Minimally invasive surgery in orthopedics


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Minimally invasive surgery in orthopedics

  1. 1. 9G.R. Scuderi and A.J. Tria (eds.), Minimally Invasive Surgery in Orthopedics: Foot and Ankle Handbook,DOI 10.1007/978-1-4614-0893-2_2, © Springer Science+Business Media, LLC 2012Percutaneous techniques are becoming popularfor treating many musculoskeletal conditions.Those developed for endoscopic carpal tunneland plantar fascial release are currently amongthe most common. The reported benefits of endo-scopicsurgeryincludesmallerincisionsandshorterpostoperative recovery time [1–3]. Visualizationwith an endoscope may also decrease periopera-tive complications from scarring such as inci-sional irritation or neuritis, although the overallsafety of these interventions has yet to be deter-mined. An endoscopic means of gastrocnemiusrecession (EGR) has recently been popularizedfor correction of ankle equinus contracture as analternative to formal open gastrocnemius release(OGR) or Achilles tendon lengthening [4–21].The OGR remains today’s gold standard foraponeurotic lengthening because of its provenrecord as a safe, rapid, and effective procedure.This open “slide,” however, can involve a largeunsightly incision, which is particularly unpopu-lar with young women, and can be associatedwith sural nerve scarring and neuritis [11, 14, 15,19, 22]. The EGR, an alternative percutaneousapproach, has been sought in an effort to avoidthose problems, but it has a significant learningcurve, can be associated with poor visualization,and is somewhat instrument dependent [14, 17].In consideration of its potential advantages anddrawbacks, the authors have tried over the lastseveral years to develop a safe and reliable endo-scopic technique for gastrocnemius recession.Gastrocnemius recession has been used suc-cessfully for over a century to correct anklecontracture, originally described to treat neuro-logically impaired individuals [16]. More recentdata suggesting the presence of isolated gastroc-nemius tightness in otherwise healthy patients,however, has popularized more widespread useof OGR in the United States and Europe duringthe past decade. EGR was first introduced as atreatment alternative in 2002 [13, 21]. Its pur-ported benefits over the standard open means ofgastrocnemius release included a smaller inci-sion, a potentially faster recovery, and the versa-tility of being performed in any patient position.While its recent interest has emerged primarily inresponse to complications from the open tech-nique, to date, its advantages remain promisingbut incompletely substantiated [14].Early results of the endoscopic procedureappear comparable to the open technique regard-ing improvement of ankle dorsiflexion [5, 10–12,14, 20]. Using an endoscopic technique, Saxenaand Widtfeldt obtained an average 15° immediateimprovement in postoperative dorsiflexion, whichremained at 12.6° after 1-year follow-up of 18cases [14]. Pinney et al. reported an 18° dorsi-flexion increase sustained 2 months after openStrayerprocedure[11].DiDomenicoetal.reportedAmol Saxena and Christopher W. DiGiovanniA. SaxenaDepartment of Sports Medicine, Palo Alto MedicalFoundation, Palo Alto, CA, USAC.W. DiGiovanni ( )Division of Foot and Ankle, Department of OrthopedicSurgery, Brown University Medical School, RhodeIsland Hospital, Providence, RI, USAe-mail: christopher_digiovanni@brown.eduEndoscopic GastrocnemiusRecession 2
  2. 2. 10 A. Saxena and C.W. DiGiovannitheir results on 31 procedures of EGR and notedan improvement of 18° with the knee extended [5].Trevino et al. did not report the amount of dorsi-flexion achieved with their endoscopic results,noting only “significant improvement in ankledorsiflexion.” [20] All three of these studies dealtwith nonspastic equinus. A recent Europeanstudy reported on 18 procedures on patients withcerebral palsy who exhibited neurological equi-nus [12]. These authors were also able to achievetotal dorsiflexion improvement of almost 20°afterusingtheendoscopictechnique.Interestingly,despite available data, the amount of equinuscorrection actually required for gastrocnemiusrecession to be successful in impacting long-termoutcome in these patients remains unknown. Infact, although many (including these authors)think that such equinus correction remediesvarying pathologies of the foot, even the relation-ship between isolated gastrocnemius release andfunctional improvement remains obscure. Forexample, as