Fig 4 - uploaded by Stephen Pinney
Content may be subject to copyright.
Gastrocnemius indentation • due to the muscle belly merging into the tendon (star). Gastrocnemius tendon insertion site/release point (arrow). Gastrocnemius tendon insertion into the Achilles to Achilles insertion in the calcaneus (Y). Length of the lower leg (X).
Source publication
The Strayer procedure (gastrocnemius recession) is a treatment option for patients with clinically relevant gastrocnemius equinus contracture. The purpose of this study was to review the surgical anatomy of the Strayer procedure with specific reference to 1) the location of the sural nerve, and 2) the gastrocnemius tendon release point.
Forty conse...
Contexts in source publication
Context 1
... gastrocnemius recession was first described in 1913. 11 The procedure is often named after Strayer, who reviewed the procedure in 1950. 10 Gastrocnemius recession is a treatment option for patients with clinically relevant gastrocnemius equinus contracture. Initially the procedure was largely used within the pediatric population. 1 – 4 , 7 , 8 In recent years, the procedure has been presented as an important component of the surgical treatment of a number of chronic foot problems. 5 , 6 The purpose of this study was to review the surgical anatomy of the Strayer procedure with specific reference to 1) the location of the sural nerve and 2) the gastrocnemius tendon release point. A detailed understanding of the surgical anatomy should improve cosmesis and decrease the incidence of sural nerve injury. Forty consecutive gastrocnemius recessions in 33 patients (15 males, 18 females) formed the study group. The average age was 49.9 years (range, 12 – 79 years). The indication for surgery was a chronic foot problem with an associated gastrocnemius equinus contracture with the knee straight which subsequently corrected with the knee bent. All patients had a preoperative diagnosis of either acquired adult flatfoot deformity, hallux valgus, or plantar fasciitis. The gastrocnemius recession was performed through a posteromedial lower leg incision approximately 7 cm in length (Fig. 1). The dissection was carried through the skin and subcutaneous tissue to the deep fascia. The deep fascia was excised in line with the skin incision. The areolar tissue overlying the gastrocnemius tendon was incised to expose the tendon. An elevator was used to clear the areolar tissue off the gastrocnemius tendon. The sural nerve was identified (Fig. 2). The nerve was then protected throughout the operation with a right angle retractor. The interval between the gastrocnemius and soleus was developed from medial to lateral using manual dissection. Adhesions between the gastrocnemius and soleus were cleared manually. A right-angled snap was passed through the gastrocsoleus interval to allow the distal extent of the gastrocnemius tendon to be cut with a scalpel under direct vision (Fig. 3). Closure was performed in layers. The cut tendinous end of the gastrocnemius was sutured to the underlying soleus fascia with 3 –0 absorbable suture. The gap between the cut ends of the gastrocnemius tendon was typically about 3 cm. The increase in ankle dorsiflexion achieved was equivalent to maximal preoperative ankle dorsiflexion with the knee bent, typically about 20 . The deep fascia was closed with running 3 – 0 absorbable suture. If necessary, interrupted 3 –0 absorbable sutures were used to close the subcutaneous layer. The skin was closed with 4 – 0 or 5 – 0 nylon suture. In each patient, standard measurements were recorded. The visible gastrocnemius indent was defined as the angled indent seen tangentially as the distal extent of the gastrocnemius muscle belly merges into the gastrocnemius tendon (Fig. 4). The distance from this visible indent to the actual gastrocnemius tendon insertion (the insertion point) was recorded. In one patient, the visible indent could not be accurately deter- mined due to excess adipose tissue. The distance from the Achilles insertion point to the gastrocnemius tendon insertion into the Achilles (Y) was recorded (Fig. 4). This was standardized as a fraction of the length of the lower leg (X) (Fig. 4). The location of the sural nerve was recorded as either superficial or deep to the fascia. In some patients, the sural nerve was found directly adherent to the gastrocnemius tendon and this was recorded. In addition, the distance from the medial border of the gastrocnemius tendon to the sural nerve was measured in millimeters (mm). The location of the actual gastrocnemius tendon insertion point into the Achilles was found to be an average of 18 mm distal to the visible indent (range, 20 mm proximal to 57 mm distal). The gastrocnemius insertion point was an average of 159 mm (range, 107 – 209 mm) proximal to the Achilles insertion into the calcaneus. The average lower leg ratio (Y/X) was 0.43 (range, 0.33 – 0.60). The sural nerve was located an average of 46 mm (range, 27 – 69 mm) from the medial border of the gastrocnemius tendon. In 17 (42.5%) legs, the sural nerve was located superficial to the deep fascia at the gastrocnemius insertion point. In the remaining 23 legs (57.5%), the nerve was located deep to the fascia. In five legs (12.5%), the nerve was applied directly to the tendon and required gentle dissection of the gastrocnemius tendon prior to performing the recession. The gastrocnemius recession was first described in 1913. 11 It was reviewed in more detail by Strayer in 1950 and is therefore often referred to as the Strayer procedure. 