- Email: [email protected]
Endoscopic plantar fascia release, calcaneal drilling and calcaneal spur removal for management of painful heel syndrome
The Foot 20 (2010) 121–125
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Endoscopic plantar fascia release, calcaneal drilling and calcaneal spur removal for management of painful heel syndrome Ossama El Shazly ∗ , Atef El Beltagy Ain Shams University Hospitals, Cairo, Egypt
a r t i c l e
i n f o
Article history: Received 10 August 2010 Received in revised form 8 September 2010 Accepted 9 September 2010 Keywords: Painful heel Plantar fascia release Calcaneal spur Calcaneal drilling
a b s t r a c t 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. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction Painful heel syndrome is a commonly seen problem by orthopedic surgeons. It refers to pain and tenderness on the inferomedial aspect of the calcaneal tuberosity. The exact etiology of pain is still uncertain. Many etiologic factors are involved in the pathogenesis of painful heel syndrome including plantar fasciitis, increased thickness of the plantar fascia, calcaneal periostitis, increased intra-osseous pressure of the os calcis, presence of calcaneal spur and entrapment of first branch of lateral plantar nerve [1–3]. More than 90% of patients respond well to conservative measures including shoe modifications, physiotherapy, extracorporeal shock wave therapy and local corticosteroid injection [4,5]. Surgical treatment is indicated for cases refractory to conservative measures. Many open surgical procedures had been described in literature for the treatment of painful heel syndrome. The main step in all of these procedures was plantar fasciotomy which might be performed alone or in association of other procedures such as
∗ Corresponding author. Tel.: +20 106349386/226672110/226671504. E-mail address: ossama [email protected] (O. El Shazly). 0958-2592/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2010.09.004
calcaneal drilling, resection of calcaneal spur and release of nerve entrapment [6–9]. Endoscopic plantar fascia release had been described in 1991 [10]. The endoscopic procedure has the advantage of shorter hospital stay, less wound complication and faster recovery than the open techniques. Although satisfactory outcome had been achieved with the endoscopic procedure, a failure rate ranging from 3% to 18.9% had been described in literature [8,11–16]. The cause of failure may be attributed to inability of endoscopic plantar fasciotomy alone to address other etiologic factors that may contribute to painful heel such as calcaneal periostitis, increased intra-osseous pressure and presence of spurs. There is very limited number of reports describing such comprehensive endoscopic approach in the management of painful heel syndrome [17]. The purpose of this study was to evaluate the clinical outcome of endoscopic plantar fascia release with calcaneal drilling and endoscopic resection of calcaneal spur. 2. Materials and methods This is a prospective case series study on 22 patients (24 feet) who were treated by endoscopic plantar fascia release; calcaneal drilling and calcaneal spur resection. All patients included in the study had painful heel syndrome for at least 6 months before
122
O. El Shazly, A. El Beltagy / The Foot 20 (2010) 121–125
Table 1 Preoperative conservative lines of treatment. Treatment
N
%
NSAIDS Silicone heel pads Conventional physiotherapy Local corticosteroid injection Extracorporeal shock wave
22 22 22 18 5
100 100 100 81.8 22.7
surgery with failure of conservative treatment to control pain. The lines of conservative treatment which had been used for these patients are listed in Table 1. Routine preoperative foot and ankle examination was done for all patients, plain radiographs were done and the presence of spur was checked in all patients. All patients had preoperative screening laboratory tests (ESR, CRP, Serum Uric Acid and Rheumatoid factor) to exclude rheumatic disorders. The diagnosis of all patients was idiopathic painful heel syndrome. 2.1. Surgical technique 2.1.1. Preparation The patient was placed in supine position with the operated foot off the edge of the table. Pneumatic tourniquet was routinely used. 2.1.2. Portals and instrumentation The medial portal was located at a point of intersection between two lines; a vertical line located 1 cm behind the medial malleolus, and a horizontal line perpendicular to the first line and runs transversely at the junction between the plantar and dorsal skin of the foot. The skin was incised with No #11 knife blade. A small mosquito forceps was used to dissect subcutaneous fat. A blunt dissector was gently used to clear the plantar surface of the fascia from the heel fat pad. The metal cannula trocar system was then introduced from the medial portal. The tip of the trocar was felt on the lateral border of the foot at the junction between plantar and dorsal skin and then the skin was incised and the cannula was advanced laterally. The cannula had three windows; a central window (40 mm × 4 mm) which was used for release of plantar fascia, and two drilling windows (25 mm × 4 mm) which were located peripherally on the opposite side of the central window. These two windows were used for drilling of the calcaneus and spur removal (Fig. 1).
