy for chronic exertional compartment syndrome (CECS). Our study’s purpose was to objectively investigate the functional outcome of fasciotomies performed for CECS in a high demand military population. Methods: A retrospective review of all fasciotomies performed for CECS at a single tertiary military medical center was performed. The primary outcome measure was the ability to return to full active duty. Diagnosis, operative technique, and number of compartments addressed were collected and analyzed. Patients were contacted and the visual analog scale (VAS) pain score, functional single assessment numeric evaluation (SANE) score, as well as overall satisfaction were reported. Return to duty status was collected on 70 of 70 (100%) consecutive operative extremities in 46 patients with an average follow-up of 26 months. Results: Only 19 patients (41.3%) were able to return to full active duty. Ten patients (21.7%) underwent a medical separation from the military and 17 patients (37%) remained in the military but were on restricted duty secondary to persistent leg pain. Thirty-five of 46 (76%) of the patients were contacted and provided subjective feedback. The average SANE score was 72.3, and there was a mean improvement of 4.4 points in VAS score postoperatively. Overall, 71% of patients were satisfied and would undergo the procedure again. Outcomes were correlated to operative technique, patient rank, and branch of military service. Conclusion: Our study showed a return to full military duty in 41% of patients who underwent elective fasciotomy for CECS. Overall 78% of patients remained in the military, which is consistent with previous military literature. Subjective satisfaction rate was 71%. Both the return to activity and subjective outcomes in our study population were substantially lower than reported results in civilian populations. Level of Evidence: Level IV, case series. Keywords: chronic exertional compartment syndrome, functional outcome, sports medicine, lower extremity
Chronic exertional compartment syndrome (CECS) is defined as an increased pressure within a closed fibro-osseous space, causing reduced blood flow and tissue perfusion in that space leading to ischemic pain and possible damage to the tissues of the compartment.6 CECS frequently occurs with exertional activities and repetitive exercise. Typically these patients begin to experience significant pain after the onset of an exertional activity, which forces them to discontinue the activity. The pain frequently resolves with cessation of activity and there are rarely lasting consequences. CECS is most commonly seen in the lower leg, particularly the anterior and lateral compartments, but has been described in all compartments from gluteus to foot and shoulder to hand. In 1956, Mavor treated CECS with
widening the fascia of the anterior compartment.10 However, it was not until 1962 that elevated compartment pressures were documented as the etiology of CECS.7 Initial treatment of CECS begins with nonoperative modalities centered around activity modification.6,12 However, for those who fail nonoperative management, whether due to recalcitrant pathology, refusal to modify 1
Tripler Army Medical Center, Honolulu, HI, USA Walter Reed NMMC, Bethesda, MD, USA
2
Corresponding Author: Jeremy R. McCallum, MD, Orthopedic Surgery, Tripler Army Medical Center, 1 Jarrett White Rd, Honolulu, HI 96859, USA. Email: [email protected]
2 activities, or job requirements demanding continued activity, fasciotomy is the mainstay of operative management.6 Studies have borne out the success of fasciotomies in allowing patients, athletes and nonathletes alike, to return to activities with a decrease in pain.8,9,12,14,15,17 These studies also report that when failures did occur, they were primarily with fasciotomy of the posterior compartments, particularly the deep compartment.8,9,14,16 However, none of these studies can directly be applied to a military population with persistent physical demands and minimal allowance for activity modification. There are 2 single case series in the literature regarding CECS in military populations; while the results were promising, one is a small series without long-term follow-up, and the other made no reference to return to duty rate.2,4 A recent military database analysis of active duty soldiers who underwent elective fasciotomy for CECS lacked functional scores and subjective results due to the study design.3 Our purpose was to report on return to duty and functional outcomes of CECS treated with fasciotomy in a US military population.