10 The early reports of the procedure described long posterior incisions. Indications for surgery were largely confined to the pediatric populations in which conditions such as cerebral palsy predispose this patient population to develop clinically significant gastrocnemius equinus contractures. More recently, gastrocnemius equinus contracture has been presented as a predisposing factor to such common foot conditions such as hallux valgus, symptomatic adult flatfoot deformity, and plantar fasciitis. , Treatment of these conditions often requires a gastrocnemius recession as a component of surgical management. Two potential complications that are of relevance to the gastrocnemius recession are poor cosmesis and sural nerve injury. The results of this article may serve to minimize these complications. Poor cosmesis due to an excessively long incision or tethering of the skin to the underlying fascia can lead to patient dissatisfaction. The length of the incision can be minimized by preoperatively identifying the visible indent created by the distal extent of the gastrocnemius muscle belly. Dissection is only required proximal to the gastrocnemius tendon insertion into the Achilles. The results of this study demonstrate that this point is on average 18 mm distal to the visible indent. Therefore, the skin incision should be initiated 2 cm distal to the visible gastrocnemius indentation and extended proximally. Excess adipose tissue can make this anatomical landmark difficult to identify. There can be variability between the anatomical landmark and the actual tendon insertion site, as this study demonstrated. To accommodate for this variability, the incision can be extended proximally or distally as required. Cosmesis of the incision can also be compromised by tethering of the skin to the underlying tissue. This relatively frequent complication can be minimized by closing the deep fascia and ensuring that homeostasis has been obtained. Sural nerve injury either by direct trauma or excessive stretch is another complication of particular relevance to the gastrocnemius recession. Because of the nearly direct posterior position of the nerve at the gastrocnemius insertion point, we recommend a posteromedial incision rather than a straight posterior incision. This will avoid inadvertently cutting the nerve during the surgical approach. We believe it is critical to identify the sural nerve. It should then be protected with a right- angled retractor throughout the operation. Results from this study show that the sural nerve is typically found 46 mm (range, 27 – 69 mm) from the medial border of the gastrocnemius tendon. In 42.5% of legs, the nerve was superficial to the fascia, and therefore unlikely to be injured except during a straight posterior approach. However, in the majority (57.5%) of legs, the nerve was deep to the fascia and at risk for direct injury if not identified and fully protracted with a retractor. The most problematic sural nerve location was encountered when the nerve was directly applied to the gastrocnemius tendon. If not identified the sural nerve would be cut in the tendon release. Furthermore, even if identified and freed from the tendon, the nerve is still at high risk for a stretch injury after the gastrocnemius recession, presumably due to the tethering of the nerve proximally and distally to the recession site. In this instance, to minimize the risk of sural nerve injury, gentle dissection of the nerve off the tendon should occur in both a proximal and distal direction. The nerve should be palpated during the gastrocnemius recession to avoid excess tension. Gastrocnemius recession (Strayer procedure) can be complicated by sural nerve injury and/or poor cosmesis. This study provides a review of the surgical anatomy of the gastrocnemius recession. The sural nerve should be protected to minimize the risk of injury. Employing a posteromedial approach instead of a straight posterior incision will help avoid direct injury. The nerve will be found deep to the fascia in the majority of patients and therefore should be identified prior to incising the gastrocnemius insertion. The length of the incision can be minimized by starting 2 cm distal to the gastrocnemius indentation and extending ...
Context 2
... gastrocnemius recession was first described in 1913. 11 The procedure is often named after Strayer, who reviewed the procedure in 1950. 10 Gastrocnemius recession is a treatment option for patients with clinically relevant gastrocnemius equinus contracture. Initially the procedure was largely used within the pediatric population. 1 – 4 , 7 , 8 In recent years, the procedure has been presented as an important component of the surgical treatment of a number of chronic foot problems. 5 , 6 The purpose of this study was to review the surgical anatomy of the Strayer procedure with specific reference to 1) the location of the sural nerve and 2) the gastrocnemius tendon release point. A detailed understanding of the surgical anatomy should improve cosmesis and decrease the incidence of sural nerve injury. Forty consecutive gastrocnemius recessions in 33 patients (15 males, 18 females) formed the study group. The average age was 49.9 years (range, 12 – 79 years). The indication for surgery was a chronic foot problem with an associated gastrocnemius equinus contracture with the knee straight which subsequently corrected with the knee bent. All patients had a preoperative diagnosis of either acquired adult flatfoot deformity, hallux valgus, or plantar fasciitis. The gastrocnemius recession was performed through a posteromedial lower leg incision approximately 7 cm in length (Fig. 1). The dissection was carried through the skin and subcutaneous tissue to the deep fascia. The deep fascia was excised in line with the skin incision. The areolar tissue overlying the gastrocnemius tendon was incised to expose the tendon. An elevator was used to clear the areolar tissue off the gastrocnemius tendon. The sural nerve was identified (Fig. 2). The nerve was then protected throughout the operation with a right angle retractor. The interval between the gastrocnemius and soleus was developed from medial to lateral using manual dissection. Adhesions between the gastrocnemius and soleus were cleared manually. A right-angled snap was passed through the gastrocsoleus interval to allow the distal extent of the gastrocnemius tendon to be cut with a scalpel under direct vision (Fig. 3). Closure was performed in layers. The cut tendinous end of the gastrocnemius was sutured to the underlying soleus fascia with 3 –0 absorbable suture. The gap between the cut ends of the gastrocnemius tendon was typically about 3 cm. The increase in ankle dorsiflexion achieved was equivalent to maximal preoperative ankle dorsiflexion with the knee bent, typically about 20 . The deep fascia was closed with running 3 – 0 absorbable suture. If necessary, interrupted 3 –0 absorbable sutures were used to close the subcutaneous layer. The skin was closed with 4 – 0 or 5 – 0 nylon