Debating The Merits Of The EPF Procedure

It was with great incredulity that I read the article by Dr. Barrett entitled “A Closer Look At Endoscopic Plantar Fasciotomy” (see the May issue, pg. 38). He writes: “Prior to the development of endoscopic foot surgery, there was a strong desire not only to find a better, less invasive method to treat … plantar fasciitis surgically … Indeed, the standard of care … has changed radically since the … EPF.”
The inference here, of course, is that after EPF, that desire has been fulfilled and it is now the standard of care. The truth is that in the facilities where I perform surgery, virtually every DPM has abandoned EPF. I tried it about a half dozen times and have also abandoned it. It is time-consuming and produced no better results than other approaches. Indeed, I found it far more invasive than the way I was trained and have performed heel surgery for 20 years.
He continues to write: “In 1990, there was an almost universal perception … that the spur was the primary cause of plantar fasciitis and any successful surgery must address that cause.” Assuming that Cleveland is still part of the universe, we were taught as far back as the late ‘70s that the spur is not the cause of heel spur pain, but rather the inflammation surrounding it. That fact is reinforced every time a lateral radiograph is interpreted and a large spur is present with no symptoms.
Most of the remaining article is spent “defusing” all the complications of EPF.
When the EPF was introduced, I was appalled at the fees Dr. Barrett was attempting to (charge) to teach this procedure. I learned it the old-fashioned way. First, I assisted others and then I was monitored by those who were qualified. How is it I have performed hundreds of Austin osteotomies and still have yet to meet Dr. Austin?
– David R. Levin, DPM
Fountain Valley, Calif.

Defending The EPF Procedure
Stephen L. Barrett, DPM, responds: The fact of the matter is that EPF overwhelmingly changed the standard of care of the management of heel pain. I am not saying nor did I say in the article that EPF is the only accepted procedure for the surgical management of recalcitrant plantar fasciitis. We all know that is not the case.
However, since the technique was introduced formally to the profession in 1992, there has been much more attention brought to the condition of heel pain and plantar fasciitis than had been paid to the topic in the prior 20 years. If Dr. Levin finds that difficult to believe, then I would invite him to do a Medline search and see the number of articles published before and after the inception of EPF.
Prior to EPF, some patients were subjected to more than two years of failed conservative care because of old “dogma” in some texts and articles. A conservative care algorithm was developed that has held up well in the medical legal arena. Now the patient does not have to be subjected to such a long period of failed non-surgical treatments and three to six months is adequate depending on the nature and extent of conservative care. EPF created debate, inspired academic investigation and propelled outcome studies.
What I find incredulous is that a physician who states “I learned it the old fashioned way. First, I assisted others and then I was monitored by those who were qualified,” is now an authority on why EPF does not work after having “tried it a half dozen times.” Obviously, this is why we were adamant about bringing adequate training courses for those who wanted to perform, “not try” this technique. Evidently, more than 4,500 surgeons throughout the world were not appalled by paying a fee to come to a course to learn the technique properly.
Any one who knows anything about our training courses knew that there were expenses associated with the training. Fresh frozen cadaveric specimens, complete endoscopic work stations, guest faculty, training manuals and videos, hotel meeting rooms, APMA and AMA CME accredidation fees, travel expenses, and the time and costs in developing the procedure and instrumentation are just some of the hidden costs in putting on a succesful training course. In fact, of all those who have attended our course, 97 percent have rated it as excellent or good.
The statement by Dr. Levin that “It is time consuming ... I found it far more invasive than the way I was trained ... ” indicates to me that perhaps he had not completed the learning curve associated with the technique in only six cases. An EPF never takes us more than eight to ten minutes of tourniquet time, and usually I am done in about four to five minutes.
As far as it being more invasive, Dr. Levin does not tell us in his critique what technique he performs so that is one point I cannot debate. I can say that we have done over 75 cases where the contralateral foot had been operated on with some “other” technique, and there is not one of those cases who did not feel the EPF was less painful, and had a faster return to normal activity.
The fact that virtually every DPM at his facility has abandoned the EPF technique is not indicative of national or international trends. There now has been more than 500,000 EPFs performed and the numbers of EPFs performed in 2001 was greater than those performed in 2000.
In response to his statement that most of the article was spent “defusing” the complications of EPF, I would like to point out that if something is 97 percent efficacious, three out of every 100 are going to have a problem. The whole point is that we now have better technology, so maybe we can make that “three” less.
Every great surgeon I know spends more time worrying about the one or two cases that did not turn out like expected rather than rejoicing about the 1,000 with a great outcome.