2.1.3. Endoscopic partial fasciotomy Endoscopic plantar fasciotomy was done first. A 4 mm scope was introduced from the medial end of the cannula. Initial irrigation was done to improve the arthroscopic view. A motorized shaver was introduced from the lateral end of the cannula to clear the protruding fat from the central window. The plantar fascia would appear as a glistening fibrous structure in the central window (Fig. 2a). The fascia was incised using a hooked radiofrequency electrode (ConmedTM , Linvatec, USA). Based on a previous study, we found this instrument an effective and safe tool for incision of the plantar fascia with proper control of bleeding [18]. The electrode was introduced from the lateral end of the cannula and the medial two thirds of the fascia were incised. Switch of portals was done and the electrode was introduced from the medial end of the cannula to cut any remaining medial fibers. Complete incision was ensured when overlaying muscle was visualized (Fig. 2b). 2.1.4. Endoscopic assisted calcaneal drilling and spur removal A 2.7 drill bit was used for drilling of the calcaneus. It was introduced from the medial drilling window to exit from the central window. The location of the drill bit in the central window was checked endoscopically (Fig. 3). Three drill holes were made on the medial side by means of changing the angle of inclination of the drill bit during drilling. Switch of portals was done and three drill holes were made laterally in the same way. The metal cannula was rotated 90◦ posteriorly so as the central window was facing the calcaneal spur. A bone burr was introduced from the medial drilling window to exit from the central window. The burr was introduced deep to the muscle fibers to be on direct contact with the spur. The location of the burr was checked on lateral view by image intensifier. The spur was completely debrided by the bony burr and complete excision was checked by the image intensifier (Fig. 4). The cannula was removed and the skin incisions were stitched by No 0/2# Vicryle® sutures (Ethicon, J & J Inc., Somerville, NJ). In bilateral cases the procedure was done in the same session. 2.2. Postoperative Bulky dressing with crepe bandage and limb elevation was done in the first 48 h to decrease postoperative edema. Posterior splint with extra padding on the heel was applied for 2 weeks and the patient was encouraged to start weight bearing to tolerance. Patients also were encouraged to perform plantar fascia stretch
Fig. 1. The modified metal cannula. (a) A central window 4 mm wide × 4 cm long is placed opposite to the plantar fascia. (b) Two drilling windows on the opposite side 4 mm wide × 25 mm long. (c) A 2.8 K-wire or drill bit can be inserted from the drilling window to exit from the central window for drilling of the calcaneus. (d) A bone burr can be inserted from the drilling window to exit from the central window for removal of the calcaneal spur.
O. El Shazly, A. El Beltagy / The Foot 20 (2010) 121–125
123
Fig. 2. (a) Arthroscopic view for the plantar fascia before release. (b) Arthroscopic view for the plantar fascia after release.
results were graded into: excellent results: 90–100 points; good results: 80–89 points; fair results: 70–79 points; poor results: <70 points. Retrospective measurement of patient’s satisfaction with the procedure was done at time of this study by telephone interviews with the patients. The patients were asked to rate their satisfaction with the procedure (0% totally unsatisfied, 100% totally satisfied) and to report what they did not like about the procedure. Plain radiographs were done immediate postoperative and at end of follow up to detect if there was recurrence of the spur. The data were coded and processed by use of SPSS software, version 16 (SPSS, Chicago, IL). P value < 0.05 was considered the cut off value of significance.
3. Results
Fig. 3. Right foot. Drilling of the calcaneus through the medial drilling window. Inset: Arthroscopic view showing the drill bit exiting from the central window to drill the calcaneus.
exercises daily after removal of stitches. Evaluation of pain was done by the visual analogue scale (VAS). The functional outcome was evaluated by “the modified Mayo clinical scoring system” for evaluating results of plantar fasciotomy operation (Table 2). The
The study was conducted on 22 patients/24 feet. The descriptive analysis of patients included 13 females (59%) and 9 males (31%) with a mean age of 43 years (±8.6 std). The mean follow up period was 26.9 months (±4.53 std). All patients completed 2 years follow up. There was statistically significant improvement in the mean visual analogue score from 82.81 (±7.8 std) preoperative to 6.63 (±2.75 std) at 2 years follow up. Also there was statistically significant improvement in the mean “modified Mayo clinical scoring system for evaluating results of plantar fasciotomy operation” form 7.05 (±3.67 std) preoperative to 87.5 (±4.81 std) at 2 years follow
Fig. 4. (a) Intra-operative lateral view radiograph for the calcaneus shows the location of the bone burr exactly over the calcaneal spur. Note: The cannula is rotated 90◦ posteriorly so as the central window will face the calcaneal spur. (b) Lateral view radiograph for the same calcaneus after debridement of the spur and removal of the cannula.
