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Cloodt E, Lindgren A, Rodby-Bousquet E. Knee and ankle range of motion and spasticity from childhood into adulthood: a longitudinal cohort study of 3,223 individuals with cerebral palsy. Acta Orthop 2024; 95:200-205. [PMID: 38708569 PMCID: PMC11072397 DOI: 10.2340/17453674.2024.40606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 03/27/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND AND PURPOSE Reduced range of motion (ROM) and spasticity are common secondary findings in cerebral palsy (CP) affecting gait, positioning, and everyday functioning. These impairments can change over time and lead to various needs for intervention. The aim of this study was to analyze the development path of the changes in hamstring length, knee extension, ankle dorsiflexion, and spasticity in hamstrings and gastrosoleus from childhood into adulthood in individuals with CP at the Gross Motor Function Classification System (GMFCS) levels I-V. METHODS A longitudinal cohort study was undertaken of 61,800 measurements in 3,223 individuals with CP, born 1990-2017 and followed for an average of 8.7 years (range 0-26). The age at examination varied between 0 and 30 years. The GMFCS levels I-V, goniometric measurements, and the modified Ashworth scale (MAS) were used for repeated assessments of motor function, ROM, and spasticity. RESULTS Throughout the follow-up period, knee extension and hamstring length exhibited a consistent decline across all individuals, with more pronounced decreases evident in those classified at GMFCS levels III-V. Ankle dorsiflexion demonstrated a gradual reduction from 15° to 5° (GMFCS I-IV) or 10° (GMFCS V). Spasticity levels in the hamstrings and gastrosoleus peaked between ages 5 and 7, showing a propensity to increase with higher GMFCS levels. CONCLUSION Passive ROM continues to decrease to 30 years of age, most pronouncedly for knee extension. Conversely, spasticity reached its peak at a younger age, with a more notable occurrence observed in the gastrosoleus compared with the hamstrings. Less than 50% of individuals had spasticity corresponding to MAS 2-4 at any age.
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Affiliation(s)
- Erika Cloodt
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund; Department of Research and Development, Region Kronoberg, Växjö.
| | - Anna Lindgren
- Centre for Mathematical Sciences, Lund University, Lund
| | - Elisabet Rodby-Bousquet
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund; Centre for Clinical Research Västerås, Uppsala University-Region Västmanland, Västerås, Sweden
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Li Y, Wang Z, Gan Y, Jiao X, Xu C, Zhao J, Dai K. A Retrospective Comparative Study of Endoscopic Treatment of Gastrocnemius Contracture using the Modified Soft Tissue Release Kit. Medicina (B Aires) 2023; 59:medicina59030635. [PMID: 36984636 PMCID: PMC10058304 DOI: 10.3390/medicina59030635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/07/2023] [Accepted: 03/18/2023] [Indexed: 03/29/2023] Open
Abstract
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.
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Affiliation(s)
- Yiming Li
- Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Zengguang Wang
- Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Yaokai Gan
- Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Correspondence:
| | - Xin Jiao
- Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Chen Xu
- Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Jie Zhao
- Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Kerong Dai
- Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
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Bull PE, Thompson MJ, McGann M, Mendez G, Berlet GC, Olaniyan A. The Medial Gastrocnemius Recession, an Alternative Surgical Treatment for Isolated Gastrocnemius Contracture: A Cadaver Study With Discussion Emphasizing Variable Conjoint Tendon Anatomy. Foot Ankle Spec 2022:19386400221133410. [PMID: 36330662 DOI: 10.1177/19386400221133410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | | | - Maria McGann
- Romano Orthopaedic Center, River Forest, Illinois
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Rocco J, Putzer D, Nogler M, Rocco A, Maitino P, Thaler M. The effect of gastrocnemius resection on knee flexion in a total knee arthroplasty model. Arch Orthop Trauma Surg 2022; 142:2503-2511. [PMID: 33772361 DOI: 10.1007/s00402-020-03695-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 12/03/2020] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Flexion contracture in knee arthritis and total knee arthroplasty (TKA) is a common and significant problem. An improvement in knee extension in patients with TKA and mild flexion contractures has been observed clinically when a gastrocnemius recession was performed for other concomitant conditions. The goal of this study was to quantify the effect of gastrocnemius recession on knee flexion in TKA cadaver model. MATERIALS AND METHODS Range of motion (ROM) of 23 cadaveric knees was determined with a navigation system before and after performing TKA using a medial parapetallar approach and after performing a gastrocnemius recession. Varus-valgus, flexion-extension, and internal-external rotation angles of the knee joint were recorded with leg in full extension and in 90°of knee flexion. Extension and flexion gaps were measured using a gap tensioning device. Dorsiflexion of the foot was measured with a goniometer when a torque moment of 10 Nm was applied to the ankle joint. RESULTS A statistically significant improvement of 5° in knee extension was observed following gastrocnemius recession (P = 0.015). Varus and valgus angles, internal, and external rotation were unaffected by gastrocnemius recession. Ankle dorsiflexion increased by 9° following gastrocnemius recession (P ≤ 0.001). CONCLUSIONS Performing a gastrocnemius recession improves the knee extension in TKA knees with flexion contractures. Gastrocnemius recession may be a useful technique to improve terminal extension in TKA.
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Affiliation(s)
- Jeffrey Rocco
- Utah Orthopaedics, 5782 Adams Avenue Parkway, Ogden, UT, 84405, USA.
| | - David Putzer
- Department of Orthopaedics-Experimental Orthopaedics, Medical University of Innsbruck, Innrain 36, 6020, Innsbruck, Austria
| | - Michael Nogler
- Department of Orthopaedics-Experimental Orthopaedics, Medical University of Innsbruck, Innrain 36, 6020, Innsbruck, Austria
| | - Alexandra Rocco
- Utah Orthopaedics, 5782 Adams Avenue Parkway, Ogden, UT, 84405, USA
| | - Paul Maitino
- Joint Reconstructive Specialists, Inc., 3110 SW 89th Street Suite 200D, Oklahoma City, OK, 73159, USA
| | - Martin Thaler
- Department of Orthopaedics, Medical University of Innsbruck, Innrain 36, 6020, Innsbruck, Austria
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Needle-based gastrocnemius lengthening: a novel ultrasound-guided noninvasive technique. J Orthop Surg Res 2022; 17:435. [PMID: 36176001 PMCID: PMC9523967 DOI: 10.1186/s13018-022-03318-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/09/2022] [Indexed: 11/11/2022] Open
Abstract
Background Gastrocnemius tendon lengthening is performed to treat numerous conditions of the foot and ankle. Gastrocnemius shortening has been associated with more than 30 lower limb disorders, including plantar heel pain/plantar fasciitis, Achilles tendinosis, equinus foot, adult flat foot deformity, and metatarsalgia. Ultrasound-guided ultraminimally invasive lengthening of the gastrocnemius is a step forward in this type of surgery. It can be performed in both legs simultaneously without ischemia using only local anesthesia plus sedation and without the need for a cast or immobilization. The truly novel advantage of the procedure is that it can be performed in the office, without specific surgical instruments. The aim of our research was to prove the effectiveness and safety of a new closed needle-based ultrasound-guided surgical procedure for lengthening the gastrocnemius tendon. Methods and results We performed ultrasound-guided gastrocnemius tendon lengthening using a needle in eight fresh frozen specimens (3 left and 5 right). None of the specimens had been affected by disease or undergone previous surgery that could have affected the surgical technique. We used a linear transducer with an 8- to 17-MHz linear transducer and the beveled tip of an Abbocath as a surgical blade to perform the lengthening procedure. The gastrocnemius Achilles tendon recession was entirely transected in all eight specimens, with no damage to the sural nerve or vessels. The improvement in dorsal flexion was 15°. Conclusion Needle-based ultrasound-guided gastrocnemius tendon lengthening is safe, since the surgeon can see all structures clearly, thus minimizing the risk of damage. The absence of a wound obviates the need for stitches, and recovery seems to be faster. The procedure can be performed in a specialist's office, as no specific surgical instruments are required. This technique could be a valid option for gastrocnemius lengthening and may even be less traumatic than using a hook-knife, as in our previous description.
