key: cord-0051851-kk3093pb
authors: Samson, Russell H.
title: Fasciotomy for chronic exertional compartment syndrome remains controversial
date: 2020-10-21
journal: J Vasc Surg
DOI: 10.1016/j.jvs.2020.06.108
sha: 90827e00ffffd4164f2f8284e402c32cc2e5cef1
doc_id: 51851
cord_uid: kk3093pb

nan

Fasciotomy for chronic exertional compartment syndrome remains controversial Russell H. Samson, MD, DFSVS, FACS, RVT, Sarasota, Fla It is not often that the Journal publishes a review of 121 articles concerned with two treatment options where the conclusion implies a total lack of consensus. However, that is the case with this article evaluating fasciotomy vs conservative therapy for chronic exertional compartment syndrome. 1 One may ask, Why did the editors choose to publish this analysis? The answer is that chronic exertional compartment syndrome is increasingly being diagnosed and treated not only by orthopedic surgeons but also by vascular surgeons, many of whom may have limited experience with this condition.

Chronic exertional compartment syndrome can be debilitating, especially for professional athletes. Therefore, it is imperative that vascular surgeons consider the diagnosis in patients who present with lower extremity exercise-induced discomfort with minimal risk factors for atherosclerosis. Most of these sufferers are involved in high-intensity exercise activities, but even somewhat sedentary patients can exhibit the classic symptoms of pain, tightness, cramping, weakness, and paresthesia. Physical findings during exercise may be negligible, but sometimes calf tenderness or fullness may be elicited. Findings on typical noninvasive tests, such as anklebrachial pressure indices with and without exercise, arterial duplex ultrasound, and computed tomography angiography evaluation of arterial anatomy, are usually normal. The only test proposed to have some diagnostic utility is intracompartment pressures, as described by Pedowitz et al. 2 Criteria for diagnosis are discussed in the manuscript of Ding et al. Although one could make a "home-made" measuring device, there is a commercially available test kit (STIC pressure monitor) made originally by Stryker and now supplied by C2Dx (Schoolcraft, Mich). Because most of these patients are predominantly diagnosed on an outpatient basis, vascular surgeons should become familiar with this device and incorporate it in their office laboratories.

The question remains, however, whether patients should have a fasciotomy or conservative therapy. Fasciotomy intuitively makes sense, but there are cosmetic side effects as well as complications, including hematoma, deep venous thrombosis, infection, and nerve damage. Furthermore, as many as 10.4% of patients reviewed required revision fasciotomy, and satisfaction rates for compartment decompression range from 48% to 94% (but 94% was for upper extremity decompressions). Currently, there is no randomized controlled clinical trial comparing these two treatment methods. Furthermore, the certainty of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation was low.

Not surprisingly, then, despite this extensive review, fasciotomy or conservative therapy remains controversial. The authors are accordingly forced to conclude with a nebulous statement, much like we are currently hearing from politicians about drugs for COVID-19. Definitive information in the form of a randomized controlled trial is "being carried out," but for now, fasciotomy "appears safe" with "promising" long-term results.

The opinions or views expressed in this commentary are those of the author and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery.

A systematic review of fasciotomy in chronic exertional compartment syndrome

Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg

From the Mote Vascular Foundation, Inc. Author conflict of interest: none

The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest

Copyright Ó 2020 by the Society for Vascular Surgery