Category Archives: surgery

Surgical treatment of a large plexiform neurofibroma of the lower extremity

by Jacob Jensen1, David Shofler2*, Della Bennett3

The Foot and Ankle Online Journal 10 (3): 5

Plexiform neurofibromas are benign nerve tumors occurring in approximately 30% of patients with neurofibromatosis type 1. They develop as neural proliferations of single or multiple nerve fascicles, and are typically highly vascular in nature. In this case report, we describe a 28-year-old male with a paternal family history of neurofibromatosis type 1 and a large plexiform neurofibroma of his left lower extremity present. Following consultation and shared decision-making, the patient underwent surgical debulking primarily to reduce pain, to improve shoe gear fit, and to improve ambulation.  

Keywords: plexiform neurofibromas, neurofibromatosis, surgery

ISSN 1941-6806
doi: 10.3827/faoj.2017.1003.0005

1 – PGY2, Chino Valley Medical Center, Chino, CA
2 – Assistant Professor, Western University of Health Sciences
3 – Gemini Plastic Surgery
* – Corresponding author: dshofler@westernu.edu


A 28-year-old male with a past medical history of neurofibromatosis type 1 was seen for evaluation and management of a painful mass on his lateral left leg (Figure 1). He was no longer able to wear normal shoes, which in turn affected his activities of daily living. His surgical history included a prior debulking procedure of his left medial leg and foot at the age of 3. His social history included active tobacco use of a ½ pack of cigarettes a day, and had not graduated from high school. The patient related an extensive paternal family history of neurofibromatosis type 1, affecting multiple family members.  He reported a paternal family member passing away from a peritoneal malignancy caused by plexiform transformation into a malignant peripheral nerve sheath tumor.

Figure 1 Preoperative weightbearing and nonweightbearing clinical appearance of the left lower extremity, depicting the large mass.

Preoperative surgical planning included a coordinated effort between podiatric and plastic surgeries.  Surgical and conservative options were discussed in detail with the patient. The elected plan for the surgery was to debulk the lateral leg mass, with the goal of reducing the associated pain and to allow the patient to fit into a shoe. Risks and benefits were discussed in detail with the patient, and the patient was educated regarding the likelihood and speed of mass regrowth.  

Results

The patient underwent surgical debulking as an outpatient. Preoperatively, blood was typed and crossed in anticipation of blood loss secondary to the highly vascular nature of plexiform neurofibromas. A thigh tourniquet was used, and the patient was placed into a lateral decubitus position. A large semi-elliptical incision was utilized, oriented in line with the mass. The mass was identified and carefully dissected, with electrocautery used as necessary. The mass was noted to readily extend through tissue planes, and was not sharply defined. Local neurovascular structures were carefully avoided during dissection of the mass. With direct and unobstructed exposure obtained, the large mass was debulked with representative samples sent to pathology. The mass was noted to extend into the peroneal tendons, lateral ankle ligaments, and the fat pad of the heel; these anatomic structures were carefully preserved during the debulking process.

Following debulking of the mass, the tourniquet was released. Electrocautery was again employed to assist in obtaining hemostasis. Epinephrine soaked gauze was also employed as a hemostatic agent to promote vasoconstriction, further reducing blood loss during dissection. The surgical site was closed in layers, with Floseal hemostatic matrix (Baxter International, Deerfield, Illinois) applied during closure. A passive, closed, surgical drain was inserted prior to skin closure (Figures 2 and 3).

Figure 2 Immediate postoperative image of the left lower extremity following surgical debulking, with the surgical drain visible.

Figure 3 Postoperative image of the left lower extremity at the first postoperative visit, with surgical drain visible.

Discussion

Neurofibromatosis type I (NF-1), formerly known as Recklinghausen’s or von Recklinghausen disease, is a subtype of neurofibromatosis accounting for 90% of cases [1]. NF-1 is an inherited, autosomal dominant, single-gene disorder of chromosome 17: this non-sense mutation takes place on the NF-1 gene, with a prevalence of 1/3000 births and an equal distribution between males and females [2]. NF-1 usually presents in childhood, and manifestations include café au lait spots, neurofibromas, skeletal dysplasia, and neuropathy secondary to space-occupying neurofibromas [3,4].

Plexiform neurofibromas occur in approximately 30% of the patients with neurofibromatosis type I [5]. Malignant transformation occurs in about 2-16% of cases and is diagnosed with histopathologic biopsy [4,6]. Treatment planning requires consideration of the patient’s goals of treatment, the extent of the deformity, and the presence of malignant transformation.

