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

Two-Compartment or 4-Compartment Fasciotomy for Lower Leg Chronic Exertional Compartment Syndrome: A Systematic ReviewThe Journal of Foot & Ankle Surgery 61 (2022) 1124−1133
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Two-Compartment or 4-Compartment Fasciotomy for Lower Leg Chronic Exertional Compartment Syndrome: A Systematic Review
Chris Weiss, BSc1,2, Sanne Vogels, MD3,4, Leonard Wee, PhD5, Loes Janssen, PhD1, Rob A de Bie, PhD, PT6, Marc R Scheltinga, MD, PhD1
1 Department of Surgery, Maxima MC, Veldhoven, DB, The Netherlands 2 Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, ER, The Netherlands 3 Department of Surgery, Alrijne Hospital, Leiderdorp, GA, The Netherlands 4 Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, GD, The Netherlands 5 Clinical Data Science, Maastricht University and Department of Radiotherapy (MAASTRO), GROW School of Oncology, Maastricht University Medical Centre, Maas- tricht, ER, The Netherlands 6 Department of Epidemiology, Caphri Care and Public Health Institute, Maastricht University, Maastricht, MD, The Netherlands
A R T I C L E I N F O
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: C. Weiss, BSc, Departm
Run 4600, 5504 DB Veldhoven, The Netherlands. E-mail address: [email protected]
1067-2516/$ - see front matter © 2022 The Author(s). Th https://doi.org/10.1053/j.jfas.2022.02.011
A B S T R A C T
Patients with lower leg chronic exertional compartment syndrome are impaired due to exercise-related pain. Fas- ciotomy is the surgical gold standard. However, it is unknown whether number of simultaneously opened com- partments affects outcome. The purpose of this systematic review was to compare patient-reported outcomes of a 2-compartment fasciotomy with a 4-compartment fasciotomy. Controlled clinical trials (randomized/nonrandom- ized), cohort studies and case series reporting on outcome following either 2-compartment or 4-compartment fas- ciotomy for lower leg chronic exertional compartment syndrome were searched until May 31, 2021 in PubMed, EMBASE, and Cochrane. Results were qualitatively synthesized. Risk of bias and levels of evidence were deter- mined. Seven studies reporting on altogether 194 athletes and military personnel (mean age 24 y) were included. Quality assessment revealed a high risk of bias in all studies. Both 2-compartment and 4-compartment fasciotomy were associated with a 50% to 100% “return to activity” rate (in studies reporting group results separately: 2-com- partment 90%-100%; 4-compartment 50%-100%) and a 41% to 100% “return to previous activity” rate (in studies reporting group results separately: 2-compartment 82-100%; 4-compartment 50%-100%) without significant differences. Mean Marx activity score of 1 study found a small significant standardized mean difference (0.196 [0.524,0.916]) favoring 4-compartment fasciotomy. Rate of satisfaction (2-compartment 74%-89%; 4-compart- ment 75%-100%) and residual symptoms (2-compartment 0%-36%; 4-compartment 0%-50%) indicated no group differences. In conclusion, a 2-compartment fasciotomy or a 4-compartment fasciotomy for lower leg chronic exertional compartment syndrome appears to be equally successful. However, included studies were ham- pered by methodological shortcomings (low sample size, selection bias, heterogeneity and no uniform outcome measures).
© 2022 The Author(s). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
Level of Clinical Evidence: 3
Keywords: chronic exertional compartment syndrome fasciotomy lower extremity patient-reported outcome systematic review
ent of Surgery, Maxima MC, De
sity.nl (C. Weiss).
