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BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

Lengthening of the Gastrocnemius-Soleus Complex

An Anatomical and Biomechanical Study in Human Cadavers
Gregory B. Firth, MBBCh, FCS(Orth)SA, MMed(Orth), Michael McMullan, MPhil, FRCS(Tr&Orth), Terence Chin, MBBS,
Francis Ma, MBBS, Paulo Selber, MD, FRACS, Norman Eizenberg, MBBS, Rory Wolfe, BSc, PhD,
and H. Kerr Graham, MD, FRCS(Ed), FRACS
Investigation performed at the University of Melbourne, Melbourne, Victoria, Australia

Background: Lengthening of the gastrocnemius-soleus complex is frequently performed for equinus deformity. Many
techniques have been described, but there is uncertainty regarding the precise details of some surgical procedures.
Methods: The surgical anatomy of the gastrocnemius-soleus complex was investigated, and standardized approaches
were developed for the procedures described by Baumann, Strayer, Vulpius, Baker, Hoke, and White. The biomechanical
characteristics of these six procedures were then compared in three randomized trials involving formaldehyde-preserved
human cadaveric lower limbs. After one of the lengthening procedures was performed, a measured dorsiflexion force was
applied across the metatarsal heads with use of a torque dynamometer. Lengthening of the gastrocnemius-soleus
complex was measured directly, by measuring the gap between the ends of the fascia or tendon.
Results: The gastrocnemius-soleus musculotendinous unit was subdivided into three zones. In Zone 1, it was possible
to lengthen the gastrocnemius-soleus complex in either a selective or a differential manneri.e., to lengthen the gastrocnemius alone or to lengthen the gastrocnemius and soleus by different amounts. The procedures performed in this
zone (Baumann and Strayer procedures) were very stable but were limited with regard to the amount of lengthening
achieved. Zone-2 lengthenings of the conjoined gastrocnemius aponeurosis and soleus fascia (Vulpius and Baker procedures) were not selective but were stable and resulted in significantly greater lengthening than Zone-1 procedures (p <
0.001). In Zone 3 (Hoke and White procedures), lengthenings of the Achilles tendon were neither selective nor stable but
resulted in significantly greater lengthening than Zone-1 or 2 procedures (p < 0.001).
Conclusions: Surgical procedures for the correction of equinus deformity by lengthening of the gastrocnemius-soleus
complex vary in terms of selectivity, stability, and range of correction. Procedures for the correction of equinus deformity
have different anatomical and biomechanical characteristics. Clinical trials are needed to determine whether these
differences are of clinical importance. It may be appropriate for surgeons to select a procedure involving the zone best
suited to the clinical needs of a specific patient.
Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

urgical lengthening of the gastrocnemius-soleus complex

to treat equinus deformity is commonly performed, either as an isolated procedure or as part of other reconstructive surgery1,2. Subcutaneous tenotomy of the Achilles
tendon was the first orthopaedic surgical procedure, and it
contributed to the development of orthopaedic surgery as an
independent specialty in the era before antisepsis and anesthesia3. After the initial enthusiasm for subcutaneous tenotomy

in patients with congenital clubfoot, the procedure was applied

to the correction of equinus deformity in patients with cerebral
palsy and other conditions. The results in patients with cerebral
palsy, although initially promising, were disappointing in the
long term4. After the development of surgical antisepsis and
general anesthesia, a variety of open procedures were devised to
replace subcutaneous tenotomy4. These included lengthening
of the conjoined gastrocnemius aponeurosis and soleus fascia

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what
is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the
article.

