Fascial hernia

Fascial hernia also known as myofascial herniations is where part of a muscle pokes through the surrounding fascia in your leg most commonly occurring between your knee and ankle ¹. Both unilateral and bilateral fascial hernias have been observed in the muscles of persons whose legs had been exposed to severe chronic strain, such as athletes, skiers, mountain climbers, foresters and foot soldiers who have exercised in hilly or mountainous country ². Hugo Idhe ³ is credited with providing the original investigation and groundwork on lower extremity muscle hernias in 1929. Symptomatic muscle fascial hernias in the leg are a rare cause of chronic leg pain and neuropathy, and are not routinely encountered in surgical practice ¹.

Muscle fascial herniation in the legs is a rare clinical entity ⁴. Most commonly, fascial hernia occurs as a result of an acquired fascial defect, i.e. after trauma ³. In symptomatic patients, fascial hernia can appear as pain or discomfort on physical exertion of the affected limb, but also paresthesia by compression of nerves. It is, however, important to note, that the true incidence of the condition of muscle herniation of the lower extremities remains unclear ⁴. Many of these herniations are asymptomatic or may be misdiagnosed, e.g. a soft tissue tumor or successfully treated as another condition ⁵. Often, even MRI findings are non-specific detecting subtle fascial and muscle signal changes ⁶.

The true incidence of leg fascial hernias is not known. Interestingly, while rarely encountered, they are considered to be quite common ⁷. Most are likely asymptomatic and remain undiagnosed because they are never brought to the attention of a physician ⁸. Leg fascial hernias are associated with the development 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 ⁹. Athletic men, such as military soldiers, athletes, mountain climbers, skiers, and those partaking in similar occupational and sporting activities, are the demographic population believed to be at the highest risk ⁹.

In the leg, the tibialis anterior is the most commonly involved muscle and the most reported in literature ¹. The fascia of tibialis anterior is the most vulnerable to trauma because it is the weakest fascial point in the lower extremity ¹⁰. Additionally, reports have described involvement of peroneus longus ¹¹, peroneus brevis ¹², extensor digitorum longus ¹³, gastrocnemius ¹⁴ and flexor digitorum longus ¹⁵. Bilateral (usually symmetrical) involvement ¹⁶ and multiple hernias within the same muscle ¹⁷ have 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 ¹⁸ and after fascia lata harvest for cruciate ligament repair ¹⁹.

A fascial hernia can be asymptomatic and does not always have to be painful and other reasons causing the complaints have to be excluded before surgery ⁴. 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 central neuropathy ²⁰. Although a clinical diagnosis, variable symptoms and a lengthy differential list may present a diagnostic challenge.

Different treatment options for symptomatic fascial herniation in the lower limb have been described ²¹. Asymptomatic fascial hernias usually require no treatment or can be treated conservatively ²². For mild cases, a support stocking, can be of benefit along with rest and activity modification ³. Most symptomatic muscle hernias are successfully treated with conservative therapy, including rest, activity restrictions and compression stockings ²³. For patients with stronger symptoms or those in whom conservative treatment has failed to improve symptoms, surgery can be considered ²⁴. There are different operative procedures, including direct repair ²⁵, fascial grafting ²⁶, fasciotomy ²² and more recently, mesh grafting ²¹. These techniques were mostly used for tibialis anterior muscle herniation and include conservative management (activity 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 ²⁷ or synthetic mesh ²⁸.

Figure 1. Fascia and muscle compartments of the leg

Figure 2. Fascial hernia

Footnote: Magnetic resonance imaging (MRI) of the left lower extremity T2 coronal plane. A skin marker 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 by a focal fascial sheath defect. Ihde ³ classified fascial hernias into two groups: constitutional (congenital) and traumatic (acquired). Congenital causes may be an overall general weakness in the muscular fascia (mesodermal insufficiency), or may occur at sites of perforating nerves 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 force applied to contracted muscle causing acute fascial rupture (indirect trauma) ²⁹. In direct trauma, the fascia itself is injured resulting e.g. from fractures, wounds or contusion. Indirect trauma means injury to the contracted muscle that can cause rupture of the fascia ³⁰. Herniation is potentiated by increases in intracompartmental pressures such as muscle hypertrophy or chronic exertional compartment syndrome (CECS). For perspective, regular cardiovascular exercise and physical activity can lead to muscle hypertrophy with a 20% increase in muscle volume ³¹. 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 volume ³¹.

