Definition
Fasciotomy is a surgical procedure that cuts away the fascia to relieve tension or pressure

 Purpose
The fascia is thin connective tissue covering, or separating, the muscles and internal organs of the body. It varies in thickness, density, elasticity, and composition, and is different from ligaments and tendons.
The fascia can be injured either through constant strain or through trauma. Fasciitis is an inflammation of the fascia.
The most common condition for which fasciotomy is performed is plantar fasciitis, an inflammation of the fascia on the bottom of the foot that is sometimes called a heel spur or stone bruise.
Plantar fasciitis is caused by long periods on the feet, being overweight, and wearing shoes that do not support the foot well. Teachers, mail carriers, runners, and others who make heavy use of their feet are especially likely to suffer from plantar fasciitis.
Plantar fasciitis results in moderate to disabling heel pain . If nine to twelve months of conservative treatment (reducing time on feet, non-steroid anti-inflammatory drugs, arch supports) under the supervision of a doctor does not result in pain relief, a fasciotomy may be done.
Fasciotomy removes a small portion of the fascia to relieve tension and pain. Connective tissue grows back into the cut space left by the cut, effectively lengthening the fascia.
When a fasciotomy is performed on other parts of the body, it is usually done to relieve pressure from a compression injury to a limb.
This type of injury often occurs during contact sports.
The blood vessels of the limb are damaged.
They swell and leak, causing inflammation.
Fluid builds up in the area contained by the fascia.
A fasciotomy is done to relieve this pressure and prevent tissue death.
Similar injury occurs in high voltage electrical burns where deep tissue damage occurs.

marked swelling of the left hand and forearm with a bluish discoloration extending to the elbow. Two large bore intravenous lines were started in the other arm. Tetanus immunization and antibiotics were given. Laboratory values including platelets, coagulation profile, fibrinogen, fibrin split products, blood urea nitrogen and creatinine were all normal. Within two hours (three hours after the bite) the swelling had moved about half way up the patient’s humerus . During this time many different people interviewed the patient because there are no indigenous venomous snakes on Manhattan, but he remained certain about his history.

 Precautions
In the case of injury, fasciotomy is done on an emergency basis, and the outcome of the surgery depends largely on the general health of the patient. Plantar fasciotomies are appropriate for most people whose foot problems cannot be resolved in any other way.
standard protocol for the management of potential compartment syndrome:
Consider consultation with orthopedic surgery or whatever service will be responsible for performing the surgery, if needed.
Measure the compartment pressure.
If it is elevated, immediately administer another 10 vials of antivenom as well as mannitol, 1 g/kg.
If the compartment pressure remains elevated, consider fasciotomy.


 Description
Fasciotomy in the limbs is usually done by a surgeon under general or regional anesthesia. An incision is made in the skin, and a small area of fascia is removed where it will best relieve pressure. Then the incision is closed.
Plantar fasciotomy is an endoscopic (performed with the use of an endoscope) procedure. It is done by a foot specialist in a doctor's office or outpatient surgical clinic under local anesthesia and takes 20 minutes to one hour. The doctor makes two small incisions on either side of the heel. An endoscope is inserted in one to guide the doctor in where to cut. A tiny knife is inserted in the other. A portion of the fascia is cut from near the heel; then the incisions are closed.

 Preparation
Little preparation is done before a fasciotomy. When the fasciotomy is related to burn injuries, the fluid and electrolyte status of the patient are constantly monitored.


 Aftercare
Aftercare depends on the reason for the fasciotomy. People who have endoscopic plantar fasciotomy can walk without pain almost immediately, return to wearing their regular shoes within three to five days, and return to normal activities within three weeks. Most will need to wear arch supports in their shoes.

 Risks
In endoscopic plantar fasciotomy, the greatest risk is that the arch will drop slightly as a result of this surgery, causing other foot problems. Risks involved with other types of fasciotomy are those associated with the administration of anesthesia and the development of blood clots.

 Normal results
Fasciotomy in the limbs reduces pressure, thus reducing tissue death. Endoscopic plantar fasciotomy has a success rate of 90?95%.

indication
 - Compartment Syndromes resulting from Tibial Fractures:
- Anterior Compartment - Lateral Compartment
 - Deep Posterior Compartment:
 - Superfical Posterior

 - Anterolateral Incision: (Two Incision Technique)
 - anterior & lateral compartments are approached thru single longitudinal incision placed halfway down leg 2 cm anterior to fibular shaft, or alternatively placed halfway between the tibial crest and the fibula;
 - incision is therefore placed over anterior intermuscular septum separating anterior & lateral compartments & allowing access to each;
 - in an elective chronic syndrome, a small 4-5 cm incision can be used;
 - in the acute traumatic syndrome, a 15 cm incision is used;
- transverse incision is made over fascia of anterior & lateral compartments, which allows clear view of the intermuscular septum;
 - attempt to identify the superficial peroneal nerve near the septum; - tension is maintained on the fascia w/ a Kocher clamp; - blunt tipped scissors are used to spread above and below the fascia on both sides of the intermuscular septum, both proximally and distally;

