Isolated Recession of the Gastrocnemius Muscle: The Baumann Procedure

ArticleinFoot & Ankle International 28(11):1154-9 · December 2007with368 Reads
DOI: 10.3113/FAI.2007.1154 · Source: PubMed
Abstract
The Baumann procedure consists of intramuscular lengthening (recession) of the gastrocnemius muscle in the deep interval between the soleus and gastrocnemius muscles. The goal of the procedure is to increase ankle dorsiflexion when ankle movement is restricted by a contracted gastrocnemius muscle. Unlike the Vulpius procedure, the Baumann procedure truly isolates the lengthening site to the gastrocnemius muscle and does not lengthen the soleus muscle. The Baumann procedure has not previously been studied in cadaver specimens. The gastrocnemius and soleus muscles of 15 normal cadaver specimens had four sequential releases: a single gastrocnemius recession, a second gastrocnemius recession, a single soleus recession, and an Achilles tenotomy. Ankle dorsiflexion was measured with a goniometer initially, after each muscle recession, and after the tenotomy. After the second gastrocnemius recession, the average increase in ankle dorsiflexion measured 14 degrees with the knee extended and 8 degrees with the knee flexed. The Baumann procedure treats equinus contracture of the gastrocnemius muscle by improving ankle joint dorsiflexion. The procedure is indicated when the results of the Silfverskiöld test are positive.
    • The present study shows that during a ventral gastrocnemius recession (Saraph et al. 2000, Blitz and Rush 2007, Herzenberg et al. 2007) through a medial incision at the MFRL, only the medial head of the gastrocnemius muscle is visualized, while the sural nerve (in a more lateral location) is not always easy to locate. A blind recession of the fascia at the MFRL puts the sural nerve at risk at the intramuscular septum (Herzenberg et al. 2007), as well as on the lateral fascia/tendon, where the nerve courses toward the lateral malleolus and is not protected by a muscle head as on the medial side (Figures 1 and 3). A more proximal recession avoids the risk of injuring the sural nerve between both heads of the gastrocnemius muscle and the descending course at the lateral side, and is therefore preferable.
    [Show abstract] [Hide abstract] ABSTRACT: Background and purpose — Many methods of gastrocnemius lengthening have been described, with different surgical challenges, outcomes, and risks to the sural nerve. Our aims were (1) to locate the gastrocnemius muscular-tendinous junction in relation to the mid-length of the fibula (from here on designated the mid-fibula), (2) to compare the dorsiflexion achieved with dorsal recession or ventral recession, and (3) to determine the risk of injury to the sural nerve during gastrocnemius recession. Methods — In 10 pairs of fresh-frozen adult cadaveric lower extremities transected above the knee, we measured dorsiflexion, performed dorsal or ventral gastrocnemius recession at the mid-fibula, and then measured the increase in dorsiflexion and fasciotomy gap. We noted the course of the sural nerve and whether the gastrocnemius muscle provided it with enough muscular coverage to protect it during recession. Results — Dorsal and ventral recession produced statistically (p < 0.05) and clinically significant mean increases in dorsiflexion with extended knee from 12° to 19°, but they were not statistically significantly different from each other in this measure or in fasciotomy gap size. At the mid-fibula, the sural nerve coursed superficially between both heads of the gastrocnemius muscle in 14 of 20 specimens. Sufficient gastrocnemius muscle coverage to protect the sural nerve was provided by the medial head in 18 of 20 specimens and by the lateral head in only 5 of 20 specimens. Interpretation — A ventral gastrocnemius recession proximal to the mid-fibula level poses less risk to the sural nerve than a recession at the mid-fibula. This procedure provides adequate lengthening (1–3 cm) and increased dorsiflexion (compared with baseline), with less risk to the sural nerve than is incurred with recession at the mid-fibular reference line.
    Article · Apr 2017
    • Gastrocnemius recession can be performed as an open or an endoscopic procedure. The many open techniques described [15][16][17][18][19]include distal gastrocnemius recession (Strayer), proximal gastrocnemius release from the femoral condyles (Silfverski?ld), division of the gastrocnemius aponeurosis (Vulpius), and various open and percutaneous Achilles tendon lengthening procedures .