of today, the mere definition of path-ological equinus has only recently been moreclosely studied.Historically, functional ankle joint dorsiflex-ion has been defined as 10° with the knee extendedand more than 10° with the knee flexed (theSilverskiold maneuver) [23]. Values below thesehave been somewhat arbitrarily defined as “equi-nus contracture.” In 2002, DiGiovanni et al. stud-ied ankle dorsiflexion in nonneurologicallyimpaired populations of individuals who were eitherasymptomatic controls or patients with symp-tomatic midfoot and/or forefoot complaints [24].They concluded that 5° of ankle dorsiflexion withthe knee extended and 10° with the knee flexedrepresented reasonably normal values, and sug-gested that values less than these should be con-sidered evidence of gastrocnemius or Achillescontracture, respectively. They also found a sta-tistically significant association between thoseindividuals who met the criteria for gastrocne-mius equinus and an increased incidence of painfulmidfoot and forefoot pathology. Another studycontended that 0° of ankle dorsiflexion with theknee in extension could be “normal” in asymptom-atic, adolescent athletes [25]. Based on this data,weconsiderpatientscandidatesforgastrocnemiusrecession when their ankle dorsiflexion is lessthan 5° with the knee extended and they exhibitsigns or symptoms of chronic foot overload orinflammation. Common examples would be pos-terior tibial tendon insufficiency, diabetic fore-foot ulceration or Charcot arthropathy, stressfractures, metatarsalgia, Morton’s foot deformity,plantar fasciitis, and insertional Achilles tendon-itis, although we think this contracture maypotentially play a role in many other biomechani-cal and functional pathologies of the foot as well.Alternative potential indications for performingan open or endoscopic gastrocnemius recessioninclude patients with symptomatic ankle contrac-ture or those who necessitate midfoot (Lisfranc)reconstruction/arthrodesis, calcaneal osteotomyfor hindfoot realignment, or subtalar arthroerei-sis (Table 2.1). Whether performed openly orendoscopically, however, the procedure is notmeant to take the place of an Achilles lengthen-ing when indicated based on the Silverskioldtest. Gastrocnemius recession should also beused cautiously in athletes.The EGR procedure is typically performedsupine under general anesthesia. It can also beperformed prone in the event the patient requiressuch positioning during their foot/ankle surgery.Spinal or local anesthesia may be considered anoption for patients who are not good candidatesfor or do not desire general anesthesia, but wehave less experience with this method under suchcircumstances. Incision placement has been clari-fied by a recent anatomic study by Tashjian et al.[22]. Ideal sites are determined by locating theinferior extension of the medial gastrocnemiusTable 2.1 Indications for endoscopic gastrocnemiusrecession1. Gastrocnemius equinus/tightness: (ankle dorsiflexion<5° with the knee in extension)2. Nonspastic and nonbony deformity andAsymmetric posttraumatic symptomatic contractureand/orCalcaneal osteotomy and/or Hindfoot realignmentand/orSubtalar arthroereisis and/orMidfoot arthrodesis and/orNoninfected forefoot ulcers/derangement
  3. 3. 112 Endoscopic Gastrocnemius Recessionmuscle belly as well as identifying the midpole ofthe fibular shaft. These landmarks provide usefulkeys to optimal aponeurotic release. Knowledgeof the neurovascular anatomy is mandatory, par-ticularly the sural and saphenous structures. Thegreat saphenous vein and the saphenous nerveshould be anterior to a medially based incision,which is ideally placed in the midaxial line. Thisincision is made adjacent to edge of the medialgastrocnemius aponeurosis, typically 9–12 cmproximal to the medial malleolus, and is 1–1.5 cmlong (Fig. 2.1). Once the superficial posteriorcompartment fascia is opened, a fascial elevatoris used to create a pathway between subcutaneousfat and gastrocnemius fascia, in a medial to lateraldirection. Care is taken to remain directly poste-rior to (on top of) the gastrocnemius aponeurosis,a characteristically glistening white structure. Anendoscopic cannula with a blunt obturator is thenplaced through the medial incision and carefullyadvanced laterally. The obturator can then beremoved for insertion of a 4.0-mm, 30° endo-scope through the cannula. The gastrocnemiustendon (Fig. 2.2) is visualized anteriorly, and theendoscope subsequently advanced toward the lat-eral