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PURPOSE OF THE STUDY One of the most common causes of chronic heel pain is plantar fasciitis (ocalcaneal spur?). This condition most frequently occurs in patients over the age of 40. In most cases pain can be reduced or ceased by conservativ treatment, but in some patients therapy-resistant chronic pain can also develop. In these cases surgery may provide long term solution. The aim of this prospective observational study was to analyse the effectiveness of endoscopic surgery in patients with plantar fasciitis.
MATERIALS Between 2001-2006 83 operations were performed on 74 patients (age: 47+/-11 years) by the same surgeon. All patients underwent conservative therapy before the operation, which did not solve their pain. In 41 cases the right and in 42 cases the left foot was affected. In 11 patients both sides had to be operated on.
METHODS In each case endoscopic partial plantar fasciotomy was performed as described previously, modified by us. Patients were allowed to load full body weight on the operated foot on the first postoperative day. The patients' body mass index (BMI) was also recorded. Pain was assessed by using a visual analog scale (VAS) from 0-10. Patients had been followedup 1, 3, 6 and 12 months after surgery.
RESULTS Pain was significantly lower at every assessment point as compared to preoperative values (p<0.01). The average period of time during which patients became pain free (i.e.: VAS=0) was 9.6 weeks. Most patients were overweight as indicated by the BMI=32.8+/-5.9 kg/m2. All but 3 operations proved to be successful as indicated by disappearence of pain. Two patients had reoperation of whom the BMI>30 kg/m2.
DISCUSSION Patients with heel spur may benefit from operation if the conservative treatment is unsuccesful. The aim is to relieve the inflammation and irritation of the plantar aponeurosis. One alternative is endoscopic partial plantar fasciotomy. During the operation at least the two-third of the aponeurosis is released without the exstirpation of its calcificated part. As indicated by our results complaints disappeared in most cases within one month after surgery. There were only 3 complications two of which had incresed BMI, suggesting, that obesity may have an important impact on the symptoms and success of surgery. However, further studies are required to come to firm conclusion regarding BMI and plantar fasciitis.
CONCLUSIONS In this prospective observational study it was found that endoscopic partial fasciotomy successfully releived pain in therapy- resistant cases of plantar fasciitis. Key words: heel pain, heel spur, plantar fasciitis, endoscopic partial plantar fasciotomy, plantar fascia release.
OBJECTIVE: To evaluate endoscopic plantar fasciotomy for the treatment of recalcitrant heel pain.
METHOD: We undertook a retrospective study of the use of endoscopic plantar fasciotomy in the treatment of chronic heel pain that was unresponsive to conservative treatment. Over a 10-year period, we reviewed the charts of 55 patients with a minimum 12-month history of heel pain that failed to respond to standard nonoperative methods and had undergone the procedure described. All patients were clinically reviewed and completed a questionnaire based on the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle and hindfoot.
RESULTS: The mean follow-up was 18 months. The mean preoperative AOFAS score was 66.5; the mean postoperative AOFAS score was 88.2. The mean preoperative pain score was 18.6; the mean postoperative pain score was 31.1. Complications were minimal (2 superficial wound infections). Overall, results were favourable in over 80% of patients.
CONCLUSION: We conclude that endoscopic plantar fasciotomy is a reasonable option in the treatment of chronic heel pain that fails to respond to a trial of conservative treatment
PURPOSE OF THE STUDY Arthroscopic treatment of calcaneal spur syndrome is a tissue-sparing and effective approach when conservative therapy has failed. This method, its results and our experience with the treatment of this syndrome are presented here.
MATERIAL Between January 2003 and November 2007, 26 patients underwent an arthroscopic procedure for calcaneal spur syndrome; of these, 20 were women with an average age of 49 years, and six were men with an average age of 45 years. Four, three women and one man, were lost to follow-up, therefore 22 patients with 24 heels were eventually evaluated. All had conservative therapy for 3 to 6 monts.
METHODS The arthroscopic method used was developed by the arthroscopic group of the Orthopaedic Service of Hospital Hermanos Ameijeiras in Havana, Cuba. The surgical technique insolves treatment of the spur and plantar fasciitis commonly found in calcaneal spur syndrome, but it also addresses adjacent calcaneal periostitis.
