Is Percutaneous Achilles Lengthening More Effective Than Gastrocnemius Recession For Equinus?
Point
Yes. Sharing insights from the literature and their experience, these authors maintain that the percutaneous Achilles lengthening can help address muscle spasticity, facilitate limb salvage or serve as a viable adjunctive procedure in combination with a tibiotalocalcaneal fusion.
By Nicholas J. Bevilacqua, DPM, FACFAS, Adam R. Johnson, DPM and Jennifer J. Spector, DPM, FACFAS
Tendo-Achilles lengthening (TAL) is achievable both through open and percutaneous techniques with a primary indication being gastrocnemius soleus equinus. A 2018 cadaveric study showed that a percutaneous triple hemisection of the Achilles tendon provided reliable, significant improvement of ankle dorsiflexion, most notably through the proximal and middle cuts.1 Additionally, a comparative study in 2013 concluded that a percutaneous technique had similar effectiveness to open Achilles lengthening with less trauma and swift recovery.2
Differentiation between the need for a gastrocnemius recession and the need for a TAL is based on the degree of the deformity and the cause of the equinus. Although gastrocnemius recession has its place in successful foot and ankle surgery, there are certain situations in which a percutaneous TAL is indicated and may indeed be a superior choice, specifically if a gastrocnemius recession is not powerful enough to achieve the desired results.
When Might One Consider A Percutaneous TAL As A Procedure Of Choice?
In cases of a deformity that requires tibiotalocalcaneal (TTC) or ankle fusion, surgeons can perform a TAL to eliminate deforming forces of equinus and correct deformity. Of note in these cases, the less invasive method provided by a TAL is especially preferable in that Achilles function is not needed after such a fusion.
When the rearfoot is in significant equinus, as one may see in patients with Charcot arthropathy, gastrocnemius recession may not be powerful enough to fully reduce the rearfoot to neutral position. A TAL may provide extra length to the Achilles tendon necessary for appropriate deformity correction. This is an example of when the lengthening power of a percutaneous TAL could be superior.
Not unlike patients with Charcot, clubfoot or residual clubfoot, patients often exhibit severe ankle equinus deformity. Releasing the Achilles contracture and gaining the appropriate length is necessary to properlycorrect the rearfoot position to neutral. A percutaneous TAL may be a good fit to accomplish this and surgeons may combine this with ankle fusion when indicated.
Several conditions may cause muscle spasticity leading to contractures and equinus deformity. The mechanics surrounding the TAL procedure weaken the lever arm of the gastrocsoleus complex to fight spasticity in conditions in which this is of particular concern. Cerebral palsy (CP) tends to cause damage in the area of the brain that controls muscle tone, resulting in excessive tension in the arms and legs. Contractures are not present at birth but are progressive with time. While a gastrocnemius recession may be effective in early stages, late-stage cerebral palsy may require a TAL to achieve the necessary correction.
Some other conditions that may lead to spasticity include but are not limited to spinal cord injuries, hypoxia leading to brain damage, cerebrovascular accident, encephalitis, meningitis, amyotrophic lateral sclerosis, phenylketonuria, multiple sclerosis and traumatic brain injury. All of these conditions require an extensive clinical examination, including a gait evaluation. It is important to determine the extent to which the gastrocnemius and soleus are involved to determine if a TAL or a gastrocnemius recession is indicated.
The percutaneous TAL procedure also has significant utility as an adjunctive procedure in flatfoot reconstruction. A study of patients undergoing a double calcaneal osteotomy with percutaneous TAL showed significant improvement with regard to pain and motion using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale.3
Understanding The Utility Of Percutaneous TAL In Limb Salvage
In some cases, a percutaneous TAL can play a vital role in limb salvage. A meta-analysis of various procedures and their relationship to DFU healing and prevention revealed no statistically significant difference between TAL and gastrocnemius recession in time to healing of diabetic foot ulcers, and the rate of healed ulcers in comparison to total contact casting alone.4 Although this study did not show the TAL to be superior per se, the risk profile and simplicity of the procedure may lend itself well to many cases.
