Open technique is more effective than percutaneous technique for TOPAZ radiofrequency coblation for plantar fasciitis

Abstract

Microtenotomy coblation using a radiofrequency (RF) probe is a minimally invasive procedure for treating chronic tendinopathy. It has been described for conditions including tennis elbow and rotator cuff tendinitis. There have been no long term studies to show its effectiveness in plantar fasciitis.
A prospective non-randomised trial was conducted on 48 patients who had failed conservative treatment for plantar fasciitis, between 2007 and 2009. The procedure was performed using the TOPAZ microdebrider device (ArthroCare, Sunnyvale, CA), either via an open or a percutaneous method. Fifty-nine feet were treated and followed up for up to 1 year thereafter. Preoperative, 3, 6 and 12 months post-operative VAS pain, American Orthopaedic Foot-Ankle Society (AOFAS) hindfoot and SF-36 scores, patient expectation and satisfaction scores were analysed.
VAS scores improved significantly in both groups at 1-year follow-up. The open group had a more significant improvement in the VAS score at 1-year follow-up. AOFAS hindfoot scores improve significantly for both groups pre- and post-operatively, but there was no significant difference between both groups at the 1-year mark. SF-36 scores showed equally significant improvement in both groups 1 year post-operatively. Expectation and satisfaction scores were equally high in both arms.
TOPAZ RF coblation is a good and effective method for the treatment of recalcitrant plantar fasciitis. Clinical results improve with time for up to 1-year post-operatively. The open method seems to have a more significant improvement in pain VAS scores at 1-year postoperatively.

Full text

Open
technique
is
more
effective
than
percutaneous
technique
for
TOPAZ
radiofrequency
coblation
for
plantar
fasciitis
Kae
Sian
Tay
MBBS*,
Yung
Chuan
Sean
Ng
MBBS,
MRCS(Edin),
MMed(Orth
Surg),
FRCS(Edin),
Inderjeet
Rikhraj
Singh
MBBS,
FRCS
(Glasg),
FAMS,
Keen
Wai
Chong
MBBS,
MRCS
(Edin),
M
Med
(Ortho),
FRCS
(Edin)(Ortho)
Department
of
Orthopaedic
Surgery,
Singapore
General
Hospital,
Outram
Road,
Singapore
169608,
Singapore
1.
Introduction
Plantar
fasciitis
is
a
common
problem,
afflicting
a
significant
proportion
of
the
population
at
some
point
in
their
life.
It
is
said
to
be
the
most
common
cause
of
heel
pain,
and
various
epidemiologi-
cal
studies
place
its
prevalence
at
10%
in
the
general
population
and
up
to
22%
in
runners
[1–3].
The
disease
has
been
shown
by
Lemont
et
al.,
more
accurately,
to
be
a
‘fasciosis’,
similar
to
tendinosis.
There
is
a
characteristic
lack
of
inflammatory
cells,
an
abundance
of
disorganised
collagen
and
fibroblastic
hypertrophy,
as
well
as
disorganised
vascular
hyper-
plasia
with
avascular
tendon
fascicles
[4].
The
result
is
reduced
nutritional
flow
to
the
affected
tendon,
with
compromised
repair
and
re-modelling
of
extracellular
matrix
required
for
healing.
Most
cases
resolve
with
conservative
therapy,
including
rest,
analgesia,
physiotherapy,
orthotics
and
steroid
injections
[5,6].
For
recalcitrant
cases,
extracorporeal
shockwave
therapy
provides
varying
degrees
of
success
[7–10].
On
the
other
hand,
the
traditional
surgical
release
of
the
plantar
fascia
yields
a
better
success
rate,
but
is
known
to
have
a
number
of
undesirable
effects,
namely
prolonged
surgical
recovery
time,
patient
apprehension,
and
various
surgical
complications
including
arch
instability,
plantar
fascia
rupture
and
excessive
strains
in
surrounding
structures
[11–13].
More
recently,
radiofrequency
microtenotomy,
by
stimulation
of
an
angiogenic
healing
response
in
tendons,
has
been
successfully
used
to
treat
tennis
elbow
and
rotator
cuff
tendinosis
[14,15,32].
Plantar
fasciitis
has
been
shown
to
respond
to
this
treatment
as
well
[33,34].
The
results
of
our
previous
pilot
study
were
also
encouraging,
when
using
this
method
to
treat
plantar
fasciitis
[16].
