Which Term Means The Surgical Repair Of Fascia?

Contents

Fascial hernia
- Fascial hernia causes
- Fascial hernia symptoms
- Fascial hernia diagnosis
- Fascial hernia treatment
  - Fascial hernia repair

Fascial hernia

Fascial hernia also known as myofascial herniations is where part of a muscle pokes through the surrounding fascia in your leg most ordinarily occurring between your knee and talocrural joint ^one) . Both unilateral and bilateral fascial hernias have been observed in the muscles of persons whose legs had been exposed to astringent chronic strain, such as athletes, skiers, mountain climbers, foresters and foot soldiers who have exercised in hilly or mountainous country ^two) . Hugo Idhe ³⁾ is credited with providing the original investigation and background on lower extremity musculus hernias in 1929. Symptomatic muscle fascial hernias in the leg are a rare crusade of chronic leg pain and neuropathy, and are not routinely encountered in surgical practice ⁴⁾ .

Muscle fascial herniation in the legs is a rare clinical entity ^v) . About ordinarily, fascial hernia occurs every bit a result of an caused fascial defect, i.e. afterwards trauma ⁶⁾ . In symptomatic patients, fascial hernia tin announced as pain or discomfort on physical exertion of the affected limb, but likewise paresthesia by compression of nerves. Information technology is, even so, important to note, that the truthful incidence of the condition of muscle herniation of the lower extremities remains unclear^seven) . Many of these herniations are asymptomatic or may be misdiagnosed, e.g. a soft tissue tumor or successfully treated as some other status^viii) . Ofttimes, even MRI findings are not-specific detecting subtle fascial and muscle indicate changes ⁹⁾ .

The true incidence of leg fascial hernias is not known. Interestingly, while rarely encountered, they are considered to exist quite common ¹⁰⁾ . Most are likely asymptomatic and remain undiagnosed because they are never brought to the attention of a physician ^eleven) . Leg fascial hernias are associated with the evolution of exertional compartment syndromes. Of patients undergoing surgery for chronic exertional compartment syndrome, fascial defects have been found in 15% to 50%, even with normal preoperative examinations ¹²⁾ . Able-bodied men, such as military soldiers, athletes, mountain climbers, skiers, and those partaking in like occupational and sporting activities, are the demographic population believed to be at the highest gamble ¹³⁾ .

In the leg, the tibialis anterior is the most normally involved musculus and the most reported in literature ¹⁴⁾ . The fascia of tibialis anterior is the well-nigh vulnerable to trauma because it is the weakest fascial indicate in the lower extremity ¹⁵⁾ . Additionally, reports take described involvement of peroneus longus ¹⁶⁾ , peroneus brevis ¹⁷⁾ , extensor digitorum longus ¹⁸⁾ , gastrocnemius ¹⁹⁾ and flexor digitorum longus ^twenty) . Bilateral (usually symmetrical) involvement ²¹⁾ and multiple hernias within the same muscle ²²⁾ accept been described in the leg. Although located in the thigh, there have also been reports of iatrogenically induced hernias involving the vastus lateralis and rectus femoris as a complication following an anterolateral thigh perforator flap ²³⁾ and after fascia lata harvest for cruciate ligament repair ²⁴⁾ .

A fascial hernia tin be asymptomatic and does not always have to be painful and other reasons causing the complaints take to be excluded earlier surgery ²⁵⁾ . A variety of differential diagnoses for which muscular hernias have been mistaken require exclusion, including hematomas, varicosities, angiomas, arteriovenous aneurysms, epidermoid cysts, lipomas, schwannomas, tumours, ankle sprains or fractures, ruptured muscle (pseudohernia) and fundamental neuropathy ²⁶⁾ . Although a clinical diagnosis, variable symptoms and a lengthy differential list may present a diagnostic claiming.

