Silfverskiold's Test in Total Ankle Replacement With Gastrocnemius Recession
ABSTRACT For patients undergoing primary total ankle replacement (TAR) with an equinus contracture, gastrocnemius recession may be performed to increase dorsiflexion. We examined whether gastrocnemius recession would significantly increase dorsiflexion even with a negative Silfverskiöld test.
Data were prospectively collected on a consecutive series of 29 patients who underwent TAR. All were deemed to require lengthening of the posterior soft tissue structures for unacceptable equinus contracture. Once each patient was under anesthesia, Silfverskiöld's test was performed. A digital photograph was taken with the ankle at maximum passive dorsiflexion with the knee at 0 degrees of flexion and again with the knee at 30 degrees of flexion. Strayer gastrocnemius recession was then performed in standard fashion in every patient. After recession, Silfverskiöld's test was again performed with photographs obtained in the same manner. The digital photographs demonstrating the results of the preoperative and postoperative Silfverskiöld's tests in both knee positions were analyzed and the degree of ankle dorsiflexion measured.
Regardless of the results of Silfverskiöld's test, after gastrocnemius recession, patients had an average increase of 12.6 ± 1.6 degrees of dorsiflexion with the knee extended compared to the same position preoperatively (P < .0001) and an increase of 10.1 ± 2.0 degrees with the knee flexed (P < .001). In 6 patients Silfverskiöld's test was markedly positive preoperatively; in this group, recession resulted in an average increase of dorsiflexion of 17.8 ± 3.6 degrees with the knee extended (P = .004) and 13.4 ± 5.4 degrees with the knee flexed (P = .055). For the remaining 23 patients with a negative preoperative Silfverskiöld's test, dorsiflexion increased by 11.3 ± 1.6 (P < .0001) and 9.3 ± 2.2 degrees (P = .0003) with the knee extended and flexed, respectively.
Our data show that a gastrocnemius recession resulted in a significant, reproducible increase in dorsiflexion regardless of the results of the Silfverskiöld test while avoiding potential push-off and plantarflexion weakness associated with an Achilles lengthening.
Level IV, case series.
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ABSTRACT: Isolated gastrocnemius contracture (IGC), which limits ankle dorsiflexion with full knee extension, can affect function and quality of life. Gastrocnemius recession is a treatment option for IGC when conservative treatment fails. The goal of this study was to assess range of motion, function, and plantarflexion strength pre- and 3-months post-gastrocnemius recession for subjects with IGC. Ankle range of motion, function, and plantarflexion strength in seven legs (four subjects), clinically diagnosed with IGC, before and after surgery were compared to matched control subjects to elucidate pre- and post-surgical intervention differences. All subjects with IGC were also diagnosed with plantar fasciitis with one leg having an additional diagnosis of metatarsalgia. Subjects with IGC had significant post surgical improvements at 3 months after surgery in dorsiflexion range of motion (p = 0.016), function (p = 0.016) and isokinetic plantarflexion strength (p = 0.018). Surgical recession enhanced range of motion and self reported function while not inducing any detrimental effects to plantarflexion strength at a 3-month followup. Post-surgically IGC subjects were more similar to healthy controls.Foot & Ankle International 05/2010; 31(5):377-84. DOI:10.3113/FAI.2010.0377 · 1.63 Impact Factor
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ABSTRACT: The accepted hallmarks of care for plantar forefoot ulceration are meticulous wound care, nutrition, management of infection, and non-weight bearing of the ulcerative area. Tendo-Achilles lengthening is crucial in healing these ulcerations when it is determined that the Achilles tendon is one of the main biomechanical stresses that led to the ulceration. The Silfverskiold test helps determine whether a percutaneous lengthening or gastrocnemius recession is called for. A gastrocnemius recession is the safer operation because it does not carry the postoperative risk of overlengthening or rupture, calcaneal gait, and subsequent plantar heel ulceration, but gastrocnemius recession carries a higher late recurrence rate of late plantar forefoot reulceration (16%). A more permanent result can be achieved with percutaneous tendo-Achilles lengthening, although one assumes the associated risk of overlengthening the tendo-Achilles, calcaneal gait, and the difficult-to-treat plantar calcaneal ulceration. It is crucial to address other biomechanical abnormalities that may have contributed to the specific plantar ulceration, such as hammer toe, prominent plantar metatarsal head, prominent sesamoids, and long metatarsal. In addition, the patient should be placed in proper footwear, which at the minimum includes orthoses but may include specialized accommodative shoe wear. Failure to include these adjunctive procedures to Achilles tendon lengthening may prevent healing or hasten ulcer recurrence. Future studies will be directed toward determining the roles of prophylactic Achilles tendon lengthening preventing equinovarus deformities, possible plantar foot ulceration, and Charcot collapse.Surgical Clinics of North America 07/2003; 83(3):707-26. DOI:10.1016/S0039-6109(02)00191-3 · 1.93 Impact Factor