Uniportal Endoscopic Gastrocnemius Recession for Treatment of Gastrocnemius Equinus with a Dedicated EGR System with Retractable Blade

This study examined the effectiveness and safety of a uniportal endoscopic gastrocnemius recession with a specifically designed uniportal endoscopic system. Fifty-three patients underwent 60 endoscopic gastrocnemius recessions. Their mean range of ankle dorsiflexion changed from a preoperative value of –2.9° ± 1.9° to a postoperative value of 12.8° ± 1.7°, for a total increase of 15.7° ± 1.8° of ankle dorsiflexion (p < .001). The average time from skin incision to closure was 4 minutes and 19 ± 33.6 seconds. Overall, 4 (6.67%) cases (procedures) were associated with a complication, including 1 (1.67%) case of triceps surae weakness that resolved after physical therapy. Three (5%) cases developed nerve complications, with 2 (3.33%) cases of transient neuritis that spontaneously resolved at 5 and 8 weeks postoperatively, respectively, and 1 (1.67%) that experienced persistent cutaneous anesthesia in the distribution of the sural nerve along the lateral aspect of the foot up to 4 months postoperatively. There were no cases of wound dehiscence or delayed healing, painful scar formation, infection at the surgical site, hematoma, or deep venous thrombosis. Endoscopic gastrocnemius recession with a uniportal system appears to be safe and effective.     

The effect on ankle dorsiflexion of gastrocnemius recession

Gastrocnemius equinus contracture has been suggested as an etiologic factor in mechanical diseases of the foot and ankle and in ulcer formation in the foot. The purpose of this study is to assess the correction in ankle dorsiflexion that can be achieved with a gastrocnemius recession. An isolated gastrocnemius release (Strayer procedure) was performed on 26 legs, in 20 consecutive patients, for clinically significant gastrocnemius equinus contracture. Ankle dorsiflexion was assessed using a validated electrogoniometer. Ankle dorsiflexion was recorded with the knee straight and with the knee bent. Measurements were recorded preoperatively, and immediately postoperatively. Measurements at an average of 55.0 days postsurgery (range, 37 to 128 days) were performed on 20 legs (15 patients). RESULTS: Average preoperative ankle dorsiflexion with the knee straight was 5.1 degrees. Average preoperative ankle dorsiflexion with the knee bent was 22.8 degrees. Immediately following surgery the average ankle dorsiflexion with the knee straight was 23.2 degrees. The average correction was 18.1 degrees and this increase was significant (p < 0.0001.) In the 15 patients (20 legs) available for follow-up, the increase in ankle dorsiflexion with the knee straight was maintained (average: 24.9 degrees). Patients with gastrocnemius contracture who underwent an isolated gastrocnemius release increased their ankle dorsiflexion (knee straight) by an average of 18.1 degrees with postoperative ankle dorsiflexion (knee straight) being equivalent (23.2 and 22.8 degrees) to preoperative ankle dorsiflexion (knee bent). This correction appears to be maintained (23.2 vs. 24.9 degrees) at short-term follow-up.     

Endoscopic gastrocnemius recession: evaluation in a cadaver model

The purpose of this study was to describe a new method of gastrocnemius recession using an endoscopic approach and to determine the accuracy of incision placement during gastrocnemius recession. Fifteen fresh-frozen cadaveric limbs underwent an endoscopic gastrocnemius recession utilizing a two-portal technique. All limbs were anatomically dissected after the procedure and each was examined for injury to the sural nerve. The ability to visualize the sural nerve intraoperatively, improvement in ankle dorsiflexion, time requirement for the procedure, incision size, and appropriateness of placement to facilitate recession were recorded for each specimen. An average of 83% of the gastrocnemius aponeurosis was transected in all 15 cadavers. After modifications of the technique, the final eight cadavers were noted to have had the entire (100%) gastrocnemius aponeurosis transected. Sural nerve injury occurred in one specimen (7%) in which the aponeurosis and the sural nerve were not well visualized. The sural nerve was definitively visualized during the procedure in 5 of 15 specimens (33%). No Achilles tendon injury was noted in any specimen. There was a mean improvement in ankle dorsiflexion of 20 degrees (range, 10 degrees-30 degrees) during full knee extension. The average length of time to perform the procedure was 20 minutes (range, 10-35 minutes). The average medial and lateral incision lengths used in the two-portal technique were 18 mm (range, 14-22 mm) and 17 mm (range, 12-19 mm), respectively, and the average distance from the midpoint of the medial incision to the level of the gastrocnemius-soleus junction was 26 mm (range, 5-60 mm). These results indicate that a complete gastrocnemius aponeurosis transection may be obtained utilizing a modified endoscopic gastrocnemius recession, but visualization of the sural nerve is poor with possible risk of iatrogenic nerve injury.     