It is of vital importance to plan preoperatively in order to anticipate the atypical surgical dissection. Surgical time may be longer than anticipated, as anatomic layers will be obscured and violated by the invasive and vascular nature of these masses. Preoperatively, blood should be typed and crossed with the anticipation of significant levels of blood loss. Careful, layered closure should be performed, with the incorporation of hemostatic agents. A closed surgical drain should be considered as well.

Due to the invasive and diffuse invagination of the mass, multiple tissue planes were carefully dissected with the anticipation of overall “debulking” rather that complete marginal resection of the soft tissue mass.

Though rarely encountered, management of large plexiform neurofibromas should include a shared-decision making process and a realistic depiction of the surgical outcome. Operative management should be deferential to the highly vascular and invasive nature of these soft tissue tumors.

References

  1. Ghalayani P1, Saberi Z, Sardari F. Neurofibromatosis type I (von Recklinghausen’s disease): A family case report and literature review. Dent Res J (Isfahan). 2012 Jul;9(4):483-8.
  2. Evans DG, Howard E, Giblin C, et al. Birth incidence and prevalence of tumor-prone syndromes: estimates from a UK family genetic register service. Am J Med Genet A. 2010;152A:327–332. 

  3. Hillier JC, Moskovic E. The soft tissue manifestations of neurofibromatosis type 1. Clin Radiol. 2005;60:960–7.
  4. Neurofibromatosis Fact Sheet NINDS, May 2011. NIH Publication No. 11-2126.
  5. Huson SM, Hughes RA. London: Chapman and Hall Medical; 1994. The Neurofibromatosis: A Pathogenetic and Clinical Overview.
  6. Sabatini C, Milani D, Menni F, et al. Treatment of neurofibromatosis type 1. Curr Treat Options Neurol. 2015;17:355. 


Funding Declaration

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Conflict of Interest Declaration

No conflict of interest to report

Intramedullary rodding of a toe – hammertoe correction using an implantable intramedullary fusion device – a case report and review

by Christopher R. Hood JR, DPM, AACFAS1, Jason R. Miller, DPM, FACFAS2pdflrg

The Foot and Ankle Online Journal 9 (4): 1

Development of a hammertoe is a commonly encountered problem by the foot and ankle surgeon. In long-standing deformity, the pathologic toe becomes fixed with patient complaints of pain, corns, and calluses and, in the immunocompromised patient, ulceration with potential infection and amputation. A common correction of the deformity is through lesser toe interphalanageal arthrodesis, commonly performed at the proximal joint. There are numerous techniques and new devices on the market to help assist in holding position until fusion is achieved.  The author demonstrates a case report utilizing a fixation device that has characteristics similar to that of an intramedullary rod. Additionally, a retrospective, observational study involving 35 toes that have undergone an arthrodesis procedure of the proximal interphalangeal joint using an intramedullary fusion device to stabilize the fusion site is reviewed. This device imparts its stability in a manner similar to that of intramedullary rods in long bone fixation.

Keywords: ArrowLokTM, arthrodesis, digit(al), fusion, hammertoe, implantable device, intramedullary, surgery, Kirschner wire

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0001

1 – Premier Orthopaedics and Sports Medicine, Malvern, PA, Malvern, PA
2 – Premier Orthopaedics and Sports Medicine, Malvern, PA, Fellowship Director, Pennsylvania Intensive Lower Extremity Fellowship, and Residency Director, Phoenixville Hospital PMSR/RRA, Phoenixville, PA
* – Corresponding author: Christopher R. Hood JR, DPM, AACFAS, crhoodjr12@gmail.com


The hammertoe deformity is one of the most common presenting problems and surgical corrections encountered and performed by the foot and ankle surgeon [1,2]. Correction through lesser interphalangeal (proximal interphalangeal joint, PIPJ, or distal interphalangeal joint, DIPJ) resection and fusion was first described by Soule in 1910 [1]. Since then many modifications have been made to the procedure from various methods of bone preparation at the fusion site to extramedullary (EM) Kirschner wires (KW) and intramedullary (IM) fusion devices (IMFD) to stabilize the fusion site until osseous healing has been achieved [1, 3-6].

