Outcomes of single versus multi-level Gastrosoleus or Achilles tendon lengthening

Techniques: A Comparative Study

1,2 Chamnanni Rungprai, M.D.

Co-authors 1Christopher Cyclosz, M.D. 1Phinit Phisitkul, M.D.

AOFAS 2015 Annual Meeting ePoster

1.University Of Iowa Hospital and Clinic, Iowa, USA 2.Phramongkutklao hospital and college of medicine, Bangkok, Thailand

NO CONFLICT TO DISCLOSE

Outcomes of single versus multi-level

Gastrosoleus or Achilles tendon lengthening Techniques: A Comparative Study

Chamnanni Rungprai, M.D.

My disclosure is in the Final AOFAS Mobile App.

I have no potential conflicts with this presentation.

Introduction

Ankle equinus contracture is a commonly encountered condition in an orthopaedic foot and ankle practice. Gastrocnemius or gastrosoleus

contracture has been postulated to be the root of numerous foot and ankle pathologies Diabetic foot ulcers Hallux valgus Metatarsalgia Adult acquired flatfoot disorder Plantar fasciitis Initial treatment should consist of

conservative management including night splints and stretching exercises If these fail, surgical treatment is

indicated.

Single level gastrocnemius or Achilles tendon lengthening including open, percutaneous, and endoscopic techniques are considered standard techniques for the treatment of equinus contracture. However, patients with severe

equinus contracture require multi-level of lengthening using combined procedures as mentioned above to achieve adequate ankle dorsiflexion. In addition, there has been no

comparative study to demonstrate clinical outcomes and complications between single versus multiple levels of gastrocnemius or Achilles tendon lengthening techniques.

Materials and methods The primary outcomes include

Foot Function Index (FFI) Short Form-36 (SF-36 Visual Analogue Scale Ankle dorsiflexion.

Secondary outcome includes

Operative time Complications

Pre- and post-operative

functional outcome scores were obtained and compared using Wilcoxon Rank Sum Test, and Chi-square Test.

Retrospective chart review with prospectively collected data of 646 consecutive patients (676 feet) diagnosed with ankle equinus contracture and underwent single level of gastrocnemius or Achilles tendon lengthening techniques (610 patients / 640 feet) including open Valpius or Strayer (VSO) 200 patients / 206 feet, Baumann 38 patients / 38 feet, percutaneous triple hemisections (Hoke) 52 patients / 52 feet, endoscopic gastrocnemius recession (EGR) (320 patients/ 344feet), and multi-level using combined techniques 36 patients / 36 feet between January 2006 and June 2013.

Figure 1: EGR was performed by two portals technique (A). The gastrocnemius aponeurosis is identified (B), retrograde knife was used to release aponeurosis (C). The gastrocnemius muscle after complete release the gastrocnemius aponeurosis (D).

Surgical technique

A B

C D

Figure 2: Percutaneous tripple hemisection of Achilles tendon was performed by using three step cut technique is shown in picture 2A. The proximal medial cut is shown is picture 2B and middle lateral cut is shown in picture 2C and distal medial cut is shown in picture 2D.

A B

C D

Table 1 Demographic characteristics of single and multiple gastrocnemius or Achilles tendon lengthening.

Parameters

Single level Multiple level

Open Strayer or

Valpius

Hoke Baumann EGR Combined procedure

Number of patients / legs

200 / 206 52 / 52 38 / 38 320 / 344 36 / 36

Age of time at surgery (year) (range)

50.4 ± 15.6 ( 16-93 )

60.2 ± 13.1 ( 27-89 )

51.3 ± 14.1 ( 23-77 )

47.1 ± 15.7 ( 13-93 )

50.8 ± 13.5 ( 22-73 )

Male : Female ratio (no. of patients)

95 : 105 28 : 24 11 : 27 140 : 180 10 : 20

BMI(Kg/m2) (range) 31.8 ± 7.0 (17.0-57.0)

33.8 ± 7.0 (23.5-55.4)

31.4 ± 7.8 (20.2-48.9)

32.8 ± 8.5 (17.4-57.5)

33.9 ± 6.9 (24.1-54.1)

Duration of follow up (month) (range)

23.9 ± 19.4 (6-90)

27.5 ± 22.6 (6-81)

