Bipolar Radiofrequency Microtenotomy: Can It Be An Effective Alternative For Plantar Fasciosis?

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Author(s): 
Bora Rhim, DPM

   There are several benefits to utilizing Topaz in treating plantar fasciosis. It is technically easy to perform and is much less invasive than conventional surgery, which allows early ambulation with rehabilitation. This device works by using a controlled plasma-mediated radiofrequency process called Coblation. The radiofrequency energy works through a conductive medium such as electrolyte (saline) solution, producing excited radicals within precisely focused plasma. In the plasma, the energized particles generate sufficient energy to break up covalent molecular bonds, resulting in the ablation of soft tissues at relatively low temperatures.9,10

A Step-By-Step Guide To Treatment

One would perform the procedure with the patient in a supine position, using an ankle pneumatic tourniquet and sterile preparation for the foot. Administer a medial calcaneal nerve block with local anesthetic. Preoperatively, mark the area of tenderness on the plantar heel. Then using a grid-like pattern, place a series of holes through the area of tenderness, spacing them 5 mm apart. Usually, the treating physician places a maximum of 20 holes within the affected area of the heel.

   Use a smooth 0.062-inch Kirschner wire to puncture the skin in a percutaneous fashion at the marked areas around the affected area of the heel. Perform the microtenotomy by using the Topaz wand until resistance occurs and then apply the radiofrequency. Advance the wand through the fascia at varied depth when using radiofrequency.

   In regard to the postoperative regimen, one should emphasize full weightbearing in a controlled ankle motion (CAM) walker at day one. The patient continues using a CAM walker for one to two weeks. A few days after the procedure, encourage patients to remove the CAM walker for stretching exercises.

What The Research Says About Topaz Results

Using the Topaz system, numerous researchers have reported good pain control with early improvement in pain and functional scores.9-11 This technique allows the surgeon to avoid cutting the plantar fascia and reduce the risk of complete rupture to the ligament. There are some concerns over jeopardizing ligament integrity with the use of the Coblation technique in areas of high stress and repetitive loading.

   Silver and colleagues performed a cadaveric study and found no difference in stress, elastic modulus, energy strain density or strain at maximal load of patellar tendons treated with bipolar radiofrequency.12 It is speculated that in vivo specimens would attain similar results although no published reports currently exist to support or refute this study.

   Radiofrequency techniques have substantially increased localized vessel counts between three and nine weeks after the procedure.10 In addition, plasma-mediated therapy in this study resulted in a more localized inflammatory response in vivo in comparison to conventional electrosurgery.

   There are limited published results regarding the treatment of plantar fasciosis using bipolar radiofrequency. Weil and colleagues published a small case series of 10 patients who underwent percutaneous microtenotomy after failing conservative care and used a visual analog scale (VAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot and Midfoot Scale to assess patient satisfaction.11 Patient assessments occurred at six months and one year after surgery. Ninety percent reported they were “extremely satisfied” to “satisfied” with their outcome. However, one patient developed recurrent heel pain one year after the procedure. There were no postoperative complications reported.

   Sean and colleagues reported on 14 patients with plantar fasciitis who were treated with Coblation from 2007 to 2008.10 When comparing preoperative and postoperative AOFAS Hindfoot and SF-36 scores, authors reported improvement from 34.47 to 69.27 and 71.33. There was a decrease in SF-36 score for bodily pain and an increase in physical and social function scores. The study found 85.7 percent of patients reported good to excellent results six months after surgery. Sean and co-authors also reported no complications.10

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