Methods We performed a retrospective review of 70 consecutive extremities in 46 patients that underwent fasciotomy at our institution based on a search of the operative database. The study protocol was approved by the Human Use Committee at the military treatment facility. Investigators adhered to the policies for protection of human subjects as prescribed in 45 Code of Federal Regulation 46. Patient medical records were reviewed to obtain information regarding age, sex, military rank, job description within the military, duty status, diagnosis, procedure type, and length, and whether there were any complications. Both clinical exam and compartment pressure measurements of all 4 compartments utilizing Pedowitz’s criteria (threshold of 30 mm Hg at 1 minute postexercise or 20 mm Hg at 5 minutes postexercise) were required for diagnosis of CECS.13 Determination of 2 versus 4 compartment release was based on the number of compartments with elevated pressures. Diagnoses other than CECS such as fascial herniations or accessory soleus muscle as diagnosed by either ultrasound or MRI were excluded. Acute compartment syndrome secondary to trauma or acute exacerbation of CECS were excluded. Our primary outcome was return to duty after fasciotomy. Patients were identified as being full active duty (returned to unrestricted military activity), restricted duty (able to remain in the military but with activity restrictions), and separated (no longer in the military due to persistent symptoms). We then attempted to contact each of these patients to obtain secondary outcome measures from a standardized questionnaire administered to each patient, which included a single assessment numeric evaluation (SANE) score, visual analog scale (VAS) pain score both preoperative
Foot & Ankle International Table 1. Demographic Patient Data. Demographic Gender Male Female Number of compartments 2 4 Branch of service Army Air Force Navy Marines Rank Officer Senior enlisted (E6-E9) Junior enlisted (E1-E5)
Number of Patients 38 8 35 11 33 7 2 4 5 9 32
and at time of questionnaire, perceived appearance of their leg, miles run per week, whether they changed jobs within the military postoperatively, and overall satisfaction. Between 2007 and 2011 elective compartment fasciotomies for the diagnosis of CECS were performed on 70 extremities in 46 patients. The operations were performed at a single tertiary medical center by multiple surgeons. Duty status was collected on all 46 patients (100%). Thirtyfive patients (76%) were able to be contacted and completed a standardized subjective phone survey to assess their operative outcome. The average follow-up was 26 months (range, 8-51 months). The mean age of the patients was 30.0 years (range, 19-50 years). Eleven patients (23.9%) underwent 4 compartment release of the operative lower extremity. Thirty-five patients (76.1%) had only their anterior and lateral compartments released. The majority of patients were junior enlisted (32/46, 69.6%), and there were more senior enlisted patients (9/46, 19.6%) than officers (5/46, 10.9%). Most of the patients were in the Army (33/46, 71.7%; see Table 1 for full demographics).
Statistical Analysis Analyses were run regarding demographic data, technique, and outcomes. Categorical data were compared using Fisher’s exact test. Continuous data were analyzed using Student’s t test. Statistical significance was placed at P = .05.
Results Return to Duty Only 41.3% (19/46) of patients returned to full active duty. Meanwhile 21.7% (10/46) were unable to remain in the
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Pain The average preoperative pain score was 8.16 (range, 5-10) on the VAS scale. The average postoperative pain was 3.76 (range, 0-10). The average decrease in pain was 4.4 (P < .0001). Lower postoperative VAS scores were associated with higher SANE scores (P = .002). Similarly, patients whose VAS scores decreased by more than 4 were significantly more likely to be satisfied with the surgery than those with less improvement (83.9% vs 52.2%, P = .017). Preoperative VAS scores of 9 or greater did not have greater decrease in pain than those whose VAS was less than 9 preoperatively (4.1 vs 4.2 avg, P = .71). Figure 1. Chart displaying the primary outcome measure— return to duty status.
military due to lower extremity pain and disability. The remaining 37% (17/46) were retained in the military on a restricted duty status which reduced their required physical activity (Figure 1). A total of 78.3% of patients were able to be retained and continued their military careers. When analyzing potential contributing factors, rank and branch of military service were significant. Officers and senior enlisted (E6 and above) were more likely to remain in the military than junior enlisted service members (100% vs 68.8%, P = .02). Despite similar rates of medical discharge, patients in either the Navy or Marines had significantly higher rates of return to full activity than those in the Army or Air Force (83.3% vs 35.0%, P = .036). Patients who returned to full duty had a statistically significant lower VAS scores than those who did not (2.1 vs 4.0, P = .0003). Those who returned to full duty also had a higher average SANE score (79.9 vs 71.0, P = .14) postoperatively, although this did not reach statistical significance. There were no significant differences for other factors such as 2 versus 4 compartment fasciotomies, bilateral versus unilateral surgery, age, and incision length with regard to return to duty.
Patient Satisfaction Analysis of the subjective data demonstrated 71.4% (25/35) of patients were pleased with the operative outcome. This was a significantly higher percentage than those who were able to return to full duty (71.4% vs 44.4%, P = .02) but was similar to the total that remained in the military (77.7%). Soldiers who returned to full duty were more likely to be satisfied than those who did not (P = .002). Satisfied patients had an average SANE score of 78.4 which was significantly higher than the SANE score of the unsatisfied patients 57.8 (P = .002). Twenty-seven of the patients who were contacted (77.1%) stated they would recommend the surgery to a close friend or family member for treatment of the same pathology. Nineteen patients elected to undergo the same procedure on the contralateral extremity for similar symptoms and diagnosis.
