Gastrocnemius Recession Research Articles

Isolated Recession of the Gastrocnemius Muscle: The Baumann Procedure

The Baumann procedure consists of intramuscular lengthening (recession) of the gastrocnemius muscle in the deep interval between the soleus and gastrocnemius muscles. The goal of the procedure is to increase ankle dorsiflexion when ankle movement is restricted by a contracted gastrocnemius muscle. Unlike the Vulpius procedure, the Baumann procedure truly isolates the lengthening site to the gastrocnemius muscle and does not lengthen the soleus muscle. The Baumann procedure has not previously been studied in cadaver specimens. The gastrocnemius and soleus muscles of 15 normal cadaver specimens had four sequential releases: a single gastrocnemius recession, a second gastrocnemius recession, a single soleus recession, and an Achilles tenotomy. Ankle dorsiflexion was measured with a goniometer initially, after each muscle recession, and after the tenotomy. After the second gastrocnemius recession, the average increase in ankle dorsiflexion measured 14 degrees with the knee extended and 8 degrees with the knee flexed. The Baumann procedure treats equinus contracture of the gastrocnemius muscle by improving ankle joint dorsiflexion. The procedure is indicated when the results of the Silfverskiöld test are positive.

Balancing of the Transmetatarsal Amputation with Peroneus Brevis to Peroneus Longus Tendon Transfer

The transmetatarsal amputation (TMA) is a commonly used procedure in salvage of the diabetic foot. The goal of the procedure is to provide a plantigrade foot that can fit into a shoe with appropriate insole and allow the patient to continue ambulating with a low risk of ulceration. This goal can be achieved with appropriate tendon balancing to avoid development of or address existing equinovarus deformity, a commonly reported complication of the TMA (1–4). To prevent this deformity, several authors have recommended a combination of Achilles’ tendon lengthening or gastrocnemius recession along with tibialis anterior tendon transfer (2–6).

Die endoskopische Verlängerungsoperation des Musculus gastrocnemius zur Behandlung des Gastrocnemius equinus

Endoscopic gastrocnemius recession is a new technique to treat gastrocnemius equinus. Smaller incisions and the ability to perform the technique in a supine position are purported advantages. This study was designed to evaluate the results and possible complications of this new technique. 47 patients undergoing 54 endoscopic gastrocnemius recessions were followed in a prospective study. Pre-operative criteria were a lack of ankle dorsiflexion with the knee extended to create a 90 degrees relationship of the foot to the leg in symptomatic patients. Pre- and postoperative ankle dorsiflexion were assessed, as were complications such as infection, nerve injury, haematoma, over-lengthening and poor cosmesis. Mean age of the patients was 49.4 years. Post-operative follow-up from the index procedure was 27 months (range: 12 - 62 months). Pre-operative dorsiflexion was - 8 +/- 4 degrees; post-operative this improved significantly to 7 +/- 4 degrees (p = 0.00001). Most patients had additional reconstructive procedures. There were no infections; six limbs had lateral foot or leg dysaesthesia, one haematoma, one over-lengthened gastrocnemius while six limbs has an unacceptable cosmesis (due to tenting of the skin). Two diabetic patients required additional Achilles tendon lengthening in subsequent surgery. Patients with pre-operative dorsiflexion of - 10 degrees or more had an untoward result, but this was not statistically significant (p = 0.13). Lateral foot dysaesthesia was observed more often in patients having a combined procedure with calcaneal osteotomy (p = 0.03). The endoscopic gastrocnemius recession procedure can significantly increase ankle dorsiflexion, but has potential complications including lateral dysaesthesia (11 %), and unacceptable cosmesis (11 %) as the most common. Modifications to the technique may be needed. Overall, the endoscopic technique appears promising in decreasing gastrocnemius contracture.

