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Marie Williams: This is the tendon Achilles lengthening and the gastroc recession, and I call it equinus because that's what we're really looking at, the equinus deformities. We, if there's redundant slides on all of the tendons, we'll go through them so that you don't have to have it repeated since this will be the third time through for you. Is that okay? Okay, good.

So remember that an equinus deformity is really a limitation of the passive ankle joint dorsiflexion to less than 90 degrees of the foot relative to the leg. When you're surgically correcting these problems, actually it was first talked about it in 1816. So we're probably still doing similar procedures to then, more for the spastic equinus in the CP patient. And now we're into the 21st century and I look back at some of those old procedures, I mean, really old procedures, and we're still doing them. We haven't changed much in the way we do that surgery, except for some of the newer technologies out that we'll talk about.

So this is something that's an old problem with similar repair. I'm going to divert one second. I was on in 1990s, I did practice guidelines for ACFAS and one of the things that I found is a lot of the literature that we did, we get a lot of literature search. And what I found was that the – everything that was based on what we were doing in that time period was based on one article that belonged with one guy, like Dr. Austin or Dr. Mitchell, or Dr. Whatever and it was interesting. Anyway, just wanted to just divert for a second to let you know that a lot of these procedures were picked up way back when and we bring them forward. And now we make them our own and now they're the new procedures or whatever.

[01:57]

The gastroc muscle superficially is the medial head which is the broader thicker tendon or muscle, and it extends more distally than the lateral head. And it forms a lateral side of the talar – the Achilles tendon area. The soleus is a deep muscle and it forms on the medial two-thirds of the Achilles tendon and then you have the plantaris. It attaches medially but it's absent in 7% of the time. Whenever my residents look for it, they just say it's absent.

So those are just are a really great picture of how the muscles are in the back of the leg when you look and why this is important as you'll see later when you do an endoscopic procedure, but you have to worry about sural nerve and the small saphenous vein, which course just in the posterior calf, actually proximal. The tendon is 15 centimeters in length. It's the thickest and strongest tendon in the body. It has that weak point, two to six centimeters proximal to the insertion of the calcaneus. That's where the blood supply is the weakest and it is actually the most frequent ruptured tendon.

Maybe because it's the largest. Maybe because it's the strongest and maybe it's because of the types of exercises. But I'm always amazed at the professional athletes that end up having Achilles tendon ruptures. I don't know if you – they're playing basketball and they go up and they come down, and pop. They're ready to throw the football and all of a sudden they're stepping off, and pop. And these guys are high end professional athletes that have round the clock physical therapy trainers, strengthening programs and everything. I just wonder about that because then you also have that guy who's out playing tennis for the first time in like three years, and pop.

Or then, you have the guy that's golfing and twist and it pops. So I don't know, I don't understand that completely and totally, except for the fact that the tendon is strong and it does have a weak point, and it's the blood supply and that blood supply does degenerate overtime.

[04:05]

There's an ankle joint equinus that you have to know about. Ankle equinus is at the talotibial area and you can develop exostosis around the anterior ankle. You may have the bridging at the tibiofibular syndesmosis. You'll get a pseudo equinus with an anterior cavus deformity, which appears to be an equinus but when you actually dorsiflex the foot without that forefoot drop, you'll find that you have motion, but it's because of the cavus deformity that you have now, that pseudo equinus. And sometimes you can have a bony bridge with an anterior equinus of the forefoot.

Muscular equinus is usually many. Some of you have the neuromuscular diseases where you'll get spastic equinus. You'll get a hyper tonic-clonic type reaction with hyperreflexia, toe walking. You'll see that in young kids, the CP patient. Posterior muscles overpower the anterior muscles, which become more weakened. Then you have the non-spastic type equinus where you have a short posterior leg muscles. You have an accessory soleus. You have low soleus insertion so it becomes lower than it is and you have less ability to pull. You can have the acquired equinus where you have traumatic injuries, iatrogenic, we'll talk about in a minute, prolonged casting and figure.

When I was a resident, a flatfoot surgery, it was so exciting and when you had a case coming in, you were like not only where you're prepared but you were prepared, because this is the time you saw all day long, and we were going to use something like a thing called a screw. Oh no. We had screws. Anyway. And we were going to lengthen the tendon with a tendon lengthener. It was exciting, right? So I remember my attending saying to me, "Now, we're going to do a tendon lengthening on this young kid. We're going to do an Achilles tendon lengthening.