Gastrocnemius Recession Leads to Increased Ankle Motion and Improved Patient Satisfaction After 2 Years of Follow-Up

The isolated gastrocnemius contracture present in neurologic healthy patients results in a significant limitation of ankle dorsiflexion causing pathologic gait patterns and a greater risk of further foot disorders. Gastrocnemius recession is an established procedure to increase ankle dorsiflexion. However, little evidence is available of the use of gastrocnemius recession in these patients. Complication rates, recurrence of gastrocnemius contracture, and the prevalence of additional foot disorders needs further evaluation. A study group of 64 operated limbs undergoing gastrocnemius recession was evaluated to determine the prevalence of foot disorders, pre- and postoperative ankle dorsiflexion, and incidence of complications. A subgroup of 15 (23.4%) patients without additional operative procedures was examined regarding ankle dorsiflexion, strength (Janda method), sensitivity in the operated limb, and the pre- and postoperative Foot Function Index scores. The prevalence of foot disorders showed pes planus (41%), hallux valgus (38%), metatarsalgia (19%), hammertoe deformity (13%), and symptomatic Haglund exostosis (11%). At 31 months of follow-up, the patients had significantly benefited from increased ankle dorsiflexion of 13.3° ± 7.9° (p < .001). Postoperatively, 16% patients experienced complications. In the subgroup of 15 patients, the follow-up examination after 44 months showed ankle dorsiflexion of 14° ± 7.1°. The plantarflexion strength was 4 of 5 (Janda method). The Foot Function Index score had improved significantly from 65.4 ± 26.5 points to 33.4 ± 19.5 points (p < .001). Patients with isolated gastrocnemius contracture seem to have a high prevalence of symptomatic foot disorders. At a mid-term follow-up examination, gastrocnemius recession (Strayer) was shown to be an effective procedure to significantly improve ankle dorsiflexion, functionality, and pain symptoms. More attention should be given to the development of postoperative complications.     

腓肠肌前方腱膜松解治疗非痉挛性腓肠肌挛缩

目的介绍及评价腓肠肌前方腱膜松解治疗非痉挛性腓肠肌挛缩的手术方法及术后疗效。方法回顾性研究2006年7月至2013年7月期间,本组采用腓肠肌前方腱膜松解治疗非痉挛性腓肠肌挛缩的患者。患者术前体检Silfverskild试验（＋）,采用Baumann入路在腓肠肌与比目鱼肌间隙之间,松解腓肠肌前方腱膜,背伸踝关节至角度满意。术前和末次随访时测量踝关节的最大被动背伸角度（膝关节伸直位和屈曲90°时）,进行美国足踝医师协会后足-踝关节（AOFAS-AH）评分,并记录术后并发症情况。结果 29例（35足）患者获得随访,平均年龄36.5岁（8~69岁）,平均随访32.6个月（7~54个月）。其中成人扁平足11例13足,儿童扁平足4例5足,踇外翻6例8足,跖筋膜炎5例6足,创伤性马蹄足3例3足。术前和末次随访时伸膝位踝关节最大被动背伸角度分别为（-5.7°±3.2°）（-15°~3°）和（8.2°±3.7°）（-6°~17°）（P〈0.01）,背伸角度平均增加13.9°。AOFAS-AH评分由术前平均46.7分提高到末次随访的75.1分（P〈0.01）。术后马蹄足畸形复发2例（2足）,无过度延长、神经血管损伤及伤口并发症发生。结论腓肠肌前方腱膜松解操作方便,术后踝关节背伸角度恢复满意,跖屈肌力良好,未见明显并发症,是治疗非痉挛性腓肠肌挛缩安全、有效的手术方法。     