Furthermore,
Weil
et
al.
have
shown
that
this
technique
can
be
administered
using
a
minimally
invasive
approach
[17].
The
long-
term
outcome
of
this
modality
has
yet
to
be
studied.
The
purpose
of
this
study
is
to
directly
compare
the
open
and
the
percutaneous
(minimally
invasive)
approach
of
radiofrequency
microtenotomy
in
the
treatment
of
plantar
fasciitis,
as
well
as
assess
its
long
term
outcome.
Foot
and
Ankle
Surgery
18
(2012)
287–292
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Received
27
April
2011
Received
in
revised
form
31
March
2012
Accepted
13
May
2012
Keywords:
Plantar
fasciitis
TOPAZ
Radiofrequency
microtenotomy
Percutaneous
Minimally
invasive
A
B
S
T
R
A
C
T
Background:
Microtenotomy
coblation
using
a
radiofrequency
(RF)
probe
is
a
minimally
invasive
procedure
for
treating
chronic
tendinopathy.
It
has
been
described
for
conditions
including
tennis
elbow
and
rotator
cuff
tendinitis.
There
have
been
no
long
term
studies
to
show
its
effectiveness
in
plantar
fasciitis.
Methods:
A
prospective
non-randomised
trial
was
conducted
on
48
patients
who
had
failed
conservative
treatment
for
plantar
fasciitis,
between
2007
and
2009.
The
procedure
was
performed
using
the
TOPAZ
microdebrider
device
(ArthroCare,
Sunnyvale,
CA),
either
via
an
open
or
a
percutaneous
method.
Fifty-
nine
feet
were
treated
and
followed
up
for
up
to
1
year
thereafter.
Preoperative,
3,
6
and
12
months
post-
operative
VAS
pain,
American
Orthopaedic
Foot-Ankle
Society
(AOFAS)
hindfoot
and
SF-36
scores,
patient
expectation
and
satisfaction
scores
were
analysed.
Results:
VAS
scores
improved
significantly
in
both
groups
at
1-year
follow-up.
The
open
group
had
a
more
significant
improvement
in
the
VAS
score
at
1-year
follow-up.
AOFAS
hindfoot
scores
improve
significantly
for
both
groups
pre-
and
post-operatively,
but
there
was
no
significant
difference
between
both
groups
at
the
1-year
mark.
SF-36
scores
showed
equally
significant
improvement
in
both
groups
1
year
post-operatively.
Expectation
and
satisfaction
scores
were
equally
high
in
both
arms.
Conclusions:
TOPAZ
RF
coblation
is
a
good
and
effective
method
for
the
treatment
of
recalcitrant
plantar
fasciitis.
Clinical
results
improve
with
time
for
up
to
1-year
post-operatively.
The
open
method
seems
to
have
a
more
significant
improvement
in
pain
VAS
scores
at
1-year
postoperatively.
ß
2012
European
Foot
and
Ankle
Society.
Published
by
Elsevier
Ltd.
All
rights
reserved.
*
Corresponding
author.
Tel.:
+65
91129240.
E-mail
address:
k_s_tay@hotmail.com
(K.S.
Tay).
Contents
lists
available
at
SciVerse
ScienceDirect
Foot
and
Ankle
Surgery
jou
r
nal
h
o
mep
age:
w
ww.els
evier
.co
m/lo
c
ate/fas
1268-7731/$
–
see
front
matter
ß
2012
European
Foot
and
Ankle
Society.
Published
by
Elsevier
Ltd.
All
rights
reserved.
http://dx.doi.org/10.1016/j.fas.2012.05.001

2.
Methods
2.1.
Patient
selection
This
was
a
prospective
non-randomised
single-centre
study.
Institutional
Review
Board
(IRB)
approval
was
obtained
before
commencement
of
the
study.
A
total
of
48
patients,
aged
20–65,
diagnosed
with
plantar
fasciitis,
were
enrolled
in
the
study.
There
were
18
men
and
30
women.
A
total
of
59
feet
were
treated,
32
right
feet
and
27
left
feet.
Most
patients
presented
with
heel
pain,
resulting
from
repetitive
trauma
to
the
plantar
fascia,
usually
from
an
activity
related
to
work
or
sports.
Study
criteria
included
patients
being
symptomatic
for
at
least
6
months,
and
have
undergone
extensive
and
failed
conservative
therapy,
including
rest,
stretching,
strengthening
exercises,
non-steroidal
anti-inflammatories
and
steroidal
injections.
