Endoscopic plantar fasciotomy, right foot

PREOPERATIVE DIAGNOSIS:  Plantar fasciitis, right foot.

POSTOPERATIVE DIAGNOSIS:  Plantar fasciitis, right foot.

PROCEDURE PERFORMED:  Endoscopic plantar fasciotomy, right foot.

HEMOSTASIS:  Right ankle pneumatic tourniquet.

ESTIMATED BLOOD LOSS:  Less than 5 mL.

ANESTHESIA:  Monitored anesthesia care with 20 mL of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain.

SPECIMENS:  None.

COMPLICATIONS:  None.

INDICATIONS FOR PROCEDURE:  This patient is a pleasant 49-year-old female who presents with persistent right heel pain.  The patient has exhausted conservative efforts, which have included corticosteroid injections to her right heel, accommodative shoe gear including orthotics.  All surgical and nonsurgical treatment options have been explained to the patient in detail, and at this time, the patient is seeking surgical correction.  At this time, all risks, complications, benefits, and alternatives were explained in detail to the patient.  Risks and complications include but are not limited to infection, recurrence of symptoms, pain, numbness, wound dehiscence, delayed healing, as well as need for future surgery.  No guarantees were given or applied.  All questions were answered to the patient’s satisfaction, and the patient has consented to the above procedure.  All preoperative labs and medical clearances have been obtained and NPO status past midnight has been confirmed.

PREPARATION FOR PROCEDURE:     The patient was brought to the operating room and placed on the operating table in supine position.  A pneumatic ankle tourniquet was placed about the patient’s right ankle but not yet inflated.  After the department of anesthesia had administered IV sedation, a local anesthetic block was administered about the patient’s right heel and ankle utilizing a total of 20 mL of a 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain.  The right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was utilized to exsanguinate the patient’s right foot, and the pneumatic ankle tourniquet was inflated to 250 mmHg.

PROCEDURE IN DETAIL:                        At this time, attention was directed to the patient’s medial right heel, where the medial calcaneal tubercle was palpated.  A vertical 1-cm incision was made approximately 2 cm distal from the medial calcaneal tubercle.  The incision was deep into the subcutaneous tissues using blunt dissection.  At this time, a blunt probe was inserted and utilized to identify the boundaries of the plantar fascia.  A positive puckering was noted to the plantar aspect of the patient’s right foot confirming proper placement of the probe.  Next, the obturator and trocar were inserted through this medial incision inferior to the plantar fascia and was transversely directed to the lateral aspect of the heel until tenting of the skin was noted on the lateral aspect.  At this site, a second vertical 1-cm incision was made to allow the exit of the trocar obturator combo.  At this point, the trocar was removed, and three to four Q-tips were run from medial to lateral to remove any fatty deposits or other debris.  The scope was then placed through the obturator from the lateral incision site to visualize the plantar fascia.  Next, the hook blade was placed along the plantar aspect of the patient’s medial heel, where the medial half of the plantar fascia was approximated and appropriately marked.  This hook blade was then inserted medially, and the central and medial band of the plantar fascia were carefully transected.  Under endoscopic evaluation, it was noted that the lateral band of the plantar fascia was intact while the medial and central half of the plantar fascia were appropriately released.  With the obturator in place, once again three to four Q-tips were run from medial to lateral to remove any remnants of fat.  The surgical site was then flushed with copious amounts of normal sterile saline.  The surgical site was also injected with 1% lidocaine with epinephrine.  The medial incision site was approximated and coapted utilizing 3-0 nylon in a horizontal mattress technique.  The lateral incision site was re-approximated and coapted utilizing 3-0 nylon.  The right foot was then dressed with Adaptic overlying the suture sites, 4 x 4 gauze, Kerlix, and Coban.  At this time, the right ankle pneumatic tourniquet was deflated, and a positive hyperemic response was noted to the right foot with the capillary refill time less than 5 seconds to digits 1 through 5.  The patient tolerated the procedure and anesthesia well.  Upon transfer to the recovery room, the patient’s vital signs were stable, and her neurovascular status was intact.  Postoperative prescriptions and instructions were written and given to the patient who will return to the office of Dr. Gregg Harris who will continue to follow up in the care and management of this patient.