124
O. El Shazly, A. El Beltagy / The Foot 20 (2010) 121–125
Table 2 Modified Mayo clinical scoring system for evaluating results of plantar fasciotomy operation (100 total points). Characteristic points Pain to heel area None Mild occasional Moderate, frequent Severe, constant Activity limitations None Minor, no limitations to daily activity Major, limitation to daily activity Foot wear and orthotics No foot wear limitation/no orthotics Minor foot wear limitation/use orthotics Major limitations/always orthotics Plantar heel tenderness Absent Mild to moderate Severe Scar No pain Painful sometimes Painful all the time Gait Normal Abnormal Total
50 40 30 0 10 5 0 10 5 0 10 5 0 10 5 0 10 0
Excellent results: 90–100 points; good results: 80–89 points; fair results: 70–79 points; poor results: <70 points.
up (P < 0.05). The overall classification of postoperative Mayo score was as follows; 10 patients (45.5%) had good score (80–89 points) and 12 patients (54.5%) had excellent score (≥90 points). No fair or poor results were reported (Table 3). The average patients’ satisfaction with the procedure was 85%. Fifteen patients reported nothing to dislike about the procedure. Three patients reported hyperkeratosis of the scar and two patients reported parasthesia on the lateral portal. None of the patients had recurrence of the calcaneal spur at 2 years follow up and also none of the patients had lateral column pain at the end of follow up. 4. Discussion The pathogenesis of chronic plantar heel pain is complex and multifactorial. Many local biological and anatomical factors may predispose to chronic painful heel syndrome [19]. Increased intraosseous pressure and vascular congestion of the calcaneus is considered part of the pathogenesis of painful heel syndrome. Calcaneal drilling was first described by Hassab and El-Sheriff in 1974 to decrease intra-osseous pressure and it was used later by many other surgeons [7,20,21]. Their technique was performed via lateral small incision with 7–10 drill holes traversing the calcaneus from lateral to medial. Santini et al. described a percutaneous technique for drilling of the calcaneus [22]. They performed only three drill holes on the medial cortex through three stab incisions. An objective method of evaluation for their patients was three-phase bone scintigraphy. Out of seven patients with abnormal preoperative increased uptake in the calcaneus, six patients had complete Table 3 Frequency of postoperative Mayo score.
postoperative resolution of the abnormal uptake on the last follow up. Percutaneous fenestration of the inferior part of the anteromedial cortex of the calcaneus, which is the main site of pathology, was also described for decompression of the calcaneus [23]. In our technique up to six drill holes can be performed as part of the endoscopic procedure with no need for additional incisions. Moreover, drilling is directed to the inferior cortex which is the most dependent area and also the site of calcaneal periostitis so we do not jeopardize the normal medial or lateral cortices of the calcaneus. The relationship of calcaneal spur to chronic heel pain was a matter of debate. However, many studies had reported strong association between calcaneal spur and painful heel syndrome [24]. Irving et al. found that calcaneal spur is the second most common association to plantar fasciitis after increased body mass index [2]. Wainwright et al. found in their observational study that calcaneal spurs were found larger in size in patients with the diagnosis of plantar fasciitis when compared to control groups [25]. There is no clear cut indication for spur resection in literature. However, removal of spur was advocated by many surgeons to improve pain and to increase patient’s satisfaction with surgery [8,9,26]. Lane and London [3] used a mini invasive plantar transverse incisional approach for plantar fasciotomy and rasping or removal of the spur. They reported a 96% success rate with their technique which is higher than those treated with classic open release. Blanco et al. described an endoscopic assisted technique for the management of painful spur [17]. Their technique included plantar fasciotomy, debridement of reactive periosteum of the calcaneus and resection of the calcaneal spur. Although they described a comprehensive approach for the management of painful heel syndrome, their technique is technically demanding and lacks the use of slotted cannula during removal of the spur causing potential damage of the heel fat pad. Our technique has the advantage of being mini invasive, comprehensive and easily applicable. Excellent to good results were reported in all patients with high satisfaction rate of patients. The results of our technique are superior to the mini open plantar fascia release and calcaneal spur excision reported by Lane [3]. The results of endoscopic plantar fascia release alone range from 81.1% to 97% in different reviews of literature [8,11–16]. Although the results in our study is superior to endoscopic plantar fascia release alone, there is difficulty in comparison with these studies due to absent standardization of the patient selection criteria and the methods of scoring. We recommend our technique for cases of idiopathic painful heel syndrome not responding to conservative treatment. Patients with plantar fasciitis secondary to nerve entrapment, foot deformity or systemic disorders should be treated first from the primary pathology to avoid persistence or recurrence of symptoms. In case of absent calcaneal spur, plantar fasciotomy and calcaneal drilling can be done in the same way to improve the outcome. 5. 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. However randomized controlled study is required to prove the superiority of this technique over the release only procedures. Conflicts of interest
Score
N
Percent
Cumulative percent
95 90 85 80 Total
3 9 6 4 22
13.6 40.9 27.3 18.2 100.0
13.6 54.5 81.8 100.0
No benefits in any form have been received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. The research was performed at Department of Orthopedics, Ain Shams University and Ain Shams specialized hospitals.