Patients’
feet
were
checked
to
exclude
any
biomechanical
abnormalities
such
as
excessive
pronation,
pes
cavus
or
a
hypermobile
first
ray.
Footwear
were
also
checked
to
ensure
that
they
fitted
well,
were
suitable
for
the
patients
and
were
not
a
cause
for
the
symptoms.
Other
exclusion
criteria
included
patients
who
have
a
body
mass
index
(BMI)
of
>35,
leg
length
discrepancies,
diabetes
mellitus,
confirmed
or
suspected
pregnancy,
coagulopathy,
infec-
tion,
tumour,
peripheral
vascular
disease,
autoimmune
disease
or
other
systemic
disease,
or
had
prior
surgery
to
the
same
plantar
fascia.
Patients
who
were
undergoing
litigation,
receiving
care
under
the
Workman’s
Compensation,
or
participating
in
another
related
study,
were
excluded.
After
undergoing
a
thorough
pre-operative
assessment,
all
the
patients
underwent
an
outpatient
RF-microtenotomy
procedure
on
the
plantar
fascia
for
the
treatment
of
plantar
fasciitis.
All
surgeries
were
carried
out
by
the
senior
orthopaedic
surgeons.
The
decision
to
use
the
open
method
or
the
percutaneous
method
was
based
on
both
surgeon
and
patient
preference.
This
preference
was
influenced
by
cost
of
procedure
(percutaneous
more
expensive)
versus
potential
benefits
(percutaneous
has
potentially
faster
recovery
time).
The
surgeons
were
comfortable
with
both
techniques
used.
Patients
were
discharged
on
the
same
day,
and
were
followed
up
in
the
clinic.
Data
collection
and
analysis
were
carried
out
by
an
independent
medical
physiother-
apist.
Baseline
radiography,
including
the
occasional
magnetic
resonance
imaging
(MRI)
was
done
to
exclude
any
other
pathological
conditions.
Due
to
the
cost
of
MRI,
it
was
only
performed
for
cases
where
significant
doubt
existed
regarding
the
diagnosis
(e.g.
atypical
symptoms).
2.2.
Clinical
outcomes
The
patients
were
assessed
via
several
modalities.
These
included
the
AOFAS
Ankle–Hindfoot
Scale
for
function
and
the
SF-36
questionnaire
for
the
quality
of
life.
Pre-operative
assess-
ment
was
done,
and
followed
up
at
3,
6,
and
12
months.
The
American
Orthopaedic
Foot-Ankle
Society
(AOFAS)
Ankle–Hindfoot
score
is
a
functional
score
assessing
the
patient’s
symptoms.
It
is
divided
into
pain,
function,
range
of
motion
and
alignment.
100
is
the
best
score,
and
0
is
the
worst
possible.
The
SF-36
questionnaire
consists
of
8
categories,
and
is
a
patient-based
health
status
assessment
survey
designed
to
assess
the
impact
of
medical
problems
across
a
broad
spectrum
of
disease
states
on
an
individual’s
general
sense
of
well-being
and
quality
of
life.
Categories
include
physical
functioning,
role
functioning,
bodily
pain,
general
health,
vitality,
social
functioning,
emotional
functioning
and
mental
health
state.
2.3.
TOPAZ
microtenotomy
machine
The
TOPAZ
microdebrider
device
(ArthroCare,
Sunnyvale,
CA),
connected
to
a
System
2000
generator
set
at
setting
4
(175V-RMS),
was
used
to
perform
the
RF-based
microtenotomy.
The
device
works
by
using
a
controlled
plasma-mediated
RF-based
process
(coblation).
The
RF
energy
is
used
to
excite
the
electrolytes
in
a
conductive
medium,
such
as
an
electrolyte
(saline)
solution,
to
generate
excited
radicals
within
precisely
focused
plasma.
The
energised
particles
in
the
plasma
thus
generate
sufficient
energy
to
break
up
covalent
molecular
bonds,
resulting
in
the
ablation
of
soft
tissues
at
relatively
low
temperatures
(typically
40–70
8C)
[18,19].
The
tip
of
the
TOPAZ
device
is
about
0.8
mm
in
diameter
and
has
a
surface
area
of
0.502
mm
2
.
The
tip
is
placed
on
the
plantar
fascia
that
has
been
exposed
following
an
incision
on
the
plantar
surface
of
the
foot.