J Bone Joint Surg Am. 2013;95:1489-96

http://dx.doi.org/10.2106/JBJS.K.01638

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by Vulpius and Stoffel in Germany in 1913, proximal gastrocnemius recession by Silfverskiold in Sweden in 1924, and distal
gastrocnemius recession by Strayer in the United States in
19505-7. Percutaneous lengthening of the Achilles tendon was
advocated in 1987 as part of the move to minimally invasive,
day-procedure surgery8. The cause of equinus contracture was
suggested by Ziv et al., on the basis of studies in a hereditarily
spastic mouse strain, to be a failure of longitudinal growth of
the gastrocnemius-soleus complex relative to tibial growth9.
In the past two decades, the outcome of surgery for
equinus gait has been evaluated to an increasing extent with use
of instrumented gait analysis, which is more objective than
clinical assessment10. Despite renewed interest in the outcome
of surgery for equinus gait, substantial differences of opinion
persist regarding the indications for the different surgical approaches11,12. Some authorities contend that the surgical procedures are similar in effect and that the outcome depends
more on patient selection and postoperative care than on the
specific operative procedure employed11. In the context of
surgery for equinus gait in children with cerebral palsy, Rang
et al. stated, When a muscle is lengthened, the site makes little
difference. There is little to choose between a tendo Achillis
lengthening and a gastrosoleus [sic] recession, for example.11
Others draw on a limited evidence base to strongly
support the use of a particular procedure. We are aware of no
randomized trials, and substantial differences of opinion exist
regarding the best method for the various indications12. Skeletal
muscle in the growing child has an intrinsic ability to add or
subtract sarcomeres in a series in order to adapt to changes in
the length of a musculotendinous unit resulting from growth
or surgical intervention9,11. These adaptations, particularly in the
growing child, may further complicate attempts to understand
the outcomes of procedures to lengthen a musculotendinous
unit9,11. The terminology used to describe operative procedures
is often imprecise, and it is difficult to know with certainty what
procedure has been employed in some published studies12. The
use of eponyms and quasianatomical terms adds further to
the confusion. We therefore conducted an anatomical study,
utilizing a human cadaveric model of equinus deformity, to
investigate the surgical anatomy of the gastrocnemius-soleus
complex and to investigate biomechanical features of the various procedures13-15.
We previously investigated the lengthening characteristics of the tibialis posterior and medial hamstring musculotendinous units with use of an Instron test apparatus14,15. The
principal findings were that the intact formaldehyde-preserved
musculotendinous units were stiff and resisted lengthening and
that intramuscular tenotomy allowed greater lengthening at a
lower applied load. The site of the tenotomy was also critical in
that greater lengthening at a particular load was possible at a
distal site compared with a more proximal site14,15. The differences between proximal and distal intramuscular tenotomies
were thought to be related to the progressive decrease in crosssectional area from proximal to distal. We wondered whether
proximal-to-distal differences might also be found in the
gastrocnemius-soleus complex. The results of the previous

experiments were variable and difficult to standardize because

of problems with secure fixation of both the muscle and the
tendon in the clamps as well as other factors14,15. For these
reasons, we investigated the gastrocnemius-soleus complex in
situ, as this would represent a more realistic surgical simulation
and one that would avoid the problems associated with securing soft tissues within clamps.
Materials and Methods

he material tested was obtained from a convenience sample of thirty-one

formaldehyde-preserved human cadavers (fourteen male and seventeen
female) with a mean age at death of eighty-three years (range, fifty-five to
ninety-seven years). The cadavers had been preserved with use of 2% formal13-15
dehyde, 2.7% phenol, 33% glycerin, and water
. The cadavers were provided
by the University of Melbourne Medical School, and all state and university
regulations pertaining to the handling of human tissues were observed. The
study was approved under the audit provisions of our institutions Ethics in
Human Research Committee.

Surgical Anatomy and Development of the Biomechanical

Testing Protocol
The surgical anatomy of the gastrocnemius-soleus complex was studied in four
formaldehyde-preserved human cadavers. Formaldehyde fixation does not
change the mineral composition or structure of soft tissues, but it can result in a
fivefold increase in stiffness because of increased cross-linking of collagen and
13
other proteins . The ankles had been in a gravitationally induced equinus
position during the formaldehyde preservation, and equinus contractures had
developed because of postmortem shortening. All of the cadaveric lower limbs
14,15
had a fixed equinus deformity ranging from 10 to 35
. Equinus was
measured with the cadaver in the prone position, with the knee fully extended,
by applying a 20-kg dorsiflexion force across the metatarsal heads with use of a
torque dynamometer.
Six different lengthening procedures were performed to standardize the
operative procedures for the subsequent comparative trials. With the cadaver in
the prone position, a long midline I-shaped incision was made from the
popliteal crease to the heel. Skin and subcutaneous tissue were reflected at the
level of the deep fascia, exposing the whole gastrocnemius-soleus musculotendinous
unit in continuity (Fig. 1). The origins of the gastrocnemius and soleus muscles
were undisturbed.