The Role of the Plantaris in Intramuscular Gastrocnemius Equinus Correction

Equinus deformity is a common cause of foot and ankle pathology. The purpose of our study was to evaluate the role of the plantaris in equinus. Secondary aims were to describe the role of the plantaris in intramuscular gastrocnemius recession and to determine the prevalence of the plantaris in our patient population. We measured ankle dorsiflexion during the steps of a Baumann-type intramuscular gastrocnemius recession. Eighty-nine patients were enrolled in our study. Fourteen of 89 (15.7%) patients did not have a plantaris. A mean dorsiflexion of 9 (interquartile range 6-12)° was obtained after transection of the plantaris tendon and an additional mean 8 (interquartile range 5-10)° was obtained after recession of the gastrocnemius aponeurosis. There was a strong positive correlation (rs = 0.842) of dorsiflexion increase after plantaris transection and dorsiflexion increase after gastrocnemius recession (p < .00). Linear regression showed that for every one-degree of dorsiflexion increase with plantaris transection, there was a predicted dorsiflexion increase of 0.69° with gastrocnemius recession. These results indicate that the plantaris is a component of equinus deformity.     

Endoscopic Gastrocnemius Recession for Treating Equinus in Pediatric Patients

Gastrocnemius recessions have been performed as open or endoscopic procedures. Most of the literature describes the outcomes of these procedures in children with specific neurologic limitations. We report an alternative approach to endoscopic gastrocnemius recessions in neurologically healthy pediatric and adolescent patients whose gastrocnemius equinus could not be corrected nonoperatively. We prospectively followed 23 patients (16 boys, seven girls) who underwent 40 procedures for equinus deformity (n = 22) or osteoarthritis (n = 1). All patients had been directly referred for surgical treatment because all previous nonoperative treatments (stretching, night splints, orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy) had failed. The indications for surgery were patients age 18 years or younger experiencing symptomatic equinus unresponsive to nonoperative care. Pre- and postoperative ankle dorsiflexion were measured. The minimum followup for study inclusion was 1 year (mean, 2.9 years; range, 2–5.1 years). For every patient, dorsiflexion range of motion improved (mean, 15°; standard deviation, 4°). No patient had diminished nerve sensation postoperatively. This technique can be used to correct gastrocnemius equinus in otherwise healthy children who have not benefited from prior nonsurgical treatment.     

Isolated recession of the gastrocnemius muscle: the Baumann procedure

BACKGROUND: The Baumann procedure consists of intramuscular lengthening (recession) of the gastrocnemius muscle in the deep interval between the soleus and gastrocnemius muscles. The goal of the procedure is to increase ankle dorsiflexion when ankle movement is restricted by a contracted gastrocnemius muscle. Unlike the Vulpius procedure, the Baumann procedure truly isolates the lengthening site to the gastrocnemius muscle and does not lengthen the soleus muscle. The Baumann procedure has not previously been studied in cadaver specimens. METHODS: The gastrocnemius and soleus muscles of 15 normal cadaver specimens had four sequential releases: a single gastrocnemius recession, a second gastrocnemius recession, a single soleus recession, and an Achilles tenotomy. Ankle dorsiflexion was measured with a goniometer initially, after each muscle recession, and after the tenotomy. RESULTS: After the second gastrocnemius recession, the average increase in ankle dorsiflexion measured 14 degrees with the knee extended and 8 degrees with the knee flexed. CONCLUSIONS: The Baumann procedure treats equinus contracture of the gastrocnemius muscle by improving ankle joint dorsiflexion. The procedure is indicated when the results of the Silfverski?ld test are positive.     