O. El Shazly, A. El Beltagy / The Foot 20 (2010) 121–125
Acknowledgement The authors would like to express their gratitude to engineer Mohsen M. Tantawy for his technical support in this article. References [1] Toomey EP. Plantar heel pain. Foot Ankle Clin North Am 2009;14(June (2)):229–45. [2] Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. J Sci Med Sport 2006;9(May (1–2)):11–22. [3] Lane GD, London B. Heel spur syndrome: a retrospective report on the percutaneous plantar transverse incisional approach. J Foot Ankle Surg 2004;43(November–December (6)):389–94. [4] Puttaswamaiah R, Chandran P. Degenerative plantar fasciitis: a review of current concepts. Foot 2007;17(March (1)):3–9. [5] Crawford F, Atkins D, Edwards J. Interventions for treating plantar heel pain. Foot 2002;11:228–50. [6] Conflitti JM, Tarquinio TA. Operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis. Foot Ankle Int 2004;25:482–7. [7] Jay RM, Davis BA, Schoenhaus HD, Beckett D. Calcaneal decompression for chronic heel pain. J Am Podiatr Med Assoc 1985;75:535–7. [8] Tomczak RL, Haverstock BD. A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome. J Foot Ankle Surg 1995;34(May–June (3)):305–11. [9] Onwuanyi ON. Calcaneal spurs and plantar heel pad pain. Foot 2000;10(December (4)):182–5. [10] Barrett SL, Day SV. Endoscopic plantar fasciotomy for chronic plantar fasciitis/heel spur syndrome: surgical technique-early clinical results. J Foot Surg 1991;30:568–70. [11] Barrett SL, Day SV. Endoscopic plantar fasciotomy: two portal endoscopic surgical techniques—clinical results of 65 procedures. J Foot Surg 1993;32:248–56. [12] Barrett SL, Day SV. Endoscopic plantar fasciotomy: a multisurgeon prospective analysis of 652 cases. J Foot Ankle Surg 1995;34:400–6.
125
[13] Jerosch J, Schunck J, Liebsch D, Filler T. Indication, surgical technique and results of endoscopic fascial release in plantar fasciitis (E FRPF). Knee Surg Sports Traumatol Arthrosc 2004;12(5):471–7. [14] Bazaz R, Ferkel RD. Results of endoscopic plantar fascia release. Foot Ankle Int 2007;28(May (5)). [15] Boyl RA, Slater GL. Endoscopic plantar fascia release: a case series. Foot Ankle Int 2003;24(February (2)). [16] Lundeen RO, Aziz S, Burks JB, Rose JM. Endoscopic plantar fasciotomy: a retrospective analysis of results in 53 patients. J Foot Ankle Surg 2000;39(July–August (4)):208–17. [17] Blanco C, Leon H, Guthrie T. Endoscopic treatment of calcaneal spur syndrome: a comprehensive technique. Arthroscopy: J Arthrosc Relat Surg 2001;17(June (5)):517–22. [18] El Shazly O, El Hilaly RA, Abou El Soud MM, El Sayed MN. Endoscopic plantar fascia release by hooked soft-tissue electrode after failed shock wave therapy. Arthroscopy: J Arthrosc Relat Surg 2010;26(September (9)):1141–268, doi:10.1016/j.arthro.2010.01.026. [19] Riddle DL, Pulisic M, Pidcoe P, Johanson RE. Risk factors for plantar fasciitis: a matched case–control study. J Bone Joint Surg 2003;85(5):872–7. [20] Hassab HK, El-Sherif AS. Drilling the os calcis for painful heel with calcaneal spur. Acta Orthop Scand 1974;45:152. [21] Boaxing C, Zumou L. Drifting of the os calcis in persistent painful heel. Clin Med J 1981;94:288–93. [22] Santini S, Rebeccato A, Schiavon R, Nogarin L. Percutaneous drilling for chronic heel pain. J Foot Ankle Surg 2003;42:296–301. [23] Abu Hassan FO. Percutaneous fenestration of the anteromedial aspect of the calcaneus for resistant heel pain syndrome. J Foot Ankle Surg 2009;15: 90–5. [24] Smith S, Tinley P, Gilheany M, Grills B, Kingsford A. The inferior calcaneal spur—anatomical and histological considerations. Foot 2007;17(March (1)):25–31. [25] Wainwright AM, Kelly AJ, Winson IG. Calcaneal spurs and plantar fasciitis. Foot 1995;5(September (3)):123–6. [26] Gormley J, Kuwada GT. Retrospective analysis of calcaneal spur removal and complete fascial release for the treatment of chronic heel pain. J Foot Surg 1992;31:166–9.