Fig. 1

The experimental setup, showing a cadaver in the prone position with the
gastrocnemius-soleus complex exposed and an equinus contracture at the
ankle. The assistant is applying a measured dorsiflexion force to the
metatarsal heads with use of a handheld torque dynamometer.

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The chosen lengthening procedure was then performed in a standardized manner by performing each of the surgical cuts at a measured site
within the musculotendinous unit (Fig. 2). The metatarsal heads were palpated
on the plantar aspect of the foot and marked with a skin marking pen. The
torque dynamometer cuff was applied over the metatarsal heads and a progressive dorsiflexion force was applied across the metatarsal heads, similar to
the method used for stretching the gastrocnemius-soleus complex during
surgical lengthening in patients. An assistant applied the dorsiflexion force to
the metatarsal heads with use of the torque dynamometer so that the applied
force could be controlled, measured, and recorded (Fig. 1). The force was
increased in 10-kg increments from 0 to 40 kg, and the lengthening was
measured with use of a vernier caliper. The choice of a 40-kg force was based on
pilot work in which fractures of the tibia and fibula occurred with forces in
excess of 45 kg. The procedures selected for investigation, starting proximally,
were intramuscular tenotomy of the gastrocnemius-soleus complex as described by Baumann and Koch, distal gastrocnemius recession as described by
Strayer, gastrocnemius-soleus complex recession as described by Vulpius and by
Baker, and slide lengthening of the Achilles tendon as described by White and
5,7,16-23
by Hoke
. The procedures chosen are in current use, with published
results. They all have some intrinsic stability and do not depend on suture
repair. The procedures were performed according to the original description by
the author(s), apart from omitting the suture repair at the end of the Baker
procedure (Fig. 2). The midline raphe was routinely divided as part of the
5,16
procedures described by Vulpius and by Baker .

more detail in the Appendix. Graphs of lengthening versus force were generated
for each procedure.
The six operative techniques were compared in three randomized trials,
each of which used nine paired cadaver limbs. The first trial compared the
Strayer and Hoke procedures, the second compared the Baker and White
procedures, and the third compared the Baumann and Vulpius procedures. In
each trial, the two procedures were used in each pair of cadaveric lower limbs,
with alternating assignment of each procedure to the right or left lower limb in
an attempt to exclude any bias that may have existed secondary to dominance.
Although six different surgical techniques were studied, eight sets of measurements were generated. In both the Strayer and the Baumann procedures,
the gastrocnemius-only portion of the procedure was performed first, after
which the first set of measurements was made. The soleus procedure (intramuscular or fascial lengthening) was then added, and a second set of mea22,23
surements was made
.
Problems with this test protocol were encountered after Achilles tendon
lengthening. Once the yield point was reached at 10 to 15 kg, rapid and continuous lengthening occurred until the tendon ruptured and the ankle was
dorsiflexed against the tibia. At this point, little or no residual force was recorded by the torque dynamometer. Accordingly, the test protocol for all testing
following the White and Hoke procedures was modified. In this modified
protocol, the applied force was reduced to zero as soon as the yield point was
reached or the slide commenced and was then slowly increased back to 10 kg, at
which point the lengthening was recorded (Fig. 3). All biomechanical testing
after the more proximal procedures continued to follow the 40-kg test protocol.