The choice to adapt fixation from EMKW to IMFD buried inside the bone stemmed from the desire to improve surgical outcomes, namely decreasing surgical site infection (SSI) rates among other inherent problems with KW use [5]. Since their introduction onto the market, many of these new have held true in decreasing these complication rates, achieving similar outcomes regarding fusion rates, with the bonus of higher patient satisfaction and a decreased (almost eliminated) infection rate [2, 7-10].

Here we present an example of an IMFD, different in construct than others on the market, which has not yet been reported on. This device gives another option to the surgeon when it comes time for digital fusion procedures with the added versatility of various lengths when multiple digital joints need to be fused simultaneously. The construct of this device, unlike others, garners its strength and stability from its length, purchasing the subchondral bone plate and acting in a manner similar to an intramedullary rod used in other orthopaedic fixations scenarios.

Methods

Case Report

Our patient, a 49 year-old female, presented with a chief complaint of a right second toe deformity. Conservative measures of strapping, padding, and shoe modifications were attempted, but ultimately failed. She elected to proceed with arthrodesis of the digit. She was followed at post-op weeks 2, 4, and 8. At week 8, osseous bridging was noted across the osteotomy site (Figure 1). The patient had no complaints and was discharged. She returned to the office 2 years later for a different complaint and x-rays revealed fusion across the PIPJ with no loss in hardware fixation (Figure 2).

fig1a fig1b

Figure 1 Case report patient at (left) 2 weeks and (right) 8 weeks post-operation. Note fusion on medial side of arthrodesis site at 8 weeks.

fig2

Figure 2 Case report patient seen 2 years later. Complete fusion with no loss of fixation.

 

Surgical Technique

A #15 blade is used to make an incision across the PIPJ of the digit. This is dissected down to the deep capsule taking care to create a surgical plane between the superficial and deep fascial layers. Retraction is utilized to protect neurovascular structures located around the digit. A transverse tenotomy of the long extensor is performed just proximal to the PIPJ and soft tissues are freed up from the proximal phalanx head and middle phalanx base. Cartilage resection is performed with a sagittal saw at the head of the proximal phalanx and base of the middle phalanx.

Implantation of the IMFD is performed per the devices surgical technique guide. First, the IM canals of the proximal and middle phalanx are reamed with the supplied 1.6mm diameter reaming device down to but not through the subchondral plate into the adjacent joint. This position is checked on fluoroscopy and length is measured off of the wire, summing the proximal and middle phalanx measurements and choosing the sized implant available. Next the proximal phalanx is broached with the supplied 2.7mm broaching device. The depth of the broach is noted per the ruler on the device (7-10mm depth). The appropriate implant is positioned at the corresponding proximal phalanx reaming depth and placed within the proximal phalanx IM canal. The digit is then grasped and manipulated to place the distal end of the implant into IM canal of the middle phalanx. Once inserted, the implant can be released and the bones are manually compressed across the resection point. Closure consists of re-approximation of the extensor tendon and capsule around the fusion site for extra-medullary stability, and layered closure of the superficial fascia and skin.

Patient Audit

A CPT code audit of 28285 (correction hammertoe, eg. Interphalangeal fusion, partial, or total phalangectomy) from March 1, 2011, to July 15, 2015, was performed. Over that time period, the resulting search yielded 60 patients who had 89 digital surgeries. Patients that had arthroplasty, arthrodesis not performed with the studied device, the studied device plus KW, or isolated DIPJ arthrodesis were excluded. Ultimately, 35 toes in 23 patients had isolated PIPJ fusions using this technique.

Results

The case patient was seen at post-operation weeks 2, 4, and 8. Signs of fusion were noted at week 4 and complete fusion was noted at week 8 radiographically. No loss of fixation was noted at any point. Patient satisfaction was high at discharge.

The CPT audit identified 35 toes that underwent PIPJ arthrodesis using the studied device. Average follow-up was 110 days. There was zero (0%) cases of hardware failure noted. In a single instance (2.8%), the device appeared to have rotated 90 degrees on its long axis, but fixation was still maintained. Two toes (5.7%) were misaligned with  slight medial angulation of the digit. There were zero occurrences of either a superficial or deep incisional infection as defined by the CDC [11]. No patient required revision surgery or a return to the operating room for a complication secondary to the index digital arthrodesis procedure.

