Results after gastrocnemius recession in 73 patients

BackgroundVery few studies describe the clinical results and complications following the surgical procedure of gastrocnemius recession.PurposeTo survey the patient reported outcomes in patients operated with gastrocnemius recession as single procedure for various foot conditions.Material and methods93 patients operated with gastrocnemius recession as single procedure between 2006 and 2011 were detected in the database. 73 patients responded to the invitation for study participation. Questionnaires containing patient reported satisfaction, complications, plantar flexion power and visual analog pain score were used for evaluation of the postoperative result.Results45/73 (62%) patients reported a good or excellent result. 8/73 (11%) patients reported a significant postoperative complication. 16/73 (22%) patients noted reduced or severely reduced plantar flexion power after surgery. VAS pain score significantly decreased from 7.0 before surgery to 1.8 (p =0.015) after surgery for patients with plantar fasciitis (n =18) and from 5.6 to 2.3 (p < 0.01) for patients with metatarsalgia (n = 28).ConclusionPatients treated with gastrocnemius recession for plantar fasciitis demonstrated good clinical results. The complication rate was higher than reported by others.     

Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients

Background

Plantar fasciitis is a common foot pathology that is typically treated non-operatively. However, a minority of patients fail non-operative management, develop chronic symptoms, and request a surgical option. Gastrocnemius recession has recently been shown to be effective for the treatment of chronic plantar fasciitis. The purpose of this paper is to present evidence that gastrocnemius recession is safe and effective in the subset of chronic plantar fasciitis patients who are overweight and obese.

Patient reported outcomes and ankle plantarflexor muscle performance following gastrocnemius recession for Achilles tendinopathy: A prospective case-control study

BackgroundProspective studies to guide the application of a gastrocnemius recession for Achilles tendinopathy are limited. Our aim was to prospectively evaluate patient reported outcomes and muscle performance.MethodsPatients with unilateral recalcitrant Achilles tendinopathy who received an isolated gastrocnemius recession (n = 8) and a healthy control group (n = 8) were included. Patient reported outcomes, ankle power during walking and stair ascent, and the heel rise limb symmetry index (total work) were collected.ResultsImprovements in pain and self-reported function were observed (six months and two years). Sport participation scores reached 92% by two years. Patients demonstrated lower ankle power during stair ascent and decreased limb symmetry during heel rise six months following treatment (p ≤ .02).ConclusionsStudy findings regarding long-term improvements in patient pain, self-reported function and sport participation, and early preservation of ankle function during walking, can help refine patient selection, anticipated outcomes, and rehabilitation strategies.     

Technique tip: using a vaginal speculum for gastrocnemius recession

Gastrocnemius tightness is commonly found in patients with foot/ankle dysfunction. Gastrocnemius lengthening or recession is commonly performed as part of the treatment for plantar fasciitis, hallux valgus, symptomatic adult acquired flatfoot, metatarsalgia, and/or diabetic foot ulcers. We describe a technique using a vaginal speculum that allows safe completion of the procedure through a very limited incision.     

CO_2气腔内窥镜下切取腓肠神经的解剖学研究

目的 为CO_2气腔内窥镜下腓肠神经切取术提供解剖学依据.方法 解剖20侧新鲜成人下肢标本,观察腓肠神经组成、走行、血供特点,及与小隐静脉的关系.结果 腓肠神经组成类型以腓肠内、外侧皮神经汇合型为主,腓肠内、外侧皮神经发出后走行于深筋膜深面,在深筋膜下的长度分别为(18.54±0.32)cm和(19.64±0.20)cm;腓肠神经走行于浅筋膜层.在小腿上段神经与小隐静脉之间有深筋膜分隔.而小腿下段腓肠神经与小隐静脉伴行密切共同走行于浅筋膜层.在腓肠肌肌峰平面,腓肠内侧皮神经位于小隐静脉深面内侧(0.70±0.06)cm,腓肠外侧皮神经位于小隐静脉深面外侧(3.16±0.04)cm.结论 在小隐静脉体表投影腓肠肌肌峰平面外侧1.5cm设计内镜入口,在内镜入口内、外侧3.0～3.5cm设计操作入口安全.在深筋膜深面切取腓肠内、外侧皮神经,长度分别为19cm和18cm;还可以避免损伤小隐静脉.腓肠神经走行于浅筋膜层内与小隐静脉关系密切,切取容易导致出血和小隐静脉的损伤.     

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.     

内窥镜镜视下切取腓肠神经的初步报告

目的 介绍内窥镜镜视下切取腓肠神经的方法。方法 对5例上肢神经大段缺损患者，沿小腿部腓肠神经行径，距外踝后侧15.cm处作长2cm的直切口，在小腿三头肌肌腹，肌腱交界处作长2cm的直切口。利用UniversaL Subcutaneous Endoscope System，在内窥镜镜视下，解剖分离腓肠神经后将其完整地自外踝处切口内抽出，并用电凝止血。将腓肠神经移植于上皮神经缺损处。结果 5例均顺利取出腓肠神经，在放大10倍手术显微镜下观察，腓肠神经无明显损伤，患肢未发生血肿等并发症。结论 内窥镜镜视下取腓肠神经是安全的，并将常规手术要35－40cm的大切口可缩短为长2cm的2－3个小切口。     

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.     