Randomized Cadaveric Trials

In the subsequent randomized cadaveric trials, the surgical procedures were
standardized to reduce variability by performing the cuts at specific measured
points in the gastrocnemius-soleus complex as illustrated and described in

Statistical Methods
A linear regression model with lengthening as the dependent variable and
surgical technique as an eight-category independent variable was used to

Fig. 2

The six procedures investigated in randomized trials, listed in order from proximal to distal, were intramuscular tenotomy of the gastrocnemius and soleus
as described by Baumann and Koch, distal gastrocnemius recession as described by Strayer, gastrocnemius-soleus complex (gastrocsoleus) recession as
described by Vulpius and by Baker, and lengthening of the Achilles tendon (TAL) by double hemisection as described by White and by triple hemisection as
described by Hoke. Note that the tongue-in-groove cut was performed as described by Baker but sutures were not inserted. The Strayer procedure was
performed as a single transverse division of the gastrocnemius aponeurosis, in accordance with the original description of the procedure; following
application of the dorsiflexion force and testing, a single transverse cut was then made in the underlying soleus fascia. This procedure is sometimes referred
to a modified Strayer procedure or a Strayer procedure plus soleal fascial lengthening (SFL). The Baumann procedure was also performed as a series of
cuts located initially only in the gastrocnemius, followed by dorsiflexion and then by the addition of cuts in the soleus fascia and repeated dorsiflexion. The
midline raphe was divided during both the Baker and Vulpius gastrocnemius-soleus complex recessions.

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Fig. 3

Lengthening as a function of force during a single trial for each of the six
procedures. The lengthening at 40 kg was recorded for the Baumann,
Strayer, Baker, and Vulpius procedures. However, given the instability
associated with Achilles tendon lengthening, the lengthening after the
White and Hoke procedures was recorded at an applied force of 10 kg.

separation. Intramuscular lengthening of the gastrocnemius

and soleus may be performed in the interval between the gastrocnemius and soleus fascia, as described by Baumann and
Koch17. The gastrocnemius may be lengthened selectively, or
differential lengthening of the gastrocnemius and soleus may
be performed by varying the number of cuts in the fascia
overlying the two muscles23,28. At the junction of Zones 1 and 2,
it is possible to perform selective lengthening of the gastrocnemius alone, as described by Strayer7 (Fig. 2). It is also possible
to perform differential lengthening of the gastrocnemius and
soleus by separating the gastrocnemius fascia from the soleus
fascia and dividing the gastrocnemius aponeurosis and soleus
fascia separately, as described by Gage and sometimes referred
to as a modified Strayer procedure27,29.
Zone 2 extends from the end of the medial belly of the
gastrocnemius muscle to the end of the soleus muscle. This
zone is characterized by condensation of the gastrocnemius
fascia into a broad aponeurosis, which lies superficial to the
soleus fascia. The layers are most accurately referred to as the
conjoined gastrocnemius aponeurosis-soleus fascia25. These
two layers can very rarely be separated in Zone 2, and then only
partially and by sharp rather than blunt dissection24,25. Zone-2

compare mean lengthening between pairs of surgical techniques. Generalized

estimating equations with an exchangeable working correlation matrix were used
to estimate the parameters of this model. The pairwise comparisons were withincadaver if the surgical techniques being compared were part of the same trial and
between-cadaver if the techniques being compared were part of different trials.
The estimation approach used robust standard errors to reflect possible excess
correlation among lengthening measurements taken from the same cadaver.
All analyses were performed with use of Stata (Release 11.0; StataCorp,
College Station, Texas). Box plots of calf lengthening were generated to summarize and compare the results of the eight procedures. Figure 4 shows these
results arranged by surgical zone, from proximal to distal.

Source of Funding
No external funding was received for this study.

