The gastrocnemius intramuscular aponeurotic recession: a simplified method of gastrocnemius recession

Subtalar arthroereisis with metallic implant is a safe and effective treatment for pediatric patients with symptomatic flexible flatfeet. A 10-year clinical and radiographic follow-up

BACKGROUND

Subtalar arthroereisis (SA) is an increasingly applied minimally invasive approach for flexible flat foot (FFF) not responsive to conservative treatment. This study aimed at evaluating the long-term clinical and radiographic outcomes of SA in pediatric patients with symptomatic FFF.

METHODS

Thirty-seven patients (11.9 ± 1.6yy) underwent SA (74 feet), with outcomes assessed after a mean 10-year follow-up. Pain, quality of life, foot functionality, and alignment were evaluated using validated tools and radiographic parameters, calculated on weightbearing x-rays pre- and post-operatively.

RESULTS

Clinical outcomes reached excellent postoperative results (FFI: 9.1, AOFAS: 94.5) with a low 0.9 NRS pain (p < 0.01) and a 92 % satisfaction. All radiographic parameters improved significantly towards normal values: CP 17.5 ± 3.9, MA 4.3 ± 5.8, TCA 42.8 ± 6.2, TNCA 21.1 ± 8.5, TNU% 26.6 ± 8.4 (all p < 0.01).

CONCLUSIONS

SA with a metallic endosinotarsal device provided significant long-term clinical and radiographic improvements, with low complication rates and high patient satisfaction, supporting its efficacy as a treatment option for pediatric symptomatic FFF.

LEVEL OF EVIDENCE

IV.

The Medial Gastrocnemius Recession, an Alternative Surgical Treatment for Isolated Gastrocnemius Contracture: A Cadaver Study With Discussion Emphasizing Variable Conjoint Tendon Anatomy

BACKGROUND

Gastrocnemius recession is a popular procedure utilized to treat chronic conditions related to isolated gastrocnemius contracture (IGC). Recent anatomical research detailing variable gastrocsoleus tendon morphology has raised important questions regarding the safety of some traditional recession procedures. Alternative gastrocnemius recession strategies may produce comparable dorsiflexion improvement results while avoiding the surgical risk related to conjoint tendon anatomical variability.

METHODS

Ten matched cadaver pairs were randomized to receive either a medial gastrocnemius recession (MGR) procedure or a gastrocnemius intramuscular recession "Baumann" procedure. Postoperative dorsiflexion improvement was measured and then compared between groups. Detailed postoperative surgical dissections were performed to assess structures at risk, conjoint tendon morphology, and anatomical symmetry.

RESULTS

Medial gastrocnemius recession and Baumann procedures were equally effective at producing significant increases in passive ankle dorsiflexion. No sural nerve injuries were observed. Thirty-five percent of specimens showed direct muscular fusion of at least a portion of the distal gastrocnemius muscular tissue to the adjacent soleus.

CONCLUSION

The MGR procedure produced comparable dorsiflexion improvement results to the Baumann procedure in our cadaver model. Surgeons must account for certain conjoint tendon anatomical variants when surgically treating IGC as traditional recession methods risk tendo-Achilles overlengthening.

LEVELS OF EVIDENCE

Level V: Cadaver Study.

Operative management of equinus associated with lower limb venous malformations

OBJECTIVES

Functional impairment is a common complaint in patients with venous malformations. Equinus can occur when the venous malformation involves the lower limb, a challenging condition with only a few studies to guide treatment choices. This study was aimed to investigate the operative management of equinus associated with lower limb venous malformations.

METHOD

Between August 2015 and September 2017, a total of 12 patients presented with equinus associated with lower limb venous malformations and underwent surgical correction. Preoperative and postoperative clinical symptoms, physical examination and orthopaedic evaluation were retrospectively reviewed. 8 patients who experienced pain underwent percutaneous sclerotherapy prior to the operation. Surgical management included gastrocnemius intramuscular aponeurotic recession, Z-lengthening of the Achilles tendon, Hoke technique and Taylor Spatial Frame external fixation.

RESULTS

There were eight female and four male patients with a mean age of 14.3 ± 5.9 years. The mean follow-up period was 34.8 ± 9 months. The range of motion of ankle dorsiflexion (with knee extended) improved for each patient (mean, 25.4 degrees; standard deviation, 8.5 degrees). No neurovascular complications were observed.

CONCLUSION

Operative correction of equinus associated with lower limb venous malformations is safe and effective. Selective preoperative sclerotherapy is necessary for optimal outcomes.

