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Chronic exertional compartment syndrome (CECS) is characterized by pain and increased intra-compartmental pressure with exertion.
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Ultrasound-guided (USG) fasciotomies have been described for the treatment of anterior and lateral leg compartment CECS.
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USG fasciotomies are performed through a 3-mm skin incision, reducing tissue trauma, and potentially reducing complications, and facilitating more rapid return to activity.
Pertinent Anatomy and Common Pathology
For more information refer to Chapter 29 (Compartment Pressure Testing).
Traditional Treatment Options
There are several nonsurgical treatment options for chronic exertional compartment syndrome (CECS). Activity modification is one option in cases where a specific activity (i.e., cycling or running) provokes symptoms. In runners with anterior compartment symptoms and a heel strike pattern, gait re-training and adopting a forefoot running pattern may assist in treating CECS. , Intramuscular botulinum toxin A injections have also been used in the treatment of CECS. However, their duration of action is limited and anterior compartment injections can cause temporary weakness, resulting in foot drop. Ultrasound-guided (USG) needle fenestration of the anterior and lateral compartments was reported as a treatment in the case of a collegiate lacrosse player with CECS, who returned to full activity after 10 days and had resolution of symptoms at the 18-month follow-up.
Open surgical fasciotomy is the traditional and best-described definitive treatment for CECS. , Waterman et al. reviewed 754 fasciotomy procedures performed for CECS in a military population. In this population 77% of cases involved a release of both the anterior and lateral compartments. They reported a complication rate of 15.7%, with infection being the most common followed by neurologic injury. The recurrence rate was 44.7%, and 5.9% went on to surgical revision. More recently, endoscopic procedures involving a balloon catheter dilation have been described. Ultrasound-assisted surgical procedures also have been reported in a recent case series. This procedure utilized Metzenbaum scissors but required initial nonguided blunt dissection to the fascial plane.
USG fasciotomy using a V-shaped meniscotome for the anterior and lateral compartments was first described in a cadaveric model by Lueders et al. in 2017. Since then it has been translated into clinical practice and was recently described in a case report of a 41-year-old female runner who underwent anterior compartment USG fasciotomy without complications; she returned to full activity 7 days after the procedure. Recently, a retrospective review of 50 USG fasciotomies showed a single complication, “sharp nerve pain,” that resolved without treatment in 2 weeks, and an average return to full activity of 10 days.
Equipment
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High-resolution ultrasound machine with a high-frequency linear array transducer.
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Indelible marker.
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Needle size: 25-guage, 2-inch and 22-gauge, 3.5-inch needles.
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Local anesthetic: a mixture of 4 mL 1% lidocaine, 4 mL 0.5% lidocaine with epinephrine, 4 mL of 0.2% ropivacaine, and 8 mL of sterile saline per compartment.
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Number 11-blade scalpel.
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A 3.00-mm V-shaped meniscotome (Smith and Nephew, Inc., Andover, MA) ( Fig. 30.1 ).
Fig. 30.1
Three-millimeter V-shaped meniscotome.
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Skin closure: Dermabond (Ethicon, LLC, San Lorenzo, Puerto Rico), benzoin tincture (3M, Maplewood, MN), and three ¼ × 1.5-inch Steri-Strips (3M, Maplewood, MN).
Technique
Pre-Procedure Planning—Anterior Compartment
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The anterior compartment borders are identified with ultrasound.
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The common peroneal nerve (CPN), superficial peroneal nerve (SPN), and deep peroneal nerve (DPN) are identified and their course is marked on the skin.
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The start (3 cm distal to tibial tuberosity) and finish (10 cm proximal to the inferior aspect of the lateral malleolus) locations for the procedure are marked on the skin.
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The optimal course of the fasciotomy from proximal to distal is determined with ultrasound and marked on the skin.
Pre-Procedure Planning—Lateral Compartment
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The lateral compartment borders are identified with ultrasound.
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The CPN and SPN are identified and their course is marked on the skin.
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The start (3 cm distal to the fibular head) and finish (10 cm proximal to the inferior aspect of the lateral malleolus) locations for the procedure are marked on the skin.
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The optimal course of the fasciotomy from proximal to distal is determined with ultrasound and marked on the skin.
Patient Position
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Supine.
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Legs extended in neutral rotation.
Clinician Position
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Seated next to the patient.
Local Anesthesia
Transducer Position
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Alternating between the long- and short-axis views relative to the needle/meniscotome trajectory.
Needle Position
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Alternating between a 25-gauge, 2-inch needle and 22-guage, 3.5-inch needle, guided in-plane relative to the ultrasound transducer, the skin surface at the proximal incision site, adjacent subcutaneous tissues, and the fascia along the pre-marked course of the fasciotomy are anesthetized.
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Multiple needle entry sites, spaced approximately 3 inches apart, are required to anesthetize the entire length of the fascia.
Injectate Volume
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10 to 20 mL per compartment.
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Recommended injectate: a mixture of 4 mL of 1% lidocaine, 4 mL of 0.5% lidocaine with epinephrine, 4 mL of 0.2% ropivacaine, and 8 mL of sterile saline.
Target
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Superficial to the fascia and deep to the subcutaneous tissue layer.
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The injection will create a plane, separating the subcutaneous tissue from fascia.
Fasciotomy
Transducer Position
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Alternate between long-short-axis views relative to the meniscotome.
Meniscotome Position
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A No.11-blade scalpel is used to make a 3-mm skin incision at the proximal fasciotomy start site for each respective compartment ( Fig. 30.2 ).
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