Partial Plantar Fasciotomy Using Endoscope with Inner Two-Channel Portals Produced Better Functional Outcomes Than Mini-Open Procedures for The Treatment of Refractory Plantar Fasciitis

Objective: To evaluate the clinical efficacy of partial fasciotomy using two-channel arthroscope in the treatment of refractory plantar fasciitis, and to compare it with the clinical effects of partial fasciotomy using minimally invasive open. Methods: Sixty-two patients with refractory fasciitis admitted from January 2015 to July 2017 were randomly assigned to the arthroscopic group and the open surgery group. Arthroscopic partial section was performed using endoscope with inner two-channel portals. The open surgery group underwent partial sacral fascia resection with minimally invasive medial incision. Then compare the pain visual analogue scale (VAS), the American foot and ankle surgery association score (AOFAS), the calcaneodynia score (CS), and the medical outcomes short form 36-item (SF-36) health survey between the two groups. Results: All patients were followed up for at least 24 months, and there was no difference in follow-up between two groups. At the last follow-up, the patient's plantar pain symptoms completely disappeared. There was no recurrence of the bone spurs, and the ankle and foot movements were normal. There was no statistically significant difference in VAS, AOFAS, and CS scores between the two groups. The SF-36 score of the arthroscopy group is significantly higher than the open surgery group. Conclusions: Arthroscopic partial fascia resection with medial access provides better clinical outcomes than the open minimally-invasive surgery. Arthroscopic partial fasciotomy with the medial access provides a new option better than the open minimally-invasive surgery for postoperative daily life.


Background
Tendon fasciitis is one of the main causes of plantar pain. The disease is more common in middle-aged and elderly people. It is a chronical disease and the patients usually has no obvious history of trauma. The incidence rate accounts for about 15% of all foot diseases. [1,2] Although it is a degenerative disease, its specific pathogenesis is still unclear.
Diagnosis relies mainly on clinical examination and developmental processes of the disease. The main discomfort of the patient is the pain in the heel, especially in the first step in the morning and the first step of weight-bearing walking after the break. [3] Although the pain symptoms are significant, affecting the patient's normal walking and quality of life, the pain symptoms can disappear after months of conservative treatment. [4][5][6]If the therapeutic effect is not significant after 6 months of conservative treatment, the disease is recognized as refractory fasciitis. Then the surgery is generally required. [7,8] Surgical treatment mainly includes traditional open large-incision surgery, minimallyinvasive surgery with small incision, percutaneous minimally-invasive surgery and arthroscopic surgery, the surgical treatment effect is not as what we expect. [9][10][11] Arthroscopic technique, as a relatively new minimally-invasive technique developed in recent years, has also been gradually applied in the treatment of fasciitis. [12][13][14] However, the current treatment effect of arthroscopic surgery, especially compared with open minimally-invasive surgery, seems to be rarely reported in the literature. The purpose of this study was to investigate the clinical efficacy of arthroscopic treatment of refractory plantar fasciitis with a minimally-invasive small incision.

Methods
Case inclusion criteria: (1) Patients with confirmed fasciitis have a course of more than 12 months; (2) Normative conservative treatment over 6 months and above, but the efficiency is not satisfactory; (3) At least 2 mechanical strategies or a drug is used in conservative treatment; (4) Preoperative MRI scan of the heel is performed to confirm fascial edema and thickening; (5) Preoperative color ultrasonic diagnosis of legs is carried out to confirm no vascular diseases; (6) The onset of disease occurs unilaterally, and the patients received the first surgical treatment of fasciitis; (7) The patients have complete surgical and follow-up data, and the follow-up time is not less than 24 months. Case exclusion criteria: (1) The disease co-occurs with other diseases of the foot; (2) Previous primary or secondary factors lead to fascia defect; (3) Conservative treatment for only rehabilitation exercise is required; (4) Case data or follow-up data are not complete; Arthroscopic surgery group: in the level of patellofemoral calcaneus (the inner side of the tendon was red and white), gave a proximal 0.5 cm incision. The vascular straight forceps were inserted, and the artificial cavity was bluntly separated to the tendon. At the distal 2 cm level of the above incision, a distal incision of about 0.5 cm in length was performed at the red-white meat place, and the vascular straight forceps were used to bluntly separate to the temporal fascia. Inserted a 4.0 mm 30° arthroscope into the proximal incision to explore the condition around the fascia. Inserted the planer head into the distal incision, cleaned the field of view, preserved the fat tissue of the foot as much as possible, and only removed some tissue blocking the operation. The lens and planer could be exchanged for better viewing and cleaning of the tissue surrounding the fascia. After cutting 1/2 of the inner side in the patellofemoral calcaneus with a planer, achieved the above and below fascia thoroughly clean and loosen. If the calcaneus spur above the fascia is existed, the nucleus pliers or electric grinder is used for cleaning. Exchanged lenses and planers to better cleanse and loosen the fascia tissue. If necessary, the superficial fasciae of abductor muscles, short and small toes could be released. Finally, the plasma cutter head was used to stop bleeding completely. Loosed the tourniquet, completely stopped the bleeding under the microscope, and then closed the wound. (Figure 1) On the second day after surgery, the patient walked normally and exercised.
Open minimally invasive group: [16] In the inner of the tendon (about the center of fascia, where the flesh is red and white), a longitudinal incision of about 4.0 cm is cut. This incision can fully retain the entire plantar structure without damaging the load-bearing parts of the heel. After cleaning the inflammatory tissue around the fascial rim, about 1 cm tissue was removed from the medial part of the fascia and the lateral part was released. If a calcaneus spur existed, remove it completely. The postoperative patient was maintained in a non-weighted state for 2 weeks using a controlled ankle motion walker (CAM) for 2 weeks, and the patient was allowed to bear weight gradually in the normal shoes for the next 2 weeks.

Outcome Measures
All measurements were performed by an experienced surgical doctor who had no knowledge of the procedure. The VAS, AOFAS, CS, and SF-36 scores of patients were mainly observed.

Statistical Analysis
All calculations were made using SPSS version 17.0 software (SPSS, Inc., Chicago, IL.).
Quantitative variables were expressed as means and standard deviations. The pre-and post-operative scores of VAS/AOFAS/CS and SF-36 were compared using the Student t test.
Significance level was set at 5 percent and p<0.05 was considered statistically significant.

Results
In both groups, 62 cases were successful, and the procedure was smooth. There were no In order to achieve the desired therapeutic effect, when the inner two-channel arthroscopic technique was adopted to treat the recalcitrant plantar fasciitis, the following points need to be paid attention to: (1) the surgical approach is recommended in the lateral medial of the foot, which is beneficial to arthroscopic instruments, operation, and identification of tendon fasciae after the arthroscopic head is inserted; (2) The distal access of the arthroscope is recommended to be 2 cm away from the proximal access.