What the Anesthesiologist Should Know before the Operative Procedure

Gastrocnemius resection is performed in corrective foot and ankle surgery, calf-contouring cosmetic surgery, or dermatologic, infectious, or oncologic pathologies directly involving the gastrocnemius muscle. Gastrocnemius recession, which involves release of the gastrocnemius tendon and subsequent lengthening of the calf muscle, is specifically indicated for patients with equinas contractures. The gastrocnemius muscle is seldom completely resected to avoid lower extremity gait and stability issues. More commonly, partial or subtotal resection of the gastrocnemius muscle is performed to achieve desired cosmetic or musculoskeletal results. Calf-contouring surgery for gastrocnemius hypertrophy has also been achieved through selective neurectomy of the sural nerve.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Nearly all surgery of the grastrocnemius muscle is elective in nature.

Emergent: Surgical resection of the gastrocnemius muscle is only considered emergent if associated with a separate traumatic, vascular, or infectious process.

Urgent: Surgical resection of the gastrocnemius muscle is only considered urgent if associated with a separate traumatic, vascular, or infectious process.

Elective:Patients undergoing resection of the gastrocnemius muscle may range from healthy ASA 1 patients undergoing cosmetic surgery to patients afflicted with severe or disabling systemic neuromuscular disorders.

2. Preoperative evaluation

Preoperative evaluation will vary depending upon the planned surgery and patient comorbidities. Patients presenting for gastrocnemius surgery may be healthy ambulatory patients seeking cosmetic improvements or may be afflicted by a variety of conditions that require orthopedic surgical intervention. Patients diagnosed with equinus contractures, for example, may possess a hereditary predisposition, or develop contractures in association with aging or diabetes. Children with cerebral palsy frequently require gastrocnemius recession to relieve equinas contractures.

Preoperative evaluation therefore should be patient specific but will likely involve age-directed cardiovascular evaluation, glucose and electrolyte laboratory evaluation, and specific evaluation of select comorbidities. If spinal anesthesia is considered, a history of spinal symptomatology and pathology, and use of anticoagulants should be elicited. For patients with cerebral palsy, appropriate preoperative considerations include assessments of development delay, musculoskeletal limitations for positioning and intubation, seizure disorders, gastroesophageal reflux disease (GERD) and secretion issues, latex allergy, and bleeding disorders related to anticonvulsant therapy.

Medically unstable conditionswarranting further evaluation include cardiopulmonary, renal, metabolic, hematologic, or neurologic comorbidities which may be unrelated to the gastrocnemius surgery.

Delaying or canceling surgerymay be indicated if unstable conditions require further diagnostic or therapeutic intervention before proceeding with elective surgery.

3. What are the implications of co-existing disease on perioperative care?

b. Cardiovascular system

Acute/unstable conditions: Prior to proceeding with surgery, acute or unstable cardiovascular conditions should be evaluated and managed according to American College of Cardiology/American Heart Association (ACC/AHA) guidelines.

Baseline coronary artery disease or cardiac dysfunction – Preoperative evaluations include patient and family history, electrocardiogram in patients over age 50, and further management if indicated according to ACC/AHA guidelines. Goals of management include optimization of myocardial oxygen supply and demand through delivery of oxygen and pharmacologic prevention of tachycardia and conditions which may precipitate ischemia.

c. Pulmonary

Chronic obstructive pulmonary disease

Because patients with significant chronic obstructive pulmonary disease (COPD) may be at increased risk of perioperative pulmonary complications, medical optimization and management should follow ATSguidelines. Maintenance therapies, such as inhaled steroids and bronchodilators, should be continued through the perioperative period. Patients with infectious processes or experiencing reductions in pulmonary function at the time of surgery should be delayed or rescheduled until treatment can be instituted and function returned to baseline.

Obstructive sleep apnea

Patients with sleep apnea should have the severity of the disease assessed, and appropriate strategies developed to reduce the potential for postoperative exacerbation of their disease by opioid-induced respiratory depression. They should continue the use of their continuous positive airway pressure (CPAP) therapy in the perioperative period.

