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.     

Innervation of calf muscles in relation to calf reduction

Plump and muscular calves, a so-called radish-like leg, embarrass young women and cause a feeling of inferiority in Korea. Damage to motor nerves innervating a muscle makes the muscle paralyzed and dystrophic, with loss of muscle volume. The authors studied the morphometry of the motor branches of the tibial nerve innervating the gastrocnemius and soleus muscle and sensory medial sural cutaneous nerve in popliteal fossa. Dissection and exploration of the tibial nerve were performed in the popliteal fossae of 70 legs (of 18 males and 17 females) of embalmed Korean cadavers. The main branch of the tibial nerve innervating medial and lateral gastrocnemius muscle originated 3 cm above and below the popliteal crease. The medial gastrocnemius muscle had an additional nerve (49%). The medial sural cutaneous nerve came off the nerve into the medial gastrocnemius muscle (30%) and diverged 5.5 mm from the tibial nerve. The nerve into the soleus muscle originated from the nerve innervating the lateral gastrocnemius muscle (30%) and was 12.3 mm away from it. Surgeons should keep in mind that the medial sural cutaneous nerve originates from the nerve to medial gastrocnemius in 30% and the nerve to soleus muscle originates from the nerve to lateral gastrocnemius in 30%.     

Die Musculus-gastrocnemius-Lappenplastiken

OBJECTIVE: Defect reconstruction by transposition of well-vascularized muscle (muscle flap) or muscle/skin tissue (myocutaneous flap). Reconstruction of missing muscle unit by free functional muscle transplantation. INDICATIONS: Treatment of first choice for defect coverage at the distal thigh, knee (including exposed and infected total knee prosthesis), and proximal lower leg. CONTRAINDICATIONS: Lesions of the popliteal artery. Concomitant lesion of the soleus muscle (impaired plantar flexion). SURGICAL TECHNIQUE: Proximally pedicled flap: the distal tendinous insertion of the medial and/or lateral gastrocnemius muscle at the Achilles tendon is cut. Vascularization is assured by the medial and lateral sural artery, respectively. - Muscle flaps (medial gastrocnemius, lateral gastrocnemius). - Muscle-skin (myocutaneous) flaps. Distally pedicled flap: the proximal tendinous origin of the medial or lateral gastrocnemius muscle is cut. Vascularization is assured by vascular anastomoses between the two muscles crossing the midline. Because of its unpredictable vascularization, especially after trauma, this technique is rarely used today. To improve arterial inflow, the cut sural artery can be anastomosed in microsurgical technique with an adequate arterial blood vessel at the recipient site. POSTOPERATIVE MANAGEMENT: Complete immobilization for 5-7 days (knee and ankle joints). Progressive increase of range of motion after 1 week (30 degrees /45 degrees /60 degrees /90 degrees ). Postoperative standardized compression therapy, combined with scar therapy (silicone sheet). RESULTS: Reliable, excellent functional and aesthetic results.     

The myofascial compartments of the foot: a cadaver study

Compartment syndrome of the foot requires urgent surgical treatment. Currently, there is still no agreement on the number and location of the myofascial compartments of the foot. The aim of this cadaver study was to provide an anatomical basis for surgical decompression in the event of compartment syndrome. We found that there were three tough vertical fascial septae that extended from the hindfoot to the midfoot on the plantar aspect of the foot. These septae separated the posterior half of the foot into three compartments. The medial compartment containing the abductor hallucis was surrounded medially by skin and subcutaneous fat and laterally by the medial septum. The intermediate compartment, containing the flexor digitorum brevis and the quadratus plantae more deeply, was surrounded by the medial septum medially, the intermediate septum laterally and the main plantar aponeurosis on its plantar aspect. The lateral compartment containing the abductor digiti minimi was surrounded medially by the intermediate septum, laterally by the lateral septum and on its plantar aspect by the lateral band of the main plantar aponeurosis. No distinct myofascial compartments exist in the forefoot. Based on our findings, in theory, fasciotomy of the hindfoot compartments through a modified medial incision would be sufficient to decompress the foot.     