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Endoscopic plantar fascia release, calcaneal drilling and calcaneal spur removal for management of painful heel syndrome Ossama El Shazly ∗ , Atef El Beltagy Ain Shams University Hospitals, Cairo, Egypt
a r t i c l e
i n f o
Article history: Received 10 August 2010 Received in revised form 8 September 2010 Accepted 9 September 2010 Keywords: Painful heel Plantar fascia release Calcaneal spur Calcaneal drilling
a b s t r a c t 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. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction Painful heel syndrome is a commonly seen problem by orthopedic surgeons. It refers to pain and tenderness on the inferomedial aspect of the calcaneal tuberosity. The exact etiology of pain is still uncertain. Many etiologic factors are involved in the pathogenesis of painful heel syndrome including plantar fasciitis, increased thickness of the plantar fascia, calcaneal periostitis, increased intra-osseous pressure of the os calcis, presence of calcaneal spur and entrapment of first branch of lateral plantar nerve [1–3]. More than 90% of patients respond well to conservative measures including shoe modifications, physiotherapy, extracorporeal shock wave therapy and local corticosteroid injection [4,5]. Surgical treatment is indicated for cases refractory to conservative measures. Many open surgical procedures had been described in literature for the treatment of painful heel syndrome. The main step in all of these procedures was plantar fasciotomy which might be performed alone or in association of other procedures such as
∗ Corresponding author. Tel.: +20 106349386/226672110/226671504. E-mail address: ossama [email protected] (O. El Shazly). 0958-2592/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2010.09.004
calcaneal drilling, resection of calcaneal spur and release of nerve entrapment [6–9]. Endoscopic plantar fascia release had been described in 1991 [10]. The endoscopic procedure has the advantage of shorter hospital stay, less wound complication and faster recovery than the open techniques. Although satisfactory outcome had been achieved with the endoscopic procedure, a failure rate ranging from 3% to 18.9% had been described in literature [8,11–16]. The cause of failure may be attributed to inability of endoscopic plantar fasciotomy alone to address other etiologic factors that may contribute to painful heel such as calcaneal periostitis, increased intra-osseous pressure and presence of spurs. There is very limited number of reports describing such comprehensive endoscopic approach in the management of painful heel syndrome [17]. The purpose of this study was to evaluate the clinical outcome of endoscopic plantar fascia release with calcaneal drilling and endoscopic resection of calcaneal spur. 2. Materials and methods This is a prospective case series study on 22 patients (24 feet) who were treated by endoscopic plantar fascia release; calcaneal drilling and calcaneal spur resection. All patients included in the study had painful heel syndrome for at least 6 months before
122
O. El Shazly, A. El Beltagy / The Foot 20 (2010) 121–125
Table 1 Preoperative conservative lines of treatment. Treatment
N
%
NSAIDS Silicone heel pads Conventional physiotherapy Local corticosteroid injection Extracorporeal shock wave
22 22 22 18 5
100 100 100 81.8 22.7
surgery with failure of conservative treatment to control pain. The lines of conservative treatment which had been used for these patients are listed in Table 1. Routine preoperative foot and ankle examination was done for all patients, plain radiographs were done and the presence of spur was checked in all patients. All patients had preoperative screening laboratory tests (ESR, CRP, Serum Uric Acid and Rheumatoid factor) to exclude rheumatic disorders. The diagnosis of all patients was idiopathic painful heel syndrome. 2.1. Surgical technique 2.1.1. Preparation The patient was placed in supine position with the operated foot off the edge of the table. Pneumatic tourniquet was routinely used. 2.1.2. Portals and instrumentation The medial portal was located at a point of intersection between two lines; a vertical line located 1 cm behind the medial malleolus, and a horizontal line perpendicular to the first line and runs transversely at the junction between the plantar and dorsal skin of the foot. The skin was incised with No #11 knife blade. A small mosquito forceps was used to dissect subcutaneous fat. A blunt dissector was gently used to clear the plantar surface of the fascia from the heel fat pad. The metal cannula trocar system was then introduced from the medial portal. The tip of the trocar was felt on the lateral border of the foot at the junction between plantar and dorsal skin and then the skin was incised and the cannula was advanced laterally. The cannula had three windows; a central window (40 mm × 4 mm) which was used for release of plantar fascia, and two drilling windows (25 mm × 4 mm) which were located peripherally on the opposite side of the central window. These two windows were used for drilling of the calcaneus and spur removal (Fig. 1).