Ankle equinus may occur after certain partial foot amputations and become a causative factor in recurrent ulcerations. Understanding the relationship and balancing of the dorsiflexory and plantarflexory muscle groups is important when addressing increased plantar pressure. One must pay attention to the balance of forces in the foot after certain partial foot amputations. Otherwise muscle tendon imbalance may result in a foot and/or ankle deformity, which could lead to an increase in plantar pressure causing an ulceration. The more proximal foot sparing amputations will result in more pronounced muscle imbalance and deformity. Some cases may require soft tissue balancing procedures and osseous reconstruction. One should consider these ramifications in amputations at or proximal to the transmetatarsal level. In this patient population, a minimally-invasive technique such as a percutaneous TAL can be a valuable tool in this process.
What You Should Know About The Risk Profile Of Percutaneous TAL
The small, percutaneous incisions of this type of TAL can minimize wound complications. This technique is advantageous in patients who have peripheral arterial disease. This may also be true for patients with equinus and venous insufficiency, who would also be at risk for healing complications with a gastrocnemius recession. Overall, the less invasive nature of this procedure may be of value for patients with higher perioperative risk.
Areas of caution for TAL procedures include the risk for overcorrection, tendon rupture and understanding that the procedure occurs at an area of poor tendon blood supply. However, proper technique and careful patient selection may mitigate some of these concerns.
In Conclusion
In the majority of cases of ankle equinus, a gastrocnemius recession will appropriately address the deformity while maintaining plantarflexory muscle strength and preserving function. However, certain situations may require a percutaneous TAL to obtain the desired length for deformity correction and anatomic repositioning. Although failure is fairly uncommon, overlengthening can cause a calcaneal gait and may result in more deleterious consequences than the patient’s initial presenting problem.
As a result, it is important to have a sound understanding of the available procedures and appreciate the advantages and disadvantages each procedure offers. The percutaneous TAL does have significant utility and one should not automatically choose a gastrocnemius recession in every case of equinus.
Dr. Bevilacqua is a fellowship-trained foot and ankle surgeon in private practice in Teaneck, NJ. He is board-certified by the American Board of Foot and Ankle Surgeons, and is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Johnson is the current Chief of Medical Staff at Sanford Health of Northern Minnesota in Bemidji, Minn. He is board-certified by the American Board of Podiatric Medicine with a certificate of Added Qualification in Amputation Prevention and Wound Care. Dr. Johnson is also board-certified by the American Board of Foot and Ankle Surgery.
Dr. Spector is board-certified by the American Board of Foot and Ankle Surgery, and is the current President of the American Association for Women Podiatrists. She is the Associate Editor for Podiatry Today.
Counterpoint
No. The authors cite the versatility, safety and effectiveness of the gastrocnemius recession as superior to that of the percutaneous Achilles lengthening. Using support from the literature, they discuss the importance of proper procedure selection as well as consideration of strength ramifications and anatomical variations as key factors in the successful treatment of equinus.
By Patrick A. DeHeer, DPM, David Smith, DPM, Josh Nichols, DPM and Bethany Hine, DPM
Surgical lengthening of the posterior column is a mainstay in treating equinus. It is useful for a myriad of pathologies including heel spur syndrome, plantar fasciitis, Achilles tendinopathy, Charcot neuropathy, metatarsalgia, hallux limitus, forefoot nerve entrapment and the treatment of diabetic foot ulcers.1 Studies have documented that a decrease in ankle dorsiflexion due to a tight posterior muscle complex can lead to all the aforementioned pathologies.
One only considers surgical intervention, whether it is tendo-Achilles lengthening (TAL) or a gastroc recession, after exhausting conservative treatment. Manually stretching the triceps surae is paramount. If a patient is able to stretch the muscle to an appropriate length where symptoms disappear, then surgery is avoidable. That being said, sometimes stretching will be insufficient. In 2006, Radford and colleagues noted, “Calf muscle stretches provide a small but statistically significant increase in ankle dorsiflexion ... However, it is unclear whether the change that occurs with stretching is clinically important. Therefore, calf muscle stretching is recommended where a small increase in ankle range of motion is thought to be beneficial.”2
Addressing The Limited Indications And Potential Risks With TAL
After a thorough round of calf stretching (with the knee extended and locked) for a minimum of 30 minutes a day and the foot in maximal supination, what does one do to lengthen the muscle if symptoms remain? With the proper indications, percutaneous TAL can increase ankle joint dorsiflexion and have a positive effect. However, the indications for a percutaneous TAL are very narrow and the potential sequelae can be detrimental. Some may argue the potential side effects outweigh the expected benefits. The indications for a TAL are traditionally a very tight posterior complex in a patient with diabetes or Charcot foot as a TAL can provide a greater gain in ankle joint range of motion than a gastroc recession.
