Chamnanni Rungprai, M.D.

Transcription

1 Outcomes of single versus multi-level Gastrosoleus or Achilles tendon lengthening Techniques: A Comparative Study 1,2 Chamnanni Rungprai, M.D. Co-authors 1 Christopher Cyclosz, M.D. 1 Phinit Phisitkul, M.D. 1.University Of Iowa Hospital and Clinic, Iowa, USA 2.Phramongkutklao hospital and college of medicine, Bangkok, Thailand AOFAS 2015 Annual Meeting eposter

2 NO CONFLICT TO DISCLOSE Outcomes of single versus multi-level Gastrosoleus or Achilles tendon lengthening Techniques: A Comparative Study Chamnanni Rungprai, M.D. My disclosure is in the Final AOFAS Mobile App. I have no potential conflicts with this presentation.

3 Introduction Ankle equinus contracture is a commonly encountered condition in an orthopaedic foot and ankle practice. Gastrocnemius or gastrosoleus contracture has been postulated to be the root of numerous foot and ankle pathologies Diabetic foot ulcers Hallux valgus Metatarsalgia Adult acquired flatfoot disorder Plantar fasciitis Initial treatment should consist of conservative management including night splints and stretching exercises If these fail, surgical treatment is indicated. Single level gastrocnemius or Achilles tendon lengthening including open, percutaneous, and endoscopic techniques are considered standard techniques for the treatment of equinus contracture. However, patients with severe equinus contracture require multilevel of lengthening using combined procedures as mentioned above to achieve adequate ankle dorsiflexion. In addition, there has been no comparative study to demonstrate clinical outcomes and complications between single versus multiple levels of gastrocnemius or Achilles tendon lengthening techniques.

4 Materials and methods Retrospective chart review with prospectively collected data of 646 consecutive patients (676 feet) diagnosed with ankle equinus contracture and underwent single level of gastrocnemius or Achilles tendon lengthening techniques (610 patients / 640 feet) including open Valpius or Strayer (VSO) 200 patients / 206 feet, Baumann 38 patients / 38 feet, percutaneous triple hemisections (Hoke) 52 patients / 52 feet, endoscopic gastrocnemius recession (EGR) (320 patients/ 344feet), and multilevel using combined techniques 36 patients / 36 feet between January 2006 and June The primary outcomes include Foot Function Index (FFI) Short Form-36 (SF-36 Visual Analogue Scale Ankle dorsiflexion. Secondary outcome includes Operative time Complications Pre- and post-operative functional outcome scores were obtained and compared using Wilcoxon Rank Sum Test, and Chi-square Test.

5 Surgical technique A B A B C D C D Figure 1: EGR was performed by two portals technique (A). The gastrocnemius aponeurosis is identified (B), retrograde knife was used to release aponeurosis (C). The gastrocnemius muscle after complete release the gastrocnemius aponeurosis (D). Figure 2: Percutaneous tripple hemisection of Achilles tendon was performed by using three step cut technique is shown in picture 2A. The proximal medial cut is shown is picture 2B and middle lateral cut is shown in picture 2C and distal medial cut is shown in picture 2D.

6 Table 1 Demographic characteristics of single and multiple gastrocnemius or Achilles tendon lengthening. Parameters Open Strayer or Valpius Single level Multiple level Hoke Baumann EGR Combined procedure Number of patients / legs 200 / / / / / 36 Age of time at surgery (year) (range) 50.4 ± 15.6 ( ) 60.2 ± 13.1 ( ) 51.3 ± 14.1 ( ) 47.1 ± 15.7 ( ) 50.8 ± 13.5 ( ) Male : Female ratio (no. of patients) 95 : : : : : 20 BMI(Kg/m 2 ) (range) 31.8 ± 7.0 ( ) 33.8 ± 7.0 ( ) 31.4 ± 7.8 ( ) 32.8 ± 8.5 ( ) 33.9 ± 6.9 ( ) Duration of follow up (month) (range) 23.9 ± 19.4 (6-90) 27.5 ± 22.6 (6-81) 24.0 ± 11.9 (6-44) 17.6 ± 56.6 (12-53) 38.9 ± 28.6 (6-96)