Appearance Patients rated the appearance of their leg from 30 to 100, with an average score of 72.1. No correlation between incision length or number of incisions with appearance score was noted.
Function
Complications
In patient reported outcomes, the average SANE score was 72.3 (range, 30-100). Patients with anterior and lateral compartments released through a single incision had better outcomes than those who had the same compartments released with a 2-incision technique (75.0 vs 56.9 P = .008). The length of the single incision was not a significant factor (P = .46). Those soldiers with higher rank showed a trend toward higher SANE scores however no significant difference was found (P = .10). Other factors such as 2 versus 4 compartment fasciotomies, unilateral versus bilateral surgery, branch, and age had no statistically significant correlation with SANE scores.
There were a total of 15 complications in the 70 extremities (21.4%). One reported a postoperative stitch abscess treated with local wound care and resolved without operative intervention. Six extremities (8.6%) had persistent numbness on the dorsum of the foot at final follow-up. Seven reported intermittent paresthesias of which 2 reported occasional swelling. One extremity in 1 patient with an anterior and lateral fasciotomy required a repeat fasciotomy for CECS after 2 months. Intraoperatively, he had scarring of his fascial release, which was excised. He eventually separated from the military due to recurrent lower extremity swelling preventing him from performing his duties.
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Foot & Ankle International Return to Full Ac vity
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Return to Full Ac vity
Figure 2. Chart displaying the published return to activity rates versus the current study’s return to activity rates.
Discussion The current study had return to full active duty rates lower than expected given results of previous civilian studies (Figure 2). For all patients, our primary outcome measure demonstrated a return to full duty in only 41.3% of patients. Even with 78.3% of patients being maintained in the military, this is a stark contrast to multiple previous studies performed in both a mixed population as well as in athletes. Rorabeck et al report 83% return to full activity in a cohort of all university athletes.14 Detmer et al reported on a predominantly athletic population having complete functional cure in 73% of patients with another 9% having significant improvement.5 Schepsis et al reported 82.6% return to activity without limitations in a larger review of patients with activity levels ranging from professional athletes to inactive adults.17 Our study has an advantage as we had a standardized outcome measure of whether the soldier returned to full activity postoperatively. As opposed to returning to recreational and even collegiate and professional sports where training and competitions can be modified to manage pain, patients returning to full duty in the same job required them to return to their preoperative level of function without room for adjustments. This frequently meant mandatory, daily physical activities often consisting of running or marching for long distances, frequently with rucksacks weighing up to 100 pounds. The inability of our study population to modify their activities may have contributed to the disparity in reported operative outcomes, particularly in junior enlisted soldiers. Three prior military studies have been published focusing on elective fasciotomies. The first was conducted in the Australian Air Force, included 14 patients with an average follow-up of 37 months, and demonstrated a 79% ability to complete a physical training test without residual symptoms.4 The second was a review of 34 Norwegian military members who underwent anterior compartment fasciotomy diagnosed with history and physical exam. The authors reported good
and excellent outcomes at 10-year follow-up in 73.2% of patients, but did not comment on ability to return to duty.2 Waterman et al recently published a database study in the U.S. military population with return to duty (full or restricted) of 82.3% which was similar to our study (78.3%).18 Their data was based on ICD-9 and CPT codes and had no reporting on diagnostic criteria, operative technique, or subjective outcomes. The current study design allows exclusion of diagnoses other than CECS as indication for elective fasciotomy. Although both studies reported similar return to active duty, our return to full unrestricted duty rate was 41.3%, which is a marked contrast to 72.3% reported by Waterman et al.18 Significant factors associated with return to duty in the current study were branch of service and rank. These demographics were not as clearly delineated in the database review and may have contributed to the differences. Our return to full duty rate in the Navy and Marines was 83.3% compared with 38.9% in the Army and Air Force. Naval and Marine soldiers cannot go on long-term, restricted duty and therefore have only 2 choices, return to duty or separate from the military. Navy and Marines had higher average SANE score than Army and Air Force, although the study was underpowered to show statistical significance. In addition, the postoperative VAS was statistically lower. This could be attributed to multiple causes. First, without profile as an option to restrict duty requirements, patients were either forced to live with pain or separate from the military. Second, the required activities might have been different. For instance the Navy service members could request to swim for their fitness test instead of run. However, the Marines have the strictest and most aggressive training requirements, so this may not have held true for them. Increased rank was associated with return to full active duty. Higher-ranking individuals, that is senior enlisted and officers, often have more incentive to stay in the military for upcoming retirement and pension. SANE scores showed a trend toward better function in higher-ranking