Procedures & Success RatesPosted by John H on 9/07/04 at 10:29 (159486)
In 1995 Licopantis described the use of a fluoroscopic technique in plantar heel surgery, enabling precise visualisation of osseous structures. Licopantis, in addition to Graves et al. (cited in Brekke and Green, 1998, p. 66) notices an overall improvement following the surgery. The procedure is as follows;
A portable fluoroscope is placed at right angles to the heel spur or calcaneal tuberosity. The instrument is used for continuous and interrupted fluoroscopy. Local anaesthetic is infiltrated via a plantar approach. No tourniquet is used. A 22 gauge 1 ? inch needle is inserted to the hub in a plantar-proximal to dorsal-distal orientation. The needle is advanced at a 45 degree angle until just touching the tip of the spur or alternatively the distal aspect of the calcaneal tuberosity. A 1 centimetre incision is made with a number 10 ribbed back blade slightly distal to the needle, leaning on it in order to maintain the same axis. Using the fluoroscope to ensure correct placement, the blade is placed at the distal tip of the spur/tuberosity and the needle is withdrawn. The foot is dorsiflexed, tautening the medial band of he plantar fascia, and the blade is pivoted medially and laterally to release the fascia from its proximal attachment. This action prevents accidental extension of the 1 centimetre incision. As it is pivoted, the blade is advanced proximally, followed by introduction of a cottle rasp, which is advanced along the axis. Again, the fluoroscope is used to ensure correct placement, and the spur is removed by rasping. The area is flushed with sterile saline under pressure (Licopantis, 1995).
The incision is not closed. Licopantis suggests dressing the area with Betadine-soaked Adaptic and bandage or elastoplast. Postoperatively, the patient is given a surgical shoe and must limit walking for the first 3 days. From days 4-10 the patient may increase activity. Licopantis (1995) observes a faster healing time because the technique is minimally invasive. He also observes the advantageous location of the incision site, avoiding disruption of local vasculature, and minimal ecchymosis or oedema.
Endoscopic plantar fasciotomy is a fairly recent technique, and may be performed under local or general anaesthesia. The patient is placed supine on the operating table with feet everted (Stone and Davies, 1996). Exsanguination is accomplished with an Esmarch's bandage, and a pressure cuff or tourniquet applied above the malleoli. A vertical incision is made 1-2 millimetres anterior to the exostosis, medial to the proximal fascial attachment. Following medial to lateral insertion of the cannula, the scope is advanced laterally and the fascial width measured at the 50% mark (Stone and Davies, 1996). Subcutaneous tissue and fat may be dissected via a haemostat (Brekke and Green, 1998). An endoscopic camera is inserted medially allowing full visualisation of the plantar fascia width. The medial and lateral boundaries of the fascia are marked on the camera, and a triangular cutting knife used to release the medial half of the plantar fascia (Brekke and Green, 1998). In order to avoid postoperative complications and side effects, Stone and Davies (1996) suggest modifications when releasing the central-medial half of the plantar fascia; the endoscope is placed laterally and the fascia released from the central aspect towards the medial investment. A blunt probe is used to inspect the underlying flexor digitorum brevis muscle belly, ensuring full thickness release of the fascia. The area is irrigated with sterile saline and closed with 4-0 polypropylene sutures (Brekke and Green, 1998), and dexamethasone phosphate infiltrated in the area (Brekke and Green, 1998; and Stone and Davies, 1996).
According to the different authors, the patient may be placed in surgical shoes and remain non-weight bearing for 1 week postoperatively, or be placed in a short leg walking cast for 4-6 weeks and allowed to ambulate without crutches. Alternatively, recent information provided on the world wide web (wysiwyg, 1999) states patients should be walking on the same day as the endoscopy without pain, and 4 weeks postoperatively the patient is able to return to normal activities without pain.
Minimal incision approach
A 5-10 millimetre plantar transverse incision is made over the distal aspect of the medial calcaneal tubercle. Subcutaneous tissue and fat are dissected to the bone via use of a haemostat. Using a Freer elevator, the orientation of the three fascial bands are determined. A small blade is used to free the bands attached to the medial calcaneal tubercle while the digits are dorsiflexed. Hepford (1991) advises cutting of the fascia in three sections, cutting the lateral band last. Bordelon (1993) and Hepford (1991) describe removal of the heel spur via use of a rongeur and curette respectively, followed by copious flushing with sterile saline. Sutures or steri-strips are used to approximate wound edges. The patient is allowed to partially weight bear with the use of surgical shoes and crutches 3-14 days postoperatively (Brekke and Green, 1998; and Hepford, 1991). Bordelon (1993) advises short leg casting, and weight bearing after 4-7 days if comfortable. A weight bearing cast or off the counter brace is used for 3 weeks postoperatively, with return to full activity around 6-12 weeks.