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Defining Equinus Foot in Cerebral Palsy. CHILDREN 2022; 9:children9070956. [PMID: 35883940 PMCID: PMC9320304 DOI: 10.3390/children9070956] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 11/26/2022]
Abstract
Background: Equinus foot is the deformity most frequently observed in patients with cerebral palsy (CP). While there is widespread agreement on the treatment of equinus foot, a clear clinical definition has been lacking. Therefore, we conducted this study to evaluate functional changes in gait analysis in relation to maximum possible dorsiflexion (0°, 5°, 10° and 15°) and in two subgroups of CP patients (unilateral and bilateral). Methods: In this retrospective study, CP patients with different degrees of clinically measured maximum dorsiflexion were included. We further subdivided patients into unilaterally and bilaterally affected individuals and also included a healthy control group. All participants underwent a 3D gait analysis. Our goal was to determine the degree of maximum clinical dorsiflexion where the functional changes in range of motion (ROM) and ankle moment and power during gait were most evident. Then, a subgroup analysis was performed according to the affected side. Results: In all, 71 and 84 limbs were analyzed in unilaterally and bilaterally affected subgroups. The clinically 0° dorsiflexion group barely reached a plantigrade position in the 3D gait analysis. Differences in ROM were observed between subgroups. Ankle moment was quite similar between different subgroups but to a lower extent in the unilateral group. All CP patients had reduced ankle power compared to controls. Conclusions: A cutoff value of clinical ≤ 5° dorsiflexion is the recommended value for defining a functionally relevant equinus foot in CP patients.
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Kow RY, Che-Ahmad A, Ayeop MAS, Ahmad MW, Yusof S. A novel technique of isolated gastrocnemius recession: A cadaveric comparison with Strayer procedure. J Orthop Surg (Hong Kong) 2022; 29:23094990211043987. [PMID: 34753329 DOI: 10.1177/23094990211043987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Strayer's gastrocnemius recession is a common technique in treating ankle equinus of gastrocnemius origin. Nevertheless, this technique is associated with a few flaws. We aim to introduce a novel technique of isolated gastrocnemius recession and perform a cadaveric study to evaluate its safety and at the same time compare this novel technique with the existing Strayer procedure biomechanically. METHODS Eight fresh cadaveric models of gastrocnemius tightness were established by isolated traction of the gastrocnemius muscles. Gastrocnemius recession was performed on all eight models with Strayer method and the novel method randomized equally. The safety of both the techniques was evaluated by identifying any iatrogenic injury to the surrounding structures. The lengthening and improvement of the ankle dorsiflexion was measured and compared between the two techniques. RESULTS There was no iatrogenic sural nerve or saphenous vein injury in all eight models. There was no significant difference between the two techniques in terms of lengthening (24.25 mm vs 21.00 mm; p = 0.838) and improvement of ankle dorsiflexion (26.5° vs 26°; p = .829). CONCLUSIONS Both Strayer technique and the novel technique of gastrocnemius recession lengthened the gastrocnemius and improved the ankle dorsiflexion in this cadaver trial. Both procedures were safe with proper techniques, and there was no significant difference in efficacy between them. LEVEL OF EVIDENCE Level II, randomized controlled trial.
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Affiliation(s)
- Ren Yi Kow
- Department of Orthopaedics, Traumatology & Rehabilitation, 162083International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Aminudin Che-Ahmad
- Department of Orthopaedics, Traumatology & Rehabilitation, 162083International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Mohd Adham Shah Ayeop
- Department of Orthopaedics, Traumatology & Rehabilitation, 162083International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Muhammad Wafiuddin Ahmad
- Department of Orthopaedics, Traumatology & Rehabilitation, 162083International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Shahril Yusof
- Department of Orthopaedics, Traumatology & Rehabilitation, 162083International Islamic University Malaysia, Kuantan, Pahang, Malaysia
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Manzi G, Bernasconi A, Lopez J, Brilhault J. Ankle dorsiflexion after isolated medial versus complete proximal gastrocnemius recession: A cadaveric study. Foot (Edinb) 2021; 49:101842. [PMID: 34687979 DOI: 10.1016/j.foot.2021.101842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 06/02/2021] [Accepted: 06/09/2021] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Giovanni Manzi
- Service de Chirurgie Orthopédique, Centre Hospitalier Saint Joseph Saint Luc, Lyon, France.
| | - Alessio Bernasconi
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, London, United Kingdom; Orthopaedic and Traumatology Unit, Department of Public Health, "Federico II" Naples University, Naples, Italy
| | | | - Jean Brilhault
- Centre de Chirurgie Orthopédique & Traumatologique, C.H.R.U Tours, 37044, Tours Cedex, France; Faculté de Médecine de Tours, 10, Boulevard Tonnelé, 37032 Tours Cedex 1, France
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Surgical Management of Musculotendinous Balance in the Progressive Collapsing Foot Deformity: The Role of Peroneal and Gastrocnemius Contracture. Foot Ankle Clin 2021; 26:559-575. [PMID: 34332735 DOI: 10.1016/j.fcl.2021.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Surgical treatment of progressive collapsing foot deformity (PCFD) relies on understanding the dynamic and deforming musculotendinous structures that contribute to hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. Equinus commonly is seen in PCFD and consideration should be given to isolated gastrocnemius or Achilles lengthening. Although transfer of the flexor digitorum longus tendon is performed in PCFD attributed to dysfunction and pathology of the posterior tibialis tendon (PTT), retention of PTT is an area for further research. The peroneus brevis, which contributes to hindfoot imbalance in chronic cases, is a possible component of tendon rebalancing.
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Kaneuchi Y, Otoshi KI, Hakozaki M, Watanabe K, Konno SI. Talipes Equinus Deformity Caused by Fibrous Gastrocnemius Muscle Contracture After Direct Contusion in Football Players: Report of Two Cases. J Foot Ankle Surg 2021; 59:816-820. [PMID: 32600565 DOI: 10.1053/j.jfas.2019.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/02/2019] [Indexed: 02/03/2023]
Abstract
Two main causes of gastrocnemius contracture have been considered: 1) congenital deformities in pediatric patients, such as limb-length discrepancy, cerebral palsy, flatfoot, and clubfoot; and 2) secondary conditions such as immobilization for trauma or a nonfunctional limb. Talipes equinus deformity caused by fibrous gastrocnemius contracture after a direct muscle contusion is extremely rare. We describe 2 cases of talipes equinus deformity caused by fibrous gastrocnemius muscle contracture after a direct contusion in football players. Both of the players had a talipes equinus deformity with a severe restriction of ankle dorsiflexion, and a cord-like structure was observed at the proximal part of the lateral gastrocnemius head. Both patients' histological examinations revealed fibrous tendon-like tissue within the structure. After discission of the cord-like structures, the restriction of ankle dorsiflexion was completely resolved, and the patients were able to fully return to playing football without any discomfort in their calves.
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Affiliation(s)
- Yoichi Kaneuchi
- Orthopaedic Surgeon, Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.
| | - Ken-Ichi Otoshi
- Professor, Department of Sports Medicine, Fukushima Medical University School of Medicine, Fukushima Japan
| | - Michiyuki Hakozaki
- Associate Professor, Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kazuo Watanabe
- Pathologist, Fukushima Pathology Laboratory, Fukushima, Japan
| | - Shin-Ichi Konno
- Professor, Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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Döring K, Vertesich K, Puchner S. [Adult Acquired Flatfoot Deformity: Diagnosis and Surgical Treatment]. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021; 160:107-126. [PMID: 33567455 DOI: 10.1055/a-1165-4994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The adult acquired flatfoot is a deformity with slow progression, which may leads to pain and restrictions of activities of daily living if untreated. Various treatment strategies, depending on the clinical and radiological presentation, exist. Therefore, an individual therapy approach is necessary for optimal treatment. This article covers etiopathologic aspects, conservative and operative treatments as well as postoperative mobilization and rehabilitation.