officers however there was not a statistically significant difference between the groups. Soldiers of higher rank often have more control over their physical training/fitness plans, may be allowed to recover longer postoperatively, and can sometimes alter their fitness activities to decrease symptoms, which allows them to remain in the military. This could, perhaps be compared to some civilian fields such as firefighters or paramedics where more senior personnel have the ability to adjust their activity level as they take a more supervisory role. The average subjective outcomes, as noted with the SANE score, were lower than previously reported in the civilian literature. This corroborates with, and strengthens, our primary outcome of return to duty. Soldiers lead a different lifestyle with less flexibility in recovery time, decreased ability to modify activities, and frequently increased demands of the work place. The technique used on the lateral side of the leg was significantly associated with SANE
5
McCallum et al scores. The 2 incision technique has been reported to have very good results in return to activity.11 However, in the current study, patients in whom a 2 incision lateral sided approach was used had significantly worse outcomes than those with 1 incision, regardless of length of that 1 incision. This study demonstrated a 71.4% patient satisfaction rate. These findings are significantly higher than the return to full active duty status of 41.3%. Multiple patients confirmed in the comment section of the questionnaire that although they could not return to full activity they experienced enough relief that everyday recreational activities were now tolerable to them. Still, this is lower than other subjective outcomes reported in young, active civilian populations (81-89%).5,12,14,17 Poorer outcomes have previously been associated with release of the posterior compartment.1,17 Our subgroup analysis of 2 versus 4 compartment fasciotomies demonstrated no statistically significant difference between the return to full duty status between the groups at 26 months; there was also no difference in SANE or VAS scores. Our study is a retrospective case series and therefore has the inherent weakness of selection and recall bias as with any other study of this design. Multiple surgeons with differing techniques performed surgeries; however, this may add to the generalizability of the data. In addition, we were only able to contact 76% of patients for subjective results due to the transient nature of the military population. The strengths of our study include a consecutive series of patients at a single center with 100% follow-up on the primary outcome measure. The analysis of the diagnostic criteria, operative technique, as well as functional and pain scores are all strengths of the study. In addition, this is a fairly homogeneous population of primarily young, active patients, which may negate many potential confounders regarding patient demographics. In conclusion, the results of this study suggest that operative fasciotomy in the setting of CECS has only a 41.4% chance of returning an active duty soldier to full duty. In addition, the patient has a 22% chance of being removed from the military. Despite overall retention of 78.3% of patients in the military and a 71% satisfaction rate, these results are substantially worse compared to results in the civilian literature, even in athletes. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The views expressed in this publication are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Abramowitz AJ, Schepsis AA. Chronic exertional compartment syndrome of the lower leg. Orthop Rev. 1994;23(3):219-225. 2. Almdahl SM, Samdal F. Fasciotomy for chronic compartment syndrome. Acta Orthop Scand. 1989;60(2):210-211. 3. Baumgarten KM. Chronic exertional compartment syndrome: are surgical outcomes worse in soldiers compared with civilians? Commentary on an article by CPT Brian R. Waterman, MD, et al.: “Surgical treatment of chronic exertional compartment syndrome of the leg: failure rates and postoperative disability in an active patient population.” J Bone Joint Surg Am. 2013;95(7):e48. 4. Cook S, Bruce G. Fasciotomy for chronic compartment syndrome in the lower limb. ANZ J Surg. 2002;72(10):720-723. 5. Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. Am J Sports Med. 1985;13(3):162-170. 6. Fraipont MJ, Adamson GJ. Chronic exertional compartment syndrome. J Am Acad Orthop Surg. 2003;11(4):268-276. 7. French EB, Price WH. Anterior tibial pain. Br Med J. 1962;2(5315):1290-1296. 8. Fronek J, Mubarak SJ, Hargens AR, et al. Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop Relat Res. 1987;220(7):217-227. 9. Howard JL, Mohtadi NG, Wiley JP. Evaluation of outcomes in patients following surgical treatment of chronic exertional compartment syndrome in the leg. Clin J Sport Med. 2000;10(3):176-184. 10. Mavor GE. The anterior tibial syndrome. J Bone Joint Surg Br. 1956;38-B(2):513-517. 11. Mouhsine E, Garofalo R, Moretti B, Gremion G, Akiki A. Two minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg. Knee Surg Sports Traumatol Arthrosc. 2006;14(2):193-197. 12. 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(2):430-436. 13. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18(1):35-40. 14. Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. J Bone Joint Surg Am. 1983;65(9):1245-1251. 15. Rorabeck CH, Fowler PJ, Nott L. The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med. 1988;16(3):224-227. 16. Schepsis AA, Lynch G. Exertional compartment syndromes of the lower extremity. Curr Opin Rheumatol. 1996;8(2):143-147. 17. Schepsis AA, Martini D, Corbett M. Surgical management of exertional compartment syndrome of the lower leg. Longterm followup. Am J Sports Med. 1993;21(6):811-817; discussion 817. 18. Waterman BR, Laughlin M, Kilcoyne K, Cameron KL, Owens BD. Surgical treatment of chronic exertional compartment syndrome of the leg: failure rates and postoperative disability in an active patient population. J Bone Joint Surg Am. 2013;95(7):592-596.