Discussion

One of the biggest problems with arthrodesis of the PIPJ can be attributed to the use of EMKW for temporary stabilization across the fusion site until osseous union is achieved. The use of KW for fixation was first described by Taylor in 1940 [1]. Since that time, surgeons have battled against the complications of this technique such as pin-tract infections, digital edema, delayed or non-union of the arthrodesis site due to lack of compression, rotational instability, bent or broken wires, and patient dissatisfaction and apprehension due to the protruding wire and its impending removal [2,10]. External wire exposure infection rates range from 0-18% [1,5,12]. Studies have reported 40% of the wire infections were related to external factors through irritation at the skin-pin interface secondary to trauma and water-contamination [5]. Because of this, Creighton et al (1995) first presented a new technique of the single buried KW in digital fusion [5]. In more recent times, various IMFDs have been manufactured to give the surgeon options of fixation other than the aging gold standard KW. Canales et al (2014) in a recent paper noted 68 IMFDs on the market as of February 1, 2014 [6]. Normal incidence of surgical site infection after foot and ankle surgery has been reported between 1% and 5.3% [13, 14]. Creighton et al (1955) reported an infection rate of 3.5% with his buried KW technique while more recent fusion products have reported similar results ranging from 0%-5% [2,5,7,10]. Our results were similar with a 0% superficial or deep infection rate for the 35 toes at average patient follow-up of 110 days.  No patient at any point or length of follow-up presented for care of digital infection.

One such product for IM digital fusion is the Arrow-LokTM Hybrid implant (Arrowhead Medical Device Technologies, LLC., Collierville, TN) and is the specific implant used by the senior author and reviewed in this article. The implant is made of one solid piece of ASTM F-138 stainless steel, has a core diameter of 1.5mm (0.059”) with a proximal 3-dimensional (3-D) barbed arrow-shaped head 3.0mm by 3.5mm or 2.5mm and distal 3-D arrow-shaped head 3.0mm by 3.5mm. It comes in variable lengths ranging between 13mm and 50mm and in 0° and 10° plantar bend angles [15-17] (Figure 3). There is no special handling or pre-operative storage restriction placing a handling time limitation on implementation [17]. Its use in various clinical situations (PIPJ and DIPJ arthrodesis) as well as surgical tips and tricks have been published on, but to the authors best knowledge no literature exists on loss of correction and infection rates [15,18].

fig3

Figure 3 Intramedullary fusion device comes in straight (top) or 10° angulation (bottom). Key regions include (A)overall length, 13-50-mm; (B) distal tip diameter, 3.5-mm; (C) proximal tip diameter, 2.5-mm or 3.5mm; (D) length of proximal angle segment, variable 6-9-mm; (E) length of proximal angle segment, variable 10-26-mm.

 

The theory of construct of the ArrowLokTM is similar to that of an intramedullary rod (IMR) in fracture care (Figure 4). One of the biggest benefits of the ArrowLokTM device is due to the various available lengths ranging from 13mm to 50mm, the largest identifiable span on the market. Both transfer loads across a break in long bones, whether it be a fusion (ArrowLokTM) or fracture (IMR) site [19]. This IM position is closer to the anatomic axis of the bone and aids to resist bending while the circular round construct resists loads equally in all planes. Mechanical load testing at a quarter of a million cycles at up to 89N showed no signs of wear or fatigue of the ArrowLokTM  or bone [16]. Furthermore, in instances where both PIPJ and DIPJ fusion is needed, one longer device can be used versus two separate devices to be squeezed into a tight space [15]. This results in a location of potential stress riser in the middle phalanx between the distal and proximal ends of the two implants as described in the above situation. This is important when a common results regarding digital fusion (either implanted devices and percutaneous k-wires), the bulk of the non-osseous fusions are made up of fibrous unions which rarely impact the outcome of the surgery and are still considered a surgical success [7,8]. When osseous fusion is not achieved and weaker fibrous tissue fills the fusion interface, much of the strength of the fusion lies in the inherent strength of the implant device.

fig4a fig4ab fig4c

Figure 4 Like an IM rod (left), the ArrowLokTM device (right) garners its strength through its length spanning the osteotomy site to transfer loads and end arrow tips acting as a locking screw, preventing rotation, shortening and gapping, all reasons for failure of fixation.

 

figure-5

Figure 5 DIPJ arthrodesis with the ArrowLokTM device.

