Ultrasound-Guided Fasciotomy for Chronic Exertional Compartment Syndrome: A Cadaveric Investigation

Accepted Manuscript Ultrasound-Guided Fasciotomy for Chronic Exertional Compartment Syndrome: A Cadaveric Investigation Daniel R. Lueders, M.D., Jacob L. Sellon, M.D., Jay Smith, M.D., Jonathan T. Finnoff, D.O. PII:

S1934-1482(16)30928-5

DOI:

10.1016/j.pmrj.2016.09.002

Reference:

PMRJ 1780

To appear in:

PM&R

Received Date: 27 May 2016 Revised Date:

24 August 2016

Accepted Date: 3 September 2016

Please cite this article as: Lueders DR, Sellon JL, Smith J, Finnoff JT, Ultrasound-Guided Fasciotomy for Chronic Exertional Compartment Syndrome: A Cadaveric Investigation, PM&R (2016), doi: 10.1016/ j.pmrj.2016.09.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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ULTRASOUND-GUIDED FASCIOTOMY FOR CHRONIC EXERTIONAL COMPARTMENT SYNDROME:

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Daniel R. Lueders, M.D. 1

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A CADAVERIC INVESTIGATION

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Jacob L. Sellon, M.D. 2 Jay Smith, M.D. 3

1 Sports

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Jonathan T. Finnoff, D.O. 4

Medicine Fellow, Department of Physical Medicine & Rehabilitation, Mayo Clinic,

2 Assistant

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Mayo Clinic Sports Medicine Center, Rochester, MN Professor, Department of Physical Medicine & Rehabilitation, Mayo Clinic, Mayo

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Clinic Sports Medicine Center, Rochester, MN 3 Professor,

Department of Physical Medicine & Rehabilitation, Mayo Clinic, Mayo Clinic

Sports Medicine Center, Rochester, MN 4 Professor,

Department of Physical Medicine & Rehabilitation, Mayo Clinic, Mayo Clinic

Sports Medicine Center, Minneapolis, MN

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Running Head: Ultrasound-Guided Compartment Fasciotomy Ultrasonography Compartment Syndrome

Surgery

Fascia

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Key Words:

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ULTRASOUND-GUIDED FASCIOTOMY FOR CHRONIC EXERTIONAL

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COMPARTMENT SYNDROME:

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A CADAVERIC INVESTIGATION

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Running Head: Ultrasound-Guided Compartment Fasciotomy

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Key Words:

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Ultrasonography Compartment Syndrome

Surgery

Fascia

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ACCEPTED MANUSCRIPT ULTRASOUND-GUIDED COMPARTMENT FASCIOTOMY Abstract

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Background: Chronic exertional compartment syndrome (CECS) is a common cause of

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exertional leg pain. It is commonly treated with a surgical fasciotomy, which has a surgical

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complication rate of up to 16% and takes approximately 6-12 weeks to return to pre-

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procedure activity levels. Therefore, the development of a less invasive, effective outpatient

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intervention to treat CECS is desirable.

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Objective: To describe and validate an ultrasound-guided (USG) fasciotomy technique for

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the anterior and lateral compartments of the lower limb in an unembalmed cadaveric

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model.

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Design: Prospective, cadaveric laboratory investigation.

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Setting: Academic institution procedural skills laboratory.

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Subjects: Ten unembalmed cadaveric knee-ankle-foot specimens from one female (2

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specimens) and 7 male donors ages 62-91 years (mean 78.6 years) with body mass indices

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of 18.9-35.3 kg/m2 (mean 27.1 kg/m2 ).

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Methods: Two experienced operators each performed USG anterior and lateral

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compartment fasciotomies on 5 unembalmed cadaveric legs. A third physician subsequently

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dissected the legs to assess the continuity of the fasciotomies and identify any

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neurovascular damage related to the procedures.

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Main Outcome Measures: Fasciotomy length (cm) and classification by completeness

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(achieved target length or did not achieve target length) and continuity (continuous or

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discontinuous) based on pre-determined criteria. Muscles, retinaculae, and neurovascular

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structures were assessed for damage.

