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CME Surgery

Endoscopic Gastrocnemius Recession

Lawrence DiDomenico, DPM

Lawrence A DiDomenico, DPM discusses the etiology, clinical presentation and assessment of conditions that benefit from EGR. Dr DiDomenico cites case examples to support his discussion.

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Goals and Objectives
  1. Describe the assessment of gastrocnemius contracture/equinus
  2. Review the surgical techniques for EGR
  3. Recognize appropriate surgical candidates for EGR
  4. Identify conditions that benefit from a conservative approach
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  • CPME (Credits: 0.75)

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    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Lawrence DiDomenico, DPM

    Adjunct Professor
    Kent State University College of Podiatric Medicine
    Chief Section of Podiatric Medicine & Surgery
    St. Elizabeth Health Center
    Youngstown, OH

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    Lawrence DiDomenico has disclosed that he serves as a Consultant to Stryker and EBI/Biomet.

  • Lecture Transcript
  • Harold: Larry DiDomenico so I’m not going to really do that again but I don’t think I did mention he’s an adjunct professor at the Ohio College of Podiatric Medicine. He’s director of Fellowship training at Youngstown, Ohio and a former director of residency training. He was on the board of directors of ACFAS, section editor in hind foot and ankle surgery. So Larry comes with great credentials. He is an excellent presenter. His pictures are phenomenal and he’s going to share with us three topics that we’re going to beat him to death with back to back to back. So just sit tight, fasten your seatbelts and welcome Dr. Larry DiDomenico.

    Larry DiDomenico: Thanks, Harold and thank you guys for inviting me to speak. So I see Harold’s already talked about endoscopic gastroc recession and those in audience. How many of you are performing gastroc recessions currently? So it’s really grown so a few – at least in my experience, I’ve been practicing say late ‘80s, early ’90 and I would say Tendo-Achilles lengthening seems to be the more popular of the two posterior muscle length themes. They’ve been done – I think people realize that gastrocnemius recessions probably more indicated. The vast majority of times and also, it’s more friendlier for you as a surgeon and also friendlier for the patients in terms of recovery. So we’ll talk about that but more importantly, we’ll talk about the – using endoscopic technique which is really I think for your diabetic patients, your female patients, your pediatric patients from a cosmetic standpoint. At least those three categories really stick out my mind more and I think it really gives you an advantage. And personally, it takes me less time to do an endoscopic gastroc recession versus an open. One, in fact, I get it right the first couple of times. Sometimes you have to fiddle with the equipment a little bit and it may take you a little bit longer but the vast majority of times, it’s a little bit quicker resolution for my hands anyway. And I’ve been doing this now for about 13 years and there’s no reason in my mind to open these up unless you can’t get it done percutaneously or endoscopically. And one more thing I