Ultrasound-Guided Gastrocnemious Lengthening: Ultraminimally Invasive Pathways
2018 AWARD WINNER
Introduction: Gastrocnemius contracture is defined as ankle dorsiflexion of less than 10° with the knee in extension. The condition may predispose patients to or aggravate various foot and ankle disorders, such as plantar fasciitis, Achilles tendinosis, flatfoot, diabetic foot ulcer, metatarsalgia, and nerve entrapment. In children, gastrocnemius contracture has been associated with equinus foot, spasticity, and cerebral palsy. Gastrocnemius recession can be performed alone or in combination with other techniques. The procedure is indicated in adults with dorsiflexion of less than 10° with the knee in extension.
Although many techniques are available for gastrocnemius recession, anesthetic, cosmetic, and wound-related complications may lead to patient dissatisfaction. Distal gastrocnemius recession can be performed via open surgery, endoscopy, or an ultrasonography-guided procedure. Open and endoscopic recession techniques usually require epidural anesthesia, the use of a tourniquet, and stitches and may lead to sural nerve damage, which is not under the complete control of the surgeon during all stages of the procedure. Proximal gastrocnemius lengthening was first described in patients with cerebral palsy in 1923 by Silfverskiöld, who recessed the medial and lateral muscle bellies at the femoral condyles. Selective medial recession was recently described by Barouk, who released only the aponeurosis of the medial gemelli. This video demonstrates ultrasonography-guided proximal and distal gastrocnemius lengthening.
Results: Our preliminary study in cadaver models showed the surgical procedure to be safe and effective, with the nerves and vessels preserved. We performed proximal lengthening in patients with less marked gastrocnemius contracture. Our preliminary results were excellent in most patients. The main indications for the surgical procedure were gastrocnemius contracture, noninsertional Achilles tendinopathy, equinus foot, plantar fasciitis, metatarsalgia, and tarsal tunnel syndrome. The mean increase was 14° for distal lengthening and 12° for proximal lengthening. Pain and function, based on visual analog scale scores and American Orthopaedic Foot and Ankle Society scores, substantially improved in all patients. Postoperative pain was minimal despite the combination of procedures.
Discussion: The approach we present is associated with a number of advantages. It reduces the size of the incision and can be performed under local anesthesia. It is relatively quick and painless and does not require the use of a tourniquet. During the procedure, the main structures, including the sural nerve and saphenous vein, are visible at all times. Few complications and contraindications are associated with the approach. Both techniques are considered stable, with no undesired over-lengthening occurring despite immediate postoperative weight-bearing. Therefore, no weakness or crouched gait is associated with the technique.
One of the most important advantages of this novel surgical procedure is the option of performing a bilateral procedure alone or in combination with other ultrasonography-guided surgical techniques in an outpatient setting, with proximal or distal ultrasonography-guided procedures. The only disadvantage of the technique is the steep learning curve, which requires the surgeon to perfect the technique in cadaver models and become competent with ultrasonography.