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ACCEPTED MANUSCRIPT ULTRASOUND-GUIDED COMPARTMENT FASCIOTOMY Results: No neurovascular injuries occurred in any of the 20 USG fasciotomies. The average

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fasciotomy length was 22.5 cm. One hundred percent (20/20) of fasciotomies achieved the

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target length. A continuous cephalocaudal fasciotomy was accomplished in 13 of 20

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fasciotomies. When a fasciotomy was not continuous, the average length and number of the

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intact fascial bands was 1.52 cm and 2.3, respectively.

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Conclusions: USG fasciotomy of the anterior and lateral leg compartments can be safely

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performed in a cadaveric model and can achieve of fasciotomy length comparable to

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surgical fasciotomy. Most procedures successfully achieved a continuous cephalocaudal

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fasciotomy, although small areas of intact fascial bands were identified in approximately

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one third of procedures. The clinical significance of this finding is indeterminate. Given the

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safety demonstrated with this minimally invasive USG fasciotomy in a cadaveric model,

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further research is warranted to develop and refine the technique for clinical application.

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ACCEPTED MANUSCRIPT ULTRASOUND-GUIDED COMPARTMENT FASCIOTOMY Introduction

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Chronic exertional compartment syndrome (CECS) is defined as an activity related elevation

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in the pressure of a limb compartment resulting in localized pain, usually involving the leg

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(95%).1,2 The anterior leg compartment is most commonly involved, followed by the deep

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posterior, lateral, and superficial posterior compartments.2-4 Treatment for CECS to date has

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consisted largely of open or endoscopic surgical fasciotomy or fasciectomy to release the

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affected compartment with 81-100% symptom relief reported using these techniques.5

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Procedural complications have been reported in up to 16% of fascial releases and return to

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unrestricted activity can take up to 6-12 weeks.2,5-9 Significant opportunity exists for the

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development of a less invasive yet equally effective and durable outpatient clinical

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intervention for CECS.

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An ultrasound assisted surgical fasciotomy utilizing long Metzenbaum scissors has been

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recently described and resulted in positive outcomes and no complications in a case series

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of 7 patients.12 Six of seven patients had complete symptom resolution and the mean return

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to sport time was 35 days. The procedure utilized two large skin incisions (20-30mm), blunt

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dissection down to the fascia to allow for scalpel incision of the fascia, and ultrasound to

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direct the Metzenbaum scissors along the fascia. However, the use of spinal anesthesia and

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requirement for relatively large skin incisions remain limitations to widespread

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implementation of this technique in an outpatient office setting.

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A recent case report described the successful treatment of a collegiate-level lacrosse player

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with CECS in the bilateral anterior and lateral leg compartments using an ultrasound-guided

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(USG), percutaneous needle fascial fenestration of the affected compartments.13 The

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intervention resulted in complete resolution of the athlete’s exertional leg pain and the

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athlete was able to return to full, unrestricted sports within one week of the procedure. The

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fenestration provided symptomatic relief in this case, it is reasonable to assume that the

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fascia was not completely transected during the procedure and that needle fascial

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fenestration in general is likely to be less effective than a surgical fasciotomy.

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Ultrasound affords the ability to visualize anatomy and pathology deep to the skin and to

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safely direct injections and minimally invasive procedures.10,11 We propose that an USG

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fasciotomy can be performed using available surgical instruments and two 3 mm skin

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incisions. In contradistinction, traditional surgical fasciotomies can require incisions of up

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to 16 cm.14,15 Small incision, minimally invasive USG fasciotomy would reduce the need for

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spinal or regional anesthesia, potentially reduce the risk of complications and accelerate

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recovery, and may enable the surgical release for CECS to be performed in an outpatient

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clinic setting.

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Consequently, the primary objective of the current study was to evaluate the safety and

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feasibility of an USG percutaneous fasciotomy of the anterior and lateral leg compartments

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in an unembalmed cadaveric model.