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Moon AS, DeBell HA, Peng J, McKissack H, Chinnakkannu K, Moraes L, Brahmbhatt A, Alexander B, Shah A. Macroscopic changes in sural nerve after gastrocnemius recession: a cadaver study. Foot (Edinb) 2020; 44:101682. [PMID: 32663773 DOI: 10.1016/j.foot.2020.101682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/18/2019] [Accepted: 03/22/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gastrocnemius recession is a common foot and ankle procedure and various techniques that have been utilized are mainly delineated by the anatomic position of the gastrocnemius transection; the 2 common ones are the Baumann and Strayer procedure. Both can adversely affect the sural nerve. The objective of this study was to evaluate the macroscopic changes in the sural nerve following gastrocnemius recession, and to compare the efficacy of the two procedures, regarding the improvement of maximal ankle dorsiflexion. METHODS Ten fresh-frozen, above knee cadaveric legs were assigned to one of two gastrocnemius recession techniques: Baumann (n = 5) or Strayer (n = 5). A goniometer was used to measure degree of ankle dorsiflexion before and after the surgery. The sural nerve was meticulously dissected and marked with two suture knots, 2 cm apart. The ankle was passively dorsiflexed from 90° to maximal dorsiflexion in 5° degree increments, and the distance between two suture knots was measured at each increment. The distance between the two cut ends of gastrocnemius muscle was measured with the ankle at 90° and at maximal dorsiflexion. RESULTS Overall, a mean increase in length between the suture knots on the sural nerve was 0.2 cm, from 90° to maximum ankle dorsiflexion (130°); both the Baumann and Strayer techniques resulted in 0.2 cm increase. The mean improvement in maximal ankle dorsiflexion in the Baumann and Strayer group was 22.6° and 22°, respectively. The mean change in distance between the two cut ends of the gastrocnemius muscle in the Baumann and Strayer group was 1.0 cm and 0.9 cm, respectively. CONCLUSION Increased dorsiflexion of the ankle following Strayer or Baumann gastrocnemius recession resulted in similar macroscopic change in the sural nerve, which may contribute to the development of sural neuritis. Further clinical studies are warranted to assess clinical implications of these findings.
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Affiliation(s)
- Andrew S Moon
- Tufts University School of Medicine, Boston, MA, USA; University of Alabama at Birmingham, AL, USA.
| | | | | | | | | | | | - Ashish Brahmbhatt
- Tufts University School of Medicine, Boston, MA, USA; University of Alabama at Birmingham, AL, USA; Edward Via College of Osteopathic Medicine, Auburn, AL, USA.
| | | | - Ashish Shah
- University of Alabama at Birmingham, AL, USA.
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Moroni S, Fernández-Gibello A, Nieves GC, Montes R, Zwierzina M, Vazquez T, Garcia-Escudero M, Duparc F, Moriggl B, Konschake M. Anatomical basis of a safe mini-invasive technique for lengthening of the anterior gastrocnemius aponeurosis. Surg Radiol Anat 2020; 43:53-61. [PMID: 32705404 PMCID: PMC7838137 DOI: 10.1007/s00276-020-02536-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 07/15/2020] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Simone Moroni
- Faculty of Health Sciences At Manresa, Department of Podiatry, Universidad de Vic-Universidad Central de Catalunya (UVic-Ucc), Clinic Vitruvio Biomecánica, BarcelonaMadrid, Spain
| | - Alejandro Fernández-Gibello
- Faculty of Health Sciences, Department of Podiatry, University of La Salle, Clinic Vitruvio Biomecánica, Madrid, Spain
| | - Gabriel Camunas Nieves
- Universidad La Salle, Centro adscrito a la Universidad Autónoma de Madrid, Madrid, Spain.,Vitruvio Biomecanica Y Cirugia Clinic, Madrid, Spain
| | - Ruben Montes
- Universidad La Salle, Centro adscrito a la Universidad Autónoma de Madrid, Madrid, Spain.,Vitruvio Biomecanica Y Cirugia Clinic, Madrid, Spain
| | - Marit Zwierzina
- Department of Plastic, Reconstructive and Aesthetic Surgery, Center of Operative Medicine, Medical University of Innsbruck (MUI), Innsbruck, Austria
| | - Teresa Vazquez
- Anatomy and Embryology Department, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Maria Garcia-Escudero
- School of Physiotherapy and Podiatry, University Catolica de Valencia, Valencia, Spain
| | - Fabrice Duparc
- Laboratory of Anatomy, Faculty of Medicine, Rouen-Normandy University, Rouen, France
| | - Bernhard Moriggl
- Department of Anatomy, Histology and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck (MUI), Müllerstr. 59, 6020, Innsbruck, Austria
| | - Marko Konschake
- Department of Anatomy, Histology and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck (MUI), Müllerstr. 59, 6020, Innsbruck, Austria.
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Shane AM, Reeves CL, Nguyen GB, Sebag JA. Revision Surgery for the Achilles Tendon. Clin Podiatr Med Surg 2020; 37:553-568. [PMID: 32471618 DOI: 10.1016/j.cpm.2020.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Treatment of Achilles tendon ruptures may be surgical or nonsurgical depending on health, history, age, acuity, and severity of the injury. With chronic or revisional injuries, the best method often requires an open repair with reconstructive soft tissue procedures. Revision surgery can be challenging because of the complexity involving tendinous deficits with nonviable and friable tissue. Surgical treatment is based on tendon approximation, size of the defect, tendon integrity, and functional demands. The goal is to restore anatomic and physiologic tension, provide adequate strength for proper ambulation, optimize functional return to activity, decrease pain, and decrease complications.
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Affiliation(s)
- Amber M Shane
- Advent Health East Orlando Podiatric Surgery Residency, Orlando Foot and Ankle Clinic- Upperline Health, 250 North Alafaya Trail Suite 115, Orlando, FL 32828, USA.
| | - Christopher L Reeves
- Advent Health East Orlando Podiatric Surgery Residency, Orlando Foot and Ankle Clinic- Upperline Health, 250 North Alafaya Trail Suite 115, Orlando, FL 32828, USA
| | - Garrett B Nguyen
- Department of Podiatric Surgery, Advent Health East Orlando Podiatric Surgery Residency, 250 North Alafaya Trail Suite 1115, Orlando, FL 32828, USA
| | - Joshua A Sebag
- Department of Podiatric Surgery, Advent Health East Orlando Podiatric Surgery Residency, 250 North Alafaya Trail Suite 1115, Orlando, FL 32828, USA
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Abstract
Metatarsalgia is a common foot disease with a multitude of causes. Proper identification of underlying diseases is mandatory to formulate an adequate treatment. Multiple surgical solutions are available to treat metatarsalgia. Only limited scientific evidence is available in the literature. However, most of the techniques used in the treatment of metatarsalgia seem to be reasonable with acceptable results.
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Affiliation(s)
- Georg Klammer
- Institute for Foot and Ankle Reconstruction, Kappelistrasse 7, 8002 Zurich, Switzerland
| | - Norman Espinosa
- Institute for Foot and Ankle Reconstruction, FussInsitut Zurich, Kappelistrasse 7, Zurich 8002, Switzerland.
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Abstract
Two theories exist in the development of central or transfer metatarsalgia. First, as the severity of hallux valgus increases, there is mechanical overload of the second metatarsal. Second, increased relative lesser metatarsal length is thought to contribute to metatarsalgia. It is imperative, in the treatment of first ray disorders (hallux valgus or hallux rigidus), to not overshorten the first ray when addressing the first ray pathologic condition. Treatment of metatarsalgia in the setting of failed hallux valgus correction can be treated with both conservative and surgical options.
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Affiliation(s)
- Angela K Walker
- Orthopedic Surgeons, Inc, 2790 Clay Edwards Drive, Suite 650, Kansas City, MO 64116, USA.
| | - Thomas G Harris
- Congress Orthopedic Associates, 800 South Raymond, 2nd Floor, Pasadena, CA 91105, USA; Foot and Ankle Surgery, UCLA Harbor Medical Center, 1000 W Carson Street, Torrance, CA 90502, USA
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17
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Abstract
A fundamental etiologic component of metatarsalgia is the repetitive loading of a locally concentrated force in the forefoot during gait. In the setting of an isolated gastrocnemius contracture, weight-bearing pressure is shifted toward the forefoot. If metatarsalgia is considered an entity more than a symptom, evaluation of gastrocnemius contracture must be a part of the physical examination, and gastrocnemius recession via the Baumann procedure alone, or in combination with other procedures, considered as an alternative treatment in an attempt to restore normal foot biomechanics.
