The study, published in Foot and Ankle Surgery, focused on 73 patients who received gastrocnemius recession as a single procedure between 2006 and 2011. Sixty-two patients reported a good or excellent result, 11 percent of patients reported a significant postoperative complication and 22 percent related having reduced or severely reduced plantarflexion power after surgery, according to the study. The authors noted that the Visual Analogue Score (VAS) on pain significantly decreased from 7.0 before surgery to 1.8 after surgery for 18 patients with plantar fasciitis and decreased from 5.6 to 2.3 for 28 patients with metatarsalgia.
Patrick DeHeer, DPM, FACFAS, has been performing gastrocnemius recession for plantar fasciitis for about two years and cites an approximate 80 percent success rate, similar to published reports. The only complication he has seen is if the recession does not work and the surgeon has to do a subsequent plantar fascia release.
“It is worth that risk in my opinion as anything to avoid cutting of the plantar fascia should be attempted before cutting it,” says Dr. DeHeer, who is in private practice with various offices in Indianapolis.
Lawrence DiDomenico, DPM, FACFAS, describes a “limited but good” experience using gastrocnemius recession for plantar fasciitis. He has performed gastrocnemius recession for this condition through the endoscopic technique.
“To the best of my knowledge, the patients that have had the procedure have done well,” notes Dr. DiDomenico, who is in private practice at Ankle and Foot Care Centers in Youngstown, Ohio. “I believe the key is truly exhausting all non-operative care first.”
When performing the endoscopic gastrocnemius recession, maintaining the principles of the technique and ensuring appropriate selection for patients who have not responded to non-operative care, Dr. DiDomenico has not experienced any substantial complications. Most commonly, he says postoperative symptoms will resolve after patients go through a period of postoperative management and rehabilitation.
Both Dr. DiDomenico and Dr. DeHeer say the patients who fare best with gastroc recession are the ones who have not responded to non-operative care after an extensive period of time. Dr. DeHeer performs gastroc recession for heel pain that does not respond to adequate conservative therapy of three to six months when there is associated equinus. He says equinus is associated with heel pain 80 percent of the time according to the literature and the incidence of equinus may be even higher than that.
In contrast, Dr. DiDomenico notes that those who do not fare well with gastroc recession are patients who have conditions with other deformities such as a post-calcaneal fracture, an alignment issue, calcaneal varus, pes planus, other structural deformities or other medical conditions not related to the biomechanical causes of pain.
Before taking any plantar fasciitis patient to surgery, Dr. DeHeer will get magnetic resonance imaging to rule out Baxter’s neuritis. He notes this requires a different approach surgically but does not exclude a gastroc recession in addition to a tarsal tunnel and Baxter’s nerve release.
Is Osteodesis A Viable Alternative To Osteotomies For Hallux Valgus?
By Brian McCurdy, Managing Editor
Osteodesis may be an alternative to osteotomies for bunions although the research is reportedly sparse. A recent study in Clinical Orthopaedics and Related Research notes that osteodesis can adequately correct hallux valgus.
Surgeons performed osteodesis procedures to correct hallux valgus, following up with 110 patients after 12 months. They used intermetatarsal cerclage sutures to realign the first metatarsal and induced postoperative fibrosis surgically between the first and second metatarsals to maintain the first metatarsal’s alignment. The study found that the intermetatarsal angle had improved from a preoperative mean of 14 to 7 degrees and the metatarsophalangeal angle improved from 31 to 18 degrees. In addition, the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score changed from 68 to 96 points.
Noman Siddiqui, DPM, has not performed osteodesis but is familiar with the technique’s variant that involves using a suture button. Although the results for osteodesis are promising, he acknowledges having a “bias toward osteotomy-based procedures.”
For osteodesis, advantages include minimal soft tissue and bony dissection with early weightbearing, according to Dr. Siddiqui, the Medical Director of Diabetic Limb Preservation at LifeBridge Health in Baltimore and the Division Chief of Podiatry at Northwest Hospital in Baltimore. In addition, with osteodesis, Dr. Siddiqui says there is no risk of bony non-union, delayed union or malunion since the procedure involves soft tissue realignment but no osteotomy.
Dr. Siddiqui notes the disadvantages include an extended, protected weightbearing period as well as a risk of second metatarsal stress fracture. Dr. Siddiqui would avoid osteodesis as a revisional procedure and in patients who are unable to follow the postoperative regimen recommendations.