suture. In each patient, standard measurements were recorded. The visible gastrocnemius indent was defined as the angled indent seen tangentially as the distal extent of the gastrocnemius muscle belly merges into the gastrocnemius tendon (Fig. 4). The distance from this visible indent to the actual gastrocnemius tendon insertion (the insertion point) was recorded. In one patient, the visible indent could not be accurately deter- mined due to excess adipose tissue. The distance from the Achilles insertion point to the gastrocnemius tendon insertion into the Achilles (Y) was recorded (Fig. 4). This was standardized as a fraction of the length of the lower leg (X) (Fig. 4). The location of the sural nerve was recorded as either superficial or deep to the fascia. In some patients, the sural nerve was found directly adherent to the gastrocnemius tendon and this was recorded. In addition, the distance from the medial border of the gastrocnemius tendon to the sural nerve was measured in millimeters (mm). The location of the actual gastrocnemius tendon insertion point into the Achilles was found to be an average of 18 mm distal to the visible indent (range, 20 mm proximal to 57 mm distal). The gastrocnemius insertion point was an average of 159 mm (range, 107 – 209 mm) proximal to the Achilles insertion into the calcaneus. The average lower leg ratio (Y/X) was 0.43 (range, 0.33 – 0.60). The sural nerve was located an average of 46 mm (range, 27 – 69 mm) from the medial border of the gastrocnemius tendon. In 17 (42.5%) legs, the sural nerve was located superficial to the deep fascia at the gastrocnemius insertion point. In the remaining 23 legs (57.5%), the nerve was located deep to the fascia. In five legs (12.5%), the nerve was applied directly to the tendon and required gentle dissection of the gastrocnemius tendon prior to performing the recession. The gastrocnemius recession was first described in 1913. 11 It was reviewed in more detail by Strayer in 1950 and is therefore often referred to as the Strayer procedure. 10 The early reports of the procedure described long posterior incisions. Indications for surgery were largely confined to the pediatric populations in which conditions such as cerebral palsy predispose this patient population to develop clinically significant gastrocnemius equinus contractures. More recently, gastrocnemius equinus contracture has been presented as a predisposing factor to such common foot conditions such as hallux valgus, symptomatic adult flatfoot deformity, and plantar fasciitis. , Treatment of these conditions often requires a gastrocnemius recession as a component of surgical management. Two potential complications that are of relevance to the gastrocnemius recession are poor cosmesis and sural nerve injury. The results of this article may serve to minimize these complications. Poor cosmesis due to an excessively long incision or tethering of the skin to the underlying fascia can lead to patient dissatisfaction. The length of the incision can be minimized by preoperatively identifying the visible indent created by the distal extent of the gastrocnemius muscle belly. Dissection is only required proximal to the gastrocnemius tendon insertion into the Achilles. The results of this study demonstrate that this point is on average 18 mm distal to the visible indent. Therefore, the skin incision should be initiated 2 cm distal to the visible gastrocnemius indentation and extended proximally. Excess adipose tissue can make this anatomical landmark difficult to identify. There can be variability between the anatomical landmark and the actual tendon insertion site, as this study demonstrated. To accommodate for this variability, the incision can be extended proximally or distally as required. Cosmesis of the incision can also be compromised by tethering of the skin to the underlying tissue. This relatively frequent complication can be minimized by closing the deep fascia and ensuring that homeostasis has been obtained. Sural nerve injury either by direct trauma or excessive stretch is another complication of particular relevance to the gastrocnemius recession. Because of the nearly direct posterior position of the nerve at the gastrocnemius insertion point, we recommend a posteromedial incision rather than a straight posterior incision. This will avoid inadvertently cutting the nerve during the surgical approach. We believe it is critical to identify the sural nerve. It should then be protected with a right- angled retractor throughout the operation. Results from this study show that the sural nerve is typically found 46 mm (range, 27 – 69 mm) from the medial border of the gastrocnemius tendon. In 42.5% of legs, the nerve was superficial to the fascia, and therefore unlikely to be injured except during a straight posterior approach. However, in the majority (57.5%) of legs, the nerve was deep to the fascia and at risk for direct injury if not identified and fully protracted with a retractor. The most problematic sural nerve location was encountered when the nerve was directly applied to the gastrocnemius tendon. If not identified the sural nerve would be cut in the tendon release. Furthermore, even if identified and freed from the tendon, the nerve is still at high risk for a stretch injury after the gastrocnemius recession, presumably due to the tethering of the nerve proximally and distally to the recession site. In this instance, to minimize the risk of sural nerve injury, gentle dissection of the nerve off the tendon should occur in both a proximal and distal direction. The nerve should be palpated during the gastrocnemius recession to avoid excess tension. Gastrocnemius recession (Strayer procedure) can be complicated by sural nerve injury and/or poor cosmesis. This study provides a review of the surgical anatomy of the gastrocnemius recession. The sural nerve should be protected to minimize the risk of injury. Employing a posteromedial approach instead of a straight posterior incision will help avoid direct injury. The nerve will be found deep to the fascia in the majority of patients and therefore should be identified prior to incising the gastrocnemius insertion. The length of the incision can be minimized by starting 2 cm distal to the gastrocnemius indentation and extending ...