High recurrence after calf lengthening with the Ilizarov apparatus for treatment of spastic equinus foot deformity

Both gastrocnemius recession and Achilles tendon lengthening lead to scarring in the calf and have high reported recurrence rates when performed under the age of 8 years. Triceps surae lengthening by external fixation seemed to be a valuable alternative. Twelve calf lengthenings have been performed with an Ilizarov device with a mean correction of 27 degrees. No calcaneal gait was observed, but there was a slow continuous loss of dorsiflexion over the observation period. The Ilizarov technique has a higher recurrence rate than most operative procedures for calf lengthening, but carries virtually no risk in producing calcaneus. The technique cannot be recommended for routine clinical use and may only be an alternative for selected cases.

The Gastrocnemius Intramuscular Aponeurotic Recession: A Simplified Method of Gastrocnemius Recession

Gastrocnemius recession is performed as an ancillary procedure in the treatment of a variety of pathologic foot and ankle conditions, most notably symptomatic adolescent and adult pes planovalgus, plantar fasciitis, and diabetic foot pathology (1–4). Several technique modifications have been introduced to potentially decrease complications (especially sural nerve–related problems), anticipate anatomic variation, improve function, decrease postoperative convalescence, and improve cosmesis (5–16).

Anatomical Aspects of the Gastrocnemius Aponeurosis and Its Insertion: A Cadaveric Study

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

Arthrodesis of the Subtalar and Talonavicular Joints for Correction of Symptomatic Hindfoot Malalignment

Triple arthrodesis has long been used for the treatment of painful malalignment or arthritis of the hindfoot. However, the effect of fusion on adjacent joints has sparked interest in a more limited arthrodesis in patients without involvement of the calcaneocuboid joint. Results of 16 feet in 14 patients who had a modified double arthrodesis for symptomatic flatfoot, cavovarus deformity, or hindfoot arthritis were reviewed retrospectively with a minimum followup of 18 (range 18 to 93) months. The most common diagnosis contributing to the hindfoot deformity was pes planovalgus. All operations were done with a consistent technique using rigid internal fixation with screws. In 15 feet, a concomitant gastrocnemius recession for equinus contracture was done at the time of the primary surgery. Clinical evaluation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale in addition to subjective assessments of pain, function, shoewear, cosmesis, and overall satisfaction. Radiographic evaluation included measurements of the anterior-posterior talo-second metatarsal angle, lateral talocalcaneal angle, and lateral talo-first metatarsal angle, and notation of arthritic changes of the ankle, calcaneocuboid, and midfoot joints, as well as an assessment of time to union of all arthrodeses. The average AOFAS Ankle-Hindfoot Scale improved from 44.7 preoperatively to 77.0 postoperatively (p < 0.01). Subjectively, patients experienced improvements in pain, function, cosmesis, and shoewear. Overall, all patients were satisfied and would have the procedure again under similar circumstances. Radiographically, all parameters statistically improved. There was an increase in arthritic scores for six ankle, six calcaneocuboid, and five midfoot joints. One talonavicular joint nonunion occurred in a rheumatoid patient, requiring revision arthrodesis. We have concluded that simultaneous arthrodesis of the talonavicular and subtalar joints is a reasonable treatment in the subset of patients with symptomatic hindfoot malalignment whose calcaneocuboid joints are not involved in the primary disease.

Morbidity Associated With High Gastrocnemius Recession: Retrospective Review of 126 Cases

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

Equinus Deformity as a Factor in Forefoot Nerve Entrapment

Forefoot nerve entrapments are common, and they are usually mistakenly categorized under the misnomer of "Morton's neuroma." Although the complete etiology of these forefoot entrapments is still not known, exogenous mechanical factors must be considered when patients present with clinical signs of forefoot nerve entrapment. It has been well established that equinus deformity can increase plantar forefoot pressures. This article provides a brief overview of equinus deformity as it relates to forefoot pathology, specifically, its mechanical contribution to forefoot nerve entrapment, and the use of endoscopic gastrocnemius recession for the treatment of forefoot nerve entrapment.

