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Chronic compartment syndrome of the lower limbs
(Portuguese PDF version)

Winston Bonetti Yoshida^1, Gustavo Muçaçah Sampaio Brandão², Sidnei Lastória³, Hamilton Almeida Rollo³, Marcelo José de Almeida⁴, Francisco Humberto de Abreu Maffei⁵

1. Associate professor, Department of Surgery and Orthopedics, School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil.
2. Resident physician, Department of Surgery and Orthopedics, School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil.
3. PhD. Assistant professor, Department of Surgery and Orthopedics, School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil.
4. Assistant professor, Department of Surgery, School of Medicine of Marília (FAMEMA), Marília, SP, Brazil.
5. Professor, Department of Surgery and Orthopedics, School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil.

Correspondence:
Winston Bonetti Yoshida
Disciplina de Cirurgia Vascular
Dep. de Cirurgia e Ortopedia
Faculdade de Medicina de Botucatu
Universidade Estadual Paulista - Unesp
CEP 18618-970 - Botucatu, SP
Brazil
Phone: +55 (14) 3811.6269
Fax: +55 (14) 3815.7428
E-mail: winston@fmb.unesp.br

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ABSTRACT

Chronic compartment syndrome is an uncommon condition characterized by painful disturbances of the lower limbs associated with a pathological increase of the intracompartmental pressure after exercises. Anatomic factors such as limited compartment size, increased intracompartmental volume, constricted fascia, loss of compartment elasticity, poor venous return, or increased muscle bulk may contribute to its cause. The diagnosis is suspected based on history and confirmed by physical examination and intramuscular pressure evaluation before and after exercise. Differential diagnosis includes intermittent claudication, popliteal artery entrapment, myositis, tendinitis, periostitis, fractures, other compression or systemic neuropathies, and cardiac abnormalities with angina or referred extremity pain. Initial treatment includes changes on the physical activities. Refractory symptoms or physical activity necessity can be managed with elective fasciectomy as a definite treatment. In this paper, it is presented a typical case of chronic compartment syndrome successfully treated with surgery. Based on this case diagnosis, pathophysiology and indications for surgery are discussed.

Key-words: anterior compartment syndrome, chronic disease, intermittent claudication, lower limbs.
Palavras-chave: síndrome do compartimento anterior, doença crônica, claudicação intermitente, membros inferiores.

J Vasc Br 2004;4(2):155-61

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Chronic compartment syndrome (CCS) is a rare condition, although its prevalence has been increasing. Its main symptom is pain in the lower and upper limbs, which is caused by the elevation of intracompartmental pressure after physical activity.^1,2 It is perceived as localized pain in the limb muscles during physical activity, which forces the patient to cease the exercise performance. In the lower limbs, it usually affects the anterior muscles, although it may also affect the posterior muscles of the legs,^3,4 similarly to popliteal artery entrapment. Athletes and soldiers are frequently affected by this condition.^3,5 A typical case of CCS successfully treated by surgery will be presented in this article. This case will serve as the basis for the discussion of differential diagnosis, physiopathology, and surgical indications.

CASE REPORT

The patient is a 42-year-old male Caucasian school teacher. At the first visit, he complained of burning pain in the anterior regions of the anterolateral fascias of both legs. He had first experienced the pain 16 years before, and it was initially triggered by a 90-minute soccer game. The pain had worsened through the years, and 1 year previous to that visit the patient started feeling the symptom after 15 minutes of game. His doctor indicated physical therapy and the patient gradually stopped practicing physical activities. However, he had recently started to feel pain while going up stairs and hills, and while driving for longer than 2 hours. He also mentioned that even when at rest the painful regions were warmer than the other parts of his body, and this sensation would get more intense after physical activity. The patient reported frequent episodes of cramps and nocturnal paresthesia for the previous 3 years. He was a non-smoker and did not have a history of alcohol abuse. The patient did not present diabetes mellitus, hypertension, dislipidemia, and previous severe diseases and had not undergone surgery. He also did not have a family history of similar conditions.

At physical examination, the patient weighed 73.8 kg, his stature was 1.59 m. The heart rate was 78 bpm, the same as the pulse rate, and the arterial pressure was 116 x 61 mmHg. Arterial pulses were palpable and normal, without murmur.

A large muscle mass was detected on the legs during limb examination, especially on the anterior regions (Figure 1). No temperature alteration was perceived.

Figure 1 - Right leg before the surgery; note the muscle swelling on the anterior region.