Reactive airway disease (asthma)

Patients with history of asthma may be prone to acute exacerbations and pulmonary complications around the time of surgery. Maintenance therapies should be continued and optimization should follow the National Heart, Lung and Blood Institute (NHLBI) guidelines. Bronchodilators in the immediate preoperative period or prior to induction of general endotracheal anesthesia should be considered.

d. Renal-GI:

Patients with a history of chronic renal insufficiency merit preoperative optimization, including evaluation and correction of any electrolyte or intravascular volume derangements. Patients who require routine dialysis should have completed renal replacement therapy the day prior or day of elective surgery. Avoidance of potential nephrotoxic medications or drugs heavily dependent upon renal elimination should be minimized in patients with limited creatinine clearance. Patients experiencing any acute renal insufficiency should delay elective surgery and undergo further diagnostic and therapeutic management by a nephrologist. Patients with cerebral palsy are frequently underweight and prone to nutritional deficiencies. Electrolyte evaluation in the preoperative period may be warranted in these patients.

e. Neurologic:

Gastrocnemius resection and recession procedures are often performed in patients with cerebral palsy and other neurologic conditions that lead to dynamic contracture and equinus deformity of the foot and ankle. Gastrocnemius recession, which functionally lengthens the musculotendinous unit, improves kinematics of functional activities such as dorsiflexion and gait. Specific preoperative considerations in patients with cerebral palsy may include assessments of development delay, musculoskeletal limitations for positioning and intubation, seizure disorders, GERD and secretion issues, latex allergy, and bleeding disorders related to anticonvulsant therapy.

Acute issues:Patients experiencing any acute neurologic injury or insult should delay elective surgery and undergo further evaluation and management. Conditions such as seizures, transient ischemic attacks or strokes will require specialized diagnostic testing and stabilization of these conditions before proceeding with gastrocnemius resection.

Chronic disease:Patients with stable or chronic neurologic conditions should continue with baseline treatment through the perioperative period. Patients with underlying neurologic conditions may require specific anesthetic considerations such as invasive hemodynamic monitoring or the avoidance of depolarizing muscle relaxants.

f. Endocrine:

Gastrocnemius hypertrophy is not known to be associated with any specific endocrine disorders. However, patients with endocrine dysfunction should maintain baseline therapies, including thyroid replacements, statins, and gluco- and corticosteroids, through the perioperative period. Diabetic patients are counseled to hold oral agents, and reduce injected insulin doses before surgery. Preoperative, intraoperative, and postoperative glucose testing and management is prudent care and recommended in diabetic patients.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan

Patients with cerebral palsy undergoing gastrocnemius recession may suffer from other musculoskeletal contractures and limitations. Evaluation of patient positioning for the planned procedure must align with the patient’s capacity for musculoskeletal movement.

4. What are the patient's medications and how should they be managed in the perioperative period?

Patients with cerebral palsy undergoing gastrocnemius recession are commonly managed with symptom-based medications including antispasmotics, anticonvulsants, anticholinergics, and laxatives.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

In general, medications used in symptom management of cerebral palsy should be continued through the perioperative period. While providers may be concerned that antispasmodic agents (baclofen, diazepam) or anticonvulsants will contribute to delayed awakening, bradycardia or hypotension during general anesthesia, these responses are rarely seen in patients on chronic therapy. Failure to continue these kinds of medications may lead to abrupt withdrawal and in more severe cases could lead to seizures, hallucinations, and disorientation.

i. What should be recommended with regard to continuation of medications taken chronically?

Given the relatively minor nature of gastrocnemius resection and recession surgery, and corresponding minimal physiologic and intravascular volume derangements, nearly all baseline medications should be continued through the perioperative period.

Cardiac: Cardiac medications, with the exception of nonsspirin platelet drugs, should be continued through the perioperative period.

Pulmonary: Pulmonary medications should be continued.

Renal: Renal medications should be continued.

Neurologic: Neurologic medications should be continued.

Antiplatelet: Medications that significantly impair platelet function are routinely held for proscribed periods of time prior to surgery. However, the risks of bleeding, hematoma, and blood transfusion associated with antiplatelet therapy continuation must be weighed against specific patient cardiovascular and neurovascular comorbidties.