24.0 ± 11.9 (6-44)

17.6 ± 56.6 (12-53)

38.9 ± 28.6 (6-96)

TABLE 2 Group comparison between single and multiple gastrocnemius or Achilles tendon lengthening. Parameters Single level Multiple level

Open Strayer or Valpius (n=200)

Hoke procedure (n=52)

Baumann procedure (n=38)

Endoscopic technique (n=320)

Combined techniques (n=36)

Operative time (minutes) 28.09 ± 5.07* (21-35)

3.15 ± 1.14* (2-5)

29.00 ± 6.45 (21-38)

18.22 ± 5.02 (12-30)

29.0 ± 7.1 (20-37)

**Pre / Post-operative Visual Analog Scale (range) (no./total)

6.3 ± 2.7 / 3.6 ± 2.9 (n=175)

7.3 ± 2.3 / 3.2 ± 2.4 (n=47)

6.9 ± 1.8 / 3.8 ± 2.9 (n=35)

7.3 ± 2.2 / 3.4 ± 2.7 (n=276)

7.8 ± 1.5 / 3.6 ± 3.1 (n=28)

SF-36 Score: at final follow up (points)

**PCS: pre / post-operative (no./total)

37.3 ± 9.1 / 43.3 ± 10.2

(n=76)

32.5 ± 9.5 / 45.5 ± 11.1

(n=32)

35.4 ± 4.9 / 44.1 ± 9.8

(n=26)

33.9 ± 9.6 / 45.1 ± 12.2

(n=185)

33.0 ± 10.1 / 40.7 ± 12.4

(n=22) **MCS: pre / post-operative (no./total)

45.4 ± 11.4 / 50.1 ± 10.9

(n=76)

42.9 ± 10.5 / 49.1 ± 11.3

(n=32)

47.5 ± 11.2 / 56.8 ± 7.8

(n=26)

43.8 ± 11.8 / 51.4 ± 11.6

(n=185)

43.9 ± 14.2 / 49.4 ± 10.6

(n=22) Foot Function Index (FFI): pre / post-operative at final follow up

** Pain: pre / post-operative (no./total)

59.2 ± 15.2 / 36.7 ± 16.6

(n=76)

54.0 ± 18.0 / 34.5 ± 13.7

(n=32)

54.7 ± 13.7 / 39.1 ± 13.1

(n=26)

63.2 ± 18.4 / 42.1 ± 19.6

(n=185)

68.8 ± 13.2 / 40.7 ± 12.4

(n=19) **Disability: pre / post-operative (no./total)

59.9 ± 15.9 / 41.0 ± 17.5

(n=76)

49.5 ± 18.1 / 36.2 ± 13.4

(n=32)

55.4 ± 14.4 / 34.6 ± 11.8

(n=26)

63.0 ± 19.6 / 43.3 ± 21.03

(n=185)

56.8 ± 27.7 / 49.4 ± 10.6

(n=19) **Activity limitation: pre / post-operative (no./total)

60.3 ± 12.2 / 40.5 ± 19.7

(n=76)

58.2 ± 14.9 / 34.5 ± 14.8

(n=32)

63.2 ± 16.0 / 39.2 ± 19.8

(n=26)

67.9 ± 17.7 / 44.4 ± 23.8

(n=185)

67.4 ± 15.4 / 41.4 ± 25.4

(n=19) **Total score: pre / post-operative (no./total)

60.1 ± 13.6 / 39.2 ± 16.2

(n=76)

53.6 ± 14.1 / 35.6 ± 12.7

(n=32)

58.9 ± 12.1 / 37.7 ± 14.1

(n=26)

64.2 ± 15.0 / 41.5 ± 19.0

(n=185)

64.3 ± 13.2 / 37.9 ± 20.0

(n=19)

Table 3 Ankle dorsiflexion between single and multiple gastrocnemius or Achilles tendon lengthening. Ankle range of

motion Single level Multiple level

Open Strayer or Valpius (n=200)

Hoke technique

(n=52)

Baumann technique

(n=38)

Endoscopic technique (n=320)

Combined techniques

(n=36) Dorsiflexion Pre-operative (range, degrees) up (number of available patients/total number)

-2.8 ± 8.9 ((-50) - 10)

(n=164)

-0.5 ± 8.1 ((-20) - 10)