Doppler ultrasound showed bilateral ankle-brachial index of 1.0 and triphasic waves up to the popliteal arteries. The posterior tibial arteries presented biphasic waves at rest. Plantar flexion maneuvers made the blood flow velocity curves of posterior tibial arteries disappear on both sides.

Duplex scanning evidenced popliteal arteries with bilateral triphasic waves at rest. Plantar flexion maneuvers made the blood flow of popliteal arteries disappear on both sides, and the flexion maneuvers did not show any abnormalities.

Nuclear magnetic resonance (NMR) of the knees showed evidence of anterior and regular extrinsic compression of distal popliteal arteries on the belly of the popliteal muscle (Figure 2).

Figure 2 - The nuclear magnetic resonance of the knee shows the popliteal muscle compressing the popliteal artery (arrow).

The arteriographic examination showed slight lateral deviation of the popliteal arteries (Figure 3). Foot extension and flexion maneuvers with active contraction of the thighs evidenced compression of the popliteal arteries (Figure 4).

Figure 3 - The digital arteriography via femoral puncture shows the slight lateral deviation of the right popliteal artery.

Figure 4 - The digital arteriography shows popliteal compression after foot plantar flexion maneuvers with active contraction of the thigh.

Intracompartmental pressure of the anterior limbs was measured using Whitesides's technique.⁶ This technique consists of puncturing the compartment with the use of a scalp needle. The needle catheter must be partially filled with saline, forming a meniscus in the middle of the catheter. The syringe is connected to a 3-way stopcock. A syringe full of air is connected to one way, while the other way is connected to a manometer or pressure transducer. Pressure is measured when the meniscus of the saline grows towards the compartment after air is injected in the system. The mean value after three measurements at rest was 25.6 mmHg. After the patient practiced enough exercise to cause pain (jogging), the intracompartmental pressure was 42.3 mmHg (Figure 5).

Figure 5 - Schematic drawing of the measurement of intracompartmental pressure according to Whitesides.⁶

After the analysis of these data, the patient received the diagnosis of Chronic Compartmental Syndrome, and fasciotomy of the anterior portion of the lower limbs was recommended. This surgical indication was chosen based on the fact that the previous clinical treatments did not produce any positive effects, and also because the patient expressed his desire to resume his usual physical activities.

Access was allowed through W-plasty angled incisions on the anterior fascias of both legs (Figure 6). As fasciotomy did not result in complete release of muscles and the edges of the fascia could cause muscle irritations, fasciectomy was performed. Resection of 2 cm of the fascias in the anterior region of the leg was carried out, and subcutaneous tissue and skin were sutured with separated stitches.

Figure 6 - Access through W-plasty angled incisions on the anterior fascias.

The patient was discharged from hospital on the day after the surgery, and the skin stitches were removed 10 days later. At that moment, he reported complete relief of the warm sensation on the anterior fascias of the legs. He had not practiced any physical activity by that time. Thirty days after the surgery, he was allowed to practice physical activities, and did not report any kind of pain in his legs even after intense physical activity, such as jogging or playing soccer for longer than 30 minutes. Sixty days after the surgery, the patient was able to play soccer for 90 minutes without any problem.

DISCUSSION

In this case, the preliminary investigation focused on the popliteal artery entrapment syndrome (PAES), and the findings of the examinations, such as Doppler ultrasound, duplex scanning, NMR, and arteriography, suggested some kind of compression of the popliteal artery, especially of the functional type.^7,8 However, the patient's symptoms were not restricted to the posterior region of the legs, the usual region affected by this condition, but were present in the anterior region of the legs. In the review of the literature, another kind of alteration in the lower limbs with more similarities to the patient's symptoms was found: the Chronic Compartment Syndrome.⁹

The main symptom of this condition is pain in the limb compartments. The pain is not related to trauma; it is typically triggered by intense physical activity, and it resolves spontaneously some minutes after physical activity ceases. Occasionally, the pain may persist for several hours after the interruption of the activity.⁹ This kind of pain is rare, usually related to burning, cramps or discomfort, or either swelling or fullness sensation and muscle tension. The physical examination does not help much, and only some muscle tension in the affected compartment can be identified by palpation. Neurological symptoms, such as itching or paresthesia, are even more uncommon.^10,11