Context 3
... gastrocnemius recession was first described in 1913. 11 The procedure is often named after Strayer, who reviewed the procedure in 1950. 10 Gastrocnemius recession is a treatment option for patients with clinically relevant gastrocnemius equinus contracture. Initially the procedure was largely used within the pediatric population. 1 – 4 , 7 , 8 In recent years, the procedure has been presented as an important component of the surgical treatment of a number of chronic foot problems. 5 , 6 The purpose of this study was to review the surgical anatomy of the Strayer procedure with specific reference to 1) the location of the sural nerve and 2) the gastrocnemius tendon release point. A detailed understanding of the surgical anatomy should improve cosmesis and decrease the incidence of sural nerve injury. Forty consecutive gastrocnemius recessions in 33 patients (15 males, 18 females) formed the study group. The average age was 49.9 years (range, 12 – 79 years). The indication for surgery was a chronic foot problem with an associated gastrocnemius equinus contracture with the knee straight which subsequently corrected with the knee bent. All patients had a preoperative diagnosis of either acquired adult flatfoot deformity, hallux valgus, or plantar fasciitis. The gastrocnemius recession was performed through a posteromedial lower leg incision approximately 7 cm in length (Fig. 1). The dissection was carried through the skin and subcutaneous tissue to the deep fascia. The deep fascia was excised in line with the skin incision. The areolar tissue overlying the gastrocnemius tendon was incised to expose the tendon. An elevator was used to clear the areolar tissue off the gastrocnemius tendon. The sural nerve was identified (Fig. 2). The nerve was then protected throughout the operation with a right angle retractor. The interval between the gastrocnemius and soleus was developed from medial to lateral using manual dissection. Adhesions between the gastrocnemius and soleus were cleared manually. A right-angled snap was passed through the gastrocsoleus interval to allow the distal extent of the gastrocnemius tendon to be cut with a scalpel under direct vision (Fig. 3). Closure was performed in layers. The cut tendinous end of the gastrocnemius was sutured to the underlying soleus fascia with 3 –0 absorbable suture. The gap between the cut ends of the gastrocnemius tendon was typically about 3 cm. The increase in ankle dorsiflexion achieved was equivalent to maximal preoperative ankle dorsiflexion with the knee bent, typically about 20 . The deep fascia was closed with running 3 – 0 absorbable suture. If necessary, interrupted 3 –0 absorbable sutures were used to close the subcutaneous layer. The skin was closed with 4 – 0 or 5 – 0 nylon suture. In each patient, standard measurements were recorded. The visible gastrocnemius indent was defined as the angled indent seen tangentially as the distal extent of the gastrocnemius muscle belly merges into the gastrocnemius tendon (Fig. 4). The distance from this visible indent to the actual gastrocnemius tendon insertion (the insertion point) was recorded. In one patient, the visible indent could not be accurately deter- mined due to excess adipose tissue. The distance from the Achilles insertion point to the gastrocnemius tendon insertion into the Achilles (Y) was recorded (Fig. 4). This was standardized as a fraction of the length of the lower leg (X) (Fig. 4). The location of the sural nerve was recorded as either superficial or deep to the fascia. In some patients, the sural nerve was found directly adherent to the gastrocnemius tendon and this was recorded. In addition, the distance from the medial border of the gastrocnemius tendon to the sural nerve was measured in millimeters (mm). The location of the actual gastrocnemius tendon insertion point into the Achilles was found to be an average of 18 mm distal to the visible indent (range, 20 mm proximal to 57 mm distal). The gastrocnemius insertion point was an average of 159 mm (range, 107 – 209 mm) proximal to the Achilles insertion into the calcaneus. The average lower leg ratio (Y/X) was 0.43 (range, 0.33 – 0.60). The sural nerve was located an average of 46 mm (range, 27 – 69 mm) from the medial border of the gastrocnemius tendon. In 17 (42.5%) legs, the sural nerve was located superficial to the deep fascia at the gastrocnemius insertion point. In the remaining 23 legs (57.5%), the nerve was located deep to the fascia. In five legs (12.5%), the nerve was applied directly to the tendon and required gentle dissection of the gastrocnemius tendon prior to performing the recession. The gastrocnemius recession was first described in 1913. 11 It was reviewed in more detail by Strayer in 1950 and is therefore often referred to as the Strayer procedure. 10 The early reports of the procedure described long posterior incisions. Indications for surgery were largely confined to the pediatric populations in which conditions such as cerebral palsy predispose this patient population to develop clinically significant gastrocnemius equinus contractures. More recently, gastrocnemius equinus contracture has been presented as a predisposing factor to such common foot conditions such as hallux valgus, symptomatic adult flatfoot deformity, and plantar fasciitis. , Treatment of these conditions often requires a gastrocnemius recession as a component of surgical management. Two potential complications that are of relevance to the gastrocnemius recession are poor cosmesis and sural nerve injury. The results of this article may serve to minimize these complications. Poor cosmesis due to an excessively long incision or tethering of the skin to the underlying fascia can lead to patient dissatisfaction. The length of the incision can be minimized by preoperatively identifying the visible indent created by the distal extent of the gastrocnemius muscle belly. Dissection is only required proximal to the gastrocnemius tendon insertion into the Achilles. The results of this study demonstrate that this point is on average 18 mm distal to the visible indent. Therefore, the skin incision should be initiated 2 cm distal to the visible gastrocnemius indentation and extended proximally. Excess adipose tissue can make this anatomical landmark difficult to identify. There can be variability between the anatomical landmark and the actual tendon insertion site, as this study demonstrated. To accommodate for this variability, the incision can be extended proximally or distally as required. Cosmesis of the incision can also be compromised by tethering of the skin to the underlying tissue. This relatively frequent complication can be minimized by closing the deep fascia and ensuring that homeostasis has been obtained. Sural nerve injury either by direct trauma or excessive stretch is another complication of particular relevance to the gastrocnemius recession. Because of the nearly direct posterior position of the nerve at the gastrocnemius insertion point, we recommend a posteromedial incision rather than a straight posterior incision. This will avoid inadvertently cutting the nerve during the surgical approach. We believe it is critical to identify the sural nerve. It should then be protected with a right- angled retractor throughout the operation. Results from this study show that the sural nerve is typically found 46 mm (range, 27 – 69 mm) from the medial border of the gastrocnemius tendon. In 42.5% of legs, the nerve was superficial to the fascia, and therefore unlikely to be injured except during a straight posterior approach. However, in the majority (57.5%) of legs, the nerve was deep to the fascia and at risk for direct injury if not identified and fully protracted with a retractor. The most problematic sural nerve location was encountered when the nerve was directly applied to the gastrocnemius tendon. If not identified the sural nerve would be cut in the tendon release. Furthermore, even if identified and freed from the tendon, the nerve is still at high risk for a stretch injury after the gastrocnemius recession, presumably due to the tethering of the nerve proximally and distally to the recession site. In this instance, to minimize the risk of sural nerve injury, gentle dissection of the nerve off the tendon should occur in both a proximal and distal direction. The nerve should be palpated during the gastrocnemius recession to avoid excess tension. Gastrocnemius recession (Strayer procedure) can be complicated by sural nerve injury and/or poor cosmesis. This study provides a review of the surgical anatomy of the gastrocnemius recession. The sural nerve should be protected to minimize the risk of injury. Employing a posteromedial approach instead of a straight posterior incision will help avoid direct injury. The nerve will be found deep to the fascia in the majority of patients and therefore should be identified prior to incising the gastrocnemius insertion. The length of the incision can be minimized by starting 2 cm distal to the gastrocnemius indentation and extending ...