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General Design

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Methods

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Two operators (JTF and JLS, with 10 and 5 years of experience, respectively, performing

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USG procedures) each performed USG anterior and lateral leg compartment fasciotomies on

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five unembalmed cadaveric knee-ankle-foot specimens utilizing a commercially available V-

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shaped meniscotome (Figure 1). A third investigator, who was not involved in performing

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the procedures, subsequently dissected each leg. The cephalocaudad length and continuity

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of the fascial transection in each compartment were evaluated. Injuries to muscles, blood

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vessels, and nerves were assessed. All procedures were performed in our institution’s

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Procedural Skills Laboratory. Cadaveric specimens were obtained through the Department of Anatomy’s Foundation Bequest Program and all were visibly free of trauma or

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postsurgical changes affecting the lower limb. The Bio-Specimens Subcommittee of the

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Institutional Review Board at our institution approved this study.

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Equipment

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All procedures were performed using either a Philips Epiq ultrasound machine with a 12-5

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MHz linear array transducer (Philips Medical Systems, Bothell, WA) or a Samsung RS-80

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ultrasound machine with a 16-3 MHz linear array transducer (Samsung Medison Co., Ltd.

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Seoul, South Korea). Each fasciotomy was performed using a single-use disposable 3mm

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straight V-meniscotome (Smith and Nephew, Inc., Andover, MA).

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Fasciotomy Procedure

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Leg specimens were placed in a side-lying position with the medial leg facing downward on

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the table and lateral leg facing upward. The anterior and lateral leg compartments were

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sonographically evaluated and their borders were identified and marked on the skin surface

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using an indelible marker as subsequently described and illustrated in Figure 2. The

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cephalad border of the anterior compartment fasciotomy was marked 3 cm distal to the

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tibial tubercle in an axial plane and the caudad border marked 10 cm proximal to the

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inferior tip of the lateral malleolus in an axial plane. A line indicating the planned course of

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the meniscotome during the anterior compartment fasciotomy was drawn on the skin 3 cm

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lateral to the tibial crest between those two axial planes. The cephalad border of the lateral

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compartment fasciotomy was marked 3 cm distal and 1 cm posterior to the fibular head in

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an axial plane and the caudad border marked 10 cm proximal and 1 cm posterior to the

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the meniscotome during the lateral compartment fasciotomy was marked on the skin over

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the lateral compartment connecting those two points. The locations of the superior

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peroneal retinaculum, superior extensor retinaculum, saphenous nerve, and the common,

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superficial and deep peroneal nerves were identified using ultrasound and their locations

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were marked on the skin in the same manner. Care was taken when drawing the lines of the

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planned fasciotomy to avoid the identified neurovascular structures and retinaculae. Small

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adjustments in the measurements and approaches for fasciotomies were implemented as

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needed during the procedure to avoid neurovascular injury and to ensure continuous

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fasciotomy.

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The cephalad to caudad lengths of the planned anterior and lateral compartment

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fasciotomies described above were measured and those lengths were divided into two

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equal segments. In each compartment, the proximal segment was designated as Segment

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One and the distal segment as Segment Two. The junctions of these segments were marked

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on the skin using an indelible marker.

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To access the anterior compartment, a 3 mm skin incision was made at the superior margin

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of anterior compartment Segment One (Figure 3A). The meniscotome was advanced under

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USG through the proximal skin incision of the anterior compartment and guided to the

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fascia layer (Figure 4 A and B). The deep portion of the meniscotome’s V-shaped blade was

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advanced through the fascia while the superficial portion of the meniscotome’s V-shaped

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blade was maintained above the fascia (Figure 5A). Utilizing both in-plane (Figure 5B) and

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out-of-plane views (Figure 5C), the meniscotome was advanced under direct USG to a point

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approximately 1 cm beyond the skin marking of the junction of Segments One and Two

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(Video 1). The meniscotome was then retracted and removed through the proximal skin

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ACCEPTED MANUSCRIPT ULTRASOUND-GUIDED COMPARTMENT FASCIOTOMY incision. A second 3 mm skin incision was then made at the skin marking of the junction of

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Segments One and Two. The meniscotome was introduced through that second skin

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incision and advanced caudally under USG to the end of the Segment One fasciotomy. The

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meniscotome blade was positioned on either side of the fascia as described above and

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advanced in a cephalad to caudad direction under USG until Segment Two was completely

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transected to the caudad skin marking. Care was taken to connect the fasciotomies of

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Segment One and Segment Two of the anterior leg compartment fascia to create a single

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fasciotomy the entire length of the anterior compartment. The same procedure was

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followed to perform a lateral leg compartment fasciotomy.