7 TABLE 2 Group comparison between single and multiple gastrocnemius or Achilles tendon lengthening. Parameters Single level Multiple level Open Strayer or Valpius (n=200) Hoke procedure (n=52) Baumann procedure (n=38) Endoscopic technique (n=320) Combined techniques (n=36) Operative time (minutes) ± 5.07* (21-35) 3.15 ± 1.14* (2-5) ± 6.45 (21-38) ± 5.02 (12-30) 29.0 ± 7.1 (20-37) **Pre / Post-operative Visual Analog Scale (range) (no./total) SF-36 Score: at final follow up (points) **PCS: pre / postoperative (no./total) **MCS: pre / postoperative (no./total) Foot Function Index (FFI): pre / post-operative at final follow up ** Pain: pre / postoperative (no./total) **Disability: pre / post-operative (no./total) **Activity limitation: pre / post-operative (no./total) **Total score: pre / post-operative (no./total) 6.3 ± 2.7 / 3.6 ± 2.9 (n=175) 37.3 ± 9.1 / 43.3 ± 10.2 (n=76) 45.4 ± 11.4 / 50.1 ± 10.9 (n=76) 59.2 ± 15.2 / 36.7 ± 16.6 (n=76) 59.9 ± 15.9 / 41.0 ± 17.5 (n=76) 60.3 ± 12.2 / 40.5 ± 19.7 (n=76) 60.1 ± 13.6 / 39.2 ± 16.2 (n=76) 7.3 ± 2.3 / 3.2 ± 2.4 (n=47) 32.5 ± 9.5 / 45.5 ± 11.1 (n=32) 42.9 ± 10.5 / 49.1 ± 11.3 (n=32) 54.0 ± 18.0 / 34.5 ± 13.7 (n=32) 49.5 ± 18.1 / 36.2 ± 13.4 (n=32) 58.2 ± 14.9 / 34.5 ± 14.8 (n=32) 53.6 ± 14.1 / 35.6 ± 12.7 (n=32) 6.9 ± 1.8 / 3.8 ± 2.9 (n=35) 35.4 ± 4.9 / 44.1 ± 9.8 (n=26) 47.5 ± 11.2 / 56.8 ± 7.8 (n=26) 54.7 ± 13.7 / 39.1 ± 13.1 (n=26) 55.4 ± 14.4 / 34.6 ± 11.8 (n=26) 63.2 ± 16.0 / 39.2 ± 19.8 (n=26) 58.9 ± 12.1 / 37.7 ± 14.1 (n=26) 7.3 ± 2.2 / 3.4 ± 2.7 (n=276) 33.9 ± 9.6 / 45.1 ± 12.2 (n=185) 43.8 ± 11.8 / 51.4 ± 11.6 (n=185) 63.2 ± 18.4 / 42.1 ± 19.6 (n=185) 63.0 ± 19.6 / 43.3 ± (n=185) 67.9 ± 17.7 / 44.4 ± 23.8 (n=185) 64.2 ± 15.0 / 41.5 ± 19.0 (n=185) 7.8 ± 1.5 / 3.6 ± 3.1 (n=28) 33.0 ± 10.1 / 40.7 ± 12.4 (n=22) 43.9 ± 14.2 / 49.4 ± 10.6 (n=22) 68.8 ± 13.2 / 40.7 ± 12.4 (n=19) 56.8 ± 27.7 / 49.4 ± 10.6 (n=19) 67.4 ± 15.4 / 41.4 ± 25.4 (n=19) 64.3 ± 13.2 / 37.9 ± 20.0 (n=19)