Macroscopic changes in sural nerve after gastrocnemius recession: a cadaver study

BackgroundGastrocnemius recession is a common foot and ankle procedure and various techniques that have been utilized are mainly delineated by the anatomic position of the gastrocnemius transection; the 2 common ones are the Baumann and Strayer procedure. Both can adversely affect the sural nerve. The objective of this study was to evaluate the macroscopic changes in the sural nerve following gastrocnemius recession, and to compare the efficacy of the two procedures, regarding the improvement of maximal ankle dorsiflexion.MethodsTen fresh-frozen, above knee cadaveric legs were assigned to one of two gastrocnemius recession techniques: Baumann (n = 5) or Strayer (n = 5). A goniometer was used to measure degree of ankle dorsiflexion before and after the surgery. The sural nerve was meticulously dissected and marked with two suture knots, 2 cm apart. The ankle was passively dorsiflexed from 90° to maximal dorsiflexion in 5° degree increments, and the distance between two suture knots was measured at each increment. The distance between the two cut ends of gastrocnemius muscle was measured with the ankle at 90° and at maximal dorsiflexion.ResultsOverall, a mean increase in length between the suture knots on the sural nerve was 0.2 cm, from 90° to maximum ankle dorsiflexion (130°); both the Baumann and Strayer techniques resulted in 0.2 cm increase. The mean improvement in maximal ankle dorsiflexion in the Baumann and Strayer group was 22.6° and 22°, respectively. The mean change in distance between the two cut ends of the gastrocnemius muscle in the Baumann and Strayer group was 1.0 cm and 0.9 cm, respectively.ConclusionIncreased dorsiflexion of the ankle following Strayer or Baumann gastrocnemius recession resulted in similar macroscopic change in the sural nerve, which may contribute to the development of sural neuritis. Further clinical studies are warranted to assess clinical implications of these findings.     

踝关节骨折术后腓肠肌挛缩型马蹄足的手术治疗

背景：足踝部创伤可导致患者较长时间的踝部制动及术后软组织粘连,易造成腓肠肌挛缩,从而诱发创伤后马蹄足。若不及时进行合理有效的治疗,容易引发跖腱膜炎、外翻、获得性平足症、前跖痛等并发症。目的：探讨腓肠肌腱膜切断松解术治疗踝关节骨折术后腓肠肌挛缩型马蹄足的效果。方法：2011年1月至2013年1月,通过腓肠肌腱膜切断松解术治疗踝关节骨折术后腓肠肌挛缩患者26例,男17例,女9例,年龄24~55岁,平均44.3岁。术前对所有患者伸膝及屈膝90°时的踝关节背屈角度进行测量,确诊为踝关节骨折术后腓肠肌挛缩。采用改良的Strayer手术对腓肠肌松解。采用美国足踝外科协会（AOFAS）踝-后足评分评估患足功能。术后再次对伸膝及屈膝90°时的踝关节背屈角度进行测量并与术前比较。结果：21例患者获得随访,随访时间12~24个月,平均17个月。所有切口均一期愈合,无感染,无腓肠神经损伤,无明显疼痛不适。伸膝状态下踝关节背屈角度由术前的0.9°±3.4°恢复到术后的13.6°±2.4°（P＜0.01）。术后AOFAS踝-后足评分为（80.9±5.7）分,与术前（57.6±6.4）分,比较差异亦有统计学意义（P＜0.01）。结论：对于踝关节骨折后并发的腓肠肌型马蹄足,腓肠肌腱松解术操作简单,创伤小,可获得满意疗效。     

Comparison of the Complication Incidence in Open Versus Endoscopic Gastrocnemius Recession: A Retrospective Medical Record Review

Gastrocnemius recession is a practical and effective procedure to address gastrocnemius equinus. It has been shown that an equinus deformity can lead to the development of plantar fasciitis, osteoarthritis, and foot ulcerations. The 2 approaches to gastrocnemius recession are open and endoscopic. Both are viable options; however, both also have associated complications. We compared and evaluated the postoperative complications associated with these procedures. The electronic database of our orthopedics division at the University of Florida College of Medicine, Jacksonville, was retrospectively searched to identify all cases of gastrocnemius recession (Current Procedural Terminology [CPT] code 27687), and unlisted arthroscopy (CPT code 29999) from February 2006 to February 2016. The difference in the outcome variable, the incidence of postoperative complications, was assessed using Fisher's exact test. A total of 39 patients (41 procedures) were in the open gastrocnemius recession group and 35 (39 procedures) were in the endoscopic gastrocnemius recession group. The median follow-up time was shorter in the open gastrocnemius recession group than in the endoscopic gastrocnemius recession group (9 versus 12 months; p?<?.001). Postoperative complications developed after 12 of the 80 procedures (15%), with a greater incidence after open than endoscopic procedures (26.8% versus 2.6%; p?=?.003). The complications associated with the open technique included 1 case of scar pain (2.4%), 5 of dehiscence (12.2%), 1 of infection (2.4%), 2 of calf abscess (4.9%), and 2 cases of nerve injury (4.9%). A single complication occurred with the endoscopic technique—1 case of dehiscence (2.6%). To the best of our knowledge, ours is the first study to compare the postoperative complications between these 2 techniques. We found the incidence of postoperative complications was significantly lower in the endoscopic group, emphasizing the benefit of using the endoscopic approach. These findings could prove invaluable when addressing gastrocnemius equinus in those with a greater risk of postoperative complications.     