Results
Surgical Anatomy
distinct anatomical and surgical plane was found between
the gastrocnemius and soleus fascia, extending from the
gastrocnemius origins and ending abruptly at the distal end of
the (longer) medial belly of the gastrocnemius7,24,25. The level at
which it was no longer possible to separate the two layers varied
little, from 1 cm proximal to the last fibers of the medial gastrocnemius belly to 1 cm distal to this point25. Beyond this
point, the two layers of fasciae became adherent and confluent
until the distal margin of the soleus muscle fibers24,25. At that
point, the gastrocnemius aponeurosis and soleus fascia combined to form the Achilles tendon. We noted rotation of the
fibers, as described by White20,26, but the pattern was variable.
On the basis of these findings, we suggest that the gastrocnemiussoleus complex be divided into three anatomical zones of surgical importance27.
Zone 1 extends from the femoral origins of the gastrocnemius muscle to the distal extent of the medial gastrocnemius muscle belly or the most distal extent of the plane of

Fig. 4

Box and whisker plot summarizing the lengthening after the six procedures
(eight sets of results), arranged from proximal to distal according to the
position in the gastrocnemius-soleus musculotendinous unit. The boxes
indicate the median and the 25th and 75th percentiles. The diamond
indicates an outlying value, more than 1.5 times the interquartile range
above the 75th percentile. The whiskers extend to the minimum and
maximum or to the outlier, whichever is closer. The median lengthening was noted to increase stepwise from proximal to distal in the
musculotendinous unit. Procedures in a given zone were more alike than
procedures in different zones. Two sets of box plots are shown for the
Baumann procedure, the first after cuts in the gastrocnemius only and the
second after the addition of the soleus cuts. Likewise, box plots for the
Strayer procedure are shown after the cuts in the gastrocnemius only
and after the addition of soleal fascial lengthening (SFL). TAL = Achilles
tendon lengthening.

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procedures include those of Vulpius and Baker, both of which

are frequently but incorrectly classified as being the same as the
Strayer procedure (Fig. 2). Neither selective nor differential
lengthening of the two layers that comprise the conjoined
tendon is possible in Zone 2.
Zone 3 extends from the end of the soleus muscle to the
insertion of the Achilles tendon on the calcaneus. The gastrocnemius aponeurosis and the soleus fascia provide two
groups of fibers that are distinct at first, then rotate, and finally
blend together within the substance of the Achilles tendon.
Zone-3 procedures include all procedures on the Achilles tendon,
including lengthening, transfer, and translocation 20,21,30,31.
Slide lengthening, by means of two or three transverse partial
tenotomies, was described by Hoke in 1931 and by White in
194318,20 (Fig. 2).
Biomechanical Features of Calf-Lengthening Surgery
The results of the Baumann procedure were very stable, allowing
for <1 mm of lengthening at each transverse intramuscular
tenotomy and a mean total lengthening of 2.1 mm. The total
lengthening of the three gastrocnemius intramuscular tenotomies
was the same as that of the three soleus intramuscular tenotomies
and did not increase during the second dorsiflexion test (p = 1.0).
The Strayer gastrocnemius recession was also very stable, with a
mean gastrocnemius lengthening of 9.7 mm, which increased to a
mean of 14.3 mm with the addition of a cut in the soleus fascia.
The lengthening after the Strayer gastrocnemius recession was
significantly greater than after the Baumann intramuscular
tenotomy (p < 0.001). The gastrocnemius recession-soleal
fascial lengthening procedure resulted in differential mean
lengthening of the gastrocnemius compared with the soleus, in
a 2.1:1 ratio (9.7 mm compared with 4.6 mm).
The Baker and Vulpius gastrocnemius-soleus recessions
were not selective but were stable, with mean lengthening of 20.7
mm and 23.2 mm, respectively, at 40 kg of force. The gap opened
slowly and progressively, requiring greater force per centimeter
of lengthening compared with the Zone-3 procedures (Figs. 3
and 4). The mean lengthenings achieved by both the Baker and
Vulpius procedures were both significantly greater than those
achieved by either of the Zone-1 procedures (p < 0.001).
The greatest lengthening resulted from lengthening of
the Achilles tendon in the Zone-3 procedures. This was measured at a force of 10 kg after the slide point had been reached.
The mean lengthening was 30.0 mm for the White double hemisection compared with 32.9 mm for the Hoke triple hemisection (Fig. 3). This difference was significant (p = 0.006). Given
that these were Zone-3 lengthening procedures, both the gastrocnemius and the soleus were lengthened equally. Lengthening in Zone 3 was significantly greater than that achieved in
both Zone 1 and Zone 2 (p < 0.001). Lengthenings of the
Achilles tendon by both the Hoke and White techniques were
neither selective nor stable (see Appendix).
Discussion
n pediatric practice, equinus deformity commonly occurs in
patients with neuromuscular diseases and many congenital

