Achilles Tendon Lengthening.pptx

ATL

1. Achilles Tendon Lengthening Ahmad Syaukat

2. Relevant Anatomy Source: netter, 2010 Act as ankle and plantar flex foot Maintain static and dynamic posture Gastrocnemius muscle Origin: Lateral and medial femoral condyles Insertion: Calcaneus (via Achilles tendon) Nerve: Tibial Soleus muscle Origin: Posterior fibular head/soleal line of tibia Insertion: Calcaneus (via Achilles tendon) Nerve: Tibial

3. Gastrocnemius muscle The gastrocnemius comprises two heads that originate from the posterosuperior region of the femoral condyle About 70% of the force of the gastrocnemius is generated by the the medial head The two heads of the gastrocnemius converge to form a large aponeurosis that merges with the soleus aponeurosis

4. Soleus muscle Formed by a large and voluminous muscle mass Lies deeply in relation to the gastrocnemius. The most powerful muscle of the ankle and It represents more than twice of the entire flexion force The aponeurosis of the soleus occupies the anterior face of this muscle and thickens distally. Fuses with the aponeurosis of the gastrocnemius to give rise to the calcaneus tendon.

5. Achilles Tendon S trong , but of the most frequently injured tendons of the human body Length 15 cm (11-26cm) , width 6.8 cm (4.5–8.6 cm) , gradually decreases at the midsection (1.8 cm, range 1.2 - 2.6 cm). The blood supply of the tendon, from the musculotendinous junction, surrounding connective tissues, and the osteotendinous junction Anatomical site: Intramuscular, free tendon, calcaneal. Del Buono A, Chan O, Maffulli N. Achilles tendon: functional anatomy and novel emerging models of imaging classification. International Orthopaedics. 2012;37(4):715-721.

6. Achilles Tendon Lengthening A surgical procedure that aims to stretch the Achilles tendon to allow a person to walk flat-footed without a bend in the knee Treating Achilles tendon/gastrocnemius contracture I mprove the dorsiflexion of ankle and correct equinus deformity I deally to 10 degrees of ankle dorsiflexion past neutral with the knee flexed and 5 degrees with the knee fully extended Open Or Percutaneous

7. Indication Operative indications a. Failure of nonoperative treatment to achieve and maintain at least 10° of ankle dorsiflexion above neutral with the subtalar joint in neutral alignment and the knee extended, if this lack of flexibility causes: i . pain under the metatarsal (MT) heads, ii. pain along the Achilles musculotendinous continuum, and/or iii. functional disability with gait disturbance. S. Mosca V. Principles and Management of Pediatric Foot and Ankle Deformities and Malformations. 1st ed. Lippincott Williams & Wilkins; 2014.

8. Preoperative Planning Thorough history and physical examination Inquire about birht history Brain injury leading to cerebral palsy Inquire about family history Heritable neuromuscular disease Physical examination: inspection of the entire lower extremities (hip, knee, and foot) in supine or prone; gait, ankle rom, neurological exam. Key diagnostic: silfverskiold test Tabaie, S., & Videckis, A. (2021). Achilles Lengthening. JPOSNA®, 3(3). https://doi.org/10.55275/JPOSNA-2021-310

9. Preoperative Planning AP and Lateral weight-bearing radiographs of the ankle Used to evaluate lateral tibiocalcanel angle (normal 25-60) Consider abnormal osseus characteristics Flattened talar dome, anterior distal tibial osteophytes Talar sphericity patterns: (A) normal, enabling good mobility of the joint, (B) slightly flattened, (C) greatly altered or flat. Ankle Joint–Lateral view: (A) grade 0 normal, (B) grade 1 anterior tibial osteophyte, (C) grade 3 anterior tibial osteophyte, (D) grade 3 anterior tibial osteophyte Tabaie, S., & Videckis, A. (2021). Achilles Lengthening. JPOSNA®, 3(3). https://doi.org/10.55275/JPOSNA-2021-310