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Following the USG compartment fasciotomies, an investigator who was not involved in the

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fasciotomy procedures immediately dissected the specimens to expose and to evaluate the

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anterior and lateral compartment fasciotomies and adjacent soft tissue structures (Figure

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6).

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Outcome Measures

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Within each compartment, the examiner measured fasciotomy length (cm), classified length

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as achieving the target fasciotomy length (ie, fasciotomy extended from the cephalad skin

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mark to the caudad skin mark) or not achieving target fasciotomy length (ie, fasciotomy did

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not extend from the cephalad skin mark to the caudad skin mark), classified the fasciotomy

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as continuous (ie, no areas of intact fascia along the course of the fasciotomy) or

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discontinuous (ie, one or more intact areas of fascia along the course of the fasciotomy), and

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determined the presence or absence of injury to the muscles, retinacula or neurovascular

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structures. In the setting of a discontinuous fasciotomy, the quantity and lengths of intact

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fascial segments were recorded.

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Statistical Analysis

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ACCEPTED MANUSCRIPT ULTRASOUND-GUIDED COMPARTMENT FASCIOTOMY Descriptive statistics were utilized to report the results for the combined and individual

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operator fasciotomy length and continuity success rates and to report neurovascular

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injuries. Ninety-five percent confidence intervals (CI) were calculated when possible. The

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small sample size did not provide adequate power to effectively compare the success rates

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of the two operators.

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174 Results

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In total, 10 anterior and 10 lateral leg compartment fasciotomies were performed in 10

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lower limbs obtained from a total of 8 donors (7 male [8 limbs] and 1 female [2 limbs]) ages

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62-91 years (mean 78.6 years) with BMIs of 18.9-35.3 kg/m2 (mean 27.1 kg/m2).

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No neurovascular injury occurred in any compartment (0/20 compartments). Minimal

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superficial excoriation occurred to the muscle directly adjacent to the fasciotomy in each

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compartment.

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All fasciotomies achieved the target length (20/20) within each respective specimen and

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compartment, with an average overall fasciotomy length of 22.5 cm (range 16.5-31 cm). The

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average fasciotomy length for Operator 1 was 23.6 cm and for Operator 2 was 20.8 cm, both

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still representing 100% success in achieving the target fasciotomy lengths. Fasciotomy

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length varied directly as a function of specimen limb length as would be anticipated given

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anthropomorphic variability in a randomly procured specimen cohort. This variability had

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no impact on the success in achieving a fasciotomy of the entire craniocaudal length of the

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skin markings as 100% of the fasciotomies achieved their target length.

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Thirteen of 20 procedures achieved a continuous fasciotomy (95% CI 9-17) (Table 1). The

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more experienced operator (Operator 1) achieved continuous fasciotomies in 8 of 10

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fasciotomies in 5 of 10 compartments (95% CI 2-8) (Table 2).

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When a fasciotomy was not continuous the average length of an intact fascial band was 1.52

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cm (range 0.3-3.7 cm) (Table 3). In the compartments with discontinuous fasciotomies, the

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longest area of intact fascia in a given compartment was less than or equal to 0.5 cm in

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length in 14% of compartments (1/7), between 0.5 cm and 1 cm in 29% of compartments

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(2/7), and greater than 1 cm in 57% of compartments (4/7). In those same compartments

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with discontinuous fasciotomies, 43% (3/7) had one area of intact fascia, 14% (1/7) had

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two areas of intact fascia, 29% (2/7) had three areas of intact fascia, and 14% (1/7) had 5

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areas of intact fascia.

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For Operator 1, 100% of fasciotomies achieved the target length (10/10) and 80% were

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continuous (8/10, CI 6-10). In the compartments with discontinuous fasciotomies, the

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length of intact fascia was less than or equal to 0.5 cm in length in one specimen and

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between 0.5 cm and 1 cm in one specimen. No compartment had more than one area of

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intact fascia.