Similar publications
Background:
The skin incision for medial displacement calcaneal osteotomy (MDCO) often damages the sural nerve. We aimed to identify the practical reference area in which the surgeon can incise the skin to minimize the injury of the sural nerve during MDCO.
Methods:
The foot and ankles of 20 cadavers were dissected. The landmarks were the follow...
The sural nerve is at risk of iatrogenic injury even during minimally invasive operative procedures to repair the calcaneal (Achilles) tendon. Through 107 cadaveric leg dissections, the data derived from the present study was used to develop a regression equation that will enable surgeons to estimate the intersection point at which the sural nerve...
Purpose
To ascertain in cadavers where the sural nerve crosses the gastro-soleus complex and where the gastrocnemius tendon merges with the Achilles tendon in relation to the calcaneal tuberosities.
Methods
Twelve cadaveric lower limbs (6 right and 6 left) were dissected. The distances between the calcaneal tuberosities and the lateral border of t...
The percutaneous repair of the calcaneal tendon (CT) places the sural nerve (SN) at high risk for injury up to 60%. The aim
of our study, therefore, was to explore and describe the course of SN in relation to the CT and to provide an anatomical description
of the area in which the SN resides in order to assist surgeons in avoiding iatrogenic injury...
Citations
... It consists of release in its insertion close to the Achilles tendon and can be performed with an open or endoscopic approach, and the patient is immobilized with cast postoperatively. Open surgery may present an unsatisfactory cosmetic result with a risk of sural nerve injury and require an immobilized period and general or regional anesthesia (22) . ...
A fascite plantar é uma condição comum e multifatorial do pé, tratada por cirurgiões ortopédicos mundialmente. É autolimitada e responde ao tratamento conservador em quase 90% dos pacientes dentro de um ano. A redução da dorsiflexão do tornozelo é, possivelmente, o fator de risco mais importante para o seu desenvolvimento. O tratamento cirúrgico é indicado quando há falha no tratamento conservador. Objetivo: Esta revisão busca avaliar a eficácia da liberação proximal do gastrocnêmio medial na fascite plantar. Métodos: Foi feita uma busca eletrônica de artigos. Foram considerados como critérios de elegibilidade ensaios clínicos prospectivos, randomizados, comparativos e em cadáveres de 2012 a 2022, com casuística mínima de 10 pacientes e com seguimento maior ou igual a um ano. Resultados: Foram identificados oito artigos em língua inglesa para serem analisados. Conclusão: Embora a liberação proximal isolada do gastrocnêmio medial seja a técnica preferida pelos autores para a maioria dos pacientes, existem poucos estudos com alto nível de evidência que comprovem sua eficácia a longo prazo na fascite plantar. Nível de evidência I. Tipo de estudo: Avaliação de resultados.
... Factors that reduce the frequency of severe crouch gait include education of medical personnel (physiotherapists, rehabilitation doctors, and orthopedists), avoiding surgeries in children who walk without prior gait laboratory diagnostics, avoiding single-level procedures (prohibiting Achilles tendon lengthening in zone III), replacing single-level surgeries with simultaneous multi-level surgeries (SEMLS -single-event multi-level surgery), of which the Strayer operation is recommended for correcting equinus position [8]. The recommended orthosis for patients with diplegia is the AFO (ankle-foot orthosis) with a fixed ankle joint (the speaker doesn't use AFO orthoses with a mobile joint or SMO (supramalleolar orthosis) type orthoses just after the surgery). ...
... Patients function better with a slightly short soleus muscle (even without orthoses) than after an excessive extension. Currently, most patients undergo Strayer lenghtening [8]. In a small percentage of cases, he performs the extension of the posterior group of the shin muscles by Baker [11]. ...
Introduction. The fourth edition of the Transatlantic Orthopedic Surgery Webinar 2022 took place on December 12th, 2022. The main theme of the webinar was the treatment of crouch gait in children with cerebral palsy (CP). Speakers from Australia, Canada, China, Germany, India, Poland, Spain, Sweden, Turkey, the United Kingdom, and the United States participated. Results. The first general session presented the biomechanics of crouch gait, the function of the hip and knee muscles in children with CP, the principles of prevention and treatment of crouch gait in spastic diplegia, and the natural course and treatment outcomes of CP in adults. The surgical sessions comprehensively presented the surgical techniques for treating crouch gait: percutaneous myofasciotomy in the posterior knee joint, straightening osteotomy of the distal femur in hemiplegia, asymmetric and symmetric diplegia, techniques for shortening and plastically reconstructing the patellar ligament, anterior hemiepiphysiodesis of the distal femur, and transfer of the hamstring muscles to the rectus femoris muscle. The second general session presented postoperative standing and walking rehabilitation protocols and evaluation of treatment outcomes (pain, fatigue, ambulatory activity, motor function, and quality of life). Summary. The most important conclusions from the event were: do not lengthen the Achilles tendon in zone III in crouch gait; laboratory gait analysis is necessary before lengthening the hamstring muscles; hemiepiphysiodesis of the distal femur can be performed when the predicted growth period is less than two years; distal femur osteotomy should be considered during adolescence for knee flexion contracture of 10-40 degrees; treatment possibilities of tendon transfers and myofasciotomies should be remembered, especially in younger patients. The webinar attracted an audience of approximately 1,600 people from 672 centers located in 57 countries. Most participants came from Poland, the United Kingdom, the United States, Norway, Sweden, and India.