will say before taking on an endoscopic technique, you must know how to open it up and be able to convert it to an open immediately type of position. So with this sight of no conflicts of interests regarding this presentation and I’m a consultant for these companies. So the objective is to understand the gastrocnemius contractures. To understand the sort of techniques of EGR and to understand who are the appropriate sort of candidates when performing endoscopic gastroc recession or a gastroc release, however you want to look at it. So here you just see a static x-ray and you see midfoot collapse and it’s like I joke around with our residents. I do work with the fellows, “You either drink the Kool-Aid or you don’t. You either believe in equinus or not. I can go to a meeting, I can have very respective individuals on a panel and some people just do not believe in equinus component has a lot to do with midfoot, forefoot or hind foot and ankle pathology. And either like I said, “You drink it or you don’t,” and if you believe in it which I do obviously, I think it has a big contribution do with cases such as you see here. There are tremendous changes that are going on and it’s a dynamic pressure that one seasons. It’s a slow breakdown over time along with foot conditions. So here is a gentleman who I performed an extraneural fixation slows gradual correction on him because he’s got significant scar tissue. He has a significant stiffness tear, his tissues – he won’t work with an open technique. And you can see that’s not the classic patient that I’ve talked about a gastrocnemius recession on. These are people walking down the street that have forefoot, midfoot, hind foot pathology in terms of – and it doesn’t have to be that toe walker or that grossly obvious patients such as this gentleman here that you see walking. So if you look at this patient, this is preoperatively. As you can see they prepped the tourniquets so on but you can see genu recurvatum. This is a compensation of the tight posterior muscle group. You can see that right there, secondary to a tight posterior muscle group. This nurse didn’t realize she was doing it but I was going to go get ready to scrub and I look at that and I said, “Let me get a picture of that,” because this clearly demonstrates one of the compensations that you will see with a tight posterior muscle group. Again, maybe having a bunionectomy done or a midfoot fusion, whatever it was that was being done. And if you look at the definition of equinus it’s all over the board and the problem is the test is very subjective doing the Silfverskiold test. So you have to know how to do the Silfverskiold test but some people believe it needs to get to 0 degrees or 90 degrees if you will – to long axis of the leg. And basically, what I tell them – our students and residents and fellows is that, “If you want to hold the subtalar joint neutral, you want to close down or adduct the midtarsal joint and then you want to dorsiflex that complex. It’s one solid complex on your physiological tension until the Achilles tendon’s tight. If you just jammed up the foot which many younger practitioners will do, you’re going to slip off the midtarsal access and you’re going to get a false reading if you will. So you got to look at the base of the fifth metatarsal and relative the long axis of the leg or the fibula.