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Affiliation(s)
- Gastón Slullitel
- Department of Foot and Ankle Surgery, J Slullitel Institute of Orthopedics, San Luis 2534, Rosario 2000, Santa Fe, Argentina.
| | - Juan Pablo Calvi
- Department of Foot and Ankle Surgery, J Slullitel Institute of Orthopedics, San Luis 2534, Rosario 2000, Santa Fe, Argentina
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18
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Mao DW, Chandrakumara D, Zheng Q, Kam C, Kon Kam King C. Endoscopic plantar fasciotomy for plantar fasciitis: A systematic review and network meta-analysis of the English literature. Foot (Edinb) 2019; 41:63-73. [PMID: 31706064 DOI: 10.1016/j.foot.2019.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 06/16/2019] [Accepted: 08/18/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Currently, there is limited evidence on outcomes for endoscopic plantar fasciotomy. OBJECTIVES An evidence-based literature review for outcomes of endoscopic plantar fasciotomy for the treatment of plantar fasciitis is provided. METHODS A comprehensive evidence-based literature review of PubMed and Cochrane databases was conducted on 9th March 2019, which identified 12 relevant articles assessing the efficacy of endoscopic plantar fasciotomy. The studies were then assigned to a level of evidence (I-IV). Individual studies were reviewed to provide a grade of recommendation (A-C, I) according to the Wright classification in support of or against endoscopic plantar fascia release. RESULTS Based on the results of this evidence-based review, there is poor evidence (grade C) to support endoscopic plantar fascia release. Release of the medial 2/3 of the plantar fascia in endoscopic plantar fasciotomy was associated with higher AOFAS score. CONCLUSION Although the majority of the level of evidence was low (level IV) and grade of recommendation was poor (grade C), there seemed to be good outcomes for endoscopic plantar fasciotomy. There is a need for more high quality level I randomized controlled trials with validated outcome measures to allow for stronger recommendations to be made.
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Affiliation(s)
- David Weijia Mao
- Department of Orthopaedic Surgery, Changi General Hospital, 2 Simei St 3, 529889, Singapore.
| | - Darshana Chandrakumara
- Department of Orthopaedic Surgery, Changi General Hospital, 2 Simei St 3, 529889, Singapore
| | - Qishi Zheng
- Department of Epidemiology, Singapore Clinical Research Institute, 31 Biopolis Way, 138669, Singapore
| | - Carmen Kam
- Clinical Trials & Research Unit, Changi General Hospital, 2 Simei St 3, 529889, Singapore
| | - Charles Kon Kam King
- Department of Orthopaedic Surgery, Changi General Hospital, 2 Simei St 3, 529889, Singapore
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19
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Villanueva M, Iborra Á, Ruiz MDM, Sanz-Ruiz P. Proximal Ultrasound-Guided Gastrocnemius Recession: A New Ultra-Minimally Invasive Surgical Technique. J Foot Ankle Surg 2019; 58:870-876. [PMID: 31345763 DOI: 10.1053/j.jfas.2018.12.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Indexed: 02/03/2023]
Abstract
Selective proximal recession of the medial gastrocnemius head has clear advantages over other approaches and can be performed as a single or combined open procedure for many indications. The purpose of this study was to evaluate the safety and efficacy of a new technique based on ultrasound-guided ultraminimally invasive proximal gastrocnemius recession. We performed a pilot study with 16 cadavers to ensure that the technique was effective and safe; we then prospectively performed gastrocnemius recession in 12 patients (23 cases) with gastrocnemius contracture associated with other indications. We evaluated pre- and postprocedure dorsiflexion, clinical outcomes (based on the visual analog scale and American Orthopedic Foot and Ankle Society scores), and potential complications. We achieved effective release of the proximal medial gastrocnemius tendon in all cases, with no damage to other tissue. Ankle dorsiflexion increased 12° (range 6° to 18°) (p = .05) and was maintained throughout follow-up. The mean preoperative visual analog scale score was 7 (range 5 to 9), which improved to 1 (range 0 to 2) (p = .01). The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score improved from a mean of 25 (range 20 to 40) to 85 (range 80 to 100) at 6 months and 90 at 12 months (p = .01). No major complications were observed. We considered the technique to be safe and effective for ultrasound-guided ultraminimally invasive proximal-medial gastrocnemius recession using a 1-mm incision in vivo. This novel technique is an alternative to open techniques, with encouraging results and with the potential advantages of reducing pain and obviating lower limb ischemia and deep anesthesia, thus decreasing complications and contraindications and accelerating recovery, although further studies are required.
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Affiliation(s)
- Manuel Villanueva
- Orthopaedic Surgeon, Avanfi Institute and Unit for Ultrasound-guided Surgery, Hospital Beata María Ana, Madrid, Spain.
| | - Álvaro Iborra
- Podiatrist, Avanfi Institute and Unit for Ultrasound-guided Surgery, Hospital Beata María Ana, Madrid, Spain
| | - María Del Mar Ruiz
- Podiatrist, Clínica María del Mar Ruíz, Alcazar de San Juan, Ciudad Real, Spain
| | - Pablo Sanz-Ruiz
- Orthopaedic Surgeon, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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20
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Siegel SJ. The Modified Lepird Procedure for Correction of Metatarsus Adductus. J Foot Ankle Surg 2019; 58:1045-1050. [PMID: 31345764 DOI: 10.1053/j.jfas.2018.12.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Indexed: 02/03/2023]
Abstract
Metatarsus adductus is a common transverse plane congenital foot deformity. Achieving anatomic correction can be challenging, as all osteotomy procedures have a steep learning curve. A multitude of complications can occur when using traditional pan-metatarsal osteotomy approaches. The modified Lepird procedure is performed with proximal base osteotomies on all 5 metatarsals oriented dorsal distal to plantar proximal. All screws are inserted parallel to each other, allowing the forefoot to move laterally as a unit. The foot and ankle surgeon is able to dial in with precision the exact amount of forefoot abduction necessary to correct the deformity. The modified Lepird procedure dynamically corrects the metatarsus adductus deformity so it can easily prevent any over- or undercorrection that may occur intraoperatively. The author recommends this procedure when pan-metatarsal base osteotomies are required for correction of metatarsus adductus and associated deformities.
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Affiliation(s)
- S Jeffrey Siegel
- Attending Foot and Ankle Surgeon, MCR Health Services, Bradenton, FL.
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21
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Abstract
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.
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Affiliation(s)
- Rose E Cortina
- Department of Orthopedic surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
| | - Brandon L Morris
- Department of Orthopedic surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Bryan G Vopat
- Department of Orthopedic surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
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22
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Lui TH, Mak CY. Cadaveric Study of the Junction Point Where the Gastrocnemius Aponeurosis Joins the Soleus Aponeurosis. Open Orthop J 2018; 11:762-767. [PMID: 29399221 PMCID: PMC5769028 DOI: 10.2174/1874325001711010762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 07/19/2016] [Accepted: 07/23/2016] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Tun Hing Lui
- Department of Orthopaedics and Traumatology, North District Hospital 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China
| | - Chong Yin Mak
- Department of Orthopaedics and Traumatology, North District Hospital 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China
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23
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Tan ACK, Tang ZH, Fadil MFBM. Cadaveric Anatomical Study of Sural Nerve: Where is The Safe Area for Endoscopic Gastrocnemius Recession? Open Orthop J 2017; 11:1094-1098. [PMID: 29152002 PMCID: PMC5676004 DOI: 10.2174/1874325001711011094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/18/2017] [Accepted: 09/09/2017] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Alvin Chin Kwong Tan
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, 90 Yishun, Central Singapore, 768828, Singapore
| | - Zhi Hao Tang
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng Singapore, 308433, Singapore
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24
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Attias M, Bonnefoy-Mazure A, De Coulon G, Cheze L, Armand S. Influence of different degrees of bilateral emulated contractures at the triceps surae on gait kinematics: The difference between gastrocnemius and soleus. Gait Posture 2017; 58:176-182. [PMID: 28797961 DOI: 10.1016/j.gaitpost.2017.07.118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 07/21/2017] [Accepted: 07/28/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ankle plantarflexion contracture results from a permanent shortening of the muscle-tendon complex. It often leads to gait alterations. The objective of this study was to compare the kinematic adaptations of different degrees of contractures and between isolated bilateral gastrocnemius and soleus emulated contractures using an exoskeleton. METHODS Eight combinations of contractures were emulated bilaterally on 10 asymptomatic participants using an exoskeleton that was able to emulate different degrees of contracture of gastrocnemius (biarticular muscle) and soleus (monoarticular muscle), corresponding at 0°, 10°, 20°, and 30° ankle plantarflexion contracture (knee-flexed and knee-extended). Range of motion was limited by ropes attached for soleus on heel and below the knee and for gastrocnemius on heel and above the knee. A gait analysis session was performed to evaluate the effect of these different emulated contractures on the Gait Profile Score, walking speed and gait kinematics. RESULTS Gastrocnemius and soleus contractures influence gait kinematics, with an increase of the Gait Profile Score. Significant differences were found in the kinematics of the ankles, knees and hips. Contractures of soleus cause a more important decrease in the range of motion at the ankle than the same degree of gastrocnemius contractures. Gastrocnemius contractures cause greater knee flexion (during the stance phase) and hip flexion (during all the gait cycle) than the same level of soleus contractures. CONCLUSION These results can support the interpretation of the Clinical Gait Analysis data by providing a better understanding of the effect of isolate contracture of soleus and gastrocnemius on gait kinematics.
