Endoscopic gastrocnemius recession: evaluation in a cadaver model

The Role of Equinus in Flatfoot Deformity

Equinus plays an important role in flatfoot deformity. Proper evaluation and surgical management are critical to comprehensively treat and successfully resolved patients' symptoms. We have discussed the cause, evaluation, and some of the common surgical options. Each procedure has its inherent benefits and risks. It is imperative that the foot and ankle surgeon identify and include these procedures as part of the complete reconstructive surgery.

A Retrospective Comparative Study of Endoscopic Treatment of Gastrocnemius Contracture using the Modified Soft Tissue Release Kit

Background and Objectives: This study aimed to evaluate the effectiveness and safety of endoscopic gastrocnemius recession using the self-developed Modified Soft Tissue Release Kit. Materials and Methods: This retrospective review followed up 22 patients (34 feet) who underwent endoscopic surgery and 20 patients (30 feet) who received open surgery between January 2020 and January 2022. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the maximum ankle dorsiflexion angle were evaluated preoperatively and at the last follow-up. Postoperative complications were recorded. Patient satisfaction was surveyed at the last follow-up. The comparison between quantitative data was analyzed with the Wilcoxon signed-rank test. The comparison between qualitative data was analyzed with the chi-square test. Results: There was no significant difference in the baseline characteristics between the two groups. The AOFAS score in the endoscopic group increased from 50 (18) points preoperatively to 90 (13) points at the last follow-up; the maximum ankle dorsiflexion angle increased from −7.7 (2.8) degrees to 10.6 (3.6) degrees. The AOFAS score in the open group improved from 47 (15) points preoperatively to 90 (18) points at the last follow-up; the maximum ankle dorsiflexion angle increased from −7.6 (4.0) degrees to 10.7 (3.3) degrees. The change values of the AOFAS scores in the endoscopic and open groups were 39 (15) and 40.5 (11) points, respectively, and there was no significant difference between them. The change values of the maximum ankle dorsiflexion angles in the endoscopic and open groups were 19.5 (4.3) and 19.1 (4.9) degrees, respectively, and there was no significant difference between them. There were no complications, such as sural nerve injury, in both groups. There was no significant difference between the two groups in satisfaction with the surgical outcome. Conclusions: Endoscopic gastrocnemius recession using the Modified Soft Tissue Release Kit can significantly improve the foot function with significant mid-term efficacy and high safety.

Surgical Anatomy of the Endoscopic Gastrocnemius Recession

The objective of this investigation was to analyze the surgical anatomy of the endoscopic gastrocnemius recession procedure with reference to the curved nature of the aponeurosis. A consecutive series of 34 magnetic resonance imaging scans were evaluated under the direction of a musculoskeletal radiologist. An angular calculation of the effective curvature of the aponeurosis was measured 2 cm distal to the musculotendinous junction based on the maximal posterior excursion and terminal medial and lateral edges. A frequency count was additionally performed of the number of deep intramuscular septa extending from the aponeurosis, as well as a description of the location of the neurovascular bundle in this location. The mean effective curvature was 126.5 degrees (standard deviation [SD] = 6.3 degrees, range 115-143 degrees, 95% confidence interval 124.3-128.7 degrees). We observed an average of 1.2 (SD = 0.5, range = 0-2) deep intramuscular septa extending from the aponeurosis, and that 20.6% of neurovascular bundles were located superficial to the aponeurosis in this location. In conclusion, we found that a straight cannula needs to be navigated around an approximate 125-degree angle during performance of the EGR procedure. We think that this information provides evidence of potentially unrecognized complications of this procedure and leads to future investigations demonstrating anatomic and procedural outcomes.

Ankle dorsiflexion after isolated medial versus complete proximal gastrocnemius recession: A cadaveric study

PURPOSE

Gastrocnemius recession has been described in the treatment of gastrocnemius contracture. The aims of this study were: (1) to assess the change in ankle dorsiflexion after isolated medial gastrocnemius recession performed according to L.S. Barouk's technique; (2) to compare ankle dorsiflexion after isolated medial head with complete proximal gastrocnemius recession.

METHODS

A cadaveric study was performed on 15 lower limb adult specimens. Isolated medial gastrocnemius head recession was initially performed, followed by an additional recession of the lateral gastrocnemius head. Ankle dorsiflexion torque was applied with 2 and 4 kg forces on second metatarsal head. Ankle dorsiflexion was measured with the knee both in extension and at 90° of flexion and values were recorded before surgery (T0), after medial head recession (T1) and after both heads recession (T2). Normality of data was assessed using the Shapiro-Wilk test, then measurements were compared in the three conditions with appropriate statistical tests.