research-article2014
FAIXXX10.1177/1071100714539661Foot & Ankle InternationalMcCallum et al
(Original) Clinical Research Article
Return to Duty After Elective Fasciotomy for Chronic Exertional Compartment Syndrome
Foot & Ankle International® 1–5 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714539661 fai.sagepub.com
Jeremy R. McCallum, MD1, Jay B. Cook, MD1, Adam C. Hines, MD1, James S. Shaha, MD1, Jefferson W. Jex, MD2, and Joseph R. Orchowski, MD1
Abstract Background: Civilian literature has reported excellent outcomes after elective fasciotomy for chronic exertional compartment syndrome (CECS). Our study’s purpose was to objectively investigate the functional outcome of fasciotomies performed for CECS in a high demand military population. Methods: A retrospective review of all fasciotomies performed for CECS at a single tertiary military medical center was performed. The primary outcome measure was the ability to return to full active duty. Diagnosis, operative technique, and number of compartments addressed were collected and analyzed. Patients were contacted and the visual analog scale (VAS) pain score, functional single assessment numeric evaluation (SANE) score, as well as overall satisfaction were reported. Return to duty status was collected on 70 of 70 (100%) consecutive operative extremities in 46 patients with an average follow-up of 26 months. Results: Only 19 patients (41.3%) were able to return to full active duty. Ten patients (21.7%) underwent a medical separation from the military and 17 patients (37%) remained in the military but were on restricted duty secondary to persistent leg pain. Thirty-five of 46 (76%) of the patients were contacted and provided subjective feedback. The average SANE score was 72.3, and there was a mean improvement of 4.4 points in VAS score postoperatively. Overall, 71% of patients were satisfied and would undergo the procedure again. Outcomes were correlated to operative technique, patient rank, and branch of military service. Conclusion: Our study showed a return to full military duty in 41% of patients who underwent elective fasciotomy for CECS. Overall 78% of patients remained in the military, which is consistent with previous military literature. Subjective satisfaction rate was 71%. Both the return to activity and subjective outcomes in our study population were substantially lower than reported results in civilian populations. Level of Evidence: Level IV, case series. Keywords: chronic exertional compartment syndrome, functional outcome, sports medicine, lower extremity
Chronic exertional compartment syndrome (CECS) is defined as an increased pressure within a closed fibro-osseous space, causing reduced blood flow and tissue perfusion in that space leading to ischemic pain and possible damage to the tissues of the compartment.6 CECS frequently occurs with exertional activities and repetitive exercise. Typically these patients begin to experience significant pain after the onset of an exertional activity, which forces them to discontinue the activity. The pain frequently resolves with cessation of activity and there are rarely lasting consequences. CECS is most commonly seen in the lower leg, particularly the anterior and lateral compartments, but has been described in all compartments from gluteus to foot and shoulder to hand. In 1956, Mavor treated CECS with
widening the fascia of the anterior compartment.10 However, it was not until 1962 that elevated compartment pressures were documented as the etiology of CECS.7 Initial treatment of CECS begins with nonoperative modalities centered around activity modification.6,12 However, for those who fail nonoperative management, whether due to recalcitrant pathology, refusal to modify 1
Tripler Army Medical Center, Honolulu, HI, USA Walter Reed NMMC, Bethesda, MD, USA
2
Corresponding Author: Jeremy R. McCallum, MD, Orthopedic Surgery, Tripler Army Medical Center, 1 Jarrett White Rd, Honolulu, HI 96859, USA. Email: [email protected]
2 activities, or job requirements demanding continued activity, fasciotomy is the mainstay of operative management.6 Studies have borne out the success of fasciotomies in allowing patients, athletes and nonathletes alike, to return to activities with a decrease in pain.8,9,12,14,15,17 These studies also report that when failures did occur, they were primarily with fasciotomy of the posterior compartments, particularly the deep compartment.8,9,14,16 However, none of these studies can directly be applied to a military population with persistent physical demands and minimal allowance for activity modification. There are 2 single case series in the literature regarding CECS in military populations; while the results were promising, one is a small series without long-term follow-up, and the other made no reference to return to duty rate.2,4 A recent military database analysis of active duty soldiers who underwent elective fasciotomy for CECS lacked functional scores and subjective results due to the study design.3 Our purpose was to report on return to duty and functional outcomes of CECS treated with fasciotomy in a US military population.
