Changes in leg pain after bilateral fasciotomy to treat chronic compartment syndrome: a case series study
Journal of Orthopaedic Surgery and Research
Changes in leg pain after bilateral fasciotomy to treat chronic compartment syndrome: a case series study
Jan Roar Orlin 0 1
Jarle en 3
John Roger Andersen 1 2
0 Section for Orthopedic Surgery, Department of Surgical Sciences, University of Bergen , Bergen , Norway
1 Department of Orthopedics, Frde Central Hospital (FSS) , N-6807 Frde , Norway
2 Department of Health studies, Sogn and Fjordane University College , N-6803 Frde , Norway
3 Department of Anesthesiology, Frde Central Hospital , N-6807 Frde , Norway
Background: Intracompartmental pressure (ICP) as the diagnostic gold standard in the management of chronic compartment syndrome (CCS) is debated. We present a diagnostic protocol in which the decision to operate can be based upon clinical findings alone. The aim of this study was to examine whether patients who underwent surgery for CCS based on clinical findings experienced significant long-term pain relief. Methods: A standardized clinical examination, including skin sensitivity, was performed in patients with bilateral leg pain and/or cramps. Before and after a symptom-provoking step test, ICPs were measured. The primary outcome was self-reported leg pain measured on a visual analogue scale. Secondary outcomes were satisfaction with the treatment result and health-related quality of life (HRQL) measured with the SF-8 questionnaire. Postoperative data were collected after 2 years. Results: Follow-up was completed for 37 of 40 patients. ICP was increased in 80.5% of the compartments examined before surgery, but did not correlate with the degree of leg pain. The remaining compartments were diagnosed as CCS based on clinical findings, despite ICPs below the threshold. Leg cramps occurred in 32 of 37 (86.5%) patients during physical activity and at night. Leg pain improved from a score of 8.0 1.5 to 2.3 2.1, P < 0.001. Satisfaction with the treatment result was reported by 81.1% of the patients, accompanied by normalized HRQL. Conclusions: The diagnostic protocol led to a fasciotomy in all compartments of both legs, which was associated with substantial and sustained relief of leg pain, improved HRQL, and patient satisfaction.
Pain; Quality of life; Fasciotomy and Chronic Compartment Syndrome
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Introduction
Chronic compartment syndrome (also known as chronic
exertional compartment syndrome) is a disorder that is
most often encountered and described in soldiers and
athletes [1-5], but it has also been reported in
nonathletes [6]. CCS is characterized by leg pain that is serious
enough to prohibit running and sometimes even
walking. The pathophysiology of CCS is unknown, but
reduced microcirculation capacity and increased ICP
has been documented [2,7]. Small observational studies
provide limited evidence that as many as 13.9% of leg
pain of unknown cause may be related to CCS, while as
many as 82% of cases referred for suspected CCS may
have elevated ICP [1]. CCS has been documented to
occur in the anterior and lateral compartments, and
surgical treatment has been directed mainly towards the
anterior compartment in the presence of appropriate
clinical findings. Recently, CCS was reported in the
posterior compartments as well [8]. To establish a
diagnosis of CCS, measurement of ICP 15 mm Hg at rest
and 30 mm Hg 1 minute after exercise has been
considered necessary [1,3]. However, a recent review
suggested that this diagnostic gold standard for CCS is flawed
and recommended that clinicians use protocol-specific
upper confidence limits to guide their diagnosis [2].
Thus, clinical practice related to referral for fasciotomy
often differs. A diagnosis of CCS that requires
fasciotomy may be based on clinical findings only [1], but
minimal or comprehensive ICP testing is usually also
performed [9,10]. Results after fasciotomy are often
good, but for lasting pain relief, decompression of an
increasing number of leg compartments may be necessary,
paralleling the complete compartmental decompression
recommended for acute cases. Poor long-term results
may be related to incorrect diagnosis or failure to address
multiple compartments in the leg simultaneously [11].
Further exploration of the role of ICP as the diagnostic
gold standard and other diagnostic approaches in the
management of the CCS appear to be indicated.
In this paper, we present a diagnostic protocol in which
the decision to operate can be based upon clinical findings
alone. The primary aim of this study was to examine
whether patients who underwent surgery for CCS, based
upon this diagnostic approach, experienced significant
long-term pain relief. Satisfaction with the treatment
results and health-related quality of life (HRQL), measured
with the SF-8 questionnaire, were secondary outcomes.
Materials and methods
Study design and patients
In this case series study, 43 patients with suspected CCS
in both legs were examined in a 2-year period (August
2007 to November 2009). Twenty-seven patients with
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