Popliteal artery entrapment syndrome. Report of two cases

We treated two patients with popliteal artery entrapment syndrome. In one, the popliteal artery was entrapped and obstructed in its abnormal course around the medial head of the gastrocnemius muscle, which was inserted into the femur laterally and cephalad (type II in Delaney's classification). In the other patient, the popliteal artery followed a normal course but was compressed laterally by the medial head of the gastrocnemius muscle, which was aberrantly inserted into the femur considerably higher and more lateral than usual, and was occluded. This could not be fitted into Delaney's or Insua's classification. Arterial reconstruction was successful with an autovein graft in the former case and an in situ bypass graft in the latter. We suggest a modification of type IV in Delaney's classification, so that when the popliteal artery is compressed by an aberrant muscular or tendinous structure in the popliteal fossa it can be included.     

Osteosynthese einer bikondylären Tibiakopffraktur in Bauchlage

Objective

The aim of the surgical treatment of intra-articular bicondylar tibial plateau fractures is the anatomical reconstruction and direct biomechanical optimal fixation of the fractured articular surface and the leg axis, taking the frequently associated soft tissue damage into account.

Indications

This article presents a cadaver model of a simulated complex bicondylar tibial plateau fracture 41C3 according to the AO classification with fracture involvement of all 10 segments and indications for surgery due to a posteromedial shearing fracture and lateral articular destruction with posterolaterocentral impaction.

Contraindications

Pronounced soft tissue damage with acute or incompletely healed infections in the area of the surgical approach.

Surgical technique

In the presented video of the operation, which is available online, the direct treatment of an intra-articular complex tibial plateau fracture from dorsal in a prone position is shown in detail: posterolateral ca. 13?cm long skin incision immediately above the fibular head with subsequent gentle preparation of the peroneal nerve at the medial border of the biceps femoris muscle. Retraction of the lateral head of the gastrocnemius muscle medially. Proximal detachment of the soleus muscle from the fibular head and retraction of the popliteus muscle medially. Horizontal capsule incision for fracture visualization. Opening of the lateral window ventral to the lateral collateral ligament. If necessary, osteotomy of the lateral femoral epicondyle for improved posterolaterocentral fracture visualization. Angular stable osteosynthetic fixation. Posteromedial approach medial to the medial gastrocnemius head. Retraction of the medial head of the gastrocnemius muscle laterally, horizontal capsular incision with sparing of the semimembranosus muscle medially and posterior cruciate ligaments laterally, fracture reduction, fixation with posteromedial support plate, image converter control, wound closure.

Follow-up

Postoperative cooling and elevation of the operated limb. Depending on the fracture 6–10 weeks partial loading of maximum 20?kg. Prior to full load bearing clinical radiological follow-up checks to determine the bony consolidation and material positioning.

Results

This is an established and safe delivery strategy for complex fracture patterns with dorsally running fractures. The risk of intraoperative malreduction is low. Postoperative reduction losses depend on fracture, operation and especially patient-specific characteristics.

     

A gastrocnemius musculocutaneous flap.

The results of injection studies in cadavers and in vivo flap construction suggested that a flap based on the medial or lateral gastrocnemius muscle and the skin of the popliteal fossa draining to the long or short saphenous systems respectively provides a good length to breadth ratio flap without prior delay. Such a flap based on the medial gastrocnemius muscle was used successfully in 1 patient.     

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.     

The case against medial pectoral releases: a retrospective review of 315 primary breast augmentation patients

Although medial pectoral releases have been recommended as an important component of retropectoral breast augmentation surgery, there has been no study that documents the benefit or need for this potentially harmful surgical maneuver. In this study, 315 patients were retrospectively reviewed to determine the effect of medial pectoral muscle releases on breast implant position, visibility, and palpability. Five patients had incomplete data, leaving 310 patients available for photographic and clinical analysis at an average of 25.7 weeks postoperatively (range 5.61-91.6 weeks). All patients received textured, saline-filled, round, retropectoral implants. Group I (n = 163) had partial medial pectoral releases to the level of the superior aspect of the areola. Group II (n = 152) had no releases; however, retropectoral pocket dissection was extended medially to the arc of the median raphe, where the tendinous origins of the pectoralis major muscle are firmly anchored to the anterior aspect of the sternum. To assess implant position, the ratio of the intermammary space to the lateral breast protrusion (IMS/LBP) was compared for all patients. There was a greater decrease in the average IMS/LBP ratio in group II compared with group I, (P = 0.0315). This indicates that subpectoral mobilization to the arc of the median raphe afforded a proportionally decreased intermammary space, better medial envelope fill, and less lateral implant displacement when compared with medial pectoral releases. Five patients (3%, P = 0.014) developed breast implant visibility and palpability on the medial aspect of the breast mounds, and 2 patients (1.2%) developed hematomas in group I. One patient (0.6%) developed implant distortion with muscle flexion in group II. To explain these results, 6 pectoral muscles were dissected in 3 female cadavers. Above the fifth rib and below the clavicular head, the secure, tendinous origin of the pectoralis major muscle arises from the central anterior aspect of the sternum forming an "arc of the median raphe." This anatomic feature allows pectoral muscle mobilization medially, negating the need for division. Maintaining the integrity of the pectoral muscle affords decreased implant visibility and palpability medially and decreased patient morbidity while delivering possibly improved esthetic proportions by decreasing the intermammary space.     

