Tec h n i q u e , I n d i c a t i o n s , a n d R e s u l t s o f P ro x i m a l M e d i a l G a s t ro c n e m i u s Lengthening Pierre Barouk,
MD
KEYWORDS Gastrocnemius Equinus Hallux valgus Metatarsalgia Proximal gastrocnemius release KEY POINTS Gastrocnemius proximal lengthening was first performed to correct spasticity in children, and was adapted for the patient with no neuromuscular condition in the late 1990s. Since that time, the proximal gastrocnemius release has become less invasive and has evolved to include only the fascia overlying the medial head of the gastrocnemius muscle. The indications for performing this procedure are a clinically demonstrable gastrocnemius contracture that influences a variety of clinical conditions in the forefoot, hindfoot, and ankle. Proximal gastrocnemius release is a safe and easy procedure that can be performed bilaterally simultaneously, and does not require immobilization of the ankle after surgery. Proximal gastrocnemius release can be performed either as an isolated procedure, or in conjunction with additional foot or ankle surgeries.
INTRODUCTION
When equinus is caused only by tightness of the gastrocnemius, lengthening only the gastrocnemius is logical. This procedure can be performed at 3 levels: proximal, intermediate, and distal. The distal open techniques are described in the article “Surgical Techniques of Gastrocnemius Lengthening” by Dr. DiGiovanni and colleagues in this issue. The intermediate-level technique was described by Bauman,1–4 but is one with which the authors have no experience, and it involves a section of the anterior aponeurosis of the gastrocnemius. Silfverskiold5 was the first to describe proximal gastrocnemius lengthening in 1923 in cases of cerebral palsy. He cut the medial and lateral gastrocnemius at their insertion on the femoral condyle (Fig. 1). According to Gage,6 spasticity first affects the
Disclosures: None. Foot Surgery Center at the Sport’s Clinic, 2 Rue Georges Ne`grevergne, Merignac 33700, France E-mail address: [email protected] Foot Ankle Clin N Am 19 (2014) 795–806 http://dx.doi.org/10.1016/j.fcl.2014.08.012 1083-7515/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
foot.theclinics.com
796
Barouk
Fig. 1. Silfverskiold’s technique. Lat, lateral; N, nerve. (From Silfverskiold N. Reduction of the uncrossed two-joints muscles of the leg to one-joint muscles in spastic conditions. Acta Chir Scand 1923;56:315–30.)
biarticular muscles, and the technique for this indication is still used and provides good results.7 The authors’ technique of proximal release of the fascia of the medial gastrocnemius is derived from experience with the Silfverskiold’s method. This procedure began with the work of Barouk7 in 1970, when the original technique of Silfverskiold was used in cerebral palsy cases. From 1997 to 2005, the authors performed section of only the white fibers (aponeurosis), but of both the medial and lateral gastrocnemius (Fig. 2) in patients with static problems (as opposed to dynamic associated with neuromuscular conditions such as spasticity) mainly related to the forefoot.8 From 2005 to present, the authors have sectioned only the aponeurosis of the medial gastrocnemius (Fig. 3) for reasons that are explained later. Indications for Proximal Gastrocnemius Release
In the authors’ practice, indications for the procedure are based on the presence of gastrocnemius tightness (a positive Silfverskiold sign), particularly when this tightness has influenced the problem for which the patient has sought help. Additional symptoms will be relieved by the proximal release, including the presence of lumbar pain cramps in the calf, calf tension, or difficulty walking in bare feet or flat shoes.9,10,11
Fig. 2. Section of the white fibers (red arrows) of medial and lateral gastrocnemius. (From Barouk LS. Forefoot reconstruction. New York: Springer-Verlag; 2003; with permission.)
Proximal Medial Gastrocnemius Lengthening
Fig. 3. Section of the white fibers of the medial gastrocnemius. (From Barouk LS. Forefoot reconstruction. New York: Springer-Verlag; 2003; with permission.)
Surgical Technique
General anesthesia can be used, but the authors’ choice is peripheral local or regional anesthesia using a sciatic nerve block with a subgluteal lateral approach, guided with ultrasound. The choice of local anesthetic agent depends on the duration of the stay of the patient. The authors use either mepivacaine, 15 mg/mL for ambulatory patients, or a mix of mepivacaine, 20 mg/mL and ropivacaine, 7.5 mg/mL for hospitalized patients. The volume injected is approximately 20 mL. This block is, however, ineffective for cutaneous anesthesia, particularly the posterior cutaneous nerve of the thigh, and is therefore supplemented with local anesthesia just above the popliteal fossa (lidocaine, 20 mg/mL with adrenalin) just before the incision. Preparation
Surgery is performed in the prone position, with a pillow under the ankles to relax the gastrocnemius. The authors have used a supine position, but this requires additional retraction and a larger incision, with more traction on the soft tissues, and they do not commonly perform the procedure in the supine position. No need exists for a tourniquet. Having 2 kinds of retractors available is preferable: 1 narrow for the superficial layers and 1 broader for the deep layer. The incision is made in the flexion crease, 1 cm lateral to the medial fovea. It is approximately 3 cm in length (Fig. 4). At this level, no vascular or nervous structures
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Fig. 4. (A, B) Incision.