Using
a
light
touch,
the
surgeon
activates
the
device
(at
setting
4),
for
500
ms,
and
microdebridements
were
performed
in
a
grid-like
pattern
at
5
mm
intervals,
to
a
depth
of
3–5
mm
within
the
fascia.
Having
the
microdebridements
too
close
to
each
other
would
increase
the
risk
of
rupture
as
more
fascia
than
necessary
is
ablated.
Assuming
that
the
mean
depth
of
each
microdebridement
is
4
mm,
each
perforation
would
remove
about
2
mm
3
of
tissue.
A
typical
plantar
fascia
microtenotomy
procedure
would
consist
of
10–20
microdebridements
(removing
20–40
mm
3
of
tissue),
depending
on
the
patient.
2.4.
Surgical
procedure
2.4.1.
Open
microtenotomy
Patients
were
put
under
general
anaesthesia
after
proper
supine
positioning.
A
tourniquet
was
inflated
over
the
affected
limb
to
the
appropriate
pressure
whilst
the
procedure
was
carried
out.
A
longitudinal
incision
of
about
3
cm
was
made
over
the
most
tender
part
of
the
foot
taking
care
to
avoid
the
weight
bearing
part
of
the
sole,
and
the
tissues
dissected
down
to
the
affected
plantar
fascia
(see
Fig.
1).
After
initiating
sterile
isotonic
saline
flow
of
1
drop
every
1–2
s
from
a
line
connected
to
the
RF
system,
the
TOPAZ
tip
was
placed
onto
the
fascia
and
the
microdebridements
carried
out
in
a
grid-
like
pattern
on
and
throughout
the
symptomatic
fascia
area
as
described
above.
After
debridement,
the
wound
was
irrigated
with
copious
amounts
of
normal
saline
solution
and
closed
in
layers
with
interrupted
Vicryl
suture
and
Prolene
to
the
skin.
A
local
anaesthetic
was
injected
into
the
skin
and
subcutaneous
tissues
around
the
wound,
and
standard
wound
dressings
were
applied.
Patients
were
allowed
to
weight
bear
fully
as
tolerated.
No
patient
required
any
orthotic
protection.
Fig.
1.
TOPAZ
scar
on
sole
of
foot.
K.S.
Tay
et
al.
/
Foot
and
Ankle
Surgery
18
(2012)
287–292
288

2.4.2.
Percutaneous
microtenotomy
The
most
tender
part
of
the
sole
was
marked
out
prior
to
anaesthetic
induction.
The
patients
were
then
put
under
general
anaesthesia
after
proper
supine
positioning,
and
the
tourniquet
was
inflated
to
an
appropriate
pressure.
A
2
mm
K-wire
was
used
to
puncture
the
skin
over
the
affected
area
in
a
grid-like
pattern,
spread
about
5
mm
apart
(see
Fig.
2).
The
TOPAZ
tip
was
then
inserted
through
the
puncture
wound,
and
activated
to
allow
the
RF
microtenotomy
to
take
place.
The
depth
of
insertion
of
the
TOPAZ
tip
was
estimated
so
as
to
achieve
an
alternate
3
mm
and
5
mm
depth
spaced
at
5
mm
intervals
apart
(corresponding
to
puncture
holes).
Wash
and
closure
of
the
wounds
were
standardised
as
in
the
open
technique
above.
2.5.
Statistical
analysis
Normally
distributed
data
were
described
using
standard
parametric
statistics.
Statistical
evaluation
of
scores
was
calculated
using
95%
confidence
intervals
and
parametric
paired
t-tests.
SPSS
for
Windows
was
the
software
used
in
this
study.
A
p
value
of
0.05
or
less
was
considered
statistically
significant.
3.
Results
The
procedures
were
performed
on
a
total
of
59
feet,
with
a
mean
age
of
43
years
(range
20.2–65.1
years).
There
were
38
female
feet
and
21
male
feet.
The
open
approach
was
taken
in
32
feet
and
the
percutaneous
approach
in
27
feet.
There
were
40
feet
at
3
months’
follow-up,
45
feet
at
6
months’,
and
21
feet
at
the
12-month
follow-up
visit.
3.1.
Analysis
as
a
single
group
Prior
to
the
procedure,
the
mean
VAS
score
was
7.0.
This
improved
to
3.38,
3.19
and
finally
1.94
at
3,
6
and
12
months’
follow-up
respectively.