切断一侧血管后腓肠肌供血的影像及应用解剖

目的 探讨切断腓肠肌内侧或外侧血管对腓肠肌血供的影响,为临床应用吻合腓肠肌血管的游离皮瓣修复下肢皮肤软组织缺损提供理论依据.方法 用造影剂泛影葡胺灌注16侧结扎腓肠肌内侧或外侧血管后的新鲜成人下肢腘血管,进行横断面血管切割点的统计学分析;观测腓肠肌血管及其分支、管径、蒂部和交通支情况;制备动脉管道铸型标本,观察腓肠肌血管的血管分布情况.结果 在切断一侧腓肠肌血管的情况下.有来自腓肠肌内、外侧头之间的交通支和来自比目鱼肌交通支的血液供应该侧腓肠肌,其中来自比目鱼肌的交通支管径较粗,但数量少,且多出现在腓肠肌肌腹下1/3的位置,位置较恒定.腓肠肌内、外侧头之间的交通支主要出现在腓肠肌中下1/3,与腓肠神经营养血管轴相交通,外径多在0.5 mm以下.结论 腓肠肌的血供为多源性,结扎腓肠肌的内侧或外侧动脉后,腓肠肌完全可以通过吻合支获得足够的血液供应.     

腓肠肌内侧头穿支动脉与腓肠神经营养血管联合蒂肌皮瓣的临床应用

目的 探讨腓肠肌内侧头穿支动脉与腓肠神经营养血管联合蒂肌皮瓣的临床应用效果.方法 自2006年2月至2010年3月,根据缺损部位及大小设计以腓肠肌内侧头穿支动脉与腓肠神经营养血管轴的联合蒂,沿腓肠肌内侧头血管轴切取皮瓣,顺行移位修复膑前及胫骨上段皮肤及软组织缺损7例.皮瓣切取范围8.0 cm×8.0 cm～12.0 cm×10.0 cm,联合血管蒂长1.8～3.0 cm,联合血管蒂发出位于腘褶皱以远10.0 ～ 17.0 cm,距后正中线2.0～5.0 cm的范围内.结果 6例伤口一期愈合.1例发生皮瓣远端表浅干性坏死,面积约1 cm×2 cm,经换药后逐渐愈合.随访6～ 15个月,无任何并发症,肌皮瓣质地优良,外观满意.结论 腓肠肌内侧头穿支动脉与腓肠神经营养血管联合蒂肌皮瓣手术操作简便,血供可靠且不牺牲主要动脉,切取面积大,转移距离长,为临床修复髌前及胫骨上段皮肤及软组织缺损提供了一种新方法.     

Surgical approaches to the calcaneus and the sural nerve: There is no safe zone

Background

Sural nerve related symptoms following the extensile lateral approach to the calcaneus (ELA) and the sinus tarsi approach (STA) are a known postoperative complication despite awareness of the course the sural nerve. While the main trunk of the sural nerve and its location relative to the approaches have been previously described, the nerve gives rise to lateral calcaneal branches (LCBs) and an anastomotic branch (AB) that may be at risk of injury. The purpose of this study was to describe the course of the sural nerve, its LCBs and the AB in relation to the ELA and STA.

Evidence of changes in sural nerve conduction mediated by light emitting diode irradiation

The introduction of light emitting diode (LED) devices as a novel treatment for pain relief in place of low-level laser warrants fundamental research on the effect of LED devices on one of the potential explanatory mechanisms: peripheral neurophysiology in vivo. A randomised controlled study was conducted by measuring antidromic nerve conduction on the peripheral sural nerve of healthy subjects (n=64). One baseline measurement and five post-irradiation recordings (2-min interval each) were performed of the nerve conduction velocity (NCV) and negative peak latency (NPL). Interventional set-up was identical for all subjects, but the experimental group (=32) received an irradiation (2 min at a continuous power output of 160 mW, resulting in a radiant exposure of 1.07 J/cm²) with an infrared LED device (BIO-DIO preprototype; MDB-Laser, Belgium), while the placebo group was treated by sham irradiation. Statistical analysis (general regression nodel for repeated measures) of NCV and NPL difference scores, revealed a significant interactive effect for both NCV (P=0.003) and NPL (P=0.006). Further post hoc LSD analysis showed a time-related statistical significant decreased NCV and an increased NPL in the experimental group and a statistical significant difference between placebo and experimental group at various points of time. Based on these results, it can be concluded that LED irradiation, applied to intact skin at the described irradiation parameters, produces an immediate and localized effect upon conduction characteristics in underlying nerves. Therefore, the outcome of this in vivo experiment yields a potential explanation for pain relief induced by LED.     