The most commonly affected compartments are anterior, deep and superficial posterior compartments of the leg.^10,11 Other compartments that may also be affected are flexor and extensor compartments of the forearm, interosseous compartments of the hand dorsum, quadriceps compartment of the thigh, and medial compartment of the foot.¹⁰ It is estimated that 14% of the cases occur in the anterior region.¹² Approximately 30% of the cases have positive findings for popliteal entrapment, while only about 10% of these cases have typical symptoms of this condition.¹¹ The differential diagnosis must be performed with intermittent claudication due to popliteal entrapment, arteriosclerosis or arteritis, myositis, tendinitis, periostitis, stress of tibial and fibular fractures, and tumors.^9,13

The diagnosis is based on the measurement of intracompartmental pressure.⁶ This measurement is taken under local anesthesia through the insertion of a needle or thin catheter connected to a pressure transducer in the affected compartment (Figure 5). The measurements should be taken at rest every minute during 5 minutes after the patient practiced enough physical activity to make him/her feel the symptoms. The critical levels of intracompartmental pressure vary according to each author (Table 1). In this case, the levels recommended by Turnipseed¹¹ were used. Based on a quite large number of cases, this author defined levels higher than 25 mmHg at rest as the diagnosis criterion.

Table 1 - Critical levels of intracompartmental pressure (mmHg) according to several authors

Author	Rest	1 min after activity	5 min after activity
Humphries10	12	30	20
Bourne & Rorabeck14	30-35	-	-
Fronek et al.15	10	-	> 25
Garcia-Mata et al.16	10	20	20

Tests performed with nuclear medicine,^17,18 SPET (single photon emission tomography),^19,20 and nuclear magnetic resonance (NMR)^21,22 were also suggested. However, because it is a simple procedure, the measurement of intracompartmental pressure still remains as the diagnosis criterion of choice for most authors. Other tests, such as simple X-ray, Doppler ultrasound, duplex scan, computerized tomography, and NMR are mainly used to rule out other diseases.⁹

The clinical treatment of CCS is based on the interruption of the physical activity responsible for triggering the symptoms. However, patients usually do not comply with this kind of treatment because they want to keep having the same life style and quality of life. Other clinical option are physical therapy, massage, postural drainage,¹⁰ etc., but there are not any studies that confirm the effectiveness of these treatments.⁹

The most effective treatment is the surgical decompression of the compartment through fasciotomy or fasciectomy,²³ although, there is not a consensus whether fasciotomy must be followed by fasciectomy. Most authors recommend only fasciotomy, leaving fasciectomy to those cases in which fasciotomy does not present positive results.

In our patient, fasciotomy did not result in complete release of the muscles. Therefore, we decided to perform fasciectomy associated to fasciotomy, since the edges of the fascia could cause muscle irritation. Turnipseed reported a success rate of 92% with the use of open fasciectomy in his 276 patients.¹¹ According to this author, fasciectomy has the advantage of causing less surgical complications and relapses. Fasciotomy can be performed through open surgery, with large or staggered incision, or through videoendoscopy. The fasciotomy performed through videoendoscopy offers the advantage of smaller scars and reduction of morbidity,^24,25 but is not frequently employed by the authors.

After the surgery, early ambulation can prevent adherences or excessive scar tissue.⁹ The patient can resume physical activities in a gradual and individual manner, reaching its normal intensity 4-6 weeks after the surgery. Surgical complications occur in 11 to 13% of the cases, and are usually hemorrhages, infection and pain relapse. Pain is usually related to failure of the surgical decompression or incorrect diagnosis.⁹ In this patient, there were not complications, and no relapse of symptoms was reported up the sixth month of follow-up.

Some time ago, the pain felt by patients with CCS was believed to be caused by the alteration of the vascular supply and by anoxia, as a consequence of the increase in the intracompartmental pressure. Intense physical activity may increase up to 20% of the muscle mass, and, therefore, it may cause a great increase in the content inside a non-extensible continent.²⁶ Recent studies performed with NMR did not confirm the alterations in the vascular supply in these cases.²⁷ Therefore, two theories were proposed to explain the painful alterations caused by the increase in the pressure inside the compartment: the first one suggests the stimulation of the sensitive nervous fibers, and the second one suggests the stimulation of pressure receptors, with or without metabolic alterations.¹⁰

In conclusion, CCS is a common condition among athletes or people who usually practice intense physical activities. It is important that the vascular surgeon has information about CCS, since its diagnosis may be mistaken for the diagnosis of popliteal artery entrapment. The correct diagnosis can be easily performed. Surgical treatment is usually successful and can provide the patients with better quality of life if correctly indicated.

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