| 1. |
- Dahl, Morten, et al.
(författare)
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Stiffness and thickness of Fascia do not explain chronic exertional compartment syndrome
- 2011
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Ingår i: Clinical Orthopaedics and Related Research. - : Ovid Technologies (Wolters Kluwer Health). - 0009-921X .- 1528-1132. ; 469:12, s. 3495-3500
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Tidskriftsartikel (refereegranskat)abstract
- Background Chronic exertional compartment syndrome is diagnosed based on symptoms and elevated intramuscular pressure and often is treated with fasciotomy. However, what contributes to the increased intramuscular pressure remains unknown. Questions/purposes We investigated whether the stiffness or thickness of the muscle fascia could help explain the raised intramuscular pressure and thus the associated chronic compartment syndrome symptoms. Patients and Methods We performed plain radiography, bone scan, and intramuscular pressure measurement to diagnose chronic compartment syndrome and to exclude other disorders. Anterior tibialis muscle fascial biopsy specimens from six healthy individuals, 11 patients with chronic compartment syndrome, and 10 patients with diabetes mellitus and chronic compartment syndrome were obtained. Weight-normalized fascial stiffness was assessed mechanically in a microtensile machine, and fascial thickness was analyzed microscopically. Results Mean fascial stiffness did not differ between healthy individuals (0.120 N/mg/mm; SD, 0.77 N/mg/mm), patients with chronic compartment syndrome (0.070 N/mg/mm; SD, 0.052 N/mg/mm), and patients with chronic compartment syndrome and diabetes (0.097 N/mg/mm; SD, 0.073 N/mg/mm). Similarly, no differences in fascial thickness were present. There was a negative correlation between fascial stiffness and intramuscular pressure in the patients with chronic compartment syndrome and diabetes. Conclusions The lack of difference in fascial thickness and stiffness in patients with chronic compartment syndrome and patients with chronic compartment syndrome and diabetes compared with healthy individuals suggests structural and mechanical properties are unlikely to explain chronic compartment syndrome. To prevent chronic exertional compartment syndrome, it is necessary to address aspects other than the muscle fascia.
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| 2. |
- Edmundsson, David, 1956-
(författare)
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Chronic compartment syndrome also affects nonathletic subjects : a prospective study of 63 cases with exercise-induced lower leg pain
- 2007
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Ingår i: Acta Orthopaedica. - : Medical Journals Sweden AB. - 1745-3674 .- 1745-3682. ; 78:1, s. 136-142
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Tidskriftsartikel (refereegranskat)abstract
- Background Chronic exertional compartment syndrome is most often reported in young and physically active people. Patients and methods We studied 73 consecutive patients (mean age 39 (16–77) years, 45 women) with a history of exercise-induced pain and suspicion of chronic exertional compartment syndrome (CECS) of the lower leg—clinically, radiographically and with intramuscular pressure measurements. Results Intramuscular pressure increased with reproduction of symptoms and fulfilled the criteria for diagnosis of CECS in 36 patients (mean age 36 (16–65) years, 22 women), with engagement of 66 anterior, 2 lateral and 7 posterior muscle compartments in 72 legs. The patients with CECS of the lower leg were divided into 4 etiological groups: 18 with overuse, 10 with earlier trauma, 4 insulin-treated diabetics, and 4 others. Two-thirds of the patients had pain during walking. The outcome after fasciotomy was excellent or good in 41/57 of the legs. Interpretation CECS of the lower leg probably has a multifactorial etiology and is more common in sedentary individuals than has been recognized previously. Fasciotomy appears to be beneficial in these cases also.
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| 3. |
- Edmundsson, David, et al.
(författare)
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Chronic exertional compartment syndrome in diabetes mellitus
- 2011
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Ingår i: Diabetic Medicine. - : Wiley. - 0742-3071 .- 1464-5491. ; 28:1, s. 81-85
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Tidskriftsartikel (refereegranskat)abstract
- Aims Intermittent claudication is common in diabetes mellitus. However, a proportion of patients with diabetes have symptoms of claudication without signs of vascular disease and these patients were evaluated for chronic exertional compartment syndrome. Methods Forty-two patients with diabetes (10 men, 32 women), earlier investigated at diabetic clinics because of claudication with no explanation for the symptoms, were examined. Their median age was 48 years (18–72 years) and the median duration of diabetes was 29 years (1–45 years). Thirty-one patients had Type 1 diabetes, 11 had Type 2 diabetes and 29 had diabetic complications. All were investigated clinically, with radiography, bone scan and intramuscular pressure measurements. Results Thirty-eight of 42 patients with diabetes were diagnosed with chronic exertional compartment syndrome of the lower leg and 32 were treated surgically. Thirty-one patients were operated with fasciotomy of the anterior compartment and 18 also with fasciotomy of the posterior compartment. Additionally, one patient had only fasciotomy of the posterior compartment. Fourteen of 32 surgically treated patients (27 legs) were followed for more than 2 years and rated the post-operative outcome as excellent or good in 21 of the treated legs. The walking distance before lower leg pain increased in all but one patient and seven patients reported unrestricted walking ability. Conclusions Chronic exertional compartment syndrome should be considered as a differential diagnoses in patients with diabetes and exercise-related lower leg pain. The results after surgery are encouraging and the increased walking ability is beneficial in the treatment of diabetes.
