Gastroc recession

[PMG03470]

For anyone who cares to share, I’m interested in everyone’s method for performing Gastroc recessions. I typically do a Strayer type with a direct posterior incision about ?? cm so that I can directly visualize the sural nerve and retract it. I recently did one on an obese patient and my usual method was very difficult. Curious to see how everyone does them.

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[Weirdy]

Your numbers is returning emojis again

 

[Feli]

I don't really have time to do the prone-to-supine stuff. This isn't residency... time is money.
With a gastroc, you're almost always doing something else too (bunion, flat foot, TMA, whatever).


I just do medial approach mini-open gastroc, frog leg (supine). About a hand-and-a-half (10-15cm) above the Achilles insert, incision over medial border edge of aponeurosis. You can see it on fit people... palpate/guess of bigger folk.
I saw it done that way on a few of my good clerkships and some of my residency attendings, and it made the most sense to me. It's really easy that way... you can typically do it anywhere from 10cm prox to calc insert up to gastroc muscle (but more proximal is more to cut and more chance of sural inj). It's about a 2-3cm incision, usually one aponeurosis stitch, one subcutic stitch, a few subcutaneous nylons. 10min or less.
You identify the gastroc aponeurosis right below adipose, blunt or finger dissect deep and superficail to the aponeurosis.
Basic Strayer cut with straight mayo scissor (or 15 blade with malleable in front of it if you want), assist dorsiflex to feel the release.
It ends up being the same thing as the ACFAS surgical procedures vid "Gastrocnemius Recession Distal" by Al Ng... except a lot smaller incision and frog leg - not prone. It's also the same result as EGR - except it's usually a bit faster and you don't have problems getting it released or the cost.

I usually go a tad distal, but you get the idea in this pic:


...EGR is not bad, but I can do my mini-open by the time the camera equipment is set up and whited out... and sometimes that cam/tube/hook knife equipment falters - or some facilities don't have EGR stuff or don't like the costs. I also don't like the multiple swipes with the baby blade that you usually need for EPF and EGR... not efficient or ideal imo.

...If I'm doing it for bad/neglected/contracted Achilles rupture repair, then I do open 'V' gastroc... up high right below gastroc heads muscle (as far from rupture as possible), through same incision as the Achilles repair (medial to midline... usually cut soleus a bit too for more length, if needed.

 

[air bud]

For anyone who cares to share, I’m interested in everyone’s method for performing Gastroc recessions. I typically do a Strayer type with a direct posterior incision about ?? cm so that I can directly visualize the sural nerve and retract it. I recently did one on an obese patient and my usual method was very difficult. Curious to see how everyone does them.

Strayer ...do almost all with patient supine. Pain in the ass but not going to do prone then flip for a flatfoot. Did one prone today for a calc fracture. I forget how much easier to do that way. Regardless ...lift the leg, do upside down, don't close the paratenon, 2 deep vicryls maybe 1 or 2 sub q and staples. They do great and always heal.

 

[air bud]

Never done the frog leg thing ....straight posterior maybe 10 to 15 cm from Achilles insert

 

[dtrack22]

only do them prone if I’m already prone for achilles/calc work in which case I do a strayer because it’s easier and I’m staring right at it. Otherwise supine (not frog leg, just no bump do they are sitting in whatever resting external rotation they have), open blade retractor, little bigger incision than Feli, Baumann type recession.

 

[Flip-flop-flerpity]

For elective cases we did exclusively posterior approach Strayer in training. Thats fine if you have someone to hold the leg. In practice for me now its a supine frogleg, medial approach Baumann. Multiple stripes if needed. Use army navy or Indians and a #7 blade handle.

 

[DYK343]

Bauman is about as easy as it gets. Havent done a strayer since residency.

Supine

Incision midleg over the gastroc/soleus.

Incision is 2 fingers below medial aspect tibia (even if larger patients I find this holds true).

Dissect to crural fascia. Watch for saphenous. After incising thru crural fascia I finger dissect to gastoc/soleus

Insert vaginal speculum between the two muscles

long handle #15 blade to lightly cut the gastroc aponeurosis. Avoid cutting the muscle. Easy to cut thru the muscle behind the aponeurosis with too much pressure.

Some cut soleus aponeurosis too. I dont think it does much and increases scaring/pain in the area.

Extra care to close the crural fascia to prevent herniation.

5ish minute skin to skin procedure.