    [05:00]

    And you can see where there’s quite a flex at 90 degrees or past 90 degrees which it is and there’s a lot of definition relative – it depends on what you read. So I’m not going to go through all that but you can just go through it on your own readings yourself and you’ll see there’s a lot of definition. Here, again, you can see this patient suffers a little bit from Genu recurvatum if I remember right, this gal was like a 25, 26 years old secondary changes, forefoot prep pathology but yet you can see her knees are hyperextended to some degree. So again, the definitions very debatable. You can read a lot of lecture out there. In my mind, it’s really whether they’re plantar flex and they get to neutral or past neutral is really – I don’t measure anymore. I don’t take a tractograph out. I don’t think it’s really necessary. It’s either free and release or not. And one thing you will learn by doing these procedures – when you’re doing surgery, you feel and once you start feeling it – when you’re doing the surgeries, you understand how this immobilizes or allows you to mobilize the hind foot and midfoot. For example, most people don’t think like somebody with Charcot-Marie-Tooth disease, who has a high calcaneal pitch angle radiographically has a tight posterior muscle group. But oftentimes when you release that, you’ll see that you can skip that calcaneous out of various deformity or two more neutral positions by release that posterior medial group. The posterior muscle group which releases that plantaris and also decrease that medial pull, if you will. And actually I spoke with [indecipherable] [06:16] a couple of years ago and he was looking at CMT patients and he was doing all soft tissue releases only and balanced out these feet. Not doing any boney procedures, demonstrating how powerful that gastroc can be in terms of helping out. So just looking at a radiograph, you can have a high calcaneal pitch angle, you can still have a tight posterior muscle group. Here’s a phrase from Ted Hanson, he said, “Our experience has suggested that the gastrocnemius muscle in particular is a predominant deforming force in people with structural breakdown and chronic pathological changes related to a foot and ankle.” And I believe that wholeheartedly and here you see this with a Charcot foot has much more obvious but I think that even the subtle pathologies when people have problems with their feet, you have to really think, “Why? Why do they have it?” No newborn baby is born with a bunion or a hammertoe, you have to think, “Why did that develop? What caused it over time?” Why do you see maybe a 10 year old have a bunion but much fewer than you see in their 20s, 30s and 40s etcetera as you go up the ladder of age there’s a much more common and because there’s a muscle tendon imbalance. You have to wonder, “What is causing the reason for these imbalances?” Subotnick made the statement, “Gastrocnemius-soleus equinus is a greater symptom produced in the human foot.” And again, I believe that as well and if you think about from a forefoot pain to capsulitis, metatarsalgia to midfoot breakdown and onward back – more proximal to the hind foot and ankle. There’s a relationship between gastrocnemius tightness and the patients who have chronic forefoot, midfoot symptoms and here you could see a whole list of different conditions that can be associated with a posterior muscle group that’s very tight. Here’s some more and here you see a patient with the Extensor Substitution although a diabetic patient, this patient also has a tight posterior muscle group. And again, there’s a reason why these toes are overpowering dorsally. They’re compensating for something and you have to sort of figure this out and are you doing really justice by just focusing your issues on the toes or should it be more globally, treating these patients, understanding the entire dynamic effects that it has on the structural effects of our foot. So you look at gastroc-soleus equinus again, this is a contracture of the soft tissues again, of the gastroc and soleus muscles itself. A lot of people do Achilles tendon lengthenings for it and again, we’ll talk about the recovery of this as much – not as much. Friendlier for you because you’re going to a much more non-evasive area in terms of the Achilles tendon versus the gastrocnemius where they’re much more vascular. And again, at least from my hands, I believe most of the equinus are tight posterior muscle groups are gastrocnemius. Then you have to always watch out for osseous equinus which is a boney block typically at the ankle joint. So you must take an x-ray and look at these patients to see if they have that. And there’s a pseudoequinus from an anterior cavus foot that you may see also, also to consider it with looking at equinus components. So again, the gastrocnemius is the most common form, the Silfverskiold test is a subtalar joint held in neutral midtarsal joint closer adducted. It’s a passive range of motion not active passive to the Achilles tendon of physiologically tight. And then you measure the long axis of fifth relative to the long axis of fibula and that will give it to you. So here are some of the affects that you will see with a tight posterior muscle group, it can affect your anterior foot, your knee, affect your lower back and you go see lumbar lordosis. You can see genu recurvatum as I already showed you. You can get hip flexion issues, knee flexion issues and again, I think this was [indecipherable] [09:54] so these patients suffer from excessive fatigue, pains in their legs all refer to the back and the nervous in the mental lassitude.