is is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
Chronic exertional compartment syndrome (CECS) of the lower leg is an injury characterized by exercise-related pain and tightness typically affecting athletes and military personnel (1-3). Symptoms such as cramps, paresthesia and muscle weakness can also be expe- rienced (4,5). Although symptoms may decrease or even disappear with rest, this condition often is highly debilitating, affecting sports performance, work and other physical activities (6). The pain is
thought to result from a nonphysiological raise in intramuscular muscle pressure during a provocative activity, thus impeding circu- lation and compromising neuromuscular tissue function (7). A dynamic intra-compartmental pressure (ICP) measurement using the Pedowitz cut-off criteria (8) serves as a gold standard diagnostic tool (4). CECS predominantly occurs in 1 or more of the 4 lower leg compartments (5,9). The anterior compartment is identified as the one most commonly affected (40%-60%) (3,10) while superficial pos- terior compartment syndrome has been described as rare (11). Even though the exact prevalence is unknown, CECS is considered as the second most common cause of activity-induced leg pain (3). Espe- cially teenagers and young adults are prone to develop CECS
C. Weiss et al. / The Journal of Foot & Ankle Surgery 61 (2022) 1124−1133 1125
although adults or even octogenarians may also be affected (5,12). Sports predisposing to CECS are running, athletics, soccer, speed skating and a variety of ball games (10).
A uniform clinical consensus on management of CECS is still lacking (3,5). If conservative treatment fails, a fasciotomy (opening the thin layer enveloping the muscle) is considered the surgical method of choice (10). In 1956, the first surgical cases were described by Mavor (13). Techniques include an open fasciotomy, fasciotomy with partial fasciectomy or a minimally invasive (endoscopic) approach (12). How- ever, the number of simultaneously released compartments (1-4) may vary (5,12) whereas the associated surgical outcome is inconsistent (5,9,12). A 4-compartment fasciotomy (4-CF) implies opening all com- partments of 1 lower leg within 1 surgical procedure (14) while a 2- compartment release (2-CF) indicates a fascia incision of 2 compart- ments, mostly -but not always - the anterior and lateral compartment (9). Although surgery may result in high rates of “return to activity” and “satisfaction” (48%-94%) (5,9) compared to nonsurgical methods (<50%) (5), outcome remains suboptimal. It is likely that a challenging diagno- sis, expertise, variability of techniques and a lack of standardized out- come measures contribute to these wide-ranging findings (9,10). Interestingly, an unknown portion of patients who undergo surgery for just 1 or 2 compartments may later on develop CECS in other compartments (14). Therefore, some have suggested to standardly open all 4 compartments in 1 surgical procedure, irrespective of level of ICPs (14). In 1 study, 4-CF resulted in a significantly improved quality of daily life (14). Whereas an isolated treatment of the deep posterior compartment resulted in suboptimal out- comes with failure rates up to 60% (6,10), when performed in a 4- CF setting it did not appear to negatively influence overall treat- ment outcome. Moreover, 1 study suggested that young patients with 4-CF had lower reoperation rates compared to patients having an isolated compartment release or a 2-CF (15).
It may seem that the optimal surgical approach for lower leg CECS is currently unclear. An adequate treatment of CECS is necessary for those with physical complaints not being able to fully live up to their ambi- tions and expectations. A growing number of interventional studies explored the efficacy of multiple-compartment fasciotomy with contra- dictory findings. However, a systematic comparison of 2-CF versus 4-CF has not been performed to date. Therefore, the aim of this systematic review is to evaluate the effectiveness of surgery in patients diagnosed with CECS in the lower leg by comparing patient-reported outcome measures of a 2-compartment fasciotomy versus a 4-compartment fas- ciotomy.
The primary outcome of interest is “return to activity,” whereas “symptoms” and “satisfaction” will be regarded as potential secondary outcomes.
Patients and Methods
Search Strategy
For this study design, national law did not require permission from an ethical committee. An initial electronic database search was conducted in PubMed, EMBASE, and Cochrane between February and May 2021 using the Cochrane Handbook as guideline (16) in accordance with the PRISMA statement on methodology (17). A final search, peer reviewed by a librarian and review expert, was performed on 31 May 2021 in accordance with the eligibility criteria. All relevant studies published until May 2021 were considered. No additional filters were applied. Key words used included terms relating to population/ disease (“compartment syndrome,” “anterior compartment,” “lateral compartment,” “peroneal compartment,” “posterior compart- ment,” “CECS,” “lower leg compartment“), location of disease (“lower leg,” “lower extremity,” “below knee,” “calf,” “tibia,” “fibula”) and interventions (“fasciotomy,” “fasciectomy,” “compartment release”). All database queries including key words and controlled vocabulary (Medical Subject Headings) are reported in Appendix 1. No language restrictions were imposed.
