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Point-Counterpoint: Heel Spurs: Can A Minimally Invasive Medial Fasciotomy Be A Viable Alternative To Resection?
Point
By Lawrence Fallat, DPM, FACFAS, and Hannah Khlopas, DPM
Sharing insights from their experience as well as the literature, these authors maintain that the percutaneous plantar fasciotomy offers a shorter operative time, reduced complications and facilitates an earlier return to work in comparison to the open fasciotomy with heel resection.
Plantar fasciitis, a common cause of pain in the inferior heel, affects approximately 10 percent of the United States population, resulting in close to 600,000 outpatient visits annually.1 McCarthy and Gorecki found that 15 percent of all patients seeking podiatric treatment had a chief complaint of heel pain.2 A majority of patients (greater than 80 percent) who have plantar fasciitis respond to conservative treatment.3 When conservative therapy fails, surgical treatment is warranted. Two surgical options are percutaneous plantar fasciotomy and open fasciotomy with heel spur resection. With these options in mind, can a minimally invasive medial fasciotomy be a viable alternative to heel spur resection?
Research has demonstrated that the use of the minimally invasive medial fasciotomy alone in the treatment of recalcitrant plantar fasciitis has excellent outcomes. Benton-Weil and colleagues reported on 51 patients who underwent percutaneous plantar fasciotomy and demonstrated that 83 percent of the patients reported that the procedure met or exceeded their expectations.4 Brekke and Green studied 44 patients who either underwent an minimally invasive medial fasciotomy, an open fasciotomy procedure or endoscopy. The minimally invasive cohort demonstrated greater pain reduction.5 Based on these studies, minimally invasive medial fasciotomy may be sufficient to treat plantar fasciitis and more invasive methods, such as heel spur resection, may not be necessary.
Many practitioners routinely perform heel spur resections with plantar fasciotomies based on the assumption that these two conditions are associated with each other. However, not all heel spurs are symptomatic or require surgery. In a study done by Rubin and Witten, the authors noted that although 21 percent of their patients (125 out of 461) possessed heel spurs, only 13 (10 percent with spurs) had symptomatic heel pain.6 In a study by Anderson and Foster, 11 out of 72 patients had only fair or poor clinical results when the spur was resected alone.7
Due to the invasive nature of the open fasciotomy with heel spur resection, patients can have higher levels of postoperative pain and a higher incidence of complications in comparison to those who have a percutaneous plantar fasciotomy. Fallat and colleagues showed a significantly lower early postoperative pain in patients who had percutaneous plantar fasciotomy in comparison to those who had an open fasciotomy with heel spur resection.8 Regarding surgical complications, the group who had open fasciotomy with heel spur resection had a 3.7 times higher complication rate than the group who had percutaneous plantar fasciotomy. Within the group who had open fasciotomy with heel spur resection, seven patients experienced lateral column pain, four developed painful scars, two had dehisced wounds and one patient developed cellulitis. A total of 21 patients in the group who had open fasciotomy with heel spur resection had a decrease in sensation on the plantar aspect of the heel.8
In a study by Manoli and colleagues, the authors reported three cases that resulted in calcaneal fractures after heel spur resection.9 In a similar study, Tomczak and Haverstock concluded that a spur that is resected too aggressively can weaken the calcaneus and may predispose patients to develop a stress fracture.10
Evaluating The Complications Of And Post-Op Course For The Percutaneous Plantar Fasciotomy
One could argue that the percutaneous plantar fasciotomy may be associated with its own postoperative complications. However, Fallat and colleagues demonstrated only three patients out of 30 had complications, all of which were lateral column pain, and this was resolved successfully with conservative treatment.8 Brugh, Fallat and Savoy-Moore demonstrated that regardless of the surgical technique used to treat plantar fasciitis, lateral column pain is a potential complication.11
Furthermore, the previously mentioned study also demonstrated shorter operative times when comparing percutaneous plantar fasciotomy (four minutes) versus open fasciotomy with heel spur resection (22 minutes), which may potentially lead to decreased costs and complications.8
One of the important metrics in post-operative recovery is return to work time. Tomczak and Haverstock demonstrated a slower return to work of 84 days for patients who had open fasciotomy with heel spur resection in comparison to 29 days for those who had an endoscopic plantar fasciotomy.10 Similarly, Brekke and Green found that patients undergoing open surgery required a mean of 12 weeks to return to normal activity.5
Concluding Thoughts
In conclusion, there are no studies demonstrating that heel spur is correlated with plantar fasciitis pain. Moreover, open fasciotomy with heel spur resection is associated with longer operative times and a higher risk of complications due to the more aggressive nature of the procedure. Researchers have also shown that those who have an open fasciotomy with heel spur resection have a slower return to work and higher post-operative pain in comparison to those who have a percutaneous plantar fasciotomy. All of this can lead us to conclude that percutaneous plantar fasciotomy is a better surgical choice with a high satisfaction rate.
