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Steve A Brigido, DPM
Director, Fellowship for Foot and Ankle Reconstruction Coordinated Health
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Male Speaker: The last talk for me that I was asked to give kind of follows up with the fusion talks, which is certainly gastrocnemius recession versus tendo-Achilles lengthening, you know, when and why. I think we all realize that soft tissue release and especially when we’re thinking about a lot of the flatfoot fusions we’re doing, a lot of the flatfoot reconstructions that we’re doing, certainly, the tendo-Achilles is a piece of anatomy that certainly will contribute significantly to the, not necessarily the cause of the flatfoot, but certainly the pathoanatomy of the flatfoot. When a patient has developed significant arthrosis from that flatfoot, a tendo-Achilles release or a gastrocnemius recession is something that is important to manage. When we think about when to utilize the gastrocnemius recession or when to utilize the Achilles tendon release, there is something that we do in our office, and this is certainly not a very complicated exam called the Silfverskiold test. We’ve only done this in our office and this is basically when we actually assess the ability for the ankle to dorsiflex with the knee flex extended. We know that the anatomy of the gastrocnemius muscle and the gastrocsoleus complex, the gastrocnemius has a medial lateral head that attaches proximally to the joint of the knee, and the soleus muscle attaches inferiorly to the joint of the knee. If a patient has a significant contracture of the gastrocnemius muscle, when you extend the knee and try to dorsiflex the ankle, they’re going to have a significant restriction of dorsiflexion. Now, if you bend the knee and you would assess the ankle, dorsiflexion and the ankle does not dorsiflex towards appropriate 10 degrees above 90, then what we’re going to know that the gastroc and the soleus aren’t going to contribute to the equinus. In which case, we’re going to opt for a tendo-Achilles lengthening. If the knee is extended and we are unable to dorsiflex the ankle at an appropriate amount, but when we bend the knee, the ankle would dorsiflex freely, then we know that the soleus is not contributing. Because remember, the soleus attaches below the knee, so once we take the knee out of it, if the ankle is able to dorsiflex, then we know the gastrocnemius muscle is the sole source of our equinus deformity, and that’s when we’re going to choose to do our gastrocnemius recession. That quite simply is the easiest way for us to determine whether or not we’re going to do a tendo-Achilles lengthening, in which we’ll show you how we do that, which is a basic triple hemisection tendo-Achilles lengthening. It’s the easiest procedure you’ll do all of that week or versus a gastrocnemius recession. We’ll do our gastrocnemius recession two ways. The first is an open and the second is an endoscopic and I’m going to show you both. When you think of the gastrocnemius recession, can you guys see that okay? I know we’re getting a little shaky here and the screen here is out as well. The Strayer and the Baker procedure are the two common gastrocnemius recessions that are most described in, when you think about the historical perspectives. The Baker procedure is modified tongue and groove. You can have your tongue, which is your vertical cut in your aponeurosis of your gastrocnemius vertically or you can have it running inferiorly, whereas the Strayer procedure is quite frankly just a simple incision across the aponeurosis of the gastrocnemius muscle. The gastrocnemius recession is done at the level of the aponeurosis. It is typically done about 2 centimeters or 2 to 3 fingerbreadths below where the medial and lateral head of the gastrocnemius muscle are palpated. If you have a patient that has some good calf definition, you can actually palpate the medial head of the gastrocnemius muscle. If you run 2 to 3 fingerbreadths below that, and you can either make your incision on the medial aspect of the leg or on the posterior aspect of the leg, and we’ll talk about that in a second. But that is typically the level as to where the recession is going to be performed. We’ve gone almost exclusively, because of the approach we’re doing, which is strictly a modified medial approach, we’re going to do almost exclusively now when we do gastrocnemius recessions, the Stayer procedure. I was taught in my training program on mostly Bakers, but we’ve gotten to the point now, because of the ability for us to go in and make small incisions, we can utilize different types of speculums and different arthroscopy tools to go in and do these procedures, the Strayer procedure is something that we’ve incorporated in our practice much more commonly. The Strayer procedure can be done again through an endoscopic aspect or through a medial approach, which we call like a mini-open approach. Again, when we’re doing our mini-open approach, what we’re going to do is we’re going to palpate the medial head of the gastrocnemius muscle. Again, about 2 fingerbreadths below that, we’re going to make a linear incision or vertical incision just along the medial margin of the muscle. That linear incision is going to run about 2 centimeters.
