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1 CHAPTER 7 Endoscopic Plantar FasciotomyGeorge R. Vrto, Plantar Fasciotomy for the treatment ofchronic plantar fascitis/heel spur syndrome is a rel-atively new procedure developed by Barrett andDay'. The procedure involves afi endoscopicapproach to the heel, allowing a plantar fasciotomyto be performed with delicate instruments, minimaldissection, and immediate weight surgical procedures for heelspv/plantar fascitis, the most common form oftreatment included complete release of the plantarfascia at its calcaneal inseftion and removal of theplantar spur from the calcaneal tuber'6.

2 However,treatment protocols ranged from countersinkingosteotomies' to calcaneal rotational open heel spur procedures,whether from a medial, planlar, or lateral approachall relate significant complications including infec-tion, calcaneal fracture, and nerve procedures often resulted in greater disabil-ity to the patient than they initially presented with,therefore many surgeons refrain from early reported lhat of all patientvisits to a podiatric physician involve heel pain,while Kenzora estimated that 900/o or more of allpatients receiving conserwative care obtained com-plete pain relief, in contrast with 70-80% of thepatients as reported by Barrett and Day',Fortunately, the majority of patients with heel orplantar fascia pain can be successfully treated withconserwative means, including steroid injections,orthotic devices, anti-inflammatory medications,and physical , for the 70-75o/o of patients who donot obtain relief from conservative care, traditionalsurgical treatment offers less than ideal results.

3 Withpotential complications outweighing surgical most instances, the traditional postoperativecourse includes non-weight bearing for a period of3 to B weeks, followed by partial weight bearingfor up to 2 , in today's society where work-man's compensation, medicare, and othergovernment agencies dictate tfeatment protocolsand rehabilitation restraints, keeping patients outof work for several weeks on end for elective sur-gical procedures is becoming an obsolete , Endoscopic Plantar Fasciotomy offersthe patient a means of obtaining complete relieffrom plantar fascitis, with early return to work anda short postoperative is essential that conservative care beexhausted before surgical intervention can beconsidered.

4 Zirm and Jimenez" suggested conserv-ative therapy for six months to one year beforeresorting to surgical intervention. Conselative careincludes padding, taping, heel cups, casting, spe-cial shoes, orthotics, stretching exercises, injectionsof local anesthetics and hydrocortisone, anti-inflammatory drugs, and physical after conservative care has failed shouldsurgical interuention be considered. If the locationof the pain is truly the planlar fascia, with or with-out radiographic evidence of an inferior spur,Endoscopic Planlar Fasciotomy should be consid-ered.

5 Proper training of the surgeon regardinginstrumentation and surgical technique must beundertaken prior to performing the surgery. It isthe author's opinion that course work and cadav-eric procedures are not sufficient to master thetechnique. Endoscopic Plantar Fasciotomy is a verytechnically precise procedure, therefore it is sug-gested that one first assist a surgeon who hasmastered this technique. This will help the trainingsurgeon avoid the possible pitfalls of the proce-dure, which could very easily compromise thepostoperative results. Prior clinical experience withthe use of an afihroscope would be a clear advan-tage in learning this 7 INSTRUMENTATIONThe instruments used to perform an EndoscopicPlanlar Fasciotomy are manufactured by theInstratek Corporation'3.

6 These instftlments are nowavailable without taking an instructional set of instruments consists of two locking knifehandles, fascial probe, lrocar, slotted cannula and afascial elevator. The instruments are housed in adurable case which is used for transport and pro-tection. The blades used with the knife handlesmust be purchased separately. Two blades arepackaged together, one being a curved blade, theother being a trtangle visualization is afforded with the use ofa standard arthroscopy system equipped with amonitor. A 30 degree lens should be used, with ascope diameter range from a mm to a inner core of the slotted cannula will onlyallow a mm or smaller diameter scope to beused.

7 It is the author's experience that a scopediameter of to mm achieves the best scope diameter greater than mm wiil notallow proper angulation within the cannula, whichis required to maneuver around possible fat obsta-cles. A scope smaller than mm may not allowproper visualization of the planlar CONSIDERATIONSWhen first performing the procedure, radiographicmeasurements should be obtained. Using a non-weight bearing lateral view, two measurements arerecorded to ensure proper skin incision reference point is created by measuring from theposterior aspect of the skin of the heel to approx-imately 2-4 mm anterior to the spur, or anterior tothe calcaneal tuber (average distance 44 to 54 mm).

8 A second measurement is taken from the inferioraspect of the heel to the same reference point justanterior to the spur or calcaneal tuber (average dis-tance 18 to 25 mm). The intersection of these twopoints is the location of the medial procedure is usually performed under IVsedation with a sterile ankle tourniquet. Prior tobeginning the procedure, the foot is prepped anddraped in the usual sterile fashion. The tourniquetis then applied, the foot is exsanguinated with anesmarch or ace wrap and the tourniquet is inflatedfrom 250-300 mm PROCEDUREA local anesthetic can be injected prior to the footscrub or after the prep and draping.

9 It is theauthor's preference to use 1o/o Xylocaine with epi-nephrine mked with 1% Xylocaine plain in a 50/50mixture. A total of 9 cc can be used with 3 cc beinginfiltrated at the medial aspect of the heel, J ccbeing used at lhe lateraT aspect of the heel and 1-3 cc can be placed at the inferior aspect of theheel. It is not necessary to perform a posterior tib-ial or sural nerve block, as local infiltration alonewiil be sufficient. One must be careful not to placemore than 7-2 cc of anesthetic inferior to the plan-tar fascia, as this may distort positioning of lhe aforementioned measurements, cm vertical incision is placed at the skin either a cured hemostat or small dissectingscissors, blunt dissection is carried down to the1evel of the medial expansion of the planter fascia.

10 \fith the use of the fascial elevator, palpation of thefascia is performed. The angle of approach is veryimportant, as one does not want to penetrate intothe fascia. The inferior aspect of the fascia shouldbe palpated and exposed. This will be a very dis-tinct structure and should always be palpated. Ifthe elevator penetrates the fascia, the canula willbe placed superior to the plantar fascial , if the canula is placed inferior to theplantar fascia, visualization of the inferior aspect ofthe piantar fascia will be obstructed by the fat padof the heel.