What are the possible causes of increased pain and swelling in a patient with a history of bilateral leg fasciotomy (fasciotomy is a surgical procedure that cuts the fascia to relieve tension or pressure)?

Late Complications Following Bilateral Leg Fasciotomy

Increased pain and swelling years after bilateral leg fasciotomy most likely represents chronic exertional compartment syndrome (CECS) due to incomplete fascial release, fascial scarring/reformation, or development of superficial peroneal nerve compression. 1, 2

Primary Differential Diagnoses to Consider

Recurrent/Chronic Exertional Compartment Syndrome

• Fascial scarring or incomplete initial release can lead to recurrence of compartment syndrome, requiring repeat fasciotomy in approximately 7% of cases 1
• Symptoms typically include pain that worsens with activity and improves with rest, often accompanied by numbness, tingling, and cramping 2
• The anterior compartment is most commonly affected, though multiple compartments may be involved 3
• Diagnosis requires compartment pressure testing before and after exercise, with pressures >30 mmHg post-exercise being diagnostic 4, 2

Superficial Peroneal Nerve Compression

• Occurs in approximately 26% of patients (5 of 19 patients in one series) either before or after fasciotomy for compartment syndrome 1
• Presents with numbness and dysesthesia along the lateral leg distribution 1
• May result from nerve entrapment by scar tissue at the fasciotomy site or anomalous nerve anatomy 1
• Requires partial fasciectomy and lateral compartment fasciotomy for definitive treatment 1

Peripheral Artery Disease (PAD)

• Consider in patients with risk factors including age ≥50 years with atherosclerotic risk factors (diabetes, smoking, dyslipidemia, hypertension) 5
• Presents with claudication symptoms that worsen with exercise but differ from compartment syndrome in timing and character 5
• Physical examination should assess all lower extremity pulses (femoral, popliteal, dorsalis pedis, posterior tibial) with abnormal pulse palpation suggesting PAD 5
• Ankle-brachial index (ABI) testing is indicated if PAD is suspected 5

Necrotizing Fasciitis (Less Likely but Critical)

• Must be excluded urgently given the history of fasciotomy and potential for late infection 5
• Key features include severe pain disproportionate to findings, hard/woody feel of subcutaneous tissue, systemic toxicity, edema extending beyond erythema, and skin necrosis 5
• Requires immediate surgical exploration if suspected, as imaging may delay definitive diagnosis 5

Diagnostic Approach

Initial Clinical Assessment

• Pain characteristics: Exertional pain relieved by rest suggests CECS; constant severe pain suggests infection or vascular compromise 4, 2
• Neurological examination: Numbness/tingling in superficial peroneal nerve distribution (lateral leg/dorsal foot) suggests nerve compression 1
• Compartment palpation: Increased firmness/tension during or after activity supports CECS, though palpation alone is unreliable (sensitivity 54%) 4
• Vascular examination: Assess all lower extremity pulses; diminished pulses suggest PAD rather than compartment syndrome 5

Definitive Diagnostic Testing

• Compartment pressure measurement is the gold standard for CECS diagnosis, performed before and immediately after exercise that reproduces symptoms 4, 2, 3
• Diagnostic thresholds: resting pressure >15 mmHg, 1-minute post-exercise >30 mmHg, or 5-minute post-exercise >20 mmHg 2
• Near-infrared spectroscopy can demonstrate prolonged tissue ischemia in affected compartments compared to normal controls 3
• MRI may show affected compartments but is not diagnostic; primarily useful to exclude other pathology 2, 3

Management Algorithm

For Confirmed Recurrent CECS

• Repeat fasciotomy is indicated when conservative measures fail and compartment pressures remain elevated 1
• Endoscopic fasciotomy techniques offer less invasive approach with quicker healing (return to activity within 2 months) compared to open revision 2, 3
• Bilateral simultaneous fasciotomy is safe and effective when both legs are affected, with average return to sports at 10.7 weeks versus 22.7 months for staged procedures 6

For Superficial Peroneal Nerve Compression

• Partial fasciectomy and lateral compartment fasciotomy provides definitive treatment 1
• All patients with exertional numbness in one series had complete resolution after operative release 6

For PAD

• Optimal medical therapy including antiplatelet agents, statin therapy, and cardiovascular risk factor modification 5
• Revascularization considered for lifestyle-limiting claudication 5

Critical Pitfalls to Avoid

• Never assume the original fasciotomy was adequate—incomplete release or fascial reformation occurs and requires objective pressure testing 1
• Never rely solely on clinical examination to diagnose recurrent compartment syndrome; compartment pressure measurement is essential 4, 2
• Never miss superficial peroneal nerve compression—specifically assess for lateral leg numbness and consider this diagnosis in up to 26% of post-fasciotomy patients 1
• Never delay evaluation for necrotizing fasciitis if severe pain, systemic toxicity, or skin changes are present—this requires emergency surgical exploration 5
• Never overlook PAD in older patients with atherosclerotic risk factors—the presentation differs from compartment syndrome but requires different management 5