RESULTS The results were evaluated on the scale that is part of the foot function index developed by Budiman-Mak for measuring rheumatoid arthritis pain. The patients were asked mine questions on pain intensity during various activities before and after surgery. Pain was evaluated on a scale with grades from 0 to 9. The average value was 5.9 before surgery and 1.4 after surgery. A 0-1 pain range was reported by 25 %, 1-2 by 26 % and 2-4 by 22 % of the patients. All patients reported improvement. DISCUSSION The orthopaedic group in Havana led by Carlos achieved 85 % excellent outcomes (pain range, 0-2) at one-year followup; this was 79 % in our study, in which no problems with foot arches or wound infection were recorded.
CONCLUSIONS The heel spur syndrome is a result of an inflamed ligament (plantar fascia) due to repeated microtrauma. It is not a traction osteophyte,but a reaction of the tissue where it attaches to the calcaneus. Adjacent calcaneal periostitis is usually present as well. Therefore, this method treting all three causes of the syndrome appears to be more effective than mere fasciotomy. Key words: calcaneal spur syndrome, plantar fasciitis, heel spur, periostitis, microtrauma.
BACKGROUND: Planter fasciitis is a common cause of heel pain in adults. Many treatment options exist. Most of patients resolve with conservative management. Approximately 10% of patients develop persistent and often disabling symptoms.
PATIENTS AND METHODS: This prospective study includes 37 patients with an established diagnosis of chronic plantar fasciitis, aiming to compare two different techniques of treatment. First group includes 17 patients with a mean age of 42 years treated by endoscopic plantar fasciotomy (EPF); the mean follow-up was 11 months. Second group includes 20 patients with a mean age of 45 years treated by extracorporeal shock Wave Therapy (ESWT); the mean follow-up was 7.6 months.
RESULTS: In the first group (EPF), using the visual analog scale the average post-operative pain was improved from 9.1 to 1.6. Post-operatively, 58.8% had no limitation of functional activities, 35.3% had minimal limitation of activities and 5.9% had moderate limitation of activities. Concerning patient satisfaction, 82.3% of patients were completely satisfied, 11.8% of patients were satisfied with reservation and 5.9% of patients were unsatisfied. For the second group (ESWT), using the visual analog scale the average post-operative pain was improved from 9 to 2.1. Post-operatively, 50% had no functional limitation of activities, 35% had minimal limitation of activities, 10% had moderate limitation of activities, and 5% had severe limitation of activities. Concerning patient satisfaction, 75% of patients were completely satisfied and 25% were satisfied with reservation or unsatisfied.
CONCLUSION: Because of better results with endoscopic release versus the benefits of no complications, no immobilization, and early resumption of full activities with ESWT, we conclude that ESWT is a reasonable earlier line of treatment of chronic plantar fasciitis before EPF.
PURPOSE: The purpose of this study was to assess the outcome of endoscopic plantar fascia release (EPFR) after failed extracorporeal shock wave therapy (ESWT).
METHODS: Eighteen patients (twenty-one feet) had persistent painful heel after treatment by ESWT for at least 6 months. The treatment protocol included 2,000 pulses of 0.12 mJ/mm(2) given in 1 session weekly for 7 sessions. Preoperative and postoperative assessment of pain and functional evaluation were done blindly by the second author using a visual analog scale (VAS) score and the modified American Orthopaedic Foot & Ankle Society (AOFAS) score for the hindfoot. EPFR was done without the use of a tourniquet under local ankle block. A monopolar hooked soft-tissue electrode (ConMed Linvatec, Largo, FL) was used to sever the plantar fascia and to control bleeding. The mean follow-up period was 25.8 months. Only 17 patients (20 feet) completed 2 years' follow-up.
RESULTS: The mean preoperative VAS score was 72.52, and the mean preoperative modified AOFAS score was 24.23. There was a statistically significant improvement in VAS score, modified AOFAS score, and morning pain at 2 years' follow-up (P < .05). Of the patients, 9 (50%) had excellent results, 6 (35%) had good results, 1 (10%) had a fair result, and 1 (5%) had failure of improvement of pain. No major complications were found; 2 patients had hyperkeratosis at the portal site, and 1 patient had paresthesia at the lateral border of the foot.
