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Results After Surgery for Leg Compartment Syndrome in Military Personnel
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Posted on: 11/30/1999
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Patients with compartment syndrome of the lower leg face the possibility of symptoms coming back after treatment, complications from surgery, and the need for a second operation. In the case of young military personnel, medical discharge due to an inability to return to full duty may be the final outcome.
In this study, surgeons from the United States Army report on the long-term results of 611 (mostly male) soldiers who had surgery for chronic exertional compartment syndrome of the lower leg. Although the study included only military personnel, nonmilitary (civilian) competitive athletes and runners often develop this condition, too. Rates of return to activity and rates of disability are therefore of interest to a broad range of surgeons and patients.
Compartment syndrome describes a condition in which fluid (swelling or blood) builds up inside one or more of the individual compartments of the leg. The "compartments" are easier to understand if you think of each group of muscles and tendons as being surrounded by a protective sheath or lining of connective tissue called fascia. There are individual compartments on the front, sides, and back of the lower leg.
In each compartment, the fascia fits closely to the outer layer of the soft tissue it surrounds -- like a sleeve or envelope. The structures are lubricated with a glistening fluid that allows everything to slide and glide against each other. There isn't a lot of give or room for increased volume of fluid from swelling.
When an injury occurs that leads to swelling, the increased pressure inside the sleeve or envelope cuts off blood supply to the muscles. The muscle cells start to necrose or die. Left untreated, this necrosis can progress to the point of gangrene. Years ago, this problem was labeled "march gangrene" when it occurred in soldiers.
Other soft tissue structures inside the compartment such as nerves can get pinched or compressed. The effect is like a crush injury with damage to the nerves. All of these effects can be irreversible (permanent). Compartment syndrome of the leg occurs in soldiers due to overexertion from exercise. One or both legs can be affected.
Soldiers have daily, intense, high-demand physical requirements. Marching and running with heavy packs while wearing stiff boots along with routine weight training and aerobic exercise adds to the physical stress placed on the lower legs.
Treatment can be successful with a conservative approach including rest, activity modification, and antiinflammatory medications. But more often, surgery (fasciotomy) to cut the surrounding fascia and release the constrictive soft tissues is required. Even with surgical decompression, complete recovery doesn't always happen.
As this study showed, almost half (44.7 per cent) of the patients had a recurrence of their painful symptoms after surgery. More than one-quarter (27.7 per cent) could not resume their previous level of activity. And a smaller group (5.9 per cent) had to have a second surgery because the first fasciotomy was not successful. Not all revision surgeries are successful either. In this study, only 14 per cent reported complete pain relief after the second operation.
In the military population, complications after surgery were the most likely reason for medical discharge. Infection, nerve pain, poor wound healing, blood clots, and complex regional pain syndrome were reported in 15.7 per cent of the soldiers.
In summary, this large study of the long-term results following surgical fasciotomy for chronic exertional compartment syndrome of the lower leg showed a poor outcome for many of the patients. Young, physically active patients expecting to return to full activity (and in the case of military personnel: return to full active duty) may be disappointed. One in five will have a failed surgery and ongoing pain and symptoms.
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References:
CPT Brian R. Waterman, MD, et al. Surgical Treatment of Chronic Exertional Compartment Syndrome of the Leg. In The Journal of Bone and Joint Surgery. April 3, 2013. Vol. 95A. No 7. Pp. 592-596.
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