Eligibility Criteria
Full texts of (randomized) controlled trials, case series and cohort studies of patients who were diagnosed with CECS based on history, clinical examination or by ICP measure- ment were considered for selection. A study was included if it involved a comparison of patients undergoing a 2-CF or a 4-CF approach and if it contained the patient-reported outcome “return to activity.” “Symptoms” and “satisfaction” were considered as second- ary outcomes, if available. An outcome description, preferably in the form of a question- naire, rating scale or termination, was required. No time limit for follow up was set. Studies referring to interventions other than a fasciotomy and referring to CECS not including the lower leg or not primary exercise-related were excluded, as were unpub- lished manuscripts and conference proceedings.
Study Selection
The selection process was summarized in a PRISMA flowchart (Fig. 1). Records identi- fied following the initial search were exported to Endnote reference management soft- ware (18). Duplicates including false negatives (19) were removed in Endnote using the Bramer method (20). Two reviewers (CW & SV) screened titles and abstracts on predeter- mined eligibility criteria utilizing Rayyan software (21). Disagreements were solved by consensus. Available full texts of potential relevant articles were evaluated on applicabil- ity. Finally, forward and backward citation tracking was conducted.
Data Extraction
Relevant information was extracted by 2 reviewers (CW & SV) working indepen- dently utilizing a self-designed data extraction sheet collecting the following: author and date, study design, setting, patients (numbers, diagnosis, gender, age, symptom duration, specific characteristics), released compartments, complications and outcomes (mean fol- low up, measures). The outcome domain “return to activity” (rate of return; rate of return to previous, desired or expected level; Marx activity scores: higher scores indicate more frequent participation; Tegner scores: states current highest activity level) was consid- ered as crucial and therefore labelled as primary outcome. The domains “symptoms” and “satisfaction” were regarded as secondary outcomes. Authors not separately reporting 2- CF and 4-CF outcomes were contacted by mail to supply missing information.
Summary Measures and Synthesis of Results
Quantitative data of age, symptoms and follow up were listed as means with standard deviation (SD) and/or range. Sample size (total, by group), gender distribution and com- plications were noted as absolute numbers. Effect sizes (ES) were calculated by the first reviewer (CW). Odds ratios (OR) including 95% Confidence Interval (CI) for dichotomous values were determined adhering to the Cochrane guidelines (9.2.2) (16), by choosing 4- CF as the reference group. An OR of 1.5 was considered as a small ES, 2.5 a medium ES and 4 a large ES (22) provided that its 95% CI did not include the number 1 denoting no statistical significance (23,24). For continuous measures, a standardized mean difference (SMD) with 95% CI was calculated using HedgesG to minimize bias for small sample sizes (25). A SMD of 0.2 was regarded to represent a small difference, 0.5 a medium difference and 0.8 a large difference (26) on the condition its 95% CI did not include zero indicating no statistical significance (24,27). Due to large study heterogeneity between studies, a systematic qualitative synthesis was considered the method of choice.
Quality Assessment
Both researchers (CW & SV) performed the quality assessment individually. The Criti- cal Appraisal Skills Programme (CASP; Oxford, England) checklist (28) was used to exam- ine the methodological quality of each study, with the full checklist being reported in Appendix 2. The overall quality of evidence was determined according to Cochrane's Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach evidence profile (16).
Results
Study Selection
The search yielded 2370 hits; 982 in PubMed, 1361 in EMBASE and 27 in Cochrane (Fig. 1). No additional titles were found using forward and backward citation. Removing duplicates resulted in 1580 records. After analysis of titles and abstract, a total of 57 records were assessed for eligibility. Of the 52 available full text articles, 45 were excluded as they did not report on a comparison of 2-CF with 4-CF procedure (n = 18), had an unspecified study design (n = 16), lacked the primary outcome (n = 4), had an unclear outcome description (n = 4), were
Fig. 1. Flow diagram of study selection.