This
was
a
statistically
significant
im-
provement
(p
<
0.001).
The
AOFAS
hindfoot
scores
also
demonstrated
significant
increases,
from
an
average
of
43.1
pre-operatively
to
68.6,
74.6,
and
80.1
at
3,
6,
and
12
months’
follow-up
respectively
(p
<
0.001)
(Fig.
3).
The
SF-36
scores
showed
significant
improvements
as
well,
in
several
aspects,
namely
physical
functioning,
role
functioning
(physical),
bodily
pain,
and
social
functioning.
Physical
functioning
scores
improved
from
a
pre-operative
mean
of
54.1
to
75.3
over
1
year
follow-up
(p
=
0.037).
Role
functioning
scores
increased
from
25.0
to
68.8
over
the
same
time
period
(p
=
0.009).
Bodily
pain
scores
increased
from
28.3
to
53.4
(p
<
0.001).
Social
functioning
scores
increased
from
50.8
pre-operatively
to
86.7
at
1
year
follow-
up
(p
=
0.009)
(Fig.
4).
Patient
satisfaction
was
reported
on
a
scale
of
1–6,
with
1
being
excellent
and
6
being
terrible.
The
mean
score
at
1
year
follow-up
was
3.06,
approximately
corresponding
to
‘good’.
14
out
of
21
patients
(66.7%)
reported
‘good’
to
‘excellent’
satisfaction
with
the
results
of
the
procedure
at
this
time.
On
a
scale
of
1–7,
measuring
meeting
of
expectations,
1
represented
‘yes,
expectations
totally
met’,
and
7
represented
‘no,
not
at
all’.
The
average
score
at
1
year
follow-up
was
2.90,
with
15
0
1
2
3
4
5
6
7
8
9
10
1 YEAR6MTH3MTHPREOP
VAS SCORE
0
20
40
60
80
100
AOFAS SCORE
VISUAL
ANALOGUE
SCALE
(VAS)
AOFAS
HINDFOOT
SCORE
Fig.
3.
VAS
pain
score/AOFAS
hindfoot
scores
over
follow-up
period.
Fig.
2.
Minimally
invasive
TOPAZ
marking.
SF36 SCORES FOR PLANTAR FASCIITIS SURGERY
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
PHYSICAL
FUNCTIONING
ROLE
FUNCTIONING -
PHYSICAL
GENERALBODILY PAIN
HEALTH
SOCIALVITALITY
FUNCTIONING
ROLE
FUNCTIONING -
EMOTIONAL
MENTAL HEALTH
PREOP
3MTH
6MTH
1 YEAR
Fig.
4.
SF-36
scores
over
follow-up
period.
K.S.
Tay
et
al.
/
Foot
and
Ankle
Surgery
18
(2012)
287–292
289

out
of
21
patients
(71.4%)
reporting
that
their
expectations,
at
least
more
or
less,
had
been
met.
3.2.
Analysis
of
open
versus
percutaneous
approach
There
were
32
feet
treated
with
the
open
approach
and
27
feet
treated
with
the
percutaneous
approach.
Although
not
random-
ised,
the
two
groups
were
demographically
and
clinically
comparable
pre-operatively.
19
out
of
32
feet
(59.4%)
in
the
open
group
were
female,
whilst
19
out
of
27
feet
(70.4%)
in
the
percutaneous
group
were
female
(p
=
0.245).
The
average
age
in
the
open
group
was
43.8
years,
whilst
that
in
the
percutaneous
group
was
42.0
years
(p
=
0.559).
The
mean
pre-operative
VAS
score
for
pain
was
7.56
in
the
open
group
compared
to
7.48
in
the
percutaneous
group
(p
=
0.858),
AOFAS
hindfoot
score
was
41.5
in
the
open
group
and
42.2
in
the
percutaneous
group
(p
=
0.850),
and
all
components
of
SF36
showed
non-significant
differences
between
the
two
groups,
with
the
exception
of
mental
health.
The
average
SF36
mental
health
score
was
74.25
in
the
open
group
and
84.0
in
the
percutaneous
group
(p
=
0.028).
At
3
months
post-procedure,
there
was
no
significant
difference
in
VAS
scores
and
AOFAS
hindfoot
scores
between
both
groups.
There
was,
however,
a
significant
difference
in
the
bodily
pain
component
of
SF36.