 

[Flip-flop-flerpity]

Bauman is about as easy as it gets. Havent done a strayer since residency.

Supine

Incision midleg over the gastroc/soleus.

Incision is 2 fingers below medial aspect tibia (even if larger patients I find this holds true).

Dissect to crural fascia. Watch for saphenous. After incising thru crural fascia I finger dissect to gastoc/soleus

Insert vaginal speculum between the two muscles

long handle #15 blade to lightly cut the gastroc aponeurosis. Avoid cutting the muscle. Easy to cut thru the muscle behind the aponeurosis with too much pressure.

Some cut soleus aponeurosis too. I dont think it does much and increases scaring/pain in the area.

Extra care to close the crural fascia to prevent herniation.

5ish minute skin to skin procedure.

Can also easily do plantaris tenotomy here which can make a big difference too

 

[air bud]

If I see the plantaris I cut it

Can also easily do plantaris tenotomy here whi

 

[DYK343]

If I see the plantaris I cut it

so uhhhh... we billing for this? 🤣

 

[diabeticfootdr]

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Bauman is about as easy as it gets. Havent done a strayer since residency.

Supine

Incision midleg over the gastroc/soleus.

Incision is 2 fingers below medial aspect tibia (even if larger patients I find this holds true).

Dissect to crural fascia. Watch for saphenous. After incising thru crural fascia I finger dissect to gastoc/soleus

Insert vaginal speculum between the two muscles

long handle # 15blade to lightly cut the gastroc aponeurosis. Avoid cutting the muscle. Easy to cut thru the muscle behind the aponeurosis with too much pressure.

Some cut soleus aponeurosis too. I dont think it does much and increases scaring/pain in the area.

Extra care to close the crural fascia to prevent herniation.

[5ish minute skin to skin procedure.

That’s what I do …

 

[DYK343]

whats going on with all the emoji and numbers lately?

 

[deleted1162946]

whats going on with all the emoji and numbers lately?

Boomers

 

[Weirdy]

whats going on with all the emoji and numbers lately?

Site wide issue.
Seems to happen with numbers and when people are maybe using the app.
Can report for technical issue if you see it happen.

 

[air bud]

That’s what I do …

Not having to watch for saphenous is precisely why I don't do this way. Always sounded easy to do, didn't have to go prone or lift leg...never learned not going to now.

 

[billBOB213]

I updated my app and the numbers things went away

 

[PointyNippers]

Any thoughts/tips on endoscopic release?

 

[air bud]

Any thoughts/tips on endoscopic release?

It's dumb and expensive

 

[Adam Smasher]

I do mine endoscopic, it doesn't cost me a penny

 

[MicroPod]

What are your thoughts on doing a gastroc recession or TAL on the same day as doing a TMA? Or do you wait until a later time and do the procedure separately?

 

[Homo sapien]

What are your thoughts on doing a gastroc recession or TAL on the same day as doing a TMA? Or do you wait until a later time and do the procedure separately?

The few I've done - ive done same day. Lift the leg, incise and stab, gently flex it, stitch and go. Why wait.

 

[Flip-flop-flerpity]

What are your thoughts on doing a gastroc recession or TAL on the same day as doing a TMA? Or do you wait until a later time and do the procedure separately?

Same day everyday. If you think the patient needs a gastroc, they do

 

[MicroPod]

I had attendings who were wary of doing it while they have an active infection.

 

[air bud]

What are your thoughts on doing a gastroc recession or TAL on the same day as doing a TMA? Or do you wait until a later time and do the procedure separately?

If the gasteoc doesn't fix it then knock out the TAL right there.

 

[DYK343]

I typically dont if there is massive infection/pus dripping out the foot.

Im sure it would be fine. But I dont want to iatrogenically extend infection to a leg fascial plane

Most of those cases I am packing it open and closing another day anyway so I do it on round 2.

 

[MicroPod]

I typically dont if there is massive infection/pus dripping out the foot.

Im sure it would be fine. But I dont want to iatrogenically extend infection to a leg fascial plane

Most of those cases I am packing it open and closing another day anyway so I do it on round 2.

That is kinda where I am at with my thinking. Just wondered what others do, probably much easier to stage these as inpatient when working at the same hospital too.

 

[air bud]

I don't understand what you guys are talking about. We do gastroc with a TMA. Some stab incisions if the gastroc doesn't get you the correction you want? BFD