RU2702867C2 - Surgical method of treating proximal plantar fasciosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology, orthopaedics and sports medicine, occupational diseases medicine, and can be used in treating a sustained-conservative therapy of proximal plantar fasciosis. Method involves surgical approach to proximal part of plantar aponeurosis, creation of series of 18–24 holes at depth of 3 mm to 5 mm at distance of 5 mm from each other in the form of mesh and 4–6 incisions along the medial edge of the plantar aponeurosis with the help of bipolar RF -action of TOPAZ needle electrode. Surgical access to the proximal part of the plantar aponeurosis is ensured by a minimum skin incision of about 2.5 cm long. A wound incision is followed by placing a TOPAZ needle electrode, the working portion of which is supplied with 0.9 % physiologic saline solution at rate of 2–3 drops per second. Position 4 is set on the controller of the ARTHROCARE ATLAS apparatus by activating the TOPAZ electrode by pressing for 0.5 seconds. Performing alternate perforations and notches along medial edge of plantar aponeurosis, wound is covered with skin suture and antiseptic dressing.

EFFECT: method provides stable clinical effect ensured by low invasiveness and reduced fascia tension.

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Description

The invention relates to medicine, namely to traumatology, orthopedics, sports medicine, occupational medicine, and can be used in the treatment of proximal plantar fasciosis resistant to conservative therapy.

This disease refers to tendinosis, characterized by chronic pain in the tendons and aponeuroses, and is associated with excessive stress, collagen degeneration, poor vascularization, and the absence of an inflammatory reaction [Tasto, J.P. Radiofrequency-Based Micro-Tenotomy for Treatment of Chronic Tendinosis. 2003], as well as an increase in the number of free afferent nerve endings [Alfredson H, Ohberg L, Forsgren S. Is vasculoneural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and color Doppler, immunohistochemistry and diagnostic injections. Knee Surg Sports Traumatol Arthosc. 2003; 11: 334-338.]. Lesions of connective tissue structures are diagnosed in a significant amount and make up from 30 to 50% of the total number of sports injuries and occupational diseases. The development of such pathological processes in the able-bodied population causes a loss or decrease in working capacity, a deterioration in the quality of life, and in sports, a decrease in results and a loss of ability to continue speaking. About one in 10 people suffered from heel pain throughout their lives [Crawford F, Thomson C: Interventions for treating plantar heel pain. Cochrane Database Syst Rev 3: CD000416, 2003.]. Demographic studies show that more than two million patients undergo treatment for plantar fasciitis every year in the United States [Pfeffer G, Bacchetti P, Deland J, et al: Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int 20 (4): 214-221, 1999.], which is 1% of all visits to orthopedic surgeons [Riddle DL, Schappert SM: Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: A national study of medical doctors. Foot Ankle Int 25 (5): 303-310, 2004].

Various approaches to the treatment of plantar fasciitis are known, including conservative and surgical methods. Conservative ones include: functional rest, immobilization, anti-inflammatory drugs, viscoelastic polymer heel, foot orthoses, Achilles tendon and plantar fascia stretching, physiotherapy, PRP therapy, extracorporeal shock wave therapy (ESWT), X-ray therapy, single injections of corticostero.

If persistent pain syndrome persists for more than a year, the inefficiency of all conservative methods and one ESWT procedure is followed by surgical treatment, including open or endoscopic release of the plantar fascia. However, after such operations a long rehabilitation is required, they are not always successful and complications are possible (superficial wound infection, venous thrombosis, phlebitis, mechanical pain due to overload in the middle and lateral columns of the foot) [Thomas N. Lee, Peter B. Maurus: Open Plantar Fascia Release Endoscopic Plantar Fascia Release Neurologic Complications Open Release Endoscopic Release. Plantar Heel Pain: 699. 2005].

A common drawback of open or endoscopic methods of surgical treatment is the insufficient clinical effect due to the fact that with the lengthening of the aponeurosis, the goal is to reduce its tension, while there is no effect on the pathogenetic mechanisms of the development of tendinosis, i.e. there is no stimulation of collagen repair and vascularization improvement.