Dissimilar treatment options for symptomatic fascial herniation in the lower limb accept been described ²⁷⁾ . Asymptomatic fascial hernias commonly require no treatment or tin exist treated conservatively²⁸⁾ . For mild cases, a support stocking, tin exist of benefit along with residue and activity modification ²⁹⁾ . Most symptomatic musculus hernias are successfully treated with conservative therapy, including rest, action restrictions and compression stockings ³⁰⁾ . For patients with stronger symptoms or those in whom bourgeois treatment has failed to improve symptoms, surgery tin can exist considered ³¹⁾ . There are different operative procedures, including direct repair ³²⁾ , fascial grafting ³³⁾ , fasciotomy ³⁴⁾ and more recently, mesh grafting ³⁵⁾ . These techniques were mostly used for tibialis inductive muscle herniation and include conservative management (action limitation, compressive stockings) as well as fasciotomy, direct approximation of the fascial defect, tibial periosteal flap, partial muscular excision, and patch repair with autologous fascia lata ³⁶⁾ or synthetic mesh ³⁷⁾ .

Figure i. Fascia and musculus compartments of the leg

Fascia and muscle compartments of the leg

Figure 2. Fascial hernia

Fascial hernia

Footnote: Magnetic resonance imaging (MRI) of the left lower extremity T2 coronal airplane. A skin mark had been placed directly over the peroneal musculature and demonstrated a focal contour irregularity on the anterior aspect, consistent with a fascial defect and herniation of peroneus brevis (arrow).

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Fascial hernia causes

Fascial hernia is caused past a focal fascial sheath defect. Ihde ³⁹⁾ classified fascial hernias into two groups: constitutional (built) and traumatic (caused). Congenital causes may exist an overall full general weakness in the muscular fascia (mesodermal insufficiency), or may occur at sites of perforating fretfulness and vessels. Acquired causes are usually secondary to trauma, occuring as either after direct or indirect trauma. Traumatic examples include penetrating trauma, closed fractures causing a fascial tear (direct trauma), or strength applied to contracted muscle causing acute fascial rupture (indirect trauma) ^forty) . In direct trauma, the fascia itself is injured resulting e.g. from fractures, wounds or contusion. Indirect trauma means injury to the contracted musculus that tin cause rupture of the fascia ⁴¹⁾ . Herniation is potentiated past increases in intracompartmental pressures such as muscle hypertrophy or chronic exertional compartment syndrome (CECS). For perspective, regular cardiovascular exercise and concrete action can atomic number 82 to muscle hypertrophy with a twenty% increment in muscle book ⁴²⁾ . Chronic exertional compartment syndrome (CECS) is defined as a reversible form of abnormally increased intramuscular pressure during exercise or physical exertion secondary to noncompliance of osteofascial tissues to exercise-induced increases in muscle book ⁴³⁾ .

Astute compartment syndrome is attributed to various causes (i.east., fracture, ischemia, improper casting, etc.) and often presents with farthermost pain in a passive country every bit an emergency. Fasciotomy is the gold standard for relieving symptoms associated with acute compartment syndrome ⁴⁴⁾ . In contrast, chronic exertional compartment syndrome is less emergent only highly disruptive for people with an active lifestyle. Chronic exertional compartment syndrome usually occurs in the lower leg and well-nigh probable results from increased force per unit area in one or more muscle compartments. Chronic exertional compartment syndrome may event in neurovascular abnormalities causing farthermost pain during and after exercise and often causes athletes to stop competing and exercising. The prevalence of chronic exertional compartment syndrome is unknown and it is likely that many people who suffer from chronic exertional compartment syndrome modify their activities in a way to reduce pain without ever seeking medical intervention. It is as well possible that some people with chronic exertional compartment syndrome are not taken seriously by athletic trainers, coaches, and master intendance physicians to whom symptoms are commencement presented ⁴⁵⁾ . Chronic exertional compartment syndrome about often affects the lower leg, which is divided into four compartments: anterior, lateral, deep posterior, and superficial posterior (Effigy 1). Of these four compartments, the anterior and lateral compartments are most unremarkably afflicted ⁴⁶⁾ . Diagnostic criteria for chronic exertional compartment syndrome include one or more of the following intramuscular pressure readings: ≥fifteen mmHg at residue; ≥30 mmHg 1 infinitesimal after exercise; ≥20 mmHg 5 minutes later on do ⁴⁷⁾ .