Ankle dorsiflexion after isolated medial versus complete proximal gastrocnemius recession: A cadaveric study

PurposeGastrocnemius recession has been described in the treatment of gastrocnemius contracture. The aims of this study were: (1) to assess the change in ankle dorsiflexion after isolated medial gastrocnemius recession performed according to L.S. Barouk’s technique; (2) to compare ankle dorsiflexion after isolated medial head with complete proximal gastrocnemius recession.MethodsA cadaveric study was performed on 15 lower limb adult specimens. Isolated medial gastrocnemius head recession was initially performed, followed by an additional recession of the lateral gastrocnemius head. Ankle dorsiflexion torque was applied with 2 and 4 kg forces on second metatarsal head. Ankle dorsiflexion was measured with the knee both in extension and at 90° of flexion and values were recorded before surgery (T0), after medial head recession (T1) and after both heads recession (T2). Normality of data was assessed using the Shapiro–Wilk test, then measurements were compared in the three conditions with appropriate statistical tests.ResultsAfter isolated medial gastrocnemius recession (Δ = T1-T0), ankle dorsiflexion assessed with the knee in extension significantly increased by 5° ± 3 (range, −2 to 10) with a 2-kg torque (p = 0.02) and by 4.5° ± 3 (range, −4 to 10) with a 4-kg torque (p = 0.04). No significant difference was observed with the knee flexed at 90° (p > 0.05 for all measurements). After both gastrocnemius heads recession (Δ = T2-T1), although a further increase in dorsiflexion was noticed, statistical significance was not reached neither with the knee in extension nor at 90° of flexion (p > 0.05 for all measurements).ConclusionIn this study, isolated medial gastrocnemius head recession performed according to LS Barouk’s technique was effective in improving ankle dorsiflexion, whereas the additional release of the lateral head did not produce any significant change.Level of evidenceLevel V, cadaveric study.     

Morbidity Associated With High Gastrocnemius Recession: Retrospective Review of 126 Cases

To evaluate morbidity associated with surgical lengthening of the gastrocnemius, medical records were reviewed retrospectively for 126 patients (mean age, 49.7 years; range, 8-78 years) who had undergone open gastrocnemius recession. Ten patients had isolated recession; 116 had gastrocnemius recession with an additional foot or ankle procedure on the ipsilateral limb. During a mean follow-up period of 19 months (range, 6-50 months), all patients were examined for any postoperative complications associated with the recession. Complications were defined as the presence of postoperative infection, wound dehiscence, nerve problems, decreased muscle strength, scar problems, or calcaneus gait (overlengthening). Uncomplicated outcome was defined as absence of all these complications and return to regular activity, both occurring during a follow-up of at least 6 months. Postsurgical complications developed in 9 (6%) of the 126 patients: 6 (4%) had scar problems, 2 (1.33%) had wound dehiscence, 2 (1.33%) had infection, 3 (2%) had nerve problems, and 1 (0.67%) developed complex regional pain syndrome. No patient complained of either a limp or gait disturbance. Neither persistent decrease in muscle strength nor calcaneus gait was seen. These data suggest that the open gastrocnemius recession procedure has low associated morbidity.     