The well-known "Method of stimulating the reparative regeneration of tendons and ligaments" (RF Patent No. 2284768, IPC АВВ 17/00, publ. 10.10.2006), in which perifocal cleavage with dispersed Alloplant biomaterial (DBMA) of the injury area at 1-6 points, moreover

the biomaterial is diluted at the rate of 150-300 mg per 10 ml of a solution of a local anesthetic. Regeneration is ensured by exposure to injured tissues of glycosaminoglycans extracted from biomaterial.

The well-known "Method for the treatment of shoulder epicondylitis" [SU copyright certificate No. 806013], including the introduction of a refrigerant into the pathological focus to a depth of 2-3 mm and freezing it for 50-60 s to a temperature of -86 to -90 ° C. The effect of cryotherapy is based on analgesic, anesthetic, hemostatic, antiexudative, reparative-regenerative, catabolic, immunomodulating, desensitizing effects.

However, when using these methods, the risk of complications arising in the process of improperly choosing the site of skin puncture or inaccurate determination of the depth of injection of the needle and the amount of DBMA or coolant is increased. This process requires the presence of specially trained highly qualified personnel.

The well-known "Method of conservative treatment of shoulder epicondylitis" (RF Patent No. 2491964, IPC A61M 1/36, publ. 09/10/2013). According to the presented method, in advance, 1-2 hours before the procedure, the patient is sampled and double centrifuged to achieve a high platelet concentration. In the point of maximum pain, the epicondyle and in closely located tissues are injected with platelet-rich autoplasma, in an amount of 3 to 5 ml. The method provides relief of pain, restoration of the tendon due to stimulation of extracellular matrix synthesis, stimulation of DNA synthesis, cell proliferation, collagen synthesis, stimulates angiogenesis due to platelet growth factor, transforming growth factor, vascular endothelial growth factor contained in autoplasma.

Extracorporeal shock wave therapy is also used to treat proximal plantar fasciosis. Shock waves stimulate the recovery process in tendons and bones by microcracking avascular or minimally vascular tissues, which stimulates revascularization due to the release of local growth factors and the inclusion of stem cells that contribute to more normal tissue healing. The disappearance of cavitation bubbles has a profound effect on the tissue, causing rupture of microcapillaries and the release of chemical mediators that stimulate neoangiogenesis and interrupt the course of the chronic process. The disadvantage of this method is the high cost of equipment, many separate painful procedures (usually 3-6), and a dubious clinical outcome.

A common drawback of all of the above methods of conservative treatment is the insufficient clinical effect due to the fact that the fascia does not decrease in tension, i.e. conditions favorable for healing are not created.

The closest analogue to the claimed invention is a method for the treatment of enthesopathy, including extracorporeal shock wave therapy, and at the same time release of the plantar fascia.

The technical task of the invention is the creation of an effective, safe and affordable method of treatment of proximal plantar fasciosis, devoid of the disadvantages of the above methods.

The technical result of the invention is to increase the effectiveness of treatment by radiofrequency exposure, carried out through the proposed minimally invasive surgical approach, and providing a rapid reduction of pain due to sufficient to relieve tension of the fascia, denervation of pathological structures [Hagiwara S, Iwasaka H, Takeshima N, Noguchi T. Mechanisms of analgesic action of pulsed radiofrequency on adjuvant-induced pain in the rat: roles of descending adrenergic and serotonergic systems. Eur J Pain. Epub ahead of print, June 5, 2008.] and simultaneously obtain the effect of stimulating collagen repair and improving local vascularization [Harwood F, Medlock B, et al. Structural and angiogenic response to bipolar radiofrequency treatment of normal rabbit Achilles tendon: a potential application to the treatment of tendinosis. Transactions of the 49th Annual Meeting of the Orthopedic Research Society. Poster 819. 2003].

The essence of the claimed invention consists in performing minimally invasive surgical access in the area of proximal plantar aponeurosis in adults, performing bipolar RF tenotomy and a series of holes using the TOPAZ needle electrode in the pathologically altered part of the aponeurosis, which leads to lengthening of the plantar aponeurosis, stimulates collagen recovery and improvement vascularization, which breaks the cycle of trauma and provides favorable conditions for the regenerative process.

