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Gastrocnemius recession

    Overview

    Learn the Gastrocnemius recession surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Gastrocnemius recession surgical procedure.
    Tightness of the achilles tendon and in particular tightness of the gastrocnemius has been implicated in a number of clinical conditions effecting the foot and ankle. These include pes planovalgus, posteromedial tibial stress syndrome, achilles tendinopathy, metatarsalgia and plantar fascitis.
    The gastrocnemius is a bipennate muscle composed of a longer medial and shorter lateral head. The medial head takes origin from on the posterior femoral surface and lies proximal to the medial condyle and posterior to the insertion of the adductor magnus muscle. The lateral head takes origin from the lateral epicondylar surface of the femur. Both heads then form a conjoined aponeurosis which together with the aponeurosis of the soleus muscle form the achilles tendon, inserting into the os calcis. During normal function the effect of contraction of these muscle bellies results in ankle flexion and secondarily knee flexion.
    There are various methods to lengthen the gastrocnemius-achilles complex including open Z-lengthening or triple cutting the achilles tendon, lengthening of the tendon of Gastrocnemius as it conjoins the soleus tendon, or a “slide” procedure to the muscle belly of gastrocnemius. The method that I prefer is one popularised by Samuel. l. Barouk from Bordeaux and Matt Solan FRCS at the Royal Surrey County Hospital. It involves dividing the aponeurosis of the medial head of gastrocnemius, which allows a controlled and easily varied lengthening to be done.
    The procedure is simple to perform, can be done on an day case basis, and importantly does not require the patient to have the ankle immobilised postoperatively. I have also found that it does not cause significant weakening of the achilles tendon function nor wasting of the calf, unlike procedures in the mid and distal part of the tendon which achieve the same correction.

    Indications

    INDICATIONS
    The specific indications for the release of the gastrocnemius are various. They can be categorised into either direct functional problems due to an inability to achieve a plantar-grade foot or due to the accentuation of other problems in the foot and ankle for instance in an acquired flat foot deformity or metatarsalgia. There is also an increasing recognition of the value of lengthening/release of the gastrocnemius in the treatment of diabetic foot problems including stubborn keratotic lesions of the sole of the foot and ulcers.
    SYMPTOMS & EXAMINATION
    Patients may complain of diffuse mechanical lower limb symptoms due to compensatory manoeuvres if unable to bring the sole of the foot fully plantar-grade during gait. They may also present more subtly and indirectly with a primary condition such as metatarsalgia and it is only when examined that the diagnosis of a tight gastrocnemius can be made.
    The diagnosis of selective Gastrocnemius tightness can be made by testing the effect of bending the knee on its tension and thereby its function. This is the basis of the Silfverskiöld test. This was described by Nils Silfverskiöld (1888-1957), an orthopaedic surgeon, who noted that the force required to dorsiflex the ankle in spastic equinus contracture decreased with knee flexion if an isolated gastrocnemius contracture was present. He advocated detaching the origins of the gastrocnemii from the femur and reattaching them to the tibia. The Silfverskiöld knee flexion test has now also been adapted to distinguish between isolated gastrocnemius contracture and combined shortening of the gastrocnemius-soleus complex in non-spastic contracture by measuring the range of ankle dorsiflexion with the knee flexed and the knee straight. (D.Singh 2012 Foot And Ankle Surgery). This test forms one of the key examinations of the foot in modern day practice to determine the effect of the gastrocnemius on pathology of the foot and the ankle.
    IMAGING
    No specific imaging is required as the diagnosis is easily made on clinical grounds by the use of the above test.
    ALTERNATIVE OPERATIVE TREATMENT
    Several methods of lengthening the gastrocnemius are available.
    NON-OPERATIVE MANAGEMENT
    Physiotherapy is useful to stretch the tight muscle. Botox injection is often used in patients with cerebral palsy and other spastic conditions of the lower limbs to ease the painful and disabling effect of calf muscles in spasm and a dynamic equinus of the ankle.
    CONTRAINDICATIONS
    -The operation should not be performed in elite athletes especially sprinters and sport involving high speed running without suitably counselling the patient about to the mild weakening effect of lengthening the muscle which may have an effect upon their sporting prowess
    -It should also not be performed on patients with severe equinus caused by a true conjoined tendon contracture as medial head release will have little or no effect upon the overall tendon length. It is contraindicated in patients with neuromuscular disease when the main and often the only muscle that can be used to ambulate is the gastrosoleus.
    -It is also of little use in patients where there has been denervation of the muscle or the muscle has been traumatised leading to fatty atrophy or fibrosis
    -The operation may be difficult to perform in very obese patients
    -The procedure is not advised in patients who have had previous surgery in the popliteal area