Alternatives to sural nerve grafts in the upper extremity

Background

The sural nerve is the most common nerve graft donor despite requiring a second operative limb and causing numbness of the lateral foot. The purposes of this study were to review our experience using nerve autografts in upper extremity nerve reconstruction and develop recommendations for donor selection.

Methods

A retrospective case series study was performed of all consecutive patients undergoing nerve grafting procedures for upper extremity nerve injuries over an 11-year period (2001–2012).

Results

Eighty-six patients received 109 nerve grafts over the study period. Mean patient age was 42.9 ± 18.3 years; 57 % were male. There were 51 median (59 %), 26 ulnar (30 %), 14 digital (13 %), 13 radial (16 %), and 3 musculocutaneous (4 %) nerve injuries repaired with 99 nerve autografts (71 from upper extremity, 28 from lower extremity). Multiple upper extremity nerve autograft donors were utilized, including the medial antebrachial cutaneous nerve (MABC), third webspace branch of median, lateral antebrachial cutaneous nerve (LABC), palmar cutaneous, and dorsal cutaneous branch of ulnar nerve. By using an upper-extremity donor, a second operative limb was avoided in 58 patients (67 %), and a second incision was avoided in 26 patients (30 %). The frequency of sural graft use declined from 40 % (n = 17/43) to 11 % (n = 7/64).

Conclusions

Our algorithm for selecting nerve graft material has evolved with our growing understanding of nerve internal topography and the drive to minimize additional incisions, maximize ease of harvest, and limit donor morbidity. This has led us away from using the sural nerve when possible and allowed us to avoid a second operative limb in two thirds of the cases.     

High resolution real time ultrasonography of the sural nerve after percutaneous repair of the Achilles tendon

Background

Percutaneous Achilles tendon repair has been developed to minimise soft tissue complications following treatment of tendon ruptures. However, there are concerns because of the risk of sural nerve injury. Few studies have investigated the relationship between the Achilles tendon, the sural nerve and its several anatomical course variants.

The influence of harvesting method on morphological changes in sural nerve graft and on the quality of motor and sensory recovery

The purpose of this study was to analyze morphological changes in the sural nerve which resulted from nerve harvesting using two methods; parallel transverse incisions (PTI) and longitudinal incisions (LI) and to evaluate the influence of those changes on the quality of sensory and motor recovery. Out of 617 patients with nerve injuries, 40 patients with an injury of the ulnar or median nerve in the distal part of the forearm and a nerve gap ranging from 4 to 6 cm were enrolled in this study. They were divided into two groups of 20 patients each. In group I the sural nerve was harvested using LI and in group II using PTI. Electron microscopy revealed considerable structural damage in the nerves harvested with PTI, while nerves harvested with LI showed little signs of damage. Patients in group I, in whom LI was used, also had better motor and sensory recovery.Presented at the 14th Annual Meeting of the European Association of Plastic Surgeons (EURAPS), Vienna, Austria, 29–31 May 2003     

保留腓肠神经的血管筋膜蒂皮瓣的解剖及临床研究

目的 研究保留腓肠神经的腓动脉穿支皮瓣的可行性、方法 及适应证,以改进常规腓肠神经营养血管皮瓣术后足外侧皮肤感觉障碍的缺陷. 方法 选择8具16个成人下肢标本,其中新鲜标本8个,经股动、静脉分别灌注红蓝色乳胶48 h后,解剖研究腓肠神经及小隐静脉伴行动脉的关系.临床应用保留腓肠神经主干或内、外侧支的血管筋膜皮瓣修复足踝皮肤缺损12例. 结果 腓肠神经及小隐静脉有各自的伴行血管,伴行血管与腓肠神经及小隐静脉的距离不恒定,在1～8哪之间,两条伴行血管相互交通.腓动脉最低穿支距踝尖12～32 min,平均22 mm,穿支直径1.0～1.5 mm,平均1.2mm.临床保留腓肠神经主干、内侧支或外侧支的皮瓣12例.术后4例腓肠神经支配区皮肤感觉正常;4例S2+～S3;2例外踝区域S0感觉消失,2例足外侧S1.经6～24个月的随访,4例S2+～S3于术后5～30 d恢复达基本正常. 结论 保留神经对保存足部皮肤感觉有积极的意义,腓肠神经及小隐静脉各有一条伴行动脉是保留神经的解剖基础.当营养血管绕过神经,很难分离神经时,可以术中放弃保留神经.     

The reverse sural artery neurocutaneous flap under combined sciatic and femoral nerve block for lower limb defects: a series of ten cases

The case of reverse sural artery neurocutaneous flap done for lower leg defects under combined sciatic and femoral nerve block is presented. Doing the flap using this method of anesthesia makes the positioning changes necessary during surgery easy. All flaps survived. Nine out of the ten blocks acted satisfactorily. The technique of giving the combined block is described in brief. The mean time of onset of action was 16.62 min, and the mean duration of action was 6.26 h using 1% Lidocaine with 1 in 200,000 adrenaline.