MODIFIEDSTRAYERGASTROCNEMIUS RECESSION ...

1 Gas tr osol eal equinus is a commondeform ing force on th efo ot an d ankl e. Pe diatric flatfoot,tibi alis poste ri or te ndo ndy sfunc ti on, and diabeticul cera tion repre sent a few of thediv erse condit ions ass ociat ed with tightne ss of the tri cepssu ra e. Whe n conser vati ve meas ures are cl ini ca lly ineffect ive,su rg ical re le ase of the pos teri or contracture is ind ica ted .Se veral surgi cal procedures have been recom mend ed tore so lve nonspast ic contr acture of the gast rocnemius orga stro soleal com plex inclu din g bo th endos cop ic and ope ngastr ocne mius rec ession, as we ll as , both per cu taneou s andop en Ach illes tendonlengt he ning . The selecti on of Achi lleste ndon len gthen ingand gastr oc nem ius rece ssion proced uresis ba sed upon the cl inic al eva this arti cl ewill be upon the ga str oc ne mius rece ss sur gic ally correctinggastrocnemius equ inus ,otherfo ot st abil iz ing pr oceduresare freque ntly in di ca ted(e.)

2 G ., Ev ans cal caneal os teotomy, medialcal cane al sli de,me dial arch stabi liz at ion, etc.). Wit h fe w exceptio ns,pe rfo rmi ng and assessingreconstructi ve pr ocedur es isop ti mal with the patient in the supine positi on. However,th ema jority of gastro cnemiusrece ss ion proce dur es ca llfor pronepo sitio ni ng of the pa tient. Agastr oc ne mi us rec essi on carri edou t in th e sup ine pos itionedpati ent would elimin ate thech allen ges and ri sks of patient repos it ioning for mul tipl epro ced ur es. It is the purpos e of this arti cle to review th ecli ni cal rat ional e and techniqueguide for perf orm ing th emod ified Straye r ga str oc nemiusre ce ssi on an effect iveprocedurewhi le ma intai ni ng the pati ent in the su pi ne posi ti on .CLINIC ALEVALUATIONSi nc ethe re isno acc epted sta ndard for mea sur ingankle joi ntran ge of moti on interobserve r reli ability is incon si sten t.

3 Notsu rp risin gl y, pr eci se ankle joi nt me asure ment remai nsco ntro ve rsia l. Ther e are, how ev er , se ve ral rec ommendati on sto enhan ce cl ini cal evaluationof ankle mot ion and thediag nosi s of equinu lish ed va lues for norma l and re stri cted ankle jointdo rsiflex ion ar e br oa d; cons equentl y, exac t mea surem ent isno t req ui red. Normal ankl e joint dor sif lex ion re ac hes 10de gr ees wi th the kne eex tende d( , dorsi flex ionof the foo tat the ankl e jo int is 10 degr ees pro xi ma l to neu tra l) anddes igna te s an abs en ce of an kl e equi nus ; gen eral ly, th is is th econs en sus min im al am ou nt of ankl e do rsi flex io n req uiredfo r nor mal ambul at ion. Re st ri ct ed ank le do rs iflex ionreach esne utral orless ( , inthe pl ant ar fl ex ed direct ion)an ddes igna te s a presen ce of an kle eq ui nu ing th ecl inical ex ami nat ionank le eq uinus can besu bcl assi fie dintoosse ous ,gast ros oleal ,and gast ro cn emi us ty ous equin us is di agno se d us in g radi ogr aph ic an d/ orcl in ic al meth od s of examin at io n.

4 The dif fer en tia tio n ofgast roso leal fr om gastr oc nemi us equinus iscarri ed ou tusingthe Si lfve rs kiold test .Adh er ing to sou nd, est ab lish ed cli ni cal ex amina tio npr ot oc ols (e .g., usi ng the Silfv er ski old metho d) impr ovesint ero bse rver reli ab il ity. The Sil fv er ski old tes t invo lvesme asur ingank le dors ifl exion wh ileho ldingthe su bt alar join tin ne ut ral or slight inve rsion. The ne utral or inv ert ed footbot h mimic s a locke d mi dt arsal and sub ta la r join t dur in gpro pu ls io n, and also elimin ate s abn orma l dor sif lexory andcom pe nsato ry mot ion at the se joi nt s durin g ex amin ation .Onc e the foot is proper ly pos itioned,the amount of ankledorsi fl exion is me asur ed wit h the kn ee in exten sion andflexio n. Th e Silf ver sk iold met hod furt he r categorizesequi -nu s as eith er ga stro cne mius or ga stro solea l if thi s re stric tedan kl edo rsi fl exionocc urs wi th the kne ein ei th erex ten sionorfl exi on resp ecti vely.