CONCLUSIONS: EPFR yielded good to excellent outcomes in 85% of 17 patients with plantar fasciitis resistant to treatment by ESWT after 2 years' follow-up
BACKGROUND: The pathogenesis of painful heel syndrome is multifactorial including plantar fasciitis, increased intra-osseous pressure of the os calcis, calcaneal periostitis and presence of calcaneal spur. The currently used endoscopic treatment of painful heel syndromes involves endoscopic plantar fascia release alone without addressing other pathological changes.
OBJECTIVES: To evaluate the clinical outcome of endoscopic plantar fascia release, calcaneal drilling and calcaneal spur removal.
METHODS: The study was conducted on 22 cases/24 feet with idiopathic painful heel syndrome resistant to conservative treatment. All cases were treated by plantar fasciotomy; calcaneal drilling and calcaneal spur removal using a modified cannula trocar system. Evaluation of pain was done using VAS and functional evaluation was done using the Modified Mayo Scoring System for Plantar Fasciotomy. Also patient's satisfaction was evaluated by direct questionnaire.
RESULTS: There was statistically significant improvement in the mean VAS from 82.81 (±7.8 std) preoperative to 6.63 (±2.75 std) and the Mayo score form 7.05 (±3.67 std) preoperative to 87.5 (±4.81 std) at 2 years follow up (P<0.05). The satisfaction rate was 85% with no major complications.
CONCLUSION: Endoscopic plantar fascia release with calcaneal drilling and calcaneal spur removal has high success rate and patient's satisfaction rate when compared to published reports on isolated endoscopic plantar release.
Re: Endoscopic Partial Plantar Fasciotomy for Plantar Fasciitis
Endoscopic Surgery for Plantar Fasciitis: Application of a Deep-Fascial Approach.
Komatsu F, Takao M, Innami K, Miyamoto W, Matsu****a T Arthroscopy. 2011 Jun 23;
PURPOSE: The purpose of this study was to determine the clinical results of deep-fascial medial and lateral portals in performing endoscopic surgery for plantar fasciitis.
METHODS: In 10 feet in 8 patients who were treated conservatively for more than 6 months with failure to relieve their symptoms, endoscopic surgery was performed. After the patient was placed in the supine position, a medial portal was made 5 mm deep to the plantar fascia and 10 mm anterior to its origin on the calcaneus under fluoroscopy. The lateral portal was established by placing a blunt trocar deep and perpendicular to the plantar fascia. A 2.7-mm-diameter arthroscope was passed through the deep-lateral portal, and the operative devices were inserted through the deep-medial portal. A motorized shaver was used for making a working space to excise the fat tissue along with a portion of the flexor digitorum brevis muscle. If a heel spur existed, it was resected to establish a clear view of the plantar fascia by use of an arthroscopic burr. After exposure of the plantar fascia, its medial half was removed with electric devices such as an Arthro-Knife (ConMed Linvatec, Largo, FL).
RESULTS: The mean score on the American Orthopedics Foot and Ankle Society Ankle Hindfoot Scale was 64.2 ± 6.3 points before surgery and 92.6 ± 7.1 points at 2 years after surgery (P < .0001). The mean duration to full weight bearing after surgery was 13.9 ± 8.4 days. All patients returned to full athletic activities by a mean of 10.7 ± 2.6 weeks. Conclusions: Endoscopic surgery for plantar fasciitis through a deep-fascial approach allows a wide field of vision and working space, permitting reliable resection of the plantar fascia and heel spur.
LEVEL OF EVIDENCE: Level IV, therapeutic case series.
The majority of cases of plantar fasciitis can be treated nonoperatively; however, a small number of patients remain refractory to nonoperative treatment and operative intervention is indicated. Historically, open treatment has been recommended, but more recently endoscopic plantar fasciotomy (EPF) has produced promising results.
Forty-eight patients (56 feet) were identified who underwent endoscopic plantar fasciotomy. Forty-one patients (49 feet) were available for followup. There were 15 men and 26 women, with an average age of 53.8 (range, 42 to 68) years. The mean followup time was 49.5 (range, 6 to 142) months. An AOFAS Hind foot Scale was used for analysis. The influence of gender, duration of symptoms, severity of symptoms, and bilateral verses unilateral release were examined.
