Release of the Tibialis Posterior Muscle Osseofascial Sheath Improves Results of Deep Exertional Compartment Syndrome Surgery: A Comparative Analysis and Long-term Results

Abstract

Background: Success rates for surgical management of chronic exertional compartment syndrome (CECS) are historically lower with release of the deep posterior compartment compared with isolated anterolateral releases. At our institution, when a deep posterior compartment release is performed, we routinely examine for a separate posterior tibial muscle osseofascial sheath and release it if present. Purpose: Within the context of this surgical approach, the aim of the current study was to compare long-term patient satisfaction and activity levels in patients who underwent 2-compartment fasciotomy versus a modified 4-compartment fasciotomy for CECS. Study Design: Cohort study; Level of evidence, 3. Methods: Patients treated with fasciotomy for lower extremity CECS from 2007 to 2017 were retrospectively identified. In all patients in whom a 4-compartment fasciotomy was indicated, the tibialis posterior muscle was examined for a separate osseofascial sheath, which was released when present. Patients completed a series of validated patient-reported outcome (PRO) surveys, including the Marx activity score, Tegner activity score, 12-Item Short Form Health Survey, and Likert score for patient satisfaction. Results: Of the 48 patients who were included in this study, 34 (71%) patients with a total of 52 operative limbs responded and completed PRO surveys. The mean follow-up for the entire cohort was 5.5 ± 2.6 years. Of the 34 patients, 23 (68%) underwent 2-compartment fasciotomy and 11 (32%) underwent 4-compartment fasciotomy. Among the patients in the 4-compartment fasciotomy group, 7 (64%) were found to have a fifth compartment. No significant difference was found in any of the validated PRO measures between patients who had a 2- versus 4-compartment fasciotomy or those who underwent 4-compartment fasciotomy with or without a present fifth compartment. At a mean 5.5-year follow-up, 74% of patients who underwent a 2-compartment release reported good or excellent outcomes compared with 82% of patients who underwent our modified 4-compartment release. Conclusion: The current study, which included the longest follow-up on CECS patients in the literature, demonstrated that the addition of a release of the posterior tibial muscle fascia led to no significant difference in PRO measures between patients who underwent a 2- versus 4-compartment fasciotomy, when historically the 2-compartment fasciotomy group has had higher success rates.

Two-Compartment or 4-Compartment Fasciotomy for Lower Leg Chronic Exertional Compartment Syndrome: A Systematic Review

“…Characteristics of the seven studies (29)(30)(31)(32)(33)(34)(35) are presented in table 1. A total of 194 patients (100 male, 94 female) with a mean age of 24 years (range 15-55) were analyzed.…”

“…A total of 194 patients (100 male, 94 female) with a mean age of 24 years (range 15-55) were analyzed. Six studies (29)(30)(31)(32)(33)(34) were retrospective cohort studies while one study (35) was a prospective cohort study. In six articles (29)(30)(31)(32)(33)35) study groups were allocated according to a two (2-CF) or four (4-CF) compartment release.…”

“…Six studies (29)(30)(31)(32)(33)(34) were retrospective cohort studies while one study (35) was a prospective cohort study. In six articles (29)(30)(31)(32)(33)35) study groups were allocated according to a two (2-CF) or four (4-CF) compartment release. The seventh study (34) compared outcomes of four groups having a different number of released compartments.…”

“…The seventh study (34) compared outcomes of four groups having a different number of released compartments. Six (29)(30)(31)(33)(34)(35) of seven studies presented in total 92 patients undergoing a 2-CF approach and 40 patients a 4-CF. Instead of stating the number of patients per group, the seventh study (32) reported that a 2-CF technique CECS: chronic exertional compartment syndrome, ICP: intra-compartmental pressure, 4-CF: four-compartment fasciotomy, 2-CF: two-compartment fasciotomy, SD: standard deviation, ES: effect sizes, OR: odds ratio, CI: confidence Interval, SMD: standardized mean difference, CASP: Critical Appraisal Skills Programme, GRADE: Grading of Recommendations Assessment, Development and Evaluation, EQ-5D: European Quality of Life -Five Dimensions questionnaire 12 was performed 48 times and 4-CF 15 times.…”

“…All studies included a varying number of bilateral leg fasciotomies. Six studies (29)(30)(31)(32)34,35) reported on athletes, one of which also included three military servicemen. A seventh study (33) investigated solely military personnel.…”