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MIninial incision PLANTAR heel spur surgery with pf release

Posted by Dr. Z on 2/22/03 at 09:45 (110301)

Could either Dr. Davis, Dr. Wander or anyone who knows could they tell me when they first learned of MIS plantar heel spur surgery and if they perform the procedure who they learned it from. We are only talking about mis surgery from the botttom not the side. I am curous as to how it got its start.

Re: MIninial incision PLANTAR heel spur surgery with pf release

Ed Davis, DPM on 2/22/03 at 12:38 (110346)

Dr. Z:

I cannot speak for that procedure in general but the version I use, I have been told, was originated by Dennis White, DPM of Auburn, California. I believe he is retired. I picked up the technique in 1992. I used the medial approach via an approximately 2 cm incision prior to that.

The operative area is identified with a fluorocope and marked with a needle. A 15 blade is used to make an approximately 3.5mm skin incision. A Beaver #67 blade is then used to make the plantar fascial cut, basically using the incision area as the pivot point. As far as how much of the fascia is cut laterally, that is still up to the preference of the surgeon.
Ed

Re: MIninial incision PLANTAR heel spur surgery with pf release

Dr. Z on 2/22/03 at 13:51 (110361)

Interesting. I know Dennis White very well, great guy, He didn't originate the plantar fascia approach from the bottom. He wrote a great paper on the procedure in the APMA journal with results but sorry it wasn't. I first saw the procedure in a lecture hall in 1981, I was in Washington, DC. A podiatrist from West Virginia named Harvey Pilsner was sitting next to me. I still remember his deep southern accent. He pulled out of his pocket pictures of this procedure and started to tell me how he started to do this procedure. He was probaby in his late 70's. Anyway he did write one or two papers about this in a very old podiatry journel called Current podiatry. Ever heard of this paper? I started doing the procedure and did one lecture on the procedure with the permission of Harvey. Guess who was the lecturer right after me . Dennis White. The reason I remember this lecture so well was the very hot hot dicussion by alot of the group. Hey Zuckerman you have to take the spur out and hey you are right on top of the spur why risk not taking it out. What the ##$$# does this smartass kid know. I know it was really a hot box. It was that lecture that made think hey they may be right why not take the bone out you are right there. I also remember that day because I was part of the part of the scientic comittee and the REAL lecture on a different topic
never showed. So I volunteered to fill in and got up there without any preparation and did a thiry minute lecture in ten minutes. I mean no slides, no x-rays, nothing, just me and my mouth. So afterward I mean it was quick. I though hey it takes ten minutes to do the procedure it shouldn't take ten minutes to do the lecture. So after looking at the crowd
and the podiatrist looked at me like who is this 3###. I made the mistake of not getting off and ask them So who at there take the spur out and why wold you do something like that.Ok the lecture just got started. In those days I would never let you prove me wrong

I had one of my teacher come up to me and really give it to me. I was one of the last times that I spoke on the topic At that time there were no
flurocopes so I used an polaroid #57 x-ray for quick look at the incision because the place was so important. I then move to a fluroscopic in
1985. It was a Xcsan office model. I owned number out of the factory. I stil have the same unit today. Now the company is owned by Dow

I still would like to really know if Harvy Pilner was the first. I do have x-ray's showing my first in 1981

Re: MIninial incision PLANTAR heel spur surgery with pf release

Dr. David S. Wander on 2/22/03 at 16:16 (110399)

David,

I'm not sure who first described a plantar approach to release of the plantar fascia, but if it's important to you, I can certainly check my journals. I do not perform MIS procedures, with the exception of a small exostosis on a toe. I am personally not comfortable placing a blade where I can't visualize the anatomical structures such as veins, arteries, nerves, etc. This is much different than endoscopic procedures, because although there is a small incision, the scope allows visualization of the tissue.

When I perform a plantar fascia release from a plantar approach, I perform a procedure similar to that described by Dr. Davis, with a transversie incision approximately 3-4 cm and full visualization of the tissues. Hope this information is helpful.

Re: MIninial incision PLANTAR heel spur surgery with pf release

Dr. Z on 2/22/03 at 17:15 (110406)

David,

You place a sharp, blade, knife, everytime an EPF procedure is done. How else can you place the sharp end of the metal trochar into the side of the foot, across the bottom and to the other side of the foot. There is no visualization when this is done. Anatomy is very important that is why we study it and learn it and most important understand it.