Dr. Fallat is a Fellow of the American College of Foot and Ankle Surgeons. He is the Director of the Podiatric Surgical Residency Program at Beaumont Wayne Hospital in Wayne, Mich.
Dr. Khlopas is a second-year resident at Beaumont Wayne Podiatric Surgery Residency Program in Wayne, Mich.
Counterpoint
By Allan Kalmus, DPM, and Romesh Dhaduk, DPM
Noting that heel spur resection may be necessary for pain relief, these authors note that advances with the percutaneous incision approach, proper technique and instrumentation can help minimize complications with heel spur resection.
Etiologies of the plantar heel spur are broadly classified into either mechanical or inflammatory etiologies. Mechanical plantar fasciitis occurs secondary to abnormal foot biomechanics such as excessive subtalar joint pronation or midtarsal joint pronation during midstance and propulsion. This places a tensile force on the plantar fascia and intrinsic muscles of the foot on their attachment to the medial plantar calcaneal tuberosity. This leads to periostitis and subsequent bone formation as this force continues.1 DuVries identified three types of spurs: horizontal spurs, spurs at the attachment of the flexor digitorum brevis and spurs pointing plantarly. Spurs that point plantarly can cause pain with weightbearing and one should resect these spurs during a fasciotomy release.2
Inflammatory plantar fasciitis is another manifestation of plantar heel pain, such as seropositive and seronegative arthritis, and may lead to enthesopathy and discomfort at the plantar calcaneal tuberosity. Pain without swelling is the hallmark of this symptomology. In these cases, resection of plantar heel spur may be appropriate for pain relief.3
Various authors have reported on and described different surgical techniques over the years for plantar heel spur resection. Historically, researchers began with larger incisions and this approach later evolved to percutaneous incisions as older surgical techniques were refined. As early as 1901, Griffith developed a method in which a surgeon could make a U-shaped full thickness flap around the posterior aspect of the heel and reflect it distally to expose the structures attached to the plantar fascia from its origin, and resect the plantar heel spur.4
Steindler described a procedure with a medial horizontal incision and excised the spur with an osteotome and rasp.5 In 1957, DuVries performed plantar heel spur resection using a longitudinal medial approach on 32 patients and reported that patients resumed weightbearing at four weeks.2 In 1970, Mercado introduced an osteotripsy technique for plantar heel spur surgery in which he resected the spur using a rasp through a percutaneous medial incision.6 This method popularized the minimal incision approach for heel spur syndrome. After employing a longitudinal plantar incision for plantar heel spur resection in 12 patients for a 1983 study, Michetti and Jacobs noted that all patients healed without a scar.7
In 1986, Leach and colleagues described a plantar medial skin incision to perform a plantar fasciotomy with heel spur resection in 15 athletes.8 Ninety-three percent of patients successfully returned to their previous level of sport activity. The author emphasized that this approach provided adequate visualization of the plantar fascia, which showed mucoid degeneration and, more importantly, the medial calcaneal nerve, which courses in close proximity. The calcaneal branches of the lateral plantar nerve can be a source of neurogenic pain from surrounding inflammation. The study authors also noted that visualization of the nerve allows the surgeon to protect it during plantar fasciotomy.