    [10:09]

    So really, when you think about that, that’s back in the early 1900s when [indecipherable] [10:11] identified all this. So this is nothing new really. This has been around for a long time. So it’s not anything that we really are recreating. So the composites that you would get from an equinus deformity, you get pronation subtalar joint, you get unlocking midtarsal joint, and makes the foot less stable if you will to some degree and you get these conditions listed there as you see below. Here’s a classic Pes Planus deformity from somebody with a tight heel cord. Again, contract that Achilles case more laterally now at this point in time and again, compensations throughout the midfoot, changes that occur throughout the midfoot and again, even oftentimes to the forefoot associated with that. So you really have to look at that. All these different changes here, they’ve occurred over time. This patient was not born with this type of deformity. It’s a slowly gradually onset and you have to ask yourself, “What caused this? What’s responsible for it?” And you have to think that equinus component certainly has a major component of it. Is it the primary reason? I don’t know that. I don’t think anybody in this room can tell us that or anybody out there can say for certainty but certainly, it is a part of the repair that needs to be done when addressing these patients. I personally don’t know how somebody can repair a hind foot, flatfoot deformity without repairing the posterior muscle group, long term – with predictable long-term result with it. Distal compensations; Hypermobility of the first ray. When you have hypermobility of the first ray, one that you’ll usually obtain and a hallux abductus deformity, that’ll get a hallux limitus deformity, equinus forme preclude is actually long-term result when [HCV] [11:40] surgery is performed. As you can see this by a [indecipherable] [11:43] so you really have to think about this, “Is this really something real or not and again, is the first ray elevated in this cases?” Here you can see a patient’s weight bearing. You see on this patient’s – what it appears to be this patient’s right foot. It’s upside down and backwards so that’s a sub two lesion and you have to think, “Is the forefoot overload from a tight posterior muscle group?” And when you get your diabetic patients, “Are they having overload when they have a sub two ulceration or an ulceration of a forefoot?” And you really have to start questioning that. Is there imbalance in this foot? What’s causing this? Is there instability to TMT1? Is this not bearing the weight that it should be? Is there too much forefoot overload? As you see, there’s a reason why people have calluses, lesions or preulcerative lesions or ulcer lesions for that matter and you have to really consider this as being a big component or part of the whole process. And again, more distal compensation as digital contractors again for example for extensor substitution because the extensors are trying to fight a tight posterior muscle group over time. They’re counterproductive if you will and they’re really trying to counterbalance the tight posterior muscle group to – without success and therefore you get this extensor recruitment that develops. And of course, you get the arch fatigue, the flat foot deformities that we see from pediatric to adult flatfoot deformities because again, compensation occurs. And one more common things that we see, plantar fasciitis. What’s the number one thing you tell a patient who presents foot or plantar fasciitis is gastroc stretching exercises. And most people in fact who are very, very well with non-operative cure for plantar fasciitis just having to stretch and really beat it up pretty good and most symptoms go away. The problem is there’s been studies demonstrating that you can’t lengthen that posterior muscle group by stretching, it’ll recoil but you’ll get release from the symptoms temporarily. So long-term, you have to do a gastroc release for patients who are not responsive to long-term sequela of tight posterior muscle group. And again, for our Charcot patients that you see, this is a rocker bottom type foot as you can see clinically, radiographically, the calcaneal pitch angle is flat. You can see there’s secondary changes, you can see this tail has been driven down to the ground. So you have to think the talus and the calcaneus works as one unit. This should be about 18 degrees dorsiflex or elevated I guess, as you want to see the calcaneal pitch angle should be. But think about the posterior muscle you’re pulling, contracting, very tight. It’s wedging up this way, therefore it’s driving down and it has to be a big major contributor to the breakdown of this midfoot. Bill Grant did a nice paper several years ago looking at diabetic histological issues with the patients Achilles versus non-diabetic showing glycosylation in the structures of the soft tissues. Definitely are different in the diabetic populations, lead to more of a contracture. Again, putting this whole complex under more stress, force and you wonder why these people breakdown. There’s a reason why they breakdown. It’s not just because they have diabetes. So again, if you want to look at these people clinically, you want to have them stand. You want to look again for the subtalar joints, the midtarsal joint and again, the passive range of motion. You want to make sure that’s reduced very nice and that’s a very important to make sure your Silfverskiold test is done appropriately. I don’t think a lot of people really understand how to do that very, very well but you must know how to do it relatively good to get a true evaluation. So conservative treatment again, it’s out there. You can’t lengthen the posterior muscle group.

    [15:01]

