Gastrocnemius Recession Research Articles

Outcomes After Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy.

Surgical treatment of insertional Achilles tendinopathy (IAT) historically consists of Achilles tendon debridement with reattachment and excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. Zadek osteotomy (ZO) is an alternative to an open midline splitting approach. The purpose of this study was to analyze patient-reported outcomes and complications after percutaneously performed ZO with minimum 2 years' follow-up. One hundred eight cases treated with percutaneous ZO with a minimum 2-year follow-up were retrospectively reviewed. Postoperative complications and patient satisfaction were evaluated. Foot Function Index (FFI) and visual analog scale (VAS) scores were recorded at preoperative and follow-up appointments to measure patients' functional outcomes and pain, respectively. Mean follow-up was 41.2 months (range, 24-65). Mean age was 51.8 years (range, 28-81). The mean FFI score improved from 56.1 (range, 47-88) to 11.0 (range, 7-59) postoperatively (P < .001). The mean VAS score improved from 7.7 (range, 5-10) to 0.4 (range, 0-7) postoperatively (P < .001). The overall complication rate was 3.8% (n = 4). Of 104 cases, 98.1% of patients said they were satisfied with their procedure (n = 102) when asked if they were satisfied with their ZO and recovery. We found the percutaneous ZO to be a safe and effective intervention for treatment of IAT. At a minimum of 2-year follow-up, this intervention is associated with minimal complications, improved function, reduced pain, and a high rate of patient satisfaction.

Surgical Techniques of Gastrocnemius Recession and Achilles Tendon Lengthening (Descriptive Review Article)

This paper aims to review the various surgical techniques for gastrocnemius–soleus recession and Achilles tendon lengthening, with a special focus on the treatment of clubfoot and cerebral palsy (CP) equinus contracture. This descriptive review article comprehensively explores different techniques for gastrocnemius recession, including the Hoke percutaneous triple hemisection, Baker’s method (Tongue-in-Groove Gastrocnemius–Soleus Recession), the Vulpius method, the Baumann procedure, and the Strayer procedure (Gastrocnemius Recession). The objective is to present a detailed analysis of these methods, covering their indications, procedural nuances, relevance in clinical practice, and outcomes.

The INVISION Talar Component in Revision Total Ankle Arthroplasty: Analysis of Early Outcomes.

Launched in 2018 for revision total ankle arthroplasty (rTAA), the INVISION talar component addresses subsidence when poor talar bone stock is present. Due to the recency of the market-availability of the INVISION, studies evaluating its efficacy are lacking. This study presents the first analysis of early-term outcomes of patients undergoing rTAA with the INVISION talar component. This was a single-center, retrospective review of 28 patients undergoing rTAA with the INVISION talar component and INBONE II tibial component performed between 2018 and 2022. Data on preoperative characteristics, postoperative complications, secondary procedures, and survivorship were collected. The primary outcome measures were rates of major complications, re-operation, and implant failure. Secondary outcomes included post-operative changes in varus and valgus alignment of the tibia and talus. The most common secondary procedures performed with rTAA were medial malleolus fixation (n = 22, 78.6%) and gastrocnemius recession (n = 14, 50%). Overall, 10.7% (n = 3) of patients underwent reoperation and 14.3% (n = 4) suffered major complications. Incidence of implant failure was 10.7% (n = 3). All reoperations were caused by infection. Mean varus alignment of the tibia and talus improved from 4.07 degrees and 4.83 degrees to 1.67 degrees and 1.23 degrees, respectively. Mean valgus alignment of the tibia and talus improved from 3.67 degrees and 4.22 degrees to 2.00 degrees and 2.32 degrees, respectively. In a series of 28 patients undergoing rTAA with the INVISION talar component, we discovered comparatively low rates of reoperation, major complication, and implant failure (10.7%, 14.3%, and 10.7%). The INVISION system appears to have a reasonable safety profile, but further studies evaluating long-term outcomes are required to assess the efficacy of the INVISION system.

Talocalcaneal Coalition Resection with Local Fat Grafting and Flatfoot Reconstruction.