RESULTS

After isolated medial gastrocnemius recession (Δ = T1-T0), ankle dorsiflexion assessed with the knee in extension significantly increased by 5° ± 3 (range, -2 to 10) with a 2-kg torque (p = 0.02) and by 4.5° ± 3 (range, -4 to 10) with a 4-kg torque (p = 0.04). No significant difference was observed with the knee flexed at 90° (p > 0.05 for all measurements). After both gastrocnemius heads recession (Δ = T2-T1), although a further increase in dorsiflexion was noticed, statistical significance was not reached neither with the knee in extension nor at 90° of flexion (p > 0.05 for all measurements).

CONCLUSION

In this study, isolated medial gastrocnemius head recession performed according to LS Barouk's technique was effective in improving ankle dorsiflexion, whereas the additional release of the lateral head did not produce any significant change.

LEVEL OF EVIDENCE

Level V, cadaveric study.

Anatomical basis of a safe mini-invasive technique for lengthening of the anterior gastrocnemius aponeurosis

Background

The surgical procedure itself of lengthening the gastrocnemius muscle aponeurosis is performed to treat multiple musculoskeletal, neurological and metabolical pathologies related to a gastro-soleus unit contracture such as plantar fasciitis, Achilles tendinopathy, metatarsalgia, cerebral palsy, or diabetic foot ulcerations. Therefore, the aim of our research was to prove the effectiveness and safety of a new ultrasound-guided surgery-technique for the lengthening of the anterior gastrocnemius muscle aponeurosis, the “GIAR”- technique: the gastrocnemius-intramuscular aponeurosis release.

Methods and results

An ultrasound-guided surgical GIAR on ten fresh-frozen specimens (10 donors, 8 male, 2 females, 5 left and 5 right) was performed. Exclusion criteria of the donated bodies to science were BMI above 35 (impaired ultrasound echogenicity), signs of traumas in the ankle and crural region, a history of ankle or foot ischemic vascular disorder, surgery or space-occupying mass lesions. The surgical procedures were performed by two podiatric surgeons with more than 6 years of experience in ultrasound-guided procedures. The anterior gastrocnemius muscle aponeurosis was entirely transected in 10 over 10 specimens, with a mean portal length of 2 mm (± 1 mm). The mean gain at the ankle joint ROM after the GIAR was 7.9° (± 1.1°). No damages of important anatomical structures could be found.

Conclusion

Results of this study indicate that our novel ultrasound-guided surgery for the lengthening of the anterior gastrocnemius muscle aponeurosis (GIAR) might be an effective and safe procedure.

Endoscopic Transverse Gastrocsoleus Recession in Children With Cerebral Palsy

Aim: The aim of this study was to evaluate the surgical outcome, in terms of gait improvement, of endoscopic transverse Vulpius gastrocsoleus recession in children with cerebral palsy compared to the traditional open surgery. Methods: Twenty-seven children with cerebral palsy who had undergone endoscopic transverse Vulpius gastrocsoleus recession were reviewed. For the comparison of gait improvement, independent ambulatory spastic diplegic patients who had undergone only endoscopic transverse Vulpius gastrocsoleus recession on both legs were selected. Seven (14 legs) children were included and the median age was 7 years (6-9 years). Seven age-matched patients with the same inclusion/exclusion criteria who underwent open surgery were selected as the control group. Physical examination and gait parameters were evaluated and compared between groups, including the gait deviation index (GDI), and gait profile score (GPS). Results: There was no significant complication in twenty-seven children after endoscopic transverse Vulpius gastrocsoleus recession. However, one patient required a revision open surgery at postoperative 1 year 9 months due to the recurrence of equinus and the incomplete division of the midline raphe which was noted during surgery. When comparing gait improvements, there were no differences between the endoscopic and open surgery groups in ankle dorsiflexion angle, ankle kinetics, GDI, and GPS. The postoperative peak ankle dorsiflexion during stance phase was slightly higher in the open group. Conclusion: This is the first study that evaluates gait improvement exclusively for children with spastic diplegia after endoscopic transverse Vulpius gastrocsoleus recession. The gait improvements after endoscopic surgery were comparable to the open surgery, however, the possibility of reduced improvement in ankle kinematics should be considered.