Pain resolved completely in 37 feet, decreased in 11 feet, and increased in one foot. The mean postoperative AOFAS Hindfoot score improved 39 points (54 to 93, p < 0.001). Patients with severe symptoms achieved higher mean improvement than the moderate symptom group (p < 0.0001). Patients with symptoms greater than 24~months trended towards lower mean improvement and lower post operative AOFAS Hindfoot scores. Both gender and laterality did not significantly influence outcome. There was one superficial infection, one third and fourth metatarsal stress fracture in the same patient, and transient lateral hindfoot pain in five patients.
EPF was an effective operation with reproducible results, low complication rate, and little risk of iatrogenic nerve injury with proper technique.
Re: Endoscopic Partial Plantar Fasciotomy for Plantar Fasciitis
A Review of 105 Consecutive Uniport Endoscopic Plantar Fascial Release Procedures for the Treatment of Chronic Plantar Fasciitis
Troy N. Morton, DPM, Jeffrey P. Zimmerman, DPM, Michael Lee, DPM, John D. Schaber, MD, PhD Journal of Foot and Ankle Surgery; Article in Press
Plantar fasciitis is a common cause of heel pain in the U.S. Army soldier, resulting in a significant loss of man hours. Given the heavy operations tempo of the U.S. military, successful treatment options need to be considered and used as quickly as possible. Plantar fasciitis can be successfully treated in up to 90% of patients using conservative measures. Operative intervention might need to be considered for those in whom conservative measures have failed. The present report is a review of 105 consecutive uniport endoscopic plantar fascial release procedures performed by the principal investigator during a 9-year period. The following data were collected and analyzed: gender, age, weight, height, body mass index, medical treatment facility, procedure laterality, preoperative pain levels, postoperative pain levels at 3 months, first ambulatory day in the controlled ankle motion boot, return to activity as tolerated, and complications. Three major points were of interest: evidence of improvement in chronic plantar fasciitis when treated with uniport endoscopic procedures; the patient attributes associated with self-reported pain levels 90 days postoperatively; and the patient attributes associated with the average time until patients were able to return to activities as tolerated in a controlled ankle motion boot. It was noted that 44.5% of those with a body mass index of 29.80 kg/m2 or greater reported a postoperative pain level of 0; and 96.3% of those with a body mass index of 25.53 kg/m2 or less reported postoperative pain levels of 0. The analyzed data were used to characterize the clinical outcomes of the procedure, identify changes in outcome with surgeon experience, and identify whether certain patient subgroups have better outcomes, allowing surgeons to identify which patient might be the best candidates for an endoscopic release procedure.
Re: Endoscopic Partial Plantar Fasciotomy for Plantar Fasciitis
Extensile Decompression of the Proximal and Distal Tarsal Tunnel Combined With Partial Plantar Fascia Release in the Treatment of Chronic Plantar Heel Pain.
Mook WR, Gay T, Parekh SG. Foot Ankle Spec. 2013 Jan 4.
Background. Chronic heel pain that is recalcitrant to nonoperative measures is a rare but disabling condition. There are no reports in the literature of extensile proximal and distal tarsal tunnel release combined with partial plantar fasciotomy in the treatment of chronic heel pain. We present our results.
Methods. A retrospective chart review was conducted, and charts were assessed for details of their presenting complaints, physical exam, diagnostic studies, medical history, Visual Analog Scale (VAS) scores for pain, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores, and complications.
Results. The mean AOFAS ankle-hindfoot score was 86 ± 12.9 (range = 69-100). Of 15 heels, 10 (67%) had an excellent or good rating at the time of the last follow-up visit. One of 15 (7%) reported a poor outcome. The mean VAS pain score changed from 6.3 ± 3.1 to 1.4 ± 1.8 (P = .001). There were no wound complications or infections.
Conclusion. This technique offers another operative option for chronic heel pain that is associated with satisfactory outcomes and rest pain relief. Despite reducing pain at rest in all patients, the majority of patients may be left with mild to moderate residual symptoms with activity that is similar to the outcomes of previously reported procedures
Several authors have reported the benefits of the recent procedure of the dual portal endoscopic plantar fasciotomy (EPF). However, very little is known concerning its potential capability via the single portal EPF without special cutting device. The present study aimed to demonstrate the effectiveness of uniportal EPF in a patient with severe intractable plantar fasciitis following a failure of several conservative treatments. The recent technique; uniportal EPF under modified method, without a special cutting device, was reviewed in an effort to improve its capability for plantar release and to provide information for the avoidance of this procedure's complications.
