Proximal Medial Gastrocnemius Recession for Recalcitrant Plantar Fasciitis.

BACKGROUND: Recalcitrant plantar fasciitis (RPF) is characterized by its unresponsiveness to conservative treatments, and its surgical management remains controversial. Although there is some evidence to suggest that gastrocnemius recession can be an effective treatment for RPF, no large series of patients with mid- to long-term follow-up has been published. The objective of this study was to compare physical performance, as measured by the Foot and Ankle Ability Measure activities of daily living score (FAAM-ADL), and pain levels before and 1 year after undergoing proximal medial gastrocnemius recession (PMGR) as a treatment for RPF. Additionally, we aimed to assess this cohort of patients in the mid- to long-term follow-up. METHODS: This retrospective cohort study included 167 patients who underwent PMGR to address RPF between 2009 and 2021. Patients were examined with the FAAM ADL, visual analog scale (VAS) and satisfaction scores at baseline, 1 year, and at the end of follow-up. Other variables recorded were weight, duration of symptoms until surgery, time between surgery to substantial clinical improvement, calf power and Silfverskiold test, and postoperative complications. RESULTS: We observed that before surgery patients had an FAAM-ADL score of 22.5 (SD 11.1) and a VAS score of 8.6 (SD 9.3). One year after surgery, patients had an FAAM-ADL score of 89 (SD 17) and VAS of 1.33 (SD 2) (P < .01). We also observed that the FAAM-ADL score in the long-term follow-up (>12.5 years) group had a median of 86.4 (SD 22.6), the VAS score was 1.90 (SD 2.84), and the patient satisfaction score had a median of 1 (interquartile range 0-1). Regarding complications, we observed 1 lateral gastrocnemius recession and 1 sural nerve neuritis. CONCLUSION: Our study provides substantial evidence supporting the use of PMGR as an effective treatment for RPF. The long-term follow-up and large sample size of our series contribute to the existing literature on this topic.

Needle­based gastrocnemius lengthening: a novel ultrasound­guided noninvasive technique: part II-clinical results.

BACKGROUND: Isolated gastrocnemius contracture has been associated with more than 30 lower limb disorders, including plantar heel pain/plantar fasciitis, Achilles tendinosis, equinus foot, adult flatfoot, and metatarsalgia. Although many techniques are available for gastrocnemius recession, potential anesthetic, cosmetic, and wound-related complications can lead to patient dissatisfaction. Open and endoscopic recession techniques usually require epidural or general anesthesia, exsanguination of the lower extremities and stitches and can damage the sural nerve, which is not under the complete control of the surgeon at all stages of the procedure. The purpose of this study is to evaluate the clinical results of a surgical technique for gastrocnemius lengthening with a needle, as previously described in cadaver specimens. METHODS AND RESULTS: We performed a prospective study of ultrasound-guided gastrocnemius tendon lengthening in level II using a needle in 24 cases (19 patients) of gastrocnemius contracture. The study population comprised 12 males and 7 females. Mean age was 41 years (18-64). All but 5 recessions were bilateral and occurred simultaneously. The indication for the procedure was gastrocnemius contracture; although the patients also presented other conditions such as non-insertional Achilles tendinopathy in 6 patients (2 were bilateral), insertional Achilles calcifying enthesitis in 4 (1 was bilateral), metatarsalgia in 4, flexible flat foot in 1 and plantar fasciitis in 5 (2 were bilateral). The inclusion criteria were the failure of a previous conservative protocol, that the Silfverskiöld test was positive, and that the pathology suffered by the patient was within the indications for surgical lengthening of the patients and were described in the scientific literature. The exclusion criteria were that the inclusion criteria were not met, and patients with surgical risk ASA 3 or more and children. In these patients, although possible, it is preferable to perform the procedure in the operating room with monitoring, as well as in children since they could be agitated during the procedure at the office. We used the beveled tip of an Abbocath needle as a surgical scalpel. All patients underwent recession of the gastrocnemius tendon, as in an incomplete Strayer release. We evaluated pre- and postoperative dorsiflexion, outcomes, and procedural pain (based on a visual analog scale and the American Orthopedic Foot and Ankle Society scores), as well as potential complications. No damage was done to the sural bundle. RESULTS: Ankle dorsiflexion increased on average by 17.89°. The average postoperative visual analog score for pain before surgery was 5.78, 5.53 in the first week, 1.89 at 1 month, and 0.26 at 3 months, decreasing to 0.11 at 9 months. The mean postoperative American Orthopedic Foot and Ankle Society Ankle-Hindfoot score the average was 50.52 before surgery, 43.42 at 1 week, 72.37 at 1 month, 87.37 at 3 months, and 90.79 at 9 months. CONCLUSION: Ultrasound-guided needle lengthening of the gastrocnemius tendon is a novel, safe, and effective technique that enables the surgeon to check all the structures clearly, thus minimizing the risk of neurovascular damage. The results are encouraging, and the advantages of this approach include absence of a wound and no need for stitches. Recovery is fast and relatively painless. A specific advantage of ultrasound-guided needle lengthening of the gastrocnemius tendon is the fact that it can be performed in a specialist's office, with a very basic instrument set and local anesthesia, thus reducing expenses.

