Applying MIS Techniques To Selected Rearfoot Pathology

Minimal-invasive surgery (MIS) may be a new surgical technique for some concerning such conditions as chronic Achilles insertional or mid-substance pathology, recalcitrant plantar fasciitis, and retrocalcaneal and infracalcaneal exostosis. Patient and procedure selection are vital when considering MIS techniques over traditional open surgery, since MIS may offer certain advantages. MIS potentially offers faster recovery time, leading to earlier return to activity, less postoperative pain, and better cosmesis.¹ However, MIS has a steep learning curve and lack of robust prospective studies. Having such treatment modalities to offer patients can also be a valuable marketing tool. Ultimately, recognizing which pathologies are amenable to MIS approaches and understanding the limitations to these techniques will increase successful outcomes.

One should generally consider conservative management first, often yielding good results utilizing a combination of treatments synergistically to reduce pain. During conservative treatment, one should understand the etiology of the pathology so as to attack the source of the problem. Repetitive strain loading to the hindfoot structures that exceeds what the body can repair is one of the main reasons for chronic musculoskeletal pathology, referred to as overuse syndrome.² Typical conservative management for retrocalcaneal exostosis includes heel lifts/pads, stretching, anti-inflammatories, casting, and physiotherapy.³ Plantar fasciitis conservative treatment may consist of  NSAIDs, steroid injection, stretching, orthosis, shoe gear, and physical therapy.⁴ Lastly, one can conservatively treat mid-substance Achilles tendonitis with stretching, exercise, external support, electrotherapeutic modalities, and physical therapy.⁵ We often utilize eccentric stretching of the Achilles tendon, as equinus appears to play a role in the pathologies discussed. Additional modalities may include platelet rich plasma injections, prolotherapy with sclerosing agents, and extracorporeal shockwave therapy.⁶ In our experience, we have a high degree of success in resolving these pathologies conservatively.

When Does Surgery Become An Option?

Only after conservative methods have failed and when a patient has painful recalcitrant pathology, do we consider surgical intervention. For example, as much as 29 percent of people treated non-operatively will go on to require surgery for Achilles pathology.⁷ There are similar trends for patients suffering from recalcitrant plantar fasciitis and infracalcaneal exostosis. Surgery only becomes a consideration after exhausting conservative methods for three-to-six months without progress. For surgical planning, advanced imaging, magnetic resonance imaging (MRI) or ultrasound are indicated at this point.

Another point of consideration during surgical planning is that the pathologies discussed above are multifactorial and the surgeon should also assess and account for equinus. Hoefnagels and colleagues found that gastrocnemius recession had good clinical outcomes in altering loading of the foot with significant pain reduction in 32 patients that had chronic therapy-resistant plantar fasciitis over a one year follow up.⁸ Similar positive results were found for Achilles pathology.⁹

Where Do MIS Techniques Come Into Play?

Surgeons should be selective in deciding when to utilize MIS or open procedures based on the degree of pathology present, as both techniques may not apply to all conditions. For example, open debridement and peritenolysis for mid-substance Achilles tendinopathy allows for 97 percent of patients to return to their respective sports.¹⁰ Paavola and team reported an 11 percent complication rate following open surgery of the Achilles with 54 percent of complications relating to wound issues.¹¹ Utilizing MIS techniques, on the other hand, may offer comparable results with faster recovery, less pain, and fewer complications compared to traditional open surgery.¹² Vascular insufficiency, poor skin integrity, and severe medical comorbidities are often concerns that one must weigh if considering any type of surgical procedure.¹³ The goal of MIS in these discussed cases is to debride bony exostoses and fibrosis within tendon or fascia by minimizing trauma to the soft tissue envelope. In 18 years of surgical experience post-residency, I have not performed a single open plantar fasciotomy. I have incorporated MIS techniques to address the ligament pathology within the plantar fascia and address the driving force of equinus with a gastrocnemius recession.