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and acquired disorders7-11,32,33. In adult reconstructive surgery,

the disorders most commonly associated with gastrocnemius
tightness are pes planovalgus, neuromuscular disorders, and
diabetic neuropathy1,34,35.
Equinus deformity may be caused by contracture of the
gastrocnemius alone or a contracture of both the gastrocnemius and the soleus36. The amount of lengthening required for
a specific degree of fixed equinus is often much less than surgeons estimate. The amount of lengthening required can be
calculated by relatively simple geometric methods and also by
musculoskeletal modeling37.
Operations designed to lengthen the triceps surae can be
assigned to one of the three anatomical zones defined in this
study, making the specific features, advantages, and disadvantages easier to understand. Procedures for equinus deformity can
be classified as intramuscular tenotomy (Baumann), muscle
recession by aponeurosis lengthening (Strayer), lengthening by
aponeurosis and fascial lengthening (Baker and Vulpius), and
lengthening at the level of the tendon (White and Hoke)5,7,16-21.
The biomechanical results of pairs of procedures in the same
zone were more alike than were procedures from different zones
(Figs. 3 and 4). Given the wide range of pathologies and of deformity severity encountered by most surgeons, it may be necessary to have experience with several of these procedures, perhaps
one from each zone27.
The advantages of experiments involving human cadavers include the ability to perform surgical simulations in a
standardized manner, to make quantitative measurements,
and to conduct randomized trials14,15,22,23. The disadvantages
are the alterations in soft-tissue characteristics secondary to
formaldehyde preservation and the inability to draw direct,
clinically relevant conclusions13-15,22,23. Formaldehyde preservation causes stiffness in soft tissues and postmortem shortening
of musculotendinous units, but the effects on tensile testing
are modest13-15,38,39.
We were looking for a model of equinus deformity in
which there would be restricted ankle dorsiflexion, fixed
shortening of the musculotendinous unit, and stiffening of the
soft tissues. We considered that this combination of features
would most closely represent the situation in neuromuscular
diseases of childhood such as cerebral palsy9,11. In this setting,
we did not consider either the age of the cadavers or the stiffness induced by formaldehyde fixation to be a disadvantage13.
The effects of formaldehyde preservation are likely to
have been reasonably uniform in all of the surgical simulations13. Thus, it is the relative differences among the surgical
simulations rather than the absolute changes that are important. For example, the lengthening achieved after the Baumann
intramuscular tenotomy in the adult cadavers appeared to be
less than that reported after such surgery in children with
equinus deformity17,28. However, the unifying principle of this
series of cadaveric trials was that stability after lengthening
decreased from proximal to distal as effective lengthening increased. Similar findings have been reported with respect to
the site of intramuscular tenotomy in the tibialis posterior and
in the medial hamstrings14,15. Similar findings have also been

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reported in animal models in which modified Vulpius, Baker,

