Silfverskiold's Test in Total Ankle Replacement With Gastrocnemius Recession
Duke University Medical Center, Durham, NC, USA. Foot & Ankle International
(Impact Factor: 1.51).
10/2013; 35(2). DOI: 10.1177/1071100713510498
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.
Available from: Robin M Queen
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Concomitant procedures are being performed with total ankle replacement (TAR) to improve alignment, function, and mobility. The purpose of this study was to examine the differences in outcomes between patients who had a concomitant triceps surae lengthening (gastrocnemius recession [GSR] or triple hemisection [TAL]) versus a group that underwent TAR alone preoperatively and 1 year after TAR.
For this prospective, nonrandomized study, 229 patients (37 GSR, 22 TAL, and 170 TAR alone) were examined. Patient-reported outcomes, physical performance, and lower extremity gait mechanics were completed preoperatively and 1 year postoperatively. A series of repeated measures ANOVAs were used to determine significant differences (P < .05), and Tukey's post hoc testing was used to follow any significant ANOVA results.
No difference existed in BMI, age, gender, or dorsiflexion (DF) angle at heel strike between the triceps surae lengthening groups or between preoperative and 1 year following TAR. Walking speed, the physical performance measures, the AOFAS Hindfoot Score, SF-36, peak plantar flexion angle, and the peak plantar flexion moment were significantly improved (P < .001) postoperatively with no differences between the triceps surae lengthening groups. The peak DF angle (P = .006) and the ankle range of motion (P = .014) demonstrated a greater improvement from preoperative to 1 year postoperatively in the triceps surae lengthening groups in comparison to the TAR alone group.
Significant improvements existed between preoperative and 1 year postoperatively for most of the variables of interest independent of the triceps surae lengthening group. This study demonstrated that the use of a concomitant triceps surae lengthening procedure (GSR or TAL) resulted in equivalent outcomes when compared with a group undergoing TAR alone.
Level of evidence:
Level II, prospective comparative study.
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ABSTRACT: Intramuscular lengthening of the gastrocnemius and/or soleus (Baumann procedure) is widely used in patients who have cerebral palsy, with several advantages over other lengthening techniques. Tightness of the gastrocnemius or gastrocnemius-soleus complex has been confirmed to be related to flatfoot deformity. The purpose of this study was to evaluate the mid-term results of the Baumann procedure as a part of the treatment of flatfoot with equinus deformity.
We reviewed 35 pediatric and adult patients (43 feet) with flatfoot who underwent the Baumann procedure for the concomitant equinus deformity. The mean duration of follow-up was 39.4 months. Preoperative and follow-up evaluations included the maximal angle of dorsiflexion of the ankle with the knee fully extended and with the knee flexed to 90 degrees, the American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores, and postoperative complications.
Preoperatively, the mean angle of passive ankle dorsiflexion with the knee extended was -4.7 ± 2.7 degrees and that with the knee flexed was 2.3 ± 2.5 degrees. At the final follow-up, both values improved significantly by a mean of 13.6 degrees (P < .001) and 9.7 degrees (P < .001), respectively. The average AOFAS-AH scores improved from 56.8 points preoperatively to 72.1 at the final follow-up. Recurrence of equinus was observed in 3 patients (4 feet). There were no cases of overcorrection, neurovascular injury, or healing problems.
Our results indicate that the Baumann procedure can effectively and sequentially correct the tightness of the gastrocnemius or the gastrocnemius-soleus complex in patients with flatfoot deformity, without obvious postoperative complications.
Level IV, retrospective case series.
© The Author(s) 2015.
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ABSTRACT: Obtaining functional alignment of a total ankle replacement, including physiologic sagittal plane range of motion, is paramount for a successful outcome. This article reviews the literature on techniques available for correction of osseous and soft-tissue equinus at the time of index total ankle replacement. These techniques include anterior tibiotalar joint cheilectomy, posterior superficial muscle compartment lengthening, posterior ankle capsule release, and release of the posterior portions of the medial and lateral collateral ligament complexes. The rationale for these procedures and the operative sequence of events for these procedures are presented.
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