aspect of the leg where the subcutaneous tis-sue appears yellow. The endoscope and cannulaare rotated posteriorly and then retrograded backmedially approximately 1 cm to locate the suralnerve. Pinney et al. found that the sural nerve canlay directly behind this aponeurosis less than 25%of the time, but is more often outside of the fieldof view, and equally common interior and exteriorto the superficial posterior compartment fasciaat this level. Regardless, care must be taken toensure that the nerve does not exist between can-nula and the site of aponeurotic release. Based onthe findings of Tashjian et al., the sural nerve hasbeen shown to course approximately 1.2 cm or20% medial to the lateral gastrocnemius border atthe myotendinous junction [19]. Their study didreport one sural nerve transection with this EGRapproach in the cadaveric setting, and the nervewas seen in only one third of the specimens eval-uated endoscopically [19, 22]. Webb et al. alsoshowed the sural nerve to cross the proximal por-tion of the Achilles tendon from the lateral side[26]. If possible, it is always advantageous todocument that the nerve is located posterior to thecannula, and thereby protected by it (Fig. 2.3).Pinney et al. have also shown in their study on theStrayer technique that the nerve can often beadherent to the gastrocnemius aponeurosis [11].Such situations may require modification or evenabandonment of the endoscopic technique inlieu of a more formal, open procedure.Transillumination of the lateral aspect of the legallows the surgeon to carefully make a cut-downincision over the cannula and insert a narrow-tipped suction device, which also helps avoidpossible portal neuromas (Fig. 2.4). The use ofsuction improves visualization due to the moisturefrom the subcutaneous fat during transection ofthe gastrocnemius. Occasionally, serial swabbingFig. 2.1 Medial incision placementFig. 2.2 Endoscopic view of gastrocnemius
  4. 4. 12 A. Saxena and C.W. DiGiovanniwith a cotton tip applicator is also helpful to cleanthe lens of the endoscope and its cannula.Once anatomy has been properly and safelydefined, the endoscope is temporarily removedand a cannulated knife is introduced as part of thecamera, stabilized over the endoscope (Fig. 2.5).This assembly is designed to transect the tendonwhile pushing the blade located forward in itsposition immediately ahead of the camera, andcan be done through only the medial portal.Alternatively, a separate independent “hook-blade” can be used, which is useful in cases whenthe sural nerve or numerous venous structures arelocated in the vicinity of the proposed transec-tion. This latter technique requires two portalsand a separate knife blade/handle, which is pulledfrom the far end toward itself during transaction,using the camera to follow the release. We haveidentified no specific advantage with either tech-nique, and in either case the foot must remainforcibly dorsiflexed to tension the thick gastroc-nemius aponeurosis and permit clean transection.Clamping the medial and lateral margins of theaponeurosis through each portal with a Kocherclamp may also facilitate this process, but requiresslightly larger incisions. This adjunct techniquecan be useful because the gastrocnemius restsmore curvilinear rather than straight when viewedin the coronal plane. Thus, the straight, rigidendoscope is sometimes ineffective at releasingthe very medial and lateral edges of the tendon asthey course more anteriorly away from the endo-scope/cannula. As the gastrocnemius is transectedwith either blade construct, the soleus muscleFig. 2.3 Endoscopic view of sural nerve with the endo-scope and cannula rotated posteriorly 180°Fig. 2.4 Creation oflateral portal
  5. 5. 132 Endoscopic Gastrocnemius Recessionbelly should become visible anteriorly (Fig. 2.6).Ideally, the fascia of the soleus is not violated. Ifthis occurs, the resultant bleeding can obscurevisualization. Although typically only superficial,however,unfortunatelythisissometimesunavoid-able, and under such circumstances suction fromthe lateral portal can be helpful. While this inad-vertent violation of the soleus fascia/muscle hasnot been of any identifiable clinical consequencein our experience, it still represents a potentialrisk and undesirable pitfall of this procedure. Ifthe neurovascular structures limit advancementof the cannulated knife, one can transect theaponeurosis from either portal with various endo-scopic blades. The hook blade can be used fromthe