PRINCIPLE: Aponeurotic and intramuscular recessions of contracted musculotendinous units can be carried out wherever there is an aponeurotic tendon that surrounds a muscle or a tendon that extends deep into a muscle. There is a limit to the amount of lengthening that can be achieved with an aponeurotic or an intramuscular recession, but overlengthening and permanent weakness are unlikely.
Gastrocnemius Recession (Strayer Procedure)
1. Indications
a. Contracture of the gastrocnemius but not the soleus (see Chapter 5), as determined by the Silfverskiold test (see Assessment Principle #12 and Figure 3-13, Chapter 3), that is creating pain, functional disability, and/or gait disturbance
i. The ankle joint can be dorsiflexed more than 10° with the subtalar joint locked in neutral alignment (see Basic Principle #7, Chapter 2) and the knee flexed, but less than 10° with the knee extended.
2. Technique (Figure 7-1)
a. 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
b. Avoid and protect the long saphenous vein
c. Open the facia longitudinally
d. Identify the plantaris tendon along the medial edge of the gastrocnemius tendon and divide it
e. Identify the musculotendinous junction of the gastrocnemius
f. Clear all soft tissues off the posterior surface of the aponeurotic tendon of the gastrocnemius
g. 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
h. 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
i. Avoid extensive proximal-to-distal separation of the two aponeurotic tendons to prevent excessive retraction of the gastrocnemius muscle
j. Cut the gastrocnemius aponeurosis as far distally as possible. Do not be concerned about cutting the distal-most fibers of the gastrocnemius. The gastrocnemius and soleus aponeurotic tendons are not always separate structures distal to all gastrocnemius muscle fibers. The last few fibers do not matter.
k. Recheck the Silfverskiold test to ensure that the ankle can now be dorsiflexed at least 10° above neutral with the subtalar joint in neutral alignment and the knee extended (see Assessment Principle #12 and Figure 3-13, Chapter 3). There should be no difference in the degree of ankle dorsiflexion whether the knee is flexed or extended.
l. There is no need to suture the gastrocnemius tendon to the soleus muscle as long as the blunt separation of the two aponeurotic tendons is limited to a few centimeters.
m. There is no need to repair the compartment fascia.
n. Close the deep fat with a few 2-0 absorbable sutures to prevent adherence of the skin to the muscle
o. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
p. Apply a short-leg walking cast with a neutral to 5° dorsiflexed ankle
q. Maintain the cast for 5 to 6 weeks, or longer if needed for other concurrently performed procedures
Figure 7-1.Strayer procedure (posteromedial left leg). A. Division of the plantaris tendon. B. Exposure and elevation of the sural nerve off the posterior surface of the gastrocnemius. C. Separation of the aponeurotic tendons of the gastrocnemius and the soleus. D. Initiation of the division of the gastrocnemius aponeurotic tendon. E. Completion of the division of the gastrocnemius aponeurotic tendon. F. Exposed soleus aponeurotic tendon.
3. Pitfalls
a. Inadequate deformity correction due to incorrect determination of the appropriateness for a gastrocnemius recession when, in fact, the soleus is also contracted
b. Release of both the gastrocnemius and the soleus aponeuroses, due to failure to separate them before release
4. Complications
a. Injury to the sural nerve
i. Avoid by isolating and protecting it before tenotomy
b. Adherence of the skin to the muscle, creating an obvious tethering effect with muscle contraction
i. Avoid by closing the deep fat with a few 2-0 absorbable sutures before closing the subcutaneous layer with interrupted 3-0 absorbable sutures
c. Excessive migration of the gastrocnemius muscle with unusually prominent ball-like contours of the two heads of the muscle
i. Avoid by limiting the extent of proximal-to-distal blunt separation of the two aponeurotic tendons
Distal Abductor Hallucis Recession
1. Indications
a. Contracture of the abductor hallucis in:
i. hallux varus (see Chapter 5)
• Also see Longitudinal Epiphyseal Bracket Resection, Chapter 8
ii. Dorsal bunion (see Chapter 5)
• Also see Reverse Jones Transfer of FHL to 1st MT Neck, this chapter
iii. Metatarsus adductus (see Chapter 5)
2. Technique (Figure 7-2)
a. Make a 2-cm longitudinal incision medial to the distal end of the 1st metatarsal (MT)
b. Identify the musculotendinous junction on the medial superficial surface of the abductor hallucis
c. Cut the tendon at its proximal end within the substance of the muscle, thereby creating a recession, and not a tenotomy
d. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
e. Apply a short-leg or long-leg weight-bearing or non–weight-bearing cast based on the requirements for the other concurrently performed procedures
Figure 7-2. The abductor hallucis muscle is exposed distally through an incision that, in this photo, is longer than necessary for a simple recession, as it was being used for a concurrent reverse Jones transfer of the flexor hallucis longus (FHL) to the 1st metatarsal (MT) neck. The tendon is divided proximally within the substance of the muscle belly to avoid complete separation of the musculotendinous unit.