Talocalcaneal (TC) coalitions typically present in the pediatric population with medial hindfoot and/or ankle pain and absent subtalar range of motion. Coalition resection with fat interposition is well described for isolated tarsal coalitions1,2; however, patients with concomitant rigid flatfoot may benefit from additional reconstructive procedures. To address this, we employ the surgical technique of TC resection with local fat grafting and flatfoot reconstruction. This procedure is described in 3 steps: (1) gastrocnemius recession and fat harvesting, (2) TC coalition resection with local fat interposition, and (3) peroneus brevis Z-lengthening and calcaneal lateral column lengthening osteotomy with allograft. A 3 to 4-cm posteromedial longitudinal incision is made at the distal extent of the medial head of the gastrocnemius muscle. The gastrocnemius tendon is identified, dissected free of surrounding tissue, and transected. Superficial fat is then harvested from this incision before wound closure. A 7-cm incision is made from the posterior aspect of the medial malleolus to the talonavicular joint. The neurovascular bundle and flexor tendons are dissected carefully from the surrounding tissue as a group and protected while the coalition is completely resected, and bone wax and the local fat are utilized at the resection site to prevent regrowth of the coalition. An approximately 7-cm incision is then made laterally and obliquely following the Langer lines and centered over the lateral calcaneus. The peroneal tendons are released from their sheaths, and the peroneus brevis is Z-lengthened. A calcaneal osteotomy is performed about 1.5 cm proximal to the calcaneocuboid joint and angled to avoid the anterior and middle subtalar facet joints. Two Kirschner wires are inserted retrograde across the calcaneocuboid joint, and the calcaneal osteotomy is opened. A trapezoid-shaped allograft bone wedge is impacted, and the Kirschner wires are advanced across into the calcaneus. The lengthened peroneus brevis tendon is repaired, and the wound is closed in a layered fashion. First-line treatment is nonoperative with orthotics and immobilization. Surgical options include coalition resection with or without calcaneal lengthening osteotomy, arthrodesis, or arthroereisis. Following coalition resection, various grafts can be utilized, including fat autografts, bone wax, or split flexor hallucis longus tendon3-6. This procedure addresses TC coalition with concomitant rigid flatfoot. Resection alone may increase subtalar motion but does not correct a flatfoot deformity. Historically, surgeons performed arthrodesis or arthroereisis, but these are rarely performed in young patients. In patients with coalitions involving >50% of the posterior facet or preexisting degenerative changes, arthrodesis may be indicated7. Patients can expect improvement in pain and function8-11. Previous investigators reported improved patient satisfaction, improved range of motion, clinical and radiographic hindfoot correction, and an improved American Orthopaedic Foot & Ankle Society hindfoot score at the time of final follow-up8,9. Carefully free the neurovascular bundle from the surrounding soft tissue so that it can be carefully retracted away from the area of coalition resection.Utilize the interval between the posterior tibialis and flexor digitorum longus tendons to approach the coalition.Expose the medial wall of the coalition and perform a careful resection that avoids inadvertently diverging into the body of the talus or calcaneus.Place a smooth lamina spreader into the resected area and gently open the subtalar joint to confirm complete coalition resection.Place 2 retrograde wires across the calcaneocuboid joint before performing the osteotomy. Without this step, up to 50% of cases experience calcaneocuboid subluxation and/or rotation after the lateral column lengthening12.To determine the size of the allograft, place a lamina spreader into the osteotomy site to measure the width.If present, rigid supination of the forefoot must be corrected with a medial cuneiform plantar-based closing osteotomy. AOFAS = American Orthopaedic Foot & Ankle SocietyFADI = Foot and Ankle Disability IndexMRI = magnetic resonance imagingCT = computed tomographyOR = operating roomK-wire = Kirschner wire.

Efficiency of Foot and Ankle Surgeries Completed on the Preoperative Stretcher vs Operating Room Table: A Randomized Controlled Trial.

Extremity surgeons frequently operate on the preoperative stretcher rather than the operating room (OR) table. This study sought to identify differences between stretcher-based (SB) and OR table-based (TB) procedures with regard to time efficiency and OR team member preferences. We conducted a prospective randomized controlled trial comparing the efficiency of SB vs OR TB foot and ankle procedures. Fifty-two patients undergoing a hardware removal, isolated gastrocnemius recession, soft tissue procedure, or foreign body removal at our day surgery unit were included. Start time and exit time were recorded. "Start time" was the number of minutes between the patient entering the OR and first incision. "Exit time" was the number of minutes between the procedure ending and the patient exiting the OR. Surveys were disseminated to OR staff who participated in the included cases. The total measured time in the OR was an average 6 minutes shorter in the Stretcher group compared to the OR Table group (10 minutes vs 16 minutes, P < .001). SB procedures were associated with a significantly shorter start time (median difference = 4 minutes, P = .001), but not exit time (median difference = 1 minute, P = .058). No difference was found in actual surgical time. Thirty (96.8%) OR team members perceived SB procedures as enhancing OR efficiency, and 30 (96.8%) respondents considered SB procedures to be equal or superior to OR TB procedures in terms of patient safety. All would recommend or strongly recommend SB procedures. We found SB foot and ankle procedures to require less room time than OR TB procedures. Particularly for high-volume specialties, an average 6 minutes saved per case may meaningfully improve overall OR efficiency. Most OR team members believed that SB surgery improves OR efficiency and is the safer option for OR team members. Level II, randomized controlled trial, survey.

Retrograde Insertion Approach for Anterior Distal Femoral Hemiepiphysiodesis Procedure: A Case Report.

A 13-year-old adolescent boy with spastic diplegic cerebral palsy (CP) presented with crouch gait and bilateral knee flexion contractures (KFCs). After failure of conservative treatments, the patient was referred to orthopaedics for surgical intervention. Anterior distal femoral hemiepiphysiodesis (ADFH), using a retrograde approach, and Strayer gastrocnemius recession were performed bilaterally. No complications were reported during surgery/follow-up. Full-active knee extension and improved gait were achieved. KFC is prevalent in ambulatory patients with CP, reducing gait function. Retrograde ADFH is an effective surgical intervention to reduce KFC and improve gait, and offers simpler insertion/removal than the traditional antegrade technique.