Cadaveric assessment of the gastrocnemius aponeurosis to assist in the pre-operative planning for two-portal endoscopic gastrocnemius recession (EGR)

The endoscopic gastrocnemius recession procedure (EGR) is becoming more utilized in the treatment of pathological gastrocnemius equinus. Equinus has been documented to be a significant deforming biomechanical force in myriad foot pathology. This study analyzed and measured 56 paired cadaveric lower extremities to assist in the quantification and development of reliable and easy to measure anatomical parameters, which could be beneficial to the operating surgeon in pre-operative planning. These findings may assist in proper anatomical placement of the instrumentation. From this analysis, the authors have determined a more precise method for ideal anatomical placement of the surgical instrumentation. Background: The endoscopic gastrocnemius recession procedure (EGR) is becoming more utilized as it provides a great non-invasive surgical option to treat patients with equinus. The authors recognize the need for a more precise description of the anatomical placement of EGR instrumentation. Objective: The objective of this study is to define an “endoscopic zone” to serve as a surface landmark for the precise placement of EGR instrumentation. Methods: In 28 previously dissected cadavers, the defined “endoscopic zone” was measured along with the length from the calcaneal insertion of the Achilles tendon to the mid-endoscopic zone. Intra- and inter-cadaveric parameters were analyzed using standard statistical indices. Results: The mean and mode for the “endoscopic zone” were 3.59 and 3.00 cm, respectively ( n = 55). The mean and mode for the length from the calcaneal insertion of the Achilles tendon to the mid-endoscopic zone were 16.40 and 17.00 cm, respectively ( n = 55). There was little intra-cadaveric variation, while more variation was measured between cadavers. Conclusions: These data provide useful parameters for the accurate placement of EGR instrumentation. On average, a surgeon should measure 16–17 cm proximally from the calcaneal insertion of the Achilles tendon in order to place the EGR instrumentation within the “endoscopic zone”.

Endoscopic Gastrocnemius Recession for the Treatment of Gastrocnemius Equinus

A prospective analysis was conducted of the amount of correction obtained and number of complications resulting from 31 endoscopic gastrocnemius recessions in 28 patients. The average amount of increase in ankle dorsiflexion was 18 degrees. Few complications were encountered, with mild "soreness" and distal "bruising" being reported by four patients. The only other complaint was "weakness." The endoscopic gastrocnemius recession is a minimally invasive technique with a low rate of complications that offers a comparable amount of correction to that of traditional open procedures in the treatment of gastrocnemius equinus.

Evaluation of Results of Endoscopic Gastrocnemius Recession

Gastrocnemius recession is traditionally done as an open procedure. The aim of this retrospective study was to evaluate the safety and efficacy of gastrocnemius recession performed endoscopically. The procedure was done in 28 patients (17 men and 11 women), ranging in age from 16 to 72 years (average 47.57, SD 13.86) between January, 2001, and September, 2003. In three patients, the procedure was done bilaterally. Followup ranged from 4 to 36 months (average 22.00, SD 11.84). The procedure was done through a single medial or lateral portal using the 3M Agee Carpal Tunnel Release System (Micro Aire Surgical Instruments, Charlottesville, VA). The initial incision for portal entry was at the wrong level in two of 31 procedures (6.5%), requiring a second incision. The recession could not be accomplished in one of 31 procedures (3.2%), so an open technique was used to complete transection of the gastrocnemius aponeurosis. One patient had a superficial wound infection (3.2%). There was no incidence of sural nerve or Achilles tendon damage. Analysis of results from a modified Olerud and Molander score using a paired student t-test revealed statistically significant improvement (p < or = 0.05) in pain, stiffness, swelling, and overall average score after the procedure. The results of endoscopic gastrocnemius recession using the Agee Carpal Tunnel Release System have been encouraging, with limited morbidity. The technique proved both feasible and safe in this study.