3. Pitfalls
a. The use of this recession rather than proximal release of the three origins of the abductor hallucis for correction of cavovarus deformity (see Superficial Medial Release, Deep Medial Release, Superficial Plantar-Medial Release, and Deep Plantar-Medial Release, this chapter)
4. Complications
a. Complete tenotomy
i. Avoid by releasing the tendon at a level where there is adequate overlapping muscle, i.e., not too far distal
Abductor Digiti Minimi Recession
1. Indications
a. Performed in conjunction with a calcaneal lengthening osteotomy (CLO; see Chapter 8) for correction of symptomatic flatfoot deformity (see Chapter 5)
i. Necessary to release the lateral soft tissue tether that would otherwise impede distraction of the osteotomy fragments
2. Technique (Figure 7-3)
a. This procedure is rarely, if ever, performed in isolation, but always performed in conjunction with a CLO.
b. The incision is, therefore, a modified Ollier incision in a Langer’s line over the sinus tarsi used for the CLO.
c. Clear the fat off the dorsal aponeurosis of the abductor digiti minimi with a Key elevator 1 to 3 cm proximal to the calcaneocuboid joint
d. Using a scalpel and/or scissors, divide the 1-mm-thick aponeurosis transversely starting medially at its attachment on the calcaneus and extending to its most lateral extent. Also release the aponeurosis from the lateral edge of the calcaneus 1 cm anterior and 1 cm posterior to the transverse aponeurotomy
e. Immobilization is based on the concurrently performed CLO—8 weeks in a non–weight-bearing short-leg cast, with a cast change at 6 weeks (see Chapter 8)
3. Pitfalls
a. There is no need to divide the muscle of the abductor digiti minimi. There are a few small veins immediately deep to the aponeurosis. By merely cutting the thin aponeurosis, the veins can often be avoided.
4. Complications
a. None
Figure 7-3. The abductor digiti minimi has been exposed through the plantar extent of a modified Ollier incision (used for a CLO) by retracting the peroneus longus (and sural nerve) laterally. The peroneus brevis has been Z-lengthened, and the soft tissue contents of the sinus tarsi have been elevated from the isthmus of the calcaneus in preparation for the osteotomy. The peroneal tubercle is seen on the lateral surface of the calcaneus. After scraping the fat (held in the forceps) off the dorsal surface of the aponeurosis of the abductor digiti minimi with a Key elevator, a transverse cut is made in this 1-mm-thick layer of collagen. It is only necessary to release the aponeurosis and not the muscle. Small veins immediately deep to the aponeurosis should be coagulated. The aponeurosis should also be released from the lateral edge of the calcaneus 1 cm anterior and 1 cm posterior to the aponeurotomy.
Posterior Tibialis Tendon Recession
1. Indications
a. Mild, flexible hindfoot varus and cavovarus deformities (see Chapter 5) with muscle imbalance; performed in conjunction with
i. a split anterior tibial tendon transfer (SPLATT) in CP (see this chapter)
ii. a superficial plantar-medial release (S-PMR) in mild forms of Charcot–Marie–Tooth (CMT) disease (see this chapter)
2. Technique
a. Make a 4-cm longitudinal incision along the posterior edge of the medial face of the tibia approximately 8 to 10 cm proximal to the tip of the medial malleolus
b. Release the fascia from the edge of the tibia
c. The first muscle encountered is the flexor digitorum longus. Confirm its identity by pulling proximally on its intramuscular tendon and observing flexion of the lesser toes. Retract it posteriorly.
d. The next muscle/tendon unit identified is the posterior tibialis. Confirm its identity by pulling proximally on its tendon and observing inversion of the foot. Divide the tendon within the substance of the muscle, cutting as few muscle fibers as possible.
e. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
f. Immobilization is based on the concurrently performed procedures, generally a short-leg non–weight-bearing cast for 6 weeks, followed by a short-leg walking cast for 2 weeks.
3. Pitfalls
a. Recession of the flexor digitorum longus (FDL) rather than the posterior tibialis
4. Complications
a. Complete tenotomy
i. Avoid by releasing the tendon at a level where there is adequate overlapping muscle, i.e., not too far distal
b. Division of tibial nerve
i. Avoid by identifying the anatomy as described earlier and ensuring that the dense white cord-like structure has muscle fibers approaching it at oblique angles and firmly attached to it