Polisner performed plantar fasciotomy and heel spur resection with a minimal incision approach on 19 patients for chronic plantar heel pain and reported an average of 2.7 months to return to full activity in a 1981 study.9 Schepsis and colleagues performed a similar procedure with decortication of the calcaneus using a curved osteotomy through a medial longitudinal approach and reported successful outcomes for 89 percent of patients in their 1991 study.10 The authors reported that decortication of the calcaneal surface stimulates fibrous healing and allows plantar fascia to heal back in a lengthened manner. In 1992, Gormley and Kuwada performed heel spur resection with a partial plantar fascial release on 89 patients and reported an average 3.2 month return to previous level of activity post-operatively.11
What The Recent Literature Reveals
The majority of studies in the recent literature that report on the short- and long-term outcomes of heel spur resection focus on the open plantar fasciotomy
and its associated complications. Tomczak and Haverstock reported that patients undergoing open fasciotomy required an average of three months to return to work.3 Brekke and Green found that patients undergoing open plantar fasciotomy with heel spur resection required three months to return to normal activity.12
In a later study, Fallat and colleagues reported that a percutaneous medial plantar fasciotomy without heel spur resection and an open plantar fasciotomy with heel spur resection are equally effective in the treatment of plantar fasciitis.13 Additionally, these authors cite an increase in the operating time and a slower return to full activity in the latter group due to longer healing time.
Other Important Considerations With Heel Spur Resections
While Tomczak and Haverstock have reported more potential complications of heel spur resection procedures such as wound dehiscence, hematoma formation, and hypertrophic scar formation, it should be noted that these complications are more associated with an open incision approach.3
Surgeons can perform a plantar heel spur resection through a percutaneous incision, which potentially minimizes skin healing problems, nerve injuries, infection and prolonged recovery time, and allows early return to normal activities.14
Another complication with heel spur resection is calcaneal fractures due to aggressive resection or improper placement of the rasp/burr on the plantar heel.3,13,15 One can primarily avoid this with proper technique. Oliva and team demonstrated the use of a plantar stab incision for a percutaneous plantar fasciotomy.14 This placement allows easy access to the plantar heel spur. The surgeon can use a rotary burr and translate it medially and laterally on the calcaneus to resect the heel spur in its entirety under fluoroscopic guidance.
The power rasp is another popular tool among foot and ankle surgeons for resecting the plantar heel spur. Apóstol-González and colleagues demonstrated the proper placement of the rasp on the heel spur to avoid damaging the plantar cortex.16 The authors demonstrated that the rasp should be parallel to the plantar cortex of the calcaneus and not perpendicular. This avoids cavitating the plantar cortex when resecting the heel spur.
In Conclusion
Plantar fasciotomy with or without heel spur resection is effective in providing long-term pain relief for patients.13 However, heel spur resections are necessary when the spur is causing the pain. One can perform heel spur resections via an open or percutaneous approach, depending on surgeon preference. There are no studies in the literature that compare plantar fasciotomy with and without heel spur resection only via a percutaneous approach.
By utilizing a percutaneous approach, one can minimize the potential complications associated with open fasciotomies. Most importantly, by performing a plantar heel spur resection, it gives patients psychological relief post-operatively when they do not see the heel spur on the radiograph.
Dr. Kalmus is a Diplomate of the American Board of Foot and Ankle Surgery and is affiliated with Beaumont Hospital in Farmington Hills, Mich. He is in private practice in Taylor, Mich.
Dr. Dhaduk is a third-year resident at the Beaumont Wayne Podiatric Surgery Residency Program in Wayne, Mich.
Point 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):303-310.
2. McCarthy DJ, Gorecki GE. The anatomical basis of inferior calcaneal lesion. a cyromicrotomy study. J Am Podiatry Assoc. 1979;69(9):527-536.
3. Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med. 2004;350(21):2159–2166.
4. Benton-Weil W, Borrelli AH, Weil LS Jr, Weil LS Sr. Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis. J Foot Ankle Surg. 1998;37(4):269-272.
