Is Gastrocnemius Recession A Procedure Of Choice For Plantar Fasciitis?

A recent systematic review published in Foot and Ankle International supports gastrocnemius recession as an effective option for managing plantar fasciitis, especially when patients with gastrocnemius contracture do not respond to conservative treatment. The authors included six studies, for a total of 118 patients, which revealed significant improvement after gastrocnemius recession in the American Orthopaedic Foot and Ankle Society, visual analog scale, 36- Item Short Form Health Survey, Foot Forum Index, and Foot and Ankle Ability Measure scores. The review also found improvement in ankle dorsiflexion range of motion and plantarflexion power. Persistent postoperative pain was the most common complication reported, and there was an overall pooled complication rate of 8.5 percent. Additionally, the reviewers found that the studies’ data suggested gastrocnemius recession resulted in greater postoperative improvement than plantar fasciotomy and stretching exercises.

Priya Parthasarathy, DPM, DABPM, FASPS says gastroc recession plays a very slim role in her practice due rarely needing to operate on patients with chronic plantar fasciitis, especially due to new regenerative therapies available. Patrick DeHeer, DPM, FACFAS, FASPS shares that the Baumann gastroc recession is his procedure of choice for chronic refractory plantar fasciitis. He says that he strongly feels surgeons should steer away from plantar fascial releases.

“The plantar fascia is such an important structure for foot function; a deficit (like cutting it via surgery) results in a pathological situation. There is a price to pay for cutting the plantar fascia. Also, this shows the direct relationship of equinus to plantar fasciitis. The literature is overwhelming, yet many ignore the importance of equinus treatment as part of the overall treatment of plantar fasciitis.”

Dr. Parthasarathy agrees that the gastroc recession plays an important role in managing plantar fasciitis, especially in the context of contracture.

“Research is needed in techniques to evaluate gastrocnemius contracture to identify the appropriate patient population,” she adds. “As the authors pointed out, it was not possible to perform a meta-analysis comparing different treatment options such as gastrocnemius recession alone, recession with concomitant procedures, and plantar fasciotomy. Also, various techniques and levels of gastrocnemius recession were utilized which makes it difficult to determine what technique is superior for best outcomes and lower complications.”

In his practice in Indianapolis, Dr. DeHeer finds this approach works about 85 percent of the time, so only a small group of patients will still have pain and may require another form of treatment. He adds that, in his experience, the vast majority of patients improve with conservative treatment and in the small majority of those that need more aggressive treatment, a gastroc recession will resolve the issue for most of them.

Dr. Parthasarathy, in practice in Silver Spring, MD, agrees, saying that although surgical intervention for chronic plantar fasciitis is no longer a common treatment modality in her practice, gastrocnemius recession appears to be a viable option with a low complication rate.

“It addresses the contractures proximally where a localized plantar fasciotomy would not,” she says.

Dr. DeHeer concludes by reminding readers that the evidence-based medicine on this topic is robust and clear on the value of gastrocnemius recession for refractory plantar fasciitis, and strongly agrees with the findings of this study that results are superior to plantar fasciotomy.

Does Diabetes Impact Opioid Use After Ankle Fracture Repair?

By Jennifer Spector, DPM, FACFAS, Managing Editor

Patients with diabetes undergoing surgical repair of ankle fracture were more likely to require prolonged postoperative opioid use, according to a recent study in Foot and Ankle International. Due to the complexity of outcomes in patients with diabetes who suffer ankle fractures, including prolonged healing, hardware issues, infection and pain, this study set out to evaluate duration of opioid utilization in this at-risk population compared to a cohort without diabetes.

This retrospective cohort study included 640 patients with ankle fractures, of whom, 73 had diabetes. Researchers extracted all dates, including first and last prescriptions, of opioid use for each patient. The descriptive analysis and logistic regression models used by the team revealed that patients with diabetes were less likely to stop using opioids within 90 days or within 180 days after repair, compared to patients without diabetes. They also identified female sex, neuropathy, and pre-fracture opioid use as potential associated factors with prolonged opioid in these cases.

Daniel C. Jupiter, PhD, a co-author on the study, hopes those reading this research will monitor their patients with diabetes carefully when undergoing ankle fracture repair.

“They may already have been on opioids before arriving at your door, but, regardless are likely to continue after surgery, for a prolonged period of time,” he says.

The number of patients that were already on opioids before surgery was actually a surprising notation made during the course of the study, according to Dr. Jupiter, an Associate Professor in the Department of Preventive Medicine and Population Health and Associate Dean for Academic Affairs, ad interim in the Graduate School of Biomedical Sciences of The University of Texas Medical Branch.

“This is our first look at this type of data,” he explains. “Understanding risk factors for continued use, understanding in-depth prescription patterns and dosages, etc., would help in determining whether patients with diabetes are at excess risk of opioid misuse.”

Peripheral Arterial Disease Measurements Predictive Of Cardiovascular Mortality

By Jennifer Spector, DPM, FACFAS, Managing Editor

Findings recently published in PLOS ONE suggest that ankle-brachial index, toe-brachial index and toe pressure should be routine measurements when evaluating overall cardiovascular mortality risk, regardless of predominant vessel disease location or clinical presentation. Researchers looked at 729 patients with lower extremity arterial disease (Rutherford classification 2-6) who underwent peripheral arterial testing. Overall, 28.8 percent of those studied died of cardiovascular causes during the follow-up period. Cox regression analyses found that no matter where the primary peripheral arterial disease location was, toe-brachial index and toe pressure had strong associations with increased cardiovascular mortality. The authors cite previous studies that already identified ankle-brachial index (elevated or decreased) as having a relationship with poor cardiovascular mortality outcomes.

Matthew G. Garoufalis, DPM, FASPS, FACPM, CWS acknowledges that podiatrists are aware of the misleading nature of the ankle-brachial index in terms of peripheral arterial disease. He goes on to say that this study frames it as a guidepost, but that toe-brachial index and toe pressure are more important globally in understanding a patient’s complete cardiovascular status.

“This helps us to plan better and act proactively on their behalf,” he explains. “Predictive mortality is a much need tool in effective patient treatment.”

John N. Evans, DPM, FACFAS, DABFAS, DABPM adds that since all three tests are quick, inexpensive, and non-invasive, measuring all would give the most predictive risk value for the severe complication of cardiovascular mortality.

In regard to non-podiatrists evaluating this study, Dr. Garoufalis points out that he feels the findings support that referral to a specialist such as a podiatrist is vitally important.

“Toe pressure and toe-brachial index are especially useful as they represent values below the ankle where foot pathology occurs,” says Dr. Evans, agreeing with the positive impact podiatrists could impart in these cases.

These findings should speak to current thinking, explains Dr. Garoufalis, Co-Chair of the Alliance of Wound Care Stakeholders. Specifically, in that one does not obtain enough or appropriate information from ankle-brachial indices alone.

“To understand the true nature of the disease, and the patient we are treating, we must get more detailed information. Using toe-brachial index and toe pressure gives us that information, as well as the predictive mortality data, that we did not previously have,” he says.

Dr. Evans, Chief of Podiatry at Beaumont Hospital in Dearborn, MI, stresses that he feels medicine as a whole should incorporate these low-tech peripheral pressure techniques into standard evaluation protocols, due to their merit and reliability, in part evidenced by this study.

“Though further research into substantiating the value of these tests is recommended, I believe present studies show the usefulness of these three simple vascular tests that can be performed with relatively inexpensive technology,” he says.