Proximal Medial Gastrocnemius Recession for Recalcitrant Plantar Fasciitis.

Recalcitrant plantar fasciitis (RPF) is characterized by its unresponsiveness to conservative treatments, and its surgical management remains controversial. Although there is some evidence to suggest that gastrocnemius recession can be an effective treatment for RPF, no large series of patients with mid- to long-term follow-up has been published. The objective of this study was to compare physical performance, as measured by the Foot and Ankle Ability Measure activities of daily living score (FAAM-ADL), and pain levels before and 1 year after undergoing proximal medial gastrocnemius recession (PMGR) as a treatment for RPF. Additionally, we aimed to assess this cohort of patients in the mid- to long-term follow-up. This retrospective cohort study included 167 patients who underwent PMGR to address RPF between 2009 and 2021. Patients were examined with the FAAM ADL, visual analog scale (VAS) and satisfaction scores at baseline, 1 year, and at the end of follow-up. Other variables recorded were weight, duration of symptoms until surgery, time between surgery to substantial clinical improvement, calf power and Silfverskiold test, and postoperative complications. We observed that before surgery patients had an FAAM-ADL score of 22.5 (SD 11.1) and a VAS score of 8.6 (SD 9.3). One year after surgery, patients had an FAAM-ADL score of 89 (SD 17) and VAS of 1.33 (SD 2) (P < .01). We also observed that the FAAM-ADL score in the long-term follow-up (>12.5 years) group had a median of 86.4 (SD 22.6), the VAS score was 1.90 (SD 2.84), and the patient satisfaction score had a median of 1 (interquartile range 0-1). Regarding complications, we observed 1 lateral gastrocnemius recession and 1 sural nerve neuritis. Our study provides substantial evidence supporting the use of PMGR as an effective treatment for RPF. The long-term follow-up and large sample size of our series contribute to the existing literature on this topic.

Outcomes of Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy with Two-Year Minimum Follow-Up: A Retrospective Study

Introduction/Purpose: Insertional Achilles tendinopathy (IAT) is a common source of posterior heel pain treated by orthopaedic foot and ankle surgeons. Traditional surgical treatment consists of an open Achilles tendon debridement with re-attachment as well as excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. However, frequent complications include wound healing issue, scar pain, weakness and sural nerve injury. Accordingly, the percutaneous ZO is gaining popularity in the field as an alternative to an open midline splitting approach. Limited literature exists describing outcomes of the percutaneous ZO using a larger sample size. The purpose of this study was to analyze patient reported outcomes and complications after percutaneous ZO with a minimum two-year follow-up period. Methods: One hundred and eight cases treated with percutaneous ZO were retrospectively reviewed across October 2017-July 2021 and outcomes data was available for 104 cases with a minimum two-year follow-up. Patient sex, age, and pertinent comorbidities were recorded. Postoperative complications and patient satisfaction following intervention were evaluated. Foot Function Index score (FFI) was utilized to measure patients’ pain and functional outcomes. Visual Analyzing Scale score (VAS) was also utilized to evaluate pain. These measurements were taken at preoperative and final follow-up. Statistical comparisons were performed using two-tailed, paired t-test with p&lt; 0.05. Results: Mean follow-up time was 41.2±13.1 months (range 24-65 months). The mean FFI score improved from 56.1±5.9 (range 47-88) preoperatively to 11.0±5.1 (range 7-59) postoperatively (p &lt; 0.001). Average VAS score improved in patients receiving percutaneous ZO from 7.6±1.3 (range 5-10) to 0.4±0.9 (range 0-7) postoperatively (p &lt; 0.001). The overall complication rate was 3.8% (N =4). Of 104 cases, 98.1% of patients were satisfied with their procedure (102/104). Conclusion: The percutaneous ZO is a safe and highly effective intervention for treatment of IAT. At a minimum of two-years follow-up, this intervention is associated with minimal complications, improved functional outcomes, reduced pain, and high patient satisfaction. Table 1 Functional and subjective pain preoperative and postoperative scores as evaluated by functional foot index (FFI) and visual analogue scale (VAS), respectively