... 9 TSL procedures, and particularly variations of the gastrocnemius recession, are also advocated by some surgeons as adjunctive interventions in the treatment of foot and ankle trauma. [4][5][6]16,19 Proponents argue that these procedures aid in the restoration of hindfoot and midfoot alignment, 16,19 facilitate fracture reduction, [4][5][6] and improve final range of motion. 14,20 However, adjunctive TSL procedures-whether performed at the time of initial fracture temporization, definitive internal fixation, or after return to weightbearing-have not been shown to improve fracture reduction, union rate, reduce pain, reduce the risk of fixation failure, or alter the risk of post-traumatic arthritis after surgical management of ankle, hindfoot, or midfoot trauma. ...
... 9 TSL procedures, and particularly variations of the gastrocnemius recession, are also advocated by some surgeons as adjunctive interventions in the treatment of foot and ankle trauma. [4][5][6]16,19 Proponents argue that these procedures aid in the restoration of hindfoot and midfoot alignment, 16,19 facilitate fracture reduction, [4][5][6] and improve final range of motion. 14,20 However, adjunctive TSL procedures-whether performed at the time of initial fracture temporization, definitive internal fixation, or after return to weightbearing-have not been shown to improve fracture reduction, union rate, reduce pain, reduce the risk of fixation failure, or alter the risk of post-traumatic arthritis after surgical management of ankle, hindfoot, or midfoot trauma. ...
... 14,20 However, adjunctive TSL procedures-whether performed at the time of initial fracture temporization, definitive internal fixation, or after return to weightbearing-have not been shown to improve fracture reduction, union rate, reduce pain, reduce the risk of fixation failure, or alter the risk of post-traumatic arthritis after surgical management of ankle, hindfoot, or midfoot trauma. TSL procedures incur additional risks of sural nerve injury, 19 loss of strength and fatigue resistance, 8 and altered gait mechanics. 7,14 Neither the prevalence of use of adjunctive TSL procedures in foot and ankle fracture surgery nor the optimal timing of TSL with regard to injury and weightbearing status has been characterized among the orthopaedic trauma and foot and ankle surgical communities. ...
Background
The prevalence, indications, and preferred methods for gastrocnemius recession and tendo-Achilles lengthening—grouped as triceps surae lengthening (TSL) procedures—in foot and ankle trauma are supported by a scarcity of clinical evidence. We hypothesize that injury, practice environment, and training heritage are significantly associated with probability of performing adjunctive TSL in the operative management of foot and ankle trauma.
Methods
A survey was distributed to members of the American Orthopaedic Foot & Ankle Society and the Orthopaedic Trauma Association. Participants rated how likely they would be to perform TSL at initial management, definitive fixation, and after weightbearing in the presence and absence of a positive Silfverskiöld test in 10 clinical scenarios of closed foot and ankle trauma.
Results
A total of 258 surgeons with median 14 years’ experience responded. Eighty-five percent reported foot and ankle fellowship training, 24% reported traumatology fellowship training, 13% both, and 4% no fellowship. Ninety-nine percent reported performing TSL with a median 25 TSL procedures per year, 72% open gastrocnemius recession, and 17% percutaneous tendo-Achilles lengthening). Across all scenarios, we observed low overall 8% probability with fair agreement (κ = 0.246) of performing TSL (range, 1% at initial management of an unstable Weber B bimalleolar ankle fracture with negative contralateral Silfverskiöld test to 29% at definitive fixation of tongue-type calcaneus fracture with positive contralateral Silfverskiöld test). Silfverskiöld testing significantly influenced TSL probability at all time points. University of Washington training (β = 1.5, P = .007) but not trauma vs foot fellowship training, years in practice, academic practice, urban setting, or facility trauma designation were significantly associated with likelihood of performing TSL.
Conclusion
Orthopaedic traumatology and foot and ankle surgeons report similar indications, methods, and low perceived propensity to use TSL in the management of foot and ankle trauma. We found that graduates of 1 fellowship training site were more likely to perform TSL in the setting of acute trauma potentially indicating the need for better scientific data to support this practice.
Level of Evidence
Level V, therapeutic.
... Initially, gastrocnemius release was performed in the musculotendinous junction of the gastrocnemius, as described by Strayer [15], with the patient in the supine position under general anesthesia. The fascial part of the gastrocnemius was released from the medial to the lateral direction. ...
... Two feet of two patients were excluded: one because of rigid flat foot and one because of cerebral palsy. A total of 23 ft of 13 teenagers (nine boys and four girls), with a mean age of 12.3 (range, [11][12][13][14][15][16] years were included in the study. The mean follow-up was 49.7 (range, 30.9-73.4) months. ...
Background
Evans calcaneal lengthening osteotomy is used to treat symptomatic flexible flatfoot when conservative treatment fails. Grafts such as autologous iliac bone grafts, allografts, and xenografts are implanted at the osteotomy site to lengthen the lateral column of the hindfoot. This study aimed to present the outcomes of an autologous mid-fibula bone graft used for calcaneal lengthening in symptomatic pes valgus in adolescents.
Methods
We retrospectively examined 23 ft of 13 adolescents who underwent surgery between July 2014 and January 2018. The radiological and clinical outcomes (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale scores) were assessed during a mean follow-up of 49.7 (range, 30.9–73.4) months. The mean distance of the lengthening site was measured to evaluate graft sinking or collapse. The Goldberg scoring system was used to determine the degree of union at the donor and recipient sites.
Results
The calcaneal pitch and the anteroposterior and lateral talo-first metatarsal (Meary) angles showed significant correction, from 14.4 to 19.6 ( p < 0.001), and from 14.5 to 4.6 ( p < 0.001) and 13.5 to 8.5 ( p < 0.001), respectively. The mean distance of the lengthening site showed no significant change ( p = 0.203), suggesting no graft sinking or postoperative collapse. The lateral distal tibial angle showed no significant difference ( p = 0.398), suggesting no postoperative ankle valgus changes. Healing of the recipient and donor sites occurred in 23 and 21 ft, respectively. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scores improved significantly, from 68.0 to 98.5 ( p < 0.001).
