Updated: 10/4/2016

Gastrocnemius Recession

Preoperative Patient Care

A

Intermediate Evaluation and Management

1

Obtains focused history and physical

  • history
  • screens for conditions that can cause equinus
  • e.g. cerebral palsy, muscular dystrophy, charcot-marie-tooth
  • duration of equinus contracture
  • symptoms
  • pain, weakness, callusing, tripping, diificulty with shoe or brace wear
  • physical exam
  • recognizes factors that could predict complications or poor outcome
  • dystonia

2

Orders and interprets required diagnostic studies

  • radiographs (often not needed)
  • weight bearing foot films if unclear if cavus is the cause of toe-walking
  • hip xrays if associated condition (e.g. Charcot-Marie-Tooth) is associated with hip dysplasia

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • failure of serial casting
  • failure of bracing
  • describes accepted indications and contraindications for surgical intervention
  • Indications
  • persistent equinus in gait after failed nonoperative management
  • with a postive silverskild test for equinus only with the knee extended and not when it it flexedo
  • contraindications
  • lateral xray demonstrating cavus instead of equinus
  • negative silverskiold test
  • persistent equinus with the knee flexed and extended- and achilles lengthening may be indicated
  • dystonia- must exercise caution with tendon lengthenings in the presence of dystonia as the opposte reaction can occur.

4

Postop: 3-4 Week Postoperative Visit

  • wound check
  • change the short leg walking cast
  • measure for AFO brace (to be provided when second cast removed 6 weeks post-op)
  • diagnose and management of early complications
  • prescribe postoperative physical therapy and bracing
  • silverskiold test
  • popliteal angle, knee flexion contractures
  • range of motion hips, arms, asses for scoiliosis
  • asses gait, look for crouch
B

Advanced Evaluation and Management

1

Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively
  • recurrent equinus
  • initiate stretching casts
  • night time stretching brace with knee immobilizer
C

Preoperative H & P

1

Obtains history and performs basic physical exam

  • check range of motion
  • performs a silverskiold test which evaluates ankle dorsiflexion with the knee flexed and extended
  • if tight only in knee extension but not in knee flexion then a gastronemius recession is necessary
  • if tight in both knee flexion and extension then an achilles lengthening may be necessary
  • identify medical co-morbidities that might impact surgical treatment
  • dystonia
  • hamstring contractures
  • if equinus is corrected and hamstring contracture is not corrected the child will crouch more

2

Screen medical studies to identify and contraindications for surgery

  • history of cardiac pathology need cardiac clearance
  • bronchopulmonary dysplasia, recurrent pneumonias, pulmonary insufficiency, need pulmonary clearance
  • screen for malnutrition if any GI history or malabsorpstion

3

Orders appropriate initial imaging and laboratory studies

  • weight bearing lateral foot films are occasionally indicated
  • can distinguish between cavus and equinus
  • gait analysis study
  • will identify associated pathologies in spastic patients with cerebral palsy that should be addressed at the same time for optimal care of the child
  • observers tend to overestimate equinus, so gait analysis is important to avoid lengthening the calf in children who do not require such surgery

4

Perform operative consent

  • describe complications of surgery including
  • overlengthening of the triceps surae

Operative Techniques

E

Preoperative Plan

1

Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
  • injury to sural nerve
  • injury to the lesser saphenous vein
F

Room Preparation

1

Room setup and equipment

  • standard OR table
  • this procedure is commonly performed as part of a SEMLS procedure (single event multilevel surgery)
  • may need a radiolucent table for the other procedures
  • tourniquet
  • right angle retractors

2

Patient positioning

  • prone for posterior incision
  • supine for medial incision
  • more conducive to doing concomitent procedures
  • patient is brought to end of table
G

Strayer Procedure

1

Makes either a posterior or medial incision

  • makes a 2- 2.5inch incision either posteriorly over the midcalf with the patient prone or medially with the patient supine
  • carry the dissection to the posterior fascia, which is then incised
  • do not confuse this with the gastrocnemius tendon

2

Protect the neurovascular structures

  • retract and protect the sural nerve and lesser saphenous vein
H

Fascia Lengthening

1

Divide the fascia

  • divide the fascia that overlies the superficial posterior compartment
  • place right angle retractor posterior to the gastrocnemius
  • this protects the saphenous vein and sural nerve

2

Identify the gastrocnemius tendon

  • identify the underlying tendon
  • identify the tendon of the gastrocnemius proximal to the conjoined tendon
  • identify the interval between gastroc tendon and the underlying soleus fascia
  • divide the fascia of the gastrocnemius transversly proximal to the conjoined tendon and leave the underlying muscle intact
  • gastrocnemius recession is done with a 15 blade

3

Test the lengthening procedure performed

  • test to see if the ankle can be dorsiflexed to ten degrees with the knee extended
  • it is essential that the hind-foot be inverted when performing this test
  • failure to do this will result in dorsiflexion coming from the foot (rather than the ankle) and will result in inadequate correction of equinus
I

Wound Closure

1

Perform a multilayer subcuticular closure

  • release tourniquet prior to closure and obtain hemostasis
  • the subcutaneous layer is closed with an absorbable 2-0 suture in a running locking layer
  • the skin is closed with a running, undyed absorbable monofiliament suture and steristrips
  • place in a cast with the foot in 5-10 degrees of dorsiflexion and inverted

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders for patients undergoing SEMLS

  • advance diet as tolerated
  • IV fluids
  • pain control
  • physical therapy
  • cast management
  • keep cast elevated and heel off of bed

2

Discharges patient appropriately

  • orders pain medication for 7-10 days
  • orders diazepam for 14-21 days for spasm
  • schedule follow up in 1 week and 4 weeks
  • cast care instructions
R

Complex Patient Care

1

Able to develop a comprehensive preoperative plan that includes options based on intraoperative findings

  • able to read do an obsevational gait analysis and make surgical recommendations based on this and physical examination findings
  • postoperative Infection
  • orders labs as part of baseline work up
  • manages wound infection in the outpatient setting with dressing changes and antibiotics when appropriate
  • recognizes and performs irrigation and debridement when necessary for a wound infection the requires more aggressive treatment.
  • complex regional pain syndrome
  • identifies the condition when it is present
  • limits immobilization and prescribes therapy for desensitization
  • refers to pain management in cases not responding quickly to desensitization
 

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