Alteration of the calf strength by heel cord lengthening, gastrocnemius recession through tenotomy or fasciotomy. A retrospective clinical force analysis before and after surgery.

BACKGROUND: Indications for surgical corrections about the Achilles tendon are increasing as additional measures in reconstructive interventions about the foot. These indications include shortened gastrocnemii, which cause a so-called 'functional pes equinus' and secondary forefoot imbalances, as well as corrections of pes planus and cavus. Surgery about the heel cord may also be indicated for achillodynia and diabetic pressure ulcers. However, there is a lack of evidence that quantifies the results of lengthening procedures about the heel cord. The aim of this study was to quantify the exact changes in calf strength one year after elongating the triceps surae, by measuring flexion forces in 90 degrees knee flexion and knee extension. METHODS: This study involves 69 patients who were examined for calf strength preoperatively and 1 year after gastrocnemius release. A new device, the Leonardo Mechanograph® (Novotec Medical) was used to measure calf strength. Measurements were performed with the knee flexed and extended. RESULTS: The operated leg had an overall statistically significant reduction in strength after surgery. Changes were similar on the contralateral leg. The difference in force reduction between the operated and non-operated leg was not statistically significant CONCLUSION: A correlation between measured plantar flexion forces of the foot after a reconstructive foot operation with or without a lengthening procedure about the calf musculature could not be established. LEVEL OF EVIDENCE: Level III: retrospective cohort study.

Outcomes After Proximal Medial Gastrocnemius Recession and Stretching vs Stretching as Treatment of Chronic Plantar Fasciitis at 6-Year Follow-up.

BACKGROUND: Evidence from prospective short-term studies suggest that proximal medial gastrocnemius recession is a safe and efficient procedure to treat chronic plantar fasciitis resistant to nonoperative treatment. The aim of this study was to evaluate the long-term clinical outcomes of proximal medial gastrocnemius recession and stretching compared to a stretching exercise protocol for patients with chronic plantar fasciitis and an isolated gastrocnemius contracture (IGC). METHODS: Forty patients with plantar fasciitis lasting more than 1 year were prospectively randomized to a home stretching exercise program only, or to proximal medial gastrocnemius recession in addition to the stretching program. Clinical and functional data in this study were obtained at baseline and 6-year follow-up. The main outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. Secondary outcomes were the visual analog scale (VAS) for pain, the Manchester Oxford Foot Questionnaire (MOxFQ), ankle dorsiflexion, and Achilles complex performance. RESULTS: Thirty-three of 40 patients completed the 6-year follow-up. Seven patients had crossed over from nonoperative treatment to operative treatment. At 6 years, the operative group demonstrated significantly better outcomes with AOFAS (88.9 vs 78.6, P = .012), for pain measured by VAS (2.5 vs 5.5, P < .001) and with the MOxFQ total score (24.4 vs 45.9, P = .05) (per protocol analysis excluding crossovers). No between-group differences were observed for ankle dorsiflexion or Achilles complex performance at 6 years. CONCLUSION: This study demonstrates that the improved function and reduced level of pain by proximal medial gastrocnemius recession and stretching is better compared to stretching alone after 6 years of follow-up for patients with chronic plantar fasciitis and a concomitant isolated gastrocnemius contracture. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Outcomes of Isolated Open Gastrocnemius Recession for the Treatment of Chronic Insertional Achilles Tendinopathy: A Retrospective Cohort Study.