Overlengthening of the Achilles tendon is the most worrisome adverse effect as this can lead to a calcaneal gait and subsequent heel ulceration. Heel ulcers are inherently difficult to manage, especially for a patient with uncontrolled diabetes and peripheral vascular disease. These cases can progress quickly to a more proximal limb amputation. Mueller and coworkers performed a TAL on 31 patients with forefoot ulcerations and 13 percent of these patients developed a heel ulceration secondary to overlengthening.3
Another study by Holstein and colleagues in 2004 assessed 68 patients with 75 neuropathic ulcerations treated with TAL.4 They found that 11 patients developed transfer heel ulcerations.4 Contrary to the documented risks of a TAL, Rush and colleagues reported on the side effects of a high open gastroc recession in 2006.5 They noted zero resultant calcaneal gait in 126 patients with the highest rate of reported complications being nerve (three patients) and scar problems (six patients). This shows that a gastroc recession is a very safe procedure to perform with very minimal risk of developing the dreaded calcaneal gait.5
Percutaneous procedures are inherently difficult as visibility is limited. As foot and ankle surgeons, we pride ourselves as lower extremity anatomists. This means that we should know where vital neurovascular structures are in relation to the Achilles tendon. The problem arises when there is abnormal anatomy or when our surgical skills are less than what the procedure requires.
In a cadaveric study looking at Hoke triple hemisections, Salamon and team measured the accuracy of the tendon cut as determined by the diameter of the hemisection divided by the width of the tendon.6 The goal was 50 percent transection of the tendon. They also measured the distance from the cut ends to various neurovascular structures. The researchers found that the cuts were 55, 50 and 60 percent accurate from the most distal to the most proximal cut. The alarming finding, however, was the proximity of other structures to the cut ends. On average, the tibial nerve, sural nerve and flexor hallucis longus tendon were 8.2, 7.9 and 5.75 mm from the hemisection respectively.6
Even with a deep understanding of the anatomy, one needs to understand the proximity of structures differs from patient to patient, and can readily account for an increased risk of iatrogenic neuromuscular injury. Surgeons do not encounter this issue with a gastroc recession as it allows for direct visualization of neurovascular structures throughout the procedure.
A Closer Look At The Advantages Of The Gastroc Recession
Another advantage for the gastroc recession is its versatility. Lamm, Paley, and Herzenberg in 2005 proposed five zones for TAL and gastroc recession.7 Zone 1 is the Achilles tendon, the location of a percutaneous TAL. Zones 2 through 5 represent different levels of gastroc recessions. This allows one to choose a procedure based on anatomic considerations and individual patient needs. For example, an intramuscular gastrocnemius fascial release takes place in Zone 4. This is known as a Baumann procedure. This procedure allows for an increase in length of just the gastrocnemius muscle without compromising strength.
In a study of 78 cases, Morales-Munoz and colleagues concluded that a Baumann procedure has the advantages of superior scar cosmesis as well as preserving muscle strength in comparison to a Strayer procedure, which is more distal in the gastrocnemius aponeurosis.8 If a Baumann gastroc recession is superior to a Strayer procedure in preserving muscle strength, it stands to reason that it is far superior to a percutaneous TAL, which surgeons perform even more distally in the posterior complex.
To further demonstrate the versatility and safety of the Baumann gastroc recessionHerzenberg and team in 2007 studied cadavers and measured ankle joint dorsiflexion prior to intervention, after a single gastroc recession, after two gastroc recessions, after a soleus fascial release and after a complete Achilles tendon tenotomy.9 After a single recession of the gastrocnemius fascia, average ankle joint dorsiflexion improved eight degrees with the knee extended and five degrees with the knee flexed. After a second gastrocnemius release, researchers found an additional six degrees and three degrees of ankle joint dorsiflexion with the knee extendedand flexed respectively. A subsequent recession of the soleus fascia only showed one degree of improvement with the knee extended and flexed. This is expected as the muscle does not cross the knee joint.
Herzenberg and colleagues have also proposed that there is a maximum length to tension ratio of the triceps surae, which explains why a soleus fascial recession would have a trivial effect.9 Continuing with their sequential release, they found a dramatic increase in ankle joint dorsiflexion as expected following a complete Achilles tenotomy. The study results show performing multiplerecessions in the gastrocnemius fascia has a compound effect on the length of the muscle belly without compromising strength.