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.     

Femoro-popliteal venous graft entrapment

The authors report a case of femoropopliteal venous bypass graft entrapped between the inner femoral condylar epiphysis and the medial head of the gastrocnemius muscle, the graft being inadvertently placed medially to this tendinous structure. What makes the case exceptional is that the indication for the venous bypass graft was a femoropopliteal thrombosis, secondary to an initially overlooked popliteal artery entrapment syndrome. In the discussion, the authors made an extensive review of the literature on this rare abnormal relationship between the popliteal artery and the medial head of the gastrocnemius (embryology, anatomical variations, clinical features, diagnostic measures and treatment).     

鼻唇沟区域解剖学研究

目的 对颌面整形美容外科提供形态学依据。方法 对20例成人新鲜尸头行10％福尔马林血管灌注固定后，在手术放大镜下进行形态学观测。结果 ①首次对少数国人与鼻唇沟区域相关的各表情肌逐块进行长、宽、厚的显微解剖测量。②测得鼻唇沟内侧脂肪厚度为1．3mm，外侧为4．5mm。③鼻唇沟内侧真皮层有肌纤维附着，外侧也有稀少肌束附着。④面部有浅肌肉宰不但存在腱膜，还由筋膜、肌肉、腱膜共同构成一个立体网状结构。结论 进一步证实了有关SMAS中央腱的理论假说。     

鼻唇沟区域解剖学研究

目的对颌面整形美容外科提供形态学依据。方法对２０侧成人新鲜尸头行１０％福尔马林血管灌注固定后,在手术放大镜下进行形态学观测。结果①首次对少数国人与鼻唇沟区域相关的各表情肌逐块进行长、宽、厚的显微解剖测量。②测得鼻唇沟内侧脂肪厚度为１３ｍｍ,外侧为４５ｍｍ。③鼻唇沟内侧真皮层有肌纤维附着,外侧也有稀少肌束附着。④面部表浅肌肉之间不但存在腱膜,还由筋膜、肌肉、腱膜共同构成一个立体网状结构。结论进一步证实了有关ＳＭＡＳ中央腱的理论假说。     

Spigelian hernia: surgical anatomy, embryology, and technique of repair

Spigelian hernia (1-2% of all hernias) is the protrusion of preperitoneal fat, peritoneal sac, or organ(s) through a congenital or acquired defect in the spigelian aponeurosis (i.e., the aponeurosis of the transverse abdominal muscle limited by the linea semilunaris laterally and the lateral edge of the rectus muscle medially). Mostly, these hernias lie in the "spigelian hernia belt," a transverse 6-cm-wide zone above the interspinal plane; lower hernias are rare and should be differentiated from direct inguinal or supravescical hernias. Although named after Adriaan van der Spieghel, he only described the semilunar line (linea Spigeli) in 1645. Josef Klinkosch in 1764 first defined the spigelian hernia as a defect in the semilunar line. Defects in the aponeurosis of transverse abdominal muscle (mainly under the arcuate line and more often in obese individuals) have been considered as the principal etiologic factor. Pediatric cases, especially neonates and infants, are mostly congenital. Embryologically, spigelian hernias may represent the clinical outcome of weak areas in the continuation of aponeuroses of layered abdominal muscles as they develop separately in the mesenchyme of the somatopleura, originating from the invading and fusing myotomes. Traditionally, repair consists of open anterior herniorraphy, using direct muscle approximation, mesh, and prostheses. Laparoscopy, preferably a totally extraperitoneal procedure, or intraperitoneal when other surgical repairs are planned within the same procedure, is currently employed as an adjunct to diagnosis and treatment of spigelian hernias. Care must be taken not to create iatrogenic spigelian hernias when using laparoscopy trocars or classic drains in the spigelian aponeurosis.     