Dr. Davis performs a mis approach just like Dr. White, which is outlined in detail in the APMA journal.(1992) You don't visualize the procedure you feel and know where to cut the fascia by feel, knowing anatomy and location.

It is very helpful if you could find who did the first mis plantar incision . I know that you don't personally don't perform mis procedure you have told me this many many many times. . I just want to know if you know who did the first mis plantar fasciotomy . That's all no big deal

Re: MIninial incision PLANTAR heel spur surgery with pf release

Dr. David S. Wander on 2/23/03 at 09:15 (110460)

David,

The trochar I use, NEVER has a sharp end. It is placed after making a tunnel via blunt dissection, and the end of the trochar is blunt. As well as we all know our anatomy, there are always anomalous courses of nerves, tendons, arteries, veins, etc. I will refer you to Sarraffian's Textbook of Anatomy of the foot and ankle, describing the dozens of variations in anatomy, including the location of nerves, blood vessels, etc. I made Denise a promise, so I'm going to end this conversation.

Re: MIninial incision PLANTAR heel spur surgery with pf release

Dr. Z on 2/23/03 at 10:09 (110463)

So what instrument are you using to make this tunnel all the way across the bottom of the foot? With mis heel spur surgery you are cutting against the bone. With EPF you aren't. I am not saying that an EPF technique is bad I just saying it is blind when placing instructments into the portal. So who is this Denise you are talking about . Never heard of her

Re: MIninial incision PLANTAR heel spur surgery with pf release

Ed Davis, DPM on 2/23/03 at 11:29 (110477)

Dr. Z:

We are getting into the open vs. MIS debate. As you know of my attitude by now is 'if it works and it is safe, do it.' I am not waiting for the double blind multi-center study to come out to settle this debate because it isn't going to happen.

There are times when open is better and times when MIS is better. One way to look at the 'visualization' issue is to look at some other specialties wheere visualization may be limited, eg. certain rhinoplasties. Yor statement, that with the MIS technique mentioned, performed properly, one is cutting on bone is correct and really is the key here. I am teaching podiatric surgical residents this technique and I basically have to keep my hand on top of theirs emphasizing that the #67 never leaves bone- ever.
I also put on an EPF seminar for the residents a couple years ago. The EPF set-up has the 'cool' factor to it -- seems high tech. Quite frankly that is about all the good I can say about EPF. One is cutting up and toward vital structures with EPF but with visualization, and equipment that limits the depth of the cut. There are medial plantar fascial fibers that emanate from the distal-medial aspect of the calcaneal tuberosity that may not be visualized with EPF and not cut - this has been demonstrated by individuals doing the release in the arch area after EPF failure.
Ed

Re: MIninial incision PLANTAR heel spur surgery with pf release

Dr. Z on 2/23/03 at 12:51 (110483)

ED,

I know . All I wanted to know was if anyone could help me determine who was the first to do a mis plantar heel spur approach. Dr. Wander is a neighbor of mine and loves to tease me and that is what he is doing. We were joking. But really all I wanted to know who was was the first. I appreciate your comments about EPF and have always agreed with this rationization. By the way the feel of bone is very important when doing mis but the sound of cutting of bone is more important. The doctor must learn the sound of the cutting of bone to do mis without injury to other tissue

Re: MIninial incision PLANTAR heel spur surgery with pf release

Dr. David S. Wander on 2/23/03 at 15:22 (110523)

Dr. Ed, Dr. Z,

I am certainly not a proponent of any plantar fascia release surgery, since I believe it's rarely necessary. The bottom line is that there's more than one way to skin a cat, and the plantar fascia can be released via small incisions, endoscopically, via C-arm guidance, via the use of a Beaver blade, Smylie knife, plantar approach, etc. These all accomplish the same task of releasing a portion of the fascia, and all the procedures have inherent risks and complications. That's the beauty of conservative care and ESWT. I did not critique MIS procedures. I am 'classically' trained with open techniques, though over the years I have been exposed to all types of procedures and have performed some 'hybrid' procedures. I simply stated that I AM PERSONALLY not comfortable not visualizing tissues and structures. This was not an attack on MIS or Dr. Z, but Dr. Z is a sensitive guy! Regardless,.....I know where he lives!!!!

Re: MIninial incision PLANTAR heel spur surgery with pf release

Dr. Z on 2/23/03 at 15:30 (110526)

If you could find out who the first podiatrist was to perform a plantar approach mis procedure with Fluroscopic assistant I really would appreciate it. Thanks