[05:59]

We're going to do it this way, this way, this way. Here's the knife, go ahead and do it." It's so exciting. So I actually do my little anterior posterior cut and I do the other cut, and then I actually literally took the foot and I dorsiflexed the foot to the ankle. And I could feel that tendon go, and then he looked at me and he goes, "Oh no." I go, "What?" He says, "Okay, you weaken that tendon so much, this poor little boy, he won't be walking or pushing off for at least six months." I was like, "Oh my God, it's true." That's sort of the iatrogenic situation where you have an equinus and then you lengthen it too much and now you have a foot that won't go. So be aware that iatrogenic both in the equinus way and the opposite way can become a problem so you want to really respect this tendon from an iatrogenic point of view.

The exam is simple. You're going to put the patient in supine, knee fully extended, subtalar joint neutral. You're going to dorsiflex the foot to the leg or ankle, and less than 10 degrees establishes that you have an equinus. And then you have the Silfverskiold test which shows that if you're trying to determine whether you have a gastrocnemius equinus or a gastroc soleus equinus, or just soleus equinus, and the way you do that is you put the foot – knees on this, and you put the foot in subtalar joint neutral. You dorsiflex, you keep the knee flexed, dorsiflex the ankle. And you get 10 degrees of motion and there's no gastroc equinus.

You bend the knee and let's say that you don't get motion, you bend the knee and now you get your motion. Then you have a gastroc equinus. A soleus equinus or a talar – where you might want to do a tendon Achilles lengthening is when you have the knee flexed and/or extended and you still have a decreased motion. Some of the compensations for equinus, the center of gravity changes so you might see – and you might even see this in young kids where you'll have lumbar lordosis.

[08:05]
You'll have hip flexion changes, knee flexion changes in that genu recurvatum to compensate for the equinus. So you should be doing gait analyses on these patients, so watch them walk and to see how much they haven't functioned. Distal compensation, you'll see a pronated subtalar joint in our midtarsal joint problem. You'll see forefoot dorsiflexion on to the rearfoot. You may even see a bunion deformity or a valgus of the forefoot. Conservative treatment consists of orthotics or figure change, physical therapy for strengthening. In the young kids, there are braces and zero casting, and orthotics for the younger child. In the toe walker, the parent comes in with their child who's two or three and they won't stop walking on their toes. I guarantee if you put them in the cast, they'll stop.

Gastroc recession versus TAL. We're going to look at the surgical repair. There's several types of procedures and you know them because when you study for your board, you're going to study all about them. I'm going to review that for you, except that there are selective procedures where you can do a selective neurectomy, especially in the spastic type equinus where you look for the tibial nerve branches, then innervate the gastroc muscle belly. You do a proximal release of the medial head of the gastroc and you do a distal resection of the gastroc aponeurosis.

I'm not one that does a lot of neurectomy type procedures, not in a diabetic and/or for this, but it is there and available, and you need to know about an isolated gastroc equinus and ones being done. Myerson actually came out with this procedure recently and shows that he isolates the medial gastroc and does a medial gastroc release. He says it's less invasive, less risky and effective for gastroc recession.

[10:01]

He goes into the popliteal fossa and he takes and does a cross-sectional tenotomy or a lengthening there at the level of the medial head of the gastroc. I will not do that but I want you to know about it because it is being done. Because it's in the medial head and there's very few structures that you can get and invade, but I stay out of the fossa myself.

The proximal recessions are done along – there's parallel incisions along the proximal aponeurosis of the gastroc and soleus are relying the muscle bellies. You have to worry because remember in that first slide I showed you, what you definitely have to worry about is the sural nerve and the small saphenous vein. You do not want to cut those structures. The distal recessions, you have several of them, the Vulpius, Strayer, Baker and McGlamry came up with his technique with Fulp. And here are the pictures of them. I show them for completeness' sake because you're going to see them in all of your reviews.

Everything that you're doing, you read about them, and you will do them. So here's a distal resection of the gastroc aponeurosis using a V-type incision and you'll actually get the proximal aponeurosis is occasionally sutured and/or not sutured to the muscle but you can see here where you're getting in the aponeurosis you'll get lengthening. Well then, Strayer is identical to Vulpius except that the proximal aponeurosis is reattached to the soleus muscle. So it's the same but now you're just reattaching it to the muscle. And then, Baker did the tongue-and-groove, which we hear about a lot. If I'm going to do this, I usually do the tongue-and-groove, I feel like I can get a lot more stretch out of it.

[11:58]

It includes dissection of the central soleus aponeurosis and it's performed to prevent the clonus, or the recurrence from the soleus stretch of the muscle, which you can get a reflective contraction. And then, you have the inverted tongue-and-groove, which may cause atrophy of the medial gastroc because of the way it's made, but it's inverted, you get a little bit longer length from the inverted procedure. So there's several ways of approaching that aponeurosis.