BACKGROUND: Insertional Achilles tendinopathy (IAT) is a common condition causing pain and dysfunction. Patients with diabetes, hyperlipidemia, hypothyroidism, and obesity are at increased risk of developing IAT. These comorbidities also carry an increased risk of wound healing complications following surgery. Therefore, there is a need for alternative management strategies for this high-risk patient population. This study investigated the potential role of isolated GR in patients with chronic IAT. METHODS: This study is a single-institution retrospective review of adult patients who underwent isolated GR to address chronic IAT with a minimum 1-year follow-up. Demographics, complications, radiographic findings, and preoperative and postoperative patient-reported outcome scores (PROs) were collected. The primary outcome was improvement in PROMIS scores from preoperative to postoperative. Secondary outcomes were complication and reoperation rates. RESULTS: Sixteen patients underwent open GR with a mean follow-up of 2.7 years. Postoperative PROMIS domain scores improved significantly from preoperative scores for physical function, pain interference, pain intensity, and global physical function. Two patients (13%) underwent reoperation (open calcaneal exostectomy and tendon debridement) at a mean time of 7 months from gastrocnemius recession. One patient developed a postoperative hematoma that resolved with conservative management. CONCLUSION: This single-institution series reports on a small cohort of patients with chronic IAT treated with open GR. We found significant improvement in patient-reported outcomes. Rates of complication and reoperation were low. This study supports the potential use of isolated gastrocnemius recession in IAT patients who, because of age or medical comorbidities, may benefit from a less invasive surgery and faster rehabilitation. LEVEL OF EVIDENCE: Level III, retrospective case control study.

Isolated Gastrocnemius Contraction and Gastroc Recession Surgery in Case of Planter Fasciitis: A Systemic Review and Meta-Analysis.

Objective: The current systematic and meta-static review aimed to analyze the correlation between isolated gastrocnemius contracture and plantar fasciitis and the effectiveness of gastroc recession surgery in the treatment of plantar fasciitis. Methodology: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to conduct this meta-analysis. A literature search was carried out on the following databases, including Google Scholar, PubMed, EMBASE, and the Cochrane databases with the appropriate medical subject headings (MeSH) to identify the eligible articles. Results: A total of 13 studies were included in this meta-analysis. In this study, there is a significant difference in chronic plantar fasciitis outcome when comparing experimental and control (RR: 0.02; 95% CI: 0.01 to 0.05; P < 0.001; I2 = 29%). There is a significant difference in pain scale outcome when comparing pre-treatment and post-treatment (RR: 3.25; 95% CI 1.44 to 7.32; P = 0.004 < 0.01; I2 = 0%). A significant difference in VAS scale outcome when comparing pre-treatment and post-treatment (RR: 2.58; 95% CI 1.52 to 4.38; P = 0.0004 < 0.01; I2 = 0%). Conclusion: In conclusion, the current systematic review and meta-analysis of gastrocnemius recession and proximal medial gastrocnemius release and other treatment measures for plantar fasciitis suggests that the improvement of ankle dorsiflexion, reduction in pain, and patient satisfaction are almost similar in all the treatment measures. Among the five treatment measures, gastrocnemius recession remains the best, followed by proximal medial gastrocnemius release.

Factors Associated With Poor Patient-Reported Outcomes in Isolated Gastrocnemius Recession for Heel Pain.