Cadaveric Study of the Junction Point Where the Gastrocnemius Aponeurosis Joins the Soleus Aponeurosis

Purpose

To study the location of the junction point where the gastrocnemius aponeurosis joins the soleus aponeurosis to form the Achilles tendon.

Methods

Twelve lower limb specimens were used. The distance between the medial tibial plateau and the superior border of the posterior calcaneal tubercle (A) was measured and the distances of the junction point to the superior border of the posterior calcaneal tubercle (B) were measured.

Result

The ratio B/A averaged 0.45. The gastrocnemius muscle reached or extended beyond the junction point in eight specimens (67%). The average distance from the lowest border of the muscle to the junction point was 0±12mm (-25-25).

Conclusion

There are great anatomical variations of the gastrocnemius insertion. Resection of muscle bound portion of the gastrocnemius aponeurosis is a more appropriate approach of endoscopic gastrocnemius aponeurosis recession.

Clinical Relevance

This report suggests that resection of muscle bound portion rather than the muscle void portion of the gastrocnemius aponeurosis is a more appropriate approach of endoscopic gastrocnemius aponeurosis recession.

Gastrocnemius recession: A cadaveric study of surgical safety and effectiveness

Background and purpose - Many methods of gastrocnemius lengthening have been described, with different surgical challenges, outcomes, and risks to the sural nerve. Our aims were (1) to locate the gastrocnemius muscular-tendinous junction in relation to the mid-length of the fibula (from here on designated the mid-fibula), (2) to compare the dorsiflexion achieved with dorsal recession or ventral recession, and (3) to determine the risk of injury to the sural nerve during gastrocnemius recession. Methods - In 10 pairs of fresh-frozen adult cadaveric lower extremities transected above the knee, we measured dorsiflexion, performed dorsal or ventral gastrocnemius recession at the mid-fibula, and then measured the increase in dorsiflexion and fasciotomy gap. We noted the course of the sural nerve and whether the gastrocnemius muscle provided it with enough muscular coverage to protect it during recession. Results - Dorsal and ventral recession produced statistically (p < 0.05) and clinically significant mean increases in dorsiflexion with extended knee from 12° to 19°, but they were not statistically significantly different from each other in this measure or in fasciotomy gap size. At the mid-fibula, the sural nerve coursed superficially between both heads of the gastrocnemius muscle in 14 of 20 specimens. Sufficient gastrocnemius muscle coverage to protect the sural nerve was provided by the medial head in 18 of 20 specimens and by the lateral head in only 5 of 20 specimens. Interpretation - A ventral gastrocnemius recession proximal to the mid-fibula level poses less risk to the sural nerve than a recession at the mid-fibula. This procedure provides adequate lengthening (1-3 cm) and increased dorsiflexion (compared with baseline), with less risk to the sural nerve than is incurred with recession at the mid-fibular reference line.

Endoscopic Gastrocnemius Intramuscular Aponeurotic Recession

Gastrocnemius aponeurotic recession is the surgical treatment for symptomatic gastrocnemius contracture. Endoscopic gastrocnemius recession procedures has been developed recently and reported to have fewer complications and better cosmetic outcomes. Classically, this is performed at the aponeurosis distal to the gastrocnemius muscle attachment. We describe an alternative endoscopic approach in which the intramuscular portion of the aponeurosis is released.

Anatomy of the triceps surae: a pictorial essay

Gastrocnemius contracture has recently gained relevance owing to its suggested relationship with foot disorders such as metatarsalgia, plantar fasciopathy, hallux valgus, and others. Consequently this has induced a renewed interest in surgical lengthening techniques, including proximal gastrocnemius release, to resolve gastrocnemius contracture in patients with foot disorders. This article describes and discusses the general anatomy of the triceps surae and the surgical anatomy of the gastrocnemius.

Gastrocnemius recession or tendo-achilles lengthening for equinus deformity in the diabetic foot?

Contracture of the Achilles-gastrocnemius-soleus complex leading to ankle equinus has been linked to the development of various foot disorders. Decrease in ankle dorsiflexion results in an increase in plantar pressures and in diabetes and neuropathy, increased pressures can lead to ulceration and possibly the formation of Charcot foot. Surgical management of the equinus deformity corrects this abnormality and has the potential to avert the development of Charcot foot or ankle. Gastrocnemius recession, tendo-Achilles lengthening, and Achilles tenotomy have all been offered as surgical solutions to this condition. This article reviews ankle equinus and compares the treatment options available. A video of Hoke's triple hemisection has been included with this article and can be viewed at www.podiatric.theclinics.com.

