The debate seems to continue on the most appropriate procedure for forefoot offloading. When the decision is made to progress to surgical lengthening of the posterior muscle group, do you have a strong opinion on how to decide between doing a TAL vs a Gastroc Recession?

This is interesting and I'm not sure anyone really knows which one is best. I usually perform TALs in all diabetic patients (based on the pathology at the tendon level), but in patients with CMT or other neuropathies I've found a higher incidence of gastrocnemius equinus and have performed recessions with success. I haven't used the endoscopic method for gastroc recession and would be interested in hearing from those that have.

I have always wondered what if you had to repeat the TAL in the future.
To retraumatize the a major tendon which in a DM patient is already
lost flexibility through nonenzymatic glycosylation and undergoing a
scarring process of healing from the TAL would likely increase the
stiffness of the tendon overall. In addition, there can be problems with
overlengthening. Advantages of a gastroc recession over TAL: I
remember Mueller et al work on following biomechanical measures of
gastroc recessions and found that forefoot pressures returned to
preoperative readings in approximately one year. So even if you
overlength, muscle strength seems to return eventually. Keenan et al
found that the lengthenings performed at the musculotendinous or
aponeurosis junctions overlying muscle belly tend to regenerate
histologically with less scarring using the vascular muscle belly as a
scaffold. She suggests that a relengthening could be performed at this
level without traumatizing the tendon. I believe that a gastroc
recession is more forgiving biomechanically and with scarring and a
TAL could be performed if recurrent equinus is seen. However, I can't
argue that operatively a TAL (especially percutaneous) is more
simplistic and less intraoperative morbidity.

[QUOTE]Original Comment:
I have always wondered what if you had to repeat the TAL in the future.
To retraumatize the a major tendon which in a DM patient is already
lost flexibility through nonenzymatic glycosylation and undergoing a
scarring process of healing from the TAL would likely increase the
stiffness of the tendon overall. In addition, there can be problems with
overlengthening. Advantages of a gastroc recession over TAL: I
remember Mueller et al work on following biomechanical measures of
gastroc recessions and found that forefoot pressures returned to
preoperative readings in approximately one year. So even if you
overlength, muscle strength seems to return eventually. Keenan et al
found that the lengthenings performed at the musculotendinous or
aponeurosis junctions overlying muscle belly tend to regenerate
histologically with less scarring using the vascular muscle belly as a
scaffold. She suggests that a relengthening could be performed at this
level without traumatizing the tendon. I believe that a gastroc
recession is more forgiving biomechanically and with scarring and a
TAL could be performed if recurrent equinus is seen. However, I can't
argue that operatively a TAL (especially percutaneous) is more
simplistic and less intraoperative morbidity.
Posted by: George Liu[/QUOTE]

Dr. Liu:

I would simply ask you: how many times have you had to repeat a TAL?
Based on your initial note, I would posit very few. This is my
experience as well. However, if one did repeat the procedure, I should
think the goal was to weaken the tendon, not to restore it to its full
strength. While I believe that a gastroc recession is a terrific and
technically accessible procedure, I think the ability to do a TAL in an
aseptic clinical setting in a diabetic foot clinic makes it a strong option.
Furthermore, there are, to my knowledge no strong data to support use
of the gastroc recession-- although it is entirely plausible that it will
yield at least a similar outcome to a TAL.

I've had to do repeat TAL's a couple of times - both having to be performed on patients in which I did not do the original lengthening. There was a 3rd patient who had SEVERE scarring in the Achilles with hypertrophic tendon scarring after 2 repeat TAL's by an Orthopedic Surgeon, I opted for a Murphy's Procedure - I figured this patient had enough invasive procedures done on the posterior muscle group & he recently had a subsequent TMA (by the ortho - who referred ths patient to me for a forefoot ulceration).
As we well know, Murphy's weakens post. muscle group by shortening the lever arm between the original insertion of the Achilles & moving it forward, closer to the fulcrum of the ankle joint; therefore it is a very biomechanically sound option to this dilemma - is it more invasive than a Gastroc Rescession? - yes, but obviously it's not my "go to" procedure & it was a viable option in this scenario due to the scarring.

For my purpose of DM forefoot ulceration and limb salvage, I have always elected to do percutaneous TAL.

As Dr. Armstrong noted, I have never had to do a revision TAL in my career. I guess it is possible that, if one is timid on the amount of Achilles tendon lengthening in the first try, you may have to do additional TAL or gastroc recession. 