5 The con ce pt is tha t kn ee fl exion releas esten si on gener at ed by the gas tro cn em ius pro xim al fem oralinse rt ion on ank le dors ifl exi on .The cl inica l ap plicat ion of thi s exami nat ion meth od liesin se lect ion of the sur gi cal proce dur e. Speci fica lly:1. Ifan kl eequi nu sisobs ervedonl ywi thkn ee ex ten sio n(i nd ic ating an is ol at ed gast rocnemi us equ in us ) th en agast rocn em ius equ inusisprese nt .Isol at ed lengt heni ngof thegast rocn emius (ap oneu ro si s) is al l th at is req uired to reso lvethe cont ra If an kl eequi nu sis obse rved bo th withkn eeex tensi onan d fle xion th en a gast ro sol eal or osse ous equ inus is present .On ce the pre sen ce an osseo us eq uinus is ruled ou t, th egastr os oleal equ inus may be re so lved by surgicall y leng th en -ing the Achi lleste nd DIFIEDST RAYERGASTROCNEMIUSREC ESSION: A Techniqu e Gui de for theSu pi ne Positioned PatientM. Jay Gro ves , IV, DPMCHAPTER45 THEGASTROCNEMIUSRECESSION:PROCEDURESELEC TIONOn ce the ga strocnemius re ces sion is ind icate d, the su rgeonma y cho ose from sever al ef fective proce dure s.

6 Th e idea lproc edur ewou ld accomplish the followi ng go al s: 1) Eff ec tiv eelim ina ti on of the contracture,2) Exposes the pati ent tomi nimal ri sks, and 3) Off ers a good cosmeti c resu le a pro cedure ma y of fer ex ce pt ional bene fits in aspe ci fi c are a the sam e proc edur e may dem ons tr atesigni fican t risks in another (Tab les 1, 2). It is thi s autho r sop in io n tha t th e modified Stra ye r gas tro cnemi us recessi onmos t ef fecti vel y accomplishes th ese go en se que ncin g multip le proceduresthe post eriorrel ea se is pe rf ormedfirst . Thi s is recom mended for th efol lo win g rea son s:1. Rel ease of ankl e cont racturedecompres ses andunl ock s ot her si te s of defor mi ty, which imp roves in tra-operative def ormity assessmentand effec tivenessof repai r,2. Do rsi fl exi on for ces require dto sep arate and lengthenth e aponeurosis may disruptoth er site s of sur gica l re pair ifth e poste rior lengthening is done late r in sequ en ci seq uent ly, at the start of cas es invol ving mult ipleproced ures the ini tial positioni ng of the pat ient is for th egastr ocn emi us re STRAYERGASTROCNEMIUSRECESSION:PATIE NTPOSITIONINGTyp icall y, th e mo dified Stray er ga str ocne mi us recessi on isper for me d wi th the patie nt unde r gen eral anest hesi a andposi tio ned anes thetiz ed ank le equ inu s isrea sse ss ed prior to carryingout the proc edur e.

7 Thesurgic al li mb need s to be sa fely pl ac ed in extern al rotati lowi ng a st er ile preparationand dr aping to the ant erio rti bi al tub ercl e, the he el and Ac hilles regi on is re ste d up ona soft st erile roll to elevat e the lower le g abo ve thesur gical tabl e; this positionin g cre at es a wo rk space wit hacces s to th e ga stroc ne mius apon eur SI ON:DETERMININGTHERI GHTLEVELA4-7 ce nt imet er transverseplane sk in incisi on is made inthesag itt al plane mids ect ion of the ap oneur os is midsectionlevel is dete rminedby first hol di ng the foot dorsi flex ed an dpal pat ing and skin markingthe proxi mal exte nt of Kaga r stria ngle thi s re presentsthe aponeurosis dista l ma rgi n(Fig ure 1). Ne xt, th ega str ocnemius med ialhea dispal pat edan d mar ke d at it s dis tal extent th is repr esen ts th egast rocne miu s apo ne ur osi s pr oxim al mar gi n. (Figu re 2).Fi nal ly,themedi al mar ginis pal pat edand mark ed (Figu re 3).