8 Table 3 Ankle dorsiflexion between single and multiple gastrocnemius or Achilles tendon lengthening. Ankle range of motion Dorsiflexion Pre-operative (range, degrees) up (number of available patients/total number) Immediate postoperative / improvement (range, degrees) (number of available patients/total number) At final follow up / improvement (range, degrees) up (number of available patients/total number) Open Strayer or Valpius (n=200) -2.8 ± 8.9 ((-50) - 10) (n=164) 12.4 ± 4.8 / (15.0) ((-5) - 30) (n=164) 7.8 ± 5.7 / (10.62) ((-10) - 30) (n=164) Hoke technique (n=52) -0.5 ± 8.1 ((-20) - 10) (n=40) 10.1 ± 5.5 / (10.6) (0-20) (n=40) 6.6 ± 5.8 / (7.08) ((-5) - 20) (n=40) Single level Baumann technique (n=38) -5.1 ± 6.6 ((-30) - 10) (n=34) 9.8 ± 4.7 / (14.9) (0-20) (n=34) 7.8 ± 4.6 / (12.82) (0-20) (n=34) Endoscopic technique (n=320) -0.8 ± 5.4 ((-50) - 10) (n=294) 14.7 ± 6.7* / (15.6) (0-30) (n=294) 11.0 ± 6.6 / (11.84) ((-10) - 30) (n=294) Multiple level Combined techniques (n=36) ± 9.0* ((-5) - (-35)) (n=27) 9.0 ± 5.1 / (22.2)* ((-5) - 15) (n=27) 5.2 ± 5.9* / (18.4)* ((-10) - 15) (n=24)

9 Table 4 Complications between single and multiple gastrocnemius or Achilles tendon lengthening. Number of complications / Total number of legs (Percent) Single level Multiple level Complications 1. Superficial infection 2. Sural nerve dysesthesia 3. Weakness of plantar flexion Open Strayer or Valpius (n=206) Baumann Technique (n=52) Hoke Technique (n=38) Endoscopic Technique (n=344) Combined Technique (n=36) 13 (6.3%) 3 (7.9%) 0 (0.0%) 0 (0.0%) 1 (2.8%) 7 (3.4%) 1 (2.6%) 1 (1.9%) 10 (2.9%) 3 (8.3%) 9 (4.4%) 1 (2.6%) 5 (9.6%) 11 (3.2%) 10* (27.7%) (p=0.001) 4. Painful scar 5 (2.4%)* 1 (1.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 5. Calf muscle atrophy 5 (2.4%) 0 (0.0%) 0 (0.0%) 8 (2.6%) 11* (30.5%) (p=0.001) 6. Rupture of the Achilles tendon 0 (0.0%) 0 (0.0%) 6* (15.8%) (p = 0.03) 0 (0.0%) 0 (0.0%)

10 Results All techniques demonstrated significant improvement in FFI, SF- 36, VAS, and ankle dorsiflexion (all p-value < 0.001). Multi-level of lengthening demonstrated significantly longer operative time than Hoke technique (p-value = 0.001) but the means improvement of ankle dorsiflexion intraoperatively and at final postoperative visit were significantly greater than all single level techniques (p-value = 0.001). The ankle dorsiflexion of multi-level at final post-operative visit was significantly lesser than endoscopic technique (p-value = 0.002) but was comparable with other single level lengthening. Weakness of plantarflexion and calf muscle atrophy was significantly higher in multi-level than all single level techniques (p-value < 0.05) while the rupture of the Achilles tendon was significant higher in single Hoke technique (p-value = 0.03). Sural nerve dysesthesia was higher in multi-level but this did not reach statistical significance while other complications were similar between groups.

11 Discussion Limitations Retrospective design, and therefore no randomization was used in the methods. Some patients were lost to follow-up and some did not response to the questionnaires, resulting in approximately fifty percent of patients available to be analyzed at final follow-up. Strengths Consecutive case collection. Relatively large number of subject. Systematically collected outcome data using validated assessment methods. All surgeries were performed by the same group of fellowship-trained orthopaedic foot and ankle surgeons. Conclusion Both single and multi-level techniques for gastrocnemius or Achilles tendon lengthening demonstrated significant improvement in outcomes as measured with the FFI, SF-36, VAS, and ankle dorsiflexion for treatment of tightness of gastrocnemius and gastrosoleus muscle. Hoke is fastest procedure but significant rapture rate of Achilles tendon. Multi-level lengthening resulted in significant improvement of ankle dorsiflexion at final post-operative visit and intraoperatively but leaded to higher sural nerve dysesthesia and significant weakness of plantarflexion and calf muscle atrophy.

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