Waterman et al. provide Level-IV evidence that outcomes of surgical treatment of chronic exertional compartment syndrome may be limited in the military population. This study revealed that members of the U.S. military treated surgically for chronic exertional compartment syndrome of the lower extremity had a 45% rate of symptom recurrence, a 28% chance of not being able to return to full activity, a 6% rate of revision surgery, and a 16% complication rate. Seventeen percent of the subjects in this cohort required a medical discharge from the military secondary to persistent symptoms of chronic exertional compartment syndrome. The information provided by this article allows military physicians to appropriately counsel their patients regarding appropriate expectations following surgical treatment of chronic exertional compartment syndrome.
The strengths of this study include a large sample size and a homogeneous study cohort including only military subjects. However, this study was limited by a methodology that depended on retrospective review of a military database that included thirty-two military centers. This database did not allow for detailed evaluation of inclusion and exclusion criterion, diagnostic approaches, surgical techniques, rehabilitation protocols, or follow-up. In addition, it did not include patient-determined outcome scores. These limitations must be considered when drawing conclusions from this article.
The results of surgical treatment of chronic exertional compartment syndrome in this study were inferior to those in previous studies examining an athletic civilian population1,2. Nevertheless, there were similarities between the results of this study and those reported by Almdahl and Samdal, who also examined only military subjects3. After reviewing the results of the current study, one must ask the question: are they unique to the military or can they also be extrapolated to the civilian athletic population? If surgical treatment of chronic exertional compartment syndrome is actually less effective in the military population compared with the civilian population, the reasons remain unknown. One can hypothesize that (1) military personnel endure physical demands even greater than those experienced by civilian athletes, (2) military personnel have less ability to decrease their activity levels to accommodate postoperative persistence of symptoms compared with the civilian population, (3) there are unique psychological stressors in the military, and/or (4) there are potential secondary-gain issues that may be correlated with job dissatisfaction similar to those found in the Workers’ Compensation population. All of these factors may have contributed to the suboptimal outcomes found in this study. However, at this point, these theories are all a matter of conjecture.
As part of the data analysis, the authors attempted to identify risk factors for surgical failure. However, instead they actually reported the characteristics of failure (i.e., persistence of preoperative pain, surgical complications, and postoperative activity limitations). Unfortunately, they did not find any modifiable preoperative risk factors for surgical failure that could be addressed to reduce the risk of failure in future treatment.
This study also raises the question of whether the failures are technical or, instead, the nature of this disorder in this population does not reliably respond to current surgical treatments. Another concern is: are more patients in the military population, as compared with civilians, being misdiagnosed with chronic exertional compartment syndrome and, as a result, not responding to its surgical treatment?
At this time, it is not well known if one, multiple, or all four compartments should be released when a patient is diagnosed with chronic exertional compartment syndrome. Waterman et al. evaluated four-compartment fasciotomy in a univariate analysis to determine if releasing all four compartments was either protective or detrimental in terms of rates of surgical failure. Although the reported odds ratio of 0.66 could represent a decreased risk of surgical failure, this odds ratio failed to reach significance. It is quite possible that patients have persistent postsurgical pain in unreleased compartments with elevated compartment pressures that were not initially diagnosed. Additionally, since only 14% of the patients in this study experienced complete resolution of symptoms after revision surgery, and only one revision was performed to release a compartment that had not been addressed at the initial surgery, one might consider releasing all four compartments in a revision setting.
There is value in following this pilot study with a military-focused, multicenter, prospective study with standardized diagnostics, surgical techniques, and rehabilitation protocols. A large enough sample would be required to power the study to determine if four-compartment release is optimal compared with focused compartment release. Determinations of patient-derived outcome scores, duration until the return to full duty, and survival curves will improve on the methodological limitations of this pilot study.