Psychiatric: Psychiatric medications should be continued.

j. How To modify care for patients with known allergies –

History and documentation of patient medication/anesthesia reactions and allergies should be performed prior to surgery. Avoidance of both medication and nonmedication (latex, chlorhexadine, iodine prep) allergens should be avoided.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

There is an increased incidence of latex allergy in cerebral palsy patients who require gastrocnemius surgery for spasticity and contracture. The high prevalence of allergy to latex in this population is probably associated with more frequent exposures to latex during procedures involving skin, mucosa, and urinary and rectal tracts. Avoidance of latex-containing products in the preoperative, intraoperative, and recovery areas is required.

l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]

Children with severe neurological impairment may have significant oral motor dysfunction and are at increased risk of nutritional deficiencies, poor growth, and aspiration pneumonia. They may therefore require frequent antibiotic therapy and allergic reactions to specific medications may develop. Avoidance of allergy inducing medications and cross-reactive medications is indicated.

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia

Documented

Avoid all trigger agents such as volatile agents and succinylcholine and ensure these are removed from the operating room prior to the patient’s arrival. It is preferable in this instance to avoid general anesthesia. Regardless of the anesthetic technique used a malignant hyperthermia (MH) cart should be immediately available.

Family history or risk factors for MH

A thorough history should elicit if the patient is at risk for the condition. If it is suspected then they should be ideally tested pre-operatively. If testing is not possible, it is safer to treat them as if they were MH positive, and a regional technique or local anesthetic technique may be the best anesthetic choice.

Local anesthetics/ muscle relaxants

If the patient has an allergy to local anesthetics it is important to determine in a history if this is to all local anesthetics and determine the names of the local anesthetics they are allergic to. If it is a true allergy then avoidance of these agents is preferred. If the patient has no allergy to an alternative local anesthetic this may be used if appropriate. If in doubt, and the previous reaction has been severe, then general anesthetic is advised. If the patient has an allergy to muscle relaxants these should be avoided. Ideally a regional technique should be used.

5. What laboratory tests should be obtained and has everything been reviewed?

The need for gastrocnemius resection or recession is a clinical diagnosis and no specific laboratory testing is indicated prior to surgery.

There are no age or gender-specific tests required unless associated with preexisting comorbidities.

Hemoglobin levels: Not required unless specific hematologic abnormalities or preexisting anemia exist.
Electrolytes: Not required unless specific nutritional, renal, or metabolic abnormalities exist.
Coagulation panel: Not required unless specific anticoagulation or hematologic conditions exist.
Imaging: Indicated only in patients with specific comorbidities (e.g., ischemic heart disease)
Other tests: Not required unless indicated by specific comorbidities.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

With any surgery of the lower extremity, both general and regional anesthesia options are available and the decision should be based upon patient and surgical factors. At this time, there is no data to demonstrate superiority of one technique over another but certain factors such as patient positioning, duration of the surgery, patient comorbidities and medication may influence the decision.

Regional anesthesia

Both neuraxial anesthesia and peripheral nerve blockade have been used successfully in gastrocnemius resection and recession surgery.

Neuraxial

Key benefits include avoidance of general anesthesia and airway instrumentation, better short-term analgesia, higher patient satisfaction, and reduced incidence of nausea and vomiting. Intubation for the prone position can be avoided, though conversion to general anesthesia if problems arise is challenging. Patients at risk for malignant hyperthermia may safely undergo neuraxial anesthesia.

Drawbacks: Patient awareness and intraoperative recall, postdural puncture headache, and common risks of infection, bleeding, and nerve injury accompany this technique.

Issues: Patients with spinal pathology, such as spinal stenosis and symptomatic radiculopathy, may be at increased risk for postoperative neurologic deficits. Anticoagulants and anti-platelet therapy may preclude use of neuraxial anesthesia due to risk of spinal hematoma and neurologic compromise. Also, conversion of neuraxial anesthesia to general anesthesia may be complicated by patient positioning and patient comorbidities.