    You can bring the ground to the foot but with an orthotic or heel lift, different things like that. You can try sole bracings and casts. Those things aren’t going to work long-term unfortunately but if the patient does not have a significant breakdown and needs surgical intervention, certainly stretching is the way to go. Conservative cares way to go. If they have a pathologic condition that warrants surgery and if you’re going to repair the foot or the ankle then you must include or consider including the gastroc release. Just review anatomy before diving in and doing procedures. You need to know the lower leg anatomy about the gastrocnemius – the different heads, the medial head, the lateral head. Where the conjoined tendon of the gastroc and the soleus come together, the aponeurosis and know the nerve vascular structures around the area in particular when we talk about incision placements where you want to make your incisions. Most systems out there depends who’s used – it’s either one portal or two portal type of incisions. And historically, these have been written up quite some time. I think most of you know these from your boards, whether you do a Vulpius or Schrader or Hook. There’s very many different type of procedures out there but typically, this is done as an adjunctive procedure. The vast majority of my hands at my clinic – I get toe walker that comes in or referred to me every now and then. If I have a young toe walker, I’ll take him in and I’ll do a gastroc release and they walk right back out with their heel on the ground. It’s amazing how quick the results are and how friendly this is. And matter of fact, when you’re doing isolated gastrocnemius recessions, which is rare, all I do is put them in a CAM boot and they’re allowed to weight bear that same day. It’s pretty clear when I’m able to do it endoscopically because there’s not much bleeding that goes on there as you’re avoiding – you’re really cutting the tendon if you will or the aponeurosis which is very much like a tendon. Doesn’t have a blood supply or much blood supply to the area. As long as you avoid cutting the muscle, you’re not going to have a whole lot of hemorrhage associated with this procedure and these are small incisions. So it’s a very friendly procedure for that toe walker who does come in. Who can’t get his or her heels down on the ground when they’re walking. The other patient who I may consider – I say gastroc, the two conditions is and one is the toe walker, the other one is somebody who’s in the state zero or early stage of Charcot with no breakdown in their foot. And again, you either believe it or no, don’t believe in it. If you believe in it, there’s a tight posterior muscle group that’s putting an increase pressures on that midfoot or forefoot whatever it is in each condition. And so taking a patient in and doing an endoscopic gastroc recession is going to alleviate some of those pressures and maybe stop or limit that breakdown before it goes on to have significant boney breakdown. So if you catch these people very, very early on, and the same treatment is immobilization and a CAM boot, these people are allowed to weight bear so it’s a very friendly course for you as a surgeon and for the patients to recover. So the anatomy you need to know is a greater saphenous veins know where they are. Know the saphenous nerves and the biggest one is visceral nerve, which one’s posterior and you have to be very, very careful of that. The gastrocnemius and the soleus muscles you need to know that. Again, their origins and their insertions. And again, Achilles musculotendinous junction or known as an aponeurosis. It is differs from patient to patient, size of each patient. Some people have very big legs all the way down their ankles and some people have very thin legs down their ankles. Some people have high gastroc and some people have a low gastroc. So you can’t indicate where in the heck you should make that incision each time. It’s based on each patient’s own anatomy. Obviously, the bigger the patient is, the wider the leg is, the more girth, the more difficult it is. More fatty tissue, more fluid in there, different things such as that. The thinner the patient is, the much easier it is to operate on. Again, know your anatomy, know the layers of the muscles from posterior to anterior and where you are that you’re trying to cut. Know where that your middle gastroc muscle belly rides a little bit lower and the leg relative to your lateral muscle belly so you have an idea. And typically, this is where you want to cut right around here. You want to get to the wider part of the aponeurosis, right in this area here. You don’t want to come down to near the Achilles here, you want to be as high as you can and more vascular. Here’s a visceral nerve, as you can see, it comes up high from the popliteal fossa runs right across, heading laterally so this would be medially, this would be laterally but you see your visceral nerves so you want to make your cuts right in this region, right around here. And what happens, is the soleus muscle’s right anterior to that. So as you cut it, almost and you’re putting pressure, you’re dorsiflexing the foot, it just fillets open. It’s a beautiful sight. You see these tissues nicely separate. They usually separate in my experience about 2 centimeters. That’s about what I get typically in length so for this old gap, about 2 centimeters and you’ll see this nice red beefy healthy muscle belly, the soleus muscle. And you can’t get a calcaneal gait by performing a gastroc recession because the Achilles is still intact and you have the soleus area. A big advantage, performing an Achilles tendon lengthening and you can’t control the length sometimes and you may obtain a calcaneal gait in your neuropathic patients. So again, a much more friendlier procedure when indicated which again, in my opinion it’s a vast majority of times so you have to know this anatomy. This is probably the biggest thing to worry about is a visceral nerve injury and you have to be very, very specific when you cut. You look at diabetes again, and again there’s no doubt in my mind most of these patients who have diabetic foot ulcers have a component of equinus deformity.