Finally, Rong and team strengthened the argument for doing a Baumann gastroc recession in 2015.10 Their study looked at 43 feet in 35 patients with flat feet and a concomitant equinus deformity. After performing a Baumann procedure, dorsiflexion of the ankle with the knee extended and flexed increased by a mean value of 13.6 degrees and 9.7 degrees respectively. The average American Orthopaedic Foot and Ankle SocietyAnkle-Hindfoot scores improved from 56.8 points preoperatively to 72.1 points at the final follow-up. Only three patients had a recurrence of equinus and there were no cases of overcorrection, neurovascular injury or healing problems. This study further supports the Baumann gastroc recession as a powerful corrector of equinus deformity without the risks associated with a percutaneous lengthening.
Final Thoughts
When considering all factors, it is clear the risk-benefit ratio is in favor of a gastroc recession. There is a nearly zero percent chance of developing a calcaneal gait and one can easily visualize vital anatomic structures to retract and protect throughout the procedure. The surgeon also does not compromise strength when performing an intramuscular lengthening. Thus, a gastroc recession is safe and effective at treating a number of pathologies associated with equinus.
Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, and the American Society of Podiatric Surgeons.
Dr. Smith is a third-year podiatric surgery resident, Dr. Nichols is a second-year podiatric surgery resident and Dr. Hine is a first-year podiatric surgery resident at St. Vincent Hospital in Indianapolis.
Point References
1. Phillips S, Shah A, Staggers JR, et al. Anatomic evaluation of percutaneous Achilles tendon lengthening. Foot Ankle Int. 2018;39(4):500-505.
2. Xie M, Li W, Xie Q, Jiang K, Zhang B, Pan X. Effectiveness comparison of modified percutaneous mini incision and open Achilles tendon lengthening for treatment of Achilles Contracture Syndrome. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2013;27(2):164-168.
3. Basioni Y, El-Ganainy A-R, El-Hawary A. Double calcaneal osteotomy and percutaneous tenoplasty for adequate arch restoration in adult flexible flat foot. Int Orthop. 2011;35(1):47-51.
4. Dallimore S, Kaminski M. Tendon lengthening and fascia release for healing and preventing diabetic foot ulcers: a systematic review and metaanalysis. J Foot Ankle Res. 2015;8:33.
Counterpoint References
1. Hill RS. Ankle equinus. Prevalence and linkage to common foot pathology. J Am Podiatr Med Assoc. 1995;85(6):295-300.
2. Radford JA, Burns J, Buchbinder R, Landorf KB, Cook C. Does stretching increase ankle joint dorsiflexion range of motion? A systematic review. Br J Sports Med. 2006;40(10):870-875.
3. Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am. 2003;85(8):1436-1445.
4. Holstein P, Lohmann M, Bitsch M, Jorgensen B. Achilles tendon lengthening, the panacea for plantar forefoot ulceration? Diabetes Metab Res Rev. 2004;20(Suppl 1):S37-40.
5. Rush SM, Ford LA, Hamilton GA. Morbidity associated with high gastrocnemius recession: retrospective review of 126 cases. J Foot Ankle Surg. 2006;45(3):156-160.
6. Salamon ML, Pinney SJ, Van Bergeyk A, Hazelwood S. Surgical anatomy and accuracy of percutaneous achilles tendon lengthening. Foot Ankle Int. 2006;27(6):411-413.
7. Lamm BM, Paley D, Herzenberg JE. Gastrocnemius soleus resection. J Am Podiatr Med Assoc. 2005;95(1):18-25.
8. Morales-Munoz P, De Los Santos Real R, Sanz PB, Perez JL, Navas JV, Alonso JE. Proximal gastrocnemius release in the treatment of mechanical metatarsalgia. Foot Ankle Int. 2016;37(7):782-789.
9. Herzenberg JE, Lamm BM, Corwin C, Sekel J. Isolated recession of the gastrocnemius muscle: the Baumann procedure. Foot Ankle Int. 2007;28(11):1154-1159.
10. Rong K, Ge WT, Li XC, Xu XY. Mid-term results of intramuscular lengthening of gastrocnemius and/or soleus to correct equinus deformity in flatfoot. Foot Ankle Int. 2015;36(10):1223-1228.
