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; (5) The disease is concomitant with severe systemic diseases, and the patients are unable to tolerate surgery; (6) The heel pain is caused by calcaneus stress fracture, heel fat pad syndrome, achilles tendinitis, lateral plantar nerve compression syndrome, tumor, trauma and infection; (7) The skin around the heel is infected, and the operator cannot be operated normally.
From January 2015 to July 2017, 62 cases (62 feet) were included according to the above inclusion and exclusion criteria. The above patients were randomized according to the random number table (33 cases in the arthroscopy group and 29 cases in the open surgery group). There are no difference in age, body mass index, preoperative VAS, AOFAS, CS [15] and SF–36 scores between the two groups (Table 1). The arthroscopic surgery group was performed by an experienced senior physician; the open surgery group was performed by a senior physician with many-year experience in minimally-invasive treatment of fasciitis. The two doctors were unaware of each other’s research. This study was approved by the institutional review boards of our hospital (ZXYY–2015061). Informed consent and Health Insurance Portability and Accountabilty Act consents were obtained from each patient.
The study was approved by the Hospital Ethics Committee, Informed Consent and Health Insurance Portability and Accountability Act. Consent was obtained from each patient.
Procedures
The patient takes the supine position. The doctors used the middle thigh airbag inflatable tourniquet to stop bleeding. The foot is placed flat on the operating bed, and the affected hip flexes externally, the knee flexes. The cotton can be placed at the bottom of the affected foot if necessary. Make the inner side of the affected foot lie flat on the operating table.
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.