Clinical and radiological outcomes of concomitant endoscopic gastrocnemius release with scarf osteotomy

BACKGROUND

Studies showed patients with hallux valgus also have tight gastrocnemius concomitantly. This study aims to investigate (1) prevalence of tight gastrocnemius in symptomatic hallux valgus (2) clinical and radiological outcomes of concomitant endoscopic gastrocnemius release with scarf osteotomy.

METHODS

Between January 2011 to December 2013, 224 patients underwent hallux valgus surgery were evaluated. They were categorized into 2 groups: scarf osteotomy (n=195), scarf and endoscopic gastrocnemius release (combine, n=29). Clinical outcome measures assessed included VAS, AOFAS Hallux MTP-IP and SF-36 scores. Radiological outcomes included HVA, IMA, HVI and TSP. All patients were prospectively followed up for 6 and 24 months.

RESULTS

The prevalence of ipsilateral gastrocnemius tightness in symptomatic hallux valgus is 12.9%. No significant difference in preoperative clinical outcomes between the two groups (all p>.05). Although AOFAS was 6±2 points poorer in the combine group compared to the scarf group at 6 months follow up (p=0.021), at 24 months, all clinical outcomes were comparable between the two groups (all p>0.05). Significant difference in the HVA change between the groups were observed but comparable radiological outcomes in IMA, TSP and HVI at 24 months follow up.

CONCLUSIONS

We conclude clinical and radiological outcomes of concomitant endoscopic gastrocnemius release and scarf osteotomy are comparable with scarf osteotomy alone at 24 months.

Gastrocnemius Recession for Metatarsalgia

Metatarsalgia is a common cause of plantar forefoot pain. Causes of metatarsalgia include foot anatomy, gait mechanics, and foot and ankle deformity. One specific cause, mechanical metatarsalgia, occurs because of gastrocnemius muscle contracture, which overloads the forefoot. Muscular imbalance of the gastrocnemius complex alters gait mechanics, which increases recruitment of the toe extensor musculature, thereby altering forefoot pressure. Patients with concomitant metatarsalgia and gastrocnemius contracture demonstrate ankle equinus and a positive Silfverskiold test. Nonoperative therapeutic modalities are mainstays of treatment. In patients in whom these treatments fail to provide metatarsalgia symptomatic relief, gastrocnemius muscle lengthening is a therapeutic option.

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.

Using Arthroscopic Techniques for Achilles Pathology

Endoscopically assisted procedures have been established to provide the surgeon with minimally invasive techniques to address common Achilles conditions. Modifications to some of these techniques as well as improvements in instrumentation have allowed these procedures to provide similar clinical results to the traditional open surgeries while reducing wound complications and accelerating patient's recoveries. The available literature on these techniques reports consistently good outcomes with few complications, making them appealing for surgeons to adopt.

Cadaveric Anatomical Study of Sural Nerve: Where is The Safe Area for Endoscopic Gastrocnemius Recession?

Purpose:

To ascertain in cadavers where the sural nerve crosses the gastro-soleus complex and where the gastrocnemius tendon merges with the Achilles tendon in relation to the calcaneal tuberosities.

Methods:

Twelve cadaveric lower limbs (6 right and 6 left) were dissected. The distances between the calcaneal tuberosities and the lateral border of the Achilles tendon where the sural nerve crosses from medial to lateral, as well as to the gastrocnemius tendon insertion into the Achilles tendon, were measured.

Results:

The mean and median longitudinal distances from the calcaneal tuberosity to where the sural nerve crosses the lateral border of the Achilles tendon are 9.9cm and 10cm respectively (range 7cm to 14cm). The mean and median longitudinal distances from the calcaneal tuberosity to where the gastrocnemius tendon inserts into the Achilles tendon are 19.9cm and 18.5cm (range 17cm to 25cm) respectively.

Conclusion:

It is generally safe to place the posterolateral incision more than 14cm above the calcaneal tuberosity to avoid the sural nerve if surgeons plan to use a posterolateral incision for endoscopic recession. The distance between the calcaneal tuberosity to the gastrocnemius tendon insertion into the Achilles tendon is too highly variable to be used as a landmark for locating the gastrocnemius insertion.

Endoscopic Recession of the Gastrocnemius Tendon

Gastrocnemius contracture is a common condition associated with painful overload symptoms in the forefoot and midfoot. Multiple techniques have been described for the recession of gastrocnemius tendon in patients who failed nonsurgical treatment. We present an endoscopic recession technique for the release of the gastrocnemius tendon just distal to the level of the musculotendinous junction as a minimally invasive operative option. This technique aims to decrease wound complications, unsightly scar, overlengthening, and postoperative pain, while having versatility for performing with supine or prone positioning.