The 3-D arrow-ends of the ArrowLokTM act similar to proximal and distal locking screws in IMRs. This secures the device and prevents rotation, compression, shortening, or gapping, resulting in loss of fixation. Compared to a standard 1.6mm  (0.0062”) EMKW, the ArrowLokTM has comparable resistance to bending, increased resistance to pull-out (21x more resistant), and increased resistance to rotational forces (12x more resistant) [16]. These problems are inherent to EMKW use due to the design lacking IM compressive purchase and inability to prevent rotation, leading to potential non-solid fusion and mal- or non-union.

IMRs bending rigidity is based off of diameter and in solid, circular nails, is proportional to nail diameter to the third power [20]. Diameter also affects nail fit with a well fitting nail, reducing movement between the nail and bone, friction between the two maintaining reduction [20]. Reaming with the initial KW and broach help increase this contact relationship. With a 1.5mm core diameter, the ArrowLokTM is a tight fit within the phalangeal canal and increases bending rigidity and construct strength. The long, solid, one-piece design differs from others on the market in not having regions of thinner diameter metal and having two pieces that snap together at the junction of the fusion site – both which lead to sites of potential breakdown [9]. One study demonstrated a 20.7% rate in fracture at internal fixation site using Smart Toe® (Stryker Osteosythesis, Mahwah, NJ) versus 7.1% in 0.062-inch buried IMKW use [9].

Conclusion

The recent literature has demonstrated that utilization of these newer devices like the ArrowLokTM for correction of the hammertoe deformity provide a safe method with low complication rates similar to other products on the market.8 Furthermore, with the decrease and almost elimination of infection rates, despite the higher cost of the implant compared to a KW, the potential for infection complications and the associated cost is avoided. In our retrospective case review, ArrowLokTM showed a lack of hardware failure, zero infection rate, and high patient satisfaction. Due to its available lengths, IMR type construct, and ability to cross two fusion sites at once, this device offers another option for the surgeon in digital fusion.

Conflict of Interest

Dr. Jason R. Miller is a consultant for Arrowhead Medical. Arrowhead Medical Device Technologies had no knowledge or influence in study design, protocol, or data collection related to this report.

References

  1. Zelen CM, Young NJ. Digital arthrodesis. Clin Podiatr Med Surg. 2013;30(3):271-282. doi:10.1016/j.cpm.2013.04.006.
  2. Angirasa AK, Barrett MJ, Silvester D. SmartToe® implant compared with kirschner wire fixation for hammer digit corrective surgery: a review of 28 patients. J Foot Ankle Surg. 2012;51(6):711-713. doi:10.1053/j.jfas.2012.06.013.
  3. Lamm BM, Ribeiro CE, Vlahovic TC, Bauer GR, Hillstrom HJ. Peg-in-hole, end-to-end, and v arthrodesis. A comparison of digital stabilization in fresh cadaveric specimens. J Am Podiatr Med Assoc. 2001;91(2):63-67.
  4. Miller JM, Blacklidge DK, Ferdowsian V, Collman DR. Chevron arthrodesis of the interphalangeal joint for hammertoe correction. J Foot Ankle Surg. 2010;49(2):194-196. doi:10.1053/j.jfas.2009.09.002.
  5. Creighton RE, Blustein SM. Buried kirschner wire fixation in digital fusion. J Foot Ankle Surg. 1995;34(6):567-570; discussion 595. doi:10.1016/S1067-2516(09)80080-X.
  6. Canales MB, Razzante MC, Ehredt DJ, Clougherty CO. A simple method of intramedullary fixation for proximal interphalangeal arthrodesis. J Foot Ankle Surg. 2014;53(6):1-8. doi:10.1053/j.jfas.2014.03.017.
  7. Basile A, Albo F, Via AG. Intramedullary fixation system for the treatment of hammertoe deformity. J Foot Ankle Surg. 2015:1-7. doi:10.1053/j.jfas.2015.04.004.
  8. Catena F, Doty JF, Jastifer J, Coughlin MJ, Stevens F. Prospective study of hammertoe correction with an intramedullary implant. Foot Ankle Int. 2014;35(4):319-325. doi:10.1177/1071100713519780.
  9. Scholl A, McCarty J, Scholl D, Mar A. Smart toe® implant versus buried kirschner wire for proximal interphalangeal joint arthrodesis: A comparative study. J Foot Ankle Surg. 2013;52(5):580-583. doi:10.1053/j.jfas.2013.02.007.
  10. Scott RT, Hyer F. The protoe intramedullary hammertoe device: an alternative to kirschner wires. Foot Ankle Spec. 2013;6 (3)(June):2013-2015. doi:10.1177/1938640013487891.
  11. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):247-278. doi:10.1016/S0196-6553(99)70088-X.
  12. Kramer WC, Parman M, Marks RM. Hammertoe correction with k-wire fixation. Foot Ankle Int. 2015;36(5):494-502. doi:10.1177/1071100714568013.
  13. Feilmeier M, Dayton P, Sedberry S, Reimer R a. Incidence of surgical site infection in the foot and ankle with early exposure and showering of surgical sites: a prospective observation. J Foot Ankle Surg. 2014;53(2):173-175. doi:10.1053/j.jfas.2013.12.021.
  14. Saxena A, Fournier M, Cooper J, Spurgeon L. Rate of surgical site infection following the implementation of an antibiotic prophylaxis protocol for foot and ankle surgery. J Am Soc Podiatr Surg. 2014;(2):1-6.
  15. Brown BC, Cohen RK, Miller JR, Roman SR. Correcting hammertoe deformities utilizing an intramedullary device: case reports. Pod Inst.:51-60. http://www.podiatryinstitute.com/pdfs/Update_2013/2013-11.pdf. Accessed July 7, 2015.
  16. Arrowhead medical device technologies, LLC. 2011. http://arrowheaddevices.com/. Accessed July 7, 2015.
  17. Moon JL, Kihm CA, Perez DA, Dowling LB, Alder DC. Digital arthrodesis: current fixation techniques. Clin Podiatr Med Surg. 2011;28(4):769-783. doi:10.1016/j.cpm.2011.07.003.
  18. Roman SR. Surgical tips and tricks when correcting hammertoe deformities utilizing an intramedullary device for proximal interphalangeal fusion. Pod Inst.:59-62. http://www.podiatryinstitute.com/pdfs/Update_2012/2012_13.pdf. Accessed July 11, 2015.
  19. Eveleigh RJ. A review of biomechanical studies of intramedullary nails. Med Eng Phys. 1995;17(5):323-331. doi:10.1016/1350-4533(95)97311-C.
  20. Bong MR, Kummer FJ, Koval KJ, Egol K a. Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg. 2007;15(2):97-106.