Acute compartment syndrome is attributed to various causes (i.e., fracture, ischemia, improper casting, etc.) and often presents with extreme pain in a passive state as an emergency. Fasciotomy is the gold standard for relieving symptoms associated with acute compartment syndrome ³². In contrast, chronic exertional compartment syndrome is less emergent but highly disruptive for people with an active lifestyle. Chronic exertional compartment syndrome usually occurs in the lower leg and most likely results from increased pressure in one or more muscle compartments. Chronic exertional compartment syndrome may result in neurovascular abnormalities causing extreme 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 also possible that some people with chronic exertional compartment syndrome are not taken seriously by athletic trainers, coaches, and primary care physicians to whom symptoms are first presented ³³. Chronic exertional compartment syndrome most often affects the lower leg, which is divided into four compartments: anterior, lateral, deep posterior, and superficial posterior (Figure 1). Of these four compartments, the anterior and lateral compartments are most commonly affected ³⁴. Diagnostic criteria for chronic exertional compartment syndrome include one or more of the following intramuscular pressure readings: ≥15 mmHg at rest; ≥30 mmHg 1 minute after exercise; ≥20 mmHg 5 minutes after exercise ³⁵.

Fascial hernia symptoms

A fascial hernia may clinically present as a visibly palpable bulge, soft tissue mass or subcutaneous nodule. Fascial hernias may be solitary, bilateral or multiple. They may or not be reducible and may present with strangulated muscle ³⁶. Patients with fascial hernia usually suffer from pain or present due to cosmetic reasons or concerns of having a tumor ²⁴. Patients may complain of tenderness or pain, cramping, discomfort, weakness or neuropathy such as hyposensitivity on the thigh and lower leg ³⁷, ³⁸. This may worsen with standing or physical activity. Tenderness may be elicited on examination and decreased sensation may occur with associated nerve involvement. 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 ³. If palpable and easily reducible, the outlined fascial defect may be appreciated. Patients may only initially present with cosmetic concerns or concerns of a tumour ³⁹. Dermatologists have reported the incidental discovery of asymptomatic hernias during unrelated examination ⁴⁰. Alhadeff et al. ⁴¹ reported an unusual case of pseudoradicular symptoms caused by compression of the common peroneal nerve in the popliteal area by gastrocnemius muscle herniation. The patient suffered from pseudoradicular symptoms that resembled sciatica ⁴¹. 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 ²².

Fascial hernia diagnosis

Radiologic imaging techniques, including magnetic resonance imaging (MRI) and CT and ultrasound have been used to have the definitive diagnosis of muscle herniation and to identify the defect ⁴².

Dynamic ultrasound must be the first imaging examination due to its low cost and ready availability ⁴³. 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 better delineate the fascial defect and the size of the muscle herniation, if dynamic ultrasound does not adequately define these features ⁴⁴. It was hypothesized that MRI can be useful in planning operative treatment ⁴⁵. MRI better visualizes musculofascial demarcation, allowing quantification of fascial splitting and muscle herniation ⁴⁶. MRI is superior to computed tomography because muscle and fascia have similar attenuation, which is not as easily differentiable on computed tomography ⁴⁶. MRI and ultrasonography are improved with dynamic imaging techniques, which incorporate fast imaging with forced muscular movements such as dorsiflexion and plantar flexion of the ankle, and enable better visualization and pinpointing of the hernia and fascial defect ¹⁴.