Proximal Gastrocnemius Release in the Treatment of Mechanical Metatarsalgia

BACKGROUND

Gastrocnemius shortening causes an equinus deformity that may clinically manifest in foot disorders, including metatarsalgia. We use this term to describe pain localized to the metatarsal heads. The purposes of this prospective study were to review the effect of medial gastrocnemius proximal release on ankle dorsiflexion and assess the outcome of this technique on pain and functional limitations in patients who have mechanical metatarsalgia and isolated gastrocnemius shortening.

METHODS

We prospectively followed a consecutive series of 78 feet in 52 patients with metatarsalgia who had an isolated gastrocnemius contracture assessed with the Silfverskiöld test. Surgical release was evaluated with visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scales. Ankle dorsiflexion was measured at 1, 3, and 6 months postoperatively.

RESULTS

Preoperative values of VAS and AOFAS were 7.4 and 46.8, respectively. After 3 months postoperatively, the values were 3.0 and 81.7, and 6 months after surgery these values were 3.5 and 83.6. No patient worsened clinically. There were no major complications. Thirty-six patients (69.2%) were completely satisfied with the results of the surgery. Preoperatively, ankle dorsiflexion with the knee straight was -17.5 degrees, which improved to 2.5 degrees at 6 months postoperatively.

CONCLUSION

We believe proximal medial gastrocnemius recession is an alternate procedure to treat selected patients with mechanical metatarsalgia and gastrocnemius shortening. It had acceptable morbidity and cosmetic results.

LEVEL OF EVIDENCE

Level IV, case series.

Effect of First Ray Insufficiency and Metatarsal Index on Metatarsalgia in Hallux Valgus

BACKGROUND

Two concepts have been proposed to explain the etiology of metatarsalgia in hallux valgus patients: First, as the magnitude of hallux valgus increases, there is a mechanical overload of the lesser metatarsals. Second, increased relative lesser metatarsal length is a factor in the development of metatarsalgia. However, there is no current evidence that these structural factors lead to primary metatarsalgia. The purpose of the study was to evaluate the factors associated with metatarsalgia in hallux valgus patients.

METHODS

A cross-sectional study of 121 consecutive adult patients with non-arthritic hallux valgus was carried out. Binary logistic regression was performed to identify the effect of the clinical and demographic factors on the occurrence of metatarsalgia. One hundred twenty-one patients (184 feet) with hallux valgus were analyzed. The median weight was 65 kg (interquartile range 58-72).

RESULTS

Metatarsalgia was present in 84 (45.6%) feet. The binary logistic regression showed that lesser toe deformity (OR 2.6, 95% CI 0.2-0.5), gastrocnemius shortening (OR 5.8, 95% CI 2.8-12.3), metatarsal index (OR 0.3, 95% CI 0.2-0.5), and weight (OR 2.5, 95% CI 1.2-5.3) were significantly associated.

CONCLUSION

Metatarsalgia occurs in almost half of hallux valgus patients. It has a multifactorial etiology. Our findings contradict the common theory that both the magnitude of hallux valgus deformity and an increased length of the lesser metatarsals, by themselves, lead to primary metatarsalgia. Metatarsalgia was associated with Achilles shortening, excessive weight, and associated lesser toe deformity. These factors should be addressed in order to treat this disorder adequately.

LEVEL OF EVIDENCE

Level III, comparative series.

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.

Endoscopic gastrocnemius release

Endoscopic gastrocnemius release (EGR) is a recently developed procedure that is a reliable option for surgical management of ankle equinus contracture. Comfort with endoscopic equipment and surgical anatomy, especially the sural nerve, is of paramount importance for performing the procedure safely, effectively, and efficiently. The primary advantage of the procedure is improved cosmesis and decreased wound complications of the smaller surgical scars. The current body of literature of clinical outcomes for EGR consists of limited level IV case series with broad variations in study rigor, author training background, and the surgical technique itself.

Gastrocnemius shortening and heel pain

Pain and reduced function caused by disorders of either the plantar fascia or the Achilles tendon are common. Although heel pain is not a major public health problem it affects millions of people each year. For most patients, time and first-line treatments allow symptoms to resolve. A proportion of patients have resistant symptoms. Managing these recalcitrant cases is a challenge. Gastrocnemius contracture produces increased strain in both the Achilles tendon and the plantar fascia. This biomechanical feature must be properly assessed otherwise treatment is compromised.

