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

It has been estimated that more than 1 million visits have been made to office-based physicians and hospital outpatient departments each year for plantar heel pain.1 For foot and ankle surgeons, much of their practice time entails treating plantar heel pain. The literature has described plantar fasciitis as a painful heel with inflammation of the plantar fascia at the proximal insertion of the plantar fascia to the calcaneus.2    In 2003, Lemont and colleagues reported histologic findings of 50 cases of heel spur samples from surgery for chronic plantar fasciitis.3 In all of the samples, there was no histopathologic evidence of inflammation. Instead, the study authors observed degenerative changes to the plantar fascia.    Currently, many use the term plantar fasciosis to describe heel pain that is associated with pain from the plantar fascia. Plantar fasciitis, heel pain syndrome or plantar fasciosis are used interchangeably. The findings from Lemont and colleagues provide evidence to question the basis of using therapies aimed at reducing inflammation and the effectiveness of these treatments. There are more questions than ever as to the most effective conservative and surgical treatment modalities for targeting the degenerative changes to the plantar fascia.    According to reports, up to 85 percent of patients treated conservatively for plantar fasciitis experience resolution of symptoms.4 For those remaining 15 percent, there is no clear consensus and limited or no supporting evidence of specific surgical treatment strategies for plantar fasciosis. Researchers agree that one should recommend surgical treatment to patients who do not improve with conservative treatment after six months.4,5    There are numerous non-invasive and invasive surgical treatment options available to treat recalcitrant plantar fasciosis. These modalities include the in-step plantar fasciotomy, endoscopic plantar fasciotomy, extracorporeal shockwave therapy, cryotherapy and bipolar radiofrequency microtenotomy.    Prior to deciding what surgical treatment of choice will be most effective for patients with recalcitrant heel pain, it is vital to have a correct diagnosis. Often, in the absence of a thorough workup, clinicians may lump patients with plantar heel pain into the diagnosis of plantar fasciosis. It is vital to rule out other causes of plantar heel pain such as neurogenic causes, arthropathy, infectious disease or an osseous mass.6 Matched case control studies concluded that decreased ankle joint dorsiflexion, high body mass index (>30/m2), pronated foot posture and increased work-related weightbearing are risk factors for developing plantar fasciosis.7,8 In treating patients conservatively and surgically, adjunctive treatment should aim at modifying risk factors.

How Bipolar Radiofrequency Works

When surgical intervention is necessary to treat recalcitrant plantar fasciosis, bipolar radiofrequency microtenotomy (Topaz MicroDebrider, ArthroCare Sports Medicine) can provide an alternative to the invasive procedures. Radiofrequency microtenotomy initially started in the orthopedic field for the treatment of tendinosis and has been successful in the treatment of tennis elbow and rotator cuff tendinosis.    In theory, the bipolar radiofrequency microtenotomy technique stimulates angiogenesis to the avascular, fibrotic and degenerative fascia. This technique appears to be an optimal treatment approach for tendinosis/fasciosis as it reportedly stimulates and organizes the angiogenic healing response to attempt to reverse this condition. Research has shown this technique promotes angiogenesis in ischemic hearts in patients with congenital heart failure and accelerates wound healing to enhance cell proliferation.9 The bipolar radiofrequency system works by increasing fibroblastic growth factor, vascular endothelial growth factor and vascular cells.10 The possibility for treatment of a tendinosis/fasciosis by a radiofrequency based approach might therefore be valuable.    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    There is a concern that bipolar radiofrequency could potentially cause excessive adjacent tissue damage.9 However, Kaplan and Uribe showed that chondrocytes still remain viable immediately below the surface of the radiofrequency treatment area.13

Other Considerations With The Bipolar Radiofrequency Microtenotomy

There are several considerations to keep in mind when treating plantar fasciosis with the radiofrequency technique. If the patient has inadequate dorsiflexion to the ankle, one should consider an adjunct procedure such as gastroc lengthening. If the patient has biomechanical faults that are contributing to the symptoms of plantar fasciosis that are causing severe tension to the plantar fascia, then consider surgical treatment that reduces the tension to the plantar fascia or custom orthotics after the surgery.    To develop a more comprehensive understanding of the effects of bipolar radiofrequency, additional research is required. A serial examination of in vivo samples treated with Coblation would yield powerful data to help delineate its potential role in tendon or ligamentous degeneration. In addition, a study with a larger clinical group with longer follow-up is necessary to understand the long-term effects of this technology upon the natural history of plantar fasciosis.    With careful patient selection and adherence to the recommended technique, bipolar radiofrequency microtenotomy offers the patient and practitioner hope in the treatment of chronic plantar fasciosis.