10. The Silfverskiold Test A. Testing the soleus and effectively, the entire triceps surae / tendo -Achilles Flex the knee to relax the gastrocnemius Ensure that the talonavicular joint is in neutral alignment (Blackdot) Maximally dorsiflex the ankle joint (black arrow above foot) and record the angle between the plantar–lateral border of the foot (red line) and the anterior border of the tibial shaft (red line). Ankle dorsiflexion greater than or equal to 1 0° is normal B. Testing the gastrocnemius: While maintaining subtalar neutral, extend the knee to tighten the proximal end of the gastrocnemius. Record the angle between the plantar–lateral border of the foot and the anterior border of the tibial shaft. In this case, the ankle lacks about 5° of dorsiflexion from neutral, indicating contracture of the gastrocnemius. Mosca V. (2014) Principles and management of pediatric foot and ankle deformities and malformations (1st ed). Wolters Kluwer Health

11. Procedure of ATL Six procedures for gastrocnemius-soleus lengthening according to zone. TAL, Tendo Achilles lengthening. Azar F, Beaty J, Canale S, Campbell W. (2021) Campbell's operative orthopaedics 14th edition . Elsevier

12. Gastrocnemius Recession (Strayer Procedure) Indications Contracture of the gastrocnemius but not the soleus as determined by the Silfverskiold te st that is creating pain, functional disability, and/or gait disturbance The ankle joint can be dorsiflexed more than 10° with the subtalar joint locked in neutral alignment and the knee flexed, but less than 10° with the knee extended S. Mosca V. Principles and Management of Pediatric Foot and Ankle Deformities and Malformations. 1st ed. Lippincott Williams & Wilkins; 2014.

13. Gastrocnemius Recession (Strayer Procedure) Procedure Make a 4- to 5-cm longitudinal incision approximately halfway between the knee and the ankle 2 fingerbreadths posterior to the posterior edge of the medial face of the tibia Avoid and protect the long saphenous vein Open the facia longitudinally Identify the plantaris tendon along the medial edge of the gastrocnemius tendon and divide it Identify the musculotendinous junction of th e gastrocnemius Clear all soft tissues off the posterior surface of the aponeurotic tendon of the gastrocnemius S. Mosca V. Principles and Management of Pediatric Foot and Ankle Deformities and Malformations. 1st ed. Lippincott Williams & Wilkins; 2014.

14. Gastrocnemius Recession (Strayer Procedure) Identify the sural nerve in the fat on the posterior surface of the gastrocnemius, elevate it off the tendon, retract it, and protect it during the tenotomy Using finger-dissection or scissor spreading, elevate a short segment of the distal musculotendinous unit of the gastrocnemius off the soleus from medial to lateral until the muscle of the soleus can be visualized lateral to the aponeurotic tendon of the soleus Avoid extensive proximal-to-distal separation of th e two aponeurotic tendons to prevent excessive retraction of the gastrocnemius muscle Cut the gastrocnemius aponeurosis as far distally as possible. Recheck the Silfverskiold test There is no need to suture the gastrocnemius tendon , or facia Apply a short-leg walking cast with a neutral to 5° dorsiflexed ankle, Maintain the cast for 5 to 6 weeks Azar F, Beaty J, Canale S, Campbell W. (2021) Campbell's operative orthopaedics 14th edition . Elsevier

15. Gastrocnemius Recession (Strayer Procedure) Pitfalls Inadequate deformity correction due to incorrect determination of the appropriateness for a gastrocnemius recession when, in fact, the soleus is also contracted Release of both the gastrocnemius and the soleus aponeuroses Complications Injury to the sural nerve Adherence of the skin to the muscle, creating an obvious tethering effect with muscle contraction Excessive migration of the gastrocnemius muscle with unusually prominent ball-like contours of the two heads of the muscle Azar F, Beaty J, Canale S, Campbell W. (2021) Campbell's operative orthopaedics 14th edition . Elsevier

16. Intramuscular Recession (Bauman Procedure) Procedure A medial incision, 8 to 12 cm long, is made at the junction of the upper and middle thirds of the lower leg B lunt dissection, between gastrocnemius and soleus , The plantaris tendon is resected The ankle is dorsiflexed Starting proximally the aponeurosis over the muscle bellies is divided by two or three parallel transverse incisions 1.5 cm apar t Similar incisions for aponeurotic lengthening of the soleus The ankle is then gradually dorsiflexed until a neutral position Apply a short-leg walking cast with the ankle dorsiflexed no more than 10° Graham HK. The Baumann procedure for fixed contracture of the gastrosoleus in cerebral palsy. J Bone Joint Surg Br. 2000 Sep;82(7):1084-5. PMID: 11041608.