Conclusions
Evans calcaneal lengthening using an ipsilateral mid-fibula bone autograft resulted in significant improvement in clinical and radiological outcomes without ankle valgus deformity. Hence, it could be a treatment option for lateral column calcaneal lengthening in adolescents.
... 16,20 The levels of gastrocnemius recession are normally named after the authors who have invented the techniques, such as Silverskoild, Barouk, Abbassian, Baumann, Strayer, Vulpius, Baker, Hoke, and White, each having their own pros and cons ( Figure 1). [21][22][23][24][25] On top of treating the ankle equinus, gastrocnemius recession has been used with success in treating other conditions such as pes planus, plantar fasciitis, metatarsalgia, Haglund's deformity, and foot ulcers. 7,10,18,26 Despite showing good outcomes in correcting isolated gastrocnemius tightness, gastrocnemius recession is sometimes associated with iatrogenic sural nerve injury, weakness of plantar flexion and overlengthening, leading to excessive dorsiflexion of the ankle. ...
Background
Strayer’s gastrocnemius recession is a common technique in treating ankle equinus of gastrocnemius origin. Nevertheless, this technique is associated with a few flaws. We aim to introduce a novel technique of isolated gastrocnemius recession and perform a cadaveric study to evaluate its safety and at the same time compare this novel technique with the existing Strayer procedure biomechanically.
Methods
Eight fresh cadaveric models of gastrocnemius tightness were established by isolated traction of the gastrocnemius muscles. Gastrocnemius recession was performed on all eight models with Strayer method and the novel method randomized equally. The safety of both the techniques was evaluated by identifying any iatrogenic injury to the surrounding structures. The lengthening and improvement of the ankle dorsiflexion was measured and compared between the two techniques.
Results
There was no iatrogenic sural nerve or saphenous vein injury in all eight models. There was no significant difference between the two techniques in terms of lengthening (24.25 mm vs 21.00 mm; p = 0.838) and improvement of ankle dorsiflexion (26.5° vs 26°; p = .829).
Conclusions
Both Strayer technique and the novel technique of gastrocnemius recession lengthened the gastrocnemius and improved the ankle dorsiflexion in this cadaver trial. Both procedures were safe with proper techniques, and there was no significant difference in efficacy between them.
Level of Evidence
Level II, randomized controlled trial.
... These include corticosteroid injections, PRP injections, Botox injections, and ESWT. 5,[13][14][15]53,54,[60][61][62][63][64][65][66][67][68][69] Unfortunately, not all patients respond to these noninvasive or minimally invasive options and must turn to surgical intervention in an attempt to resolve their pain. Surgical options to treat recalcitrant plantar heel pain include plantar fasciotomy (open, mini open, endoscopic) with or without spur removal, calcaneal drilling, and more recently a gastrocnemius recession. ...
... In particular, the gastrocnemius recession has become a popular choice of many surgeons to treat this problem, in part because of the documented success of the procedure, 14,15,58 and low risk of complications. 13,14,[59][60][61][62][63] It is important preoperatively to perform a correct Silfverskiold test 52 and assess the origin of the deformity. If the patient has an IGC, it is important to understand the procedure needed to correct the deformity. ...
... If the incision is too lateral or too low it can place the sural nerve at risk or make it more difficult to isolate the gastrocnemius from the soleus. 13,61 In order to identify the correct location, the leg is elevated, the knee is extended and the ankle is maximally dorsiflexed to stretch the gastrocnemius. The surgeon takes the flat part of the thumb and runs the thumb proximal to palpate for the myotendinous junction of the gastrocnemius (Fig. 1). ...
Plantar fasciitis is a common cause of heel pain that is seen by both orthopedic surgeons and primary care providers. It is a condition that was previously thought to be because of inflammation of the plantar fascia but has more recently been linked an equinus contracture of the gastrocnemius muscle. The condition can be handled both conservatively and surgically, with the primary management being nonoperative. For operative interventions, the treatment of choice was classically a plantar fasciotomy. Over the past several years, the gastrocnemius recession has become an operative treatment of choice. The gastrocnemius recession has shown better symptom relief with less morbidity. The technique to perform a gastrocnemius recession is described within the chapter, as well as the postoperative management. In the future, the duration of nonoperative management for recalcitrant disease may be reduced. However, more randomized control trials showing positive results of the gastrocnemius recession may allow for shorter nonoperative management period creating a new standard treatment algorithm.
Level of Evidence: Diagnostic level I, systematic review of studies.
... El alargamiento del tendón calcáneo tiende a debilitar la fuerza muscular, lo cual es perjudicial; esto se minimiza mediante el alargamiento de los músculos gastrocnemios [57,58] . La anatomía quirúrgica ha sido mejor especificada, así como las ganancias en movilidad [59][60][61] . ...
Resumen
La retracción de los músculos gastrocnemios es común a cualquier edad. Afecta a más del 50% de la población adulta. Es responsable de patología a distancia de forma aislada o en combinación: lesión degenerativa del tendón tibial posterior con pie plano valgo secundario, tendinopatía calcánea (Aquiles), fascitis plantar, metatarsalgia, sinovitis metatarsofalángica, hallux valgus, hallux rigidus, dedos en martillo, úlceras plantares en diabéticos, neuroartropatía de Charcot. También puede afectar a la articulación femororrotuliana y a la columna lumbar. Los gastrocnemios medial y lateral son músculos con fibras de tipo II, fásicas, blancas. Contribuyen a la formación del tríceps sural y le dan la característica de un músculo biarticular (rodilla-tobillo). También participan en el sistema aquiliano-calcáneo-plantar y pertenecen a la cadena muscular posterior, que tiene la capacidad de retraerse. La detección de esta retracción, reversible en la mayoría de los casos, es un deber del médico porque su tratamiento es sencillo y eficaz en la mayoría de los casos (autoestiramientos en una plataforma móvil durante 2-3 minutos por la mañana y por la noche). Frente a cualquier dolor de pie es aconsejable hacer cuatro preguntas: ¿tiene dolor en las pantorrillas, tiene dolor de rodilla, tiene dolor lumbar, tiene problemas de equilibrio? La brevedad muscular debe buscarse de forma sistemática al comienzo de la exploración física mediante la maniobra de dorsiflexión del pie, con la rodilla flexionada y la rodilla extendida. Esto también descarta una retracción del tríceps sural, que provoca un equino irreducible del pie, sea cual sea la posición de la rodilla. Es importante señalar que la distensibilidad de la unidad musculotendinosa es variable y depende de múltiples factores. El tratamiento es siempre conservador al principio y las indicaciones quirúrgicas deben ser prudentes. En los diabéticos, el alargamiento de los músculos gastrocnemios ayuda a prevenir los trastornos tróficos de tipo mal perforante plantar.