Fascial hernia symptoms

A fascial hernia may clinically present as a visibly palpable bulge, soft tissue mass or subcutaneous nodule. Fascial hernias may exist solitary, bilateral or multiple. They may or not exist reducible and may present with strangulated muscle ⁴⁸⁾ . Patients with fascial hernia usually suffer from pain or nowadays due to cosmetic reasons or concerns of having a tumor⁴⁹⁾ . Patients may mutter of tenderness or pain, cramping, discomfort, weakness or neuropathy such as hyposensitivity on the thigh and lower leg ⁵⁰⁾ , ⁵¹⁾ . This may worsen with standing or physical action. Tenderness may be elicited on test and decreased sensation may occur with associated nerve interest. If not readily apparent, herniation may be elicited with limb dependency, movements causing involved muscular contraction or certain stances. For example, pronounced herniation of the tibialis anterior may occur with resisted dorsiflexion of the foot or with the 'lunge' or 'fencing' position ⁵²⁾ . If palpable and easily reducible, the outlined fascial defect may be appreciated. Patients may simply initially present with cosmetic concerns or concerns of a tumour ⁵³⁾ . Dermatologists have reported the incidental discovery of asymptomatic hernias during unrelated test ⁵⁴⁾ . Alhadeff et al. ⁵⁵⁾ reported an unusual instance of pseudoradicular symptoms caused by pinch of the common peroneal nervus in the popliteal area past gastrocnemius muscle herniation. The patient suffered from pseudoradicular symptoms that resembled sciatica ⁵⁶⁾ . Therefore, neurologic symptoms such as hyposensitivity on the thigh and lower leg are possible in patients with fascial hernia occurring at the site of nerve perforation of the fascia ⁵⁷⁾ .

Fascial hernia diagnosis

Radiologic imaging techniques, including magnetic resonance imaging (MRI) and CT and ultrasound accept been used to accept the definitive diagnosis of muscle herniation and to identify the defect ⁵⁸⁾ .

Dynamic ultrasound must be the first imaging examination due to its low toll and set up availability ⁵⁹⁾ . However, a fascial thinning is sometimes difficult to detect. It has been suggested the use of dynamic MRI in the evaluation of suspected muscle herniations to meliorate delineate the fascial defect and the size of the musculus herniation, if dynamic ultrasound does non adequately define these features ^sixty) . It was hypothesized that MRI can be useful in planning operative treatment ⁶¹⁾ . MRI better visualizes musculofascial demarcation, allowing quantification of fascial splitting and muscle herniation ⁶²⁾ . MRI is superior to computed tomography because muscle and fascia have similar attenuation, which is not equally easily differentiable on computed tomography ⁶³⁾ . MRI and ultrasonography are improved with dynamic imaging techniques, which incorporate fast imaging with forced muscular movements such every bit dorsiflexion and plantar flexion of the ankle, and enable better visualization and pinpointing of the hernia and fascial defect ⁶⁴⁾ .

Fascial hernia treatment

Treatment of fascial hernias is mainly dependent on clinical symptoms and may range from conservative measures to operative intervention. Asymptomatic fascial hernias usually crave no handling or can be treated conservatively⁶⁵⁾ . For mild cases, a support stocking, tin be of do good along with rest and activeness modification ⁶⁶⁾ . Most symptomatic muscle hernias are successfully treated with conservative therapy, including residual, activity restrictions and compression stockings ⁶⁷⁾ . Considering asymptomatic fascial hernias do not necessitate treatment, a general guideline may advise conservative therapy only for mildly symptomatic musculus hernias. Injections of sclerosing agents (sodium morrhuate) ⁶⁸⁾ , local anesthetic (triamcinolone) ⁶⁹⁾ and botulinum toxin ⁷⁰⁾ have been described. Surgical referral is warranted for patients with moderate to severe symptoms that are not amenable to a conservative therapy trial. Operative repair for cosmetic concerns has also been described and is debated ⁷¹⁾ . For patients with stronger symptoms or those in whom conservative treatment has failed to improve symptoms, surgery tin can be considered ⁷²⁾ .

Fascial hernia repair

Optimal surgical treatment is controversial. A multifariousness of surgical techniques accept been described, ranging from fasciotomy to anatomical repair of the fascial defect, with no consensus. Described treatments include decompressive fasciotomy ⁷³⁾ , direct main fascial repair ⁷⁴⁾ , tibial periosteal flap ⁷⁵⁾ , fascial patch grafting or stripping (woven strips of fascia) using autologous fascia lata ⁷⁶⁾ and the use of constructed mesh ⁷⁷⁾ . Partial musculus excision has been described every bit a solitary treatment and as an offshoot for excessive muscle volume interfering with repair ⁷⁸⁾ .