The
open
group
had
a
mean
score
of
59.2
whilst
the
percutaneous
group
had
a
mean
score
of
44.2
in
this
category
(p
=
0.017).
The
other
components
of
SF36
did
not
demonstrate
any
significant
differences.
At
6
months
post-procedure,
there
was
again
no
demonstrable
significant
difference
between
the
two
groups
in
terms
of
VAS
scores
and
AOFAS
hindfoot
scores.
Three
components
of
the
SF36
showed
significant
differences:
vitality,
role
functioning
(emo-
tional)
and
mental
health.
The
mean
score
for
vitality
was
56.5
in
the
open
group
and
72.0
in
the
percutaneous
group
(p
=
0.007),
the
mean
score
for
role
functioning
(emotional)
was
75.6
in
the
open
group
and
100.0
in
the
percutaneous
group
(p
=
0.006),
and
the
mean
score
for
mental
health
was
74.9
in
the
open
group
and
84.4
in
the
percutaneous
group
(p
=
0.049).
At
12
months
post-procedure,
the
open
group
had
a
signifi-
cantly
lower
mean
VAS
score
of
0.78
compared
to
3.00
in
the
percutaneous
group
(p
=
0.035)
(Fig.
5).
The
open
group
had
a
higher
AOFAS
hindfoot
score
of
87.0
as
well,
versus
74.9
in
the
percutaneous
group,
but
this
did
not
reach
statistical
significance
(p
=
0.159)
(Fig.
6).
There
were
no
significant
differences
in
all
components
of
SF36.
At
this
point,
the
open
group
had
better
scores
for
patient
satisfaction
(2.56)
and
meeting
expectations
(2.67)
compared
to
the
percutaneous
group
(3.17
and
3.83
respectively);
however
this
was
not
statistically
significant
either.
Throughout
the
follow-up,
there
were
no
side-effects
or
adverse
events
from
the
procedure.
In
particular,
there
were
no
complica-
tions
of
plantar
fascial
rupture,
wound
infection
or
neurological
deficits.
4.
Discussion
It
is
well
documented
that
plantar
fasciitis
largely
resolves
with
conservative
therapy,
yet
there
remains
a
significant
minority
of
patients
for
whom
this
is
insufficient.
Our
study
focuses
on
this
group
of
patients.
Conventional
surgery
for
these
patients
would
involve
partial
plantar
fascial
release,
resection
or
debridement
of
the
affected
part
of
the
plantar
fascia.
Multiple
studies
have
placed
success
rates
for
surgical
intervention
between
70%
and
90%
[35–43].
Unfortunately,
as
stated
previously,
there
are
multiple
drawbacks
with
regards
to
surgery
[11–13].
As
such,
alternative
therapies
have
been
proposed.
Extracorporeal
shockwave
therapy
(ESWT)
was
first
applied
to
the
treatment
of
chronic
tendinoses
in
the
early
1990s
[20].
However,
inconsistent
results
have
plagued
studies
on
ESWT:
randomised
controlled
trials
and
even
systematic
reviews
and
meta-analyses
have
produced
contrasting
conclusions,
with
success
rates
ranging
from
30%
to
80%.
Some
trials
have
shown
no
difference
between
ESWT
and
placebo
[8–10,44–49].
Radiofrequency
coblation
was
later
studied
and
found
to
have
properties
making
it
suitable
for
use
in
such
conditions
–
namely
increased
angiogenesis,
reduction
of
inflammatory
responses,
and
increased
expression
of
growth
factors
such
as
VEGF
and
fibroblast
growth
factor
[21–25].
This
would
directly
address
the
patho-
physiology
of
chronic
tendinoses.
Early
studies
on
RF
microtenotomy
in
the
treatment
of
plantar
fasciitis
have
shown
promising
results.
However,
there
have
also
been
concerns
regarding
the
safety
of
this
procedure,
most
significantly
that
of
adjacent
tissue
injury
[26–28].
Other
studies
have
allayed
some
of
these
fears,
with
tissue
damage
shown
to
be
much
less
than
conventional
electrocautery
[29].
Our
results
confirm
that
RF
microtenotomy
is
indeed
effective
in
treating
plantar
fasciitis,
with
an
overall
satisfaction
rate
of
66.7%
and
meeting
expectations
of
71.4%
of
the
patients
at
1
year
follow-up.
Other
clinical
parameters
improved
as
well,
with
significant
improvements
in
both
pain
scores
and
AOFAS
hindfoot
scores.
