July 2013

How Effective Is Percutaneous Plantar Fasciotomy?

By Brian McCurdy, Senior Editor

The percutaneous plantar fasciotomy has the advantage of being less invasive than other fasciotomy techniques but how does it compare in its ability to get patients back on their feet quicker with less pain?

   The authors of a new study in the Journal of Foot and Ankle Surgery (JFAS) retrospectively reviewed the charts of patients with plantar fasciitis who had either open fasciotomy with heel spur resection (32 feet) or percutaneous medial fascial release (23 feet). The study notes the percutaneous group showed a mean pain reduction of 5.69 points at the first postoperative visit while the open fasciotomy group exhibited a mean pain reduction of 3.53 points on the Visual Analogue Scale.

   Researchers concluded that percutaneous medial fascial release was as effective at resolving recalcitrant plantar fasciitis pain as the open procedure and that patients who had the percutaneous technique experienced less postoperative pain and returned to full activity faster.

   In his experience, Allen Jacobs, DPM, FACFAS, has found all techniques of plantar fasciotomy are effective in properly selected patients, including in-step, endoscopic, percutaneous and open techniques. He says all those techniques are associated with equal incidence of long-term sequelae, namely lateral column pain, decreased arch height with associated stress induced pathology and nerve injury.

   “The key to success for all fasciotomy approaches lies in proper performance of technique, as well as the recognition and management of etiologic factors such as obesity, pronation syndromes or equinus,” notes Dr. Jacobs, who is in private practice in St. Louis.

   Similarly, Martin Pressman, DPM, FACFAS, finds that both the open and percutaneous plantar fasciotomy techniques yield long-term favorable results, noting that he uses ultrasound guidance when performing percutaneous releases. Dr. Pressman recently finished an as yet unpublished study of 175 percutaneous releases and found an 86 percent good to excellent result with a two-year follow-up.

   The advantage to percutaneous release is that it does not require expensive endoscopic equipment and is less invasive than open procedures, according to Dr. Pressman. He performs percutaneous release with a 16 gauge needle or a fasciotome, noting this seems to allow a quicker recovery similar to the JFAS study. He notes that his study did not compare open versus percutaneous.

   Dr. Pressman says percutaneous fasciotomy is effective for most of recalcitrant fasciitis cases. He advises that for patients with persistent heel pain after percutaneous release, in the absence of neurologic complaints, one should follow initial treatment with a formal partial fasciectomy.

   Dr. Jacobs generally prefers to use open fasciotomy, saying it allows limited decompression of the first branch of the lateral plantar nerve and, when necessary, permits spur reduction or partial fasciectomy. He will consider performing percutaneous fasciotomy in the patient with a clinically prominent, palpable and isolated painful band of the plantar fascia. On the other hand, Dr. Jacobs avoids percutaneous fasciotomy in those with diffuse or laterally expressed heel pain, or in patients with signs or symptoms that suggest possible nerve compression syndromes.

   Dr. Pressman, an Assistant Professor of Orthopaedics and Rehabilitation at the Yale School of Medicine, would avoid the percutaneous release in patients with mixed symptoms of neuritic pain and enthesopathy, or those who have had other procedures such as Topaz or radiofrequency ablation, opting instead for open partial fasciectomy.

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