Thursday #12 Dr. Fagan Endoscopic Tx o Chronic Exertional … · 2018-07-23 · •Non-operative...

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© Aurora Health Care, Inc.© Aurora Health Care, Inc.

Endoscopic Treatment of Chronic Exertional Compartment Syndrome

Paul A. Fagan, D.O.

Aurora Health Care – Neenah, Oshkosh & Fond du Lac, WI

Detroit Regional Sports Medicine Symposium, July 19, 2018

© Aurora Health Care, Inc.

Disclosure

• I have no actual or potential conflict of interest in relation to this presentation.


Overview

• History

• Epidemiology

• Anatomy

• Pathophysiology

• Presentation / Diagnosis

• Diagnostic testing

• Treatment

• Summary / Questions

Image: https://www.idahoankleandfoot.com/chronic‐exertional‐compartment‐syndrome

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Overview

• Objectives– Add CECS to your differential

– Develop an algorithm for diagnosis

– Outline treatment approaches

– Outline rehabilitation from surgical treatment of CECS


History

• 1881 – Volkmann – Describes ischemic contracture

• 1906 – Hildebrand– Related Volkmann’s ischemic contracture with elevated tissue pressure

• 1910-1912 – Wilson– Probably first description of CECS on Scott’s Antarctic Expedition

• 1914 – Murphy– Fasciotomy to relieve elevated compartment pressure

• 1945 – Horn– “March gangrene” – first publication

• 1956 – Mavor– The anterior tibial syndrome

• 1967 – Seddon, Kelly, Whitesides– 4 compartments in lower leg– Necessary to address all compartments


Epidemiology

• Incidence– No statistics in general population

– 0.49 cases per 1,000 person-years in a physically active military population

• Waterman (AJSM 2013)

• Occurs in a variety of activities– Detmer (AJSM 1985)

• Involved in sports (87%)

• Running (69%)

Image: Buda Mendes/Getty

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Anatomy

• Multiple areas of occurrence– Lower leg, thigh, foot, forearm…

• Most common in lower leg: 95%– Barnes (BJSM 1997)

• Bilateral lower leg involvement in 82%– Detmer (AJSM 1985)


Anatomy

• Rajasekaran (PM&R 2012)– CECS involves:

• Anterior 40%-60%

• Lateral 12%-35%

• Superficial posterior 2%-20%

• Deep posterior 32%-60%


Pathophysiology

• Etiology– Multiple theories - Lecoq (Ann Re Med Phys 2004)

• Muscle hypertrophy

• Noncompliant fascia

• Decreased venous return

• Muscular microtrauma

• Myopathy

– Increased intramuscular pressure causes transient neuromuscular ischemia during exercise

• Styf (Compartment Syndromes 2004)

Image: https://www.nps.gov

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Pathophysiology

• Etiology– Predisposing factors - Anuar (Phys Sing 2006)

• Leg length discrepancy

• Varus or valgus malalignment

• Poor muscle control

• Inappropriate training (frequency/intensity)

• Diminished strength & endurance

Image: https://www.theodysseyonline.com


Presentation / Diagnosis

• Pain– Dull, aching, cramping, sense of pressure

• Reproducible– Usually at a certain, predictable time or

distance

– Usually cannot run through pain

• Crescendo - decrescendo– Pain resolves after activity cessation

• 10-60 minutes (Anaur)

Image: http://www.compositeur‐arrangeur.com/



• When severe, pain may occur at rest – Pedowitz (AJSM 1990)

• Neurologic symptoms– Paresthesia / numbness

– Transient foot drop – “slapfoot”

Image: www.mattsms.com

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• Differential - Vajapey (Phys SM 2017)– CECS

– Medial tibial stress syndrome / stress fracture

– Tendinitis / myositis

– Radiculopathy / peripheral nerve entrapment

– Venous thromboembolism

– Popliteal artery entrapment syndrome

– Arterial vascular disease / claudication

– Sickle cell disease

– Tumor


Diagnostic Testing

• X-rays


Diagnostic Testing

• Nuclear medicine bone scan

Image: Iwamoto et al

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Diagnostic Testing

• MRI

Image: DeLee & Drez


Diagnostic Testing

• Electromyogram / Nerve Conduction Study– For those with persistent neurologic symptoms

Image: https://clinicalgate.com/routine‐lower‐extremity‐nerve‐conduction‐techniques/


Diagnostic Testing

• Near-infrared spectroscopy

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Diagnostic Testing

• Post-exercise needle manometry– When other causes ruled out


Diagnostic Testing


Treatment

• Non-operative management– Cessation of activities

– Physical therapy - gait training • Transition to forefoot running

– (Diebal – AJSM 2012 & Helmhout – Orthop J Sports Med 2015)

– Significant decrease in post-run compartment pressures

– Significant increase in running distance

– Massage

– Orthotics

– Botulinum toxin A (Isner-Horobeti – AJSM 2013)

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Treatment

• Open fasciotomy

• Percutaneous fasciotomy

• Endoscopic-assisted fasciotomy

• Other techniques– Ultrasound-guided

– Thermal


Treatment

• Fasciotomy is gold standard– (Fronek – CORR 1987, Rorabeck – JBJS-A 1983 & AJSM 1988, Styf – JBJS-A 1986, Howard – CJSM 2000)