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Affiliation(s)
- M Attias
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals and Geneva University, Switzerland; HES-SO University of Applied Sciences and Arts Western Switzerland, School of Health Sciences, Geneva, Switzerland; Univ Lyon, Université Lyon 1, IFSTTAR, LBMC UMR_T9406, F69622, Lyon, France.
| | - A Bonnefoy-Mazure
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals and Geneva University, Switzerland
| | - G De Coulon
- Pediatric Orthopaedic Service, Department of Child and Adolescent, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - L Cheze
- Univ Lyon, Université Lyon 1, IFSTTAR, LBMC UMR_T9406, F69622, Lyon, France
| | - S Armand
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals and Geneva University, Switzerland
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25
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Hoefnagels EM, Belkoff SM, Swierstra BA. Gastrocnemius recession: A cadaveric study of surgical safety and effectiveness. Acta Orthop 2017; 88:411-415. [PMID: 28403726 PMCID: PMC5499333 DOI: 10.1080/17453674.2017.1314157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Eva M Hoefnagels
- Department of Orthopedics, Sint Maartenskliniek, Nijmegen, the Netherlands;,Correspondence:
| | - Stephen M Belkoff
- International Center for Orthopedic Advancement, Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Bart A Swierstra
- Department of Orthopedics, Sint Maartenskliniek, Nijmegen, the Netherlands
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Abstract
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.
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Affiliation(s)
- Phinit Phisitkul
- 1 Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Alexej Barg
- 2 Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Annunziato Amendola
- 3 Department of Orthopedic Surgery, Chief, Division of Sports Medicine, Duke University, Durham, NC, USA
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27
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Abstract
Equinus is linked to most lower extremity biomechanically related disorders. Defining equinus as ankle joint dorsiflexion less than 5° of dorsiflexion with the knee extended is the basis for evaluation and management of the deformity. Consistent evaluation methodology using a goniometer with the subtalar joint in neutral position and midtarsal joint supinated while dorsiflexing the ankle with knee extended provides a consistent clinical examination. For equinus deformity with an associated disorder, comprehensive treatment mandates treatment of the equinus deformity. Surgical treatment of equinus offers multiple procedures but the Baumann gastrocnemius recession is preferred based on deformity correction without weakness.
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Affiliation(s)
- Patrick A DeHeer
- Surgery Department, Indiana University Health North Hospital, Carmel, IN, USA; Surgery Department, Johnson Memorial Hospital, Franklin, IN, USA; Department of Podiatric Medicine and Radiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.
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28
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Villanueva M, Iborra Á, Rodríguez G, Sanz-Ruiz P. Ultrasound-guided gastrocnemius recession: a new ultra-minimally invasive surgical technique. BMC Musculoskelet Disord 2016; 17:409. [PMID: 27716217 PMCID: PMC5048654 DOI: 10.1186/s12891-016-1265-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 09/24/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Isolated gastrocnemius contracture is thought to lead to numerous conditions. Although many techniques have been described for gastrocnemius recession, potential anesthetic, cosmetic, and wound-related complications can lead to patient dissatisfaction. Open and endoscopic recession techniques require epidural anesthesia, lower limb ischemia, and stitches and may lead to damage of the sural nerve, which is not under the complete control of the surgeon at all stages of the procedure. The purpose of this study was to evaluate the safety and efficacy of a new technique based on ultrasound-guided ultra-minimally invasive gastrocnemius recession. METHODS We performed a pilot study with 22 cadavers to ensure that the technique was effective and safe. In the second phase, we prospectively performed gastrocnemius recession in 23 patients (25 cases) with chronic non-insertional Achilles tendinopathy, equinus foot, and other indications. In the clinical study, we evaluated the range of dorsiflexion before and after the procedure, clinical outcomes with VAS and AOFAS scores, and potential complications, including neurovascular injuries. RESULTS We achieved complete release of the gastrocnemius tendon in all cases in the cadaveric study, with no damage to the sural nerve or vessels and minimal damage to the underlying muscle fibers. Ankle dorsiflexion increased for every patient in the study (mean, 14°; standard deviation, 3°) and was maintained throughout follow-up. The mean preoperative VAS score was 7 (6-9), which improved to 0 (0-1). The AOFAS Ankle-Hindfoot Score improved from a mean of 30 (20-40) to 93 (85-100) at 6 months. No major complications were observed. All patients returned to their previous sports after 6 months. CONCLUSIONS After cadaveric and clinical study, we considered the technique to be safe and effective to perform ultrasound-guided ultra-minimally invasive gastrocnemius recession using a 1-mm incision in vivo. This novel technique represents an alternative to open techniques, with encouraging results and with the advantages of reducing pain, obviating lower limb ischemia, deeper anaesthesia, thus decreasing complications and contraindications and accelerating recovery.
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Affiliation(s)
- Manuel Villanueva
- Avanfi Institute and Unit for Ultrasound-guided Surgery, Hospital Beata María Ana, Calle Orense 32., 28020, Madrid, Spain.