AOFAS Diabetic Foot Survey Results

Introduction: Foot and ankle pathology in patients with diabetes mellitus is prevalent in the United States and may be associated with significant morbidity. Patient outcomes can be improved by optimal medical management; deformity management and correction to limit the development of infection and ulceration; and timely, appropriate treatment of infection and ulceration when it occurs. Orthopaedic foot and ankle surgeons are well-qualified to treat these patients, either individually or as members of a healthcare professional team. However, there are some healthcare professionals and members of the public who are under the impression that orthopaedic foot and ankle surgeon are either unwilling or uninterested in treating this patient population. The authors hypothesized that this impression was a misconception and this study was designed to address this question. Methods: An online survey was sent to 1376 AOFAS members practicing in the United States. There were six questions, two of which were demographic and one that asked for additional comments. The survey was completed by 297 (22%) members from 45 states and the District of Columbia. Results: Nonoperative treatment of foot and ankle disorders in patients with diabetes mellitus was performed by 98.7% of responders including 98.7% for fractures; 97.6% for common disorders (e.g., bunions, hammer toes, flatfeet, plantar fasciitis, osteoarthritis, tendon disorders); 89.9% for Charcot arthropathy; 77.1% for infections; and 69.0% for ulcers. Operative treatment of foot and ankle disorders in patients with diabetes mellitus was performed by 98.7% of responders including 97.0% for fracture fixation; 96.3% for gastrocnemius recession and/ or Achilles tendon lengthening; 94.6% for arthrodesis for osteoarthritis; 94.3% for hammer toe surgery; 92.6% for bunion surgery; 89.6% for Charcot exostectomy; 83.8% for Charcot reconstruction; 83.5% for amputations within foot; 81.1% for below knee amputations; 74.8% for operative debridement of infections/ ulcers; and 57.9% for total ankle replacement. When asked which healthcare professionals treat diabetic patients in their community, 96.6% listed podiatrists; 91.3% listed orthopaedic foot and ankle surgeons; 69.0% listed other MD/ DO surgeons (e.g. general, plastics, vascular); 64.0% listed nurses (e.g., APRN, wound care specialist); 37.4% listed other orthopaedic surgeons; 31.7% listed non- surgeon MD/ DO physicians; 32.3% listed physician assistants; and 2% listed other. Conclusion: The vast majority of orthopaedic foot and ankle surgeons practicing in the United States who responded to the survey provide operative and nonoperative treatment to patients with diabetes mellitus and foot and ankle disorders. Given the extensive medical education and training of orthopaedic foot and ankle surgeons, their knowledge and surgical skill, and the benefits patients with diabetes receive from appropriate and timely foot and ankle care, efforts should be made to educate the public and other healthcare professionals of the availability of most orthopaedic foot and ankle surgeons to provide this care.

Needle‑based gastrocnemius lengthening: a novel ultrasound‑guided noninvasive technique: part II—clinical results

BackgroundIsolated gastrocnemius contracture has been associated with more than 30 lower limb disorders, including plantar heel pain/plantar fasciitis, Achilles tendinosis, equinus foot, adult flatfoot, and metatarsalgia. Although many techniques are available for gastrocnemius recession, potential anesthetic, cosmetic, and wound-related complications can lead to patient dissatisfaction. Open and endoscopic recession techniques usually require epidural or general anesthesia, exsanguination of the lower extremities and stitches and can damage the sural nerve, which is not under the complete control of the surgeon at all stages of the procedure. The purpose of this study is to evaluate the clinical results of a surgical technique for gastrocnemius lengthening with a needle, as previously described in cadaver specimens.Methods and resultsWe performed a prospective study of ultrasound-guided gastrocnemius tendon lengthening in level II using a needle in 24 cases (19 patients) of gastrocnemius contracture. The study population comprised 12 males and 7 females. Mean age was 41 years (18–64). All but 5 recessions were bilateral and occurred simultaneously. The indication for the procedure was gastrocnemius contracture; although the patients also presented other conditions such as non-insertional Achilles tendinopathy in 6 patients (2 were bilateral), insertional Achilles calcifying enthesitis in 4 (1 was bilateral), metatarsalgia in 4, flexible flat foot in 1 and plantar fasciitis in 5 (2 were bilateral). The inclusion criteria were the failure of a previous conservative protocol, that the Silfverskiöld test was positive, and that the pathology suffered by the patient was within the indications for surgical lengthening of the patients and were described in the scientific literature. The exclusion criteria were that the inclusion criteria were not met, and patients with surgical risk ASA 3 or more and children. In these patients, although possible, it is preferable to perform the procedure in the operating room with monitoring, as well as in children since they could be agitated during the procedure at the office. We used the beveled tip of an Abbocath needle as a surgical scalpel. All patients underwent recession of the gastrocnemius tendon, as in an incomplete Strayer release. We evaluated pre- and postoperative dorsiflexion, outcomes, and procedural pain (based on a visual analog scale and the American Orthopedic Foot and Ankle Society scores), as well as potential complications. No damage was done to the sural bundle.ResultsAnkle dorsiflexion increased on average by 17.89°. The average postoperative visual analog score for pain before surgery was 5.78, 5.53 in the first week, 1.89 at 1 month, and 0.26 at 3 months, decreasing to 0.11 at 9 months. The mean postoperative American Orthopedic Foot and Ankle Society Ankle-Hindfoot score the average was 50.52 before surgery, 43.42 at 1 week, 72.37 at 1 month, 87.37 at 3 months, and 90.79 at 9 months.ConclusionUltrasound-guided needle lengthening of the gastrocnemius tendon is a novel, safe, and effective technique that enables the surgeon to check all the structures clearly, thus minimizing the risk of neurovascular damage. The results are encouraging, and the advantages of this approach include absence of a wound and no need for stitches. Recovery is fast and relatively painless. A specific advantage of ultrasound-guided needle lengthening of the gastrocnemius tendon is the fact that it can be performed in a specialist's office, with a very basic instrument set and local anesthesia, thus reducing expenses.

Carbon Footprint of Minor Foot and Ankle Surgery: A Randomized Controlled Trial.