In muscle lengthening surgery multiple aponeurotomy does not improve intended acute effects and may counter-indicate: an assessment by finite element modelling

The goal was to assess the effects of multiple aponeurotomy on mechanics of muscle with extramuscular myofascial connections. Using finite element modelling, effects of combinations of the intervention carried out at a proximal (P), an intermediate (I) and a distal (D) location were studied: (1) Case P, (2) Case P-I, (3) Case P-D and (4) Case P-I-D. Compared to Case P, the effects of multiple interventions on muscle geometry and sarcomere lengths were sizable for the distal population of muscle fibres: e.g. at high muscle length (1) summed gap lengths between the cut ends of aponeurosis increased by 16, 25 and 27% for Cases P-I, P-D and P-I-D, respectively, (2) characteristic substantial sarcomere shortening became more pronounced (mean shortening was 26, 29, 30 and 31% for Cases P, P-I, P-D and P-I-D, respectively) and (3) fibre stresses decreased (mean stress equalled 0.49, 0.39, 0.38 and 0.33 for Cases P, P-I, P-D and P-I-D, respectively). In contrast, no appreciable effects were shown for the proximal population. The overall change in sarcomere length heterogeneity was limited. Consequently, the effects of multiple aponeurotomy on muscle length-force characteristics were marginal: (1) a limited reduction in active muscle force (maximal 'muscle weakening effect' remained between 5 and 11%) and (2) an even less pronounced change in slack to optimum length range of force exertion (maximal 'muscle lengthening effect' distally was 0.2% for Case P-I-D) were shown. The intended effects of the intervention were dominated by the one intervention carried out closer to the tendon suggesting that aponeurotomies done additionally to that may counter-indicated.

Gastrocnemius recession as an alternative to tendoAchillis lengthening for relief of forefoot pressure in a patient with peripheral neuropathy: a case report and description of a technical modification

The gastrocnemius recession is a popular surgical procedure for the treatment of equinus contracture. Lengthening the gastrocnemius tendon has been show to be an effective means of reducing pressure to the plantar forefoot by weakening the triceps surae complex. The more traditional method of weakening the triceps surae is a modification of Hoke's triple hemisection through the tendoAchillis. This technique unfortunately carries a serious risk of the development of a calcaneal gait. The purpose of this case report is to demonstrate that the gastrocnemius recession is an effective and safe alternative to the traditional tendoAchillis lengthening. The authors also describe a minimally invasive technique that uses a pediatric speculum for a self-retrained retractor and portal for instrumentation and visualization.

Flexible pediatric and adolescent pes planovalgus: conservative and surgical treatment options

Pediatric and adolescent flexible flatfoot is a pathomechanically complex deformity. Conservative and surgical treatment is directed at realigning the foot and alleviating symptoms. When surgical intervention is considered, there are various methods and techniques that may be performed to realign the foot. The treatment goals are directed first at resolution of pain, and second at the realignment of the foot. A specific treatment algorithm does not exist, although planal dominance influences direct the surgeons when considering surgical intervention. Open physis often dictates the direction of the reconstruction. Attempts at essential joint preservation should be strongly considered in this young patient population. This article provides an overview of the common treatment pathways that highlight methods to structurally realign the pediatric and adolescent flatfoot.

Pediatric & adolescent flatfoot reconstruction in combination with middle facet talocalcaneal coalition resection

Surgical reconstruction of symptomatic flatfoot associated with middle facet tarsal coalition is becoming more widely used. This article demonstrates that coalition-concomitant flatfoot is a pathologic entity that is worthy of surgical management. The literature, although limited, has suggested that poor outcomes with isolated simple coalition resection may have been related to the preoperative pes planus that was not addressed. More recently studies have demonstrated improved clinical and radiographic postoperative outcomes when the flatfoot correction is combined with the coalition resection. This article reviews a surgical treatment algorithm that considers the presence of varying degrees of pes planus and rearfoot arthrosis associated with coalition.

Optimizing outcomes in bunion surgery

The goal of fine-tuning bunion surgery is to optimize outcomes and prevent complications. This is accomplished through restoring anatomic alignment, imparting first ray stability, meticulous surgical technique, and accounting for other causes that may contribute to first ray instability. Despite various soft tissue and osseous surgical procedures along with anatomic variations of each patient, the principles of anatomic restoration and stability remain consistent. Maintenance of correction is predicated on the treatment of underlying pathology and the establishment of optimal stability and first ray alignment.