– Variable outcomes but good overall relief• Campano (Arthroscopy 2016) – systematic review

– 66% overall success

– Satisfaction rate 84%

– Return to previous or full activity 75%

– Symptom recurrence 0% to 44.7%

– Reoperation 0% to 19%

– Overall complication rate 13%

• Packer (AJSM 2013)– Compared non-operative to operative management

– Satisfactory outcomes in 41% vs. 81%

Image: https://www.primehealthchannel.com/compartment‐syndrome.html


Treatment - Open

• Open fasciotomy– Anterior & lateral compartments

• Identify / protect superficial peroneal nerve

Images: Vajapey – Phys SM 2017

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Treatment - Open

• Open fasciotomy– Posterior release

• Split fascia of superficial and deep compartments

• Avoid saphenous NV bundle

Image: Vajapey – Phys SM 2017


Treatment - Open

• Open fasciotomy– Failure of open surgical treatment

• Schepsis (AJSM 2005)– 18 patients with failure after open fasciotomy

» 60% localized fibrosis / constriction

» 40% recurrence of entire compartment


Treatment – Minimally Invasive

• Minimally invasive / percutaneous– Small incision, done essentially blind

– Most common complication: superficial peroneal nerve injury

• Finestone (FAI 2014) – 3/36 patients with nerve injury

– One reoperation

• Drexler (AOTS 2017)– 4/54 patients with nerve injury

– 8 with recurrence of symptomsImage: DeLee & Drez

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Treatment

• Hutchenson (AJSM 2003)– Cadaveric study of endoscopic vs. mini-open

– Endoscopic had lower rate of SPN injury

– Both had high rates of saphenous vein injury

http://www.jugosparabajardepeso.info/organdiagram/44692‐44693


Treatment - Endoscopic

• Lohrer (Arch Orthop Trauma Surg 2007)– 19 deep posterior, 16 anterior, 3 lateral in 17

athletes

– No complications in anterior & lateral

– Deep posterior • Hemorrhage in 2 patients

• Required conversion to open

• Recommend against endoscopic deep compartment release

– 10/17 returned to previous level of activity



• Lui (Arthrosc Tech 2017)– Posterior compartments

– Incision away from saphenous n./v.

– No outcomes published

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• Wittstein (AJSM 2010)– 8/9 returned to previous level of activity

– 2 hematomas – resolved without intervention

• Lohrer (Sports Med Arthrosc 2016)– Systematic review of endoscopic vs. mini-open

– No statistically significant difference



• Standard 30 degree scope

• 12” curved Metzenbaum scissors

• “Finger” retractors



• Incisions over raphe– At junction of prox/mid & mid/distal 1/3

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• Superficial peroneal nerve– Identified in distal incision





• Small transverse incision in fascia– Work distal to level of superior retinaculum

– Work as proximal as able to visualize

– Move scope and instruments to proximal incision

– Connect to distal fasciotomy

– Work proximal

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Treatment - Pearls

• Protect SPN – it’s in the fat

• Avoid perforating veins

• Ensure complete release


Treatment

• Closure– I do not use a drain

– Monocryl & Dermabond

– Toe-to groin ACE wrap

https://www.signs4safety.co.za/


Rehabilitation

• Phase 1 – Protect weightbearing with crutches

• NWB for 3 days

• WBAT to follow

– Rest / Ice / Compression / Elevation

– Stretching (AROM / AAROM)

Image: Wikimedia

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Rehabilitation

• Phase 2 (2-3 weeks post-op)– Wound check in office, begin formal PT

– Continue ROM of ankle & knee

– Low-impact• Stationary bike, elliptical, Alter-G, hydrotherapy

• Phase 3 (4-6 weeks post-op)– Progress strength

– Progress running

– Increase duration of activity

Image: https://twitter.com/hashtag/alterg


Rehabilitation

• Phase 4 (by 8 weeks post-op)– Impact / plyometrics

– Speed / agility drills

– Sport-specific activities

• Phase 5 (~12 weeks post-op)– Return to all activities without restriction


Summary

• Objectives– Add CECS to your differential

– Develop an algorithm for diagnosis

– Outline treatment approaches

– Outline rehabilitation from surgical treatment of CECS

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Summary

• CECS exists!

• You can diagnose CECS

• You have the tools & skills to treat surgically if necessary

Image: https://bestforacar.com


Sources

• Anuar K, Gurumoorthy P. Systematic review of the management of chronic compartment syndrome in the lower leg. Physiotherapy Singapore. 2006;9:2–15.

• Barnes M. Diagnosis and management of chronic compartment syndromes: a review of the literature. Br J Sports Med. Mar 1997;31(1):21-27.

• Bederka B and Amendola A. Leg Pain and Exertional Compartment Syndromes:1857-1864. In DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice. Ed DeLee J, Drez D., Miller MD. 3rd ed. Philadelphia, PA: Elsevier/Saunders; c2009. Volume 1, Chapter 24, Section B.

