Anatomic study of selective neurectomy of gastrocnemius muscle for calf reduction in Chinese

Endoscopic Concurrent Gastrocnemius Muscle Resection and Soleus Muscle Neurectomy for Severe Muscular Calf Hypertrophy

BACKGROUND

Selective neurectomy or muscle resection techniques for calf reduction conventionally focus on the gastrocnemius muscle. However, the underlying soleus muscle plays an important role in muscular calf hypertrophy. In the authors' experience, the results of calf reduction have been suboptimal in patients with severe muscular calf hypertrophy who underwent gastrocnemius muscle resection only. This article describes a new calf reduction method that uses concurrent gastrocnemius muscle resection and soleus muscle neurectomy using an endoscope-assisted single-incision approach in patients with severe muscular calf hypertrophy.

METHODS

A total of 139 patients who underwent simultaneous gastrocnemius muscle resection and soleus muscle neurectomy for severe calf hypertrophy from March of 2017 to June of 2020 were retrospectively analyzed.

RESULTS

After combined gastrocnemius resection (mean weight per calf, 349 g) and soleus neurectomy, about 3.8 to 8.2 cm (mean, 6.4 cm) or 12.8% to 24.3% (mean, 16.6%) of the calf was reduced. Complications included cellulitis, hematoma, seroma, and mild depression ( n = 1 each). Two patients had traction injury to the sural nerve. One patient developed Achilles tendon rupture at 2 months postoperatively. No patient complained of functional impairment with respect to easy fatigability, stability, gait, or sport activities at 6 months postoperatively.

CONCLUSION

This study is the first to combine gastrocnemius muscle resection with selective soleus muscle neurectomy to achieve the most efficient calf reduction for severe muscular calf hypertrophy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Anatomical study of the motor branches of the tibial nerve and incision design for hyperselective neurectomy

PURPOSE

Selective tibial neurotomy (STN) is a surgical procedure for treating spastic equinovarus foot. Hyperselective neurectomy (HSN) of tibial nerve is a modified STN procedure, which was rarely discussed. This study aimed to describe the branching patterns of the tibial nerve and propose an optimal surgical incision of HSN for treatment of spastic equinovarus foot.

METHODS

Sixteen lower limbs were dissected to determine the various branching patterns of the tibial nerve and categorized according to these branching patterns. The mean distances from the nerve entry points to the tip of femur's medial epicondyle were measured, as well as their percentage to the overall length of the leg. The surgical incision was designed according to the range of these nerve entry points.

RESULTS

The tibial nerve sent out proximal and distal motor branches based on their position relative to the soleus muscle's tendinous arch. For proximal motor branches, the branches innervating the medial gastrocnemius, lateral gastrocnemius and proximal soleus were categorized into types I (9/16), II (5/16) and III (2/16). Measurements from the medial epicondyle to the nerve entry points into the medial gastrocnemius, lateral gastrocnemius and proximal soleus ranged from 14 to 33 mm (4-9% of leg length), 22-45 mm (6-12%) and 35-81 mm (10-22%), respectively. Distal motor branches including the distal soleus, posterior tibialis, flexor digitorum longus and flexor hallucis longus, were classified as types A (8/14), B (4/14) and C (2/14), with the distances from their respective terminal points to the medial epicondyle were 67-137 mm (19-39%), 74-125 mm (20-35%), 116-243 mm (33-69%) and 125-272 mm (35-77%).

CONCLUSIONS

The motor branches of tibial nerve were classified into two groups and each subdivided into three types. Detailed location parameters may serve as an anatomical basis for designing incision of HSN.

Modified Oblique Lobenhoffer (MOL) approach for posterolateral and posteromedial column access in tibial plateau fractures: a detailed cadaveric anatomical study

BACKGROUND

Tibial plateau fractures involving posteromedial (PM) and posterolateral (PL) columns are complex injuries that require an appropriate approach. The management of the PL column in these cases can be controversial, and limitations using deep posteromedial interval approaches have been referenced. In this paper, a modification of the Lobenhoffer approach, designed to optimize the access to the PL column, is described in detail. The aim of this study was to assess the feasibility of this approach in a cadaveric anatomical study.