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For Operator 2, 100% of fasciotomies achieved the target length (10/10) and 50% were

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continuous (5/10, CI 2-8). In the compartments with discontinuous fasciotomies, the

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longest area of intact fascia in a given compartment was between 0.5 cm and 1 cm in 20% of

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compartments (1/5) and greater than 1 cm in 80% of compartments (4/5). In the

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compartments with discontinuous fasciotomies, 20% (1/5) had one area of intact fascia,

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20% (1/5) had two areas of intact fascia, and 60% (3/5) had three or more areas of intact

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fascia.

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ACCEPTED MANUSCRIPT ULTRASOUND-GUIDED COMPARTMENT FASCIOTOMY Discussion

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To the best of our knowledge, this is the first study to investigate USG fasciotomy of the

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anterior and lateral leg compartments using a meniscotome in an unembalmed cadaveric

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model. Our findings indicate that this procedure achieves a fasciotomy of the target length

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in all cases and a continuous fasciotomy in 65% of cases. Importantly, no neurovascular

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injuries occurred. These findings suggest that USG fasciotomy of the anterior and lateral leg

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compartments can be safely performed in a cadaveric model and can achieve of fasciotomy

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length comparable to surgical fasciotomy. Due to the small size of the incision, this

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procedure can likely be performed in an outpatient clinic setting utilizing only local

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anesthesia, as has been the case with US guided fascial fenestration to treat CECS.13

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However, further investigation is required prior to recommending its clinical use.

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All of the fasciotomies achieved the target length based upon complete extension of the

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fasciotomy from the cephalad to caudad skin markings used in this study. The average

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cephalocaudad fasciotomy length was 22.5 cm (range 16.5 – 31 cm) which is consistent

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with what has been described for open surgical fasciotomy lengths.14,15 As previously stated,

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the length variability was due to the differences in leg lengths among the specimens. The

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findings of this study suggest that the described procedure can reliably transect an

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adequate length of fascia to release the compartment and, as such, the procedure could have

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clinical applicability in a patient with CECS.

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Notably, approximately one-third of the fasciotomies had one or more intact fascial bands

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and those intact bands averaged 1.52 cm in length. It is currently unknown whether the

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presence of these intact fascial bands would represent a risk for incomplete symptom

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resolution or symptom recurrence in patients with CECS. It is also not known whether an

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intact fascial band could “auto-lyse” with time and activity or if it might serve as a nidus for

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ACCEPTED MANUSCRIPT ULTRASOUND-GUIDED COMPARTMENT FASCIOTOMY fascial healing. If a primary goal of fasciotomy is to relieve intracompartmental pressure

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and to alleviate symptoms, it is possible that a continuous craniocaudal release of the fascia

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is not absolutely required to still achieve an excellent clinical outcome. This hypothesis is

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supported by the positive clinical results of needle fenestration of the transverse carpal

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ligament for carpal tunnel syndrome and the positive clinical results of needle fascial

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fenestration to treat CECS in an active athlete.13,16 Furthermore, it is possible and perhaps

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probable that any small remaining fascial bands may stretch out over time.

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Although the number of procedures performed by the two operators was inadequate to

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allow a statistical comparison, differences were observed between the two investigators

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that warrant mention and discussion. Operator 1 had fewer discontinuous fasciotomies

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than Operator 2 overall and, in the specimens with discontinuous fasciotomies, the number

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of intact fascial segments was fewer for Operator 1 than for Operator 2. This is important

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for multiple reasons. First, Operator 1 had performed USG procedures for longer than

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Operator 2, suggesting that experience may influence the success of this procedure. Second,

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Operator 1 has performed multiple USG percutaneous needle fascial fenestrations for the

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treatment of CECS in athletes whereas Operator 2 had no prior experience with that

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procedure. Although needle fenestration is different from the currently described

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procedure it similarly requires that the operator be able to position an instrument (ie,

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needle) into the fascia. Opportunity to practice the procedural technique might have

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enhanced the ability of Operator 2 to successfully perform the study procedure. Third,

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Operator 1 had performed the USG fasciotomy procedure described in this study once prior

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to execution of the current study, whereas Operator 2 had never before performed the

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procedure. The sum of these factors suggests that experience performing USG procedures

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and practice performing fasciotomies may improve the ability to successfully perform the