and Z-plasty techniques were compared38,39.
We suggest that the principle underlying the findings of
all of these studies is that the stability of the musculotendinous
unit after lengthening as well as the lengthening achieved are
directly related to the residual cross-sectional area of the soft
tissues remaining intact at the site of the lengthening14,15. For
example, after Baumann intramuscular tenotomy, all of the
soleus and gastrocnemius muscle fibers, plus the intact fascia
on the posterior aspect of the gastrocnemius and the anterior
aspect of the soleus, remain intact and thus confer stability and
resist lengthening (Fig. 2). Clinical reports on the Baumann
procedure are very limited, but it has been reported to yield
good results in children with spastic diplegia and mild equinus
deformities, with no reported overcorrections28. It may well
achieve greater lengthening in children than the very small
amounts achieved in the adult cadavers in the present study.
Zone-2 procedures achieved greater lengthening than did
Zone-1 procedures (Figs. 3 and 4). This may be related to the
decreasing cross-sectional area of muscle at the site of the
fascial division, enhanced by division of the midline raphe .
Division of the midline raphe was not performed in the Zone1 procedures but was performed routinely in the Zone-2 procedures. The effects of division of the raphe may be worthy of
further study.
In contrast, the stability of the musculotendinous unit
after the Hoke triple hemisection depends entirely on the
rather flimsy side-to-side links between the largely parallel
collagen fibers of the tendon, which have been divided at three
contiguous levels. Our experiments indicated little intrinsic
stability and substantial lengthening of both the gastrocnemius
and the soleus at low applied loads (Fig. 3). This may contribute to overlengthening and poor outcomes, especially in
children with spastic diplegia12,40,41.
If this underlying principle of a trade-off between effective lengthening and stability is accepted, it can be concluded
that one type of lengthening is not necessarily superior or inferior to the others. Rather, certain procedures may be more
appropriate for certain clinical indications. For example, in
children with spastic hemiplegia and equinus deformity, the
Silfverskiold test usually reveals a substantial fixed contracture
of both the gastrocnemius and the soleus. A Zone-2 lengthening (Baker or Vulpius) or a Zone-3 procedure (White or
Hoke) might be selected, depending on severity26,40. The longterm results of the White slide procedure in patients with
spastic hemiplegia have been reported to be excellent26.
In contrast, a growing body of evidence has revealed that
Zone-3 procedures in patients with spastic diplegia are associated with a very high prevalence of calcaneus deformity and
crouch gait at long-term follow-up12,29,40,41. For example, this
was demonstrated in a recent systematic review12 of studies
utilizing gait analysis as an outcome measure and having a
follow-up of more than five years40,41. In patients with spastic
diplegia, the Silfverskiold test usually reveals either an isolated
contracture of the gastrocnemius or a contracture of the gastrocnemius that is greater than that of the soleus27,36. Computer

modeling has revealed that forces and moments developed by

the ankle plantar flexors are extremely sensitive to changes in
tendon length. For example, lengthening of the soleus by 1 cm
reduces the moment-generating capacity by 30%, and a 2-cm
lengthening reduces the moment by 85%42. The soleus acts to
restrain and control the advancement of the tibia over the
planted foot during the midstance and late stance phases42. This
critical function may be impaired by excessive lengthening and
subsequent muscle weakness43. When lengthening of both the
gastrocnemius and the soleus is required, modeling suggests
that lengthening in a 2:1 ratio is appropriate43. The present
study confirmed that isolated lengthening of the gastrocnemius
is feasible by means of the distal recession described by Strayer7.
In addition, we found that gastrocnemius recession plus division of the soleus fascia with a single transverse cut resulted in a
2.1:1 lengthening ratio. This is very close to the optimum 2:1
ratio suggested by musculoskeletal modeling43. The Strayer
procedure would seem to be ideally suited to the management
of equinus in both patients with spastic diplegia and adults with
gastrocnemius equinus.29,34,44,45 It is important to note that the
Zone-2 procedures (Baker and Vulpius) do not result in differential lengthening of the gastrocnemius and soleus. The
Zone-2 procedures are neither anatomically nor biomechanically equivalent to the Zone-1 procedures. This critical point
may not be sufficiently clear in some standard texts and in some
original papers1,2,46,47. The Vulpius procedure is often grouped
with the Strayer procedure and referred to as a gastrocnemius
recession, when it is in fact a gastrocnemius-soleus complex
recession1,2,46,47 (see Appendix).
The disadvantage of selective and differential lengthening
of the gastrocnemius-soleus complex is principally that the
procedures are more complex than lengthening of the Achilles
tendon. The procedures take longer, scarring is greater, and
there are increased risks of injury to the sural nerve and lesser
saphenous vein44,45. However, the most important complication
of surgery for equinus deformity is weakness and calcaneus
gait12,29,40,41. Surgery for recurrent equinus is relatively straightforward, but it is usually impossible to correct an excessively
long and weak gastrocnemius-soleus complex27.
The stability of the gastrocnemius-soleus musculotendinous
unit after surgical lengthening may also be relevant to postoperative care and rehabilitation protocols. Specifically, the
intrinsic stability after Zone-1 or 2 lengthening may permit
very early weight-bearing and relatively short periods of cast
immobilization45. The relative instability after Zone-3 lengthening and the documented tendency for continued lengthening
under small loads suggest greater caution26. The position of the
lengthened gastrocnemius-soleus complex in the postoperative
cast, the postoperative rehabilitation, and the use of a postoperative ankle-foot orthosis may all have an important bearing on long-term clinical outcomes12.
The present study has several strengths. We standardized
the most commonly performed operative procedures for
lengthening of the triceps surae on the basis of anatomical
dissections utilizing standardized terminology, and we devised
a zonal classification system. The biomechanical effects of the