In our next blog, we will discuss some cases utilizing the ultrasound aspiration debrider for hindfoot osseous and soft tissue pathologies: insertional and mid-substance Achilles tendinopathy; retrocalcaneal and infracalcaneal exostoses; and plantar fasciitis. This technology utilizes fluoroscopy-guided treatment for osseous conditions and ultrasound-guided visualization for soft tissue pathology. The ultrasound aspirator employs a vibrating horn to fragment tissue causing cavitation leading to emulsification and the debrided tissues are aspirated. The frequency is determined by the pressure and thermal feedback loop around 23kHz.¹⁴ Two prospective studies treating recalcitrant plantar fasciitis utilizing percutaneous ultrasonic fasciotomy with a follow up of 24-months had excellent results. Patel and colleagues found 100 percent pain resolution in 12 patients in a prospective study and Razdan and team found 96 percent pain resolution in 100 patients.^15,16 Two retrospective studies looking at ultrasonic tenotomy of the Achilles tendon for chronic insertional Achilles pathology concluded the procedure was a safe alternative that can be used before proceeding to a more invasive open procedure. Freed and coworkers found an 84 percent Foot Functional Index success rate in 25 patients and Chimenti and colleagues found reduction of baseline pain from 68 to 15 percent at follow-up in 34 patients.^17,18

In our next blog post, we will present some pertinent case examples when ultrasonic aspiration debridement made a difference for rearfoot pathology. Hopefully, a closer look at minimally invasive techniques like this could lead to improved outcomes for patients.

Dr. Husain is the Residency Director of the McLaren Oakland Hospital Podiatric Surgery and Medicine Residency Program in Pontiac, MI. He is a Fellow of the American College of Foot and Ankle Surgeons and a Fellow of the American Society of Podiatric Surgeons. Dr. Husain is also the President-Elect of the Michigan Podiatric Medical Association and Chairman of the Michigan Podiatric Residency Consortium.

Dr. Kipp is a second-year podiatric resident at McLaren Oakland Hospital in Pontiac, MI.

References

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3. Vaishya R, Agarwal AK, Azizi AT, and Vijay V. Haglund's syndrome: a commonly seen mysterious condition. Cureus. 2016;8(10). doi:10.7759/cureus.820.

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6. Gerdesmeyer L, Mittermayr R, Fuerst M, Muderis MA, Thiele R, Saxena A, and Gollwitzer H. Current evidence of extracorporeal shock wave therapy in chronic achilles tendinopathy. Int J Surg. 2015; 24(Pt B):154-9.

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8. Hoefnagels EM, Weerheijm L, Witteveen AG, Louwerens JWK, Keijsers N. The effect of lengthening the gastrocnemius muscle in chronic therapy resistant plantar fasciitis. Foot Ankle Surg. 2021;27(5):543-9.

9. Tallerico VK, Greenhagen RM, Lowery C. Isolated gastrocnemius recession for treatment of insertional achilles tendinopathy: a pilot study. Foot Ankle Spec. 2015;8(4):260-5.

10. Saxena A, Hong BK, and Hofer D. Peritenolysis and debridement for main body (mid-portion) achilles tendinopathy in athletic patients: results of 107 procedures. J Foot Ankle Surg. 2017;56(5):922-8.

11. Paavola M, Orava S, Leppilahti J, Kannus P, and Järvinen M. Chronic achilles tendon overuse injury: complications after surgical treatment. an analysis of 432 consecutive patients. Am J Sports Med. 2000;28(1):77-82.

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14. Cimino WW and Bond LJ. Physics of ultrasonic surgery using tissue fragmentation: part I. Ultrasound Med Biol. 1996;22(1):89-100.

15. Patel MM. A novel treatment for refractory plantar fasciitis. Am J Orthop. 2015;44(3):107-10.

16. Razdan R and Vanderwoude E. Percutaneous ultrasonic fasciotomy: a novel approach to treat chronic plantar fasciitis. J Vasc Interv Radiol. 2015;26(2).

17. Freed L, Ellis MB, Johnson K, and Haddon TB. Fasciotomy and surgical tenotomy for chronic achilles insertional tendinopathy: a retrospective study using ultrasound-guided percutaneous microresection. J Am Podiatr Med Assoc. 2019;109(1):1-8.

18. Chimenti RL, Stover DW, Fick BS, Hall MM. Percutaneous ultrasonic tenotomy reduces insertional achilles tendinopathy pain with high patient satisfaction and a low complication rate. J Ultrasound Med. 2019;38(60):1629-35.