Compensatory Hypertrophy of Calf Muscles After Selective Neurectomy

Background Unexpected contour changes frequently occurred after surgical contouring of the calves by selective neurectomy of the nerve to the medial gastrocnemius muscle. We recently experienced a rather unusual case, in which the nerve to the medial gastrocnemius muscle was selectively transected on one side, whereas on the other side, the nerve to the soleus was transected by mistake. Methods To investigate the reason for the contour change, the authors compared the muscle volume ratio of the posterior compartment of eight normal calves of eight normal volunteers with two calves in the reported case by using MRIs. Results The volume ration of normal control calves was 0.22:0.12:0.66, respectively, for the medial and lateral gastrocnemius muscles and the soleus muscle. In the case of the calf with atrophy of the medial gastrocnemius muscle, the volume ratio was 0.13:0.20:0.67, respectively. In the case of the calf with atrophy of the soleus muscle, the volume ratio was 0.27:0.14:0.59, respectively. Conclusions Physician and the patient should keep in mind before the operation that even though one muscle in the calf is selectively atrophied after the selective neurectomy, the other muscles can hypertrophy for compensation, thus causing possible distortion of aesthetic result.     

Physiological cross-sectional area of human leg muscles based on magnetic resonance imaging.

Magnetic resonance imaging techniques were used to determine the physiological cross-sectional areas (PCSAs) of the major muscles or muscle groups of the lower leg. For 12 healthy subjects, the boundaries of each muscle or muscle group were digitized from images taken at 1-cm intervals along the length of the leg. Muscle volumes were calculated from the summation of each anatomical CSA (ACSA) and the distance between each section. Muscle length was determined as the distance between the most proximal and distal images in which the muscle was visible. The PCSA of each muscle was calculated as muscle volume times the cosine of the angle of fiber pinnation divided by fiber length, where published fiber length:muscle length ratios were used to estimate fiber lengths. The mean volumes of the major plantarflexors were 489, 245, and 140 cm3 for the soleus and medial (MG) and lateral (LG) heads of the gastrocnemius. The mean PCSA of the soleus was 230 cm2, about three and eight times larger than the MG (68 cm2) and LG (28 cm2), respectively. These PCSA values were eight (soleus), four (MG), and three (LG) times larger than their respective maximum ACSA. The major dorsiflexor, the tibialis anterior (TA), had a muscle volume of 143 cm2, a PCSA of 19 cm2, and an ACSA of 9 cm2. With the exception of the soleus, the mean fiber length of all subjects was closely related to muscle volume across muscles. The soleus fibers were unusually short relative to the muscle volume, thus potentiating its force potential.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical anatomy of the gastrocnemius recession (Strayer procedure)

BACKGROUND: The Strayer procedure (gastrocnemius recession) is a treatment option for patients with clinically relevant gastrocnemius equinus contracture. The purpose of this study was to review the surgical anatomy of the Strayer procedure with specific reference to 1) the location of the sural nerve, and 2) the gastrocnemius tendon release point. METHODS: Forty consecutive Strayer procedures in 33 patients (15 males, 18 females) served as the study group. Recorded measurements included: 1) the location of the sural nerve relative to the deep fascia, 2) the distance from the medial border of the gastrocnemius tendon to the sural nerve, and 3) the distance from the distal end of the gastrocnemius muscle belly (identified by surface landmarks) to the actual release site. RESULTS: At the point of the gastrocnemius release, the sural nerve was located superficial to the fascia in 17/40 legs (42.5%) and deep to the fascia in 23/40 legs (57.5%). In five legs (12.5%), the nerve was directly applied to the gastrocnemius tendon and needed to be gently dissected off the tendon. The gastrocnemius release point was located an average of 18 mm distal (range, 20 mm proximal to 57 mm distal) to the surface landmark created by the distal extent of the gastrocnemius muscle belly. CONCLUSION: Knowledge of the relevant anatomy associated with the gastrocnemius recession should allow surgeons to minimize the rate of sural nerve injuries and improve cosmesis by decreasing the length of the surgical incision. A posteromedial incision that begins 2 cm distal to the gastrocnemius indentation and extends proximally will minimize the length of the incision required.     