Salvage of the neuropathic foot by using bone resection and tendon balancing: A retrospective review of 10 patients

Medical records were retrospectively reviewed for 10 patients (mean age, 48.7 years) who had a chronic, recurrent neuropathic forefoot ulceration or osteomyelitis in the presence of an abnormal metatarsal parabola. Two patients had multiple lesser metatarsal osteomyelitis, 3 patients had chronic ulceration in the presence of an abnormal metatarsal parabola, and 5 patients had previous lesser ray resection or metatarsal head resection. None of the patients had signs of skin breakdown under the first metatarsal. All of the patients were treated with a combination gastrocnemius recession, peroneus longus to peroneus brevis tendon transfer, and resection of the second through fifth metatarsal heads to decrease plantar forefoot pressure and preserve the first ray without increasing the risk of ulceration under the first metatarsal head. All patients achieved a healed plantigrade foot without ulcer recurrence, transfer callus development, or contralateral foot breakdown at a mean follow-up of 14.2 months. Postsurgical complications consisted of dehiscence of various incision sites on 3 individual patients and one local reaction to antibiotic-impregnated beads. This preliminary study suggests that this combination of reconstructive procedures may provide an alternative method of foot salvage to panmetatarsal resection and transmetatarsal amputation.

Changes to medial gastrocnemius architecture after surgical intervention in spastic diplegia

We assessed the architecture of the medial gastrocnemius in nine children (five males, four females; age range 6 to 15 years; mean 10 years 10 months, SD 3 years 6 months) with spastic diplegia by ultrasound imaging before and after a gastrocnemius recession. The children were ambulant (seven independent, one with a posterior walker, one using crutches) before and after surgical intervention. We compared values for fascicle lengths and deep fascicular‐aponeurosis angles with those from a group of normally developing children (five males, five females; age range 6 to 11 years; mean 8 years 4 months, SD 1 year 4 months). Despite a variable interval between assessments (from 56 to 610 days), fascicles were shorter (p=0.00226) and the deep fascicular‐aponeurosis angle increased (p=0.0152) after intervention. Fascicle lengths of patients were similar to those in the group of normally developing children before surgery. After surgery, fascicles in the group of children with spastic diplegia were shorter than in their normally developing peers (p=0.00109). The gastrocnemius recession procedure alters muscle architecture, though the degree of fascicular shortening varied, with four of the participants in our study losing less than 10% of their original fascicular length at maximum dorsiflexion. Increases in ankle‐joint power in walking, observed after surgical intervention in children with spastic diplegia, may be due to a more normal ankle position rather than to improvements in the active mechanical performance of the gastrocnemius.

Changes to medial gastrocnemius architecture after surgical intervention in spastic diplegia.

We assessed the architecture of the medial gastrocnemius in nine children (five males, four females; age range 6 to 15 years; mean 10 years 10 months, SD 3 years 6 months) with spastic diplegia by ultrasound imaging before and after a gastrocnemius recession. The children were ambulant (seven independent, one with a posterior walker, one using crutches) before and after surgical intervention. We compared values for fascicle lengths and deep fascicular-aponeurosis angles with those from a group of normally developing children (five males, five females; age range 6 to 11 years; mean 8 years 4 months, SD 1 year 4 months). Despite a variable interval between assessments (from 56 to 610 days), fascicles were shorter (p=0.00226) and the deep fascicular-aponeurosis angle increased (p=0.0152) after intervention. Fascicle lengths of patients were similar to those in the group of normally developing children before surgery. After surgery, fascicles in the group of children with spastic diplegia were shorter than in their normally developing peers (p=0.00109). The gastrocnemius recession procedure alters muscle architecture, though the degree of fascicular shortening varied, with four of the participants in our study losing less than 10% of their original fascicular length at maximum dorsiflexion. Increases in ankle-joint power in walking, observed after surgical intervention in children with spastic diplegia, may be due to a more normal ankle position rather than to improvements in the active mechanical performance of the gastrocnemius.

Endoscopic Gastrocnemius Recession

ABSTRACTGastrocnemius contracture plays a significant role in a variety of foot and ankle problems such as diabetic forefoot ulcers, symptomatic acquired flatfoot, metatarsalgia, hallux valgus, and plantar fascitis. Gastrocnemius recession is being increasingly used as a component in the surgical tr