5. Brekke MK, Green DR. Retrospective analysis of minimal incision, endoscopic, and open procedures for heel spur syndrome. J Am Podiatr Med Assoc. 1998;88(2):64–72.
6. Rubin G, Witten M. Plantar calcaneal spurs. Am J Orthop. 1963;5:38-41.
7. Anderson RB, Foster MD. Operative treatment of subcalcaneal pain. Foot Ankle. 1989;9(6):317-323.
8. Fallat LM, Cox JT, Chahal R, Morrison P, Kish J. A Retrospective Comparison of Percutaneous Plantar Fasciotomy and Open Plantar Fasciotomy with Heel Spur Resection. J Foot Ankle Surg. 2013;52(3):288-290.
9. Manoli A, Harper MC, Fitzgibbons TC, McKernan DJ. Calcaneal fracture after cortical bone removal. Foot Ankle. 1992;13(9):523-525.
10. Tomczak RL, Haverstock BD. A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome. J Foot Ankle Surg. 1995;34(3):305–311.
11. Brugh AM, Fallat LM, Savoy-Moore RT. Lateral column symptomatology following plantar fascial release: a prospective study. J Foot Ankle Surg. 2002 Nov-Dec;41(6):365-71.
Counterpoint References
1. Barrett SL, Day SV. Endoscopic plantar fasciotomy for chronic plantar fasciitis/heel spur syndrome: surgical technique- early clinical results. J Foot Surg. 1991;30(6):568-570.
2. DuVries HL. Heel spur (calcaneal spur). AMA Arch Surg. 1957;74(4):536-542.
3. Tomczak RL, Haverstock BD. A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome. J Foot Ankle Surg. 1995;34(3):305–311.
4. Griffith JD. Osteophytes of the os calcis. Am J Orthop Surg. 1901;8:501.
5. Steindler A. A Textbook of Operative Orthopedics. New York: Appleton and Company; 1925. Chapter 14, page 253.
6. Mercado OA. Osteotripsy for heel surgery. J Am Podiatry Assoc. 1970;60(2):76-79.
7. Michetti ML, Jacobs SA. Calcaneal heel spurs: etiology, treatment, and a new surgical approach. J Foot Surg. 1983;22(3):234-239.
8. Leach RE, Seavey MS, Slater DK. Results of surgery in athletes with plantar fasciitis. Foot Ankle. 1986;7(3):156-161.
9. Polisner RI. Early ambulation after minimal incision surgery for calcaneal spurs. Clin Podiatry. 1985;2(3):497-502.
10. Schepsis AA, Leach RE, Gorzyca L. Plantar fasciitis, etiology, treatment, surgical results, and a review of the literature. Clin Orthop. 1991;266:185-196.
11. Gormley J, Kuwada GT. Retrospective analysis of calcaneal spur removal and complete facial release for the treatment of chronic heel pain. J Foot Surg. 1992;31(2):166-169.
12. Brekke MK, Green DR. Retrospective analysis of minimal incision, endoscopic, and open procedures for heel spur syndrome. J Am Podiatr Med Assoc 1998;88(2):64–72.
13. Fallat LM, Cox JT, Chahal R, Morrison P, Kish J. A retrospective comparison of percutaneous plantar fasciotomy and open plantar fasciotomy with heel spur resection. J Foot Ankle Surg. 2013;52(3):288-290.
14. Oliva F, Piccirilli E, Tarantino U, Maffulli N. Percutaneous release of the plantar fascia. New surgical procedure. Muscles Ligaments Tendons J. 2017;7(2):338-340.
15. Malay DS. Heel surgery. In: McGlamry ED, Downey MS, Banks AS (eds): Comprehensive Textbook of Foot Surgery, Ch. 16, Williams & Wilkins, Baltimore, 1992, pp. 439-440.
16. Apóstol-González S, Herrera J, Herrera I. Fractura de calcáneo como complicación de tratamiento percutáneo de fascitis plantar. Reporte de un caso. Acta Ortopedica Mexicana. 2014;28(2):134-136.