Peripheral nerve block

Key benefits of peripheral nerve blockade include superior analgesia, reduced risk of nausea and vomiting, reduction in narcotic and other analgesia medications, and shorter hospital length of stay.

Drawbacks:Risks of any peripheral nerve blockade include infection, bleeding, and nerve injury.

Issues: Options of single shot peripheral nerve blockade versus continuous catheter techniques should be made in collaboration with the patient and surgeon after defining pain control goals. Patients with neurologic compromise (recent chemotherapy, peripheral neuropathy, etc.) may not be acceptable candidates for peripheral nerve blockade.

General anesthesia

Benefits: General anesthesia is likely the best option in patients with limited psychosocial coping skills, prone positioning, or contraindication to neuraxial techniques.

Drawbacks: Higher risks of postoperative nausea and vomiting (PONV), sore throat, potential airway trauma during instrumentation, postoperative cognitive dysfunction.

Other issues:Modified general anesthesia techniques required (nontriggering agents) in patients with history or risk of MH. Prone positioning may require special head, neck padding and monitoring. Risk of blindness is associated with prolonged prone positioning during surgery.

Airway concerns:For gastrocnemius surgery, prone positioning may preclude use of laryngeal mask airway devices.

Monitored anesthesia care

Benefits: Compared with general and neuraxial anesthesia, considered a minimal anesthetic risk. Benefits include avoidance of airway instrumentation and neuraxial techniques, rapid recovery, and low incidence of PONV.

Drawbacks: Must be accompanied by surgeon local anesthetic infiltration anesthesia for any open surgical procedure. Monitored anesthesia care (MAC) may be difficult in prone positioning with unsecured airway. Patient movement is possible.

Other issues:Patients with significant obstructive sleep apnea may be poor candidates for monitored anesthesia care.

6. What is the author's preferred method of anesthesia technique and why?

If prone positioning is required, general endotracheal tube anesthesia is typically performed with the advantage of a secured airway and unlimited anesthesia time. For shorter procedures and/or lateral positioned surgical procedures, or patients who do not request/require significant sedation, spinal anesthesia is an excellent alternative. At our institution, premedication with acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), oral opioids, and gabapentin is prescribed on a patient-specific basis. Intraoperative anesthesia is usually maintained with propofol infusion and oxygen/nitrous oxide gas mixture.

Analgesia is guided by the extent and duration of the surgery but may include a combination of local anesthetic infiltration by the surgical team, intravenous opioids, low-dose ketamine, and ketorolac. Anti-emetic therapy is guided by patient risk factors but a minimum of one agent is routinely administered, typically ondansetron or granisetron.Because the surgery involves soft tissues, single injection peripheral nerve blockade of the popliteal and saphenous nerves using long-acting local anesthetics may yield favorable postoperative analgesia.

What prophylactic antibiotics should be administered?

Cefazolin or cefuroxime administered within 60 minutes of incision is indicated for all patients. Patients with allergic reactions to cephalosporins or penicillin may alternatively receive vancomycin or clindamycin.

What do I need to know about the surgical technique to optimize my anesthetic care?

Gastrocnemius resection surgery, with intended goals of cosmetic reduction of muscular hypertrophy, may be performed as a subtotal resection or by selective sural nerve neurectomy. In subtotal resection, a 5-cm incision is made midline over the popliteal fossa and another incision of 2 cm in length is made at the muscle insertion into the achilles tendon. A significant portion of the gastrocnemius muscle is resected and removed through the proximal incision but care is taken to preserve 4-6 cm of muscle to maintain function. This procedure is typically two hours in length. In gastrocnemius recession (GR), an incision is typically made on the back inside part of the lower leg to expose the gastrocnemius tendon. This is then sutured to the underlying tissue in a newly lengthened position. This has been shown to correct equinus deformity and improved kinematic function.

What can I do intraoperatively to assist the surgeon and optimize patient care?

Intraoperatively the surgeon may request the use of muscle relaxation. Pharmacologic blockade of the neuromuscular junction can provide significant muscle relaxation for the surgeon during lengthening procedures.

What are the most common intraoperative complications and how can they be avoided/treated?