In
addition,
patients
reported
better
quality
of
life
as
measured
by
the
SF36
questionnaire,
in
several
components.
In
the
group
of
patients
where
conservative
therapy
has
failed,
RF
microtenotomy
may
be
a
useful
alternative
to
surgery
or
ESWT.
Whilst
it
may
not
enjoy
a
similarly
high
success
rate,
it
has
the
advantage
of
less
complications
and
faster
recovery
time
compared
to
surgery.
With
regard
to
ESWT,
the
effectiveness
of
RF
microtenotomy
seems
to
be
comparable.
Although
more
invasive
than
ESWT,
it
can
also
avoid
some
associated
complications
such
as
local
haematomas.
Another
niche
this
technique
could
fill
would
TOTAL AOFAS HINDFOOT SCORES (OPEN VS PERCUTANEOUS)
41.50
68.35 68.64
87.00
42.22
69.25
76.60 74.92
40.00
50.00
60.00
70.00
80.00
90.00
1YR6MTH3MTHPREOP
OPEN
PERCUTANEOUS
Fig.
6.
Comparison
of
AOFAS
hindfoot
scores
(open
versus
percutaneous
technique).
VAS SCORES (OPEN VS PERCUTANEOUS)
7.56
4.05
3.58
0.78
7.48
3.57
3.05 3.00
.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
1YR6MTH3MTHPREOP
OPEN
PERCUTANEOUS
Fig.
5.
Comparison
of
VAS
scores
(open
versus
percutaneous
technique).
K.S.
Tay
et
al.
/
Foot
and
Ankle
Surgery
18
(2012)
287–292
290

be
patients
who
have
failed
conservative
therapy
and
ESWT,
but
do
not
wish
to
undertake
the
risks
involved
with
conventional
surgical
release.
With
regards
to
the
open
technique
versus
the
minimally
invasive
technique,
our
findings
support
the
conclusion
that
the
open
technique
is
superior
in
terms
of
outcome
at
1
year
follow-up,
with
a
significantly
reduced
pain
score
compared
to
the
percutaneous
technique.
We
postulate
that
this
difference
may
be
due
to
the
lack
of
precision
in
the
percutaneous
technique.
In
the
open
technique,
there
is
direct
visualisation
of
the
plantar
fascia
and
thus
application
of
the
RF
probe
directly
onto
the
fascia.
In
contrast,
the
depth
of
placement
of
the
probe
in
the
percutaneous
technique
may
be
affected
by
a
number
of
variables,
including
skin
thickness
and
soft
tissue
swelling
present
at
the
time
of
procedure.
As
such,
the
amount
of
stimulation
received
by
the
fascia
will
be
variable
and
most
likely
less
than
that
provided
by
the
open
technique.
This
may
explain
why,
despite
a
significant
response
in
the
3–6-month
post-procedural
period,
there
is
a
plateauing
of
improvement
in
both
pain
score
and
functional
scoring
up
to
the
1
year
mark.
One
possible
way
to
overcome
this
would
be
imaging
guidance
to
ensure
appropriate
depth
of
placement
of
the
RF
probe.
Ultrasound
guided
RF
ablation
has
been
in
use
for
renal
cell
carcinoma
and
breast
carcinoma
[30,31].
This
would
potentially
reduce
the
risk
of
wound
infection
compared
to
open
surgery,
and
also
reduce
recovery
time
post-operatively.
In
conclusion,
radiofrequency
microtenotomy
is
a
safe
and
effective
procedure
for
the
treatment
of
plantar
fasciitis.
Although
both
the
open
and
percutaneous
methods
achieve
good
patient
satisfaction
and
meet
expectations,
the
open
approach
is
superior
at
1
year
follow-up.
Further
studies
can
be
conducted
with
longer
follow-up
to
determine
recurrence
rates
with
this
treatment,
and
thus
enable
a
firmer
conclusion
to
be
made
on
the
long
term
efficacy
of
the
therapy.
In
addition,
a
similar
trial
with
a
larger
cohort,
controls
and
randomisation
would
provide
more
concrete
and
stronger
evidence
for
our
conclusions.
Conflict
of
interest
statement
None
of
the
authors
have
any
conflicts
of
interest
to
declare.
Acknowledgement
There
were
no
additional
sources
of
funding
and
no
con-
tributors
other
than
the
authors
were
involved
in
this
study.
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