Surgical techniques of gastrocnemius lengthening

This article summarizes the various alternatives for direct gastrocnemius lengthening and elucidates the relative strengths and tradeoffs of each as a means of providing balanced perspective in selecting the appropriate procedure for any given patient.

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.

Modified endoscopic release of gastrocnemius aponeurosis

Recession of the gastrocnemius aponeurosis is the operation of choice in the case of isolated gastrocnemius contracture, because it addresses the major deforming force without weakening the entire musculotendinous unit. Endoscopic recession of the gastrocnemius aponeurosis has been proved to be effective but can be associated with the wrong level of release, incomplete release, sural nerve injury, or a palpable gap at the aponeurosis. A modification of the endoscopic technique is described to provide solutions to these potential problems.

Endoscopic Gastrocnemius Recession for the Treatment of Isolated Gastrocnemius Contracture: A Prospective Study on 320 Consecutive Patients

BACKGROUND

Endoscopic gastrocnemius recession has been proposed as a minimally invasive technique for the treatment of isolated gastrocnemius contracture. We report on the safety and efficacy of endoscopic gastrocnemius recession, as an isolated procedure or combined with other concomitant procedures in terms of improvement in ankle dorsiflexion, functional outcome, and postoperative morbidities.

METHODS

The data were prospectively collected in this case series. Endoscopic gastrocnemius recession was performed by a single surgeon in 320 consecutive patients (344 feet) who were diagnosed with isolated gastrocnemius contracture and failed nonoperative treatments between March 2009 and December 2012. There were 180 women and 140 men with mean age, 47.1 ± 15.7 years. The minimum follow-up was 1 year (mean, 18 months; range, 12 to 53 months). Pre- and postoperative ankle dorsiflexion, pain (Visual Analog Scale [VAS]), SF-36, and Foot Function Index (FFI) were obtained and compared using paired sample t test and Wilcoxon signed-rank test.

RESULTS

The mean ankle dorsiflexion significantly improved from -0.8 ± 5.4 degrees preoperatively to 11.0 ± 6.6 degrees at average of 13 months postoperatively (n = 294) (P < .001). Complete preoperative and 1-year postoperative pain (VAS) (n = 274) and functional outcome scores (n = 185) were collected when possible. The mean pain (VAS) decreased from 7/10 to 3/10 postoperatively (all P < .01). The mean SF-36 including physical component summary score (PCS) and mental component summary score (MCS) increased from 34 and 44 to 45 and 51, respectively (P < .01 for both PCS and MCS). The mean FFI improved from 63 to 42 for pain, 63 to 43 for disability, 68 to 44 for activity limitation, and 61 to 41 for total score postoperatively (all P < .01). Postoperative morbidity included weakness of ankle plantarflexion (N = 11/320; 3.1% respectively) and sural nerve dysesthesia (N = 10/320; 3.4%). Wound complications or Achilles tendon rupture did not occur. There was no difference in the average improvement in ankle dorsiflexion, outcome scores, and rate of complications between the isolated and combined procedures.

CONCLUSION

Endoscopic gastrocnemius recession demonstrated promising results in the treatment of isolated gastrocnemius contracture. Ankle dorsiflexion was significantly improved with minimal morbidity. The procedure was found effective in improving functional outcomes and relieving pain as a sole operative treatment and as a part of combined procedures in our patients.

LEVEL OF EVIDENCE

Level IV, case series.

Endoscopic surgery of the Achilles tendon

The value of endoscopic surgery as a minimally invasive treatment is well recognized and includes less perioperative pain, less scarring, minimal blood loss, and faster recovery. While open surgery on the Achilles tendon is notorious for wound complications, the tendon is situated in a well-formed tunnel allowing surgical procedures to be performed endoscopically. Various endoscopic techniques have been successfully applied to the treatment of non-insertional Achilles tendinopathy, Haglund's syndrome, Achilles tendon rupture, and equinus contracture. Although the evidence is currently limited, results from authors acquainted with the techniques have been encouraging. Both an understanding of surgical anatomy of the hindfoot and familiarity in soft tissue endoscopy are required to achieve successful outcomes while minimizing complications.

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.