A patient, with the recalcitrant conditions and the progression of the severe plantar fasciitis of bilateral feet after a failure of the conservative treatments for 13-month period, was included in this report. All data of the preoperative and each successive postoperative period (1, 6 months and last follow-up) were prospectively collected including American Orthopedic Foot and Ankle Society (AOFAS) score, Visual Analogue Scale-Foot and Ankle (VAS-FA) score and any related complications. The operations were carried out by a single surgeon with the modified uniportal EPF via a simple hooked soft-tissue blade, without a special cutting device, on both feet simultaneously. All feet had uniportal EPF with transection of the medial 50% of the plantar fascia. Postoperatively, a patient was instructed to have partial-weight bearing for the first 2 weeks with wearing of full-length silicone insoles. Then, she is allowed to start to fully weightbear with the insoles. She is advised to cautiously return to daily activities and works at 2nd week after the operation. In regard to the EPF in two feet, there were clearly improvements in the comparison between preoperative and last follow-up period in terms of the increasing AOFAS scores, and VAS-FA scores. There were no significant iatrogenic-related complications including the lateral column pain in the present report.
The recalcitrant condition of severe plantar fasciitis is not uncommon for several orthopedic surgeons. Regarding the emerging of several minimally invasive procedures for this condition, our modified uniportal EPF with a simple device was encouraging as a treatment option in releasing the plantar fascia with satisfactory effectiveness and lower risks of complications.
Minimally invasive surgery for the treatment of recalcitrant heel pain is a relatively new approach. To compare the 2 approaches, a retrospective chart review was conducted of 53 patients (55 feet) who had undergone surgical treatment of plantar fasciitis by either open fasciotomy with heel spur resection or percutaneous medial fascial release. The outcomes measures included perioperative pain and the interval to return to full activity. Pain was measured on a subjective 10-point visual analog scale. Of the 55 fasciotomies performed, 23 were percutaneous and 32 were open, with adjunctive heel spur resection. The percutaneous group experienced a mean pain reduction of 5.69 points at the first postoperative visit, whereas open fasciotomy group experienced a mean pain reduction of 3.53 points. At 12 months postoperatively, no statistically significant difference was found in the pain levels between the 2 groups. The results also showed that the percutaneous group returned to normal activity an average of 2.82 weeks (p < .001) faster than the open group. In the patient cohorts studied, percutaneous medial fascial release was as effective at resolving recalcitrant plantar fasciitis pain as the open procedure and involved less postoperative pain and a faster return to full activity.
Re: Endoscopic Partial Plantar Fasciotomy for Plantar Fasciitis
Endoscopic approach for plantar fasciopathy: a long-term retrospective study.
Nery C, Raduan F, Mansur N, Baunfeld D, Del Buono A, Maffulli N. Int Orthop. 2013 Mar 13.
The purpose of this study was to report the long term effectiveness of endoscopic plantar fascia release for recalcitrant plantar fasciopathy.
Twenty-three consecutive patients underwent endoscopically-assisted plantar fascia release for symptomatic plantar fasciopathy unresponsive to nonoperative measures. The clinical diagnosis was supported by imaging (plain radiographs and magnetic resonance imaging [MRI]) and the American Orthopaedic Foot & Ankle Society (AOFAS) score was administered to all patients. All patients underwent endoscopic plantar fascia release. Postoperatively, patients were assessed at clinical examination and the AOFAS score was administered.
Twenty-two (26 feet) of the 23 patients included in our original cohort returned to our clinic at an average final follow-up of 9.6 years. The mean preoperative AOFAS score of 51 (range, 41-63) improved to 89 (range, 41-97) at the last follow-up, with no statistically significant difference between patients with or without calcaneal bone spur (p = 0.43). At the last appointment, physically active patients reported significantly higher AOFAS scores than sedentary patients (p = .008).
This endoscopic plantar approach could be a viable alternative to more invasive procedures for management of recalcitrant plantar fasciopathy. Future randomised controlled trials are needed.