No significant intraoperative complications are specifically associated with this surgery.

Complications

Cardiac:Poorly controlled pain and sympathetic stimulation may lead to tachycardia and myocardial ischemia in susceptible patients. Measures to improve the balance of oxygen demand and supply should be undertaken and appropriate monitoring and management should commence if injury is suspected.

Pulmonary: No unusual respiratory complications are anticipated. Patients undergoing general anesthesia are at standard risks for atelectasis, aspiration, hypoxemia, hypoventilation, and obstructive sleep apnea. These are routinely managed with oxygen, therapy, pulmonary toilet, and non-invasive support.

Neurologic: See below.

a. Neurologic:

Unique to procedure: Patients undergoing subtotal gastrocnemius resection are at risk during the procedure for injury to both the lateral sural cutaneous nerve and the common peroneal nerve overlying the lateral gastrocnemius muscle. Postoperative neurologic assessments should be included in routine post-surgical assessments.

b. If the patient is intubated, are there any special criteria for extubation?

Standard extubation criteria apply to patients undergoing gastrocnemius surgery. Extubation criteria include hemodynamic stability, appropriate level of consciousness, absence of neuromuscular blockade, normothermia, and acceptable oxygen and ventilation support parameters.

c. Postoperative management

What analgesic modalities can I implement?

A multimodal, or balanced analgesia plan, offers the greatest likelihood of optimal pain management and low adverse effects. Use of NSAIDs, oral and intravenous opioids, low-dose ketamine, and scheduled acetaminophen frequently are adequate for analgesia. Single injection peripheral nerve blockade, if not implemented preoperatively, is occasionally used in patients with refractory postoperative pain. Informed consent should be obtained during the preoperative interview and documentation of intact neurologic status should be completed before regional anesthesia is performed.

What level bed acuity is appropriate?

Unless specific and unrelated patient comorbidities dictate a higher level of postoperative monitoring. Routine floor care is appropriate for patients undergoing gastrocnemius surgery.

What are common postoperative complications, and ways to prevent and treat them?

Post-operative complications associated with gastrocnemius are very uncommon. However, in a large series of patients who underwent gastrocnemius recession, problems reported included wound dehiscence, infection, chronic pain, nerve injury, and issues with scarring. Attention to infection prevention strategies and surgical technique are important for minimizing the incidence of these complications.

With any operation to the lower extremity, and subsequent limb immobilization in post-operative period, patients undergoing gastrocnemius surgery are at a higher risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). Therefore, appropriate thromboprophylaxis is warranted. Risks of bleeding or reoperation are no higher for this surgery than any other.

What's the Evidence?

Wren, TA, Cheatwood, AP, Rethlefsen, SA, Hara, R, Perez, FJ, Kay, RM. “Achilles tendon length and medial gastrocnemius architecture in children with cerebral palsy and equinus gait”. J Pediatr Orthop. vol. 30. 2010. pp. 479-84.

Kim, SC, Kang, MH, Ock, JJ. “Calf-contouring surgery of gastrocnemius hypertrophy: selective neurectomy of the sural nerve”. Aesthetic Plast Surg. vol. 32. 2008. pp. 889-93.

Lee, JT, Wang, CH, Cheng, LF, Lin, CM, Huang, CC, Chien, SH. “Subtotal resection of gastrocnemius muscles for hypertrophic muscular calves in Asians”. Plast Reconstr Surg. vol. 118. 2006. pp. 1472-83.

Delfico, AJ, Dormans, JP, Craythorne, CB, Templeton, JJ. “Intraoperative anaphylaxis due to allergy to latex in children who have cerebral palsy : a report of six cases”. Dev Med Child Neurol. vol. 39. 1996. pp. 194-7.

Rush, SM, Ford, LA, Hamilton, GA. “Morbidity associated with high gastrocnemius recession: retrospective review of 126 cases”. J Foot Ankle Surg. vol. 45. 2006. pp. 156-60.

Gan, TJ. “Risk factors for postoperative nausea and vomiting”. Anesth Analg. vol. 102. 2006. pp. 1884-98.

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