    [20:05]

    And those are a lot of money spent. All this is relatively older literature now. You can see the amount of money that’s spent is quite significant and it’s only grown as our diabetic population continues to grow. So here’s a gal who – this girl is a PhD. She was in her 30s or maybe early 40s. I can’t remember when I saw her. I treated her probably about 10 years ago. She had bilateral Charcot feet. This is a weight bearing x-ray. This is the power of the equinus deformity. And you wonder why she breaks down? Think of a nutcracker effect. It’s just going to breakdown. It’s a leverage. The ground’s pushing up. She’s got probably – if I remember right, she’s about 150 pounds. Her weight’s coming down. This is being contracted. No wonder why it breaks down in midfoot. And so this is the problem and here – and she has an ulcer right underneath this area but her foot – her heel never gets down on the ground. If you release that, it takes changes changes the dynamics, how it effects on the foot. So again, and in my mind, you cannot fix these feet without appropriately fix them without doing a gastroc release. And if you did a fusion, you got every single one lined up, they can’t get their heel back down on the ground so you’re really done nothing except fuse the foot. And again, I will promise you it’ll breakdown at some point in time if you leave it like that. So in order to get it down, you have to get the calcaneus down on the ground and you have to think this talar calcaneal joint all works as one unit unless there’s some dislocation, the subtalar joint that area. It works as one functional unit in there. And again, I’m just showing you that the studies done. I’ve shown you about the gastroc release with it. Armstrong did this paper a long time ago, demonstrating with Achilles tendon lengthenings which is very similar to gastroc in terms of relief that you reduce the forefoot pressures off about by 20%. Like I said, if you think of this as a nutcracker effect, it’s going to breakdown the foot and if you think about it because of the tight muscle group, from a Charcot standpoint or diabetic standpoint, these joints are very flexible. If these joints were stiff out here, your ulcerations – your Charcot would curve more at the metatarsal phalangeal joints. In my career, I’ve seen several cases like this but they’re seldom relatively here because these are very forgiving joints. Well this phalanges joint doesn’t have much movement, that’s why the vast majority of Charcot occur here. It’s all because of mechanical pressure of the tight posterior muscle group. As you work more proximal, underneath the direct line, if you will of the extra load, there’s less indication for Charcot. So if you breakdown the Charcot, the more distal you are, the more common it is in terms of percentage number of cases you see. The more proximal you are, you have less effect on it and you’re going to see less amount of Charcot cases. So you must know how to do the open technique. This is the deep fascia tissue, this is the gastroc aponeurosis. This is the soleus muscle belly, this is the proximal portion aponeurosis after release. And as you dorsiflex, you’ll see this stretch out and be wider. As you plantar flex, it’ll come a little closer together and what happens is people just fibrous in just like a torn tendon, immobilization, they’ll go onto heal. But what I try to do now is avoid the large incisions like this to not perform these and I try not to have to flip the patients so we do it frog leg position now. Our patients stay supine. Most of the surgeries we’re doing are supine, just frog legging. We take a medial approach rather than having a patient lay prone or breakdown the dressing flip them and do – go through a whole bunch of other issues and take a long time to do it. So really is not a long procedure. Here’s another example of a medial approach and basically what we’ve done is gone through the skin subcutaneous tissue, now we’re going to enter the deep fascial tissues what it looks like before you get inside the fascial planes. This is an open technique again, which you’ll need to know if you’re going to try to do these endoscopically. So the advantages of doing an AGR or better causes leases without a doubt. Patients like it so one stitch technique on the medial side if you’re using a one portal system or on both sides if you use a bi-portal system. You get direct visualization of that aponeurosis. Early return to function, it’s much easier as I told you with those isolated cases. I let the people walk in a CAM boot. Really, all my other surgical procedures associated as adjunct procedures dictate what my patients are doing post-operatively. So the gastroc really has no control over my post-operative course versus Achilles tendon lengthening does. Early return to function, preferred again, those patients with diabetes, PDB, or as females and different patients such as that. So here just mapped out your anatomy, what you want to look for and basically, here’s a making a stab incision just right below that gastroc aponeurosis. You want to divide the leg basically into thirds, anterior thirds, posterior thirds this should be up a little higher. And now I just make a blade – I just get a 15 blade puncture to the skin and that’s all I do. That’s how big my incision now so these are old slides, just make a puncture hole. And then what you want to do is get a fascial elevator here and the idea is get this fascial elevator and you’re only goal here is try to separate the subcutaneous tissue from the deep fascial tissue and the visceral nerve runs in that subcutaneous layer. So you want to separate that area out. And then here’s your obturator. Once you get that in there, you want to go all the way from medial to lateral pop through if you’re using a bi-portal system and you want to make an incision here.

