Understanding And Managing Equinus Deformities

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Author(s): 
Stephen L. Barrett, DPM, MBA, FACFAS

What You Should Know About Performing An Endoscopic Gastrocnemius Recession

The advantages of the endoscopic approach to gastrocnemius recession are not only limited to the lesser invasive nature of the procedure but also to the fact that one can easily perform it with the patient in the supine position, and it does not increase intraoperative time for the surgeon. I have previously described my surgical technique using the Endotrac system (Instratek).4 There have been relatively few technique changes since then. However, as with any surgical technique, increased surgical experience combined with critical assessment has led to more refinements, which I have learned both in teaching the technique as well as performing it.

   Since exact precision is required for ideal anatomical placement of the endoscopic instrumentation in any endoscopic surgical technique to afford maximum outcomes, there are a couple of pearls that can aid the surgeon. In a 2005 publication, we presented results from a cadaveric anatomic study of 28 embalmed specimens.15 We were able to describe an “endoscopic zone” for proper placement of the cannula for an endoscopic gastrocnemius recession. It should be noted that in contrast to endoscopic decompression of intermetatarsal nerves and endoscopic plantar fasciotomy, there is more latitude for placement of the endoscopic gastrocnemius recession instrumentation while still being able to perform the procedure successfully.16-19

   The surgical technique should begin with appreciation of the topical anatomy with palpation of the “edge” of the medial aspect of the gastrocnemius aponeurosis on the medial aspect of the calf within the “endoscopic zone.” This is where one should place the medial portal incision. Separation with blunt dissection of the subcutaneous fat allows the surgeon to palpate the dense tissue of the aponeurosis.

   Usually, there is minimal (2 to 5 mm) subcutaneous fat between the dermis and this tissue plane. In some patients, there is virtually no subcutaneous tissue and the passage of the instrumentation feels like it is just below the skin. After establishing this surgical plane, one can use an elevator to separate the subcutaneous fat from the superficial surface of the aponeurosis.

   Performing this step judiciously facilitates maximum protection of the sural nerve from injury. However, the surgeon must take caution as nerve injury can occur even with the most exact and refined surgical technique. Considering that this is only a cutaneous nerve with a small amount of innervation, and that it is the biopsy and donor nerve of choice, the risk is relatively small in comparison to the maximal benefit of improvement in biomechanics for the patient.

   True sural nerve injury occurs only rarely, almost always without any sequelae except for “numbness,” but the patient can end up with an amputation neuroma, which could require revision surgery. Neuropraxia of the sural nerve is common. However, due to the subsequent traction of the sural nerve with the increased range of dorsiflexion, this is almost always transient and fades within six to eight weeks.

   Once you have placed the instrumentation, it is recommended to begin the transection of the aponeurosis from medial to lateral as there is often only a need for a medial one-third release to reach the desired level of dorsiflexion. If more tissue is required to be cut, it can be based on the intraoperative assessment by the surgeon. Many times, in severe cases, it has been my experience that a complete medial to lateral release is needed.

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Neal M. Blitz, DPM, FACFASsays: May 14, 2011 at 7:41 pm

I am not sure that endoscopic gastroc recessions should be termed "gastroc recessions." They are really gastrosoleal recessions.

Anatomically, the gastroc muscles form an muscular-free aponeurosis that inserts onto the soleus aponeurosis and together form the Achilles. The muscular free portion of the gastroc is termed the "gastroc run-out." In some cases, there is no run-out and the gastroc muscle inserts directly on the soleus aponeurosis.

Nonetheless, if you transect deep to muscle, then both the gastroc and soleus aponeurosis have been transected.

The clinical effect is unclear, but the anatomy is the anatomy.

Neal M. Blitz, DPM, FACFAS
Chief of Foot Surgery & Associate Chairman of Orthopaedics
Bronx-Lebanon Hospital Center
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References:

Blitz NM, Eliot DJ. Anatomical Aspects of the Gastrocnemius Aponeurosis and its Muscular-Bound Portion. A Cadaveric Study. Part II. J Foot Ankle Surg 47(6):533-40, 2008

Blitz NM, Rush SM. The Gastrocnemius Intramuscular Aponeurotic Recession. A Simplified Method of Gastrocnemius Recession. J Foot Ankle Surg 46(2):133-8, 2007

Blitz NM, Eliot DJ. Anatomical Aspects of the Gastrocnemius Aponeurosis and its Insertion. A Cadaveric Study. J Foot Ankle Surg 46(2):101-8, 2007

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