Climate change poses a substantial threat to human health, and operating rooms (ORs) have an outsized environmental impact. The Program for Research in Sustainable Medicine (PRiSM) designed a protocol for minor foot and ankle surgery intended to reduce waste, streamline instrument trays, and minimize laundry. We conducted a randomized controlled trial to compare the carbon footprint of procedures performed using the PRiSM protocol vs a traditional protocol. Forty adult patients undergoing foreign body removal, hammertoe correction, toe amputation, hardware removal, mass excision, or gastrocnemius recession were randomized to the PRiSM or our "Traditional" protocol. The PRiSM protocol used a smaller instrument tray, fewer drapes and towels, and minimal positioning blankets. No changes were made to surgical site preparation or operative techniques. Environmental impact was estimated using the carbon footprint, measured in kilograms of carbon dioxide equivalents (CO2e). Emissions associated with OR waste, instrument processing, and laundry were calculated. On average, PRiSM cases had a smaller carbon footprint than Traditional cases (17.3 kg CO2e [SD = 3.2] vs 20.6 kg CO2e [SD = 2.0], P < .001). Waste-associated emissions from PRiSM cases were reduced (16.0 kg CO2e [SD = 2.7] vs 18.4 kg CO2e [SD = 1.8], P = .002), as were modeled instrument processing-related emissions (0.34 vs 0.91 kg CO2e). One superficial surgical site infection occurred in each group. We found a small but statistically significant reduction in the environmental impact of minor foot and ankle surgery when using the PRiSM vs Traditional protocol. The environmental impact of these cases was dominated by plastic waste-related emissions. Orthopaedic surgeons should think critically about what components of their surgical setup are truly necessary for patient care, as minor changes in product utilization can have significant impacts on waste and greenhouse gas emissions. Level I, randomized controlled trial.

Patient Reported Outcomes Following Triple Arthrodesis for Adult Acquired Flat Foot Deformity: Minimum Two Year Follow Up

The aim of this study is to analyze patient-reported outcomes following this procedure as well as any demographics that may confer prognostic capability. A retrospective analysis was conducted of patients who underwent Triple Arthrodesis at our facility from 2014-2021. Patients were selected if they underwent an isolated triple arthrodesis. All cases included either a gastrocnemius recession versus a percutaneous tendo-achilles lengthening depending on the patient's Silverskiold examination. The electronic medical record was utilized to collect basic patient demographics, previous foot and ankle surgeries, hardware failures, additional procedures, and surgical complications. To evaluate outcomes, we compared patient reported outcomes measurement information system (PROMIS) survey scores with the general population and preoperative versus postoperative visual analog scale (VAS) scores. Foot function index (FFI) scores and scores were utilized as a validation tool for our results. A total of 132 patients met the criteria for our study with a total of 50 participants completing the PROMIS and FFI surveys. The average time point at which the outcomes were collected was 5.50 y postoperatively, ranging from 1.65 to 7.57 y. The average PROMIS physical function was 38.35, pain interference was 61.52, and depression was 49.82 for this population. The mean FFI scores were 58.56 for pain, 60.07 for disability, and 48.07 for activity limitation. There was a significant decrease in preoperative and postoperative VAS scores from 5.4 to 2.55 (p < .001). Three patients experienced wound complications related to decreased sensation. Our results indicated that only PROMIS depression scores were within one standard deviation of the population mean following a triple arthrodesis procedure. PROMIS physical function and pain interference were both outside of one standard deviation for the population.

Nationally Representative Trends in Incidence of Procedures Done Concomitantly With Primary and Revision Total Ankle From 2012 to 2020

Background As new literature emerges and practice patterns fluctuate, there is a significant potential for variation with regard to adjunctive procedures performed with primary total ankle arthroplasty (pTAA) and revision total ankle arthroplasty (rTAA). Our study aims to evaluate yearly trends in the incidence of concomitant procedures and compare the incidence of adjunctive procedures between pTAA and rTAA. Methods The 2012-2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all pTAA and rTAA. The number of concurrent procedures was compared between pTAA and rTAA and compared across years available in the most current version of the NSQIP database (2012-2020). Results Patients undergoing pTAA had a higher mean age than patients undergoing rTAA (64 vs 61 years; P &lt; .001), and patients undergoing rTAA had higher wound class (P &lt; .001), indicating higher levels of contamination. Concurrent procedures were performed significantly less frequently with pTAA than rTAA (mean procedures 0.82 vs 1.30; P &lt; .001). Removal of deep implants was more commonly coded with rTAA than pTAA (9.0% vs 17.7%; P &lt; .001). Gastrocnemius recession was more frequently performed with pTAA than rTAA (10.4% vs 3.0%; P = .001). Conclusion As pTAA and rTAA increase in incidence throughout the United States, there is increased importance on furthering our understanding of these procedures. This study provides a nationally representative analysis of adjunctive procedures with pTAA and rTAA from 2012 to 2020. Generally, more adjunctive procedures are performed with rTAA versus pTAA, confirming the high complexity of rTAA. Levels of Evidence: Level III

Alteration of the calf strength by heel cord lengthening, gastrocnemius recession through tenotomy or fasciotomy. A retrospective clinical force analysis before and after surgery