The endoscopic gastroc recession is what I predominantly like to do. I find it to be safe and easy. I find it to be very minimally invasive and have been doing that for years now, very rarely do I open them. And you can see here where you're actually looking at the leg where there's a small incision that you're going to make and you're going to use your endoscope to go in and resect. The key here is that you do not want to invade the saphenous nerve and/or the saphenous vein because now you have a small little procedure that becomes a problem. So just be aware of that.

So here's where the incision is made and then you're going to insert your scope. You're going to make your cut. You're going to make sure that you're up against the actual fascial tissue before you make your cut, similar to that of an endoscopic plantar fasciotomy. You're doing this same thing here. And you can see when you're in there, you're looking for the fascia and then you're looking at the muscle. You don't want to see vein or nerve. You don't want a lot of bleeding.

Lengthening of the tendon Achilles is done. It actually is due to a gastroc soleus equinus where you need to do it distally to the conjoining of the tendons into one structure. You can do it percutaneously or open. You can slide Z, a slide either V – a slide in a Z fashion, anterior, posterior manner.

[13:59]

And as I said, we can do them either or. I don't think it makes that much of a difference if you do them – you just have to make sure that you're getting your length and – anatomy of the Achilles tendon includes a gradual internal rotation of the fibers, beginning 15 – 12 to 15 centimeters proximal to the calcaneal insertion, remember, about the rotation.

This rotation has been found to range from 11 degrees to 90 degrees, so there's a twist. You have the medial fibers rotating posteriorly and the posterior fibers rotating laterally. This contributes to the concern with the percutaneous sections and it is actually remember you're working in some different planes. And that's where the anterior, posterior slide is what I like to do. The percutaneous TAL, it's called the White procedure. It may be done partially opened based on the internal rotation of the Achilles tendon. You want to transect anteriorly one-half to two-thirds of the tendon.

And then, go proximally 2.5 centimeters proximal to the insertion and transect the medial, or I call it the posterior portion of the tendon, about six centimeters proximal to the first transection. And here are the incisions on that percutaneous talo – the percutaneous procedure. And you can see here we're also realigning the heels. So also there's two small incisions and you just slide that and I don't suture them back. Here's the procedure just a little bit closer where you're going to see the small skin incision. You're going to put something underneath the tendon so you can get a good cut going anteriorly and then a good cut going posteriorly. You can do a hemi section. There's actually three incision approach.

[15:59]

Here's drawn out where you'll do hemi sections on the tendon both six centimeters apart and you're just doing partial cuts and you're weakening the tendon to lengthen it, and then you're going to dorsiflex the foot. Here's where that example I was telling you. Just be careful. You're going to have a nice sequence and iatrogenically possibly make it too much so just be aware that you want to get a good dorsiflexion and you don't want to overstretch.

Open lengthening Zs and slides are done and they require the patient to be in a more of a prone position, and you have to have meticulous dissection in order to avoid not only the sural nerve damage but you want to maintain the peritenon. You don't want to get a lot of scarring so you have a greater risk of non-healing adhesions, pain, scarring and rerupture. And this is also an option though.

Just an example of some of the types of procedures that have been done just to get a good concept that there's always of lengthening that tendon. This is an example of a female, 18 year old female who had a tendon lengthening using three transverse incisions and you can see that there is a scar in her leg as well from the other problem, but these three transverse incisions from an aesthetic standpoint can be very good with less adhesions. So it's just another option.

What I do in my Achilles tendon lengthening 68 weeks and on a non-weight bearing, or a cast, or boot post-operatively, physical therapy for gradual motion and stretching to prevent adhesions. This is a very busy chart but it's just something that I wanted to address with you from this standpoint. You have the gastroc recession and then you have the tendon Achilles lengthening and the types of indications. You can see that there's a lot of different indications and risks.

[17:59]

One of the things on the gastroc recession, you get inadequate length and you can get a recurrence of ulcerations which I've seen. And in the tendon Achilles lengthening in the wrist, you get overlengthening which I've discussed. You can get a rupture. You can get that calcaneal gait where the heel doesn't come off the ground, so kind of moves slowly. So just be aware of the risks of each because there are risks.

This is a great study of a randomized cadaver trial where it showed the actual lengthening of the tendon in millimeters in where you were going to get the best length, and it was the tendon Achilles lengthening where you actually had the tendon. The fibers were actually getting – you'd get more stretch to the tendon itself and the more distal procedures. It illustrated that the length is achieved more commonly distally but the tradeoff exists with the tendon where you'll get more correction with possible risk of higher rupture, so be aware of that.

Here it is, evaluating all of the types of procedures and the lengthening, and in the zone two and three, or as you come down into the tendon. You're going to get more lengthening and more stretch at the level of the tendon Achilles lengthening procedures than you would if you did it more in the gastroc area.

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