As George mentioned, the beauty of the percutaneous TAL is in its simplicity. It takes no more than a few minutes on the operating table, before or after the debridement or minor amputation procedures. If the stab incision doesn't bleed too much, I often don't even bother to put sutures in them, and just apply non-adherent gauze with compressive/absorbent dressing on it.

KISS always works... Keep It Simple, Steinberg!

Just my 2 cents... KS. 

I agree with Kazu.

I personally prefer  a percutaneous TAL approach.  The simplicity makes this procedure a very appropriate option.  I routinely preform this procedure in the office, wound care center, and the OR.  To date I have not had to do any revisional work.  

I would like to point out that it is important to explain to the patient that you may not be able to increase dorsiflexion to much if there is significant  contracture of the posterior ankle joint of stenosis of the flexor tendons.  Although in those cases when I was not able to dorsiflex the foot as much as I would like, those patients still did well with pressure off-loading.

It is a simple procedure that has some very nice benefits.

Karr 

 

Like Dr. Karr, I prefer a percutaneous TAL approach in my diabetic patients.  As has previously been described throughout this thread, such a procedure can provide significant forefoot offloading and can be performed easily (and safely) in the high-risk diabetic foot patients.  This is of particular importance if you are managing a patient with significant comorbidities which preclude being able to safely make a trip to the operating room.  In those patients with forefoot ulcerations, the combination of posterior lengthening and appropriate wound care and offloading can make a significant impact in the management of these challenging patients and can make the difference between limb preservation and amputation.  The question you should ask yourself is "Are you doing ENOUGH TALs?"

 

Generally speaking, I perform GR and EGR in my young healthy patients (many of these are pediatric flatfoot recons).  In this patient population, with healthy native tissues, I feel that i can provide a better result by specifically isolating the muscle group that is involved in the posterior equinus.  I utilize the silverskoid test and plan my surgical approach accordingly.  Commonly this translates to Gastroc Recession in conjunction with additional foot or ankle procedures to address the specific pathology.  I feel that the risk of recurrence is significantly greater in patients in which an underlying equinus deformity is not addressed.

I agree that a TAL is simple to perform and it effectively reduces plantar forefoot pressures.  However, recently I have been performing more and more gastroc recessions for this purpose.   With a TAL, the amount of tendon lengthening cannot be controlled and over lengthening (or rupture) can result in a calcaneal gait and in patients with an insensate heel, this can result in a difficult to heal heel ulceration.   This potential complication (reported to occur up to 10% of the time) has certainly not caused me to abandon the procedure, but now, I  will consider a gastroc recession more often, especially in those patients with insensate heels.

I would echo Nicholas' post.  I currently perform percutaneous TALs for this condition more than gastroc recessions.  As noted above, I've done these in the office (when an isolated procedure) and have found them to be invaluable in the diabetic patient.  I've never had a rupture, but did overlengthen one TAL with a subsequent heel ulceration. 

 

However, I have had a small number of patients whom I've chosen an endoscopic gastrocnemius recession for a diabetic plantar forefoot ulceration/preulceration.  I'll quickly mention 2 patients:

 

The first was a 65 y/o diabetic with a continually recurring preulcerative callus sub 3rd met head (cavus foot, clawtoes, extensor substitution, plantar fat pad migration, etc) that didn't respond to offweighting methods.  He was healthy enough to undergo a gastroc recession and wanted minimal surgery.  He could not be NWB.  I recommended an EGR as a minimally invasive option, explaining that the current research didn't support this for equinus yet.  The patient understood that he was trying something that might fail.  After the procedure his callus disappeared after about 6 weeks.  Presumably the epidermal tissue took this time to normalize.  I did no other procedures with the EGR.

 

The second patient is a 59 y/o DM 2 female with a similar circumstance.  She has a moderate hallux valgus with a chronically reulcerating medial hallux pinch callus.  I offered her a reconstructive procedure since, again, my offweighting attempts were not eliminating the pressure once she healed the ulcer.  Again, this patient wanted a minimally invasive procedure.  Additionally, I had concerns about her postop compliance and wanted her as mobile as possible.  After the same consent process as noted above I performed her EGR 8 days ago. 

 

I'm not sure how successful this will be but I'll keep everyone appraised.  I'm hopeful of the result.