Endoscopic gastrocnemius recession: Preliminary report on 18 cases

A technique of endoscopic gastrocnemius recession was evaluated. Fifteen patients undergoing 18 procedures were prospectively studied with a minimum follow-up of 1 year. There were 9 women and 6 men (mean age, 44.1 +/- 22.6 years). One patient had an isolated recession; the others had various adjunctive flatfoot or reconstructive procedures. Pre- and postoperative ankle dorsiflexion was evaluated, as was the amount of time before patients could perform a single-leg heel raise postoperatively. The mean preoperative ankle dorsiflexion with the knee extended was -8.7 degrees +/- 3.5 degrees , which improved from a mean 14.9 degrees at 3 months postoperatively to a mean 6.2 degrees +/- 2.6 degrees . At 12 months postoperatively, this value was 3.6 degrees +/- 1.8 degrees , a net postoperative improvement of 12.6 degrees (P < .00001). Patients were able to perform a single-leg heel raise on an average of 13.0 +/- 6.0 weeks. Complications were mostly related to lateral foot dysesthesia in the distribution of the sural nerve (N = 3). Furrowing of the medial leg was noted in 1 patient. No hematomas or neuromas associated with the portal sites were found. These results show endoscopic gastrocnemius recession to be an acceptable method of lengthening the gastrocnemius complex.

Surgical anatomy of the gastrocnemius recession (Strayer procedure).

The Strayer procedure (gastrocnemius recession) is a treatment option for patients with clinically relevant gastrocnemius equinus contracture. The purpose of this study was to review the surgical anatomy of the Strayer procedure with specific reference to 1) the location of the sural nerve, and 2) the gastrocnemius tendon release point. Forty consecutive Strayer procedures in 33 patients (15 males, 18 females) served as the study group. Recorded measurements included: 1) the location of the sural nerve relative to the deep fascia, 2) the distance from the medial border of the gastrocnemius tendon to the sural nerve, and 3) the distance from the distal end of the gastrocnemius muscle belly (identified by surface landmarks) to the actual release site. At the point of the gastrocnemius release, the sural nerve was located superficial to the fascia in 17/40 legs (42.5%) and deep to the fascia in 23/40 legs (57.5%). In five legs (12.5%), the nerve was directly applied to the gastrocnemius tendon and needed to be gently dissected off the tendon. The gastrocnemius release point was located an average of 18 mm distal (range, 20 mm proximal to 57 mm distal) to the surface landmark created by the distal extent of the gastrocnemius muscle belly. Knowledge of the relevant anatomy associated with the gastrocnemius recession should allow surgeons to minimize the rate of sural nerve injuries and improve cosmesis by decreasing the length of the surgical incision. A posteromedial incision that begins 2 cm distal to the gastrocnemius indentation and extends proximally will minimize the length of the incision required.

Outcome of gastrocnemius recession and tendo-achilles lengthening in ambulatory children with cerebral palsy

Outcome of gastrocnemius recession and tendo-achilles lengthening in ambulatory children with cerebral palsy

Gastrocnemius and soleus lengths in cerebral palsy equinus gait—differences between children with and without static contracture and effects of gastrocnemius recession

Equinus gait is one of the most common abnormalities in children with cerebral palsy. Although it is generally assumed that the calf muscles are abnormally short in equinus gait, no studies have been done to confirm that the muscles are short and that this shortness contributes to the equinus. This study used musculoskeletal modeling combined with computerized gait analysis to examine medial gastrocnemius (MGAS), lateral gastrocnemius (LGAS), and soleus (SOL) musculotendinous lengths during equinus gait in children with cerebral palsy. All three muscles were abnormally short during equinus gait whether or not the children had equinus contractures ( P⩽0.005). Children with static contractures had shorter maximum static MGAS and LGAS lengths than children with dynamic equinus ( P⩽0.002). The children with static contractures had ratios of peak dynamic length to maximum static length close to 1.0 for MGAS and LGAS (1.005±0.015) but lower ratios for SOL (0.984±0.024). For the children with static contracture, these ratios did not change significantly after gastrocnemius recession ( P⩾0.14) because both static and dynamic lengths increased postoperatively ( P⩽0.04). These results support the current clinical understanding of the role of calf “tightness” in equinus gait, including the appropriateness and effectiveness of gastrocnemius recession for children with equinus contracture.