TIPS, QUIPS, AND PEARLS

"Tips, Quips, and Pearls" is a special section in The Journal of Foot & Ankle Surgery which is devoted to the sharingof ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in theform of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making asurgical procedure a little bit easier, or virtually any other "pearl" that the reader believes will assist the foot and anklesurgeon in providing better care. Please address your tips to: John M. Schuberth, DPM, Editor, The Journal of Foot &Ankle Surgery, American College of Foot and Ankle Surgeons, 515 Busse Highway, Park Ridge, lL 60068-3150; Fax:847-292-2022; E-mail: JFASeditor@aol.com

Endoscopic Gastrocnemius Tenotomy

Arnol Saxena, DPM, FACFAS

Posterior heel cord contracture (ankle equinus) has beenimplicated in many types of foot and ankle deformi­ties 0, 2). Lengthening of the Achilles tendon and theassociated gastrocnemius-soleus complex has been advo­cated in reducing these equinus deformities. This can bedone as an open or a percutaneous procedure. The openprocedures tend to have unappealing cosmesis and greaterrisk of wound complications. Percutaneous procedures donot allow for direct visualization. Furthermore, the func­tionality of posterior lengthening procedures has not beenfully assessed. Over-lengthening can be disastrous, espe­cially for patients who need to be able to stand on their toes.

Approximately 2 years ago, endoscopic tenotomieswere performed on cadavers using the AM SurgicalUniportal System (Smithtown, NY). After dissectingseveral cadavers to verify transection of the gastrocnemiusaponeurosis and the lack of neurovascular injury, thisprocedure has been subsequently performed successfullyon five patients. This can be performed with the patienteither supine or prone. The technique is as follows.

A l-cm vertical incision is made medially on the leginferior to the medial gastrocnemius muscle belly (Fig. 1).A clamp is used to bluntly dissect down to the fascia.The plantaris tendon may need to be dissected away. Afascial elevator is used to separate the subcutaneous tissue(which contains the saphenous neurovascular structures)from the gastrocnemius fascia. The obturator/cannula isinserted followed by the 4-mm endoscope (Fig. 2). Theneurovascular structures are completely protected in thismanner. The fascia is well visualized and looks similar toendoscopic visualization of the plantar fascia (Fig. 3). The

From Department of Sports Medicine, Palo Alto Medical Foundation,Palo Alto, CA 94301; e-mail: HeySax@AOL.com.The Journal of Foot & Ankle Surgery 1067-2516/02/4101-0057$4.00/0Copyright © 2002 by the American College of Foot and Ankle Surgeons

FIGURE 1 Foot placed on "bump" to facilitate passage ofinstruments. Note medial gastrocnemius muscle belly.

endoscope is temporarily removed. A cannulated, camera­mounted knife, which only can cut what is in the cannula,is then carefully inserted vertically through the incision.Carefully rotating the knife 90° towards the fascia avoidspotential damage to neurovascular structures.

The knife cuts as it is pushed through the cannula. Thefoot is dorsiflexed to aid in transection; however, entranceinto the soleus muscle can result in hemorrhage, obscuringvisualization. One should be able to appreciate at least 10°of improvement. In younger patients, the gastrocnemiusfascia is wider. Therefore the lateral fibers may need tobe transected form a second portal laterally. The cannulacan be pushed laterally from the medial incision so that acut-down incision can be made. The cannula is re-insertedlaterally, and a similar technique is used to cut the fibers

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FIGURE 2 A 4-mm endoscope is introduced.

FIGURE 3 Endoscopic view of gastrocnemius aponeurosis.

from lateral to medial. Similar to an endoscopic plantarfasciotomy, which allows visualization of the first layer ofplantar musculature after a successful release, the soleusmuscle should be visualized after the tenotomy (Fig. 4).Instrumentation is then removed, the wounds are irrigated,and skin closure is performed. Postoperatively, the footis splinted according to the other procedures performed.Otherwise, a below-knee cast boot is maintained for 3-4weeks.

There is minimal morbidity and convalescence with thisprocedure. To date, none of the five patients have had anyneurovascular or wound compromise (an advantage fordiabetics), and they have gained at least 10° of dorsiflexion.More importantly, this procedure does not compromisepropulsion, which is restored usually within 6-12 weeks.This procedure in essence is creating a "tennis leg" or

58 THE JOURNAL OF FOOT & ANKLE SURGERY

FIGURE 4 Endoscopic view of transected gastrocnemius aponeu­rosis, with soleus muscle visualized above.

medial gastrocnemius tear. Patients sustaining this injuryusually are able to return to athletic activity with properrehabilitation. There have been disappointing results withthe functionality of tendo Achilles lengthening. Similarly,there has not been a study documenting the time frame inwhich patients are able to toe-raise.

It is hoped that the endoscopic gastrocnemius tenotomywill be a useful and less invasive method of performingposterior lengthening.

References

I. Hansen, S. T. Functional Reconstruction of the Foot and Ankle.Lippincott Williams & Wilkins, Baltimore, 2000.

2. Sgarlato, T. E. Medial gastrocnemius tenotomy to assist in bodyposture balancing. J. Foot Ankle Surg. 37(6):546-547, 1998.