SLR - April 2017 - Ben Blodgett
Reference: Villanueva M. Iborra Á, Rodríguez G, Sanz-Ruiz P. Ultrasound-Guided Gastrocnemius Recession: A New Ultra-Minimally Invasive Surgical Technique. BMC Musculoskelet Disord. 2016 Oct 3;17 (1):409.Scientific Literature Review
Reviewed By: Ben Blodgett, DPM
Residency Program: Kentucky One Health, Louisville, KY
Podiatric Relevance: Gastrocnemius recessions can be performed open or arthroscopically with many techniques having been described. Neurovascular injury, wound complications and poor cosmesis are all known contributors to patient dissatisfaction. Arthroscopic techniques are less invasive and are performed using a smaller incision but are not without complications. This study presents a surgical technique that can reduce the incision size and provide better clinical outcomes and fewer complications, which are vital to patient satisfaction and thus our grading as surgeons.
Methods: This study reveals a novel surgical technique to perform an ultra-minimally invasive gastrocnemius recession. The procedure is performed with the patient in the prone position without use of tourniquet or general anesthesia. The sural nerve is found using an ultrasound probe and its course followed proximally to 2 to 3 cm below the medial head where it is then marked. A 1 mm stab incision is then made with a 16-gauge needle lateral to the nerve, and a blunt instrument is then passed underneath the nerve until the medial border is reached. A hook knife is then inserted, advanced medially, then turned 90 degrees and cut from medial to lateral using direct ultrasound control with the foot maximally dorsiflexed.
The initial pilot study utilized 22 cadavers to evaluate the efficacy and safety of this technique. In the second phase, a gastrocnemius recession was performed in 23 patients (25 cases) with chronic noninsertional Achilles tendinopathy, equinus and other indications. The authors evaluated ankle dorsiflexion pre/post procedure, clinical outcomes using VAS and AOFAS scores and potential complications.
Results: In the cadaveric portion of the study, the authors achieved complete release of the gastrocnemius tendon with no damage to the sural nerve. In the clinical portion of the study, ankle joint dorsiflexion increased in every patient (mean, 14 degrees, standard deviation, three degrees) with postoperative dorsiflexion maintained throughout follow-up. The mean preoperative VAS score was seven (six to nine), which improved to 2.8 at three months postoperative, one at six months and zero at one year. The AOFAS Ankle-Hindfoot Score improved from a preoperative mean of 30 (20 to 40) to 68.77 (44 to 82) at three months, 92.84 (85 to 100) at six months and 93 at one year. All patient developed a superficial hematoma, which resolved uneventfully within one month. Four patients developed slight muscle weakness that resolved at six months. There were no infections, wound complications, nerve complications or overlengthening/rupture of the Achilles tendon. All patients returned to their preoperative level of sports activity after six months.
Conclusions: The authors consider this novel technique to be safe and effective to perform ultra-minimally invasive gastrocnemius recession via a 1 mm incision using ultrasound guidance. This technique represents an alternative to open procedures, as well as arthroscopic procedures, and gives encouraging results. The benefits of this technique include reducing postoperative pain compared to more invasive procedures, reducing need for deeper anesthesia, decreasing complications and accelerating recovery.