    [25:00]

    Again, the posterior, one third of leg again if you divide it. That’s roughly in this area right here and just make a little 15 blade nick incision and you pop your obturator through and then you put your pin over top. And this is what we have, the cannula system and obturator going 90 degrees along the long axis of the leg. And typically, I do – I keep this – I put this against my chest and I dorsiflex and plantar flex my weight so I can see the aponeurosis moving superiorly to my vision. This is what the obturator looks like, my scope goes in from lateral and my blade goes in from medial. And that’s what it looks like, and the foot’s against my belly and again, I rock as I dorsi – plantar flex so I can see the aponeurosis moving up and down when performing the procedure. Clean this out, use cotton tip applicators. Here’s my scope going in. You see the scope and this is what you should see when you go in. You should see the aponeurosis. If you see fatty tissue, if you see a nerve, do not cut that tissue because you’re more likely not going to hurt that visceral nerve. Only time you should ever cut this tissue is only when you see gastroc aponeurotic fibers. If you see anything else, pull it out because more likely or not, you’re going to injure the patient, so only if you see the gastroc aponeurotic fibers and nothing else and they’re clear as day. Unfortunately, sometimes they don’t show up as well on these photos but there’s striations that you can clearly demarcate and you can clearly see what is a gastroc aponeurosis, what is not. And once you start making the cut, as you’re leaning into the leg and you’re dorsiflexing, you’ll see it fillet open and right there, you’ll see a beautiful red beefy muscle belly of the soleus as I talked about earlier. See, that’s very limited window here but again, I can’t emphasize enough. If you see anything other than gastroc aponeurotic fibers, do not cut. Go back in with your obturator and you keep working until you only see the aponeurosis. So again, this is the aponeurosis here, here’s the soleus muscle bellies and really, you’d have to be really ignorant to cut into this muscle. I like to use the triangle blade. You can use the hook blade, there’s different types of blades out there but basically just fillets it open because you’re putting tension on it as you’re learning forward. So here’s a picture, this is what it looks like and again, sorry about it’s not as clear you’d like it to be but as we’re cutting, you can see the aponeurosis looks just like a tendon. There’s a soleus muscle as we go from lateral to medial and this is what it going to looks like. You could see a little better, the red beefy muscle. Now, if I also go back and look, once you get it cut here they are the deep intramuscular septate and you’ll have to put your blade up there and you’ll find them. They’re like little guitar strings basically of aponeurosis within the soleus muscle and you’re going to go in there and just pop them like little guitar string and you’ll get complete release this way. So this picture’s a little better, here you can appreciate a little better when I’m talking about the striations of the aponeurosis and again, unfortunately, in real life, you’ll see them very, very clear. And again, if there’s nothing else; some of the systems have like almost like almost like a rasp. You can rasp a nerve is strong, if you toggle on it and it doesn’t go in a way, that’s a nerve. Fatty tissue will pull away, nerve is very strong. So you rasp it if you’re uncertain and then you start cutting, you can see the pristine beautiful red pink muscle belly, our aponeurosis as we’re dorsiflexing as we’re cutting with this very fine blade and this is what it looks like. So as you do range of motion, you look for the septate, if there are any more up there, you go get them. If not, you see your range of motion, pull out the equipment and you just do one stitch on each side and dorsiflex it. And again, I usually leave the sutures in and then again, my post recovery course, whatever I’m doing is going to dictate what I’m going to do, how I’m going to handle post-operatively, cosmetically people even forget about the procedure because it really doesn’t hurt. It’s a very, very friendly procedure for you and again the patients cosmetically. I think it’s great. Anytime anybody does a gastrocnemius recession, you always want to indicate to your patients that their leg will get a little bit weaker for initial time and they’ll lose some muscle mass diametrically on their calf muscles. So you have to indicate to them and I tell patients, “You’ll gain strength back,” but as far as explosive sports, if you have a sprinter, if you have a high profiled athlete, [Coughs] excuse me, whether they do it open or closed or endoscopically, you will lose that explosive sport such as jumping or sprinting. But long distance running, different things like that, they get over time but again, you will lose the explosive sport and a diametrical size of leg will be a little different. So just some really quick cases because we’re running short on time. Diabetic foot ulcer again. Again I’m going to straighten out this guy’s hammertoes, balance out of the first ray and do gastroc release and here he is long-term. You can see, ulcer is healed. You don’t have to do these metatarsal head resections. I don’t think that’s really necessary to do unless they’re acutely infected in their [indecipherable] [29:30] infected. But you can go ahead and end up remodeling this. Here’s a flatfoot deformity, here’s a post-op one. This patients left, you can see the endoscopic marks, you can see his foot back in alignment. Pre-op will be on this side, you can see the changes. This is this foot and this is this foot post-operatively so you see the dynamic effects it has on it. Here’s another patient post-op, bi-lateral HDB endoscopic gastroc recession. This was years ago. I did a procedure and again, it’s a female. She’s probably about in her 40s but you can see what the legs look like from a cosmetic standpoint, there’s no – I should say no scars, minimal scar.

