A Closer Look At Endoscopic Plantar Fasciotomy
- Volume 15 - Issue 5 - May 2002
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The Evolution Of The Two-Portal Technique
Given the high degree of patient satisfaction with the less invasive, endoscopic approach, there was strong motivation to develop another endoscopic technique. This led to the development of the Barrett-Day two-portal approach, which proved to be advantageous over the one-portal technique in many ways.
First, the two-portal procedure allowed for better visualization of the anatomical structures. It also had a smaller diameter so it was less traumatic than the one-portal system. Most importantly, far more surgeons have been able to achieve successful results in using the two-portal approach. This is evidenced now by the fact that more than 500,000 EPFs have been performed since the two-portal procedure was granted FDA approval in 1992.12
The two-portal EPF technique has certainly evolved over the years. Initially, it was believed that you had to perform significant physiological lengthening of the plantar fascia in order to resolve the patient’s symptoms. Our initial study demonstrated a very high efficacy in resolving heel pain, but it also revealed a nearly 10 percent incidence of complications.13 Primarily referred to as lateral column destabilization phenomena, these symptoms could include pain in the sinus tarsi, peroneal tenosynovitis, pain in the calcaneal cuboid joint or just a generalized pain throughout the lateral column of the foot.
The data from the study indicated that when you cut the plantar fascia, it lost much of its stabilizing forces until it healed, albeit in a lengthened position. Clinically, some of these cases proved difficult to treat and for some patients, the complication seemed worse than the patient’s initial heel complaint. Certainly, this was not satisfactory, even in light of the overwhelming majority of success with the technique.
The procedure evolved to the point where we only cut part of the fascia. Clinically, there was no loss of surgical efficacy but we did notice a significant reduction in lateral column problems. Much of what we saw in this early series of patients has now been demonstrated in biomechanical, cadaveric experiments.14-16
Over the next two years, the standard of care centered on cutting only the medial one-third of the plantar fascia. Quantification of fascial dimensions indicated that you needed to release 13.5 mm of fascia, on average, in order to achieve a medial one-third fasciotomy. The instrumentation was subsequently modified to reflect these measurements, with intra-cannular markings to guide the surgeon during the technique.