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Image-guided surgery ??

Posted by BrianG on 12/14/03 at 19:15 (140001)

Hi all,

I took about a month off, to do a little bird hunting, and bond with my 18 month old Britt. My heels took a beating, which didn't leave me enough energy to be posting, or reading, at HS.com. I'm back now, and I have something I'd like to run by everyone.

Our local hospital is the first in the area to offer a new sinus surgery. It's 'image guided' which allows a 'surgeon the precision necessary to perform intricate sinus surgery by pin pointing the exact location of the surgical instuments within the sinus cavity'. They go on to expain how close the sinus cavity is to the optic nerve, brain, etc. It also reports that risks are greatly reduced.

OK, so take out the wods 'sinus cavity' and add in 'heels'. Right now I believe there about 3 main types of heel surgery. EPF, open heel, and coming in from the bottom, like Dr Z practices. Personally I like the thoery of the EPF method, but I really don't think the 'kit' that is now used, it's not worth a dime. I've read where different patients have been cut anywhere from 1/3 to 3/4 of their fascia. I personally had this surgery, and doctors have told me that not enough of the fascia was cut, therefore the procedure was a failure. The 'open' procedure can take up to a year to heal, and you are still relying on the surgeons hand to make the cut. With Dr. Z's method, I believe a flourescope is used, and the cut is made by feel.

WHY can't this new technology be incorporated into the EPF method, (discarding the kit), allowing for quicker healing, and more precise cutting????

Unless someone can show me a major flaw with this thinking, I believe we should all start asking questions of the 'movers and shakers', in the world of heel surgery. I think this might just work, resulting in successful surgery, the likes of which have never been seen before.


Cut and Pasted from Mayo Clinic web site:

Endoscopic Sinus Surgery
Endoscopic Sinus Surgery
Some patients have sinus diseases which even the best medication cannot adequately treat. Nasal and sinus polyps and chronic sinusitis that does not respond to appropriate medications are common reasons patients have sinus surgery. Such surgery is usually done by physicians in the Department of Otorhinolaryngology who specialize in evaluating and treating problems in the head and neck.
At Mayo Clinic in Jacksonville, most sinus surgery can be done endoscopically. Endoscopic sinus surgery is a modern, minimally invasive procedure that avoids external incisions. Its development over recent years has helped revolutionize the management of sinus disease. Using special miniaturized video cameras and instruments, endoscopic sinus surgery allows a surgeon to precisely target the affected areas of the nose and sinuses while leaving healthy areas untouched.

The unparalleled view of nasal and sinus anatomy allowed by endoscopic surgery minimizes unnecessary trauma while ensuring complete treatment. In addition, virtually all endoscopic sinus surgery at Mayo Clinic in Jacksonville can be done on an outpatient (day surgery) basis.

Modern Technology: Safety and Control
A microdebrider
Instruments used for image-guided sinus surgery. All sinus surgery at Mayo Clinic in Jacksonville is done by a board-certified otolaryngologist. For particularly complex cases, Mayo Clinic surgeons are equipped with state-of-the-art instruments.

These include a device known as a microdebrider & mdash; a powered instrument that allows delicate yet efficient removal of diseased tissue. The surgeon also may use a specialized three-dimensional, computer-enhanced visualization system known as the Stealth Station. This system provides the surgeon with a real-time display of a surgical instrument's location and trajectory overlayed on the patient's CT scan for extremely precise control.

What to Expect From Surgery
Before surgery, patients undergo a thorough evaluation of their symptoms, a physical examination, CT imaging scan and relevant laboratory tests. The risks, goals, benefits and expectations are thoroughly discussed, and the patient's questions are answered.

Surgery is done in a modern surgical facility with state-of-the-art monitoring equipment to help ensure safety, comfort and convenience for our patients. General anesthesia is usually recommended. At the conclusion of the procedure, a small gauze dressing is placed beneath the nose. Often small nasal packs are also placed in the nose. Packs are made of a comfortable, gel-like material.
After fully recovering from anesthesia, patients will be allowed to go home. Patients usually have little to no pain, bruising or swelling. Discomfort is equivalent to that of a bad head cold (that is, a stuffy, runny nose, dry throat and a groggy, tired feeling). Postoperative care is usually simple and includes rest, medication and replacing the dressing. Packing, if present, is removed by the surgeon one to three days later in the office.
Good postoperative care is essential after sinus surgery to help ensure optimal results. Patients are given specific postoperative schedules based on their unique situations.

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Re: Image-guided surgery ??

Dr. Z on 12/14/03 at 19:41 (140004)

Welcome back,
I hope you enjoyed some time away. I believe this is the EPF method that they are using in the nose. The problem I have with any cut of the pf is you damage the biomechanical structure when you cut any portion of the heel. This can lead to pain, weakness and further tendon compensation.
That risk can't be eliminated period. It can be reduced but not eliminated

Re: Image-guided surgery ??

BrianG on 12/14/03 at 23:19 (140009)

Hi Dr. Z,

I realize the artcle is talking about the nose. What I'm thinking about is the 'exact' direction, and amount of the cut. If every fascia was cut at exactlly the same place (which is open to some debate now), at least each patient would have the best chance of recovery possible (through surgery). Right now, that precision is not happenening in fascia releases. Why should we have 2nd class treatment? Let the surgeons do some trials, to see what the exact pecentage of cutting will lead to the best chance of success.

I'm not saying it will ever replace ESWT, but there will always be people who do not respond to the the shockwaves. Why shouldn't this group have the same surgical accuracy as patients with nasal problems !!! Right now there is NO standard, or exact amount of fasca that should be cut. Let make the surgeons take this cutting to the next level! First, they find out exactly which percentage of cutting it takes, for maximum healing to occur. Next they can use the imaging machine to ensure everyone gets the 'gold standard' cut. That scope cut will give patients the best chance for recovery, with the least amount of time off of their feet.