• Blackman PG, Simmons LR, Crossley KM. Treatment of chronic exertional anterior compartment syndrome with massage: a pilot study. Clin J Sport Med. 1998;8:14–17.

• Campano D., Robaina J.A., Kusnezov N., Dunn J.C., Waterman B.R. Surgical management for chronic exertional compartment syndrome of the leg: A systematic review of the literature. Arthroscopy. 2016;32:1478–1486.

• Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. The American journal of sports medicine. May-Jun 1985;13(3):162-170.

• Diebal AR, Gregory R, Alitz C, et al. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am J Sports Med. 2012;40:1060–1067

• Drexler M, Rutenberg TF, Rozen N, et al. Single minimal incision fasciotomy for the treatment of chronic exertional compartment syndrome: outcomes and complications. Arch Orthop Trauma Surg. 2017;137:73–79.

• Finestone AS, Noff M, Nassar Y, et al. Management of chronic exertional compartment syndrome and fascial hernias in the anterior lower leg with the forefoot rise test and limited fasciotomy. Foot Ankle Int. 2014;35:285–292.

• Freedman BJ. Dr. Edward Wilson of the Antarctic: a biographical sketch, followed by an inquiry into the nature of his last illness. Proc R Soc Med. 1954;47:183–189.

• Fronek J, Mubarak SJ, Hargens AR, et al. Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop Relat Res. 1987;220:217–227.

• 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;10:176–184.

• Hutchinson MR, Bederka B, Kopplin M. Anatomic structures at risk during minimal-incision endoscopically assisted fascial compartment releases in the leg. Am J Sports Med. 2003;31:764–769.

• Isner-Horobeti M-E, Dufour SP, Blaes C, et al. Intramuscular pressure before and after botulinum toxin in chronic exertional compartment syndrome of the leg: a preliminary study. Am J Sports Med. 2013;41:2558–2566.

• Iwamoto J, Sato Y, Takeda T, Matsumoto H. Analysis of stress fractures in athletes based on our clinical experience. World J Orthop. Jan 18, 2011; 2(1): 7-12

• Lecocq J, Isner-Horobeti ME, Dupeyron A, et al. [Exertional compartment syndrome]. Ann Readapt Med Phys. 2004;47:334–345.


Sources

• Lohrer H, Nauck T. Endoscopically assisted release for exertional compartment syndromes of the lower leg. Arch Orthop Trauma Surg. 2007;127:827–834.

• Lohrer H, Nauck T, Lohrer L. Endoscopic-assisted release of lower leg chronic exertional compartment syndromes: results of a systematic literature review. Sports Med Arthrosc. 2016;24:19–23.

• Lui, TH,. Endoscopic Fasciotomy of the Superficial and Deep Posterior Compartments of the Leg. Arthroscopy Techniques, Vol 6, No 3 (June), 2017: pp e711-e715 .

• Mavor GE. The anterior tibial syndrome. J Bone Joint Surg Br. 1956;38-b:513–517.

• 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;41:430–436.

• Pedowitz RA, Hargens AR, Mubarak SJ, et al. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18:35–40.

• Rajasekaran S, Hall MM. Nonoperative management of chronic exertional compartment syndrome: a systematic review. Curr Sports Med Rep. 2016;15:191–198.

• Rorabeck CH, Bourne RB, Fowler PJ. The surgical treatment of exertional compartment syndrome in athletes. J Bone Joint Surg Am. 1983;65:1245–1251.

• Rorabeck CH, Fowler PJ, Nott L. The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med. 1988;16:224–227.

• Schubert AG. Exertional compartment syndrome: review of the literature and proposed rehabilitation guidelines following surgical release. Int J Sports Phys Ther. 2011;6:126–141.

• Styf J. Definitions and terminology. Etiology and pathogenesis of chronic compartment syndrome. In: Styf J, editor. Compartment syndromes: diagnosis, treatment, and complications. Boca Raton (FL): CRC Press LLC; 2004.

• Styf JR, Körner LM. Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy. J Bone Joint Surg Am. 1986;68:1338–1347.

• Vajapey S, Miller TL. Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome: a review of current literature. Phys Sportsmed. 45:4, 391-398.

• an den Brand JG, Nelson T, Verleisdonk EJ, van der Werken C. The diagnostic value of intracompartmental pressure measurement, magnetic resonance imaging, and near-infrared spectroscopy in chronic exertional compartment syndrome: a prospective study in 50 patients. Am J Sports Med. 2005 May;33(5):699-704. Epub 2005 Feb 16.

• Waterman BR, Liu J, Newcomb R, Schoenfeld AJ, Orr JD, Belmont PJ Jr. Risk factors for chronic exertional compartment syndrome in a physically active military population. Am J Sports Med 2013;41:2545-2549.

• Wittstein J, Moorman CT 3rd, Levin LS. Endoscopic compartment release for chronic exertional compartment syndrome: surgical technique and results. Am J Sports Med. 2010;38:1661–1666.

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Thursday #12 Dr. Fagan Endoscopic Tx o Chronic Exertional … · 2018-07-23 · •Non-operative...

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