Superficial Peroneal Nerve Injury Risk During a Semiblind Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg: An Anatomical and Clinical Study

Abstract

Background: Up to 8% of patients who underwent a fasciotomy for leg anterior chronic exertional compartment syndrome (ant-CECS) report sensory deficits suggestive of iatrogenic superficial peroneal nerve (SPN) injury. In the current study we aimed to thoroughly assess the risk of SPN injury during a semiblind fasciotomy of the anterior compartment using 2 separate approaches. Methods: A modified semiblind fasciotomy of the anterior compartment was performed via a longitudinal 2-cm skin incision 2 cm lateral of the anterior tibial crest halfway along the line fibular head-lateral malleolus both in cadaver legs and in patients with ant-CECS. In the cadaver legs, the skin was removed after the procedure and possible SPN injuries and spatial relationships between the SPN and the opened fascia were studied. Between January 2013 and December 2016, 64 ant-CECS patients who underwent a fasciotomy of the anterior compartment were prospectively followed. Iatrogenic SPN injuries were assessed using questionnaires and physical examinations. Results: Macroscopic SPN nerve injury was not observed in any of the 9 cadaver legs. In 8 specimens, the SPN was located at least 5 mm posterolateral to the opened fascia. In 1 specimen, an undamaged SPN branch crossed the operative field in a ventral plane. De novo sensory deficits suggestive for iatrogenic SPN injury were not observed in any of the 64 patients (120 legs; 36 females; median age, 22 years) who underwent a fasciotomy of the anterior compartment. Conclusion: The proposed semiblind fasciotomy for treatment of ant-CECS was not associated with SPN injury in either the cadaveric study or our clinical series. Level of Evidence: Level IV, case series.

Letter Regarding: Superficial Peroneal Nerve Injury Risk During a Semiblind Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg: An Anatomical and Clinical Study

“…The technique described by de Bruijn et al is elegant, 2 and very similar to the one we published in 2016, 3 though we started using it at least two decades earlier. Using the simple technical tips described in that article, 3 which de Bruijn et al reproduced in their own cadaveric study, 2 we demonstrated that the neural structures at risk were not injured, and that excellent results can be obtained using routinely available surgical instruments. Other previous studies demonstrated that diagnosis obtained by measurement of intracompartmental pressure (ICP) was necessary to decide the best treatment options and the more indicated surgical technique.…”

Minimally Invasive Lower Leg Fasciotomy for Chronic Exertional Compartment Syndrome—How Safe Is It? A Cadaveric Study

“…De Bruijn and colleagues 4 investigated the safety of a modified percutaneous fasciotomy technique to decompress the anterior compartment using 9 cadaveric legs and 64 patients. Despite the small numbers, they found no iatrogenic neurovascular injuries.…”

“…5,13 The anterior compartment of the leg has been thought to be most commonly affected, and the literature has been heavily focused on techniques to decompress this compartment. 2,4 Recent studies have suggested that deep posterior compartment CECS (dp-CECS) is often overlooked, and its incidence may be higher than anticipated. 22,23 Traditionally, skin and fascial incisions for lower limb fasciotomy have been longitudinal, although some recent studies have demonstrated that transverse incisions may be a suitable alternative.…”

“…The superficial peroneal nerve (SPN) is closely anatomically related to the anterior and peroneal compartments, with a variable rate (0%-8%) of iatrogenic SPN injury reported. 4,5 This variation reflects both the differences in surgical techniques and the small sizes, particularly in cadaveric studies. 4 Fasciotomy for dp-CECS is considered technically challenging, and studies have reported a high risk of injury to neurovascular structures with both open and endoscopic techniques.…”

“… 4 , 5 This variation reflects both the differences in surgical techniques and the small sizes, particularly in cadaveric studies. 4 Fasciotomy for dp-CECS is considered technically challenging, and studies have reported a high risk of injury to neurovascular structures with both open and endoscopic techniques. 11 , 12 , 14 The authors of 1 cadaveric study found a concerningly high risk (67%) of iatrogenic neurovascular damage with minimally invasive fasciotomy without the use of an endoscope, although they used a small number of specimens (n = 6).…”