17. Vauman Procedure A useful procedure in children with hemiplegia who have a moderate degree of fixed contracture affecting both the gastrocnemius and the soleus A longitudinal incision of 4 cm the aponeurosis of the gastrocsoleus is divided in chevron fashion and the midline fibrous septum of the soleus is transected, but the soleus muscle fibers are not disturbed Immobilisation in a plaster cast was not required , s upporting bandage was retained for one week in order to prevent local swelling Rehabilitation began on thefirst postoperative day. Either a knee-ankle-foot orthosis(KAFO) or an ankle-foot orthosis (AFO) was used to assist mobilisation Outcome: early rehabilitation, significant improvement of equinus deformity Lengthening of the gastrocnemius by the Vulpius technique Herring J. Tachdjian's pediatric orthopaedics From The Texas Scottish Rite Hospital For Children: Sixth Edition. 6th ed. Elsevier; 2014. Takahashi S, Shrestha A. The Vulpius procedure for correction of equinus deformity in patients with hemiplegia. The Journal of Bone and Joint Surgery British volume. 2002;84-B(7):978-980.

18. Gastrocnemius Recession (Baker Procedure) Azar F, Beaty J, Canale S, Campbell W. (2021) Campbell's operative orthopaedics 14th edition . Elsevier

19. Achilles Tendon Lengthening Indications Contracture of the tendo-achilles as determined by the Silfverskiold te st that is creating pain, functional disability, and/or gait disturbance The ankle joint can be dorsiflexed more than 10° with the subtalar joint locked in neutral alignment and the knee flexed 90° (with an even greater lack of ankle dorsiflexion with the knee extended) Open or Percutaneous Open Adv: Overlengthening, complete tenotomy Disadv: less cosmetic Percutaneous: quick, inexpensive, and free of complications Cont: a percutaneous technique often doesn’t result in adequate correction and can lead to scar formatio n. Disadv: a complete tenotomy can be inadvertently created Compl ication Complete tenotomy, rather than a lengthening, Excessive release of fibers in the percutaneous technique S. Mosca V. Principles and Management of Pediatric Foot and Ankle Deformities and Malformations. 1st ed. Lippincott Williams & Wilkins; 2014.

20. Percutaneous Triple-Cut Tendo-Achilles Lengthening (TAL), a.k.a. Hoke Procedure Procedure I nsert a #15 scalpel through the skin from posterior to anterior ( in the sagittal plane ) just proximal to the calcaneus with the face of the blade parallel with the direction of the tendon fibers. Rotate it 90° and translate it medially (for a varus hindfoot deformity) or laterally (for a valgus hindfoot deformity) to cut the desired half of the tendon’s fibers. Reinsert the scalpel in the same manner approximately 10 to 15 mm more proximally . Reinsert the scalpel again in the same manner approximately 10 to 15 mm more proximally from the second cut Dorsiflex the ankle with the knee extended until a noticeable Apply a short-leg walking cast with the ankle dorsiflexed no more than 10° Maintain the cast for 5 to 6 weeks S. Mosca V. Principles and Management of Pediatric Foot and Ankle Deformities and Malformations. 1st ed. Lippincott Williams & Wilkins; 2014.

21. Open Double Hemisection Procedure Make a 5- to 7-cm longitudinal incision posteromedial aspect of the ankle Divide the plantaris tendon distally Scalpel is inserted distally in the midsagittal plane of the tendo -Achilles , rotated 90° medially and translated until the hemitendon is released. Scalpel inserted proximally in the midcoronal plane of the tendon approximately 4 to 6 cm more proximal than the first cut . The scalpel is rotated 90° posteriorly and translated until the hemitendon is released Dorsiflex the ankle with the knee extended until a noticeable As the ankle is dorsiflexed, the tendon halves begin to slide past each other Apply a short-leg walking cast with the ankle dorsiflexe d no more than 10° Maintain the cast for 5 to 6 weeks S. Mosca V. Principles and Management of Pediatric Foot and Ankle Deformities and Malformations. 1st ed. Lippincott Williams & Wilkins; 2014.