    [30:02]

    I think the shape of her legs again, when you do bi-lateral legs, not so much an issue. If you only do one, make sure you talk to your patients about it. Another diabetic ulcer, same type of thing. Again, it’s really the toes and the equinus really causing the problems not the metatarsal. The metatarsal hasn’t changed. It’s a soft tissue and it effects around the metatarsal that’s caused it. So we straightened this guy’s toes out get a gastroc release, and guess what, patient goes on to heel because now the forefoot is offloaded and that pressure off that metatarsal is offloaded. Again, same type of thing here where the patient who is diabetic. For total ankle replacements, if you’re doing them – after all my procedures, I assess it. If you have a tight posterior muscle group, you need to do gastrocnemius lengthening and you’ll get increase range of motion there. This is very unusual for have a total ankle have this much motion but here’s somebody who had a gastroc and agility done probably about 10 years ago. With the literature says - suggests is about one seven year gastroc gapping, yields about 10 to 15 degrees of increased ankle sagittal joint range of motion, if you will. To me, it’s just midtarsal joints, excessive sagittal plane rotation and just because we’re running out of time here, I’m not going to go through these papers. But basically, I was supposed to say this review this one. Patients, I say gastroc tightness who have a TEL have shown to lose plantar flexion strength and or many – develop calcaneal deformities. Near normal moment, generating characteristics could be restored when isolated gastrocnemius contractures are treated with lengthening of the gastroc aponeurosis again. So it’s just demonstrating again, much more friendlier type of procedures. There’s a lot about there on it, the gastroc EGR really came out in the early 2000s I would say. And I think people are doing them – have done them. And I don’t think I’ve really seen any new studies recently but there’s something we did on our studies. We did intraoperatively on average 18 degrees of motion, increase had noted on our patients and Hanson in St. Georgia published paperback a while back too. They had 18.1 degrees so very similar in terms of – again, Brian Dolly in his one paper talked about it that it mostly opens about 7 centimeters so people tell me that they can do it smaller. And it’s fine if you do it smaller but still, 2 centimeter incision or 3 centimeter incision versus a stab incision is much better. So the benefits are direct visibility. It sort of creates a tennis leg or basically I tell patients, “It’s like tearing muscle. Like tearing your hamstring and running it down the football field.” It’s really not much different, that’s all we’re doing, is really tearing out the area. Patient is able to do toe raises, regain their strength back over time except for diabetics, older patients. Cosmetically; we need more studies to be done in the future but if you can get about 18 degrees of increased range of motion at the ankle joint. So any questions regarding the gastroc recessions we’re doing endoscopically? No. Okay, so I guess we just keep moving forward.