2.1.3. Endoscopic partial fasciotomy Endoscopic plantar fasciotomy was done first. A 4 mm scope was introduced from the medial end of the cannula. Initial irrigation was done to improve the arthroscopic view. A motorized shaver was introduced from the lateral end of the cannula to clear the protruding fat from the central window. The plantar fascia would appear as a glistening fibrous structure in the central window (Fig. 2a). The fascia was incised using a hooked radiofrequency electrode (ConmedTM , Linvatec, USA). Based on a previous study, we found this instrument an effective and safe tool for incision of the plantar fascia with proper control of bleeding [18]. The electrode was introduced from the lateral end of the cannula and the medial two thirds of the fascia were incised. Switch of portals was done and the electrode was introduced from the medial end of the cannula to cut any remaining medial fibers. Complete incision was ensured when overlaying muscle was visualized (Fig. 2b). 2.1.4. Endoscopic assisted calcaneal drilling and spur removal A 2.7 drill bit was used for drilling of the calcaneus. It was introduced from the medial drilling window to exit from the central window. The location of the drill bit in the central window was checked endoscopically (Fig. 3). Three drill holes were made on the medial side by means of changing the angle of inclination of the drill bit during drilling. Switch of portals was done and three drill holes were made laterally in the same way. The metal cannula was rotated 90◦ posteriorly so as the central window was facing the calcaneal spur. A bone burr was introduced from the medial drilling window to exit from the central window. The burr was introduced deep to the muscle fibers to be on direct contact with the spur. The location of the burr was checked on lateral view by image intensifier. The spur was completely debrided by the bony burr and complete excision was checked by the image intensifier (Fig. 4). The cannula was removed and the skin incisions were stitched by No 0/2# Vicryle® sutures (Ethicon, J & J Inc., Somerville, NJ). In bilateral cases the procedure was done in the same session. 2.2. Postoperative Bulky dressing with crepe bandage and limb elevation was done in the first 48 h to decrease postoperative edema. Posterior splint with extra padding on the heel was applied for 2 weeks and the patient was encouraged to start weight bearing to tolerance. Patients also were encouraged to perform plantar fascia stretch
Fig. 1. The modified metal cannula. (a) A central window 4 mm wide × 4 cm long is placed opposite to the plantar fascia. (b) Two drilling windows on the opposite side 4 mm wide × 25 mm long. (c) A 2.8 K-wire or drill bit can be inserted from the drilling window to exit from the central window for drilling of the calcaneus. (d) A bone burr can be inserted from the drilling window to exit from the central window for removal of the calcaneal spur.
O. El Shazly, A. El Beltagy / The Foot 20 (2010) 121–125
123
Fig. 2. (a) Arthroscopic view for the plantar fascia before release. (b) Arthroscopic view for the plantar fascia after release.
results were graded into: excellent results: 90–100 points; good results: 80–89 points; fair results: 70–79 points; poor results: <70 points. Retrospective measurement of patient’s satisfaction with the procedure was done at time of this study by telephone interviews with the patients. The patients were asked to rate their satisfaction with the procedure (0% totally unsatisfied, 100% totally satisfied) and to report what they did not like about the procedure. Plain radiographs were done immediate postoperative and at end of follow up to detect if there was recurrence of the spur. The data were coded and processed by use of SPSS software, version 16 (SPSS, Chicago, IL). P value < 0.05 was considered the cut off value of significance.
3. Results
Fig. 3. Right foot. Drilling of the calcaneus through the medial drilling window. Inset: Arthroscopic view showing the drill bit exiting from the central window to drill the calcaneus.
exercises daily after removal of stitches. Evaluation of pain was done by the visual analogue scale (VAS). The functional outcome was evaluated by “the modified Mayo clinical scoring system” for evaluating results of plantar fasciotomy operation (Table 2). The
The study was conducted on 22 patients/24 feet. The descriptive analysis of patients included 13 females (59%) and 9 males (31%) with a mean age of 43 years (±8.6 std). The mean follow up period was 26.9 months (±4.53 std). All patients completed 2 years follow up. There was statistically significant improvement in the mean visual analogue score from 82.81 (±7.8 std) preoperative to 6.63 (±2.75 std) at 2 years follow up. Also there was statistically significant improvement in the mean “modified Mayo clinical scoring system for evaluating results of plantar fasciotomy operation” form 7.05 (±3.67 std) preoperative to 87.5 (±4.81 std) at 2 years follow
Fig. 4. (a) Intra-operative lateral view radiograph for the calcaneus shows the location of the bone burr exactly over the calcaneal spur. Note: The cannula is rotated 90◦ posteriorly so as the central window will face the calcaneal spur. (b) Lateral view radiograph for the same calcaneus after debridement of the spur and removal of the cannula.