The technical result of the invention is achieved due to the denervation of afferent nerve fibers, a combination of a decrease in the mechanical tension of the plantar aponeurosis, stimulation of collagen recovery and stimulation of vascularization. An initial rapid and significant reduction in pain is achieved due to the degeneration of afferent nerve fibers, further supported by a decrease in "concentrated tension" of the plantar aponeurosis [Lapidus P.W., Guidotti F.P. / Painful heel: Report of 323 patients with 364 painful heels. Clin Orthop 39: 178-186, 1965]. The lengthening of the aponeurosis is the most important factor not only for reducing pain, but also creates optimal mechanical conditions for the restoration of collagen and stimulation of vascularization arising from the intensive synthesis of the vascular endothelial growth factor after bipolar radiofrequency exposure.

A method for the treatment of proximal plantar fasciosis in adults is as follows. In the preoperative period, the general condition of the patient is assessed, including the history of heel pain treatment, and the nature of his professional activity and hobbies is determined. A comprehensive physical examination of the foot and ankle joint is carried out, the state of the Achilles tendon is assessed, functional radiography, ultrasound and pedobarometric examination are performed. Surgery consists of a series of sequential steps. Under conduction anesthesia (ankle block), the patient is placed on the operating table on his back, the operated leg is located above the other, in the lower third of the lower leg they apply air brakes. Three times the processing of the surgical field is carried out with an antiseptic solution. Minimum surgical access is made to the proximal part of the plantar aponeurosis by performing a skin incision about 2.5 cm long along its medial part (Fig. 1), and the aponeurosis is detected and dissected. The equipment for RF exposure is prepared: the electrode is connected to a drop source of a sterile isotonic NaCl solution, the tube with the solution is washed, removing all air bubbles from it. Set position 4 on the controller of the device ARTHROCARE ATLAS with a feed rate of isotonic solution of 2-3 drops per second (Fig. 2). The electrode (Fig. 4) is placed perpendicular to the surface of the aponeurosis and is activated by light pressing for 0.5 seconds. In the aponeurosis, create a series of 18-24 holes to a depth of 3 mm to 5 mm at a distance of 5 mm from each other in the form of a mesh to create a 3D effect (Fig. 3) In the same way, 4 to 6 incisions are made along the medial edge of the plantar aponeurosis . After this, the surgical wound is abundantly washed with isotonic saline, infiltrated with a local anesthetic, and then sutures and an aseptic dressing are applied.

In the postoperative period recommend: 0-2 day - ice and rest; 7-10 day - passive and active movements, walking in the appropriate unloading boot; in the first two months - the transition to the usual load at work and at home, with a complete ban on sports and hard work; in the third month after the operation - for professional athletes and hard physical workers - the exception is heavy training and stress (unless the surgeon has indicated otherwise).

Clinical examples

Example 1:

Patient P., 55 years old, overweight, works as a foreman at a construction site (walks a lot during the working day), has a household. Diagnosis: Proximal plantar fasciosis on the left. Left-side flat valgus foot, longitudinal flatfoot of I degree. He complained of plantar pain in the left calcaneal region when walking in the morning after rising, after a period of rest during the day and at the end of the day. Sick since June 2016, when, against the background of summer work in the wrong shoes, the above complaints appeared. It was treated conservatively: R-therapy was 10 sessions, with a positive effect - the pain decreased on a visual-analogue scale (VAS) from 8 to 2.5. In August, after harvesting the potatoes, again exacerbating, I took ESWT No. 9, the pain completely stopped. In January 2017, when the aggravation again. He was treated in a clinic (magnet, laser, NSAIDs, compresses with dimexide, blockade with diprospan), acquired serial framed orthopedic insoles at the pharmacy, the effect is incomplete, YOUR from 8 to 2.5. In March 2017, against the background of the beginning of the summer season, a sharp deterioration. He completed ESWT No. 9, the pain completely stopped. At the moment, exacerbation, the intensity of pain according to YOUR - 9

Objectively: walks without additional support, limping on his left leg. Installation of the left foot is hallux valgus, the type of foot is square. The transverse arch is saved, the longitudinal arch is omitted. On palpation, sharp pain is determined along the medial edge of the plantar surface of the calcaneal region in the projection of attachment of the plantar aponeurosis. On the radiograph of the left foot in a lateral projection with a load, a decrease in height and an increase in the angle of the longitudinal arch are noted. There is a small, about 2 mm osteophyte in the area of the calcaneal tuber. Ultrasound of the left foot revealed a thickening of the plantar aponeurosis. With pedography, a decrease in the load time on the calcaneal region, redistribution of the load on the outer edge of the foot and 5 metatarsophalangeal joint is determined.