Background: Gastrocnemius recession is commonly performed for a variety of pathologies of the foot and ankle, yet studies characterizing risk factors associated with patient-reported outcomes are limited. In this cohort study, patient outcomes were compared against the general population for PROMIS scores with correlation analysis comparing demographics and comorbidities. Our primary goal in this study is to identify risk factors associated with poor patient-reported outcomes following isolated gastrocnemius recession for patients with plantar fasciitis or insertional Achilles tendinopathy. Methods: A total of 189 patients met inclusion criteria. The open Strayer method was preferred. However, if the myotendinous junction could not be adequately visualized without expanding the excision, then a Baumann procedure was performed. The decision between the two did not depend on preoperative contracture. Patient demographics and visual analog scale (VAS) scores were obtained via the electronic medical record. Telephone interviews were completed to collect postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) and Foot Function Index (FFI) scores. The data were analyzed using the type 3 SS analysis of variance test to identify individual patient factors associated with reduced PROMIS, FFI, and VAS scores. Results: No demographic variables were found to be significantly associated with postoperative complications. Patients who reported tobacco use at the time of surgery had significantly decreased postoperative PROMIS physical function (P = .01), PROMIS pain interference (P < .05), total FFI scores (P < .0001), and each individual FFI component score. Patients undergoing their first foot and ankle surgeries reported numerous significant postoperative outcomes, including decreased PROMIS pain interference (P = .03), higher PROMIS depression (P = .04), and lower FFI pain scores (P = .04). Hypertension was significantly associated with an increased FFI disability score (P = .03) and, along with body mass index (BMI) >30 (P < .05) and peripheral neuropathy (P = .03), significantly higher FFI activity limitation scores (P = .01). Pre- and postoperative VAS scores demonstrated improvement in patient-reported pain from a mean of 5.53 to 2.11, respectively (P < .001). Conclusion: We found in this cohort that numerous patient factors were independently associated with differences in patient-reported outcomes following a Strayer gastrocnemius recession performed for plantar fasciitis or insertional Achilles tendinopathy. These factors include, but are not limited to, tobacco use, prior foot and ankle surgeries, and BMI. This study strengthens previous reports demonstrating the efficacy of isolated gastrocnemius recession and elucidates variables that may affect patient-reported outcomes. Level of Evidence: Level III, retrospective cohort study.

PROMIS Scores for Plantar Fasciitis Before and After Gastrocnemius Recession.

BACKGROUND: There has been an established relationship between increased loading on the Achilles tendon and tension on the plantar fascia. This supports the idea that either tight gastrocnemius and soleus muscles or contractures of the Achilles tendon are risk factors for plantar fasciitis. Gastrocnemius recession has gained popularity as a viable surgical intervention for cases of chronic plantar fasciitis due to isolated gastrocnemius contracture. To our knowledge, this is the first study to investigate Patient-Reported Outcome Measurement Information Systems (PROMIS) scores in patients with plantar fasciitis before and after gastrocnemius recession. METHODS: The Electronic Medical Record was queried for medical record numbers associated with Current Procedural Terminology code 27687 (gastrocnemius recession). Our study included all patients with a preoperative diagnosis of chronic plantar fasciitis with treatment via isolated gastrocnemius recession with 1-year minimum follow-up. Forty-one patients were included in our study. Patient variables were collected via chart review. Preoperative and postoperative PROMIS scores were collected in the clinic. RESULTS: We followed up 41 patients with a median age of 48 years (interquartile range [IQR] 38-55) and median body mass index of 29.02 (IQR 29.02-38.74) for 1 year post surgery. Preoperative and postoperative PROMIS scores improved for physical function from 39.3 to 44.5 (P = .0005) and for pain interference from 62.8 to 56.5 (P = .0001). PROMIS depression scores were not significantly different (P = .6727). Visual analog scale (VAS) scores significantly decreased from 7.05 to 1.71 (P < .0001). CONCLUSION: In this case series, we found the gastrocnemius recession to be an effective option for patients with refractory pain in plantar fasciitis. Our PROMIS and VAS data confirm this procedure's utility and highlight its ability to significantly decrease pain and improve physical function in patients with chronic plantar fasciitis, although final median scores did not reach normative standards for the population, suggesting some residual pain and/or dysfunction was, on average, present. Based on the results of this study, the authors conclude that gastrocnemius recession is a reasonable treatment option for chronic plantar fasciitis patients who fail nonoperative management. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The Role of Equinus in Flatfoot Deformity.