Post-surgical plantar fasciitis

by Priya P. Sundararajan , DPM¹pdflrg

The Foot and Ankle Online Journal 7 (2): 4

Current evidence suggest that plantar fasciitis is multi-factorial in etiology. The following report introduces an extended post-surgical nonweightbearing period (6-10 weeks) as a previously unknown cause of plantar fasciitis. Through a univariate statistical analysis, the present study compares the presence of heel pain in twenty patients who remained nonweightbearing for 2-6 weeks (group 1) and twenty patients who remained nonweightbearing for 6-10 weeks in the post-surgical period (group 2). Results indicate a statistically significant correlation (p<0.05) between patients who endured an extended postoperative nonweightbearing period (group 2) and the presence of plantar fascial symptoms in the immediate weightbearing period. Findings of the present study suggest that a stretching regimen should be initiated prior to ambulation for patients remaining nonweightbearing greater than six weeks post-surgery.

Key Words: Plantar fasciitis, postoperative, nonweightbearing, heel pain, surgery, fascia

ISSN 1941-6806
doi: 10.3827/faoj.2014.0702.0004


Address correspondence to: Priya Sundarararjan DPM,
Wilmington Veterans Affairs Hospital, 1601 Kirkwood Highway, Wilmington, DE 19805

¹ Director of Podiatric Surgical Services, Wilmington Veterans Hospital 302-994-2511 Email: Priya.Sundararajan@va.gov


Plantar fasciitis is one of the most common pedal pathologies requisitioning medical evaluation and treatment, which translates to over one million outpatient visits annually in the United States [1]. Though the pain associated with plantar fasciitis can be debilitating, the syndrome is characterized as self-limiting since approximately 90% of symptomatic patients find relief through conservative measures [2,3]. Plantar fasciitis is the result of multi-factorial etiologies from increased body mass index to ankle equinus [1,4]. The following retrospective analysis introduces the extended post-surgical nonweightbearing period as a previously unknown cause of plantar fasciitis.