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missing a sufficient description of involved compartments (n = 2), or the intervention was not accepted (n = 1). Eventually, 7 studies fulfilling all inclusion criteria were considered for the qualitative synthesis.
Summary of Included Studies
Characteristics of the 7 studies (29-35) are presented in Table 1. A total of 194 patients (100 male, 94 female) with a mean age of 24 y (range 15-55) were analyzed. Six studies (29-34) were retrospective cohort studies while 1 study (35) was a prospective cohort study. In 6 articles (29-33,35) study groups were allocated according to a 2 (2-CF) or 4 (4-CF) compartment release. The seventh study (34) compared out- comes of 4 groups having a different number of released compart- ments. Six (29-31,33-35) of 7 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 was performed 48 times and 4-CF 15 times. All studies included a varying number of bilateral leg fasciotomies. Six studies (29- 32,34,35) reported on athletes, one of which also included 3 military servicemen. A seventh study (33) investigated solely military person- nel. In 5 studies (29-32,35) an open fasciotomy was performed, the sixth study (34) used an endoscopic approach whereas the last study
(33) did not state their operative technique. Mean follow up interval was 67 months (range 2-329).
Quality Appraisal
Most studies were mislabeled as case series. However, all 7 should be considered cohort studies since sampling was based on intervention and risk calculation was possible (36) Table 2. illustrates the assessment based on the CASP checklist. The methodological quality of each report was sufficient, so exclusion was not considered. Five studies (30,32-35) performed poorly on cohort recruitment validity. The address of a clearly focused issue, identification of confounders, follow-up, accor- dance with evidence and implications were scored positively in all 7 studies, whereas the credibility of all study results was uncertain. The GRADE assessment judged the quality of all studies to be very low because of the risk of selection bias, inconsistency and imprecision of results (Table 1).
Heterogeneity
Performing a meta-analysis was impossible due to clinical heteroge- neity as a high variability in the patients’ baseline activity and measure- ment instruments was present. A chi-square test to access statistical
Table 1 Study characteristics (N = 194 patients)
Study Design
m Duration Symptoms §SD
Population Type Released Compartments
Outcome Measures
RC Very low AMC, Georgia. 1 surgeon
Symptomatic/ examination, ICP for symp- tomatic compartments
2-CF : 23 (12/11) 4-CF : 11 (2/9)
26 § 9 (15-42). 2-CF :27 § 8 4-CF : 22§ 8
na na (indication of post Tegner activ- ity score: recrea- tional athletes)
2-CF (A/L), 4-CF (A,L,DP,SP). 52 legs (uni- and bilateral)
2- :resolved n = 1, nor persisting ptoms n = 1 4-
:resolved n=3
106 (17-146) Activity (Marx activity scale; Tegner activity scale); SF-12; Likert Scale satisfaction
Irion et al (30), 2014
RC Very low AMC, Ohio Clinical examina- tion, ICP
2-CF : 11 (5/6) 4- CF : 2 (1/1)
20 (17-24) 1 week − 4 months (of 2 patients unknown)
Athletes (elite-level) 2-CF (A/L), 4-CF (A,L,DP,SP). 20 legs (uni- and bilateral)
Re lved n = 1, nor persisting ptoms n = 1,
rsisting/revi- n surgery eded n = 1
11 (2-60) Return to sports at previous level; time to return; Return of symptoms
Maher et al (31), 2018
RC Very low Surgery institu- tion, Massachu- setts, 4 surgeons
Clinical examina- tion and diag- nostic testing (not further described)