Equinus plays an important role in flatfoot deformity. Proper evaluation and surgical management are critical to comprehensively treat and successfully resolved patients' symptoms. We have discussed the cause, evaluation, and some of the common surgical options. Each procedure has its inherent benefits and risks. It is imperative that the foot and ankle surgeon identify and include these procedures as part of the complete reconstructive surgery.

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.

Tibiopedal Motion Following Tendo-Achilles Lengthening or Gastrocnemius Recession in Total Ankle Replacement: A Comparative Cohort Study.

BACKGROUND: End-stage ankle arthritis is a debilitating condition often necessitating total ankle replacement (TAR). Tendo-Achilles lengthening (TAL) and gastrocnemius recession (GR) are commonly performed with TAR to improve ankle dorsiflexion (DF). No studies to date have radiographically analyzed tibiopedal motion to guide surgical management. The purpose of this study is to determine the effect of a TAL or GR during TAR on radiographic tibiopedal range of motion (ROM). METHODS: A retrospective review of a prospectively maintained database was conducted followed by a propensity score-matched analysis of 110 patients who underwent TAL (n = 26), GR (n = 29), or no lengthening procedure (n = 55) with TAR. Minimum of 1-year ROM radiographic follow-up was required. Exclusion criteria included (1) calcaneal osteotomies, (2) simultaneous or previous hindfoot or midfoot arthrodesis, (3) prior ankle arthrodesis, or (4) revision TAR. Demographic data were extracted from the TAR database. Radiographic assessment included tibiopedal dorsiflexion (DF) and plantarflexion (PF). RESULTS: DF improved by 2.8 degrees (P = .0286) and by 6.0 degrees (P < .0001) in the TAL and GR cohorts, respectively, with no difference in the control group (+0.7 degrees, P = .3764). PF was decreased by 4.5 degrees (P = .0152) and by 7.2 degrees (P = .0002) in the TAL and GR cohorts, respectively, with no difference in the control group (-0.2 degrees, P = .8546). Minimal differences were observed for total arc of motion for all 3 groups (control 0.5 degrees, GR -1.2 degrees, TAL -1.7 degrees), all of which were nonsignificant (all P > .05). There was no between-group difference in the change in overall arc of motion between the groups (P = .3599). GR resulted in a greater increase in DF (6.0 vs 2.8 degrees; P = .1074), with a reciprocal greater decrease in PF (7.2 vs 4.5 degrees; P = .2416) compared with the TAL cohort. CONCLUSION: Both TAL and GR increased postoperative DF; however, this was accompanied by a reciprocal loss in PF. Minimal differences were observed for total arc of motion. Patients should be counseled that concomitant procedures performed to increase DF will do so at the expense of PF. LEVEL OF EVIDENCE: Level III, retrospective review of prospectively collected data.

Triceps Surae Lengthening in Foot and Ankle Trauma: A Survey of OTA and AOFAS Members.

Background: The prevalence, indications, and preferred methods for gastrocnemius recession and tendo-Achilles lengthening-grouped as triceps surae lengthening (TSL) procedures-in foot and ankle trauma are supported by a scarcity of clinical evidence. We hypothesize that injury, practice environment, and training heritage are significantly associated with probability of performing adjunctive TSL in the operative management of foot and ankle trauma. Methods: A survey was distributed to members of the American Orthopaedic Foot & Ankle Society and the Orthopaedic Trauma Association. Participants rated how likely they would be to perform TSL at initial management, definitive fixation, and after weightbearing in the presence and absence of a positive Silfverskiöld test in 10 clinical scenarios of closed foot and ankle trauma. Results: A total of 258 surgeons with median 14 years' experience responded. Eighty-five percent reported foot and ankle fellowship training, 24% reported traumatology fellowship training, 13% both, and 4% no fellowship. Ninety-nine percent reported performing TSL with a median 25 TSL procedures per year, 72% open gastrocnemius recession, and 17% percutaneous tendo-Achilles lengthening). Across all scenarios, we observed low overall 8% probability with fair agreement (κ = 0.246) of performing TSL (range, 1% at initial management of an unstable Weber B bimalleolar ankle fracture with negative contralateral Silfverskiöld test to 29% at definitive fixation of tongue-type calcaneus fracture with positive contralateral Silfverskiöld test). Silfverskiöld testing significantly influenced TSL probability at all time points. University of Washington training (ß = 1.5, P = .007) but not trauma vs foot fellowship training, years in practice, academic practice, urban setting, or facility trauma designation were significantly associated with likelihood of performing TSL. Conclusion: Orthopaedic traumatology and foot and ankle surgeons report similar indications, methods, and low perceived propensity to use TSL in the management of foot and ankle trauma. We found that graduates of 1 fellowship training site were more likely to perform TSL in the setting of acute trauma potentially indicating the need for better scientific data to support this practice. Level of Evidence: Level V, therapeutic.