Methods

A retrospective review of forty patients who underwent surgery between August 2010 and August 2011 was conducted. These patients remained nonweightbearing between 2 and 10 weeks in the postoperative period. Twenty patients who were completely offloaded between 2 and 6 weeks post surgery were consecutively enrolled in the study as group 1. Similarly, twenty patients who remained completely nonweightbearing between 6 and 10 weeks after surgery were consecutively enlisted as group 2. The six-week mark was considered the divide as most reconstructive surgeries involve offloading for more than 6 weeks. Additionally, all patients remained nonweightbearing between 2 and 10 weeks; thus 6 weeks is the mean week. Exclusion criteria included any prior complaint or treatment of plantar heel pain or any surgery involving the plantar fascia. Patients who bore weight in the heel or forefoot without a two-week nonweightbearing period were also excluded from the study.

All patients were questioned as to the areas of discomfort in the beginning two weeks of the post-surgical weightbearing (WB) period. Specifically, each patient was questioned as to the presence or absence of heel pain. The heel was anatomically defined as the area underlying the calcaneal tuberosity. The presence of postoperative heel pain during the initial weightbearing period was recorded and statistically evaluated with a univariate analysis. If the patient related to having heel pain when first bearing weight, they were instructed to perform at least 15 minutes of calf stretching exercises daily. Patients were monitored until complete resolution of symptoms.

Results

Twenty patients in each group yielded usable results. A description of groups 1 and 2 are depicted in Tables 1 and 2, respectively. A statistically significant difference (p=0.0002) in the presence of heel pain in the early weightbearing period was found between patients who remained nonweightbearing between 2 and 6 weeks (group 1) and those who remained nonweightbearing between 6 and 10 weeks (group 2). Noting that the presence and resolution of symptoms are “yes” and “no” questions, the mean was calculated by assigning “yes” to 1 and “no” to 0. In group 1, 15% of patients reported heel pain during the first two weeks of bearing weight on the operated limb (Table 1). Of these patients, 100% reported total resolution of symptoms within the first six weeks of the weightbearing period with conservative calf stretching exercises. In group 2, 70% of patients reported heel pain during the first two weeks of bearing weight on the operated limb (Table 2). All patients who reported heel pain in both groups related complete relief of symptoms to the heel of the operated extremity within six weeks using conservative modalities, primarily through regimented stretching exercises. However, one patient in group 2 (patient 15) who reported significant relief without total resolution of symptoms was additionally fitted with custom-molded orthotics. With a stretching exercise protocol and orthoses, the patient found complete resolution within 6 weeks of bearing weight.

Discussion

Plantar fasciitis is a complex pathology involving the ligament-bone interface at the inferior aspect of the calcaneal tuberosity [3]. As a primary supporter of the plantar arch, the plantar fascia minimizes transverse plane motion between the calcaneus and metatarsals [3]. Vertical forces from the body travel down the body and exert pressure flattening the medial longitudinal arch [5]. Subjected to significant traction as weight is transferred from the rearfoot to the forefoot, the plantar fascia accommodates the transfer with minimal disruption to the plantar arch [6]. Biomechanical studies simulating total fascial release demonstrate extensive arch deformation in stance and over 200% increase in stresses to the long plantar ligament [7]. Rapid fascial elongation occurs before midstance, hence patients with plantar fasciitis present with sharp pains between heel strike and midstance [6]. Furthermore, research has shown that with 90N of force, the plantar fascia will stretch 4% with the failure point being the clamps [8]. Such research confirms the integrity of the plantar fascia and indicates the majority of the pathology occurs at the fascial-calcaneal interface.

Factors

As demonstrated in the present study, post-static dyskinesia is a hallmark of plantar fasciitis [3]. Frequently, patients give a history of sharp pain with insidious onset when first bearing weight after recumbent periods. Typically patients complain of maximal pain with initial ambulation in the morning. Plantar fasciitis is caused by bearing weight after a state of relative inactivity [9]. In the static nonweightbearing state, the plantar fascia is void of tension and thus rests in a contracted state [9]. In the immediate weightbearing period following recumbency, the plantar fascia undergoes a rapid elongation up to 4%, thus the patient experiences sharp, stabbing pains with initial weightbearing [6,8]. When extrapolating the recumbent state from a few hours to several weeks, the fascia is in a state completely void of weightbearing tension. Consequently, patients applying pressure to the heel of a limb which has not carried weight for a significant period of time will likely exhibit symptoms of plantar fasciitis as demonstrated by the current study.

fasciitis1

Table 1 Heel pain in patients remaining nonweightbearing between 2 and 6 weeks (Group 1).

