Using Medial Band Plantar Fasciotomy for Plantar Hallux Ulcers

Offloading plantar hallux diabetic foot ulcers can prove challenging, but is there a population that may benefit from a medial band plantar fasciotomy? In this column, the authors share relevant literature, along with their experience, regarding this potential intervention.  

A 77-year-old male with diabetic neuropathy and coronary artery disease had a partial hallux amputation performed several years ago. He was ulcer-free up until 6 months prior, when he developed a full-thickness ulceration that has not healed (Figure 1). On physical exam, the first metatarsophalangeal joint has a smooth range of motion that decreases when loading the first ray, confirming the presence of hallux limitus. He has no radiographic evidence of osteoarthritis or osteomyelitis.

At this point, what surgical options do we really have? There is no head of the proximal phalanx to remove. Shortening the toe or performing a Keller arthroplasty¹ would leave so little bone, it would basically be an amputation. What about soft tissue releases? The only attachment to this stump location that can exhibit active motion is the flexor hallucis brevis. It is possible the flexor hallucis longus and extensor hallucis longus could have adhesions to the skin and bone stump to help move the toe, but this is unlikely. Lastly, the plantar fascia distal attachment attaches to both the plantar foot skin and the proximal phalanges.²

So, surgical options to consider would then include release of the flexor hallucis brevis tendon, plantar fasciotomy,³ or amputation. The patient was not interested in a toe amputation, and a flexor hallucis brevis tendon release could be considered experimental, so this leaves us with the plantar fasciotomy as the primary reasonable surgical option at this time.

Overview of Selective Plantar Fascia Release for DFUs

Kim and colleagues first described the selective plantar fascia release in 2012.³ The plantar fascia divides into 5 slips at the level of the tarsometatarsal joint (TMTJ), inserting into the plantar plate of its corresponding ray. The authors thought that selective release of the plantar fascia could offload ulcers at the corresponding metatarsal head or toe. Their description of the technique involves a plantar transverse incision distal to the TMTJ along the same slip of plantar fascia where the ulcer is located, and the authors found mixed levels of success with the procedure. However, patients who healed remained healed at 2-year follow-up. Although the technique uses a 1cm plantar skin incision, complications were minimal; the authors saw no wound infections or dehiscence.

The lead author adopted this idea for treatment of specifically plantar hallux ulcers with a modified technique using an 18g needle through a medial approach.⁴ This patient underwent a medial band plantar fasciotomy (MBPF) and the ulcer healed in a month (Figure 2) after the procedure and remains healed at 1-year follow-up.

The plantar fascia distal attachment attaches to both the plantar foot skin and the proximal phalanges via a complex ligamentous network of structures such as the sagittal septae and the mooring ligament. This allows tension along the plantar fascia to act on the proximal phalanges, plantar foot skin, and fat pad to move simultaneously. Releasing of the structure can have a surprisingly powerful effect on the range of motion of the metatarsophalangeal joint in the right patient.

A Closer Look at Medial Band Plantar Fasciotomy

I have performed over 20 medial band plantar fasciotomies (MBPF) over the past 3 years, and have found mixed levels of success. Anecdotally, I’ve found that most of my failures were in patients with plantar hallux ulcers that have flat feet and obesity. For these failures, options to consider include Keller arthroplasty, and hallux interphalangeal joint arthroplasty.^5-6 This is an example of a different patient with a plantar hallux ulcer who failed to heal after MBPF (Figure 3). I removed the head of the proximal phalanx and she went on to heal a month later (Figure 4).

Other concerns of the MBPF include collapse of the longitudinal arch.⁷ Cadaver and computer simulations do not simulate advanced glycation end-products (AGEs) associated with soft tissue stiffness in patients with long-term diabetes. It is possible that the increased stiffness associated with AGEs contribute to maintenance of the arch after transection of the plantar fascia. However, we do know that surgical release of the plantar fascia to treat plantar fasciitis has been successful in treating heel pain with no collapse of the arch.^8–9

Another concern of the MBPF procedure is transfer lesion to the first metatarsal head due to hammertoe deformity in patients with diabetes.¹⁰ Anecdotally, I’ve noticed that patients with plantar hallux ulcers under the interphalangeal joint do not usually have hammertoes associated with the hallux. In my small case series and experience, I found that in fact the most common transfer ulcer was to the second toe. While any transfer ulcer risk needs to be discussed with the patient, a second toe ulcer has less morbidity than a great toe ulcer, and can be easily treated with a flexor tenotomy.¹¹

There is very little published literature about the selective plantar fascia release procedure. More studies will be required to demonstrate the safety and efficacy of this procedure. However, given the low cost and ease of this procedure, the MBPF may be an option to consider for surgical treatment of plantar hallux ulcers earlier in the course of ulcer management to prevent infection and amputation.¹²

In Conclusion

Based on the authors’ experience, the medial band plantar fasciotomy should be used with particular caution in patient populations with morbid obesity and flat feet. However, it has potential to be a surgical treatment option to offload plantar hallux ulcerations in patients with hallux limitus and low levels of activity.

Haywan Chiu, DPM, FACFAS, is a board-certified podiatric specialist for foot surgery and reconstructive rearfoot/ankle surgery at Albuquerque Associated Podiatrists in Albuquerque, NM. He specializes in diabetic limb salvage.

Allyssa Chiu, DPM, MS, is a Clinical Assistant Professor at the University of New Mexico School of Medicine.

References
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2.    Bojsen-Moller F, Flagstad KE. Plantar aponeurosis and internal architecture of the ball of the foot. J Anat. 1976;121(Pt 3):599-611.
3.    Kim JY, Hwang S, Lee Y. Selective plantar fascia release for nonhealing diabetic plantar ulcerations. J Bone Joint Surg Am. 2012;94(14):1297-1302. doi:10.2106/JBJS.K.00198
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8.    De Prado M, Cuervas-Mons M, De Prado V, Golanó P, Vaquero J. Does the minimally invasive complete plantar fasciotomy result in deformity of the plantar arch? A prospective study. Foot Ankle Surg. 2020;26(3):347-353. doi:10.1016/j.fas.2019.04.010
9.    Ward L, Mercer NP, Azam MT, Hoberman A, Hurley ET, Butler JJ, Ubillus H, Cronin J, Kennedy JG. Outcomes of endoscopic treatment for plantar fasciitis: a systematic review. Foot Ankle Spec. 2022 Nov 7:19386400221129167. doi:10.1177/19386400221129167
10.    Bus SA, Maas M, Cavanagh PR, Michels RPJ, Levi M. Plantar fat-pad displacement in neuropathic diabetic patients with toe deformity: a magnetic resonance imaging study. Diabetes Care. 2004;27(10):2376-2381. doi:10.2337/diacare.27.10.2376
11.    Bonanno DR, Gillies EJ. Flexor tenotomy improves healing and prevention of diabetes-related toe ulcers: a systematic review. Int J Low Extrem Wounds. 2020;19(2):112-119. doi:10.1177/1534734619888361
12.    Yammine K, Assi C. Surgical offloading techniques should be used more often and earlier in treating forefoot diabetic ulcers: an evidence-based review. Int J Low Extrem Wounds. 2020;19(2):112-119. doi:10.1177/1534734619888361. PMID: 31744347.