Open Achilles tendon and posterior ankle release for severe ankle equinus contracture. surgical technique
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Severe equinus contracture at the ankle, with associated contracture of the long flexors and joint capsules, can be the end point of a wide variety of congenital, developmental and acquired neurological conditions as well the result of acute, but recovered, vascular compromise to the limb.
In general with ankle and hindfoot deformity one can never go far wrong adhering to Paul Cookes mantra “place a balanced foot squarely beneath the tibia in the coronal and sagittal planes”. These are the sort of patients however where this advice needs on occasion to be tempered as the examples at the start of the operation technique illustrate. A significant ankle equinus can be highly functional in a short and undeveloped limb and neurological patients with a crouch type gait and proximal muscle weakness may be dependent for ambulation upon the relatively powerful but contracted achilles and gastrocsoleus complex.
The decision about what might be achieved with soft tissue correction and what more appropriate for corrective fusion surgery is often a multi-faceted one. The issue is not simply having the surgical ability to correct the deformity. The subsequent function and also stability afforded if an extensive soft tissue release is chosen, over fusion surgeries which require a longer recovery period, needs to be weighed up. In patients with spasticity and multi-level lower limb contractures deciding what will respond to extensive soft-tissue releases can be difficult. It is often a team decision with key insights from other members into the patients potential future function and current ability at the heart of this.
Other associated techniques which may be usefully read in conjunction with this are https://www.orthoracle.com/library/gastrocnemius-recession/
Author: Mark Herron FRCS.
Institution: The Wellington Hospital, London, UK.