Joint space width of the tibiofemoral and of the patellofemoral joint in chronic knee pain with or without radiographic osteoarthritis: a 2-year follow-up

OBJECTIVES: To assess the interval change of the minimal joint space width (MJS) in radiographs of the tibiofemoral (TF) joint and of the patellofemoral (PF) joint with a 2-year follow-up in middle-aged people with longstanding knee pain with or without radiographic osteoarthritis (OA) and to study the precision of the MJS measurements. DESIGN: In the format of a prospective study of early OA the signal knee in 55 people, 28 men and 27 women (aged 41-57 years, median 50), with chronic knee pain at inclusion was examined with a 2-year interval (median 25 months, range 21-30). The MJS of the TF joint was measured using a flexed PA view in weightbearing and the MJS of the PF joint using an axial view in standing. RESULTS: The MJS of the TF joint decreased medially by 0.056+/-0.44mm (n.s.) and increased laterally by 0.080+/-0.51mm (n.s.) during the time of observation. In knees with an MJS medially that was less or the same as compared with the lateral compartment, the MJS decreased by 0.14+/-0.38mm (p=0.038) and in a subgroup of these knees, without osteophytes, the MJS decreased by 0.14+/-0.27mm (p=0.018). The MJS of the PF joint decreased by 0.019mm (n.s.) during the time of observation. The coefficient of variation for intra- and interobserver MJS measurements of the TF joint was 1.0 and 1.1% medially and 2.3 and 2.7% laterally, and for measurement error 6.9% medially and 4.8% laterally, respectively. The coefficient of variation for intra- and interobserver MJS measurements of the PF joint was 8.1 and 5.8% medially and 7.5 and 10.1% laterally and for the measurement error it was 8.1% medially and 8.5% laterally, respectively. CONCLUSIONS: A statistically significant reduction of the MJS was only demonstrated in the medial compartment of the TF joint in those individuals who had an MJS in this compartment which was less or the same as compared with the lateral compartment as well as in a subgroup of these knees without osteophytes. The radiographic examinations and the MJS measurements were reproducible.     

Les lambeaux musculaires pédiculés

Muscle pedicle flaps are extremely useful for covering open fractures to provide a blood supply and replace loss of substance. Our experience is based on 44 flaps (26 done as an emergency) or which 5 failed. As an emergency the medial gastrocnemius (or possibly the lateral gastrocnemius) is the most used for tissue loss in the proximal third of the leg. Use of the overlying aponeurosis and skin allows to increase the radius of rotation to the middle third but with less effectiveness and more important sequellae. The soleus, either all of it or its medial half, allows cover to the middle third of the leg. Plexor digitorum longus, although more difficult to develop, allows one to cover the lower quarter of the leg.     

Flexion-extension gap changes during total knee arthroplasty: effect of posterior cruciate ligament and posterior osteophytes removal

Flexion and extension gap heights were measured in 50 consecutive primary posterior-stabilized total knee arthroplasties (TKAs) to determine whether posterior cruciate ligament (PCL) release or re-establishment of the posterior condylar recess increased gap width. After PCL release, a slight symmetrical increase was noted in both gaps. In extension, gap width increased on average 1.3 mm and 1 mm in the medial and lateral compartments, respectively. The same pattern was observed in flexion, averaging 1.3 mm medially and 1.3 mm laterally. Another increase in the two gaps was observed after the posterior condylar osteophytes were removed and the posterior recess was re-established. The gaps in extension increased, with respect to the base-line value, on average 1.8 mm medially and 1.8 mm laterally, whereas flexion increased an average 2 mm medially and 2.2 mm laterally. No statistical differences were noted between flexion and extension gaps. No independent differences between the flexion and extension gaps were found in any surgical phase. Posterior cruciate ligament removal and re-establishment of posterior condylar recess does not require additional consideration in gap balancing during posterior-stabilized TKA.