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procedures were shown to vary according to the anatomical

zone and the structures divided. The weaknesses of this study
include its reliance on length measurements in formaldehydepreserved adult human cadavers and its failure to address the
issue of muscle weakness. Our findings are probably relevant to
the correction of fixed equinus deformity, but the complex
issue of dynamic equinus deformity could not be addressed by
our study. The next logical step would be the testing of these
findings in clinical trials. However, in a recent clinical study of
gastrocnemius-soleus complex lengthening in children with
spastic diplegia, we found that equinus gait could be corrected
in the majority of children by means of conservative Zone1 surgery. In addition, severe crouch gait was abolished and the
prevalence of calcaneus deformity was very low48. In that study,
the intraoperative goal was to correct equinus to between
neutral and 5 of dorsiflexion, and this may be a critical factor
in the prevention of overlengthening in all zones49.
In conclusion, we have described the anatomical basis of
methods of gastrocnemius-soleus complex lengthening for
equinus deformity based on a three-zone classification of the
gastrocnemius-soleus complex. Surgical procedures from the
same zone were more alike than procedures from different
zones, both anatomically and biomechanically, particularly in
terms of the effective lengthening achieved (Figs. 3 and 4).
Correlations of the results with those of clinical outcome
studies will be very important. In this context, it is important to
note that although outcomes with instrumented gait analysis
may show little difference among procedures at short-term
follow-up, long-term follow-up studies with instrumented gait
analysis suggest substantial differences in outcome related to

both the zone of surgery for equinus deformity and concomitant procedures such as those performed in multilevel
surgery12,28,29,40,41,45-47,49.
Appendix
More detailed descriptions and photographs of the operative procedures as well as a historical review of the
literature are available with the online version of this article as a
data supplement at jbjs.org. n
NOTE: The authors acknowledge the help of their orthopaedic surgeon colleagues Dr. Jan Matussek,
MD (Regensburg, Germany) and Dr. Erich Rutz, MD (Basle, Switzerland) for the English translations
of References 5 and 17, respectively.

Gregory B. Firth, MBBCh, FCS(Orth)SA, MMed(Orth)

Michael McMullan, MPhil, FRCS(Tr&Orth)
Terence Chin, MBBS
Francis Ma, MBBS
Paulo Selber, MD, FRACS
H. Kerr Graham, MD, FRCS(Ed), FRACS
Hugh Williamson Gait Laboratory (T.C., F.M.),
Orthopaedic Department (G.B.F., M.M., P.S., H.K.G.),
The Royal Childrens Hospital, Flemington Road,
Parkville, Victoria 3052, Australia.
E-mail address for H.K. Graham: kerr.graham@rch.org.au
Norman Eizenberg, MBBS
Rory Wolfe, BSc, PhD
Department of Anatomy and Developmental Biology (N.E.) and
Department of Epidemiology and Preventive Medicine (R.W.),
The Alfred Centre, Monash University, Commercial Road,
Melbourne, Victoria 3800, Australia

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