Methods We performed a retrospective review of 70 consecutive extremities in 46 patients that underwent fasciotomy at our institution based on a search of the operative database. The study protocol was approved by the Human Use Committee at the military treatment facility. Investigators adhered to the policies for protection of human subjects as prescribed in 45 Code of Federal Regulation 46. Patient medical records were reviewed to obtain information regarding age, sex, military rank, job description within the military, duty status, diagnosis, procedure type, and length, and whether there were any complications. Both clinical exam and compartment pressure measurements of all 4 compartments utilizing Pedowitz’s criteria (threshold of 30 mm Hg at 1 minute postexercise or 20 mm Hg at 5 minutes postexercise) were required for diagnosis of CECS.13 Determination of 2 versus 4 compartment release was based on the number of compartments with elevated pressures. Diagnoses other than CECS such as fascial herniations or accessory soleus muscle as diagnosed by either ultrasound or MRI were excluded. Acute compartment syndrome secondary to trauma or acute exacerbation of CECS were excluded. Our primary outcome was return to duty after fasciotomy. Patients were identified as being full active duty (returned to unrestricted military activity), restricted duty (able to remain in the military but with activity restrictions), and separated (no longer in the military due to persistent symptoms). We then attempted to contact each of these patients to obtain secondary outcome measures from a standardized questionnaire administered to each patient, which included a single assessment numeric evaluation (SANE) score, visual analog scale (VAS) pain score both preoperative
Foot & Ankle International Table 1. Demographic Patient Data. Demographic Gender Male Female Number of compartments 2 4 Branch of service Army Air Force Navy Marines Rank Officer Senior enlisted (E6-E9) Junior enlisted (E1-E5)
Number of Patients 38 8 35 11 33 7 2 4 5 9 32
and at time of questionnaire, perceived appearance of their leg, miles run per week, whether they changed jobs within the military postoperatively, and overall satisfaction. Between 2007 and 2011 elective compartment fasciotomies for the diagnosis of CECS were performed on 70 extremities in 46 patients. The operations were performed at a single tertiary medical center by multiple surgeons. Duty status was collected on all 46 patients (100%). Thirtyfive patients (76%) were able to be contacted and completed a standardized subjective phone survey to assess their operative outcome. The average follow-up was 26 months (range, 8-51 months). The mean age of the patients was 30.0 years (range, 19-50 years). Eleven patients (23.9%) underwent 4 compartment release of the operative lower extremity. Thirty-five patients (76.1%) had only their anterior and lateral compartments released. The majority of patients were junior enlisted (32/46, 69.6%), and there were more senior enlisted patients (9/46, 19.6%) than officers (5/46, 10.9%). Most of the patients were in the Army (33/46, 71.7%; see Table 1 for full demographics).
Statistical Analysis Analyses were run regarding demographic data, technique, and outcomes. Categorical data were compared using Fisher’s exact test. Continuous data were analyzed using Student’s t test. Statistical significance was placed at P = .05.