MATERIALS AND METHODS

In total, five fresh-frozen cadaveric specimens were used for detailed anatomical study surrounding the approach. Relationships with cutaneous and deep neurovascular structures were evaluated. The exposure area of the PL and PM columns using this approach was assessed.

RESULTS

The cadaveric study showed safe and adequate exposure. Oblique skin and fascia incision just medial to the posterior midline was safe to protect the medial sural cutaneous nerve and the small saphenous vein. Elevation of the popliteus and tibialis posterior muscles offered safe protection of the anterior tibial artery and popliteal neurovascular bundle during retractor placement. Adequate full proximal exposure of the PM and PL columns, including the posterolateral lateral (PLL) and posterolateral central (PLC) segments, was obtained in all specimens.

CONCLUSIONS

The Modified Oblique Lobenhoffer (MOL) approach can be a feasible option to access PL and PM columns in tibial plateau fractures.

LEVEL OF EVIDENCE

IV.

Simultaneous calf reduction and contouring with customized differential subtotal gastrocnemius resection and muscle transposition: Analysis of 200 cases

BACKGROUND

Oversized muscular calves can cause severe emotional distress. Total, partial, and subtotal resections of the gastrocnemius muscle for calf reduction have been described. However, the amount of muscle resected may be inappropriate, and the resultant leg contour may not be straight or esthetically pleasing enough.

OBJECTIVES

This study aimed to describe a technique of customized differential subtotal gastrocnemius resection and muscle transposition.

METHODS

A total of 200 patients who underwent customized differential subtotal gastrocnemius resection and muscle transposition for hypertrophic muscular calves from July 2013 to June 2016 were included in the study.

RESULTS

A total of 148 patients underwent subtotal resection of both heads, and calf reduction ranged from 3.2 to 7.2 cm (mean 14.8%). Forty-two patients underwent subtotal resection of the medial head alone, and calf reduction ranged from 2.8 to 5.5 cm (mean 9.2%). Ten patients underwent subtotal resection of the lateral head alone, and calf reduction ranged from 1.2 to 2.1 cm (mean 4.6%). The medial gastrocnemius muscle was subtotally resected in 190 (95%) patients. In 130 (65%) patients, the preserved medial gastrocnemius muscle was transposed superomedially to achieve a straighter medial contour. None of the patients complained that their legs were too thin because of over-reduction. Cybex test showed that near-total muscle strength recovery was achieved within 6 months.

CONCLUSION

Customized differential subtotal gastrocnemius resection together with muscle transposition resulted in enhanced calf reduction with straighter leg contour, without any impairment of the leg function. This approach may be more appealing to both patients and surgeons.

Single Incision Endoscope-Assisted Gastrocnemius Muscle Resection for Calf Hypertrophy: Analysis of 300 Cases

BACKGROUND

Muscular calf hypertrophy can cause severe psychological distress. Total or subtotal resection of the gastrocnemius muscle results in significant calf reduction. However, both techniques require a second incision of 5 and 2 cm, respectively, at the posterior mid-calf. The resultant mid-calf scar is more difficult to conceal when wearing short skirts or pants.

OBJECTIVES

The authors sought to describe the technique of endoscope-assisted gastrocnemius muscle resection to obviate the need for a mid-calf scar and to review the outcomes of patients who underwent this procedure.

METHODS

A retrospective study of 300 patients in a single center in Taiwan who underwent endoscope-assisted subtotal resection of the gastrocnemius muscle for hypertrophic muscular calves, between March 2015 to June 2019, were included in this study.

RESULTS

The combined weight of the resected gastrocnemius muscle ranged from 156 to 484 g per calf (mean = 276 g). The mean maximal calf circumference was 36.1 cm preoperatively and 30.9 cm postoperatively. The calf reduction achieved was 3.0 to 8.1 cm (mean = 5.2 cm), or 8.9% to 19.8% (mean = 14.4%). The complications were minor, and the rate was low (2%). As for the popliteal fossa scar, 6 patients underwent further treatment of their hyperpigmented or hypertrophic transverse scar. There were no complaints of impaired leg function regarding gait or sports activities 3 to 6 months postoperatively.

CONCLUSIONS

At present, gastrocnemius muscle resection remains unrivaled in its ability to achieve calf reduction. The surgery is now much more appealing to patients as a result of employing the endoscope-assisted technique to obviate the mid-calf scar.