As we make our incision down through the layer of the subcutaneous tissue, and what we’ll do is just typically take a wet sponge, pull our subcutaneous fat out of the way and we’re going to visual the medial board of the muscle belly. We’re going to visualize the aponeurosis. We’re going to make a small incision over the deep fascia that’s sitting directly on top of the aponeurosis. We’re going to reflect that. Then, through our medial approach that’s going to be open, what we’ll do now, and this is a tip I got off of Mary Crawford out in Seattle. We’re actually going to take a small vaginal speculum and we’re going to take that speculum and we’re going to run it traversely across the posterior aspect of the leg, just sitting deep to that deep fascia. The reason why it’s important to be deep to that deep fascia is because the nerve, the sural nerve is going to sit in most instances, immediately superficial to that deep fascia. If we can reflect that out of the way and we get our speculum in there, we’re going to know that we’re also going to protect that nerve, and then we’re going to be able to visualize on top of that aponeurosis, so we’re going to be able to make our cut. We’ll typically start our cut with a number 11 blade. Utilizing the [indecipherable] [06:08] fashion, we’ll penetrate that aponeurosis, we’ll make a cut. Once we’ve get a layer of it, so we can isolate our aponeurosis, we’ll then take a pair of scissors and we’ll traverse across the leg and do a resection of our aponeurosis. We’ll go all the way across the leg. You want to make sure that you get the lateral bands, which are probably going to your most challenging to get with the medial portal, but it is certainly very possible and it is very repeatable. You also want to make sure that if you have any medial slips that are catching up when you’re trying to dorsiflex the leg, you do so. We’ll dorsiflex the leg and we do not then reapproximate anything. We’ll let that sit open and typically, we’ll go from there. Then, the scalpic approach is very, very similar. Our surgical approach, the start of the procedure is the exact same way. It’s just done with a smaller medial incision, again, 2 fingerbreadths distal to the medial head of the gastrocnemius muscle, on the medial border of the muscle and the medial aspect to the leg. What it does is it gives you the ability to do this through a camera so that you can visualize things. You can visualize that deep fascia. If the nerve is in the way, you’re actually going to see it with your own eyes. Again, here we go, here we are with our surgical technique. We’ve got 2 fingerbreadths medial to the leg as our incision, about a centimeter and a half, vertical incision. There’s our incision, so that you can see the deep fascia on the aponeurosis. My fellow is clearly pulling on that skin way too much, but it’s for the sake of getting a good picture. What we’re going to do is we’re going to take a number 15 blade and we’re going to do a linear incision along our deep fascia that’s sitting directly on top of the aponeurosis. We’re going to take, at this time, a little probe or what we call spatula. I’m going to take the spatula and I’m going to get underneath that incision and I’m going to create a subfascial flap between the aponeurosis and the fascia. We’re going to traverse that across the posterior aspect of the leg. One of the benefits of doing the endoscopic procedure is that you can have the patient at supine position. You create this flap across the posterior aspect of the leg. As you can see here, we’re going to take our trocar for the scope and we’re going to replace that trocar in our flap. Once our trocar is inserted and is traversing the posterior aspect of the leg, we’re then going to take a camera. For the endoscopic procedures, you’re going to utilize a 4 millimeter scope that’s going to have a 30-degree angle to it, and you’re going to insert that so that the camera is facing your aponeurosis. The bevel is going to be facing our aponeurosis. If you’re prone, that’ll be facing away from you. If you’re supine, it’s going to be facing towards you. This is what our aponeurosis looks like endoscopically. We’re going to through and we’re going to look at our medial zone of our gastrocnemius aponeurosis. We’re going to look at our central and our lateral zones. As we get into our central and lateral zone, we’re going to be cognizant of our nerve. If we’ve penetrated through our deep fascia, there’s a chance we’re going to see nerve running in this orientation. If we see a nerve running, we pull everything out and we start over again. We do not want to go and stick our knife back there with our nerve visualized, because that means that we’re going to cut a nerve. As long as you’re deep to that deep fascia, you’re going to be fine, and like I said, 99% of all instances. This is an example of what our endoscopy blade looks like to do our gastrocnemius recession. You can see, it’s a unidirectional blade. It’s got a little tooth in it, so that what happens is the aponeurosis will actually sit between the angle of the tooth, so as you’re driving it forward and traversing the leg, you’re actually taking a cut as you’re inserting the camera. This sheath will actually sit on top of the camera, so it’s done through a uniportal approach. You don’t have to create a second portal. You may have to pull it out and push it across two or three times to make sure that you get all the fibers.