Anatomical aspects of the gastrocnemius aponeurosis and its muscular bound portion: a cadaveric study-part II

Gastrocnemius intramuscular aponeurotic recession is performed on the anterior surface of the muscular-bound portion of the gastrocnemius aponeurosis, in the "transection zone" located inferior to the region where the aponeurosis is formed by the separate tendons of the medial and lateral heads of gastrocnemius, and superior to the inferior portions of the muscle's 2 heads. Measurements showed the mean proximal-to-distal length of the transection zone to be 50 mm (range 7 to 100 mm), and the mean width was 88 mm (range 48 to 19 mm). The part of the aponeurosis associated with the medial head contributed 60% of the width of the transection zone (mean 53 mm, range 30 to 80 mm), and the lateral head contributed 40% (mean 35 mm, range 18 to 53 mm). The mean lengths of the parts of the medial and lateral heads that were inferior to the transection zone were 40 mm (range 16 to 68 mm) and 22 mm (range 6 to 35 mm), respectively. In theory, a distal transection will have a large biomechanical effect, releasing more gastrocnemius fibers from their plantarflexory action; whereas a proximal transection will have less effect. An oblique incision or step-cut positioned distally on the medial side may be appropriate if the transection zone is short, if the transection is far distal in the zone, and/or if the medial head extends far distal to the lateral head.

Bilateral single-stage middle facet talocalcaneal coalition resection combined with flatfoot reconstruction: a report of 3 cases and review of the literature. Investigations involving middle facet coalitions--part 1

Talocalcaneal middle facet coalitions are associated with rigid pes planovalgus that often requires surgical intervention. Simple resection of the coalition is preferred for symptomatic cases in the absence of rearfoot arthritis. While resection of the coalition will remove the osseous restriction of motion and may eliminate pain, the procedure does not specifically correct the concomitant pes planovalgus. In this report of 6 feet in 3 patients, we advocate combining resection of the coalition with concomitant flatfoot reconstruction in a single-stage operation. The patients in this series averaged 13.67 (range 12-17) years of age at the time of their foot surgeries, and their follow-up averaged 30 (range 16-54) months. All of the patients displayed bilateral middle facet talocalcaneal coalitions and underwent bilateral resection combined with flatfoot reconstruction. Each patient had 1 foot corrected followed by a period of at least 6 months before the contralateral foot was corrected. The mean postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot score was excellent (94.33+/-2.81 points) overall. The median radiographic values for calcaneal inclination, Meary's, and anteroposterior talar-first metatarsal angles demonstrated statistically significant improvements: 9 degrees (3 degrees, 13 degrees) (P= .0273), 4 degrees (2 degrees, 7 degrees) (P= .0269), and 6 degrees (3 degrees, 11 degrees ) (P= .0277), respectively, and all feet demonstrated improved subtalar joint motion without pain. Although long-term results remain to be determined in a larger cohort, it is hoped that this combined approach to talocalcaneal coalition will delay or obviate future rearfoot arthrosis and the need for arthrodesis.

LEVEL OF CLINICAL EVIDENCE

4.

Management of hindfoot disease in rheumatoid arthritis

There is a wide variety of hindfoot disease seen in patients with rheumatoid arthritis. Initial treatment is conservative including optimizing medical management to control the disease process. Should symptoms persist, surgical treatment may be performed, although there is an increased complication rate related to both the disease and the side effects of the medications used to treat it.

Anatomical aspects of the gastrocnemius aponeurosis and its insertion: a cadaveric study

Anatomical variation in the attachment of the gastrocnemius muscle to the soleus muscle has not been studied previously. The gastrocnemius muscle may insert directly onto the tendinous superficial surface of the soleus; however, in most cases, the distal end of the gastrocnemius aponeurosis extends for a variable distance as a thin, tendinous sheet void of muscular attachments. Surgeons performing a gastrocnemius recession may target the exposed inferior portion of the aponeurosis that is not directly covered by muscle. This is the subject of this anatomical study. Fifty-three embalmed cadaveric specimens were dissected to measure the length of the gastrocnemius aponeurosis medially and laterally. Three aponeurosis length categories were subjectively developed according to the ease with which a surgeon might release the gastrocnemius from the soleus: long aponeurosis (minimum aponeurosis length greater than 10 mm; 53% of specimens); short aponeurosis (9%), and direct attachment of the gastrocnemius muscle to the soleus on the medial side, lateral side, or both (38%). The typical gastrocnemius aponeurosis in the sample was distinctly shorter medially and longer laterally. For aponeuroses in the long aponeurosis category, the median length medially was 22.5 mm and median length laterally was 51 mm. In the short aponeurosis category, median medial length was 5 mm and lateral length was 22 mm. The lateral length was 1.8 times greater than the medial length for the long aponeurosis and 5 times greater for the short aponeuroses. Understanding the variation of the gastrocnemius aponeurosis will aid the surgeon in choosing a recession technique, performing the procedure, and preventing iatrogenic complications.