Results Return to Duty Only 41.3% (19/46) of patients returned to full active duty. Meanwhile 21.7% (10/46) were unable to remain in the
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Pain The average preoperative pain score was 8.16 (range, 5-10) on the VAS scale. The average postoperative pain was 3.76 (range, 0-10). The average decrease in pain was 4.4 (P < .0001). Lower postoperative VAS scores were associated with higher SANE scores (P = .002). Similarly, patients whose VAS scores decreased by more than 4 were significantly more likely to be satisfied with the surgery than those with less improvement (83.9% vs 52.2%, P = .017). Preoperative VAS scores of 9 or greater did not have greater decrease in pain than those whose VAS was less than 9 preoperatively (4.1 vs 4.2 avg, P = .71). Figure 1. Chart displaying the primary outcome measure— return to duty status.
military due to lower extremity pain and disability. The remaining 37% (17/46) were retained in the military on a restricted duty status which reduced their required physical activity (Figure 1). A total of 78.3% of patients were able to be retained and continued their military careers. When analyzing potential contributing factors, rank and branch of military service were significant. Officers and senior enlisted (E6 and above) were more likely to remain in the military than junior enlisted service members (100% vs 68.8%, P = .02). Despite similar rates of medical discharge, patients in either the Navy or Marines had significantly higher rates of return to full activity than those in the Army or Air Force (83.3% vs 35.0%, P = .036). Patients who returned to full duty had a statistically significant lower VAS scores than those who did not (2.1 vs 4.0, P = .0003). Those who returned to full duty also had a higher average SANE score (79.9 vs 71.0, P = .14) postoperatively, although this did not reach statistical significance. There were no significant differences for other factors such as 2 versus 4 compartment fasciotomies, bilateral versus unilateral surgery, age, and incision length with regard to return to duty.
Patient Satisfaction Analysis of the subjective data demonstrated 71.4% (25/35) of patients were pleased with the operative outcome. This was a significantly higher percentage than those who were able to return to full duty (71.4% vs 44.4%, P = .02) but was similar to the total that remained in the military (77.7%). Soldiers who returned to full duty were more likely to be satisfied than those who did not (P = .002). Satisfied patients had an average SANE score of 78.4 which was significantly higher than the SANE score of the unsatisfied patients 57.8 (P = .002). Twenty-seven of the patients who were contacted (77.1%) stated they would recommend the surgery to a close friend or family member for treatment of the same pathology. Nineteen patients elected to undergo the same procedure on the contralateral extremity for similar symptoms and diagnosis.
Appearance Patients rated the appearance of their leg from 30 to 100, with an average score of 72.1. No correlation between incision length or number of incisions with appearance score was noted.
Function
Complications
In patient reported outcomes, the average SANE score was 72.3 (range, 30-100). Patients with anterior and lateral compartments released through a single incision had better outcomes than those who had the same compartments released with a 2-incision technique (75.0 vs 56.9 P = .008). The length of the single incision was not a significant factor (P = .46). Those soldiers with higher rank showed a trend toward higher SANE scores however no significant difference was found (P = .10). Other factors such as 2 versus 4 compartment fasciotomies, unilateral versus bilateral surgery, branch, and age had no statistically significant correlation with SANE scores.
There were a total of 15 complications in the 70 extremities (21.4%). One reported a postoperative stitch abscess treated with local wound care and resolved without operative intervention. Six extremities (8.6%) had persistent numbness on the dorsum of the foot at final follow-up. Seven reported intermittent paresthesias of which 2 reported occasional swelling. One extremity in 1 patient with an anterior and lateral fasciotomy required a repeat fasciotomy for CECS after 2 months. Intraoperatively, he had scarring of his fascial release, which was excised. He eventually separated from the military due to recurrent lower extremity swelling preventing him from performing his duties.
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Foot & Ankle International Return to Full Ac vity
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Return to Full Ac vity
Figure 2. Chart displaying the published return to activity rates versus the current study’s return to activity rates.