Needle-based gastrocnemius lengthening: a novel ultrasound-guided noninvasive technique.

BACKGROUND: Gastrocnemius tendon lengthening is performed to treat numerous conditions of the foot and ankle. Gastrocnemius shortening has been associated with more than 30 lower limb disorders, including plantar heel pain/plantar fasciitis, Achilles tendinosis, equinus foot, adult flat foot deformity, and metatarsalgia. Ultrasound-guided ultraminimally invasive lengthening of the gastrocnemius is a step forward in this type of surgery. It can be performed in both legs simultaneously without ischemia using only local anesthesia plus sedation and without the need for a cast or immobilization. The truly novel advantage of the procedure is that it can be performed in the office, without specific surgical instruments. The aim of our research was to prove the effectiveness and safety of a new closed needle-based ultrasound-guided surgical procedure for lengthening the gastrocnemius tendon. METHODS AND RESULTS: We performed ultrasound-guided gastrocnemius tendon lengthening using a needle in eight fresh frozen specimens (3 left and 5 right). None of the specimens had been affected by disease or undergone previous surgery that could have affected the surgical technique. We used a linear transducer with an 8- to 17-MHz linear transducer and the beveled tip of an Abbocath as a surgical blade to perform the lengthening procedure. The gastrocnemius Achilles tendon recession was entirely transected in all eight specimens, with no damage to the sural nerve or vessels. The improvement in dorsal flexion was 15°. CONCLUSION: Needle-based ultrasound-guided gastrocnemius tendon lengthening is safe, since the surgeon can see all structures clearly, thus minimizing the risk of damage. The absence of a wound obviates the need for stitches, and recovery seems to be faster. The procedure can be performed in a specialist's office, as no specific surgical instruments are required. This technique could be a valid option for gastrocnemius lengthening and may even be less traumatic than using a hook-knife, as in our previous description.

Gastrocnemius release is an effective management option for Achilles tendinopathy: a systematic review.

PURPOSE: This systematic review aims to summarise the outcomes of gastrocnemius release in the management of Achilles Tendinopathy. METHODS: A systematic review was performed according to PRISMA guidelines. A computer-based search was performed in PubMed, Embase, Cinahl, Scopus and ISI Web of Science. Two independent reviewers performed both title/abstract and full-text screening according to a-priori selection criteria. English-language original research studies reporting outcomes for gastrocnemius recession in patients with Achilles tendinopathy were included. Study quality and risk of bias were assessed using the MINORS criteria. RESULTS: Of the 229 articles identified following database searching, nine studies describing 145 cases of gastrocnemius recession were included in the review. Clinically important differences were reported across a range of validated patient reported outcome scores including VISA-A, FFI, FAAM and VAS pain score. Outcomes appear to be superior in patients with noninsertional Achilles tendinopathy, however further research is required to confirm this. Studies also reported an increase in ankle dorsiflexion range of motion and a good rate of return to sport/work. The overall complication rate was 10/123 (8.1%), with sural nerve injury being the most common complication, occurring in 5/123 (4.1%) of cases. CONCLUSION: The results of this review suggest gastrocnemius release to be an effective treatment option in the management of patients with Achilles tendinopathy, who have gastrocnemius contracture and have previously failed to respond adequately to non-operative treatment. LEVEL OF EVIDENCE: Level IV.

Gastrocnemius Release in the Management of Chronic Plantar Fasciitis: A Systematic Review.