You will be able to visualize this as you’re doing it. Here’s how the blade attaches to the scope. This is how we cut our aponeurosis as we’re traversing across the leg. Now, you can see, once our aponeurosis is cut and the foot is dorsiflexed, you’re going to see muscle belly. If you see any fibers that are running across that, you’re going to have to go back in and resect those fibers because, again, that will hold you up when you’re trying to dorsiflex the foot. Again, the biggest key to this is making sure that when you’re deep to the fascia, you can make sure you do not visualize that nerve. As long as you stay away from that, you’ll be fine. This is a completely released gastrocnemius muscle at this point, or gastrocnemius aponeurosis. Postoperatively, certainly what we’ll do is if we’ve done the procedure by itself, meaning we did not do any osseous correction with that, we’ll hold the foot at 90 degrees for about four weeks. We’ll let them ambulate a CAM walker boot, but we do want the boot at 90 degrees. If done with bony procedures, I’ll typically let the bony procedure dictate our postoperative course. After the patient has been cleared, whether it’s with a bony procedure or after four weeks of CAM walker boot, modified weightbearing initiative, we’ll do an additional four weeks of guarding activity. We’ll start physical therapy with limited dorsiflexion. Our goal is to basically increase the strength of the gastrocnemius and soleus complex. We tell every patient that we do that it may take a full year to gain our full push up strength. I feel one of the benefits of doing the gastrocnemius recession is that it does give you a little bit better push-off strength than a full tendo-Achilles lengthening. Certainly, the complications associated with a gastrocnemius recession are that of nerve damage and entrapment. Again, that sural nerve is something that you want to stay away from. Hematoma, when you do Bakers or any type, even when you do a Strayer procedure, you certainly have, when you resect that aponeurosis and you expand that opening, that area will fill with something and that can fill with scar. Sometimes, that scar can be painful and will cause some subcutaneous adhesions that you have to look that. Certainly, you want to make sure that you’re doing your release at an appropriate level. If you’re too distal, you’re going to start cutting into the soleus. As we know, the soleus is one of the predominant plantar flexions of the foot. If we cut the soleus, you’re going to see a significant inability for heel raise and a diminished propulsive force during gait. That is something that you want to focus on. Make sure that that release is done at the appropriate level. Now, again, thinking about our Silfverskiold test and our indications for tendo-Achilles lengthening, this is when we’ve got a significant gastrocsoleus contracture. The dorsiflexion is restricted with the knee flexed then extended. We’ll also utilize these with our diabetic foot in our complex reconstructions. A triple hemisection tendo-Achilles lengthening is certainly very straightforward. It's probably, like I said, it’s one of the easier procedures you’ll do. We do this in situations where we know that our patient is not going to need significant propulsive push off. There are some really neat multiple papers out there that have talked about tendo-Achilles lengthening results during the propulsive phase of gait as well as the dorsiflexion range of motion. What we’ll look at is we consider the plantarflexor [indecipherable] [13:17] of the foot is reduced by 21% in eight weeks. I mean, that in itself is the reason why we can do this in a diabetic patient. It's really significant, save our diabetics from developing some forefoot and midfoot ulcerations because of that. Typically, average seven months postoperatively, our plantar pressure is reduced up to 55%, again, another indication as to why this is a benefit in our diabetic population. Our triple hemisection TAL and you can do this in either the sagittal plane or on the frontal plane. What we’re going to do is basically make, starting at the midline, we’re going to make three incisions and we’re going to basically be in our critical zone, our watershed area of our Achilles tendon. But, what we’re going to do is we’re going to split the Achilles tendon into a medial and lateral half and we’re going to make a horizontal incision, two of them, typically medial or quite frankly you can two lateral if you want a one medial. You want to make one incision to the midline then go to the opposite side of the tendon, make another transverse incision to the midline, and then the same thing down inferiorly. Then, you’re going to dorsiflex the foot. What you’re going to see is you’re going to get the Z type lengthening where the medial and lateral fibers are going to slide upon themselves, and that’s going to lengthen that tendo-Achilles complex. You don’t have to make two medial incisions and one lateral. You can make them midline and you can put your blade in vertically and then twist your blade and work to the margins of the tendon. That way, you can have centralized incisions. Either way, the principles are the same. You want to make sure that when you're do utilizing this, you do not sacrifice and take this incision across that midline, because when you do so, you’ll just basically create a rupture.
You want to make sure that you do get an effective Z lengthening of the tendon fibers so that they slide upon themselves. The complications with the tendo-Achilles lengthening are, again, overresection and rupture. Certainly, wound complications back there should be minimal because your incisions are basically percutaneous incisions. The loss of propulsive force can be a complication when done in the wrong patient, but can be a benefit for the other patients, and it can create some dense scarring in the Achilles tendon. You’ll notice that you do develop some mucoid degeneration. In most instances, it’s not painful. When you’re doing osseous correction with the tendo-Achilles lengthening, because those patients are functioning so much better, they typically do not even notice any of the dense scar that can form. That’s my discussion on the tendo-Achilles lengthening and gastrocnemius. Anybody have any questions regarding that? Great. Thank you guys for your time. Great week.