Discussion The current study had return to full active duty rates lower than expected given results of previous civilian studies (Figure 2). For all patients, our primary outcome measure demonstrated a return to full duty in only 41.3% of patients. Even with 78.3% of patients being maintained in the military, this is a stark contrast to multiple previous studies performed in both a mixed population as well as in athletes. Rorabeck et al report 83% return to full activity in a cohort of all university athletes.14 Detmer et al reported on a predominantly athletic population having complete functional cure in 73% of patients with another 9% having significant improvement.5 Schepsis et al reported 82.6% return to activity without limitations in a larger review of patients with activity levels ranging from professional athletes to inactive adults.17 Our study has an advantage as we had a standardized outcome measure of whether the soldier returned to full activity postoperatively. As opposed to returning to recreational and even collegiate and professional sports where training and competitions can be modified to manage pain, patients returning to full duty in the same job required them to return to their preoperative level of function without room for adjustments. This frequently meant mandatory, daily physical activities often consisting of running or marching for long distances, frequently with rucksacks weighing up to 100 pounds. The inability of our study population to modify their activities may have contributed to the disparity in reported operative outcomes, particularly in junior enlisted soldiers. Three prior military studies have been published focusing on elective fasciotomies. The first was conducted in the Australian Air Force, included 14 patients with an average follow-up of 37 months, and demonstrated a 79% ability to complete a physical training test without residual symptoms.4 The second was a review of 34 Norwegian military members who underwent anterior compartment fasciotomy diagnosed with history and physical exam. The authors reported good
and excellent outcomes at 10-year follow-up in 73.2% of patients, but did not comment on ability to return to duty.2 Waterman et al recently published a database study in the U.S. military population with return to duty (full or restricted) of 82.3% which was similar to our study (78.3%).18 Their data was based on ICD-9 and CPT codes and had no reporting on diagnostic criteria, operative technique, or subjective outcomes. The current study design allows exclusion of diagnoses other than CECS as indication for elective fasciotomy. Although both studies reported similar return to active duty, our return to full unrestricted duty rate was 41.3%, which is a marked contrast to 72.3% reported by Waterman et al.18 Significant factors associated with return to duty in the current study were branch of service and rank. These demographics were not as clearly delineated in the database review and may have contributed to the differences. Our return to full duty rate in the Navy and Marines was 83.3% compared with 38.9% in the Army and Air Force. Naval and Marine soldiers cannot go on long-term, restricted duty and therefore have only 2 choices, return to duty or separate from the military. Navy and Marines had higher average SANE score than Army and Air Force, although the study was underpowered to show statistical significance. In addition, the postoperative VAS was statistically lower. This could be attributed to multiple causes. First, without profile as an option to restrict duty requirements, patients were either forced to live with pain or separate from the military. Second, the required activities might have been different. For instance the Navy service members could request to swim for their fitness test instead of run. However, the Marines have the strictest and most aggressive training requirements, so this may not have held true for them. Increased rank was associated with return to full active duty. Higher-ranking individuals, that is senior enlisted and officers, often have more incentive to stay in the military for upcoming retirement and pension. SANE scores showed a trend toward better function in higher-ranking officers however there was not a statistically significant difference between the groups. Soldiers of higher rank often have more control over their physical training/fitness plans, may be allowed to recover longer postoperatively, and can sometimes alter their fitness activities to decrease symptoms, which allows them to remain in the military. This could, perhaps be compared to some civilian fields such as firefighters or paramedics where more senior personnel have the ability to adjust their activity level as they take a more supervisory role. The average subjective outcomes, as noted with the SANE score, were lower than previously reported in the civilian literature. This corroborates with, and strengthens, our primary outcome of return to duty. Soldiers lead a different lifestyle with less flexibility in recovery time, decreased ability to modify activities, and frequently increased demands of the work place. The technique used on the lateral side of the leg was significantly associated with SANE
5
McCallum et al scores. The 2 incision technique has been reported to have very good results in return to activity.11 However, in the current study, patients in whom a 2 incision lateral sided approach was used had significantly worse outcomes than those with 1 incision, regardless of length of that 1 incision. This study demonstrated a 71.4% patient satisfaction rate. These findings are significantly higher than the return to full active duty status of 41.3%. Multiple patients confirmed in the comment section of the questionnaire that although they could not return to full activity they experienced enough relief that everyday recreational activities were now tolerable to them. Still, this is lower than other subjective outcomes reported in young, active civilian populations (81-89%).5,12,14,17 Poorer outcomes have previously been associated with release of the posterior compartment.1,17 Our subgroup analysis of 2 versus 4 compartment fasciotomies demonstrated no statistically significant difference between the return to full duty status between the groups at 26 months; there was also no difference in SANE or VAS scores. Our study is a retrospective case series and therefore has the inherent weakness of selection and recall bias as with any other study of this design. Multiple surgeons with differing techniques performed surgeries; however, this may add to the generalizability of the data. In addition, we were only able to contact 76% of patients for subjective results due to the transient nature of the military population. The strengths of our study include a consecutive series of patients at a single center with 100% follow-up on the primary outcome measure. The analysis of the diagnostic criteria, operative technique, as well as functional and pain scores are all strengths of the study. In addition, this is a fairly homogeneous population of primarily young, active patients, which may negate many potential confounders regarding patient demographics. In conclusion, the results of this study suggest that operative fasciotomy in the setting of CECS has only a 41.4% chance of returning an active duty soldier to full duty. In addition, the patient has a 22% chance of being removed from the military. Despite overall retention of 78.3% of patients in the military and a 71% satisfaction rate, these results are substantially worse compared to results in the civilian literature, even in athletes. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The views expressed in this publication are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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