Complications Associated with Uni-portal Endoscopic Gastrocnemius Recession in a Diabetic Patient Population: An Observational Case Series

The purpose of this article was to report the complications associated with uni-portal endoscopic gastrocnemius recession for surgical treatment of pathologic soft tissue ankle equinus contracture in diabetic patients. This is an observational case series involving a retrospective review of prospectively collected data of 23 uni-portal endoscopic gastrocnemius recessions used to treat pathologic soft tissue ankle equinus contracture in 18 consecutive diabetic patients between November 2006 and January 2009. Each patient underwent uni-portal endoscopic gastrocnemius recession under general or spinal anesthesia with thigh tourniquet control in combination with soft tissue and/or osseous reconstructive foot and/or ankle surgery. Patients were kept non–weight bearing based on the index procedure and followed until clinical healing occurred or failure was declared. There were 9 male and 9 female patients with a mean age ± SD of 69.0 ± 7.4-years (range: 47.0 to 71.0 years). There were 11 right and 12 left lower limbs involved, with 5 procedures performed bilateral. Complications included 3 conversions to an open incision secondary to difficulty dissecting through excessive adipose tissue, delayed healing of 3 incision sites in patients with uncontrolled diabetes mellitus at the time of surgery, and 3 undercorrections in patients with spastic contractures. The remainder of the procedures were deemed successful with no saphenous nerve, sural nerve, or lesser saphenous vein related injuries occurring. When properly performed, uni-portal endoscopic gastrocnemius recession represents a safe, reliable, and minimally invasive technique useful for correcting pathologic soft tissue ankle equinus contracture in patients with diabetes. A percutaneous tendo-Achilles lengthening should be performed in patients who have marginal arterial inflow that precludes tourniquet use or have a spastic contracture. An open rather than endoscopic gastrocnemius recession should be performed in patients with excessive adipose tissue. Before surgery, the risk of delayed wound healing should be discussed with patients who have uncontrolled diabetes mellitus and in-patient management with tight glycemic control considered.     

Isolated gastrocnemius tightness

BACKGROUND: Contracture of the gastrocnemius-soleus complex has well-documented deleterious effects on lower-limb function in spastic or neurologically impaired individuals. There is scarce literature, however, on the existence of isolated gastrocnemius contracture or its impact in otherwise normal patients. We hypothesized that an inability to dorsiflex the ankle due to equinus contracture leads to increased pain in the forefoot and/or midfoot and therefore a population with such pain will have less maximum ankle dorsiflexion than controls. We further postulated that the difference would be present whether the knee was extended or flexed. METHODS: This investigation was a prospective comparison of maximal ankle dorsiflexion, as a proxy for gastrocnemius tension, in response to a load applied to the undersurface of the foot in two healthy age, weight, and sex-matched groups. The patient group comprised thirty-four consecutive patients with a diagnosis of metatarsalgia or related midfoot and/or forefoot symptoms. The control group consisted of thirty-four individuals without foot or ankle symptoms. The participants were clinically examined for gastrocnemius and soleus contracture and were subsequently assessed for tightness with use of a specially designed electrogoniometer. Measurements were made both with the knee extended (the gastrocnemius under tension) and with the knee flexed (the gastrocnemius relaxed). RESULTS: With the knee fully extended, the average maximal ankle dorsiflexion was 4.5 degrees in the patient group and 13.1 degrees in the control group (p < 0.001). With the knee flexed 90 degrees, the average was 17.9 degrees in the patient group and 22.3 degrees in the control population (p = 0.09). When gastrocnemius contracture was defined as dorsiflexion of < or = 5 degrees during knee extension, it was identified in 65% of the patients compared with 24% of the control population. However, when gastrocnemius contracture was defined as dorsiflexion of < or = 10 degrees, it was present in 88% and 44%, respectively. When gastrocnemius-soleus contracture was defined as dorsiflexion of < or = 10 degrees with the knee in 90 degrees of flexion, it was identified in 29% of the patient group and 15% of the control group. CONCLUSIONS: On the average, patients with forefoot and/or midfoot symptoms had less maximum ankle dorsiflexion with the knee extended than did a control population without foot or ankle symptoms. When the knee was flexed 90 degrees to relax the gastrocnemius, this difference was no longer present. Clinical Relevance: These findings support the existence of isolated gastrocnemius contracture in the development of forefoot and/or midfoot pathology in otherwise healthy people. These data may have implications for preventative and therapeutic care of patients with chronic foot problems.     

