What is the protocol for repairing a gastrocnemius (calf muscle) laceration?

Gastrocnemius Laceration Repair Protocol

Primary repair of gastrocnemius lacerations should include intramuscular nerve repair along with muscle tissue approximation to achieve optimal functional recovery and prevent muscle atrophy. 1

Initial Assessment and Preparation

• Evaluate the extent of the laceration, including depth and involvement of neurovascular structures
• Ensure adequate anesthesia (regional or general) for proper pain control during repair 2
• Prepare the wound site with appropriate antiseptic solution (povidone-iodine or chlorhexidine if iodine allergic) 2
• Achieve proper visualization and exposure of the wound

Surgical Repair Technique

Step 1: Wound Preparation

• Debride devitalized tissue and irrigate the wound thoroughly
• Identify and isolate intramuscular nerve branches if visible

Step 2: Suture Selection

• Use monofilament sutures for muscle repair to minimize bacterial seeding and reduce infection risk 3
• Preferred options:
  • Synthetic monofilament absorbable sutures (e.g., poliglecaprone/MONOCRYL)
  • Non-absorbable sutures may be considered for high-tension repairs

Step 3: Muscle Repair Technique

• Use either 4-strand Kessler or Mason-Allen suture technique:
  • 4-strand Kessler technique provides the highest maximum load (15.5N) and stiffness 4
  • Mason-Allen technique also provides good strength (13.2N) 4
  • Avoid simple mattress sutures as they provide significantly less strength (4.4N) 4

Step 4: Intramuscular Nerve Repair

• Identify and repair intramuscular nerve branches using microsurgical techniques
• Nerve repair is critical for preventing muscle atrophy and preserving function
• Studies show significantly less muscle atrophy, less scar tissue formation, and better preservation of fast-twitch muscle fibers with nerve repair 1

Step 5: Fascial Closure

• Close the crural fascia with continuous non-locking sutures to distribute tension evenly 2
• Avoid excessive tension which can lead to tissue necrosis

Step 6: Skin Closure

• Use continuous non-locking subcuticular sutures for skin closure to minimize pain 2
• Consider skin adhesives for superficial lacerations with minimal tension

Post-Operative Protocol

Immediate Post-Op (0-2 weeks)

• Immobilization in functional position to protect repair
• Pain management with appropriate analgesics
• Monitor for hematoma formation

Early Rehabilitation (2-6 weeks)

• Begin gentle range of motion exercises as tissue healing permits
• Implement calf stretching exercises to prevent contracture formation 5
• Avoid forceful muscle contraction against resistance

Advanced Rehabilitation (6+ weeks)

• Progressive strengthening exercises
• Functional training specific to patient's activities
• Monitor recovery with functional assessments

Expected Outcomes

• Electrophysiological recovery of muscle typically begins around 8 weeks post-repair 6
• Histological studies show gradual regeneration of muscle fibers across the suture site 6
• Muscle tension recovery reaches approximately 60% of normal by 6 weeks post-repair 6

Potential Complications and Management

• Hematoma formation: Ensure proper hemostasis during surgery
• Infection: Consider monofilament sutures to reduce bacterial seeding 3
• Muscle atrophy: Implement proper nerve repair and early rehabilitation
• Contracture: Encourage early stretching exercises once healing permits 5

Clinical Pearls

• Intramuscular nerve repair is critical for optimal functional recovery and should not be overlooked 1
• The 4-strand Kessler technique provides superior biomechanical strength compared to simple mattress sutures 4
• Continuous non-locking suture techniques distribute tension more evenly and result in less pain 2
• Ultrasound biomicroscopy can be used to monitor muscle healing progress post-repair 7