Re: Image-guided surgery ??

Pauline on 12/14/03 at 23:20 (140010)

Welcome back. Nice to see you posting again. Your article is very interesting. Why not write to this department at Mayo and ask them about the future of this type of surgery applied to other conditions.

Mayo always has a lot of research and development going on and it would be interesting to find out how these research teams see this type of surgery being used in the future.

The one thing I think we must remember is that we don't walk on our nose, so my guess would be a surgery by any name that weakens the main supporting structure of the foot, the P.F., will still continue to cause it's share of complications, scar tissue, and pain.

Now if they could transplant the entire P.F. with reconstructive surgery using synthetic fibers that cannot be injured, we might looking at a whole new ballgame.

Personally I like the idea of being able to screw off the foot at the ankle and just ordering a whole new replacement part. You know 'just in time' body parts. It would certainly give new meaning to the world of logistics.

Re: Image-guided surgery ??

Kathy G on 12/15/03 at 09:16 (140023)

Hi Brian,

Intersting that you should bring this up. My husband had to have some dental surgery on a thirty-one-year old root canal that had infected and he was referred to a new endotontist in our area. He had to see him on an emergency basis on a Sunday afternoon and I had to drive him because he was on painkillers. My husband asked him if he'd show me his dental equipment as he was quite amazed by it.

It was just extraordinary. He used digital xrays and looked through a kind of magnification device to guide him as he went into the root of my husband's tooth. Using the computer screeen, he was able to enlarge the area he was working on in order to get a better view. He let me look at the tooth though the magnification device and it was something else; I could actually see the root and the area of infection kind of pulsating.

What you're describing must involve similar equipment. It's technology at its finest and so amazing. I can imagine how well it would work on the sinus area and probably other areas of the body but I don't see how it could translate to the foot but I'm no expert.

Thanks for sharing this exciting technology with us!

Re: Image-guided surgery ??

BrianG on 12/16/03 at 22:04 (140125)

Hi Kathy,

I'm thinking that it can replace the 'kit' that is used with the EPF method. In it's day, it was probably a big improvement over the other methods. Smaller incision than the open surgery, means quicker healing.

What I found, through research, is that the 'kit' is not all that accurate. Some surgeons have gone so far as to say that using the kit, does not cut enough of the fascia. They suggest the surgeon should go back in, when the EPF is completed, and snip a little more of the fascia, by hand! Now, how acurate is that?

Why do some patients heal from the EPF surgery, and others don't? It might just be that the incision needs to be 100% accurate, for healing to occur. I'm not saying that it's a fact, but it's one thing that comes to my mind, when I think about why I wasn't cured by my EPF.

I am going to write to the Mayo clinic, to see if their new image guided surgery can be adapted for cutting the fascia. Their foot and ankle surgeons must be having the same healing rate as the rest of the surgeons in this country. The doctor who developed the EPF claims over an 80% cure rate, which I highly doubt. I wouldn't be surprised if it was only 50%, or less !!!


Re: Image-guided surgery ??

John H on 12/17/03 at 17:30 (140164)

There is always danger of damaging nerves as you push the endoscope into the foot. From what most of the doctors post the relesase (cut) of the fascia is by 'feel' and not visual. I doubt all would agree on how much to cut not do they know how much they release unless they release it all which would be my last last last last resort.

Re: Image-guided surgery ??

John H on 12/17/03 at 17:36 (140166)

Brian: My guess is that each of us has PF in perhaps a different place and the amount of fascia to cut might vary from person to person depending on how tight the fascia is, the severity of the injury to the fascia and other factors. Probably no scientific way to know how much fasia to cut or if cutting the fascia is appropriate for any one individual.As you are well aware some people get a cure from PF surgery, some get worse, and some just stay the same.

Re: Image-guided surgery ??

BrianG on 12/18/03 at 08:39 (140201)

Hi John,

My thoughts are that 'maybe' there is a magic percentage for cutting the fascia. When you cut exactlly this much, you have your best chance of healing. What that percentage is, I have no idea. I doubt anyone knows, thats why I'm calling for some research. With this new technology, the doctors will be able to make the cut, at the exact percentage they need to. This would probably mean they would have to cut so many people at 50%, another group at 55%, more at 60%, and so on. It would take a while to realize the results, but after a year or so, the doctors should know which percentage has given the most relief.

When I had my EPF done, I did my research. One thing that I remember is that the cut is made in an area that has little, or no, nerves. When the EPF is done correctly, there is very little chance of nerve damage. As far as I know, I have no nerve damage from my procedure. Doctors tell me that the reason my surgery failed, is because not enough of the fascia was cut. This is why I want to see the cutting portion of the kit replaced, with something more accurate (the image guided surgery). The kit, as it is currently made, allows for only one size cut to be made, once it's in place. This could be the reason for so many failures. Cut the exact, correct amount, and the healing percentage will probably go up.

Lastly (and then I'll jump down off my soap box) is that I have a post saved, from a Pod who used to visit these boards. He was at a convention where Dr. Barrett (the EPF founder) gave a demonstration on about 6 frozen cadaver feet. After the procedure was completed on each foot, they were opened up, to see the results. This Pod reported that NONE of the cuts were long enough to facilitate healing. He suggested that the Pod doing the procedure, should go back in, and snip an additional amount of the fascia, after the EPF was completed. All that technology, and the final snip has to be done by hand!!!

Makes sense to me,