Reconstruction of Neglected Achilles’ Tendon Defect With Peroneus Brevis Tendon Allograft: A Case Report

This case report describes the use of a peroneus brevis allograft to reconstruct a neglected Achilles' tendon injury in a 75-year-old woman. She had difficulty walking, had stiffness, and was unable to perform a heel raise from a single-leg standing position. Magnetic resonance imaging confirmed a 6.8-cm wide defect 13 months after the initial injury. Surgical repair of the neglected rupture was performed using 4 strands of peroneus brevis allograft to bridge the defect. Early weight bearing and rehabilitation was allowed. At follow-up clinical examination 14 months postoperation, the patient could perform 15 full-range standing heel raises on the involved side versus 22 on the noninvolved side. Maximum calf circumference was 30.7 cm in the operated leg versus 33 cm at the noninvolved side. At 24 months postoperation the patient could perform 16 full-range standing heel raises on the injured leg versus 24 on the normal leg (33% deficit). The maximum calf circumference improved to 31 cm on the injured side compared with 34 cm on the noninvolved side (9% deficit). The AOFAS Ankle-Hindfoot Clinical Rating System score improved from 55 just before operation to 96 at 14 months postoperatively. The score further improved to 100 at the 2-year follow-up examination. The patient was playing recreational doubles tennis 1 to 2 times per week without symptoms.     

The modified Hohmann osteotomy: An alternative joint salvage procedure for hallux rigidus

The purpose of this study was to evaluate the effectiveness of the modified Hohmann osteotomy for treatment of hallux rigidus. By allowing plantarflexion of the first metatarsal head, this osteotomy was theorized to protect gliding motion and to decompress the joint. Twenty-two patients (25 procedures) were assessed preoperatively and postoperatively for the first metatarsal plantarflexory osteotomy. The average postoperative follow-up was 12 months, with a range of 6 to 60 months. Postoperative subjective patient questionnaires showed the following: 96% reported excellent subjective ratings with no fair or poor ratings, 80% reported a return to normal activity within 1 to 2 months, no patients reported any significant limitations in their activity or reoccurrence of pain, and no patients reported any need for a revision surgery other than hardware removal. A goniometer was used to measure preoperative and postoperative dorsiflexion and plantarflexion at the first metatarsophalangeal joint. The patient first metatarsophalangeal joint dorsiflexion increased from a mean 17.76 degrees preoperatively to a mean 58.92 degrees postoperatively. The ability to hold a piece of paper under the hallux for purchase power was also evaluated. Only 2 of 25 procedures lacked the purchase power to effectively hold a piece of paper with the hallux. Thus, the modified Hohmann osteotomy provides an excellent alternative joint-salvaging procedure for moderate to severe hallux rigidus.     

Association of Ankle Dorsiflexion With Plantar Fasciitis

This study aimed to compare the mean ankle dorsiflexion range between individuals with and without plantar fasciitis using passive ankle dorsiflexion with consistent pressure, and to identify the prevalence of an isolated gastrocnemius and gastrocnemius soleus complex contracture in 2 groups. 91 participants were prospectively classified into the plantar fasciitis group (45 subjects) and the control group (46 subjects). Ankle dorsiflexion was measured with the knee extended and with the knee flexed 90° using a standard orthopedic goniometer while a consistent force of 2 kg was applied under the plantar surface of the forefoot using a custom-made scale. Intraclass correlation coefficients (ICC) were calculated to determine the interobserver and intraobserver reliability of the current ankle dorsiflexion measurement. The current ankle dorsiflexion measurement revealed excellent interobserver and intraobserver reliability. The mean ankle dorsiflexion in the knee extended was -9.6° ± 8.1° and -11.2° ± 8.2° in the study and control groups, respectively (p = .353). The mean ankle dorsiflexion in the knee flexed was 7.8° ± 6.5° and 5.1° ± 7.4° in the study and control groups, respectively (p = .068). In the study and control groups, 68.9% and 65.2%, respectively, had an isolated gastrocnemius contracture and 24.4% and 30.4%, respectively, had a gastrocnemius-soleus complex contracture (p = .768). The present study demonstrated that there were no significant differences in passive ankle dorsiflexion and in the prevalence of an isolated gastrocnemius or gastrocnemius soleus complex contracture between individuals with and without plantar fasciitis.