The patient was offered treatment according to the claimed method. Under conduction anesthesia (ankle block), surgical access was made to the proximal part of the plantar aponeurosis by performing a skin incision about 2.5 cm long along the medial edge, paratenon was opened, and a tendon was isolated. Using the TOPAZ needle electrode, 20 holes were made at a distance of 5 mm from each other in the form of a mesh at different depths. In the same way, 6 incisions were made along the medial edge of the plantar aponeurosis. No complications were noted.

After the procedure, the patient noted moderate soreness at the incision site. On the 7th day, the pain in the aponeurosis significantly decreased. The postoperative period proceeded standardly according to the protocol, for 4 weeks the patient walked in a special unloading boot. After removing the unloading boot, the patient freely stepped on the left heel without pain. After 1 month, he began his work.

Example 2:

Patient M., 53 years old, overweight, works head. the production of cafes (walks a lot during the working day), is engaged in fitness. Diagnosis: Proximal plantar fasciosis on the right. She complained of plantar pain in the right calcaneal region when walking in the morning after rising, after a period of rest during the day and at the end of the day. Sick since February 2017, when, after training in low-quality sports shoes, the above complaints appeared. It was treated conservatively: NSAIDs, ointments, compresses with dimexide, folk remedies, with a weakly positive effect, the pain decreased by YOUR from 7 to 5, the effect was short-lived. In April, a course of 3 ESWT procedures was completed, the effect is slightly positive: the pain has decreased according to YOUR from 7 to 5, the effect is short-lived. From May 15 to May 25, 2017, inpatient treatment (u / c with corticosteroids, iv infusion with dexamethasone, vitamins, diclofenac), without effect. At the time of treatment in 05/28/2017, the intensity of pain according to YOUR 8-9.

Objectively: Walks without additional support, limping on his right leg. Installation of the right foot varus, type of foot - square. The transverse arch is saved. Hallux valgus deformity of the first finger. Varus deviation Ml. The longitudinal arch is saved. On palpation, sharp pain along the medial edge of the plantar surface of the heel region in the projection of attachment of the plantar aponeurosis. On the radiograph of the right foot in a lateral projection with a load of bone-traumatic pathology there. Ultrasound of the right foot revealed a thickening of the plantar aponeurosis. With pedography, a decrease in the load time on the calcaneal region, redistribution of the load on the outer edge of the foot and 5 metatarsophalangeal joint is determined.

The patient was offered treatment according to the claimed method. Under conduction anesthesia (ankle block), surgical access was made to the proximal part of the plantar aponeurosis by performing a skin incision about 2.5 cm long along the medial edge, paratenon was opened, and a tendon was isolated. Using the TOPAZ needle electrode, 18 holes were made at a distance of 5 mm from each other in the form of a mesh at different depths. In the same way, 5 incisions were made along the medial edge of the plantar aponeurosis. No complications were noted. After the procedure, the patient noted moderate soreness at the incision site. On the 7th day, the pain in the aponeurosis significantly decreased. The postoperative period was standard according to the protocol, for 4 weeks the patient walked in a special unloading boot. After removing the unloading boot, the patient stepped freely on the right heel without pain. After 1 month, she began her work.

Claims (2)

1. A method for surgical treatment of proximal plantar fasciosis, including surgical access to the proximal plantar aponeurosis, creating a series of 18-24 holes to a depth of 3 mm to 5 mm at a distance of 5 mm from each other in the form of a mesh and 4-6 notches the medial edge of the plantar aponeurosis using bipolar RF exposure with a TOPAZ needle electrode. 2. The method according to p. 1, characterized in that surgical access to the proximal part of the plantar aponeurosis is performed by a minimum skin incision of about 2.5 cm in length, through the performed incision, a TOPAZ needle electrode is placed in the wound under the control of vision, to the working part of which using the drip mechanism, 0.9% physiological saline is continuously supplied at a rate of 2-3 drops per second, position 4 is set on the controller of the ARTHROCARE ATLAS apparatus, activating the TOPAZ electrode by pressing for 0.5 seconds, perform alternate perforations and a notch on the medial edge of the plantar fascia, the wound suture and the skin is applied antiseptic dressing.

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