21 (5/16) 2-CF : 9 4-CF : 12
25 § 8 15 § 9 months Athletes (profes- sional, collegiate, high school, recreational)
2-CF (na), 4-CF (A,L,DP,SP). 37 legs (uni- and bilateral)
Re lved n = 1 213 (32-329) Return to exer- cise; expecta- tion with regard to pain, strength, motion, daily living, sporting; EQ-5D; Sports subscale FAAM, SANE
Mangan et al (32), 2020
RC Very low AMC, Pennsylva- nia, 1 surgeon
History, Clinical examination, ICP
59 (24/35) 27 (15-55) 39 months Athletes (n = 56; recreational, com- petitive) Military personnel (n = 3)
2-CF (na), 4-CF (A,L,DP,SP). 63 legs (2-CF n = 48, 4-CF n = 15; uni- and bilateral)
Re lved n = 5 59 (10-115) Return to sports; Sport subscale FAAM; Sport SANE; VAS dur- ing sporting
Rorabeck et al (35), 1983
PC Very low AMC, University of Western Ontario
History, clinical examination, ICP, differential diagnosis to exclude other diseases
12 (9/3) 2-CF : 10 4-CF : 2
21 § 2 (18-26) 11 § 4 months Athletes (university) 2-CF (A/L or DP/SP), 4-CF (A,L,DP,SP). 24 legs (all bilateral)
na 12 (6-24) Return to athletic activity, resid- ual symptoms
McCallum et al (33), 2014
RC Very low Tertiary medical center, Hono- lulu, multiple surgeons
Clinical examina- tion, ICP
46 (38/8) 2-CF : 35 4-CF : 11
30 (19-50) na Military personnel 2-CF (A/L), 4-CF (A,L,DP,SP). 70 legs (uni- and bilateral)
Re lved n = 1, per- ting symptoms 15. In 2-CF:
rsisting/revi- n surgery eded n = 1
26 (8-51) Return to duty; SANE; VAS; per- ceived appear- ance of leg; miles run/week; job change within military; satisfaction
Wittstein et al (34), 2010
RC Very low AMC, North Caro- lina/ Pennsylvania
History, Clinical examination, ICP
9 1-CF : 2 2-CF : 4 (2/2) 3-CF : 1 4- CF : 2 (1/1)
24 (13-54). 2-CF :29 § 17 4-CF :15 § 6
na Athletes (collegiate, recreational)
1-CF, 2-CF (A/L; A/SP),,3-CF, 4-CF (A,L,DP,SP); 14 legs (uni-and bilateral)
Re lved n = 2 45 (5-90) Return to sport/ activity; symp- tom recurrence; further treat- ment necessary
Abbreviations: m, mean; SD, standard deviation; na, not available; RC, retrospective cohort study, according to description proposed by Dekkers et al (36); PC, prospective cohort s dy; AMC, academic medical center; ICP, intracom- partmental pressure measurement; 1-CF, 1-compartment fasciotomy; 2-CF, 2-compartment fasciotomy; 3-CF, 3-compartment fasciotomy; 4-CF, 4-compartment fasciotomy; A, a rior; L, lateral; DP, deep posterior; SP, superficial posterior; SF-12, 12-Item Short Form Health Survey; EQ-5D, European Quality of Life − 5 Dimensions; FAAM, Foot and Ankle Ability Measure; SANE, Single Assessment Numeric Ev ation; VAS, visual analog scale.
y Return of presurgery symptoms do not fall into this category. Explanations: GRADE: 4 levels of quality (high, moderate, low, very low) for each individual outcome.
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heterogeneity was not performed since it has low power in case of small sample sizes, and not all effect sizes provide information about the event’s probability. Given the clinical diversity, methodological short- comings and CI values statistical heterogeneity is likely to be present.
Primary Outcome: Return to Activity
Differences in outcomes between patients who underwent 2-CF and 4-CF are summarized in Table 3. In 5 studies (30,32-35), no significant difference regarding the rate of return to activity was shown. Two of these studies resulted in a 100% return rate in both groups (30,34), whereas 2 other studies did not state outcomes separately, reporting an overall return to activity in 78.26% to 93.22% (32,33). A fifth study (35) identified…