Every operation has disadvantages and potential complications that must exist weighed. Anatomical repair of the fascial defect (eg, main repair, fascial grafting, constructed mesh) requires close ascertainment secondary to risks of acute or chronic compartment syndrome and hernia recurrence ⁷⁹⁾ . Fascial grafting may require additional or longer incisions, and creates new potential sites for hernia germination ^fourscore) . Synthetic mesh carries the take chances of infection due to foreign body incorporation and may undesirably adhere to underlying structures.

Earlier rather than afterward elective surgical repair may exist benign in patients with symptomatic muscle hernias and evidence of nerve interest. Overstretched nerves cause severe hurting, and even after the traction forces have been removed, pathological changes in the nerve may go on to progress secondary to connected inflammation and vascular degeneration ⁸¹⁾ . In their handling of a symptomatic peroneus brevis hernia, Garfin et al ⁸²⁾ speculated that continued irritation of the superficial peroneal-nerve may business relationship for failure of the fasciotomy to relieve symptoms.

The safest surgical option for the treatment of symptomatic muscular hernias of the leg is a longitudinal fasciotomy. This belief is the opinion of the authors and one shared by others ⁸³⁾ . Almost all techniques involve surgical exploration, which allows for autopsy and release of the involved nerve. Fasciotomy treats the muscle hernia by enlarging the defect and eliminating risks of muscle ischemia or strangulation, which are potential causes of hurting. Virtually importantly, it eliminates any future risks of acute or chronic compartment syndrome, which can still occur with anatomical repair of the fascia. Potential complications with fasciotomies are universal to whatever surgery in the lower extremity that crosses a musculofascial plane and includes exposed tendon or bone, neuromuscular damage with dysesthesias or weakness, muscle herniation and venous disease from disruption of the dogie muscle pump. Incomplete hurting resolution may occur with fasciotomies ⁸⁴⁾ . For the patient with high corrective concerns or expectations, enlarging the defect may cause more pronounced muscular bulging. Additionally, selective fasciotomy of only the involved compartment may benefit overall patient satisfaction compared with releasing multiple compartments ⁸⁵⁾ . Equally with any surgery, the technique should exist tailored to the individual and multiple feasible options may be. No absolute consensus exists regarding optimal surgical handling.

Directly repair is possible when the fascial defect is minor and the laxity of the borders permits approximation; this has been practiced in the past ⁸⁶⁾ . However, because of reports of compartment syndrome later on direct repair ⁸⁷⁾ , this method should merely be used when the defect is small and essential close postoperative follow upward is assured ⁸⁸⁾ . Some authors consider the longitudinal fasciotomy the safest method of treatment ⁸⁹⁾ .

There are several reports near successful results after fascial defect coverage using artificial meshes ⁹⁰⁾ ,⁹¹⁾ . They suggest that the operative procedure is uncomplicated, more than rapid, and less complicated than other techniques and can be used for large defects. The mesh is fixed to a higher place and not under the fascia assuasive the underlying muscle to slide without any friction by the mesh or sutures ⁹²⁾ ,⁹³⁾ .

Lee et al. ⁹⁴⁾ reported a patient who had multiple herniation of the tibialis inductive muscle. Large defects of the fascia were repaired using a mesh. A compartment syndrome as the typical complication after repair of fascial defects was non seen ⁹⁵⁾ .

Using a permanent mesh in the treatment of hernia is advantageous because it is robust and very durable. Vicryl-Propylene blended meshes are made from fifty% resorbable vicryl and l% non-absorbable Polypropylene. It is therefore partially resorbable and makes a tension free fixation possible. Potential disadvantages may be an increased risk of infection every bit there is a constructed nonabsorbable strange trunk and there is the risk of adhesion between the mesh and the underlying structures.

The event in the follow upwardly test after 6 weeks showed a subtract of the preoperative pain and a adept functionality with total physical load, complete mobilization and 100% employability postoperative. It can be causeless that approximately 2 months are needed to induce a stable scarring. This is similar to the results of Siliprandi et al. ⁹⁶⁾ , who could bear witness that this procedure tin provide good functional results and a practiced cosmetic appearance without complications and complications. Results from various studies indicate towards a skillful long fourth dimension issue without recurrence of the hernia also after years ⁹⁷⁾ .

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