| | - Álvaro Iborra
- Avanfi Institute and Unit for Ultrasound-guided Surgery, Hospital Beata María Ana, Calle Orense 32., 28020, Madrid, Spain
| | - Guillermo Rodríguez
- Avanfi Institute and Unit for Ultrasound-guided Surgery, Hospital Beata María Ana, Calle Orense 32., 28020, Madrid, Spain
| | - Pablo Sanz-Ruiz
- Orthopaedic and Trauma Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Morales-Muñoz P, De Los Santos Real R, Barrio Sanz P, Pérez JL, Varas Navas J, Escalera Alonso J. Proximal Gastrocnemius Release in the Treatment of Mechanical Metatarsalgia. Foot Ankle Int 2016; 37:782-9. [PMID: 27036137 DOI: 10.1177/1071100716640612] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Patricia Morales-Muñoz
- Foot and Ankle Unit, Orthopaedic Surgery, Infanta Sofia University Hospital, Madrid, Spain
| | | | - Patricia Barrio Sanz
- Foot and Ankle Unit, Orthopaedic Surgery, Infanta Sofia University Hospital, Madrid, Spain
| | - Jose Luis Pérez
- Foot and Ankle Unit, Orthopaedic Surgery, Infanta Sofia University Hospital, Madrid, Spain
| | - Jesús Varas Navas
- Foot and Ankle Unit, Orthopaedic Surgery, Infanta Sofia University Hospital, Madrid, Spain
| | - Javier Escalera Alonso
- Foot and Ankle Unit, Orthopaedic Surgery, Infanta Sofia University Hospital, Madrid, Spain
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Rong K, Ge WT, Li XC, Xu XY. Mid-term Results of Intramuscular Lengthening of Gastrocnemius and/or Soleus to Correct Equinus Deformity in Flatfoot. Foot Ankle Int 2015; 36:1223-8. [PMID: 26041542 DOI: 10.1177/1071100715588994] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intramuscular lengthening of the gastrocnemius and/or soleus (Baumann procedure) is widely used in patients who have cerebral palsy, with several advantages over other lengthening techniques. Tightness of the gastrocnemius or gastrocnemius-soleus complex has been confirmed to be related to flatfoot deformity. The purpose of this study was to evaluate the mid-term results of the Baumann procedure as a part of the treatment of flatfoot with equinus deformity. METHODS We reviewed 35 pediatric and adult patients (43 feet) with flatfoot who underwent the Baumann procedure for the concomitant equinus deformity. The mean duration of follow-up was 39.4 months. Preoperative and follow-up evaluations included the maximal angle of dorsiflexion of the ankle with the knee fully extended and with the knee flexed to 90 degrees, the American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores, and postoperative complications. RESULTS Preoperatively, the mean angle of passive ankle dorsiflexion with the knee extended was -4.7 ± 2.7 degrees and that with the knee flexed was 2.3 ± 2.5 degrees. At the final follow-up, both values improved significantly by a mean of 13.6 degrees (P < .001) and 9.7 degrees (P < .001), respectively. The average AOFAS-AH scores improved from 56.8 points preoperatively to 72.1 at the final follow-up. Recurrence of equinus was observed in 3 patients (4 feet). There were no cases of overcorrection, neurovascular injury, or healing problems. CONCLUSIONS Our results indicate that the Baumann procedure can effectively and sequentially correct the tightness of the gastrocnemius or the gastrocnemius-soleus complex in patients with flatfoot deformity, without obvious postoperative complications. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Kai Rong
- Shanghai Institute of Traumatology and Orthopaedics, Shanghai, China Department of Orthopaedics, Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen-tao Ge
- Shanghai Institute of Traumatology and Orthopaedics, Shanghai, China Department of Orthopaedics, Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xing-chen Li
- Shanghai Institute of Traumatology and Orthopaedics, Shanghai, China Department of Orthopaedics, Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiang-yang Xu
- Shanghai Institute of Traumatology and Orthopaedics, Shanghai, China Department of Orthopaedics, Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Cychosz CC, Phisitkul P, Belatti DA, Glazebrook MA, DiGiovanni CW. Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations. Foot Ankle Surg 2015; 21:77-85. [PMID: 25937405 DOI: 10.1016/j.fas.2015.02.001] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 11/13/2014] [Accepted: 02/13/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gastrocnemius recession is a surgical technique commonly performed on individuals who suffer from symptoms related to the restricted ankle dorsiflexion that results when tight superficial posterior compartment musculature causes an equinus contracture. Numerous variations for muscle-tendon unit release along the length of the calf have been described for this procedure over the past century, although all techniques share at least partial or complete release of the gastrocnemius muscle given its role as the primary plantarflexor of the ankle. There exists strong evidence to support the use of this procedure in pediatric patients suffering from cerebral palsy, and increasingly enthusiastic support-but less science-behind its application in treating adult foot and ankle pathologies perceived to be associated with gastrocnemius tightness. The purpose of this study, therefore, was to evaluate currently available evidence for using gastrocnemius recession in three adult populations for whom it is now commonly employed: Achilles tendinopathy, midfoot-forefoot overload syndrome, and diabetic foot ulcers. METHODS A systematic review of the literature was performed on December 21, 2013 using the PubMed, Scopus, and Cochrane databases along with the search term "(gastrocnemius OR gastrocsoleus) AND (recession OR release OR lengthening)." This search generated 1141 results; 12 articles found in the references of these papers were also screened for inclusion. In total, 18 articles met our inclusion criteria. These articles were reviewed and assigned a classification (I-V) of Level of Evidence, according to the criteria recommended by the Journal of Bone & Joint Surgery. Based on these classifications, a Grade of Recommendation was assigned for each of the indications of interest. RESULTS Grade B evidence-based literature ("fair") exists to support the use of gastrocnemius recession for the treatment of isolated foot pain due to midfoot/forefoot overload syndrome in adults. There are some data in support of utilizing gastrocnemius recession to treat midfoot or forefoot ulcers and non-insertional Achilles tendinopathy in adults, but to date this evidence remains Grade Cf. Insufficient evidence (Grade I) is currently available to make any recommendation either for or against this procedure for the treatment of insertional Achilles tendinopathy. CONCLUSION Scientific literature continues to grow in support of using isolated gastrocnemius recession as an effective treatment strategy for a variety of lower limb pathologies, although it remains clear that higher evidence levels and more carefully controlled investigations will be necessary to more convincingly define the true efficacy and ideal applications of gastrocnemius recession in the adult population. LEVEL OF EVIDENCE Level IV systematic review.
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Affiliation(s)
- Chris C Cychosz
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Phinit Phisitkul
- Department of Orthopaedics and Rehabilitation, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Daniel A Belatti
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | | | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
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Nawoczenski DA, Barske H, Tome J, Dawson LK, Zlotnicki JP, DiGiovanni BF. Isolated gastrocnemius recession for achilles tendinopathy: strength and functional outcomes. J Bone Joint Surg Am 2015; 97:99-105. [PMID: 25609435 DOI: 10.2106/jbjs.m.01424] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Gastrocnemius recession has emerged as a viable intervention for patients with recalcitrant foot and ankle disorders associated with isolated gastrocnemius contracture. The purpose of this case-control study was to investigate the effects of an isolated gastrocnemius recession on pain, patient-reported function, and strength in patients with chronic Achilles tendinopathy and an isolated gastrocnemius contracture. METHODS Thirteen patients with unilateral Achilles tendinopathy (mean age [and standard deviation], fifty-two ± 7.7 years) who received a gastrocnemius recession and ten matched-control subjects participated. A visual analog scale was used to assess pain, and the Foot and Ankle Ability Measure was used to evaluate patient-reported function in activities of daily living and sports. Patients were asked about their satisfaction with the results of the gastrocnemius recession. Ankle plantar flexion peak torque was assessed at 60°/sec and 120°/sec. Appropriate t tests were used to assess limb symmetry and strength differences between the groups. RESULTS The mean duration of follow-up was eighteen months (range, twelve to twenty-eight months). Gastrocnemius recession provided significant pain relief (mean preoperative visual analog scale score [and standard deviation], 6.8 ± 1.8; mean follow-up visual analog scale score, 1.4 ± 2.7; p < 0.05). Foot and Ankle Ability Measure outcomes showed between-group differences in activities of daily living (Achilles tendinopathy group, 89.7; control group, 98.5; p = 0.05) and sports subscales (Achilles tendinopathy group, 71.9; control group, 95.1; p = 0.05). The activities reported to be the most challenging included going up hills, climbing stairs, running, and jumping. Eleven of the thirteen patients in the Achilles tendon group were satisfied with treatment. Side-to-side strength comparisons showed no differences at 60°/sec. Significant differences were observed at 120°/sec (Achilles tendinopathy group, 21%; control group, 3%; p < 0.05); however, the involved limb reached a peak torque similar to that in the control limb. CONCLUSIONS Isolated gastrocnemius recession provides significant and sustained pain relief for chronic Achilles tendinopathy. Good function can be expected for activities of daily living, but power and endurance activities were more problematic for the Achilles tendinopathy group. Isokinetic strength assessment may not effectively capture patient-reported functional deficits. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Deborah A Nawoczenski
- Center for Foot and Ankle Research, Rochester Center, Ithaca College, 1100 South Goodman Street, Rochester, NY 14620. E-mail address for D.A. Nawoczenski:
| | - Heather Barske
- Winnipeg Regional Health Authority, Pan Am Clinic, 75 Poseidon Bay, Winnipeg, Manitoba R3M 3E4, Canada
| | - Joshua Tome
- Center for Foot and Ankle Research, Rochester Center, Ithaca College, 1100 South Goodman Street, Rochester, NY 14620. E-mail address for D.A. Nawoczenski:
| | - Laura K Dawson
- Department of Orthopaedic Surgery, Blanchfield Army Hospital, 650 Joel Drive, Fort Campbell, KY 42223
| | - Jason P Zlotnicki
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642. E-mail address for B.F. DiGiovanni:
| | - Benedict F DiGiovanni
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642. E-mail address for B.F. DiGiovanni:
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Abstract
Gastrocnemius proximal lengthening was first performed to correct spasticity in children, and was adapted for the patient with no neuromuscular condition in the late 1990s. Since then, the proximal gastrocnemius release has become less invasive and has evolved to include only the fascia overlying the medial head of the gastrocnemius muscle. The indications for performing this procedure are a clinically demonstrable gastrocnemius contracture that influences a variety of clinical conditions in the forefoot, hindfoot, and ankle. It is a safe and easy procedure that can be performed bilaterally simultaneously, and does not require immobilization of the ankle after surgery.
