Outcomes and Incidence of Complications Following Endoscopic Gastrocnemius Recession: A Systematic Review

Introduction: Equinus contracture of the ankle can lead to a multitude of foot and ankle pathologies. The gastrocnemius recession has been used to address equinus deformity via various methods, including either an open or an endoscopic approach. Open techniques require increased intraoperative time and complication risks of sural nerve injury, wound complications, and poor cosmesis. Resultantly, the aim of the current study is to review the complications and outcomes of the endoscopic gastrocnemius recession. Methods: A systematic review of electronic databases was performed. The authors compiled data from retrospective and prospective patient studies including general patient demographics, outcomes, qualitative scoring measures, complications, and surgical technique. Results: Eleven studies met our inclusion criteria. A total of 697 feet in 627 patients were included in the current systematic review. The weighted mean age was 45.3 years and weighted mean follow-up was 18.4 months. The most common indication for an endoscopic gastrocnemius recession was equinus contracture. The weighted mean preoperative ankle range of motion was −2.3° and the weighted postoperative ankle range of motion was 10.9°. The most common complications included plantarflexion weakness of the ankle at 3.5%, a sural nerve injury of 3.0% and wound complication rate was 1.0% with no deep infection. The overall complication rate was 7.5%. Conclusion: The endoscopic gastrocnemius recession is a valuable surgical tool in the treatment of ankle equinus. The endoscopic approach has satisfactory outcomes including low incidence of plantarflexion weakness and sural neuritis. Patients should be counseled on these risks preoperatively. Compared with previously reported systematic review of the open technique, the endoscopic approach has a lower overall incidence of complications. Prospective clinical trials comparing open and endoscopic techniques are warranted. Levels of Evidence: Level IV

Effectiveness of achillotomy in children with arthrogryposis

Introduction. Ponseti method is a widespread treatment for clubfoot in children with arthrogryposis. Closed subcutaneous achillotomy in these patients could not completely rectify the equinus deformity due to tissue rigidity which often leads to reconsideration of the tenotomy principles. Aim. This study aimed to formulate the anticipating criteria to assess the effectiveness of achillotomy in order to develop a different achillotomy approach for children with arthrogryposis. Materials and methods. This study retrospectively analyzed closed subcutaneous achillotomy in 28 patients (56 feet) with arthrogryposis. The mean age of the patients was 5.4 months (range 2–8 months). The children were subdivided into two groups according to the residual equinus deformity after the completion of Ponseti serial casting. All patients were physically and radiographically examined. Results and discussion. The first group included 12 patients (24 feet), which achieved foot neutral position or dorsiflexion ≥5° after achillotomy. The second group consisted of 16 patients (32 feet) with residual equinus after achillotomy who required surgery. X-ray images showed that the patients in the second group had significantly wider tibiocalcaneal angle and smaller talocalcaneal angle in lateral view (р < 0.01). The correction values of the equinus deformity after achillotomy in the children with arthrogryposis were greatly limited: 27° (20°–30°) and 19° (10°–30°) in the first and second groups, respectively. Conclusion. Closed subcutaneous achillotomy for effective equinus elimination during clubfoot treatment by Ponseti method should be performed only after complete correction at the level of tarsal joints. X-ray examination of the feet is recommended for the children with arthrogryposis in order to evaluate the talocalcaneal divergence and heel position more comprehensively. Furthermore, the values of tibiocalcaneal and talocalcaneal angles in lateral view prior to achillotomy are essential prognostic factors of its effectiveness. Moreover, the severity of equinus contracture should be considered prior to achillotomy. Achilles tenotomy is inappropriate if equinus deformity exceeds 30°. In such cases, open surgery should be considered.

Hallux Valgus

Hallux valgus is a common condition that results from a complex positional deformity of the first ray. The bunion or medial prominence that results from the lateral deviation and pronation of the hallux is only one component of the 3-dimensional deformity. Hallux valgus can lead to considerable pain and altered joint mechanics. The precise biomechanical etiology remains under debate. Predisposing factors include female sex, age, constricting footwear, and family history. Metatarsus adductus, equinus contracture, hammertoe deformity, and pes planus often coexist with hallux valgus. Nonoperative treatment involves patient education, shoe modifications, toe pads and positioning devices, and activity modifications. Surgery is considered in patients who fail nonoperative treatment with the goal of pain relief, correction of the deformity, improved first ray stability, and improved quality of life. More than 100 different procedures have been described to treat hallux valgus; they include combinations of soft tissue balancing, metatarsal osteotomies, and fusion of either the metatarsophalangeal (MTP) or tarsometatarsal (TMT) joint. The choice of procedures depends on the severity and location of the deformity as well as surgeon preference. Recent advances in operative techniques include minimally invasive surgery and correction of rotational deformity.