can be damaged, as is well described by the anatomic study of Hamilton and colleagues.12 The subcutaneous fat is retracted and the authors look for the posterior fascia of the leg, which is opened in the axis of the leg. The authors find, just underneath, the medial gastrocnemius covered by a thin aponeurosis and marked by a fat layer of variable thickness. The tendon is on the medial side, extending anteriorly (Fig. 5). All the white fibers are cut with scissors (Fig. 6). The authors use a finger to check that no more tension is present in the muscle while they move the ankle into dorsiflexion. Indications for including the lateral head are limited, but this may be considered in some cases when a medial section alone is insufficient. The authors divided both heads systematically for several years. To do this, the incision is extended laterally. The authors then locate the muscle with the finger, lateral to the popliteal artery. The posterior fascia of the leg is opened carefully because the sural communicating branch of the common peroneal nerve is at risk, and this now places the authors on the muscle. The white fibers are in fact a narrow aponeurotic band, slightly lateral (Fig. 7). Here again, one must be careful of the common peroneal nerve, which is close and must be seen before the white fibers are sectioned.
Fig. 5. Medial tendon, lateral aponeurosis.
Proximal Medial Gastrocnemius Lengthening
Fig. 6. Tendinous fibers already cut, and aponeurotic ones in progress.
Hemostasis is checked and the authors close subcutaneous tissue and skin with an intradermal suture. Use of a drain is not necessary. Postoperatively, no immobilization is recommended. Walking is allowed as soon as the local anesthesia has worn off. A rehabilitation program is begun by the physiotherapist, and consists of passive dorsiflexion of the ankle with the knee in extension (Fig. 8). The authors recommend walking in a shoe without a heel to keep the ankle in dorsiflexion. The authors reviewed a series of 354 proximal gastrocnemius releases—274 medial and lateral and 80 only medial—at 2 years’ follow-up. In 354 interventions they noted: Four cases of moderate pain of the calf, resolved at 1 year, except one with persistent unexplained popliteal pain One case of deep vein thrombosis (this patient was operated on for correction of hallux valgus simultaneously) One case of lateral tension of the calf in a patient who had medial release only
Fig. 7. Proximal insertion of the medial and lateral gastrocnemius. (From Barouk LS. Forefoot reconstruction. New York: Springer-Verlag; 2003; with permission.)
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Fig. 8. Patient-directed rehabilitation.
Two cases of transient lateral dysesthesia (in the case of lateral and medial release) Ten cases of keloid scar, each time when lateral and medial gastrocnemius were elongated, which tends to be associated with greater scarring Ten cases of weakness (subjective evaluation by the patient) in 7 cases of medial and lateral lengthening; in these 10 cases, 1 was really symptomatic (excessive lengthening with too much dorsiflexion of the ankle that restricted the patient in sports activities) Since this study, the authors have performed medial gastrocnemius release in 368 patients, among whom they observed: Four hematomas: 2 that spontaneously regressed and 2 that had to be drained; the authors believe that this coincided with the use of a new antithrombosis prophylaxis agent that they have since discontinued Two deep vein thrombosis (both patients underwent simultaneous hallux valgus correction) No dysesthesia, no keloid scar, and no weakness With section of only the medial gastrocnemius aponeurosis, complications are rare and of no significance. Whether the release was performed to include the medial head only or both heads, ankle dorsiflexion with the knee extended was improved in all the cases of the series described. However, estimation of the results depends on the manner in which the gastrocnemius is examined. The authors test for an equinus contracture with the subtalar joint reduced to slight varus and then with moderate strength to dorsiflex the ankle. If one is going to compare these results, the maneuver must be able to be reproduced from one patient to another, and preoperatively and postoperatively. Preoperatively, 69% of the patients had an equinus contracture of –15 , with the ankle in dorsiflexion and the knee extended, and this decreased to 4% postoperatively. A contracture between 0 and –15 was seen in 22% of the patients, and 19% postoperatively. The ankle dorsiflexion test with the knee extended increased from 9% to 77% postoperatively. In a blinded series of 30 patients, no differences were seen in the amount of improvement of ankle dorsiflexion with the medial alone compared with the medial and lateral (Table 1).
