Response to “Letter Regarding: Superficial Peroneal Nerve Injury Risk During a Semiblind Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg: An Anatomical and Clinical Study”

Dear Editor:

We are delighted with the interest that is expressed by Professor Maffulli et al regarding our recent work on the safety of neural structures (and in particular the superficial peroneal nerve) during a minimally invasive fasciotomy of the leg anterior tibialis muscle (ant-CECS). ¹ We agree that a “one-incision fasciotomy” for ant-CECS is (initially) technically demanding, but the learning curve is steep. We reported that the integrity of the superficial peroneal nerve (SPN) and its unpredictable branches was maintained, both in cadaveric specimens and in 120 operated legs of patients with ant-CECS. The most important factor of the procedure is the location of the incision. We used a 2-cm vertical incision halfway from the fibular head line to the lateral malleolar bone some 2-3 cm lateral to the anterior tibial crest. We earlier reported on this approach in a feasibility study encompassing 28 legs with ant-CECS in a 2015 issue of this journal. ² As a high-volume center, we now surgically treat more than 150 CECS patients yearly, approximately half with a bilateral type ant-CECS. In over 750 legs to date, we have not observed SPN damage once confirming its safety.

A difference from Maffulli’s approach that was published in 2016 is related to the instrument. ⁴ Professor Maffulli’s technique may be considered a variant on the fasciotomy according to Due and Nordstrand. ³ These Scandinavian surgeons introduced a “semiblind” technique with a fasciotome (rather than a pair of scissors) in 1987, possibly a minimally invasive technique “avant la lettre.” Whereas Maffulli et al prefer scissors for their fasciotomy, we use a specially designed speculum coined FascioMax. This instrument has 2 blades that tightly fixate the fascia during the fasciotomy and protect the surrounding anatomical structures.^1,2 We strongly feel that the risk of collateral tissue damage is minimized using this approach. Although we completely agree with Professor Maffulli that regular scissors may suffice in highly experienced hands, we believe our technique may have advantages for (orthopedic) surgeons who do not routinely perform minimally invasive fasciotomies.

We support Maffulli et al on their closing remarks that randomized controlled trials are required prior to fully embracing this minimally invasive technique for ant-CECS. To that extent, we have recently completed patient inclusion of a randomized trial determining whether the FascioMax technique performs at least as well as the Due gold standard fasciotome in experienced hands.