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Affiliation(s)
- Pierre Barouk
- Foot Surgery Center at the Sport's Clinic, 2 Rue Georges Nègrevergne, Merignac 33700, France.
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Abstract
The Grand Rapids Arch Collapse classifications create a novel system for categorizing and correlating numerous common foot and ankle conditions related to a falling arch. The algorithm for treating these conditions is exceptionally replicable and has excellent outcomes. Gastrocnemius equinus diagnosis plays a crucial role in the pathology of arch collapse. A contracture of the gastrocnemius muscle is increasingly recognized as the cause of several foot and ankle conditions. The authors have expanded their indications for gastrocnemius recession to include arch pain without radiographic abnormality, calcaneus apophysitis, plantar fasciitis/fibromas, Achilles tendonosis, early-onset diabetic Charcot arthropathy, and neuropathic forefoot ulcers.
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Affiliation(s)
- John G Anderson
- Spectrum Health Department of Orthopaedics, Orthopaedic Associates of Michigan, PC, 1111 Leffingwell Avenue NE, Grand Rapids, MI 49525, USA.
| | - Donald R Bohay
- Orthopaedic Associates of Michigan, PC, 1111 Leffingwell Avenue NE, Grand Rapids, MI 49525, USA
| | - Erik B Eller
- The CORE Institute, 26750 Providence Parkway suite 200, Novi, MI 48374, USA
| | - Bryan L Witt
- Suncoast Orthopedics, 13211 Walsingham Road, Largo, FL 33774, USA
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Abstract
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.
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Affiliation(s)
- Matthew C Solan
- Department of Trauma and Orthopaedic Surgery, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 5XX, UK; University of Surrey, Guildford, UK; Surrey Foot and Ankle Clinic, Guildford, UK; London Foot and Ankle Centre, London, UK.
| | - Andrew Carne
- Department of Trauma and Orthopaedic Surgery, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 5XX, UK
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Abstract
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.
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Affiliation(s)
- Raymond Y Hsu
- Department of Orthopaedic Surgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Scott VanValkenburg
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Altug Tanriover
- Department of Orthopaedic Surgery, Cankaya Hospital, Bulten Street 44, Kavaklıdere, Ankara 06700, Turkey
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Dalmau-Pastor M, Fargues-Polo B, Casanova-Martínez D, Vega J, Golanó P. Anatomy of the triceps surae: a pictorial essay. Foot Ankle Clin 2014; 19:603-35. [PMID: 25456712 DOI: 10.1016/j.fcl.2014.08.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Miquel Dalmau-Pastor
- Laboratory of Arthroscopic and Surgical Anatomy, Human Anatomy Unit, Department of Pathology and Experimental Therapeutics, School of Medicine, University of Barcelona, C/Feixa Llarga, s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain
| | - Betlem Fargues-Polo
- Laboratory of Arthroscopic and Surgical Anatomy, Human Anatomy Unit, Department of Pathology and Experimental Therapeutics, School of Medicine, University of Barcelona, C/Feixa Llarga, s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain
| | - Daniel Casanova-Martínez
- Anatomy Unit, Biomedical Department, University of Antofagasta, Av. Universidad de Antofagasta s/n (Campus Coloso), Antofagasta 1240000, Chile
| | - Jordi Vega
- Unit of Foot and Ankle Surgery, Hospital Quirón, Plaça d'Alfonso Comín 5, Barcelona 08023, Spain.
| | - Pau Golanó
- Laboratory of Arthroscopic and Surgical Anatomy, Human Anatomy Unit, Department of Pathology and Experimental Therapeutics, School of Medicine, University of Barcelona, C/Feixa Llarga, s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain; Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, 4200 Fifth Avenue, Pittsburgh, PA 15213, USA
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Monteagudo M, Maceira E, Garcia-Virto V, Canosa R. Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession. INTERNATIONAL ORTHOPAEDICS 2014; 37:1845-50. [PMID: 23959221 DOI: 10.1007/s00264-013-2022-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 07/04/2013] [Indexed: 12/21/2022]
Abstract
PURPOSE The purpose of this study was to compare results of partial proximal fasciotomy (PPF) with proximal medial gastrocnemius release (PMGR) in the treatment of chronic plantar fasciitis (CPF). METHOD This retrospective study compares 30 patients with CPF that underwent PPF with 30 that underwent isolated PMGR. Both groups were matched in terms of previous treatments and time from onset of symptoms to surgery. Different standardised evaluation scales (VAS, Likert, AOFASh) were used to evaluate results. RESULTS Plantar fasciotomy had satisfactory results in just 60 % of patients, with an average ten weeks needed to resume work and sports. Patient satisfaction in the PMGR group reached 95 %, being back to work and sports at three weeks on average. Functional and pain scores were considerably better for PMGR and fewer complications registered. CONCLUSION In our series, isolated PMGR is a simple and reliable procedure to treat patients with CPF. It provides far better results than conventional fasciotomy with less morbidity and better patient satisfaction, and thus has become our surgical procedure of choice in recalcitrant CPF.
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Affiliation(s)
- Manuel Monteagudo
- Orthopaedic Foot and Ankle Unit, Orthopaedics and Trauma Department, Hospital Universitario Quiron Madrid, Spain.
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Firth GB, McMullan M, Chin T, Ma F, Selber P, Eizenberg N, Wolfe R, Graham HK. Lengthening of the gastrocnemius-soleus complex: an anatomical and biomechanical study in human cadavers. J Bone Joint Surg Am 2013; 95:1489-96. [PMID: 23965699 DOI: 10.2106/jbjs.k.01638] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lengthening of the gastrocnemius-soleus complex is frequently performed for equinus deformity. Many techniques have been described, but there is uncertainty regarding the precise details of some surgical procedures. METHODS The surgical anatomy of the gastrocnemius-soleus complex was investigated, and standardized approaches were developed for the procedures described by Baumann, Strayer, Vulpius, Baker, Hoke, and White. The biomechanical characteristics of these six procedures were then compared in three randomized trials involving formaldehyde-preserved human cadaveric lower limbs. After one of the lengthening procedures was performed, a measured dorsiflexion force was applied across the metatarsal heads with use of a torque dynamometer. Lengthening of the gastrocnemius-soleus complex was measured directly, by measuring the gap between the ends of the fascia or tendon. RESULTS The gastrocnemius-soleus musculotendinous unit was subdivided into three zones. In Zone 1, it was possible to lengthen the gastrocnemius-soleus complex in either a selective or a differential manner-i.e., to lengthen the gastrocnemius alone or to lengthen the gastrocnemius and soleus by different amounts. The procedures performed in this zone (Baumann and Strayer procedures) were very stable but were limited with regard to the amount of lengthening achieved. Zone-2 lengthenings of the conjoined gastrocnemius aponeurosis and soleus fascia (Vulpius and Baker procedures) were not selective but were stable and resulted in significantly greater lengthening than Zone-1 procedures (p < 0.001). In Zone 3 (Hoke and White procedures), lengthenings of the Achilles tendon were neither selective nor stable but resulted in significantly greater lengthening than Zone-1 or 2 procedures (p < 0.001). CONCLUSIONS Surgical procedures for the correction of equinus deformity by lengthening of the gastrocnemius-soleus complex vary in terms of selectivity, stability, and range of correction. Procedures for the correction of equinus deformity have different anatomical and biomechanical characteristics. Clinical trials are needed to determine whether these differences are of clinical importance. It may be appropriate for surgeons to select a procedure involving the zone best suited to the clinical needs of a specific patient.