Simple two-portal technique for endoscopic gastrocnemius recession: clinical tip

Level of Evidence: V, Expert Opinion

Idiopathic toe walking and contractures of the triceps surae

Toe walking is a common feature in immature gait and is considered normal up to 3 years of age. As walking ability improves, initial contact is made with the heel. Toe-walkers will stand out as different once heel-strike is achieved by most of their peers. This difference gives rise to parental concern. Therefore toe-walkers are often referred at 3 years of age. This article examines the evidence for the management of children who have idiopathic toe walking and reviews the literature on surgery for the lengthening of a calf contracture.

Complications associated with uni-portal endoscopic gastrocnemius recession in a diabetic patient population: an observational case series

The purpose of this article was to report the complications associated with uni-portal endoscopic gastrocnemius recession for surgical treatment of pathologic soft tissue ankle equinus contracture in diabetic patients. This is an observational case series involving a retrospective review of prospectively collected data of 23 uni-portal endoscopic gastrocnemius recessions used to treat pathologic soft tissue ankle equinus contracture in 18 consecutive diabetic patients between November 2006 and January 2009. Each patient underwent uni-portal endoscopic gastrocnemius recession under general or spinal anesthesia with thigh tourniquet control in combination with soft tissue and/or osseous reconstructive foot and/or ankle surgery. Patients were kept non-weight bearing based on the index procedure and followed until clinical healing occurred or failure was declared. There were 9 male and 9 female patients with a mean age +/- SD of 69.0 +/- 7.4-years (range: 47.0 to 71.0 years). There were 11 right and 12 left lower limbs involved, with 5 procedures performed bilateral. Complications included 3 conversions to an open incision secondary to difficulty dissecting through excessive adipose tissue, delayed healing of 3 incision sites in patients with uncontrolled diabetes mellitus at the time of surgery, and 3 undercorrections in patients with spastic contractures. The remainder of the procedures were deemed successful with no saphenous nerve, sural nerve, or lesser saphenous vein related injuries occurring. When properly performed, uni-portal endoscopic gastrocnemius recession represents a safe, reliable, and minimally invasive technique useful for correcting pathologic soft tissue ankle equinus contracture in patients with diabetes. A percutaneous tendo-Achilles lengthening should be performed in patients who have marginal arterial inflow that precludes tourniquet use or have a spastic contracture. An open rather than endoscopic gastrocnemius recession should be performed in patients with excessive adipose tissue. Before surgery, the risk of delayed wound healing should be discussed with patients who have uncontrolled diabetes mellitus and in-patient management with tight glycemic control considered.

Gastrocnemius recession to treat isolated foot pain

BACKGROUND

Gastrocnemius recession is performed to correct an isolated gastrocnemius equinus contracture of the ankle that may accompany foot and ankle pathology in the adult. It has been proposed that this equinus deformity leads to excessive strain throughout the foot, thus causing pain. This can manifest itself in the form of plantar fasciitis, metatarsalgia, posterior tibial tendon insufficiency, osteoarthritis, and foot ulcers. The purpose of this retrospective study was to review the efficacy of the gastrocnemius recession in providing pain relief for patients who have foot pain without structural abnormality who have failed conservative treatment and have an isolated gastrocnemius contracture.

MATERIALS AND METHODS

Twenty-nine patients (34 feet) who had chronic foot pain without any structural abnormality other than an isolated gastrocnemius contracture underwent a gastrocnemius recession and were available for follow up at an average of 19.5 (range, 7 to 44) months. The outcome measurements were related to pain relief (Visual Analog Scale) and patient satisfaction.

RESULTS

Preoperatively the average pain score was 8/10 which improved postoperatively to 2/10. Twenty-seven patients (93.1%) said they would recommend this procedure for isolated foot pain to a friend. Twenty-seven patients (93.1%) said they were satisfied with the results of the procedure. Twenty-three of 25 patients (92%) who had a unilateral procedure stated they would have the contralateral leg done if needed.

CONCLUSION

Gastrocnemius recession was found to be an effective procedure when used to relieve recalcitrant foot pain in those patients with an isolated gastrocnemius contracture without deformity.

Achilles lengthening procedures

Contracture of the gastrocnemius-soleus complex with equinus deformity is a common hindfoot condition. In children, it is frequently associated with neuromuscular conditions such as cerebral palsy. In the adult population, it is linked to numerous pathologies such as adult-acquired flatfoot, diabetic neuropathic ulcers, and plantar fasciitis. With the medial column reduced, failure to achieve 10 degrees of passive ankle dorsiflexion with the knee flexed and extended suggests a contracture. This article reviews the anatomical and evolutionary basis for human foot structure, implications of tight gastrocnemius, and specific disease states. Operative releases for lengthening, including proximal gastrocnemius recession, tendo-Achilles lengthening, and endoscopic recession, are detailed.