Study: Off-The-Shelf Orthoses Reduce Plantar Pressure In Patients With Rheumatoid Arthritis
By Brian McCurdy, Managing Editor
Patients with early-stage rheumatoid arthritis can find relief from plantar pressure with prefabricated orthoses, according to a recent study in the Journal of the American Podiatric Medical Association.
Researchers recorded plantar pressures in gait for 35 patients with early-stage rheumatoid arthritis at three and six months. They analyzed patients while walking barefoot, wearing shoes and wearing shoes with off-the-shelf orthoses. The study notes off-the-shelf foot orthoses reduced forefoot peak plantar pressure by 22 percent and reduced the pressure-time integral by 14 percent in comparison with shod feet. The study authors speculate these orthoses could contribute to reductions in foot pain.
Joseph C. D’Amico, DPM, DABPO, notes the mechanism of action for the “non-specific, generic inserts” is the improved translation of forces inherent in a three-dimensional foot that must function on a hard, flat, unyielding two-dimensional surface due to a better contoured matching of the weightbearing foot inside the shoe. This means there is an improvement in weight distribution patterns that now disperse across a broader surface area, thereby lessening plantar pressures, according to Dr. D’Amico.
“In essence, these off-the-arch shelf devices function as arch supports by empirically buttressing the longitudinal arch and randomly shifting weight laterally, thereby unlocking the longitudinal axis of the midtarsal joint,” says Dr. D’Amico, a Professor and Past Chairman of the Division of Orthopedics at the New York College of Podiatric Medicine.
Dianne Mitchell, DPM, agrees with the study that a prefab orthotic device can be effective for patients with early-stage rheumatoid arthritis, especially if the patient has a neutral foot type and little deformity. For those with foot deformities such as a planus or cavus foot type, she notes a custom-molded device would be superior as it would best transfer plantar pressures, reduce pain and control the foot. As rheumatoid arthritis progresses and the patient has nodule formation and/or increased deformity, Dr. Mitchell says a custom-molded device is best.
Dr. D’Amico cites studies showing that custom foot orthoses are always more effective than prefab devices. “Since no two feet are exactly alike from patient to patient and from right to left, a prefab type device will never be able to accurately and efficiently neutralize structural deficiencies or conform as well to the foot as custom foot orthoses would,” says Dr. D’Amico.
The major initiating factor in the production of foot and ankle deformities in the adult rheumatoid arthritic foot is muscle imbalance, according to Dr. D’Amico. He says the subsequent misalignment and dysfunction result from the inflammatory and post-inflammatory pathology that are directly linked to the disease process itself. He says preexisting biomechanical pathology serves to compound the severity and accelerate the rate of progression in this disorder.
Dr. D’Amico has found that due to the high degree of digital contractures as well as metatarsal head involvement, metatarsal pads have been effective for patients with rheumatoid arthritis. He adds that a digital crest may help restore some element of function to the toes.
Insights On Orthotic Modifications For Rheumatoid Arthritis
What orthotic modifications are effective in reducing plantar pressure for patients with rheumatoid arthritis? Due to the tendency for an increasing valgus compensatory position of the calcaneus with or without peroneal brevis spasm, Dr. D’Amico says a significantly deepened heel seat is often required. Dr. Mitchell prefers a semi-rigid orthotic shell with a deep heel cup as a base, saying it must be strong enough to effect a change underneath the patient’s foot versus a soft, accommodative device. She will order minimum fill to the device so it will contour the arch of the foot like a glove to achieve optimal plantar pressure transfer.
Dr. D’Amico advises that controlling the rearfoot with a rigid or semi-rigid device is beneficial and essential. Dr. D’Amico suggests considering a Blake inverted cast technique and Kirby skive if aggressive rearfoot posting is not effective. An EVA rearfoot post will provide shock absorption in comparison with a more firm polypropylene post. One can add a well padded topcover to provide comfort. In addition, a reinforced forefoot extension of padding, such as Poron, will pad the metatarsal heads and a metatarsal bar is effective at further decreasing forefoot load, according to Dr. Mitchell, a Fellow of the American Academy of Podiatric Sports Medicine, who is in private practice with Mercy Medical Group in Sacramento, Calif.