SLR - March 2020 - Alex S. Mattia
Reference: Brandao R, So E, Steriovski J, Hyer C, Prissel M. Outcomes and Incidence of Complications Following Endoscopic Gastrocnemius Recession A Systematic Review. Foot Ankle Spec. 2020 Jan;12Scientific Literature Review
Reviewed By: Alex S. Mattia, DPM
Residency Program: MedStar Georgetown University Hospital – Washington, DC
Podiatric Relevance: The effects of ankle equinus can have various manifestations in the hindfoot, midfoot, and forefoot. Traditionally, surgical correction of ankle equinus has been performed in an open manner to lengthen the gastroc-soleus complex. Although reproducible, complications of an open approach consist of sural nerve injury, wound healing complications, and poor cosmesis. Through a minimally invasive approach, using endoscopy, it is suggested that complications can be mitigated. With reimbursement models of podiatric surgeons shifting to incorporate value-based metrics such as patient satisfaction, it is paramount that we continue to evolve our technique for better patient outcomes. The authors conducted a systematic review of the literature involving endoscopic gastrocnemius recession, to investigate if the minimally invasive approach led to better patient results, quicker recovery, and less complications than its open counterpart.
Methods: A systematic review identified 1584 studies in which only 11 (one retrospective comparative study, five prospective case series and five retrospective case series) of these studies met their inclusion criteria. Data from 697 operations, spanning from 2004-2018 were extracted from these studies. Criteria for exclusion were sample sizes less than three feet, non-endoscopic gastrocnemius recession, non-English articles, cadaveric studies, and inadequately collected data. Extracted data included the following means: age, number of feet, follow up time, adjunctive procedures simultaneously performed, AOFAS, VAS, and SF-36 scores. These averages were subsequently weighed, and a report was compiled.
Results: The collected data was analyzed regarding patient’s outcome scores, postoperative complications, indications for surgery, and simultaneous adjunctive procedures. Findings included a mean age of 45.3 years and mean follow up time of 18.4 months. The most common indication for endoscopic recession was equinus contracture (30.3 percent). Mean ankle ROM improved from -2.3 degrees preoperatively to 10.9 degrees postoperatively. Through analysis, the authors found the functional outcomes scores were inconsistent, but showed a trend of improvement for both the AOFAS and VAS scale. The most common complication was postoperative plantarflexory weakness (3.5 percent). Sural nerve injury was reported at a prevalence of 3.0 percent. There were no deep infections reported in all included 11 studies.
Conclusions: In this systematic review, the authors were able to portray that postoperative complications from an open approach still manifest in the minimally invasive endoscopic gastrocnemius recession but appear less prevalent than their traditional open counterpart concerning sural nerve injury, scar cosmesis, and postoperative plantarflexory weakness. Limitations of the study included the lack of high-level designed studies that were included in the systematic review due to the paucity of literature that fit the outlined inclusion criteria. Also, only articles written in English were included in this reviews design, possibly excluding high level designed research that may have contributed greatly to the data that was compiled in this review. This review of pooled data suggests that patients undergoing surgical lengthening of the gastrocnemius may benefit from an endoscopic approach due to less dissection, less operative time, and the inherent minimally invasive nature of the procedure leading to better patient satisfaction and outcomes.