Previous research has demonstrated an increased incidence of plantar fasciitis in individuals experiencing weight gain in the cases of pregnancy or obesity [10]. The mechanical overload causes excessive strain to the arch supporting capacity of the plantar fascia resulting in microtears in the plantar fascia [3]. Histopathological analysis of fascial specimens in chronically symptomatic patients reveal fibroblastic proliferation and granulomatous tissue signifying the cyclic degeneration and limited inflammatory response sustained at the fascial origin [11]. MRI and ultrasound reviews indicate that the dorsal-plantar thickness of plantar fascia in symptomatic patients can increase to 10 mm in thickness, whereas normal plantar fascia is approximately 3 mm [12,13,14]. Though patients in the present study did not exhibit chronicity in their fascial symptoms, the weight gain generally associated with the post-surgical nonweightbearing period may have exacerbated plantar fascial symptoms demonstrated in the early ambulatory stage.

In addition to an elevated body mass index, studies have reported patients with limited ankle flexion to have an increased incidence of plantar fasciitis [10]. Patients with ankle equinus are unable to fully utilize the entire length of the plantar fascia since the heel is bearing less than its proportional weight [10]. Similarly, in the nonweightbearing state the ankle usually rests in some degree of plantarflexion, thus allowing the plantar fascia to contract [9]. When patients begin ambulation after an extended nonweightbearing period, they may experience an incapacitating plantar fascial pain as demonstrated by the current study. All patients exhibited acute manifestations of fasciitis; hence, time to resolution of symptoms was abbreviated in the present study compared to clinical patients demonstrating chronic symptoms. With persistence of plantar fasciitis, pain becomes recalcitrant throughout the day and night [15]. Research correlates the presence of rest pain and night pain with a high failure rate of conservative treatment and serves as an indication for surgical intervention [15].

fasciitis2

Table 2 Heel pain in patients remaining nonweightbearing between 6 and 10 weeks (Group 2).

Treatment

Preliminary treatment protocols for acute plantar fasciitis involve regimented stretching exercises. Plantar fasciitis has earned the reputation of being a self-limiting condition since most patients achieve resolution of symptoms with conservative treatment alone as supported by the present study [2,16]. Stretching protocols often focus on either the posterior compartment of the leg or the plantar fascia itself. Prospective studies demonstrate that regular stretching of either focal point decreases overall pain and pain experienced with initial ambulation [17]. Fascial stretching exercises involve dorsiflexion of the hallux and lesser digits which passively tensions the plantar fascia [3]. Calf stretching exercises work by actively tensing the gastrosoleal complex as well as the plantar fascia [4]. Over 80% of patients with plantar fasciitis demonstrate a concomitant equinus; consequently, equinus is characterized as an etiologic factor of plantar fasciitis [4]. Research has shown that calf stretching exercises result in increased ankle dorsiflexion which directly increases fascial stretch [18,19]. The effectiveness of calf stretching exercises alone is evident in the present study. Furthermore, one case in the current study supported the effectiveness of combining calf stretching exercises with custom molded arch supports as demonstrated by previous research [20].

Conclusion

To the author’s knowledge, the following statistical analysis is the first to introduce an extended post-surgical nonweightbearing period (6-10 weeks) as an etiology of plantar fasciitis. The data presented suggests a statistically significant correlation between the length of postoperative nonweightbearing period and the presence of plantar fascial symptoms in the early ambulatory stage. The lack of fascial tension in the recumbent state, post-surgical weight gain, and ankle plantarflexion may be factors which intensify plantar fasciitis. These compounding factors deserve further research to clarify their significance in post-surgical plantar fasciitis. The clinical implication of the present research suggests that practitioners should implement stretching protocols prior to initiating ambulation. Accordingly, surgeons may facilitate a smoother transition to return to activity by preventatively countering plantar fascial symptoms. The current study is limited in its capacity to determine the full nature of post-surgical plantar fasciitis by its inability to accurately access patient compliance to the nonweightbearing regimen and patient adherence to the prescribed stretching program. By correlating post-surgical plantar fasciitis in terms of ranges, the current study obviates the need to determine exact patient compliance to the nonweightbearing timeline. Moreover, the minute p-value (p=0.0002) indicates a strong correlation between a nonweightbearing postoperative period greater than six weeks and plantar fascial symptoms. In conclusion, the current study presents a new etiology and clinical scenario associated with plantar fasciitis which surgeons and practitioners may preventatively treat by implementing stretching protocols prior to ambulation for patients with a lengthened post-surgical nonweightbearing period.

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