(n=40)

-5.1 ± 6.6 ((-30) - 10)

(n=34)

-0.8 ± 5.4 ((-50) - 10)

(n=294)

-13.2 ± 9.0* ((-5) - (-35))

(n=27)

Immediate post-operative / improvement (range, degrees) (number of available patients/total number)

12.4 ± 4.8 / (15.0)

((-5) - 30) (n=164)

10.1 ± 5.5 / (10.6)

(0 - 20) (n=40)

9.8 ± 4.7 / (14.9) (0 - 20) (n=34)

14.7 ± 6.7* / (15.6)

(0 - 30) (n=294)

9.0 ± 5.1 / (22.2)*

((-5) - 15) (n=27)

At final follow up / improvement (range, degrees) up (number of available patients/total number)

7.8 ± 5.7 / (10.62)

((-10) - 30) (n=164)

6.6 ± 5.8 / (7.08)

((-5) - 20) (n=40)

7.8 ± 4.6 / (12.82) (0 - 20) (n=34)

11.0 ± 6.6 / (11.84)

((-10) - 30) (n=294)

5.2 ± 5.9* / (18.4)*

((-10) - 15) (n=24)

Table 4 Complications between single and multiple gastrocnemius or Achilles tendon lengthening.

Complications

Number of complications / Total number of legs (Percent) Single level Multiple level

Open Strayer

or Valpius (n=206)

Baumann Technique

(n=52)

Hoke

Technique (n=38)

Endoscopic Technique (n=344)

Combined Technique

(n=36) 1. Superficial infection

13 (6.3%) 3 (7.9%) 0 (0.0%)

0 (0.0%) 1 (2.8%)

2. Sural nerve dysesthesia

7 (3.4%) 1 (2.6%) 1 (1.9%) 10 (2.9%) 3 (8.3%)

3. Weakness of plantar flexion

9 (4.4%) 1 (2.6%) 5 (9.6%) 11 (3.2%) 10* (27.7%) (p=0.001)

4. Painful scar 5 (2.4%)* 1 (1.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

5. Calf muscle atrophy

5 (2.4%) 0 (0.0%) 0 (0.0%) 8 (2.6%) 11* (30.5%) (p=0.001)

6. Rupture of the Achilles tendon

0 (0.0%) 0 (0.0%) 6* (15.8%) (p = 0.03)

0 (0.0%) 0 (0.0%)

Results All techniques demonstrated

significant improvement in FFI, SF-36, VAS, and ankle dorsiflexion (all p-value < 0.001). Multi-level of lengthening

demonstrated significantly longer operative time than Hoke technique (p-value = 0.001) but the means improvement of ankle dorsiflexion intraoperatively and at final post-operative visit were significantly greater than all single level techniques (p-value = 0.001).

The ankle dorsiflexion of multi-level at final post-operative visit was significantly lesser than endoscopic technique (p-value = 0.002) but was comparable with other single level lengthening. Weakness of plantarflexion and calf

muscle atrophy was significantly higher in multi-level than all single level techniques (p-value < 0.05) while the rupture of the Achilles tendon was significant higher in single Hoke technique (p-value = 0.03). Sural nerve dysesthesia was higher

in multi-level but this did not reach statistical significance while other complications were similar between groups.

Limitations Strengths

Discussion

Retrospective design, and therefore no randomization was used in the methods.

Some patients were lost to follow-up and some did not response to the questionnaires, resulting in approximately fifty percent of patients available to be analyzed at final follow-up.

Consecutive case collection.

Relatively large number of subject.

Systematically collected outcome data using validated assessment methods.

All surgeries were performed by the same group of fellowship-trained orthopaedic foot and ankle surgeons.

Both single and multi-level techniques for gastrocnemius or Achilles tendon lengthening demonstrated significant improvement in outcomes as measured with the FFI, SF-36, VAS, and ankle dorsiflexion for treatment of tightness of gastrocnemius and gastrosoleus muscle. Hoke is fastest procedure but significant rapture rate of Achilles tendon. Multi-level lengthening resulted in significant improvement of ankle dorsiflexion at final post-operative visit and intraoperatively but leaded to higher sural nerve dysesthesia and significant weakness of plantarflexion and calf muscle atrophy.

Conclusion

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