Robert S.Marsh, D.O. OrthoIndy

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1 Robert S.Marsh, D.O. OrthoIndy

2 What is a gastrocnemeus recession? Definition of a gastrocnemeus recession Indications Literature Technique

4 This is not a new idea. Surgical history can be traced back to Delpech in the early 1800 s who described the first TAL for spasticity. Vulpius and Stoffel in 1913 and Strayer in 1950 reviewed the management of spastic gastrocsoleus complex with either a tendoachilles lengthening or a gastrocnemeus recession. Finally, the Silverskiold test was introduced

Still controversial, but the literature is finally emerging The gastrocnemeus recession is a technique used to balance the foot It is not a tendo-achilles

5 Still controversial, but the literature is finally emerging The gastrocnemeus recession is a technique used to balance the foot It is not a tendo-achilles lengthening It is performed just inferior to the gastrocnemeus muscle belly It does not increase the risk of achilles tendon rupture It Works.I Drank the Koolaide! JGA

$Recalcitrant stress fractures Achilles tendonosis Insertional calcific tendonosis Metatarsalgia Posterior Tibial$

6 Recalcitrant stress fractures Achilles tendonosis Insertional calcific tendonosis Metatarsalgia Posterior Tibial Tendonitis Plantar Fascitis Adjunct to any fusion/ankle fracture Diabetic ulcers Recurrent posterior tibial stress syndrome

7 Ankle requires 7 degrees dorsiflexion for normal ambulation Generically, when there is a discrepancy of ankle dorsiflexion with the foot in the reduced position when the knee is extended and flexed

8 A gastrocnemeus contracture prematurely elevates the heel during the stance phase causing the forefoot to be loaded earlier This results in forefoot, midfoot, and hind foot overload

10 Young and adolescent Recurrent plantar fascitis Achilles tendonitis Navicular stress fracture Shin Splints Flexible Pes Planus Toe walking

11 Adults Posterior tibial tendonitis/pes planus Hallux valgus Noninsertional and insertional achilles tendonitis Midfoot arthrosis Hammer toes Extensor tendonitis Stress fracture

12 General anesthetic or Regional block with MAC Supine Assistant holds the leg with the foot dorsiflex and the hip extended Roughly 2 cm inferior to the medial gastroc and 2 cm medial to the midline a 2-4 cm is made (patient size dictates)

13 I use a 15 blade scapel to incise the skin. Blunt digital dissection exposes the paratenon which is open using metzenbaum Blunt dissection separates the gastrocnemeus from the paratenon, typically the sural nerve is palpated laterally

Place a ribbon or army navy retractor in the interval Using a pick-up and fresh 15 blade scapel, start laterally and carefully only cut the gastroc fascia.

14 Place a ribbon or army navy retractor in the interval Using a pick-up and fresh 15 blade scapel, start laterally and carefully only cut the gastroc fascia. The soleus facsia can be seen uderneath I typically release the plantaris as well Close the subcutaneus tissue with 3-0 monocryl and the skin with staple

15 WBAT in a walking boot for the first 2 weeks post-op At 2 weeks dressings and staples removed Wean from boot as tolerated Initiate physical therapy, ROM, scar tissue massage, theraband, aquatherapy Initiate running at 3 months Anecdotally, obesity are much slower

16 DiGiovanni et al. in a prospective study comparing a cohort of patients with midfoot and forefoot pain with an asymptomatic control group that isolated gastrocnemeus contracture is a clinical entity associated with forefoot and midfoot pain in the nonneuromuscular population. When defined as less than 10 degrees of dorsiflexion with the leg extednded, gastrocnemeus contracture was present in 88%.

17 Maskill et al. used a gastrocnemeus recession to treat isolated foot pain. They looked at 29 patients who had chronic foot pain without any structural abnormality. Preop pain score was 8/10 and postop was 2/ % said they would recommend this procedure to a friend.

18 Laborde evaluated 11 patients with 11 neuropathic plantar midfoot ulcers treated primarily with a gastrocnemeus recession with an average 39 month follow-up. Ten healed but one patient was lost to followup after his ulcer healed.

19 Chimera et al. looked at the range of motion, function and plantar flexion strength pre-op and 3 month post-op. At 3 months post-op had a significantly improved dorsiflexion (9 deg), higher level of function activities of daily living, and self reported global rating of function. Peak isometric plantar flexion strength did not decrease 3 months post-op. Isokinetic strength actually increased

20 Duthon et al. performed a prospective study on gastrocnemeus recession for non-insertional achilles tendinopothy. Repeat MRI at 1 year post-op showed improved tendon signal and tendon size. At 2 years all but one were able to resume their previous level of activity. Had a mean gain of 13 degrees of dorsiflexion

21 It has been reported the 75% of patients with adult acquired pes planus due to posterior tibial tendon insufficiency, and a recession is usually required before any hindfoot osteotomy or reconstruction of a stage 3 deformity.

22 The studies are starting to emerge and it is no longer the rogue surgery. Dr. Crawford CCH Remember, you may not see it, but the pathology is always looking at you.

Baker, LD: A rational approach to the surgical needs of the cerebral palsy patient. JBJS. 38A:313-323, 1956. Vulpius, O; Stoeffel, A: Tenotmeie der end schen dermm.

24 Baker, LD: A rational approach to the surgical needs of the cerebral palsy patient. JBJS. 38A: , Vulpius, O; Stoeffel, A: Tenotmeie der end schen dermm. Gastrocnemius el soleus mettels rutschenlassens nach Vulpius. IN: Orthopaedische Operationslehre, Ferdinard Enke, Stuttgart, pp.29-31, Strayer, LM: Recession of the gastrocnemius. An operation to releive spastic constracture of the calf muscles. JBJS. 32A:671-76, 1950 Silverskiold, N: Reduction of the uncrossed two-joint muscles of the leg to one-joint muscles in spastic conditions. Acta Chir. Scand. 56:315-30, DiGiovonni, CW; Kuo, R; Tewanin, N; et al.: Isolated gastrocnemius tightness. JBJS AM. 84: , Laborde, JM. Midfoot Ulcers Treated with Gastrocnemius-Soleus Recession. FAI 2009: Duthon, VB, Lubbeke, A, Duc, SR, Stern, R, Assal, M. Noninsertional Achilles Tendinoapthy Treated with Gastrocnemeus Lengthening. FAI 2011, 32:4: Thordason, DB; Nunley, JA; Pfeffer, GB; Sanders, RW; Trepman, E (eds): Advanced reconstruction of the foot and ankle, American Academy of Orthopaedic Surgeons, Rosemont, pp , 2004.

Toe walking gives rise to parental concern. Therefore, toe-walkers are often referred at the 3 years of age.

Toe walking gives rise to parental concern. Therefore, toe-walkers are often referred at the 3 years of age. IDIOPATHIC TOE WALKING Toe walking is a common feature in immature gait and is considered normal up to 3 years of age. As walking ability improves, initial contact is made with the heel. Toe walking gives