Can Endoscopic Debridement Be Effective For Chronic Plantar Fasciitis?

A recent study in the Journal of Foot and Ankle Surgery touts endoscopic debridement as an innovative treatment for chronic heel pain.

The authors say endoscopic debridement is minimally invasive and maintains the integrity of the plantar fascia. The study focused on 46 consecutive patients who had endoscopic debridement after failing conservative treatment for plantar fasciitis with a mean follow-up of 20 months. Mean Visual Analogue Scale (VAS) pain scores decreased from 8.95 to 1.34 and mean American Orthopedic Foot and Ankle Society (AOFAS) scores increased from 51.29 to 89.91, according to the study.

Lead study author James Cottom, DPM, FACFAS, cites advantages with this technique including that one can fully visualize the origin of the plantar fascia and debride it along with resection of a heel spur if needed. He notes documented comorbidities associated with release of the plantar fascia including lateral column overload and metatarsalgia.

Dr. Cottom says physicians should consider endoscopic debridement only after exhausting other options for chronic plantar fasciitis, saying it is “truly a last option in my practice.” He has performed over 80 endoscopic debridements and has attained excellent clinical results. In his patients, VAS, AOFAS and Foot Function Index (FFI) scores have all demonstrated that the technique is effective and statistically significant when comparing preoperative data to postoperative data, according to Dr. Cottom, the Fellowship Director and an Attending Physician at Florida Orthopedic Foot and Ankle Center in Sarasota, Fla.

In contrast, Stephen Barrett, DPM, FACFAS, would “never” consider endoscopic debridement, saying there are “much less invasive techniques with less risk that are more established.”

Dr. Barrett says debridement of plantar fasciopathy has been well established as a viable technique. However, he argues the surgical technique in the study seems to be more invasive than necessary when surgeons can get the same result effectively with a needle-like rasp under sonography. With less invasive techniques, there is no need to remove the inferior calcaneal exostosis, according to Dr. Barrett, an Adjunct Professor within the Arizona Podiatric Medicine Program at the Midwestern University College of Health Sciences. Furthermore, with endoscopic debridement, he speculates there could be a high risk of nerve damage at the porta pedis.

For further reading, see “Advanced Regenerative Healing Options For Chronic Plantar Fasciitis” and “An Evidence-Based Medicine Approach To Plantar Fasciitis,” both in the November 2013 issue of Podiatry Today, or “Developing A Comprehensive Plan To Treat Plantar Fasciitis” in the January 2013 issue.

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Study Assesses Posterolateral Approach For Posterior Malleolar Fractures

By Brian McCurdy, Managing Editor

Can a posterolateral approach be beneficial in open reduction and internal fixation (ORIF) of posterior malleolar fractures?

A recent study in the Bone and Joint Journal assessed the use of the posterolateral approach to address posterior malleolar fractures in 52 patients. The authors were able to achieve anatomic reduction in all patients with a residual step in the articular surface of less than 1 mm. In 82 percent of C-type fractures, the syndesmosis was stable after fixation of the posterior fragment and the study notes a syndesmosis screw was not required. The authors say the posterolateral surgical approach provides adequate access to the posterior malleolus, facilitating anatomical reduction and stable fixation.

“When fixing any fracture, anatomic reduction must be the goal and this technique allows much more confidence in perfect reduction than a percutaneous or ligamentotaxis type technique,” says Kevin Palmer, DPM. “This allows you to ensure that there is no soft tissue interposition, which would prevent osseous healing.”

However, Dr. Palmer does cite some risks with the technique. He notes visualization is difficult unless one has the patient in a prone position whereas surgeons are used to fixing an ankle fracture with the patient in a supine position.

Additionally, creating the posterolateral incision midway between the Achilles tendon and the fibula fracture itself places the incision directly over the sural nerve distribution, according to Dr. Palmer, who is in private practice with Golden Orthopaedic in Boca Raton, Fla.

“I am personally very surprised by the authors having almost no sural nerve entrapment or paresthesias after this incisional technique,” adds Dr. Palmer.  

For a patient with trimalleolar fractures, Dr. Palmer considers the patient’s age, activity demand, bone quality and overall health status. For patients with significant comorbidities, he will use a fibula rod through a percutaneous technique and will fix a posterior malleolar fracture percutaneously as well.

He feels surgeons should fixate trimalleolar fractures with an open approach and anatomic reduction in the younger, healthier and/or very active population. Dr. Palmer prefers utilizing a small plate for fixation, saying it is a much stronger construct and the patient can begin passive range of motion much sooner. 

New Study Shows Benefits Of Home Exercise In Preventing Diabetic Foot Complications

By Brian McCurdy, Managing Editor

A recent study in the Journal of the American Podiatric Medical Association shows a home exercise program can improve range of motion (ROM) and plantar pressure distribution in patients with diabetes, preventing lower extremity complications.

The program included exercises for ROM, stretching and strengthening, according to researchers. The study includes 76 patients with diabetes, 38 with neuropathy. In patients who performed the exercises, authors noted significant improvements in ROM for the ankle and first metatarsophalangeal joints, significant reduction in right forefoot medial pressure, and significant decreases in peak plantar pressure at the medial left forefoot, lateral right forefoot, left midfoot and right hindfoot.

David G. Armstrong, DPM, MD, PhD, supports having rehabilitation and “prehab” techniques for patients with diabetes. He and other researchers are working on the next generation of technologies that can help patients with diabetes rehab and “age in place” while increasing their stability and improving their mobility and quality of life, notes Dr. Armstrong, the Director of the Southern Arizona Limb Salvage Alliance and a Professor of Surgery at the University of Arizona Medical Center in Tucson, Ariz.

For patients with diabetes, Michael Maier, DPM, recommends non-impact type exercises, such as an elliptical trainer, recumbent bicycle, stationary bicycle or swimming instead of higher impact activities like a stair climber, running or aerobics.

Walking exercise alone is a class A1 recommendation for patients with peripheral arterial disease, according to Dr. Maier, the Director of the Lower Extremity Wound Clinic at the Cleveland Clinic in Cleveland. He emphasizes the importance of appropriate footwear, calling it “critical to optimize mechanics and avoid increased pressure points.”

Clarifications
In the June 2016 Technology In Practice article, “Innovative Implant Facilitates Improved Soft Tissue To Bone Fixation,” the end of the second paragraph on page 70 should have read as follows: “The implant enhances dynamic load stability by 95 percent without the presence of cortical bone, according to Stryker’s product literature.”

In the May 2016 feature article “Bone Growth Stimulation: What The Evidence Reveals,” a sentence on page 45 should have read as follows: “Conversely, studies have demonstrated accelerated healing time with the use of bone stimulation in smokers.”