Evaluating Outcomes of Compartment Release for CECS
A recent study of adolescents who had surgery for chronic exertional compartment syndrome provides insight into the important differences between adolescent and adult patients – including the timing of surgery following presentation – that could improve outcomes in the younger population.
Warren K. Young, MD
Beck JJ, Tepolt FA, Miller PE, Micheli LJ, Kocher MS. Surgical treatment of chronic exertional compartment syndrome in pediatric patients. Am J Sports Med 2016 44: 2644. DOI: 10.1177/0363546516651830
Beck et al performed a retrospective review of adolescent patients who underwent compartment release for chronic exertional compartment syndrome (CECS) in an effort to describe the characteristics and surgical outcomes of this patient population.
The researchers identified 155 patients (286 legs) with a mean age of 16.4 years at presentation in whom compartment release was performed between 1995 and 2014. All surgeries were performed by 1 of 6 surgeons at Boston Children’s Hospital.
Through review of medical records, clinical and demographic data were collected, including compartment pressure results, postoperative complications, return to sport, and need for revision surgery.
The data showed that 88% of patients were female, 85% presented with bilateral leg symptoms, and 84% had more than 6 months of symptoms at presentation. Running and soccer were the most common sports in which the patients participated (25% and 23% of patients, respectively).
The average time to surgery was 5 months, with a range of 0 to 47 months. Patients were followed for an average of 11 months after surgery, with 18.8% requiring reoperation at a median time of 1.3 years after the initial procedure.
There was an 11.2% wound complication rate, with the superficial posterior release being the most common location of infection/dehiscence (37% of wound complications). Infection/dehiscence occurred in 33% of patients who underwent a 4-compartment release, compared with only 8% of patients who underwent anterior and lateral releases.
Analysis of patients who required reoperation showed significantly lower after-activity compartment pressures at presentation compared with patients who did not need reoperation. Legs with only anterior and lateral releases were 3.4 times more likely to need reoperation than legs with 4-compartment release.
The only independent predictor of recurrence of CECS requiring revision surgery was the time between presentation and surgery: The odds of reoperation decreased by 12% for every additional month between initial presentation and surgery.
Chronic exertional compartment syndrome can be a difficult diagnosis to make. The differential diagnosis of lower leg pain in the athletic population includes tibial stress fracture, fibular stress fracture, medial tibial stress syndrome, tendonitis, muscle strain, nerve entrapment, and vascular issues such as popliteal artery entrapment syndrome. To date, this is the largest analysis of CECS in the adolescent population, and it suggests that CECS should be managed differently in this population than in the adult population.Contrary to studies of CECS in the adult population, adolescent patients are:
- More likely to be female
- Present with more bilateral symptoms
- Experience lower reoperation rates when there is more time between presentation and surgery
It was also significant that lower pressures at presentation had higher rates of reoperation despite using the Pedowitz criteria.
Although more research is needed, this study by Beck et al may prove helpful in the management of CECS in the adolescent population:
- Delaying surgery may be beneficial in improving outcomes after compartment release.
- Other causes of CECS, such as biomechanical and athletic conditioning, may be addressed during the delay.
- A higher threshold for intracompartmental pressure as a means of determining the timing of surgery may also lead to improved outcomes.
Warren K. Young, MD, is an Assistant Professor of Orthopaedic Surgery, Division of Primary Care Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.