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| 4. |
- Edmundsson, David, 1956-
(författare)
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Chronic exertional compartment syndrome of the lower leg : a novel diagnosis in diabetes mellitus: a clinical and morphological study of diabetic and non-diabetic patients
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Chronic exertional compartment syndrome (CECS) of the lower leg, defined as a condition with exercise-induced pain due to increased intramuscular pressure (IMP), has previously mainly been described in running athletes, and etiologic factors are poorly described. CECS has not been reported to occur together with other diseases and information about consequences on muscles morphology after treatment with fasciotomy is largely unknown. We investigated etiologic and pathophysiologic aspects to CECS in a consecutive series of 63 patients with exercise-related leg pain and in 17 diabetic patients with symptoms of intermittent claudication but no circulatory insufficiency. Clinical examination, radiography, scintigraphy and IMP measurements at rest and after reproduction of symptoms were done. Patients with CECS were recommended treatment with fasciotomy. Biopsies were taken from the tibialis anterior muscle at time of fasciotomy and at follow-up 1 year later. For comparison muscle samples were taken from normal controls. Enzyme- and immunohistochemical and morphometric methods were used for analysis of muscle fiber morphology/pathology, fiber phenotype composition, mitochondrial oxidative capacity and capillary supply. Thirty-six of the 63 patients fulfilled the criteria for diagnosis of CECS in the anterior tibial compartment. The CECS patients could be divided into different etiologic groups: 18 healthy, 10 with history of trauma against the lower leg, 4 diabetic patients and 4 others. Only 5 of 36 CECS patients were athletes. The results after fasciotomy were good or excellent in 41 of 57 treated legs. Sixteen of the 17 diabetic patients were diagnosed with CECS, 11 with diabetes type 1 and 5 with type 2. The diabetic patients differed from the other groups with longer symptom-duration, shorter pain-free walking distance, firm and tender lower leg muscles and higher IMP. The postoperative outcome was good or excellent in 15 of 18 treated legs. The muscle biopsies taken at fasciotomy showed frequent histopathological changes including small and large sized fibers, fiber atrophy, internal myonuclei, split fibers, fibrosis, disorganization of mitochondria in contrast to healthy CECS subjects having low muscle capillarization as the main finding. Muscular abnormalities were generally more complex, severe and widespread in diabetic patients. After 1 year, the majority of CECS patients could return to unrestricted physical activity and the histopathological muscle changes were clearly reduced. The muscle fiber size was larger and the muscles contained signs of regeneration and repair. Remaining muscle abnormalities were present mainly in diabetic patients. CECS is a new differential-diagnosis in diabetic patients with symptoms of claudication without signs of vascular disease. A low ability for physical activity, reflected by the signs of both myopathy and neuropathy, indicates that high IMP and circulatory impairment has deleterious effects for the involved muscles. Increased physical activity and normalization of muscle morphology 1 year after treatment shows the benefit of fasciotomy. The more severe clinical and morphological findings in diabetic compared to healthy subjects with CECS indicate differences in the pathogenesis. The unrestricted physical ability after treatment is very important for diabetic patients, since physical activity is an essential part of the therapy of the disease.
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| 5. |
- Edmundsson, David, 1956-, et al.