Open or complete approach
An open approach allows for better visualisation of anatomical structures, and according to Reeves et al. (1997) may reduce the chance of damage to the FBLP nerve. Bordelon (1993) suggests the complete surgical exploration technique to be indicated in recalcitrant conditions, without guarantee of return to pre-injury level. A long incision (4-8 centimetres) is made from the posterior aspect of the malleolous to the medial tubercle, and is extended distally. Blunt dissection was performed through the subcutaneous tissues to the level of the deep plantar fascia. The total width of the fascia is released form its proximal attachment to the calcaneus in a medial to lateral fashion (Bordelon, 1993; Brekke and Green, 1998; and Ketterer and Palladino, 1991). In the presence of a heel spur, a rongeur, bone cutters, osteotome, or rasp is used to excise the exostosis. Steroid and/or local anaesthetic may be infiltrated into the area; Brekke and Green (1998) did this in approximately half of their subjects. Malay (1992) suggests the use of closed suction drainage. Deep and superficial tissue layers are closed, and the patient is maintained in a short leg cast for 2 weeks. Where spur resections were undertaken, non-weight bearing with crutches was indicated for 1-4 weeks (Brekke and Green, 1998).
Criterion required for a good result vary between authors; Sammarco and Helfrey (1996) state reduction in pain, increase in activity, elimination of the requirement for shoe inserts, and return to status observed before the disease within a reasonable period of time, as parameters set for a good postoperative result. Within their study, the former authors found 92% of patients exhibited satisfactory functional outcome, 8% unsatisfactory, and 10% with some degree of heel pain post-surgery. Weil (1998) observes tarsal tunnel surgery to be successful in 70% of cases.
Minimal approaches tend to have more rapid healing rates due to a decrease in soft tissue disruption. Licopantis (1995) found the fluoroscopic technique to have quicker healing times, but does not compare these ‘quicker' times to other procedures.
Baxter and Pfeffer (1992) describe a good to excellent result in 89% of cases following fascial release in combination with release of the FBLP nerve. Benton-Weil et al. (1998) found 83% satisfaction following percutaneous plantar fasciotomy, similar to Berlin (cited in Benton-Weil, 1998, p. 272) who described 89% good to excellent relief.
Hawkins and colleagues (cited in Brekke and Green, 1998, p. 66) performed a 2-portal endoscopic release on cadaver specimens and concluded that a plantar approach would result in a more accurate release of the medial plantar fascial band. Barrett et al. (cited in Benton-Weil et al., 1998, p. 272) reported 87% of patients having less pain post-endoscopic plantar fasciotomy.
Brekke and Green (1998) performed a retrospective analysis of endoscopic, minimal incision, and open procedures, and found the minimal incision group had the greatest reduction of pain (78? 6%). The open procedure group exhibited greatest satisfaction of 78? 8%. The endoscopic group and the shortest follow-up time of 17 months and quickest return to activity. In general, however, all groups exhibited successful results.
Several possible complications may arise following any surgery. Most common is recurrence of pain post-surgery. Aggressive exostectomy may lead to fracture, as reported by Sammarco and Idusuyi (1998) following endoscopic plantar fasciotomy. Excessive retraction of soft tissue structures and haematoma may lead to wound dehiscence and skin slough (Malay, 1992). Licopantis (1995) avoids disrupting the medial and lateral vasculature if the heel, reducing the likelihood of venous congestion, wound dehiscence, and oedema.
The plantar heel pad, comprised of specialized fibrous stroma containing adipose tissue, is also at risk of damage. Violation of this structure reduces its effectiveness as a shock absorber and scar tissue may form (Schwartz, 1990).
Damage to the medial plantar nerve may occur, although this is less likely with the open approach as the prospect of encountering the nerve is greater (Malay, 1992). The lateral plantar nerve is most likely to be injured with a semi closed approach. Malay (1992) observes that accurate placement of scissors at the proximal fascial attachment with avoidance of muscular structures may circumvent possible nerve injury.
The most common complications, in descending order, found Stone and Davies (1996) were cuboid syndrome, fatigue and stiffness, arch strain, and pain in the ball and toe region.
Sammarco and Helfrey (1996) found 11% of patients exhibited postoperative complications including superficial wound infection, superficial thrombophlebitis, and deep venous thrombosis.
Weil (1998) observes the complication rate post-tarsal tunnel surgery may reach 30%, but does not describe these complications.
In an effort to reduce complications, general advice should be given to all surgical patients. Stone and Davies (1996, p. 419) outline the following management principles that should be undertaken following any plantar fascial surgery;
preoperative counselling and education of potential risks and complications of the procedure
recognition and acknowledgment of the problem with open, honest communication
appropriate management of the problem by accepted treatment protocols i.e. physical therapy, antibiotics, casting, orthotic therapy, non-weight bearing, corticosteroid injections, manipulation, and time
Effect on plantar fascial function
Kitaoka et al. (1997) examined 5 cadaver specimens and found measurable rotation in all 3 cardinal planes occurred in all joints following plantar fasciotomy. The plantar fascia is a significant stabiliser of the arch, and fasciotomy altered tarsal bone position significantly. Arangio et al. (1997) observed that plantar fasciotomy reduced stiffness of the foot and creates a less rigid and more deformable arch. Thordarson and colleagues (1997) demonstrated a progressive loss of arch-supporting function of the plantar fascia following sequential sectioning from medial to lateral. Additionally, the windlass mechanism was impaired, most notably after complete sectioning. Sharkey et al. (1998) found that complete plantar fasciotomy caused significant collapse of the arch in the sagittal plane, and the role of extrinsic musculature (aside from tibialis posterior) was not significant.
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