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.

Surgical correction of soft-tissue ankle equinus contracture

Soft-tissue ankle equinus contracture is an important component of numerous foot and ankle deformities. In high-risk patients who have multiple co-morbidities, procedure selection and careful surgical technique are paramount to increase the likelihood of postoperative success. This article discusses the indications for percutaneous Achilles tendon lengthening, open gastrocnemius recession, and endoscopic gastrocnemius recession, and provides a detailed description of each surgical technique with pearls to avoid intra-perative and postoperative complications specific to the high-risk patient. Thorough knowledge of each of these techniques will aide the foot and ankle surgeon in appropriate peri-operative management of equinus deformity in a complex patient population.

Radiographic evaluation of endoscopic gastrocnemius recession, subtalar joint arthroereisis, and flexor tendon transfer for surgical correction of stage II posterior tibial tendon dysfunction: a pilot study

The best procedure for surgical correction of stage II posterior tibial tendon dysfunction has long been a source of debate among foot and ankle surgeons. A combination of endoscopic gastrocnemius recession, subtalar joint arthroereisis, and flexor digitorum longus tendon transfer has been used in an attempt to avoid some of the complications seen with calcaneal osteotomies, and to allow an earlier return to function and weight bearing. A retrospective analysis of preoperative and postoperative radiographic changes in 10 patients for whom surgical correction of the deformity was performed between 2003 and 2006 is presented as a pilot study. Seven radiographic variables considered standard for the radiographic assessment of posterior tibial tendon dysfunction were measured. The outcome measure of interest was the return of radiographic variables to normal ranges following surgical correction of the deformity. In addition, preoperative and postoperative clinical outcomes were assessed to evaluate the long-term clinical benefits of this trio of procedures. Radiographic values were noted to return to normal ranges in all cases following this trio of surgical procedures; these changes were statistically significant (P < or = .05). These preliminary results suggest that this surgical combination provides satisfactory correction of deformity in patients presenting with stage II posterior tibial tendon dysfunction.

LEVEL OF CLINICAL EVIDENCE

4.

Video-assisted gastrocnemius-soleus and hamstring lengthening in cerebral palsy patients

The aim of the study was to present the results of video-assisted fractional lengthening of the triceps surae muscle and the hamstrings in children with spastic cerebral palsy. In the period from September 2003 to December 2004, triceps surae muscle contractures were treated in 35 lower extremities (22 patients) and hamstring lengthening was performed in 12 knees (eight patients). The patients were between 4 and 10 years of age. Lengthening of the gastrocnemius-soleus was sufficient for achieving 10 degrees dorsiflexion of the foot in 31 of the 35 extremities. The short-term follow-up, at least 1 year after operation, did not reveal any complications. The hamstring lengthening resulted in full correction in nine knees; one endoscopic procedure required conversion to open surgery owing to bleeding. In one case, incomplete sciatic nerve palsy developed. Video-assisted gastrocnemius-soleus recession as well as video-assisted lengthening of the hamstrings proved to be fully efficient in the group reported here.

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.

The conjoint junction of the triceps surae: Implications for gastrocnemius tendon lengthening

Forty embalmed cadaver lower limbs were dissected to identify the morphology of the conjoint junction of the tendons of gastrocnemius and soleus and the location of the gastrocnemius tendon relative to bony landmarks. Five patterns of conjoint junction morphology were found: transverse (25%), oblique passing distally and medially (45%), oblique passing distally and laterally (5%) and arcuate as an inverted U (17.5%) and a U-shape (7.5%). Left-right asymmetry of the junction was observed in 31.6% of 19 paired cadaver legs. On the medial side of the calf the gastrocnemius tendon could be located between 38 and 46% of the proportion of the distance between the upper border of the calcaneus and the fibular head. Corresponding values for the midline and lateral side of the calf were 45-58% and 48-51%. The location of the gastrocnemius tendon relative to bony landmarks may help to guide incision planning for open or endoscopic division of the tendon.