22. Open Z-lengthening TAL A dvantage : ability to correct the most severe contractures ( greater than 20 degrees plantarflexion deformity ) that require the greatest amount of lengthening Disadv: Cosmetic, Overlengthening Procedure Make a 5- to 7-cm longitudinal incision posteromedial aspect of the ankle , proximal to distal Divide the plantaris tendon distally , released it The scalpel is inserted into the tendo -Achilles in the midsagittal plane proximal to its insertion on the calcaneus. The scalpel is advanced distally to the insertion site on the calcaneus and turned 90° medially The medial half of the tendon fibers are released from the calcaneus and the free end is elevated . The tendon division is continued proximally . Place tagging sutures in both tendon ends The lateral half of the tendon is divided approximately 5 to 6 cm. proximal to the distal cut. With the ankle dorsiflexed 10° and the knee extended, the lead sutures are pulled in opposite directions to create moderate tension on the overlapping halves of the tendon. repair the overlapping ends of the tendon under moderate tension with 2-0 absorbable sutures Apply a short-leg walking cast with the ankle dorsiflexe d no more than 10° Maintain the cast for 5 to 6 weeks S. Mosca V. Principles and Management of Pediatric Foot and Ankle Deformities and Malformations. 1st ed. Lippincott Williams & Wilkins; 2014.

23. Post Operative Care Apply short leg cast Four – six weeks, the patient is allowed to bear full weight The cast is removed, and an ankle-foot orthosis in maximal dorsiflexion or molded with AFO Physical therapy Azar F, Beaty J, Canale S, Campbell W. (2021) Campbell's operative orthopaedics 14th edition . Elsevier

24. Complications Overlengthening of tendon is most common complication Reoccurance of contracture 9 – 21 % in spastic hemiplegia and diplegic children with cerebral palsy Casting and transitioning to an AFO to minimize reoccurance

25. Summary Achilles Lengthening correct fixed ankle equinus Improve ankle dorsiflexion 10° past neutral with knee flexed, 5° with knee fully extended Ensure fixed ankle equines exist with both knee flexed and extended (Silfverskiold test) Gastrocnemious resection (open or percutaneous) and Achilles tendon lenthening Asses preoperative, intraoperative and postoperative care

26. References Azar F, Beaty J, Canale S, Campbell W. (2021) Campbell's operative orthopaedics 14th edition . Elsevier S. Mosca V. Principles and Management of Pediatric Foot and Ankle Deformities and Malformations. 1st ed. Lippincott Williams & Wilkins; 2014. Herring J. Tachdjian's pediatric orthopaedics From The Texas Scottish Rite Hospital For Children: Sixth Edition. 6th ed. Elsevier; 2014. Weinstein S, Flynn J. Lovell and Winter's pediatric orthopaedics . Philadelphia, PA: Lippincott Williams & Wilkins; 2014. Del Buono A, Chan O, Maffulli N. Achilles tendon: functional anatomy and novel emerging models of imaging classification. International Orthopaedics. 2012;37(4):715-721. Tabaie S, Videckis A. Achilles Lengthening. jposna [Internet]. 2021Jul.26 [cited 2022Jul.15];3(3). Available from: https://www.jposna.org/ojs/index.php/jposna/article/view/310 Rong K, Li X, Ge W, Xu Y, Xu X. Comparison of the efficacy of three isolated gastrocnemius recession procedures in a cadaveric model of gastrocnemius tightness. International Orthopaedics. 2015;40(2):417-423. Firth G, McMullan M, Chin T, Ma F, Selber P, Eizenberg N et al. Lengthening of the Gastrocnemius-Soleus Complex. 2022. Volpon J, Natale L. Critical evaluation of the surgical techniques to correct the equinus deformity . Revista do Colégio Brasileiro de Cirurgiões. 2019;46(1). Graham HK. The Baumann procedure for fixed contracture of the gastrosoleus in cerebral palsy. J Bone Joint Surg Br. 2000 Sep;82(7):1084-5. PMID: 11041608. Takahashi S, Shrestha A. The Vulpius procedure for correction of equinus deformity in patients with hemiplegia. The Journal of Bone and Joint Surgery British volume. 2002;84-B(7):978-980.