Plantar Calcaneal Spurs: Is Surgery Necessary?
What You Should Know About Potential Complications
While surgery is generally successful, one must consider potential postoperative complications.27 These complications include recurrent heel pain, permanent local numbness, painful nerve entrapment, wound dehiscence, infection and hypertrophic scar formation. Furthermore, any procedure involving plantar fascial release can also lead to instability, foot pain, cramping, metatarsalgia, metatarsal stress fractures, tendonitis and sinus tarsitis. These complications are not unique whether clinicians perform the surgery by minimal incision, open or endoscopically. Additionally, these complications are irrespective of whether one performs the fasciotomy with or without plantar heel spur resection.
Of particular concern is whether one should combine the fasciotomy with osseous work to remove the heel spur. Two of the more serious complications following heel spur surgery are a calcaneal fracture, presumably from stress risers following minimal bone removal, and deep infection in the surgical area.
Manoli, et. al., observed three calcaneal fractures following a fascial release and spur resection for chronic plantar fasciitis.28 One patient developed displacement with nonunion and arthritis, and ultimately required a subtalar joint arthrodesis. The authors treated another patient successfully with a short leg cast. Both cases resulted in calcaneal fractures with weightbearing before the patients even left the surgery centers. A third patient required an open reduction and internal fixation through a conventional posterolateral approach when she fractured the os calcis 10 days after primary heel spur resection. A fourth patient ultimately required a below knee amputation secondary to painful nonunion after she underwent plantar bone debridement. This particular situation was complicated by diabetes, neuropathy and local osteomyelitis.28
Hoffman and Thul reported two cases of calcaneal fractures following subcalcaneal spur resection. They treated both patients successfully with casting and offloading.29 The patients fell two days and two weeks respectively after their primary heel surgery. Donohue, et. al., performed closed reduction with Steinman pin fixation after a patient fractured her right calcaneus two months following heel spur and plantar fascia surgery.30
The senior author of this article has also observed at least two cases of calcaneal fractures in the immediate post-op period following heel spur resection with no history of additional trauma to the area.
Stress fractures arise from excess repetitive fatigue on normal bone (fatigue fractures) or from nominal weightbearing forces on insufficient bone stock (insufficiency fractures).31 They generally do not arise from direct impact but can propagate from a region where focal integrity has been compromised (i.e. stress riser). Gordon described this notion from a material science perspective and also cited other works that showed fracture progression from small holes and cracks within structures that grossly appeared undisturbed macroscopically.32 Smith, et. al., outlined four progressive stages of “standard” calcaneal fatigue fractures before surgical intervention, describing the fatigue perturbation emanating from the plantar tubercle region.33 This is noteworthy given the fact that calcaneal fractures following heel spur surgery have arisen from this same region of apparent weakness in the os calcis.28-30
Deep infections can be very difficult to eradicate when they occur at this surgical site. Some surgeons have suggested rasping the spur down using either hand or power instrumentation to minimize the risk of creating heel stress risers. However, increased potential still exists for creating local infection or even osteomyelitis by violating the periosteal and cortical structures, or by burring.