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procedure. Positive correlation between operator ultrasound experience and USG

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ACCEPTED MANUSCRIPT ULTRASOUND-GUIDED COMPARTMENT FASCIOTOMY procedure success has been demonstrated previously and further study is required to

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determine if this holds true for USG compartment fasciotomy as well.17

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A recent case series introduced a novel modified surgical technique utilizing curved

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Metzenbaum scissors to perform an USG anterior compartment fasciotomy.12 Complete

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symptom resolution was achieved in six of seven subjects and resulted in 100% return to

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pre-symptomatic levels of exercise and sport at a median of 35 days post-procedure (range

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30-45 days). Such a timeline is consistent with published surgical fasciotomy outcomes and

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is notably longer than the time to return to play described in the aforementioned needle

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fascial fenestration case report.6,13,14 The modified surgical technique was also performed in

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an operating room and required epidural anesthesia, two large skin incisions (20-30mm),

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blunt dissection down to the fascia to allow for scalpel incision of the fascia, and suture

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closure of the skin after the procedure. Thus, the procedure might be best described as an

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ultrasound-assisted surgery rather than a percutaneous USG procedure. Although the

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procedure described herein appears to be less invasive and could be performed in an

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outpatient setting with local anesthesia, a direct comparison of efficacy, complications,

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return to sport time, and cost-effectiveness between the two procedures cannot be

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performed with this cadaveric-based study. Future research is required to directly compare

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these two interventions.

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Intramuscular botulinum toxin A injections and running gait retraining are two non-

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operative CECS treatment options that warrant discussion and should be considered prior

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to performing any type of interventional procedure. 18-20 Two case series publications have

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reported that intramuscular botulinum toxin A injections resulted in anterior/lateral CECS

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symptomatic relief, although those studies are limited by short-term follow up.18,19 The

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longest reported duration of relief with botulinum toxin to date is 14 months in a case

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botulinum toxin’s benefit in CECS, this may not be a definitive treatment. Botulinum toxin

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injections for CECS are relatively expensive and typically not reimbursed by 3rd party payers

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in the United States which must be considered in treatment planning. Running gait

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retraining involves transitioning initial contact from a heel strike pattern to a mid or

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forefoot strike pattern.20 This can be effective for anterior CECS by decreasing the eccentric

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muscular contraction in the anterior compartment and reducing the metabolic demand of

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the relevant musculature, thereby reducing the intra-compartment pressure. Prior

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research showed that approximately 6 weeks of expert analysis and directed intervention

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were required to change an athlete’s gait pattern. Such a timeline and training-intensive

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process may not be feasible or realistic for some athletes. Furthermore, deceleration and

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certain direction change maneuvers require initial heel contact which could limit the

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potential benefit of this intervention in multi-directional athletes. An USG percutaneous

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procedure may provide a more simple, expedient, and definitive option for select

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individuals.

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The procedure described in this study is intriguing for a number of reasons. If proven by

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future studies to be clinically safe and effective, it provides an office-based minimally

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invasive alternative for the treatment of CECS. This could potentially lead to substantial

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cost savings to the healthcare system relative to surgical procedures performed in a

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hospital or surgical center setting. Furthermore, since only two 3 mm incisions are

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required for this procedure, it may lead to a relatively rapid recovery and allow athletes to

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resume sports earlier than following standard surgical fasciotomies or fasciectomies. The

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ability to visualize and to avoid the relevant local neurovascular structures with this USG

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procedure may also decrease the incidence of complications of this procedure relative to a

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standard surgical procedure that requires a larger incision and more tissue disruption.

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However, before conclusively supporting such possibilities, further study in the clinical

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setting is required.

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Limitations of this study relate to its exploratory nature in a relatively small number of

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cadaveric specimens. This precludes the ability to statistically compare the operators to

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each other and to estimate a true success rate of the procedure to accomplish a continuous

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fasciotomy. No procedures were performed on live subjects so no comments or conclusions

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can be made about an ability to relieve clinical symptoms related to CECS with this

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procedure. Thirty-five percent of the attempted procedures resulted in discontinuous

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fasciotomies and the clinical result and significance of a discontinuous fasciotomy is not

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known.