124
O. El Shazly, A. El Beltagy / The Foot 20 (2010) 121–125
Table 2 Modified Mayo clinical scoring system for evaluating results of plantar fasciotomy operation (100 total points). Characteristic points Pain to heel area None Mild occasional Moderate, frequent Severe, constant Activity limitations None Minor, no limitations to daily activity Major, limitation to daily activity Foot wear and orthotics No foot wear limitation/no orthotics Minor foot wear limitation/use orthotics Major limitations/always orthotics Plantar heel tenderness Absent Mild to moderate Severe Scar No pain Painful sometimes Painful all the time Gait Normal Abnormal Total
50 40 30 0 10 5 0 10 5 0 10 5 0 10 5 0 10 0
Excellent results: 90–100 points; good results: 80–89 points; fair results: 70–79 points; poor results: <70 points.
up (P < 0.05). The overall classification of postoperative Mayo score was as follows; 10 patients (45.5%) had good score (80–89 points) and 12 patients (54.5%) had excellent score (≥90 points). No fair or poor results were reported (Table 3). The average patients’ satisfaction with the procedure was 85%. Fifteen patients reported nothing to dislike about the procedure. Three patients reported hyperkeratosis of the scar and two patients reported parasthesia on the lateral portal. None of the patients had recurrence of the calcaneal spur at 2 years follow up and also none of the patients had lateral column pain at the end of follow up. 4. Discussion The pathogenesis of chronic plantar heel pain is complex and multifactorial. Many local biological and anatomical factors may predispose to chronic painful heel syndrome [19]. Increased intraosseous pressure and vascular congestion of the calcaneus is considered part of the pathogenesis of painful heel syndrome. Calcaneal drilling was first described by Hassab and El-Sheriff in 1974 to decrease intra-osseous pressure and it was used later by many other surgeons [7,20,21]. Their technique was performed via lateral small incision with 7–10 drill holes traversing the calcaneus from lateral to medial. Santini et al. described a percutaneous technique for drilling of the calcaneus [22]. They performed only three drill holes on the medial cortex through three stab incisions. An objective method of evaluation for their patients was three-phase bone scintigraphy. Out of seven patients with abnormal preoperative increased uptake in the calcaneus, six patients had complete Table 3 Frequency of postoperative Mayo score.
postoperative resolution of the abnormal uptake on the last follow up. Percutaneous fenestration of the inferior part of the anteromedial cortex of the calcaneus, which is the main site of pathology, was also described for decompression of the calcaneus [23]. In our technique up to six drill holes can be performed as part of the endoscopic procedure with no need for additional incisions. Moreover, drilling is directed to the inferior cortex which is the most dependent area and also the site of calcaneal periostitis so we do not jeopardize the normal medial or lateral cortices of the calcaneus. The relationship of calcaneal spur to chronic heel pain was a matter of debate. However, many studies had reported strong association between calcaneal spur and painful heel syndrome [24]. Irving et al. found that calcaneal spur is the second most common association to plantar fasciitis after increased body mass index [2]. Wainwright et al. found in their observational study that calcaneal spurs were found larger in size in patients with the diagnosis of plantar fasciitis when compared to control groups [25]. There is no clear cut indication for spur resection in literature. However, removal of spur was advocated by many surgeons to improve pain and to increase patient’s satisfaction with surgery [8,9,26]. Lane and London [3] used a mini invasive plantar transverse incisional approach for plantar fasciotomy and rasping or removal of the spur. They reported a 96% success rate with their technique which is higher than those treated with classic open release. Blanco et al. described an endoscopic assisted technique for the management of painful spur [17]. Their technique included plantar fasciotomy, debridement of reactive periosteum of the calcaneus and resection of the calcaneal spur. Although they described a comprehensive approach for the management of painful heel syndrome, their technique is technically demanding and lacks the use of slotted cannula during removal of the spur causing potential damage of the heel fat pad. Our technique has the advantage of being mini invasive, comprehensive and easily applicable. Excellent to good results were reported in all patients with high satisfaction rate of patients. The results of our technique are superior to the mini open plantar fascia release and calcaneal spur excision reported by Lane [3]. The results of endoscopic plantar fascia release alone range from 81.1% to 97% in different reviews of literature [8,11–16]. Although the results in our study is superior to endoscopic plantar fascia release alone, there is difficulty in comparison with these studies due to absent standardization of the patient selection criteria and the methods of scoring. We recommend our technique for cases of idiopathic painful heel syndrome not responding to conservative treatment. Patients with plantar fasciitis secondary to nerve entrapment, foot deformity or systemic disorders should be treated first from the primary pathology to avoid persistence or recurrence of symptoms. In case of absent calcaneal spur, plantar fasciotomy and calcaneal drilling can be done in the same way to improve the outcome. 5. 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. However randomized controlled study is required to prove the superiority of this technique over the release only procedures. Conflicts of interest
Score
N
Percent
Cumulative percent
95 90 85 80 Total
3 9 6 4 22
13.6 40.9 27.3 18.2 100.0
13.6 54.5 81.8 100.0
No benefits in any form have been received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. The research was performed at Department of Orthopedics, Ain Shams University and Ain Shams specialized hospitals.