Proximal Medial Gastrocnemius Lengthening
Table 1 Ankle dorsiflexion, knee extended >1
Between 0 and L15
MD
KEYWORDS Gastrocnemius Equinus Hallux valgus Metatarsalgia Proximal gastrocnemius release KEY POINTS Gastrocnemius proximal lengthening was first performed to correct spasticity in children, and was adapted for the patient with no neuromuscular condition in the late 1990s. Since that time, the proximal gastrocnemius release has become less invasive and has evolved to include only the fascia overlying the medial head of the gastrocnemius muscle. The indications for performing this procedure are a clinically demonstrable gastrocnemius contracture that influences a variety of clinical conditions in the forefoot, hindfoot, and ankle. Proximal gastrocnemius release is a safe and easy procedure that can be performed bilaterally simultaneously, and does not require immobilization of the ankle after surgery. Proximal gastrocnemius release can be performed either as an isolated procedure, or in conjunction with additional foot or ankle surgeries.
INTRODUCTION
When equinus is caused only by tightness of the gastrocnemius, lengthening only the gastrocnemius is logical. This procedure can be performed at 3 levels: proximal, intermediate, and distal. The distal open techniques are described in the article “Surgical Techniques of Gastrocnemius Lengthening” by Dr. DiGiovanni and colleagues in this issue. The intermediate-level technique was described by Bauman,1–4 but is one with which the authors have no experience, and it involves a section of the anterior aponeurosis of the gastrocnemius. Silfverskiold5 was the first to describe proximal gastrocnemius lengthening in 1923 in cases of cerebral palsy. He cut the medial and lateral gastrocnemius at their insertion on the femoral condyle (Fig. 1). According to Gage,6 spasticity first affects the
Disclosures: None. Foot Surgery Center at the Sport’s Clinic, 2 Rue Georges Ne`grevergne, Merignac 33700, France E-mail address: [email protected] Foot Ankle Clin N Am 19 (2014) 795–806 http://dx.doi.org/10.1016/j.fcl.2014.08.012 1083-7515/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
foot.theclinics.com
796
Barouk
Fig. 1. Silfverskiold’s technique. Lat, lateral; N, nerve. (From Silfverskiold N. Reduction of the uncrossed two-joints muscles of the leg to one-joint muscles in spastic conditions. Acta Chir Scand 1923;56:315–30.)
biarticular muscles, and the technique for this indication is still used and provides good results.7 The authors’ technique of proximal release of the fascia of the medial gastrocnemius is derived from experience with the Silfverskiold’s method. This procedure began with the work of Barouk7 in 1970, when the original technique of Silfverskiold was used in cerebral palsy cases. From 1997 to 2005, the authors performed section of only the white fibers (aponeurosis), but of both the medial and lateral gastrocnemius (Fig. 2) in patients with static problems (as opposed to dynamic associated with neuromuscular conditions such as spasticity) mainly related to the forefoot.8 From 2005 to present, the authors have sectioned only the aponeurosis of the medial gastrocnemius (Fig. 3) for reasons that are explained later. Indications for Proximal Gastrocnemius Release
In the authors’ practice, indications for the procedure are based on the presence of gastrocnemius tightness (a positive Silfverskiold sign), particularly when this tightness has influenced the problem for which the patient has sought help. Additional symptoms will be relieved by the proximal release, including the presence of lumbar pain cramps in the calf, calf tension, or difficulty walking in bare feet or flat shoes.9,10,11
Fig. 2. Section of the white fibers (red arrows) of medial and lateral gastrocnemius. (From Barouk LS. Forefoot reconstruction. New York: Springer-Verlag; 2003; with permission.)
Proximal Medial Gastrocnemius Lengthening
Fig. 3. Section of the white fibers of the medial gastrocnemius. (From Barouk LS. Forefoot reconstruction. New York: Springer-Verlag; 2003; with permission.)
Surgical Technique
General anesthesia can be used, but the authors’ choice is peripheral local or regional anesthesia using a sciatic nerve block with a subgluteal lateral approach, guided with ultrasound. The choice of local anesthetic agent depends on the duration of the stay of the patient. The authors use either mepivacaine, 15 mg/mL for ambulatory patients, or a mix of mepivacaine, 20 mg/mL and ropivacaine, 7.5 mg/mL for hospitalized patients. The volume injected is approximately 20 mL. This block is, however, ineffective for cutaneous anesthesia, particularly the posterior cutaneous nerve of the thigh, and is therefore supplemented with local anesthesia just above the popliteal fossa (lidocaine, 20 mg/mL with adrenalin) just before the incision. Preparation
Surgery is performed in the prone position, with a pillow under the ankles to relax the gastrocnemius. The authors have used a supine position, but this requires additional retraction and a larger incision, with more traction on the soft tissues, and they do not commonly perform the procedure in the supine position. No need exists for a tourniquet. Having 2 kinds of retractors available is preferable: 1 narrow for the superficial layers and 1 broader for the deep layer. The incision is made in the flexion crease, 1 cm lateral to the medial fovea. It is approximately 3 cm in length (Fig. 4). At this level, no vascular or nervous structures
797
798
Barouk
Fig. 4. (A, B) Incision.