(författare)
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Evidence for low muscle capillary supply as a pathogenic factor in chronic compartment syndrome
- 2010
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Ingår i: Scandinavian Journal of Medicine and Science in Sports. - Copenhagen : Munksgaard. - 0905-7188 .- 1600-0838. ; 20:6, s. 805-813
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Tidskriftsartikel (refereegranskat)abstract
- There is a paucity of data regarding the pathogenesis of chronic exertional compartment syndrome (CECS), its consequences for the muscles and the effects of treatment with fasciotomy. We analyzed biopsies from the tibialis anterior muscle, from nine patients, obtained during a decompressing fasciotomy and during follow-up 1 year later. Control biopsies were obtained from nine normal subjects. Muscle capillarity, fiber-type composition and fiber area were analyzed with enzyme- and immunohistochemistry and morphometry. At baseline, CECS patients had lower capillary density (273 vs 378 capillaries/mm(2), P=0.008), lower number of capillaries around muscle fibers (4.5 vs 5.7, P=0.004) and lower number of capillaries in relation to the muscle fiber area (1.1 vs 1.5, P=0.01) compared with normal controls. The fiber-type composition and fiber area did not differ, but focal signs of neuromuscular damage were observed in the CECS samples. At 1-year follow-up after fasciotomy, the fiber area and the number of fibers containing developmental myosin heavy chains were increased, but no enhancement of the capillary network was detected. Thus, morphologically, patients with CECS seemed to have reduced microcirculation capacity. Fasciotomy appeared to trigger a regenerative response in the muscle, however, without any increase in the capillary bed.
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| 6. |
- Edmundsson, David, 1956-, et al.
(författare)
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Intermittent claudication in diabetes mellitus due to chronic exertinal compartment syndrome of the leg : an observation study of 17 patients
- 2008
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Ingår i: Acta Orthopaedica. - Basingstoke : Taylor & Francis. - 1745-3674 .- 1745-3682. ; 79:4, s. 534-539
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Tidskriftsartikel (refereegranskat)abstract
- Background and purpose: Intermittent claudication in diabetes mellitus is commonly associated with arterial disease but may occur without obvious signs of peripheral circulatory impairment. We investigated whether this could be due to chronic exertional compartment syndrome (CECS). Patients and methods: We report on 17 patients (3 men), mean age 39 (18–72) years, with diabetes mellitus—12 of which were type 1—and leg pain during walking (which was relieved at rest), without clinical signs of peripheral arterial disease. The duration of diabetes was 22 (1–41) years and 12 patients had peripheral neuropathy, retinopathy, or nephropathy. The leg muscles were tender and firm on palpation. Radiography, scintigraphy, and intramuscular pressure measurements were done during exercises to reproduce their symptoms. Results: 16 of the 17 patients were diagnosed as having CECS. The intramuscular pressures in leg compartments were statistically significantly higher in diabetics than in physically active non‐diabetics with CECS (p < 0.05). 15 of the 16 diabetics with CECS were treated with fasciotomy. At surgery, the fascia was whitish, thickened, and had a rubber‐like consistency. After 1 year, 9 patients rated themselves as excellent or good in 15 of the 18 treated compartments. The walking time until stop due to leg pain increased after surgery from less than 10 min to unlimited time in 8 of 9 patients who were followed up. Interpretation: Intermittent claudication in diabetics may be caused by CECS of the leg. The intramuscular pressures were considerably elevated in diabetics. One pathomechanism may be fascial thickening. The results after fasciotomy are good, and the increased pain‐free walking time is especially beneficial for diabetics.
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| 7. |
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| 8. |
- Edmundsson, David S., et al.
(författare)
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Muscle changes in patients with diabetes and chronic exertional compartment syndrome before and after treatment with fasciotomy
- 2018
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Ingår i: Muscle and Nerve. - : John Wiley & Sons. - 0148-639X .- 1097-4598. ; 57:2, s. 229-239
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: Muscle changes in patients with diabetes and lower leg pain due to chronic exertional compartment syndrome (CECS) were investigated before and after fasciotomy.Methods: The tibialis anterior muscle was analyzed with histochemical and morphological techniques in 7 patients with diabetes and CECS before fasciotomy and in 5 of them 1 year after fasciotomy. Nondiabetic patients with CECS and healthy participants served as references.Results: Before treatment, walking distance until occurrence of pain was limited (<0.2 km). Intramuscular pressure was significantly higher than in reference participants. Muscle analysis showed changes pathognomonic for neuropathy and myopathy and a restricted capillary network, with significantly more severe changes in the muscles of patients with diabetes than in the muscles of nondiabetic patients. Treatment with fasciotomy improved clinical signs, increased walking ability, and reduced muscle abnormalities, but muscle capillarization remained low.Discussion: Patients with diabetes and CECS have distinct pathological changes in affected muscles. Pressure-relieving fasciotomy triggers a regenerative response in the muscle tissue but not in the capillary bed.
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| 9. |
- Gustafsson, Patrik, et al.