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 require no treatment or can be treated conservatively ²². For mild cases, a support stocking, can be of benefit along with rest and activity modification ³. Most symptomatic muscle hernias are successfully treated with conservative therapy, including rest, activity restrictions and compression stockings ²³. Because asymptomatic fascial hernias do not necessitate treatment, a general guideline may suggest conservative therapy only for mildly symptomatic muscle hernias. Injections of sclerosing agents (sodium morrhuate) ⁴⁷, local anesthetic (triamcinolone) ⁴⁸ and botulinum toxin ¹⁹ 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 ⁴⁹. For patients with stronger symptoms or those in whom conservative treatment has failed to improve symptoms, surgery can be considered ²⁴.

Fascial hernia repair

Optimal surgical treatment is controversial. A variety of surgical techniques have been described, ranging from fasciotomy to anatomical repair of the fascial defect, with no consensus. Described treatments include decompressive fasciotomy ⁵⁰, direct primary fascial repair ¹⁶, tibial periosteal flap ⁵¹, fascial patch grafting or stripping (woven strips of fascia) using autologous fascia lata ⁵² and the use of synthetic mesh ¹⁸. Partial muscle excision has been described as a solitary treatment and as an adjunct for excessive muscle volume interfering with repair ¹⁵.

Every operation has disadvantages and potential complications that must be weighed. Anatomical repair of the fascial defect (eg, primary repair, fascial grafting, synthetic mesh) requires close observation secondary to risks of acute or chronic compartment syndrome and hernia recurrence ²⁹. Fascial grafting may require additional or longer incisions, and creates new potential sites for hernia formation ¹⁸. Synthetic mesh carries the risk of infection due to foreign body incorporation and may undesirably adhere to underlying structures.

Earlier rather than later elective surgical repair may be beneficial in patients with symptomatic muscle hernias and evidence of nerve involvement. Overstretched nerves cause severe pain, and even after the traction forces have been removed, pathological changes in the nerve may continue to progress secondary to continued inflammation and vascular degeneration ⁵³. In their treatment of a symptomatic peroneus brevis hernia, Garfin et al ⁵⁴ speculated that continued irritation of the superficial peroneal-nerve may account 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 ⁵⁵. Almost all techniques involve surgical exploration, which allows for dissection 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 pain. Most 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 any 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 calf muscle pump. Incomplete pain resolution may occur with fasciotomies ⁵⁶. For the patient with high cosmetic 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 ⁵⁷. As with any surgery, the technique should be tailored to the individual and multiple viable options may exist. No absolute consensus exists regarding optimal surgical treatment.

Direct repair is possible when the fascial defect is small and the laxity of the borders permits approximation; this has been practiced in the past ³⁰. However, because of reports of compartment syndrome after direct repair ²⁴, this method should only be used when the defect is small and essential close postoperative follow up is assured ²². Some authors consider the longitudinal fasciotomy the safest method of treatment ⁴³.

There are several reports about successful results after fascial defect coverage using artificial meshes ²⁸, ²¹. They suggest that the operative procedure is simple, more rapid, and less complicated than other techniques and can be used for large defects. The mesh is fixed above and not under the fascia allowing the underlying muscle to slide without any friction by the mesh or sutures ²⁸, ²¹.

Lee et al. ³⁸ reported a patient who had multiple herniation of the tibialis anterior muscle. Large defects of the fascia were repaired using a mesh. A compartment syndrome as the typical complication after repair of fascial defects was not seen ⁵⁸.

Using a permanent mesh in the treatment of hernia is advantageous because it is robust and very durable. Vicryl-Propylene composite meshes are made from 50% resorbable vicryl and 50% non-absorbable Polypropylene. It is therefore partially resorbable and makes a tension free fixation possible. Potential disadvantages may be an increased risk of infection as there is a synthetic nonabsorbable foreign body and there is the risk of adhesion between the mesh and the underlying structures.

The outcome in the follow up examination after 6 weeks showed a decrease of the preoperative pain and a good functionality with full physical load, complete mobilization and 100% employability postoperative. It can be assumed that approximately 2 months are needed to induce a stable scarring. This is similar to the results of Siliprandi et al. ²⁸, who could show that this procedure can provide good functional results and a good cosmetic appearance without complications and complications. Results from various studies point towards a good long time outcome without recurrence of the hernia also after years ²¹.

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