    [Show abstract] [Hide abstract] ABSTRACT: Background Isolated gastrocnemius contracture is thought to lead to numerous conditions. Although many techniques have been described for gastrocnemius recession, potential anesthetic, cosmetic, and wound-related complications can lead to patient dissatisfaction. Open and endoscopic recession techniques require epidural anesthesia, lower limb ischemia, and stitches and may lead to damage of the sural nerve, which is not under the complete control of the surgeon at all stages of the procedure.The purpose of this study was to evaluate the safety and efficacy of a new technique based on ultrasound-guided ultra–minimally invasive gastrocnemius recession. Methods We performed a pilot study with 22 cadavers to ensure that the technique was effective and safe. In the second phase, we prospectively performed gastrocnemius recession in 23 patients (25 cases) with chronic non-insertional Achilles tendinopathy, equinus foot, and other indications. In the clinical study, we evaluated the range of dorsiflexion before and after the procedure, clinical outcomes with VAS and AOFAS scores, and potential complications, including neurovascular injuries. ResultsWe achieved complete release of the gastrocnemius tendon in all cases in the cadaveric study, with no damage to the sural nerve or vessels and minimal damage to the underlying muscle fibers. Ankle dorsiflexion increased for every patient in the study (mean, 14°; standard deviation, 3°) and was maintained throughout follow-up. The mean preoperative VAS score was 7 (6–9), which improved to 0 (0–1). The AOFAS Ankle-Hindfoot Score improved from a mean of 30 (20–40) to 93 (85–100) at 6 months. No major complications were observed. All patients returned to their previous sports after 6 months. Conclusions After cadaveric and clinical study, we considered the technique to be safe and effective to perform ultrasound-guided ultra–minimally invasive gastrocnemius recession using a 1-mm incision in vivo. This novel technique represents an alternative to open techniques, with encouraging results and with the advantages of reducing pain, obviating lower limb ischemia, deeper anaesthesia, thus decreasing complications and contraindications and accelerating recovery.
    Full-text · Article · Oct 2016
    • While the most popular method of recession in the past few years has been a modified variation of the Strayer technique, the proximal medial gastrocnemius release has been gaining popularity recently [12,13,18,33]. Advantages of release at the proximal aponeurosis as opposed to more distal techniques include a superior cosmetic scar, diminished risk of injury to the sural nerve, and a lower risk of calf weakness as opposed to more distal techniques [13,28]. Abbassian et al. [13] noted that the proximal technique is especially well suited to individuals suffering from more mild contractures.
    [Show abstract] [Hide abstract] ABSTRACT: Gastrocnemius recession is a surgical technique commonly performed on individuals who suffer from symptoms related to the restricted ankle dorsiflexion that results when tight superficial posterior compartment musculature causes an equinus contracture. Numerous variations for muscle-tendon unit release along the length of the calf have been described for this procedure over the past century, although all techniques share at least partial or complete release of the gastrocnemius muscle given its role as the primary plantarflexor of the ankle. There exists strong evidence to support the use of this procedure in pediatric patients suffering from cerebral palsy, and increasingly enthusiastic support—but less science—behind its application in treating adult foot and ankle pathologies perceived to be associated with gastrocnemius tightness. The purpose of this study, therefore, was to evaluate currently available evidence for using gastrocnemius recession in three adult populations for whom it is now commonly employed: Achilles tendinopathy, midfoot-forefoot overload syndrome, and diabetic foot ulcers.
    Full-text · Article · Feb 2015
    • Hierzu hat sich der Silverskjöld-Test bewährt [24]. Die allgemein verbreitete Operationsmethode zur Behandlung der Gastroknemiuskontraktur ist die offene Technik in Bauchlage des Patienten [2, 4, 5, 6, 7, 11, 16, 17, 18, 20, 25, 26, 27] . Beschrieben wurde auch ein posteromedialer Zugang, der in Rückenlage angewendet werden kann [22].