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Barske HL, DiGiovanni BF, Douglass M, Nawoczenski DA. Current concepts review: isolated gastrocnemius contracture and gastrocnemius recession. Foot Ankle Int 2012; 33:915-21. [PMID: 23050719 DOI: 10.3113/fai.2012.0915] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Heather L Barske
- Department of Orthopaedic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
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41
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De los Santos-Real R, Morales-Muñoz P, Payo J, Escalera-Alonso J. Gastrocnemius proximal release with minimal incision: a modified technique. Foot Ankle Int 2012; 33:750-4. [PMID: 22995263 DOI: 10.3113/fai.2012.0750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Level of Evidence: V, Expert Opinion
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42
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Late Reconstruction for Sequelae of Compartment Syndrome. Tech Orthop 2012. [DOI: 10.1097/bto.0b013e31824b246d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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43
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Abbassian A, Kohls-Gatzoulis J, Solan MC. Proximal medial gastrocnemius release in the treatment of recalcitrant plantar fasciitis. Foot Ankle Int 2012; 33:14-9. [PMID: 22381231 DOI: 10.3113/fai.2012.0014] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Isolated gastrocnemius contracture has been implicated as the cause of a number of foot and ankle conditions. Plantar fasciitis (PF) is one such condition that can be secondary to altered foot biomechanics as a result of gastrocnemius contracture. In this paper, we report our results with an isolated release of the proximal medial head of gastrocnemius for recalcitrant PF. METHODS We prospectively followed a consecutive series of 21 heels in 17 patients following a Proximal Medial Gastrocnemius Release (PMGR). PF was diagnosed clinically and confirmed radiologically in all cases. To be included, at least 1~year of conservative treatment must have been tried and an isolated gastrocnemius contracture confirmed clinically using Silfverskiold's test preoperatively. Outcome measures included a 5-point Likert scale as well as subjective and objective calf weakness assessments. Final followup was on average 24 (range, 8 to 36) months after the surgery. RESULTS Seventeen of the 21 heels (81%) reported total or significant pain relief following the surgery and none reported worsening of their symptoms. The majority did not have subjective or objective evidence of calf weakness. There were no `major' complications and only one case that suffered a `minor' complication. CONCLUSION We believe a PMGR is a simple way of treating a patient with PF who has failed to respond to conservative management. In our series, the results were favorable, the recovery fast and the morbidity low.
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Affiliation(s)
- Ali Abbassian
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.
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Takigami J, Hashimoto Y, Yamasaki S, Hara Y, Nishikino S, Nakamura H. Gastrocnemius contracture caused by traumatic injury without fracture: a case report. Foot Ankle Int 2011; 32:1152-4. [PMID: 22381200 DOI: 10.3113/fai.2011.1152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Level of Evidence: V, Expert Opinion
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45
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Indikation und Technik der endoskopischen Gastroknemiusverlängerung. ARTHROSKOPIE 2011. [DOI: 10.1007/s00142-010-0615-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Yucesoy CA, Seref-Ferlengez Z, Huijing PA. In muscle lengthening surgery multiple aponeurotomy does not improve intended acute effects and may counter-indicate: an assessment by finite element modelling. Comput Methods Biomech Biomed Engin 2011; 16:12-25. [PMID: 21806415 DOI: 10.1080/10255842.2011.599803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- Can A Yucesoy
- Biomedical Engineering Institute, Boğaziçi University, 34684, Çengelköy, Istanbul, Turkey.
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Lamm BM, Gottlieb HD, Paley D. A two-stage percutaneous approach to charcot diabetic foot reconstruction. J Foot Ankle Surg 2010; 49:517-22. [PMID: 20864361 DOI: 10.1053/j.jfas.2010.07.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Indexed: 02/03/2023]
Abstract
The goals of Charcot deformity correction are to restore osseous alignment, regain pedal stability, and prevent ulceration. Traditional reconstructive surgical approaches involve large, open incisions to remove bone and the use of internal fixation to attempt to fuse dislocated joints. Such operations can result in shortening of the foot and/or incomplete deformity correction, fixation failure, incision healing problems, infection, and the longterm use of casts or braces. We recommend a minimally invasive surgical technique for the treatment of Charcot deformity, which we performed on 11 feet in 8 patients. Osseous realignment was achieved through gradual distraction of the joints with external fixation, after which minimally invasive arthrodesis was performed with rigid internal fixation. Feet were operated on at various stages of Charcot deformity: Eichenholtz stage I (1 foot), Eichenholtz stage II (6 feet), and Eichenholtz stage III (4 feet). When comparing the average change in preoperative and postoperative radiographic angles, the transverse plane talar-first metatarsal angle (P = .02), sagittal plane talar-first metatarsal angle (P = .008), and calcaneal pitch angle (P = .001) were all found to be statistically significant. Complications included 3 operative adjustments of external or internal fixation, 4 broken wires or half-pins, 2 broken rings, and 11 pin tract infections. Most notably, no deep infection, no screw failure, and no recurrent ulcerations occurred and no amputations were necessary during an average follow-up of 22 months. Gradual Charcot foot correction with the Taylor spatial frame plus minimally invasive arthrodesis is an effective treatment.
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Affiliation(s)
- Bradley M Lamm
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA.
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Abstract
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.
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Endoscopic gastrocnemius recession for treating equinus in pediatric patients. Clin Orthop Relat Res 2010; 468:1033-8. [PMID: 19763722 PMCID: PMC2835597 DOI: 10.1007/s11999-009-1084-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 08/27/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED Gastrocnemius recessions have been performed as open or endoscopic procedures. Most of the literature describes the outcomes of these procedures in children with specific neurologic limitations. We report an alternative approach to endoscopic gastrocnemius recessions in neurologically healthy pediatric and adolescent patients whose gastrocnemius equinus could not be corrected nonoperatively. We prospectively followed 23 patients (16 boys, seven girls) who underwent 40 procedures for equinus deformity (n = 22) or osteoarthritis (n = 1). All patients had been directly referred for surgical treatment because all previous nonoperative treatments (stretching, night splints, orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy) had failed. The indications for surgery were patients age 18 years or younger experiencing symptomatic equinus unresponsive to nonoperative care. Pre- and postoperative ankle dorsiflexion were measured. The minimum followup for study inclusion was 1 year (mean, 2.9 years; range, 2-5.1 years). For every patient, dorsiflexion range of motion improved (mean, 15 degrees ; standard deviation, 4 degrees ). No patient had diminished nerve sensation postoperatively. This technique can be used to correct gastrocnemius equinus in otherwise healthy children who have not benefited from prior nonsurgical treatment. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Fuhrmann RA, Wagner A. [Dorsal release of the ankle with transfer of the posterior tibial tendon in patients with paralytic drop foot]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2010; 21:533-44. [PMID: 20087715 DOI: 10.1007/s00064-009-2003-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Realignment of a fixed drop foot to restore gait pattern. INDICATIONS Drop foot due to various neurologic disorders (cerebral spastic palsy, traumatic nerve palsy, Charcot-Marie-Tooth disease) with/without dynamic equinovarus deformity and undisturbed function of the posterior tibial muscle-tendon unit. CONTRAINDICATIONS Osseous deformities leading to drop foot, degenerative joint disease of the ankle, flexion deformity of the midfoot, scar adhesions around the muscle-tendon unit of the posterior tibial muscle, functional deficits of the posterior tibial muscle, ulcers, or soft-tissue damage. SURGICAL TECHNIQUE Prone position: Z-shaped lengthening of the Achilles tendon and open arthrolysis of the posterior ankle and subtalar joint. Supine position: distal tenotomy of the posterior tibial tendon at the navicular. Exposure of the tendon proximally to the medial malleolus. Transposition of the tendon slip along the posterior tibial surface through the interosseous membrane to the distal lower leg. Further rerouting of the tendon beneath the extensor retinaculum to the midfoot. Reinsertion of the posterior tibial tendon to the second or third cuneiform bone. POSTOPERATIVE MANAGEMENT Immobilization of the ankle in neutral position within a plaster or a walker for 6 weeks, followed by a rigid orthosis and physiotherapy. RESULTS Six patients (mean age 52 years) presented with a neurologic fixed drop foot deformity that had developed more than 8.3 years ago. After 12 months, five patients showed a neutral hindfoot position; one patient exhibited a plantar flexion of 5 degrees . Active dorsiflexion was limited in four patients (MRC [Medical Research Council] 2/5) and not visible in one patient. Total range of motion comprised 20 degrees (active) and 35 degrees (passive). During barefoot walking patients showed a regular swing phase of the concerned leg. Patients estimated the overall result as good or excellent.
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Affiliation(s)
- Renée A Fuhrmann
- Lehrstuhl für Orthopädie der Friedrich-Schiller-Universität Jena am Rudolf-Elle-Krankenhaus, Eisenberg, Germany.
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