... 2,3 It alters the biomechanics of the foot-ankle complex and affects other musculotendinous and ligamentous constrains in the ankle, causing or contributing to ulceration, plantar fasciitis, adult acquired flatfoot, hallux valgus, generalized metatarsalgia, plantar intermetatarsal neuroma, posterior tibial tendinopathy, pes planus, and Achilles tendinopathy. [4][5][6][7] Di Giovanni's paper defined patients having gastrocnemius tightness when there is less than 5° of ankle dorsiflexion with the knee extended. 7 Meanwhile Pinney's definition included the inability to dorsiflex the ankle more than 10° past neutral with the knee fully extended but which subsequently corrects with the knee flexed. ...
... 8 The most commonly used method for the recession of the gastrocnemius has been that described by Strayer in 1950, which is a modification of the procedure first described in 1913. 4 Subsequently, this procedure has been shown to be both safe and effective. 9,10 This procedure entails incision of the gastrocnemius muscle distal to the musculoligamentous junction with sparing of the soleus muscle ensured. ...
... 9,10 This procedure entails incision of the gastrocnemius muscle distal to the musculoligamentous junction with sparing of the soleus muscle ensured. 4 The main complications associated with this procedure include injury to the sural nerve, and poor cosmesis secondary to the large incisional wound with adhesions of the muscle to the skin. 4,9 Strayer's technique has been modified, including the use of endoscopic approaches, to try and reduce the poor cosmesis and reduce the risk of iatrogenic injury to the sural nerve. ...
... It is important to appreciate that variation in the course of the sural nerve leaves it at risk of iatrogenic injury, since it can be superficial, deep, or closely adherent to the deep fascia at the level of a Strayer release. 42 We recommend formally identifying and protecting the nerve. There is usually a period of immobilization for 2e4 weeks in a cast or boot following this procedure, during which time we recommend chemical venous thromboembolism prophylaxis. ...
Heel pain at or around the insertion of the Achilles tendon is a common presenting complaint affecting both young, active patients and those who are older and more sedentary. So-called posterior heel pain is often presumed to run a self-limiting course over a few months, resolving with rest, weight loss and stretching exercises. However, a small number of patients suffer with increasingly disabling symptoms that are refractory to this regimen. Posterior heel pain is classically split into insertional and non-insertional types, and in order to select an appropriate management plan the diagnosis must be precise. Further management without a clear understanding of the pathology is potentially detrimental to the patient. This review aims to provide a structured approach to careful clinical and radiological assessment and treatment of this condition.
... AMIC + PBC was performed in similar fashion except using PBC instead of BMAC for the impregnation of the matrix (detailed description below). The other procedures included joint preserving measures such as synovectomy, lateral ligament reconstruction, peroneal tendon debridement/tenolysis, gastrocnemius tendon lengthening and others [1,[8][9][10]. A gastrocnemius tendon lengthening was performed if ankle dorsiflexion was less than 10 with positive Silverskiöld-test [8][9][10]. ...
... The other procedures included joint preserving measures such as synovectomy, lateral ligament reconstruction, peroneal tendon debridement/tenolysis, gastrocnemius tendon lengthening and others [1,[8][9][10]. A gastrocnemius tendon lengthening was performed if ankle dorsiflexion was less than 10 with positive Silverskiöld-test [8][9][10]. A longitudinal medial 3 cm-skin incision was performed above the origin of the gastrocnemius tendon [11]. ...
Background:
The aim of the study was to compare Matrix-Associated Stem Cell Transplantation (MAST) with Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral lesions at the ankle.
Methods:
In a matched-patient clinical follow-up study, patients with chondral lesion at the ankle that were treated with MAST from April 1, 2009 to July 15, 2016, and patients that were treated with AMIC+PBC from July 17, 2016 to May 31, 2017 were included and compared. Size and location of the chondral lesions and the Visual-Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Bone Marrow Aspirate Concentrate (BMAC) was used for MAST and Peripheral Blood Concentrate (PBC) for AMIC+PBC to impregnate a collagen I/III matrix (Chondro-Gide, Wollhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue.
Results:
One hundred and twenty-nine patients with 136 chondral lesions were included in both groups. The chondral lesions were located as follows (MAST/AMIC+PBC, n (%)), medial talar shoulder only, 59 (43)/62 (46); lateral talar shoulder only, 44 (32)/42 (31); medial and lateral talar shoulder, 7 (10)/7 (10); tibia, 19 (14)/18 (13). The lesion size was 1.6/1.8cm2 on average and VAS FA was 46.9/45.7 (MAST/AMIC+PBC). For MAST/AMIC+PBC groups, 107 (83%)/105 (81%) with 112/110 previous chondral lesions completed the defined 2-year-follow-up after 24.4/23.8 months on average. VAS FA improved to 82.3/79.8 (MAST/AMIC+PBC). No parameter significantly differed between MAST and AMIC+PBC groups.
Conclusions:
MAST and AMIC+PBC as part of a complex surgical approach led to improved and high validated outcome scores in 2-year-follow-up. MAST and AMIC+PBC showed similar results.