LEVEL OF EVIDENCE: 4

A bilateral third head of the gastrocnemius which is morphologically similar to the plantaris

PURPOSE

An extra muscle was observed on both sides of the popliteal fossa in the cadaver of a 78-year-old Japanese male during dissection. The aim of this case report was to identify whether this variant is a double plantaris or a third head of the gastrocnemius according to its morphological characteristics and innervation.

METHODS

The muscles were displayed by careful dissection and delineation of surrounding structures. The size of each of the muscle bellies and tendons of those extra muscles were measured manually by the vernier caliper.

RESULTS

The origin of each extra muscle was lateral to the tibial nerve and superior to the plantaris, and each extra muscle which transitioned to a descending tendon parallel to the plantaris had a cone-shaped belly. However, the tendon of the extra muscles was fused into the investing fascia of the gastrocnemius with a tendon length of 4.5 cm on the left and 4.6 cm on the right. The extra muscles were innervated by the branch of the tibial nerve to the medial head of the gastrocnemius on both sides.

CONCLUSION

Although they had an origin and shape similar to that of the plantaris, we identified the extra muscles in this case as a third head of the gastrocnemius, because of innervation to the plantaris arises directly from the tibial nerve. This case highlighted that the innervation is essential to understanding the myogenesis of extra muscles, especially in cases which are difficult to categorize based on the morphological features of the muscle.

Intramuscular innervations of lower leg skeletal muscles: applications in their clinical use in functional muscular transfer

PURPOSE

This study aims to investigate nerve distribution patterns of human lower leg skeletal muscles using a modified Sihler's staining method.

METHODS

Sixteen lower leg from eight fresh adult cadavers were used in this study and all the skeletal muscles were dissected. The muscle specimens were classified according to Lim's classification. The specimens were then stained by further modified Sihler's staining technique. Data were analyzed according to research results.

RESULTS

After the staining, we found four patterns of nerve distribution in human lower leg muscles: (1) Type 1: single nerve pattern in which the nerve branches into two either running parallel to each other or radiating in a spray pattern (such as the extensor digitorum longus, extensor hallucis longus, fibularis brevis and flexor hallucis longus). (2) Type 2: double nerve pattern, one being proximal and the other being distal (such as the extensor digitorum longus, flexor digitorum longus, flexor hallucis longus). (3) Type 3: multiple branch pattern (such as the tibialis anterior, fibularis longus, gastrocnemius, soleus, tibialis anterior and popliteus).

CONCLUSION

Our modified Sihler's staining method is useful for research of large muscles and intramuscular nerves in human. These findings might provide guidance for clinicians for muscle reconstruction surgery.

Safety and Efficacy of Selective Neurectomy of the Gastrocnemius Muscle for Calf Reduction in 300 Cases

BACKGROUND

Liposuction alone is not always sufficient to correct the shape of the lower leg, and muscle reduction may be necessary.

OBJECTIVE

To assess the outcomes of a new technique of selective neurectomy of the gastrocnemius muscle to correct calf hypertrophy.

METHODS

Between October 2007 and May 2010, 300 patients underwent neurectomy of the medial and lateral heads of the gastrocnemius muscle at the Department of Cosmetic and Plastic Surgery, the Second People's Hospital of Guangdong Province (Guangzhou, China) to correct the shape of their lower legs. Follow-up data from these 300 patients were analyzed retrospectively. Cosmetic results were evaluated independently by the surgeon, the patient, and a third party. Preoperative and postoperative calf circumferences were compared. The Fugl-Meyer motor function assessment was evaluated 3 months after surgery.

RESULTS

The average reduction in calf circumference was 3.2 ± 1.2 cm. The Fugl-Meyer scores were normal in all patients both before and 3 months after surgery. A normal calf shape was achieved in all patients. Six patients complained of fatigue while walking and four of scar pigmentation, but in all cases, this resolved within 6 months. Calf asymmetry was observed in only two patients.

CONCLUSION

The present series suggests that neurectomy of the medial and lateral heads of the gastrocnemius muscle may be safe and effective for correcting the shape of the calves.

LEVEL OF EVIDENCE V

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