lateral portal to complete the transection.After complete transaction of the tendon, ankledorsiflexion improvement should be noted of atleast 10–15°. Anything short of this suggestseither the need for an Achilles lengthening orincomplete resection of the gastrocnemius. Recentresearch by Barouk et al. suggests that most if notalmostallofthedorsiflexioncorrectionisobtainedby release of the medial as opposed to the lateralgastrocnemius aponeurosis [27]. This is in keep-ing with our own observations. Once instrumentsare removed, the medial incision is explored forthe plantaris tendon, which is then also transected.In our experience, leaving this tendon behindintact can result in medial-sided discomfort as aresult of its bowstringing while under dorsiflex-ion tension. Surgical sites are thereafter irrigatedand 5 mL of 0.5% bupivacaine are introduced intothe portals. Incisions are closed with one or two3–0 nylon sutures, which remain for 2 weekspostoperatively. Oral muscle relaxants, along withFig. 2.5 Cannulatedendoscopic blade appliedto endoscopeFig. 2.6 Endoscopic view of gastrocnemius transectionwith soleus muscle above
  6. 6. 14 A. Saxena and C.W. DiGiovannidorsiflexion night splinting, can be useful in thepostoperative setting to maintain release and min-imize muscle cramping. If EGR is performed asan isolated procedure, patients are maintained in abelow-knee walking boot for 4–6 weeks, duringthe latter half of which, it is only required at nightand patients are allowed ambulation as toleratedduring waking hours. When more extensive footor ankle procedures are concomitantly performed,they generally dictate postoperative immobiliza-tion and weightbearing status. During the firstfew months of recovery, self-massage of thetransection region and portals is recommended.Physical therapy after surgery is also encouraged,and can be helpful to improve gait and decreasefibrosis. The ability to single-leg “heel-raise” canoccur as soon 6 weeks post-EGR [14].The EGR procedure represents an evolvingpercutaneous technique that has the potential tominimize postoperative scar formation and maxi-mize recovery after gastrocnemius recession.Caution must be exercised in recommendingthis technique, however, because its long-termoutcome and relative complication rate as com-pared with the traditional open technique remainunknown. The most common adverse event notedpostoperatively with this approach appears to betransient lateral foot dysesthesia. In our experi-ence, this is most likely due to traction neuritis ofthe sural nerve, which we have also seen with theopen procedure after obtaining an acute increasein ankle dorsiflexion [5, 15]. However, this istypically a benign and self-limiting problem.Based on cadaveric experimentation, sural nervelaceration and/or incomplete gastrocnemiusrelease may prove to be significant risks of thisprocedure as compared with the open approach,primarily due to impaired visualization. Otherpotential complications of EGR yet to be fullydefined include hematoma, adherence/tenting,push-off weakness, and calcaneus deformity(Fig. 2.7). The procedure is also highly equip-ment dependent, requiring significantly greateramounts of instrumentation as compared with thestandard release. Unfortunately, this equipment isoften not otherwise required for most foot/ankleprocedures that might be required at the time ofgastrocnemius recession, and thus this need rep-resents an added burden to both surgeon andoperating room personnel. With experience, thetotal time required for the EGR approaches thatfor the OGR.Experience with the EGR technique remainsin its infancy. Few studies have been publishedon any advantages, disadvantages, or compara-tive results of EGR. While the procedure mayhold promise in terms of minimizing incisionalissues and maximizing recovery times after iso-lated gastrocnemius recession, its use should beconsidered cautiously, and more thorough evalu-ation is mandatory before EGR can be safelyadvocated for general use (Table 2.2). Withincreased experience, however, we think the EGRmay eventually become a safe and preferablemeans of gastrocnemius recession. To date, how-ever, the open technique remains the gold stan-dard and should still be considered the mostefficient, reliable, and user-friendly means ofgastrocnemius recession.Fig. 2.7 “Tenting” or soleus adherence to subcutaneoustissue