O. El Shazly, A. El Beltagy / The Foot 20 (2010) 121–125
Acknowledgement The authors would like to express their gratitude to engineer Mohsen M. Tantawy for his technical support in this article. References [1] Toomey EP. Plantar heel pain. Foot Ankle Clin North Am 2009;14(June (2)):229–45. [2] Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. J Sci Med Sport 2006;9(May (1–2)):11–22. [3] Lane GD, London B. Heel spur syndrome: a retrospective report on the percutaneous plantar transverse incisional approach. J Foot Ankle Surg 2004;43(November–December (6)):389–94. [4] Puttaswamaiah R, Chandran P. Degenerative plantar fasciitis: a review of current concepts. Foot 2007;17(March (1)):3–9. [5] Crawford F, Atkins D, Edwards J. Interventions for treating plantar heel pain. Foot 2002;11:228–50. [6] Conflitti JM, Tarquinio TA. Operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis. Foot Ankle Int 2004;25:482–7. [7] Jay RM, Davis BA, Schoenhaus HD, Beckett D. Calcaneal decompression for chronic heel pain. J Am Podiatr Med Assoc 1985;75:535–7. [8] Tomczak RL, Haverstock BD. A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome. J Foot Ankle Surg 1995;34(May–June (3)):305–11. [9] Onwuanyi ON. Calcaneal spurs and plantar heel pad pain. Foot 2000;10(December (4)):182–5. [10] Barrett SL, Day SV. Endoscopic plantar fasciotomy for chronic plantar fasciitis/heel spur syndrome: surgical technique-early clinical results. J Foot Surg 1991;30:568–70. [11] Barrett SL, Day SV. Endoscopic plantar fasciotomy: two portal endoscopic surgical techniques—clinical results of 65 procedures. J Foot Surg 1993;32:248–56. [12] Barrett SL, Day SV. Endoscopic plantar fasciotomy: a multisurgeon prospective analysis of 652 cases. J Foot Ankle Surg 1995;34:400–6.
125
[13] Jerosch J, Schunck J, Liebsch D, Filler T. Indication, surgical technique and results of endoscopic fascial release in plantar fasciitis (E FRPF). Knee Surg Sports Traumatol Arthrosc 2004;12(5):471–7. [14] Bazaz R, Ferkel RD. Results of endoscopic plantar fascia release. Foot Ankle Int 2007;28(May (5)). [15] Boyl RA, Slater GL. Endoscopic plantar fascia release: a case series. Foot Ankle Int 2003;24(February (2)). [16] Lundeen RO, Aziz S, Burks JB, Rose JM. Endoscopic plantar fasciotomy: a retrospective analysis of results in 53 patients. J Foot Ankle Surg 2000;39(July–August (4)):208–17. [17] Blanco C, Leon H, Guthrie T. Endoscopic treatment of calcaneal spur syndrome: a comprehensive technique. Arthroscopy: J Arthrosc Relat Surg 2001;17(June (5)):517–22. [18] El Shazly O, El Hilaly RA, Abou El Soud MM, El Sayed MN. Endoscopic plantar fascia release by hooked soft-tissue electrode after failed shock wave therapy. Arthroscopy: J Arthrosc Relat Surg 2010;26(September (9)):1141–268, doi:10.1016/j.arthro.2010.01.026. [19] Riddle DL, Pulisic M, Pidcoe P, Johanson RE. Risk factors for plantar fasciitis: a matched case–control study. J Bone Joint Surg 2003;85(5):872–7. [20] Hassab HK, El-Sherif AS. Drilling the os calcis for painful heel with calcaneal spur. Acta Orthop Scand 1974;45:152. [21] Boaxing C, Zumou L. Drifting of the os calcis in persistent painful heel. Clin Med J 1981;94:288–93. [22] Santini S, Rebeccato A, Schiavon R, Nogarin L. Percutaneous drilling for chronic heel pain. J Foot Ankle Surg 2003;42:296–301. [23] Abu Hassan FO. Percutaneous fenestration of the anteromedial aspect of the calcaneus for resistant heel pain syndrome. J Foot Ankle Surg 2009;15: 90–5. [24] Smith S, Tinley P, Gilheany M, Grills B, Kingsford A. The inferior calcaneal spur—anatomical and histological considerations. Foot 2007;17(March (1)):25–31. [25] Wainwright AM, Kelly AJ, Winson IG. Calcaneal spurs and plantar fasciitis. Foot 1995;5(September (3)):123–6. [26] Gormley J, Kuwada GT. Retrospective analysis of calcaneal spur removal and complete fascial release for the treatment of chronic heel pain. J Foot Surg 1992;31:166–9.