BackgroundIndications for surgical corrections about the Achilles tendon are increasing as additional measures in reconstructive interventions about the foot. These indications include shortened gastrocnemii, which cause a so-called ‘functional pes equinus’ and secondary forefoot imbalances, as well as corrections of pes planus and cavus. Surgery about the heel cord may also be indicated for achillodynia and diabetic pressure ulcers. However, there is a lack of evidence that quantifies the results of lengthening procedures about the heel cord. The aim of this study was to quantify the exact changes in calf strength one year after elongating the triceps surae, by measuring flexion forces in 90 degrees knee flexion and knee extension. MethodsThis study involves 69 patients who were examined for calf strength preoperatively and 1 year after gastrocnemius release. A new device, the Leonardo Mechanograph® (Novotec Medical) was used to measure calf strength. Measurements were performed with the knee flexed and extended. ResultsThe operated leg had an overall statistically significant reduction in strength after surgery. Changes were similar on the contralateral leg. The difference in force reduction between the operated and non-operated leg was not statistically significant ConclusionA correlation between measured plantar flexion forces of the foot after a reconstructive foot operation with or without a lengthening procedure about the calf musculature could not be established. Level of evidenceLevel III: retrospective cohort study.

PROMIS Scores for Chronic Plantar Fasciitis Before and After Gastrocnemius Recession

Category: Ankle; Hindfoot Introduction/Purpose: There has been an established relationship between increased loading on the Achilles tendon and tension on the plantar fascia. This supports the idea that either tight gastrocnemius and soleus muscles or contractures of the Achilles tendon are risk factors for plantar fasciitis. Gastrocnemius recession has gained popularity as a viable surgical intervention for cases of chronic plantar fasciitis due to isolated gastrocnemius contracture. To our knowledge, this is the first study to investigate PROMIS scores in patients with plantar fasciitis before and after gastrocnemius recession. Methods: The Electronic Medical Record was queried for medical record numbers associated with Current Procedural Terminology code 27687 (gastrocnemius recession). Our study included all patients with a preoperative diagnosis of chronic plantar fasciitis with treatment via isolated gastrocnemius recession with one-year minimum follow-up. 40 patients were included in our study. Patient variables were collected via chart review. Preoperative and postoperative PROMIS scores were collected in the clinic. Results: Preoperative and postoperative PROMIS scores improved for physical function and pain interference from 39.27 and 62.78 to 44.54 and 56.5 (p=0.0005, p=0.0001) respectively, PROIMS Depression scores were not significantly different (p=0.6727). VAS scores significantly decreased from 7.05 to 1.71 (p &lt; 0.0001). Patients with preoperative peripheral neuropathy had significantly lower improvement in PROMIS physical function scores (p=0.0029). Tobacco use led to significantly lower improvement in in PROMIS depression (p=0.0202). Conclusion: Gastrocnemius recession is an effective option for patients with refractory pain in plantar fasciitis. Our PROMIS and VAS data confirm this procedure's utility and highlight its ability to significantly decrease pain and improve physical function in patients with chronic plantar fasciitis. We believe we have added to the literature by incorporating the, inherently superior, PROMIS scores. Based on the results of this study, the authors recommend gastrocnemius recession for patients who fail conservative management for plantar fasciitis.

Comparison Between Clinical, Radiological and Functional Outcome of Arthroereisis vs Corrective Osteotomies for Correction of Symptomatic Flexible Pes Planovalgus in Adolescents

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Flexible pes planovalgus is a common deformity in young adolescents. It can interfere with daily activities and athletic participation. If conservative treatment fails, operative intervention is justified. Operative interventions include lateral column lengthening alone, multiple osteotomies (medial translation calcaneal osteotomy, lateral column lengthening, and Cotton osteotomies), and arthroereisis. All these options can be combined with gastrocnemius recession, excision of accessory navicular, or other soft tissue procedures. Arthroereisis is a highly controversial procedure with a great debate regarding indications, safety and clinical outcome. The literature comparing corrective osteotomies to arthroereisis in young adolescents is deficient and non conclusive. This study was done to compare the clinical and radiological outcome of multiple corrective osteotomies to arthroereisis in young adolescents. Methods: This is a case control prospective study that included 40 feet (20 feet in each group) in 25 patients with flexible pes planovalgus deformity in patients aged 10 to 13 years, after failure of conservative treatment. Exclusion criteria included generalised ligamentous laxity, neurogenic disorders, and rigid deformity. Cases with severe talonavicular uncoverage (angle more than 40 degrees) were excluded as this might be a contraindication to arthroereisis. Group 1 underwent correction by multiple osteotomies (medial translation calcaneal osteotomy, lateral column lengthening, and Cotton osteotomies) and group 2 underwent arthroereisis using a conical titanium subtalar spacer. Gastrocnemius recession and resection of painful accessory navicular were done if indicated in both groups. Clinical outcome was assessed using AOFAS, FAAM scores and subjective patient satisfaction. Radiological assessment included lateral talocalcaneal angle, anteroposterior and lateral talus first metatarsal angle, talonavicular coverage angle, and calcaneal pitch angle. Results: The mean follow up in group 1 was 29 months compared to 25 months in group 2. Preoperatively, there was no statistically significant difference between the two groups regarding patient demographics, clinical scores, or radiological measurements. Clinically, 18 patients were satisfied in group 1, compared to 17 patients in group 2. The mean AOFAS score improved significantly from 73 (62-90) to 91(73-100) in group 1 and from 73 (62-90) to 89 (73-100) in group 2. FAAM score improved significantly from 76% (68-87) to 95.75% (74-100) in group 1, and from 73% (62-86) to 91% (71-98) in group 2. The difference between the two groups was not statistically significant. All radiological measurements improved significantly in both groups without a statistically significant difference between the two groups. Conclusion: Clinical and radiological outcome of arthroereisis is comparable to corrective osteotomies in young adolescents with symptomatic pes planovalgus deformity and can be a valid option in management of these cases, but long term follow up is needed. Also, consensus regarding the perfect age, implant removal, and the degree of talonavicular uncoverage that can be corrected by arthroereisis need further studies.