8 The dist an ce be twee n the apone urosis pr oxim al and distalma rg insis mea sur ed, di videdinhalf, andmarked .This is thelevel of sk in incision (F igur e 4).Th e med ial porti on of thi s tran sver se incisio n levelneed s to exten d media l to the ga stro cnemiu s aponeur os is media l la te ral por tion of the inc ision needs topro vi de acces s to th e lat era l ap oneu rosis bord er at thesu bcuta neo uslevel. Counter- in tu itive ly, the later al portionof th e skin inc isi on doe s not ne ed to ov erl ie nor exte nd tothe la te ra l apon eur osi s bord er (Figur e 5) .CH APT ER 45260Ta ble 1 RIS KS/ASSOCIATEDCOMPLICATIONSGR PROCEDURESura l Ner ve-E nd osc opi centra pm entSurg ical field-B ake r*conta mi nation-I nv er te d Bake r*Injur y/f all risk-B ake r*-Inver te d Bake r*Inc rea se d-B ake r*ane sth esia tim e-I nv er te d Bake r*Sc ar (inci sion )-C eph alic to Cau dalhy pe rtrop hyinc isi on plac eme nt-Bake r-Inver te d Bake r* ble 2 BENEFITSASSOCIATEDGRPROCEDURERe sol utio n of-B ake rcontra ctur e-I nv er te d Bake r-End osc opi c-Stra yer (modi fied)Re po siti onin g-E nd osc opi cunn ecessar y-S tra yer (modi fie d)Re duc ed-E nd osc opi cane sth esia tim e-S tra yer (modi fie d)Goo d cosme tic-E nd osc opi cre sul t-Stra yer (mod ifie d)SUBCUTANEOUSDISSECTIONAn at om ic di ssect ion proceedsthroughthe sup erfi cial fascia inth e tran sve rse plane from medialto lat eral.

9 Vig il an ce isma in tai ne d thr oug hout thi s dis sectionle vel to avoi dlac erati ng the sural nerve and small sap henousvei n. It isth e au th or s ex periencethat thes e de licat e neur ova sc ul arst ruc tures are enc ou ntered in 30 -4 0% ofmo difie dStra yer GRpro ced ur es. When encountered, ves sel loop s ar e used toge ntly re tract , protect,and vis uall y ale rt the sur geo n tothe ir loc ati deep fasci al pla ne lev el is identifi ed by placi ng thean kle th rough its ra nge of motion and vis ua lizi ng mo vem entofthe underly ing apone urosis. Adissectioninter va lis cr eat edat th is le ve l, and the subcutaneousti ssues (incl udi ng theneu ro -va sc ul ar bundle) are care fully retr acted. A1- 2cm wi dema llea bl eret ract or inse rted from the late ral asp ect iseff ect ivein protec ting these tissues and cre ating spac e fo r incis ion ofthe deep fa sci a (F igur e 6).DEEPFASCIAINCI SI ONANDGASTROCNEMIUSRECESSIOND orsi flexi ng the ankle is impor ta nt whi le incisi ng both thede ep fasci a an d pa ra te non, as we ll as, du ring subse quentse ction in g of the apone ur osis.

10 Wit h th e an kle at 0 deg re esof dorsi fle xi on the de ep fasc ia and parate non ar e sharpl yin ci sed bot h in line wi th th e len gth of the ori gin al ski nin ci si on (Fi gu re 7). The parat en on is elevat ed from theapo neu ro si s and the med ia l ma rgi n of th e gast rocnem iusap oneu rosis (G A) is ident ifi ed. The less visiblelater alma rg in of the de ep fasc ia and pa ra tenon ov erl yi ng the GAne ed not be inc ised. The in ci sed ed ge s of the par at enonare eleva ted fro m th e GA. A diss ec tion interva l betwe enthe par at en on and ap on eu ro sis is crea ted with a Freerel evat or wh ich is adva nced lat era ll y th ereb y creat ing adi sse cti on tu nne l to the latera l bo rde r of the GA (Fig ure8) . Thi s bo rde r is easily pa lp at ed, but no t easil y visuali zedwi th the pa ti en t in the su pin e positi The aponeurosis distal marginbeginsat Kagar 2. The aponeurosis proximalmarginbegins at the gastrocnemius medial head distal 3.