    [Show abstract] [Hide abstract] ABSTRACT: Das endoskopische Release des M.gastrocnemius ist eine minimalinvasive Behandlungsmöglichkeit des muskulär bedingten Spitzfußes. Die kleinen Inzisionen und die Möglichkeit, den Eingriff in Rückenlage durchzuführen, stellen Vorteile dieses Operationsverfahrens dar. Mehrere Studien belegen eine Verbesserung der Dorsalextension im oberen Sprunggelenk (OSG) von durchschnittlich 13–20° durch die endoskopische Gastroknemiusverlängerung. Im folgenden Beitrag wird die endoskopische Operationstechnik dargestellt. Endoscopic gastrocnemius recession is a minimally invasive technique to treat gastrocnemius equinus. Smaller incisions and the ability to perform the procedure with the patient in the supine position are the advantages. Several studies have shown an increase in ankle dorsiflexion of 13–20° by endoscopic gastrocnemius recession. In the following article the endoscopic technique of gastrocnemius recession is presented. SchlüsselwörterAchillessehne–M.gastrocnemius–Verlängerung–Spitzfuß–Endoskopie KeywordsAchilles tendon–Gastrocnemius muscle–Lengthening–Equinus–Endoscopy
    Full-text · Article · Nov 2011
    • Surgical techniques referred to as open (Strayer 1950; Pinney et al. 2004; Lamm et al. 2005; Herzenberg et al. 2007) or endoscopic muscle recession (e.g. Saxena and Widtfeldt 2004; Grady and Kelly 2010), intramuscular aponeurotic recession (Blitz and Rush 2007), muscle release (e.g.
    [Show abstract] [Hide abstract] ABSTRACT: The goal was to assess the effects of multiple aponeurotomy on mechanics of muscle with extramuscular myofascial connections. Using finite element modelling, effects of combinations of the intervention carried out at a proximal (P), an intermediate (I) and a distal (D) location were studied: (1) Case P, (2) Case P-I, (3) Case P-D and (4) Case P-I-D. Compared to Case P, the effects of multiple interventions on muscle geometry and sarcomere lengths were sizable for the distal population of muscle fibres: e.g. at high muscle length (1) summed gap lengths between the cut ends of aponeurosis increased by 16, 25 and 27% for Cases P-I, P-D and P-I-D, respectively, (2) characteristic substantial sarcomere shortening became more pronounced (mean shortening was 26, 29, 30 and 31% for Cases P, P-I, P-D and P-I-D, respectively) and (3) fibre stresses decreased (mean stress equalled 0.49, 0.39, 0.38 and 0.33 for Cases P, P-I, P-D and P-I-D, respectively). In contrast, no appreciable effects were shown for the proximal population. The overall change in sarcomere length heterogeneity was limited. Consequently, the effects of multiple aponeurotomy on muscle length-force characteristics were marginal: (1) a limited reduction in active muscle force (maximal 'muscle weakening effect' remained between 5 and 11%) and (2) an even less pronounced change in slack to optimum length range of force exertion (maximal 'muscle lengthening effect' distally was 0.2% for Case P-I-D) were shown. The intended effects of the intervention were dominated by the one intervention carried out closer to the tendon suggesting that aponeurotomies done additionally to that may counter-indicated.
    Full-text · Article · Aug 2011
    • With these improvements, the ranges of values may better meet the comparable standards of dorsiflexion for child athletes [13]. Increased dorsiflexion serves as a key outcome for many studies of equinus deformity [5, 8, 11, 14]. By ensuring proper visualization of the sural nerve every time before making the cut, nerve dysesthesia was avoided.
    [Show abstract] [Hide abstract] ABSTRACT: Gastrocnemius recessions have been performed as open or endoscopic procedures. Most of the literature describes the outcomes of these procedures in children with specific neurologic limitations. We report an alternative approach to endoscopic gastrocnemius recessions in neurologically healthy pediatric and adolescent patients whose gastrocnemius equinus could not be corrected nonoperatively. We prospectively followed 23 patients (16 boys, seven girls) who underwent 40 procedures for equinus deformity (n = 22) or osteoarthritis (n = 1). All patients had been directly referred for surgical treatment because all previous nonoperative treatments (stretching, night splints, orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy) had failed. The indications for surgery were patients age 18 years or younger experiencing symptomatic equinus unresponsive to nonoperative care. Pre- and postoperative ankle dorsiflexion were measured. The minimum followup for study inclusion was 1 year (mean, 2.9 years; range, 2–5.1 years). For every patient, dorsiflexion range of motion improved (mean, 15°; standard deviation, 4°). No patient had diminished nerve sensation postoperatively. This technique can be used to correct gastrocnemius equinus in otherwise healthy children who have not benefited from prior nonsurgical treatment. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
    Full-text · Article · Sep 2009
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