Adjacent Joint Arthritis Incidence Rate Following Fusion of the First Tarsometatarsal Joint as Treatment for a Forefoot Deformity

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Nontraumatic forefoot deformities such as hallux valgus (HV) are common causes for patients seeking reconstructive surgery. Known as a “bunion,” HV is characterized by 1-2 intermetatarsal angle widening and first metatarsal head medial drift, resulting in the great toe pointing laterally. Surgery is indicated for patients who fail to find relief with conservative management. However, there is no consensus among orthopedic surgeons on whether osteotomy or first tarsometatarsal (TMT) arthrodesis is the better surgical treatment method. Additionally, no known studies have explored the development of adjacent joint arthritis in patients who have received a first TMT fusion. This study aims to investigate the rate of arthritis development in the adjacent joints following arthrodesis of the first TMT joint. Methods: A retrospective chart review at a tertiary foot and ankle clinic was performed on subjects who received a first TMT fusion between January 2004 and December 2017. This included subjects who received concomitant gastrocnemius recession, tendo-achilles lengthening, 1-2 intermetatarsal arthrodesis, 1-2 intercuneiform arthrodesis, hammertoe corrections, and other soft tissue releases deemed by the senior authors to be inconsequential in the case of adjacent joint arthritis development. Pre- operative, operative, and post-operative indications will be evaluated throughout this thorough chart review, and charts will be continually reviewed for inclusion and exclusion criteria. Patient information gathered includes age, sex, height, weight, BMI, activity level, smoking history, medications, time spent with hardware retained, the method of arthritis diagnosis (x-ray alone, CT, MRI, bone scan), relevant additional diagnoses, and operative data. Pre- and post-operative pain levels and satisfaction scores will follow the AOFAS Score Criteria. Results: Preliminary Results: 899 subjects (148 males, 751 females) are included in this study. The age range was 67 years (18 - 85), with an average age of 56.6 at surgery. Patient BMI varied from 12.7 to 53.1. Concurrent operative soft tissue procedures: gastrocnemius recession (749), tendo-Achilles lengthening (13), and a combination of the two (1). Concomitant fusions: isolated 1- 2 intermetatarsal arthrodesis (799) and combined with 1-2 intercuneiform arthrodesis (695). Clinical follow-up ranged from three to 186 months, averaging 34 (2 years, ten months). Presently, radiographic assessment has been performed for 154 of the 899 patients included in this study. Of these, 11 had developed adjacent joint arthritis at last radiographic follow-up (7.1%); two with naviculocuneiform arthritis, eight with talonavicular arthritis, and one with both. Conclusion: Based on preliminary data, a successful fusion of the first TMT joint, as treatment of a forefoot deformity such as HV, does not appear to accelerate the development of arthritis in the adjacent joints.

The Invision Talar Component as a Revision Total Ankle Arthroplasty Option: Analysis of Early Outcomes

Category: Ankle; Other Introduction/Purpose: The Invision talar component was launched in 2018 as a revision total ankle arthroplasty (TAA) specific option geared towards avoiding further subsidence when poor talar bone stock is present. Due to the recency of the market- availability of the Invision, studies evaluating the efficacy of the implant, even in the short-term, are lacking. Thus, the purpose of this study was to present the early-term outcomes of a series of patients undergoing revision TAA with the use of the Invision talar component. Methods: This was a single-center, retrospective review of 28 patients undergoing revision TAA with the Invision talar component and Inbone II tibial component (Wright Medical; Memphis, Tennessee) performed between 2007 and 2022. Mean follow-up was 1.3 ± 0.93 years. Data on patient preoperative characteristics, postoperative complications, and survivorship were collected. The primary outcome measures were time to major complication, reoperation, and infection. Results: The most common concurrent procedures performed with revision TAA with the Invision talar component were gastrocnemius recession (n=14, 50%), subtalar arthrodesis (n=3, 10.7%) and cotton osteotomy (n = 1, 3.6%). The mean preoperative coronal deformity off the tibia was 4.07 ± 3.06 degrees for varus and 3.67 ± 4.36 degrees for valgus deformities, respectively, and postoperatively, was 1.67 ± 2.16 degrees for varus and 2.00 ± 3.48 degrees for valgus. The mean preoperative coronal plane deformity off the talus was 4.83 ± 6.68 degrees for varus and 4.22 ± 4.21 degrees for valgus, respectively, and postoperatively, was 1.23 ± 2.45 degrees for varus and 2.32 ± 3.93 degrees for valgus. The survivorship from any complication, major complication, reoperation, and infection is shown in Table 2. Conclusion: In a series of 28 patients undergoing revision TAA with the Invision talar component and Inbone II tibial component, we demonstrate a survivorship of 92.7% at 1-year follow up. The Invision appears to have a reasonable safety profile in this non- designer series. The implant compares favorably with others utilized in the revision TAA setting at the early-term, but further studies evaluating mid-and long-term outcomes are required to fully assess the efficacy of the Invision.