can be damaged, as is well described by the anatomic study of Hamilton and colleagues.12 The subcutaneous fat is retracted and the authors look for the posterior fascia of the leg, which is opened in the axis of the leg. The authors find, just underneath, the medial gastrocnemius covered by a thin aponeurosis and marked by a fat layer of variable thickness. The tendon is on the medial side, extending anteriorly (Fig. 5). All the white fibers are cut with scissors (Fig. 6). The authors use a finger to check that no more tension is present in the muscle while they move the ankle into dorsiflexion. Indications for including the lateral head are limited, but this may be considered in some cases when a medial section alone is insufficient. The authors divided both heads systematically for several years. To do this, the incision is extended laterally. The authors then locate the muscle with the finger, lateral to the popliteal artery. The posterior fascia of the leg is opened carefully because the sural communicating branch of the common peroneal nerve is at risk, and this now places the authors on the muscle. The white fibers are in fact a narrow aponeurotic band, slightly lateral (Fig. 7). Here again, one must be careful of the common peroneal nerve, which is close and must be seen before the white fibers are sectioned.
Fig. 5. Medial tendon, lateral aponeurosis.
Proximal Medial Gastrocnemius Lengthening
Fig. 6. Tendinous fibers already cut, and aponeurotic ones in progress.
Hemostasis is checked and the authors close subcutaneous tissue and skin with an intradermal suture. Use of a drain is not necessary. Postoperatively, no immobilization is recommended. Walking is allowed as soon as the local anesthesia has worn off. A rehabilitation program is begun by the physiotherapist, and consists of passive dorsiflexion of the ankle with the knee in extension (Fig. 8). The authors recommend walking in a shoe without a heel to keep the ankle in dorsiflexion. The authors reviewed a series of 354 proximal gastrocnemius releases—274 medial and lateral and 80 only medial—at 2 years’ follow-up. In 354 interventions they noted: Four cases of moderate pain of the calf, resolved at 1 year, except one with persistent unexplained popliteal pain One case of deep vein thrombosis (this patient was operated on for correction of hallux valgus simultaneously) One case of lateral tension of the calf in a patient who had medial release only
Fig. 7. Proximal insertion of the medial and lateral gastrocnemius. (From Barouk LS. Forefoot reconstruction. New York: Springer-Verlag; 2003; with permission.)
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800
Barouk
Fig. 8. Patient-directed rehabilitation.
Two cases of transient lateral dysesthesia (in the case of lateral and medial release) Ten cases of keloid scar, each time when lateral and medial gastrocnemius were elongated, which tends to be associated with greater scarring Ten cases of weakness (subjective evaluation by the patient) in 7 cases of medial and lateral lengthening; in these 10 cases, 1 was really symptomatic (excessive lengthening with too much dorsiflexion of the ankle that restricted the patient in sports activities) Since this study, the authors have performed medial gastrocnemius release in 368 patients, among whom they observed: Four hematomas: 2 that spontaneously regressed and 2 that had to be drained; the authors believe that this coincided with the use of a new antithrombosis prophylaxis agent that they have since discontinued Two deep vein thrombosis (both patients underwent simultaneous hallux valgus correction) No dysesthesia, no keloid scar, and no weakness With section of only the medial gastrocnemius aponeurosis, complications are rare and of no significance. Whether the release was performed to include the medial head only or both heads, ankle dorsiflexion with the knee extended was improved in all the cases of the series described. However, estimation of the results depends on the manner in which the gastrocnemius is examined. The authors test for an equinus contracture with the subtalar joint reduced to slight varus and then with moderate strength to dorsiflex the ankle. If one is going to compare these results, the maneuver must be able to be reproduced from one patient to another, and preoperatively and postoperatively. Preoperatively, 69% of the patients had an equinus contracture of –15 , with the ankle in dorsiflexion and the knee extended, and this decreased to 4% postoperatively. A contracture between 0 and –15 was seen in 22% of the patients, and 19% postoperatively. The ankle dorsiflexion test with the knee extended increased from 9% to 77% postoperatively. In a blinded series of 30 patients, no differences were seen in the amount of improvement of ankle dorsiflexion with the medial alone compared with the medial and lateral (Table 1).
Proximal Medial Gastrocnemius Lengthening
Table 1 Ankle dorsiflexion, knee extended >1
Between 0 and L15