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Conclusion

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The USG percutaneous anterior and lateral leg compartment fasciotomy technique

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described herein in a cadaveric model can be safely performed without neurovascular

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injury. Each fasciotomy performed achieved the target length and a majority of the

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procedures achieved a continuous fasciotomy. Small areas of intact fascial bands were

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present in approximately one third of the procedures and the clinical significance of those

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intact bands is not known. The safety demonstrated in this procedure technique is

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encouraging and, with additional research to refine the procedure and to further improve

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fasciotomy continuity, this procedure could have significant clinical utility.

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References

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1. Barnes M. Diagnosis and management of chronic compartment syndromes: a review of the literature. Br J Sports Med 1997;31:21-7.

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2. Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. Am J Sports Med 1985;13:162-70.

3. Martens MA, Backaert M, Vermaut G, Mulier JC. Chronic leg pain in athletes due to a recurrent compartment syndrome. Am J Sports Med 1984;12:148-51.

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4. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 1990;18:35-40.

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5. Packer JD, Day MS, Nguyen JT, Hobart SJ, Hannafin JA, Metzl JD. Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome. Am J Sports Med 2013;41:430-6. 6. Knight JR, Daniels M, Robertson W. Endoscopic compartment release for chronic exertional compartment syndrome. Arthrosc Tech 2013;2:e187-90. 7. Slimmon D, Bennell K, Brukner P, Crossley K, Bell SN. Long-term outcome of fasciotomy with partial fasciectomy for chronic exertional compartment syndrome of the lower leg. Am J Sports Med 2002;30:581-8.

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8. Wittstein J, Moorman CT, 3rd, Levin LS. Endoscopic compartment release for chronic exertional compartment syndrome. J Surg Orthop Adv 2008;17:119-21.

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9. Waterman BR, Laughlin M, Kilcoyne K, Cameron KL, Owens BD. Surgical treatment of chronic exertional compartment syndrome of the leg: failure rates and postoperative disability in an active patient population. J Bone Joint Surg Am 2013;95:592-6. 10. Smith J, Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound: part 1. Fundamentals. Pm R 2009;1:64-75.

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11. Smith J, Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound: part 2. Clinical applications. Pm R 2009;1:162-77. 12. Balius R, Bong DA, Ardevol J, Pedret C, Codina D, Dalmau A. Ultrasound-Guided Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg. J Ultrasound Med 2016. 13. Finnoff JT, Rajasekaran S. Ultrasound-Guided, Percutaneous Needle Fascial Fenestration for the Treatment of Chronic Exertional Compartment Syndrome: A Case Report. PM & R : the journal of injury, function, and rehabilitation 2016;8:286-90. 14. Rorabeck CH, Fowler PJ, Nott L. The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med 1988;16:224-7.

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17. Curtiss HM, Finnoff JT, Peck E, Hollman J, Muir J, Smith J. Accuracy of ultrasoundguided and palpation-guided knee injections by an experienced and less-experienced injector using a superolateral approach: a cadaveric study. Pm R 2011;3:507-15.

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18. Isner-Horobeti ME, Dufour SP, Blaes C, Lecocq J. Intramuscular pressure before and after botulinum toxin in chronic exertional compartment syndrome of the leg: a preliminary study. Am J Sports Med 2013;41:2558-66.

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19. Lecocq J. Treatment of exertional compartment syndrome leg with botulinum toxin A: a first open pilot study. J Rehabil Med 2008:111-2. 20. Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am J Sports Med 2012;40:1060-7. 21. Baria MR, Sellon JL. Botulinum Toxin for Chronic Exertional Compartment Syndrome: A Case Report With 14 Month Follow-Up. Clin J Sport Med 2016.

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16. McShane JM, Slaff S, Gold JE, Nazarian LN. Sonographically guided percutaneous needle release of the carpal tunnel for treatment of carpal tunnel syndrome: preliminary report. J Ultrasound Med 2012;31:1341-9.

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15. Mouhsine E, Garofalo R, Moretti B, Gremion G, Akiki A. Two minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg. Knee Surg Sports Traumatol Arthrosc 2006;14:193-7.