(författare)
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Muscle oxygenation in Type 1 diabetic and non-diabetic patients with and without chronic compartment syndrome
- 2017
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Ingår i: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 12:10
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Tidskriftsartikel (refereegranskat)abstract
- Background. Type 1 diabetic patients and non-diabetic patients were referred for evaluation for chronic exertional compartment syndrome (CECS) based on clinical examination and complaints of activity-related leg pain in the region of the tibialis anterior muscle. Previous studies using near-infrared spectroscopy (NIRS) showed greater deoxygenation during exercise for CECS patients versus healthy controls; however, this comparison has not been done for diabetic CECS patients.Methods. We used NIRS to test for differences in oxygenation kinetics for Type 1 diabetic patients diagnosed with (CECS-diabetics, n = 9) versus diabetic patients without (CON-diabetics, n = 10) leg anterior chronic exertional compartment syndrome. Comparisons were also made between non-diabetic CECS patients (n = 11) and healthy controls (CON, n = 10). The experimental protocol consisted of thigh arterial cuff occlusion (AO, 1-minute duration), and treadmill running to reproduce symptoms. NIRS variables generated were resting StO2%, and oxygen recovery following AO. Also, during and following treadmill running the magnitude of deoxygenation and oxygen recovery, respectively, were determined.Results. There was no difference in resting StO2%between CECS-diabetics (78.2±12.6%) vs. CONdiabetics (69.1±20.8%), or between CECS (69.3±16.2) vs. CON (75.9±11.2%). However, oxygen recovery following AO was significantly slower for CECS (1.8±0.8%/sec) vs. CON (3.8±1.7%/sec) (P = 0.002); these data were not different between the diabetic groups. StO2%during exercise was lower (greater deoxygenation) for CECS-diabetics (6.3±8.6%) vs. CON-diabetics (40.4±22.0%), and for CECS (11.3±16.8%) vs. CON (34.1±21.2%) (P<0.05 for both). The rate of oxygen recovery post exercise was faster for CECS-diabetics (3.5±2.6%/sec) vs. CON-diabetics (1.4±0.8%/sec) (P = 0.04), and there was a tendency of difference for CECS (3.1±1.4%/sec) vs. CON (1.9±1.3%/sec) (P = 0.05).Conclusion. The greater deoxygenation during treadmill running for the CECS-diabetics group (vs. CON-diabetics) is in line with previous studies (and with the present study) that compared non-diabetic CECS patients with healthy controls. Our findings could suggest that NIRS may be useful as a diagnostic tool for assessing Type 1 diabetic patients suspected of CECS.
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| 10. |
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| 11. |
- Wiberg, Rebecca, 1988-, et al.
(författare)
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Outcome following soft tissue coverage with a medial gastrocnemius flap of an exposed or infected total knee arthroplasty
- 2023
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Ingår i: Scandinavian Journal of Surgery. - : Sage Publications. - 1457-4969 .- 1799-7267. ; 112:3, s. 173-179
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Soft tissue defects or periprosthetic infections after total knee arthroplasty (TKA) are severe complications that may lead to loss of the arthroplasty or the limb. Reconstructions with medial gastrocnemius flaps (MGF) are occasionally used to provide soft tissue coverage around the knee.AIMS: The study aimed to establish the rate of implant survivorship after MGF reconstruction for soft tissue coverage in the treatment of exposed or infected TKA and to establish functional outcome.METHODS: A retrospective analysis was performed on all patients who received soft tissue coverage with an MGF of an exposed or infected TKA between 2000 and 2017 at the Department of Hand and Plastic Surgery at Umeå University Hospital. The outcomes were implant survivorship and patient-reported outcome measures (PROMs) using the five-level EQ-5D version and The Knee Injury and Osteoarthritis Outcome Score.RESULTS: Forty-seven patients (mean age = 67 years, 30 women) were included. The mean time between flap coverage and follow-up was 6.7 (±3.4) years. Implant survivorship was observed in 28 of 47 (59.6%) patients at follow-up. Flap failure was rare, with only 3 of 47 (6.4%) cases. Of the 20 patients who answered the PROMs, 10 of 20 experienced moderate to severe pain or discomfort.CONCLUSIONS: Due to unfavorable underlying conditions, MGF reconstruction after TKA is often associated with a compromised functional outcome. Because donor site morbidity is limited and flap failure is unusual, the procedure can be considered prophylactically in a small subset of patients with risk factors to prevent soft tissue defects and periprosthetic joint infection.
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