    Setup

    This procedure can be done either under local anaesthesia or under regional / general anaesthesia. It is done with the patient lying supine with a sandbag under the opposite buttock so that the area for surgery can be adequately accessed by externally rotating the leg with a bent knee. Although it is somewhat awkward , this is the position I have tended to use as the procedure is usually an adjunct to foot and ankle surgery and it obviates the need to change the position from prone to supine after the lengthening is done. If it is an isolated procedure or a bilateral procedure is done, i would use a prone position for ease of operation.
    If I am doing this under a local anaesthetic I use 30 ml of 0.25 % chirocaine or 2 % lignocaine to generously infiltrate the region.
    Superficial and deep Langenbeck retractors along with a self retaining retractor are essential for this procedure.
    Prior to commencing the procedure, it is essential to define and mark the mid line of the popliteal region by lifting the leg to visualise the region as this becomes more ambiguous when the leg is externally rotated to access the site.

    Operation

    The incision lies just below the transverse popliteal crease by about 1.5 to 2 cm, and just medial to the longitudinal mid line. The two heads of the gastrocnemius are felt and often seen clearly. They can also be palpated and felt to move by flexion and extension at the ankle.
    The other important landmarks are the medial hamstring tendons which lie medial to the medial head of gastrocnemius. Branches of the sural nerve as well as the small saphenous system may also be visualised during the approach. The area between the two heads at the level of the popliteal crease must not routinely be accessed and if there is a need to do so it must be remembered that the popliteal vein artery and nerve lie virtually in the mid line. The popliteal vessels travel deep to this area and must be protected throughout any procedures in the fossa.

    The incision site can then be accessed by externally rotating the leg to reveal the surface markings. Again the anatomy of the region must be familiar to the operating surgeon. The semimembranosus and semitendinosus tendons lie medial to the medial head.

    The incision is made and then deepened to the deep fascia. Throughout the procedure meticulous haemostasis is maintained with bipolar diathermy. A self retaining retractor is used to tension the deep fascia lying deep to the adipose layer. Often, a significant thickness of fatty tissue is encountered at this stage. Care must be taken not to cut away this fat as it maintains the contour of the popliteal fossa.

    The exposure is deepened by initially transversely dividing the deep fascia

    The underlying muscle with its covering layer of fascia bulges into the wound. The ankle is again put through its range of movement to confirm the local of the medial head by identifying its movement.
    The aponeurosis lies somewhat medially over the muscle and curves deeper just lateral to the medial hamstring tendons. It is very important to protect the medial hamstrings to avoid their damage or division.

    The aponeurosis of the medial head is much thicker and whiter medial and thins out into a perimysial layer laterally. This thinner section is not divided as it lies too close the the muscle and if incised is likely to result in the muscle being cut with resultant bleeding problems.

    A transverse incision is then made dividing the aponeurosis from medial to lateral . The medial most part of the muscle is defined by retracting with a deep Langenbeck retractor so the full width of the medial head aponeurosis can be divided. A finger is then used to test the completed division of the aponeurosis with the knee straight. The efficacy of the division of the aponeurosis can also be tested by performing the Silfverskiöld test to show the correction of the dynamic equinus contracture.

    I close the wound after ensuring meticulous haemostasis. This is key as the occurrence of a haematoma in this region may make the patient prone to compartment syndrome or deep vein thrombosis by the pressure over the neurovascular structures in the vicinity.
    Loose Vicryl sutures are used to close the deep fascia with an absorbable suture for skin. I close the wound with the leg elevated and the knee straight to avoid the problems of difficulty with straightening the knee due to a tight skin closure.

    The 3 cm scar is now well apposed and aesthetic.

    Post Operative

    The patient is advised to start mobilising normally immediately after the procedure. The ability to weight bear is determined by the other procedures done on the limb. If it is an isolated release then the patient is advised to weight bear immediately. Stretching exercises are commenced 2 weeks after the operation to allow the wound to heal satisfactorily. Thromboprophylaxis is only used if the patient is non weight bearing.

    Recommended Reading

    The results of the proximal medial gastrocnemius release have been reported in the literature. Matt Solan and his group published the 2.5 year results of this procedure in patients with Achilles tendinopathy with 2/3rd of patients in his group having a good or excellent outcome. He found that patients with non insertional tendinopathy fared much better than those with the insertional variety (Gurdesi et al Foot and Ankle International May 2013). Pierre Barouk published the indications technique and results in 2014 (P.Barouk Foot and Ankle Clinics 2014) and found the results to be good in his cohort of patients.
    The results in my hands have been very good for patients with non insertion achilles tendinopathy of the recalcitrant variety, as also other conditions such as plantar fascitis, metatarsalgia and diabetic forefoot pathology.

    Reference

    • orthoracle.com

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