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Overall Cephalocaudad Length Anterior Compartment Lateral Compartment Segment 1 to Segment 2 Segment 1 Segment 2

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Table 1.

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95% Confidence Interval 44-86% 42-98% 30-90% 56-94% 62-98% 44-86%

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Overall Fasciotomy Results Fasciotomy Continuity Percentage

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ACCEPTED MANUSCRIPT ULTRASOUND-GUIDED COMPARTMENT FASCIOTOMY Individual Operator Fasciotomy Results Operator 1 Operator 2 Percentage 95% Percentage 95% Confidence Confidence Interval Interval Overall Cephalocaudad Length 80% 55-100% 50% 19-81% Anterior Compartment 60% 17-100% 80% 45-100% Lateral Compartment 100% 20% 0-55% Segment 1 to Segment 2 80% 55-100% 70% 42-98% Segment 1 100% 60% 30-90% Segment 2 80% 55-100% 50% 19-81% 416 417 418 Table 2. 419 420

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Fasciotomy Continuity

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3 4 6 8 8 9 10

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Intact Fascia in Discontinuous Fasciotomies Compartment Number of Intact Lengths of Intact Fascial Bands Fascial Bands (mm) Anterior 1 4.5 Lateral 3 8, 10, 35 Lateral 3 16, 18, 20 Anterior 1 37 Lateral 5 4, 8, 8, 24, 30 Anterior 1 9 Lateral 2 9, 3

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Figure 1. V-shaped meniscotome instrument. Instrument tip is enlarged in inset image.

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Figure 2. Skin markings over the anterolateral leg illustrating bony landmarks, measurements, and neural structures relevant to anterior and lateral leg compartment releases. Care was taken to first identify and to avoid the common peroneal nerve (chevrons) and superficial peroneal nerve (SPN). The cephalad margin of the anterior compartment fasciotomy (asterisks) was measured 3 cm distal to the tibial tubercle (TT) and the caudad margin (black diamonds) 10 cm proximal to the inferior tip of the lateral malleolus (LM). The anterior fasciotomy course was then drawn as a dotted line 3 cm lateral from the tibial crest (open triangles). The cephalad margin of the lateral compartment fasciotomy was marked on the skin (black circles) 3 cm distal to the fibular head (FH) and the caudad extent as a line (black diamonds) 10 cm proximal to the inferior tip of the lateral malleolus (LM). The lateral fasciotomy course was then drawn as a dotted line (black triangles) 1 cm posterior to a line connecting the fibular head (FH) and lateral malleolus (LM).

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Figure 3. (A) Insertion of meniscotome under ultrasound guidance through a skin incision and into the lateral compartment fascia. (B) Utilization of ultrasound guidance to advance the meniscotome deep to the skin and through the fascia in a cephalad to caudad direction.

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Figure 4. (A) Anatomic axial ultrasound image demonstrating intact fascia (asterisks) overlying the lateral leg compartment musculature. Left = anterior. Right = posterior. Top = superficial. Bottom = deep. (B) Anatomic axial ultrasound image demonstrating intact (asterisks) and transected (diamond) fascia overlying the lateral leg compartment. Left = anterior. Right = posterior. Top = superficial. Bottom = deep.

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ACCEPTED MANUSCRIPT ULTRASOUND-GUIDED COMPARTMENT FASCIOTOMY Figure 5. (A) Gross anatomical depiction of fasciotomy with skin dissected and retracted. (B) Anatomic sagittal ultrasound image over the lateral leg compartment with the meniscotome (white diamonds) in long-axis relative to the transducer. The superficial end of the V-shaped meniscotome blade can be seen superficial to the fascia (black asterisks). Left = cephalad. Right = caudad. Top = superficial. Bottom = deep. (C) Anatomic axial ultrasound image over the lateral leg compartment with the transducer in short-axis relative to the meniscotome (black diamond). The superficial aspect of the V-shaped meniscotome blade can be seen superficial to the fascia (asterisks). Left = anterior. Right side = posterior. Top = superficial. Bottom = deep.

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Figure 6. Post-procedural dissection of the cadaveric specimen demonstrating completely transected fascia overlying the anterior and lateral leg compartments. Left = medial. Right = lateral. Bottom = caudad. Top = cephalad.

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