Morbidity associated with high gastrocnemius recession: retrospective review of 126 cases

To evaluate morbidity associated with surgical lengthening of the gastrocnemius, medical records were reviewed retrospectively for 126 patients (mean age, 49.7 years; range, 8-78 years) who had undergone open gastrocnemius recession. Ten patients had isolated recession; 116 had gastrocnemius recession with an additional foot or ankle procedure on the ipsilateral limb. During a mean follow-up period of 19 months (range, 6-50 months), all patients were examined for any postoperative complications associated with the recession. Complications were defined as the presence of postoperative infection, wound dehiscence, nerve problems, decreased muscle strength, scar problems, or calcaneus gait (overlengthening). Uncomplicated outcome was defined as absence of all these complications and return to regular activity, both occurring during a follow-up of at least 6 months. Postsurgical complications developed in 9 (6%) of the 126 patients: 6 (4%) had scar problems, 2 (1.33%) had wound dehiscence, 2 (1.33%) had infection, 3 (2%) had nerve problems, and 1 (0.67%) developed complex regional pain syndrome. No patient complained of either a limp or gait disturbance. Neither persistent decrease in muscle strength nor calcaneus gait was seen. These data suggest that the open gastrocnemius recession procedure has low associated morbidity.

The effect of triceps surae contracture force on plantar foot pressure distribution

BACKGROUND

Triceps surae contractures have been associated with foot and ankle pathology. Achilles tendon contractures have been shown to shift plantar foot pressure from the heel to the forefoot. The purpose of this study was to determine whether isolated gastrocnemius contractures had similar effects and to assess the effects of gastrocnemius or soleus contracture on midfoot plantar pressure.

METHODS

Ten fresh frozen cadaver below-knee specimens were loaded to 79 pounds (350 N) plantar force with the foot unconstrained on a 10-degree dorsiflexed plate. Combinations of static gastrocnemius or soleus forces were applied in 3-lb increments and plantar pressure recordings were obtained for the hindfoot, midfoot, and forefoot regions.

RESULTS

The percentage of plantar force borne by the forefoot and midfoot increased with triceps surae force, while that borne by the hindfoot decreased (p<or=0.005). Increasing gastrocnemius force had similar results. Increasing triceps surae force from 0 to 21 lbs (93 N) increased average percent forefoot and midfoot force 59% and 38%, respectively, and reduced average percent hindfoot force 18%. Increasing gastrocnemius force from 0 to 18 lbs increased average percent forefoot and midfoot force 50% and 32%, respectively, and reduced average percent hindfoot force 16%. For a given triceps surae force, there was no statistical difference in pressure distribution noted between different combinations of gastrocnemius and soleus force.

CONCLUSIONS

In a static model, increased triceps surae or isolated gastrocnemius force shifted weightbearing plantar pressure from the hindfoot to the midfoot and forefoot. Similar results were noted whether the triceps surae force was applied through the gastrocnemius or soleus or both. The results of this study are consistent with the clinical association of triceps surae contracture with foot and ankle disorders including diabetic foot ulcers and metatarsalgia. The similar effects with triceps surae force application through the gastrocnemius or soleus suggest that patients with isolated gastrocnemius contractures may obtain similar clinical benefits with potentially less morbidity after gastrocnemius aponeurosis lengthening as compared to Achilles tendon lengthening.

Evaluation of results of endoscopic gastrocnemius recession

BACKGROUND

Gastrocnemius recession is traditionally done as an open procedure. The aim of this retrospective study was to evaluate the safety and efficacy of gastrocnemius recession performed endoscopically.

METHODS

The procedure was done in 28 patients (17 men and 11 women), ranging in age from 16 to 72 years (average 47.57, SD 13.86) between January, 2001, and September, 2003. In three patients, the procedure was done bilaterally. Followup ranged from 4 to 36 months (average 22.00, SD 11.84). The procedure was done through a single medial or lateral portal using the 3M Agee Carpal Tunnel Release System (Micro Aire Surgical Instruments, Charlottesville, VA).

RESULTS

The initial incision for portal entry was at the wrong level in two of 31 procedures (6.5%), requiring a second incision. The recession could not be accomplished in one of 31 procedures (3.2%), so an open technique was used to complete transection of the gastrocnemius aponeurosis. One patient had a superficial wound infection (3.2%). There was no incidence of sural nerve or Achilles tendon damage. Analysis of results from a modified Olerud and Molander score using a paired student t-test revealed statistically significant improvement (p < or = 0.05) in pain, stiffness, swelling, and overall average score after the procedure.

CONCLUSION

The results of endoscopic gastrocnemius recession using the Agee Carpal Tunnel Release System have been encouraging, with limited morbidity. The technique proved both feasible and safe in this study.