Revision Total Ankle Arthroplasty Outcomes in a Large Single-Center Series: Evaluation of Coronal Plane Deformity Correction and Patient Reported Measures

Category: Ankle Arthritis Introduction/Purpose: As total ankle arthroplasty (TAA) rises in popularity nationwide, the incidence of major complications and need for revision TAA will continue to increase. A better understanding of the ability to durably correct deformity and improve patient reported outcomes (PROs) in the TAA revision setting is paramount for surgeons facing the impending wave of failed TAA. Thus, the purpose of this study was to present the largest single-center case series of revision TAA to date and to evaluate improvement in PROs and maintenance of correction of coronal plane deformity in patients undergoing this procedure. Methods: This was a single-center, retrospective review of 87 revision TAAs performed between 2007 and 2022. Reoperations for cyst formations only or without metallic component exchange were excluded. The two most common implants used for revision TAA were Inbone II (n=65) and Inbone I (n=14). Mean follow-up was 2.8 ± 2.9 years. Data on patient preoperative characteristics, concurrent procedures, and postoperative complications were collected. The primary outcome measures were time to major complication, reoperation, and infection. Secondary outcomes included PROs and correction of coronal plane deformity measured from both the tibial plafond and talar articulating surface from pre- to post-operatively. Cox regression analyses were performed to compute survivorship. Results: The most common concurrent procedures performed concomitantly with revision TAA were gastrocnemius recession (n=31, 35.6%), subtalar arthrodesis (n=18, 20.7%), and talonavicular arthrodesis (n=5, 5.7%). Mean preoperative coronal plane deformity measured off both the tibial plafond and talar articular surface improved after revision TAA. 1- and 5-year survivorship from major complication, reoperation, and infection is shown in Table 2. Fourteen patients underwent subsequent revision, including TAA (n= 6, 6.9%), arthrodesis (n= 4, 4.6%), below-the-knee amputation (n= 2, 2.3%), or implantation of an antibiotic spacer (n= 2, 2.3%). At one-year postoperatively, mean VAS pain score, SF36, and AOFAS Hindfoot score was 18.2 ± 16.0, 73.0 ± 13.3, and 68.8 ±:9.3, respectively, representing an improvement in PROs after revision TAA. Conclusion: In the largest single-center series of patients undergoing single or double component exchange revision TAA, we demonstrate durable improvements in coronal plane deformity measured off both the tibial plafond and talar articular surface. We also noted 63.0% survivorship with regards to reoperation and improvements in average PROs across the cohort. Overall, revision TAA is a successful procedure, but is associated with higher failure rates at 5 years than primary TAA.

The Role of Ultrasound Guidance in Mini-Invasive Musculoskeletal Surgery—A Pictorial Essay

In this article, the authors review the role of ultrasound guidance in MSK mini-invasive surgery. Ultrasound imaging has become an important tool in the field of musculoskeletal examination and has advantages over the X-ray guidance traditionally used by orthopaedic surgeons. Ultrasound provides the 3D localization of the area where the instruments are being used, does not require X-ray’s certified personnel, and poses less of a health risk to the patient and the medical staff. This article explores the development and application of ultrasound navigation in mini-invasive surgery, including the use of ultrasound during different stages of arthroscopic procedures or for the entire operation. Ultrasounds can assist in setting access points around the joint, localize the pathology and assure its complete resection, identify vessels and nerves, establish access to and constant control of difficult operating areas with a high potential for neurovascular complications. In this paper, the authors also acknowledge that there are some disadvantages, including the need for additional equipment and personnel, a long learning curve, and the potential elongation of the procedure. To identify all of the essential studies that report relevant information and data concerning the ultrasounds navigation in mini-invasive MSK surgery, an extensive search of the major and significant electronic databases was performed by two authors. An investigation was conducted in January 2023 using the following key terms: ultrasounds navigation, ultrasounds in arthroscopy, ultrasounds in MSK, with no limits regarding the year of publication. The authors focused both on the advantages and disadvantages of ultrasound navigation in MSK mini-invasive surgery, and also on particular techniques in mini-invasive and arthroscopic surgeries. The described techniques are the application of ultrasound in arthroscopy (knee, hip, and shoulder), hallux rigidus surgery, mini-invasive Achilles tendon surgery, gastrocnemius recession, carpal tunnel release, and hematoma evacuation.