In Conclusion

This minimally invasive technique is a viable surgical treatment option for patients with recalcitrant plantar fasciosis who have failed conservative care. However, proper patient selection is key with this surgical treatment option. While this technique offers a surgical alternative to conventional surgery, one should avoid using this technique on inflammatory conditions.    There is still a need for further study to investigate the long-term outcomes of the procedure in the treatment of recalcitrant plantar fasciosis. I still believe that the future of plantar fasciosis treatment is in stimulating treatments that allow the body to heal itself without sacrificing the plantar fascia.    Dr. Rhim is an Assistant Professor at the College of Podiatric Medicine, Surgery, and Biomechanics at the Western University of Health Sciences, Pomona, Ca.
 

References:

1. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int 2004; 25(5):303.
2. Kwong PK, Kay D, Voner PT, White MW. Plantar fasciitis: mechanics and pathomechanics of treatment. Clin Sports Med. 1988; 7(1):119–126.
3. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. JAPMA 2003; 93(3):234-237.
4. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg 2008; 16(6):338-346.
5. Thomas JL, et al. The diagnosis and treatment of heel pain: a clinical practice guideline revision. J Foot Ankle Surg 2010; 49(3):S1-S19.
6. Lui E. Systemic causes of heel pain. Clin Pod Med Surg 2010; 27(3):431-441.
7. Riddle DL, Pulisic M, Pidcoe P, et al. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Am 2003; 85(5):872-877.
8. Irving DB, Cook JL, Young MA, et al. Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matches case-control study. BMC Musculoskelet Disord 2007; 8:41.
9. Tasto JP. The use of bipolar radiofrequency microtenotomy in the treatment of chronic tendinosis of the foot and ankle. Tech Foot Ankle 2006; 5(2):110-116.
10. Sean NY, Singh I, Wai CK. Radiofrequency microtenotomy for the treatment of plantar fasciitis shows good early results. Foot Ankle Surg 2010; 16(4):174-7.
11. Weil L, Glover JP, Weil LS. A new minimally invasive technique for treating plantar fasciosis using bipolar radiofrequency: a prospective analysis. Foot Ankle Spec 2008; 1(1):13-18.
12. Silver WP, Creighton RA, Karas SG. Thermal microdebridement does not affect time zero biochemical properties of human patellar tendons. Am J Sports Medicine. 2004; 32(8):1946-1932.
13. Kaplan L, Uribe JW. The acute effects of radiofrequency energy in articular cartilage: an in vivo study. Arthroscopy 2000; 16(1):2-5.

References:

1. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int 2004; 25(5):303.
2. Kwong PK, Kay D, Voner PT, White MW. Plantar fasciitis: mechanics and pathomechanics of treatment. Clin Sports Med. 1988; 7(1):119–126.
3. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. JAPMA 2003; 93(3):234-237.
4. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg 2008; 16(6):338-346.
5. Thomas JL, et al. The diagnosis and treatment of heel pain: a clinical practice guideline revision. J Foot Ankle Surg 2010; 49(3):S1-S19.
6. Lui E. Systemic causes of heel pain. Clin Pod Med Surg 2010; 27(3):431-441.
7. Riddle DL, Pulisic M, Pidcoe P, et al. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Am 2003; 85(5):872-877.
8. Irving DB, Cook JL, Young MA, et al. Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matches case-control study. BMC Musculoskelet Disord 2007; 8:41.
9. Tasto JP. The use of bipolar radiofrequency microtenotomy in the treatment of chronic tendinosis of the foot and ankle. Tech Foot Ankle 2006; 5(2):110-116.
10. Sean NY, Singh I, Wai CK. Radiofrequency microtenotomy for the treatment of plantar fasciitis shows good early results. Foot Ankle Surg 2010; 16(4):174-7.
11. Weil L, Glover JP, Weil LS. A new minimally invasive technique for treating plantar fasciosis using bipolar radiofrequency: a prospective analysis. Foot Ankle Spec 2008; 1(1):13-18.
12. Silver WP, Creighton RA, Karas SG. Thermal microdebridement does not affect time zero biochemical properties of human patellar tendons. Am J Sports Medicine. 2004; 32(8):1946-1932.
13. Kaplan L, Uribe JW. The acute effects of radiofrequency energy in articular cartilage: an in vivo study. Arthroscopy 2000; 16(1):2-5.