  7. 7. 152 Endoscopic Gastrocnemius RecessionTable2.2Otherauthors’resultsofendoscopicgastrocnemiusrecessionAuthorCommentNetimprovementinankledorsiflexionNervetransectionLateraldysesthesiaHematomaCalcanealgaitPoorcosmesisTashjianetal.[19,22]CadavericNS1NANANANASaxenaandWidtfeldt[14]18cases12.6°None3NSNS1Trevinoetal.[20]31casesNSNoneNSNSNSNSDiDomenicoetal.[5]31cases18°NoneNS13NSPouletal.[12]18caseswithcerebralpalsy20°NSNS0NSNSSaxenaandWidtfeldt[15]54cases14.8°None6/54(11%)116/54(11%)NSnotstudied,NAnotapplicable
  8. 8. 16 A. Saxena and C.W. DiGiovanniReferences1. Leversedge F, Casey P, Seiler J, Xerogeanes J.Endoscopically assisted fasciotomy: description oftechnique and in-vitro assessment of lower-legcompartment decompression. Am J Sports Med 30(2):272–278, 20022. Mirza A, King E. Newer techniques of carpal tunnelrelease. Orthop Clin North Am 27:355–371, 19963. Saxena A. Uniportal endoscopic plantar fasciotomy: aprospective study on athletic patients. Foot Ankle Int25(12):882–889, 20044. Armstrong D, Stacpoole-Shea S, Nguyen H,Harkless L. Lengthening of the achilles tendon indiabetic patients who are at high risk for ulceration ofthe foot. J Bone Joint Surg 81A(4):535–538, 19995. DiDomenico L, Adams H, Garehar, D. Endoscopicgastrocnemius recession for the treatment of gastroc-nemius equinus. J Am Podiatr Med Assoc 95(4):410–413, 20056. Hansen ST. Midfoot arthrodesis In: Wulker N,Stephens M, Cracchiolo A (eds.) Atlas of Foot andAnkle Surgery. St. Louis, MO, Mosby, p. 154, 19987. Hansen ST: Tendon transfers and muscle balancingtechniques. Achilles tendon lengthening. In: Hansen S(ed.) Functional Reconstruction of the Foot andAnkle.LippincottWilliams&Wilkins,Baltimore,MD,pp. 415–421, 20008. Laborde J. Tendon lengthenings for forefoot ulcers.Wounds 17(5):122–130, 20059. Mueller M, Sinacore D, Hastings M, Johnson J. Theeffect of Achilles tendon lengthening on neuropathicplantar ulcers: a randomized clinical trial. J BoneJoint Surg 85-A(8):1436–45, 200310. Pinney S, Sangeorzan B, Hansen ST. Surgical anat-omy of the gastrocnemius recession (Strayer proce-dure) Foot Ankle Int 25(4): 247–250, 200411. Pinney SJ, Hansen ST, Sangeorzan BJ. The effect onankle dorsiflexion of gastrocnemius recession. FootAnkle Int 23(1):26–29, 200212. Poul J, Tuma J, Bajerova J. Video-assisted tenotomyof the triceps muscle of the calf in cerebral palsypatients. Acta Chir Orthop Traumatol Cech 72(3):170–172, 200513. Saxena A. Endoscopic gastrocnemius tenotomy.J Foot Ankle Surg 41(1):57–58, 200214. Saxena A, Widtfeldt A. Endoscopic gastrocnemiusrecession: a preliminary report on 18 cases. J FootAnkle Surg 43(5):302–306, 200415. Saxena A, Gollwitzer H, DiDomenico L, Widtfeldt A,Die endoskopische Verlängerungsoperation desMusculus gastrocnemius zur Behandlung desGastrocnemius equinus (German) Z Orthop Unfall145:1–6, 200716. Saxena A, DiGiovanni C. Ankle equinus and the ath-lete. In: Maffulli N, Almekinders M (eds.) TheAchilles Tendon. Springer, New York, 200617. Sgarlato TE. Medial gastrocnemius tenotomy to assistin body posture balancing. J Foot Ankle Surg37(6):546–547, 199818. Takao M, Ochi M, Shu N, Uchio Y, Naito K, Tobita M,Matsusaki M, Kawasaki K. A case of superficial per-oneal nerve injury during ankle arthroscopy.Arthroscopy 17(4):403–404, 200119. Tashjian RZ, Appel AJ, Banerjee R, DiGiovanni CW.Anatomic study of the gastrocnemius-soleus junctionand its relationship to the sural nerve. Foot Ankle Int24:473–476, 200320. Trevino S, Gibbs M, Panchbhavi V. Evaluation ofresults of endoscopic gastrocnemius recession. FootAnkle Int 26(5):35–364, 200521. Trevino S, Panchbhavi V. Technique of endoscopicgastrocnemius recession: cadaveric study. Foot AnkleSurg 8:45–47, 200222. Tashjian R, Appel A, Banerjee R, DiGiovanni C.Endoscopic gastrocnemius recession: evaluation in acadaver model. Foot Ankle Int 24:607–613, 200323. Silverskiold N. Reduction of the uncrossed two-jointsmuscles of the leg to one-joint muscles in spastic con-ditions. Acta Chir Scand 56:315–30, 192424. DiGiovanni C, Kuo R, Tejwani N, Price R, Hansen T,Cziernecki J, Sangeorzan B. Isolated gastrocnemiustightness. J Bone Joint Surg 84A(6):962–970, 200225. Saxena A, Kim W. Ankle dorsiflexion in adolescentathletes. J Am Podiatr Assoc 93(4):312–314, 200326. Webb J, Moonjani N, Radford M. Anatomy of thesural nerve and its relation to the Achilles tendon.Foot Ankle Int 21(6):475–477, 200027. Barouk L, Barouk P. Techniques, results and compari-son between the medial and lateral proximal gastroc-nemius release. Presented at the International SpringMeeting, French Foot Society. Toulouse, France June8–10, 2006
  9. 9.