Gastrocnemius Recession to Treat Chronic Insertional and Noninsertional Achilles Tendinopathy

Category: Hindfoot Introduction/Purpose: Small studies on gastrocnemius recession for Achilles tendinopathy with associated contracture of the gastrocnemius muscle are encouraging. The analyses have demonstrated fewer postoperative complications, shortened recovery time, and earlier return to work as compared to traditional surgical management of Achilles debridement and repair. Investigators have reported good patient satisfaction, substantial pain reduction, and restoration of dorsiflexion. However, there have been no large studies specifically looking at the outcomes of gastrocnemius recession for either chronic insertional or noninsertional Achilles tendinopathy. The purpose of this study was to review the efficacy of the gastrocnemius recession in mitigating pain for patients who have chronic Achilles tendinopathy with isolated gastrocnemius contracture and have failed nonoperative management. Methods: The records of patients with isolated gastrocnemius contracture were retrospectively reviewed who underwent an isolated gastrocnemius recession to treat insertional or noninsertional Achilles tendinopathy as performed by a single surgeon spanning from 2011 to 2017. Minimum follow-up time required was 6 months with an average of 25.5 months follow-up among all responders with a range from 6 to 63 months. Patients were excluded by the criteria of any other concomitant foot deformities, diagnoses, or surgical procedures performed. Clinical outcome was evaluated using a mail-in patient satisfaction questionnaire. One hundred and thirty-nine patients were identified to have underwent an isolated gastrocnemius recession to treat chronic insertional or noninsertional Achilles tendinopathy that was refractory to conservative management for a minimum of six months. Sixty-six patients (76 legs) of those eligible responded. Results: Sixty-three out of 66 patients (95.5%) were satisfied with the results of the procedure overall. Sixty-two out of 66 patients (93.9%) would elect to repeat the surgery if they knew their results in advance. Sixty-one out of 66 patients (92.4%) would recommend the surgery to a family or friend with the same diagnosis. The most frequently reported postoperative complication was 9 accounts of swelling (out of 76 legs; 11.8%). There were no reports of sural nerve injury. Responses for Visual Analogue scale (VAS) for pain were only eligible if they had reported a preoperative VAS score on their preoperative intake form. This made 23 patients eligible with an average preoperative pain of 8.43/10 and an average postoperative pain of 0.91/10. Conclusion: Gastrocnemius recession for treating chronic Achilles tendinopathy was found to be an effective procedure to mitigate pain in patients with isolated equinus contracture. To our knowledge, this is the largest study assessing gastrocnemius recession for treatment of chronic Achilles tendinopathy.

Isolated Gastrocnemius Recession for Plantar Fasciitis

Category: Hindfoot Introduction/Purpose: Plantar fasciitis is a debilitating problem that can cause long-term pain. Multiple different studies with various modalities have been suggested to treat the inflammation of the plantar fascia. None of them have provided a cause for the inflammation. A few recent studies have shown gastrocnemius equinus to be a driving factor in foot pain, which includes plantar fasciitis. Our belief is that the inflammation is due to a stretch placed on the plantar fascia due to a gastrocnemius equinus contracture and the beginning of an arch collapse per the Grand Rapids arch collapse model. As such, we wanted to review our results with an isolated gastrocnemius recession for the treatment of plantar fasciitis. Methods: We retrospectively reviewed patient data collected by isolating ICD-9 and ICD-10 codes for plantar fasciitis. These patients presented to the senior author’s office with a complaint of plantar heel pain, were diagnosed with a gastrocnemius equinus contracture and plantar fasciitis, failed conservative treatment, and opted for an isolated gastrocnemius recession as a definitive treatment of the fasciitis. From the timeframe of 1/1/2015 to 6/12/17, there were 68 out of 97 patients who qualified for the study based on the necessary criteria: an initial consultation pain score, initial post-operative pain score at two weeks, and second post-operative pain score at eight weeks. These patients did not have coexisting surgeries at the time of the gastrocnemius recession or prior surgery to the area in discussion. Results: For the 68 patients (five of which underwent bilateral procedures at a minimum of six weeks apart), who elected to have a gastrocnemius recession for plantar fasciitis, the average initial presenting pain was a 7.4 on a scale of 0 to 10. The average initial post-operative pain score was 2.8 and the average second post-operative pain score was 3.3. The average number of days from initial to second post-operative appointment was 136 days. Of the 68 patients, 21 returned after their eight-week post-operative visit for evaluation. Only 3 returned with recurrent plantar heel pain, 4 more presented with new onset tarsal tunnel syndrome, three more with heel pain different from their pre operative pain and the remaining patients had new onset unrelated pain. Conclusion: We have demonstrated that an isolated gastrocnemius recession can decrease the pain score in patients with recalcitrant plantar fasciitis. Follow up care beyond eight weeks post operation is not routinely performed due to the limited nature of the procedure. The improvement demonstrated in the VAS scores of the patients included in this study show a definite improvement and as such, we believe that an isolated gastrocnemius recession should be considered as a definitive treatment of plantar fasciitis. Future prospective randomized studies will need to be completed to further evaluate the effectiveness of this procedure.