BACKGROUND: This systematic review aims to summarize the outcomes of gastrocnemius recession in the treatment of plantar fasciitis. METHODS: A systematic review was performed according to PRISMA guidelines using the PubMed, Embase, Emcare, Web of Science, Scopus, and CINAHL databases. A 2-stage title/abstract and full text screening process was performed independently by 2 reviewers. Randomized controlled trials, cohort, and case-control studies reporting the results of gastrocnemius recession in patients with plantar fasciitis were included. The MINORS and Joanna Briggs Institute Criteria were used to assess study quality and risk of bias. RESULTS: A total of 285 articles were identified, with 6 of these studies comprising 118 patients being ultimately included. Significant postoperative improvement in American Orthopaedic Foot & Ankle Society, visual analog scale, 36-Item Short Form Health Survey, Foot Forum Index, and Foot and Ankle Ability Measure scores were reported. Included studies also described an increase in ankle dorsiflexion range of motion and plantarflexion power. An overall pooled complication rate of 8.5% was seen, with persistent postoperative pain accounting for the most common reported complication. Gastrocnemius recession is associated with greater postoperative improvement than plantar fasciotomy and conservative stretching exercises. CONCLUSION: The current evidence demonstrates that gastrocnemius recession is effective in the management of plantar fasciitis, specifically in patients with gastrocnemius contracture who do not respond to conservative treatment. LEVEL OF EVIDENCE: Level III, Systematic review of level I-III studies.

The effect of gastrocnemius resection on knee flexion in a total knee arthroplasty model.

INTRODUCTION: Flexion contracture in knee arthritis and total knee arthroplasty (TKA) is a common and significant problem. An improvement in knee extension in patients with TKA and mild flexion contractures has been observed clinically when a gastrocnemius recession was performed for other concomitant conditions. The goal of this study was to quantify the effect of gastrocnemius recession on knee flexion in TKA cadaver model. MATERIALS AND METHODS: Range of motion (ROM) of 23 cadaveric knees was determined with a navigation system before and after performing TKA using a medial parapetallar approach and after performing a gastrocnemius recession. Varus-valgus, flexion-extension, and internal-external rotation angles of the knee joint were recorded with leg in full extension and in 90°of knee flexion. Extension and flexion gaps were measured using a gap tensioning device. Dorsiflexion of the foot was measured with a goniometer when a torque moment of 10 Nm was applied to the ankle joint. RESULTS: A statistically significant improvement of 5° in knee extension was observed following gastrocnemius recession (P = 0.015). Varus and valgus angles, internal, and external rotation were unaffected by gastrocnemius recession. Ankle dorsiflexion increased by 9° following gastrocnemius recession (P ≤ 0.001). CONCLUSIONS: Performing a gastrocnemius recession improves the knee extension in TKA knees with flexion contractures. Gastrocnemius recession may be a useful technique to improve terminal extension in TKA.

A novel technique of isolated gastrocnemius recession: A cadaveric comparison with Strayer procedure.

BACKGROUND: Strayer's gastrocnemius recession is a common technique in treating ankle equinus of gastrocnemius origin. Nevertheless, this technique is associated with a few flaws. We aim to introduce a novel technique of isolated gastrocnemius recession and perform a cadaveric study to evaluate its safety and at the same time compare this novel technique with the existing Strayer procedure biomechanically. METHODS: Eight fresh cadaveric models of gastrocnemius tightness were established by isolated traction of the gastrocnemius muscles. Gastrocnemius recession was performed on all eight models with Strayer method and the novel method randomized equally. The safety of both the techniques was evaluated by identifying any iatrogenic injury to the surrounding structures. The lengthening and improvement of the ankle dorsiflexion was measured and compared between the two techniques. RESULTS: There was no iatrogenic sural nerve or saphenous vein injury in all eight models. There was no significant difference between the two techniques in terms of lengthening (24.25 mm vs 21.00 mm; p = 0.838) and improvement of ankle dorsiflexion (26.5° vs 26°; p = .829). CONCLUSIONS: Both Strayer technique and the novel technique of gastrocnemius recession lengthened the gastrocnemius and improved the ankle dorsiflexion in this cadaver trial. Both procedures were safe with proper techniques, and there was no significant difference in efficacy between them. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

The effect of lengthening the gastrocnemius muscle in chronic therapy resistant plantar fasciitis.

BACKGROUND: The aetiology of chronic therapy resistant plantar fasciitis (CTRPF) is multifactorial with more focus in recent times on the gastroc-soleus complex. This study evaluates the effect of lengthening the gastrocnemius muscle in CTRPF. METHODS: All patients with CRTPF complaints for at least one year underwent the same standard conservative treatment prior to surgery. 32 patients failed this treatment and underwent gastrocnemius recession. Silfverskiöld test, questionnaires and plantar pressure measurements were obtained at 5 visits. RESULTS: One year follow up showed a significantly increase in dorsiflexion of the ankle (16 degrees), a decrease in VAS; 78 (SD: 19) to 20 (SD: 24) and significant improved functional scores. Plantar pressure measurements showed an increase of pressure under the medial proximal part of the midfoot and the 1 st metatarsal and a decrease under the hallux. CONCLUSIONS: A gastrocnemius recession results in a significant gain in dorsiflexion, altered loading of the foot and good clinical outcome in patients with CTRPF. LEVEL OF EVIDENCE: Level 2.

Effect of Achilles Tendon Lengthening and Gastrocnemius Recession on Radiographic Tibiotalar Motion Following Total Ankle Replacement.

BACKGROUND: Surgeons frequently add an Achilles tendon lengthening or gastrocnemius recession to increase dorsiflexion following total ankle replacement. Previous studies have looked at the effects of these procedures on total tibiopedal motion. However, tibiopedal motion includes motion of the midfoot and hindfoot as well as the ankle replacement. The current study examined the effects of Achilles tendon lengthening and gastrocnemius recession on radiographic tibiotalar motion at the level of the prosthesis only. METHODS: Fifty-four patients with an average of 25 months follow-up after total ankle replacement were divided into 3 groups: (1) patients who underwent Achilles tendon lengthening, (2) patients who had a gastrocnemius recession, (3) patients with no lengthening procedure. Tibiotalar range of motion was measured on lateral dorsiflexion-plantarflexion radiographs using reference lines on the surface of the implants. RESULTS: Both Achilles tendon lengthening and gastrocnemius recession significantly increased tibiotalar dorsiflexion when compared to the group without lengthening. However, the total tibiotalar range of motion among the 3 groups was the same. Interestingly, the Achilles tendon lengthening group lost 11.7 degrees of plantarflexion compared to the group without lengthening, which was significant. CONCLUSION: Both Achilles tendon lengthening and gastrocnemius recession increased radiographic tibiotalar dorsiflexion following arthroplasty. Achilles tendon lengthening had the unexpected effect of significantly decreasing plantarflexion. Gastrocnemius recession may be a better choice when faced with a tight ankle replacement because it increases dorsiflexion without a compensatory loss of plantarflexion. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Preliminary Results of Subtalar Arthroereisis with Vulpius Procedure for Symptomatic Flatfoot in Patients with Type I Osteogenesis Imperfecta.

In this retrospective study, we aim to assess the safety and feasibility of adapting subtalar arthroereisis (SA) for type I osteogenesis imperfecta (OI) patients with symptomatic flatfoot. From December 2013 to January 2018, six type I OI patients (five girls and one boy, 12 feet) with symptomatic flexible flatfoot were treated with SA and the Vulpius procedure. All the patients were ambulatory and skeletally immature with failed conservative treatment and unsatisfactory life quality. The median age at the time of surgery was 10 years (range 5-11), and the median follow-up period was 55 months (range 33-83). All functional and radiographic parameters improved (p < 0.05) after the procedure at the latest follow-up. The median American Orthopaedic Foot and Ankle Society ankle-hindfoot scale improved from 68 (range 38-80) to 95 (range 71-97). All of the patients ambulated well without significant complications. The weight-bearing radiographs showed maintained correction of the tarsal bone alignment with intact bony surfaces adjacent to implants during the post-operative follow-up period. This is the very first study on symptomatic flatfoot in pediatric patients with type I OI. Our data suggest that SA is a potentially viable approach, as functional improvements and maintained radiographic correction without significant complication were observed.