- anterior compartment: - after identifying septum, small nick is made in fascia of anterior intermuscular septum midway between the septum & tibial crest; - tension is maintained on the fascia w/ a Kocher clamp; - blunt tipped scissors are used to spread above and below the fascia both proximally and distally; - fascia is opened proximally & distally w/ long, blunt-pointed scissors; - proximally aim for the patella and distally to the center of the ankle inorder to ensure that the fasciotomy stays in anterior compartment; - distally, avoid straying too medially so as too avoid injury to the dorsalis pedis;


 - lateral compartment fasciotomy:
 - made in line w/ fibular shaft;
- distally direct scissors toward lateral malleolus inorder to keep instrument posterior to superficial peroneal nerve;
 - superficial peroneal nerve exits from lateral compartment about 10 cm above lateral malleolus and courses into anterior compartment;
- if tip of scissors has strayed from fascia, instrument is left in place and two centimeter incision is made over its tip & fasciotomy is completed;
 - once the fascia has been partially transected, tension on the fascia will be lost, which means that the scissors cannot re-enage the edge of the fascia in a blind fashion;


 - Posteromedial Incision: (Two Incision Technique)
 - deep and superficial posterior compartments are approached thru a single 15 cm longitudinal incision in distal part of leg 2 cm posterior to posterior medial palpable edge of the tibia;
 - once down to fascia undermine anteriorly to posterior tibial margin, which will avoid saphenous vein and nerve;
 - the saphenous vein should be retracted anteriorly;


 - superficial compartment: - retract saphenous vein & nerve & release fascia over superfical posterior compartment;

- tension is maintained on the fascia w/ a Kocher clamp; - blunt tipped scissors are used to spread above and below the fascia both proximally and distally;


 - deep posterior compartment: - the soleus takes origin from the proximal 1/3 of the tibia and fibula and covers the proximal portion of the deep posterior compartment; - detach soleal bridge and retract it to expose fascia covering FDL & tibialis posterior;

 - note that the FDL lies just posterior to the tibia, and this fascia needs to be released to decompress the compartment;

 - the neurovascular bundle is protected, lying between the tibialis posterior and the soleus;

 - in the distal half of the tibia the deep posterior compartment lies just below the subcutaneous tissue;

 - again, releasing the fascia over the FDL is required to decompress the deep posterior compartment;

 - fascia is opened distally and proximally under the belly of soleus;

 - wounds are left open if swelling is too much to allow for primary skin closure; - skin grafting is rarely needed if full week is allowed for dissipation of edema;

- One Incision Technique:
 - performed thru one long incision over lateral compartment

 - make incision in line w/ fibula extending just distal to head of fibula to 3 to 4 cm proximal to the lateral malleolus;

 - the incision should be either directly over or slightly posterior to the fibula;

- proximally identify the common peroneal nerve; - undermine skin anteriorly & avoid injuring superficial peroneal nerve; - perform longitudinal fasciotomy of anterior and lateral compartments; - undermine skin posteriorly & perform fasciotomy of superfical posterior compartment;

 - define the interval between the soleus and the FHL; - identify interval between superficial & lateral components distally & develop this interval proximally by detaching soleus from fibula; - subperiosteally dissect the flexor hallucis longus from the fibula; - retract the muscle and the peroneal vessels posteriorly;

 - now identify fascial attachment of the tibialis posterior muscle to fibula and incise this fascia longitudinally; - exposure of deep fascia for a short distance anterior & posterior to this incision, followed by transverse incision thru fascia at midpoint, allows easy identification of vertical fascial planes separating compartments; - release each compartment independently w/ longitudinal incision extending the full length of the compartment;

 - after releasing superfical posterior compartment bluntly dissect posterior to lateral compartment & release fascia of deep posterior compartment;

Uniportal Plantar Fasciotomy

Plantar fasciitis is a common problem in the foot that usually causes pain toward the heel, particularly after periods of rest.

The pain is thought to be caused by chronic inflammation of the plantar fascia, a ligament [tight band] that helps support the arch in the foot. When this ligament is inflamed, a heelspur may also develop.

To relieve the pain, your physician may suggest non-surgical therapies such as shoe inserts (orthotics), strappings, and injections. Most patients respond to these treatments, but if the pain is not alleviated, some patients may require surgical treatment.

The goal of surgery is to cut part of the plantar fascia so that the tightness from this ligament (and thus the pain) can be relieved.

Years ago, the common surgical practice included making relatively large incisions and removing the heel spurs. However, these aspects of the procedure caused patients considerable post-operative pain and contributed to a longer recuperative time.

More recently, endoscopic plantar fascia release surgery was developed in order to minimize post-op pain and hasten recovery.

Utilizing these techniques, the surgeon can now cut the plantar fascia with the aid of an endoscope--enabling the surgeon to see deep into the foot through very small incisions.

A.M. Surgical's uniportal plantar facsciotomy technique facilitates this procedure by requiring only one very small incision on the medial aspect (inside) of the foot. This allows the patient to the foot to get back on his or her feet with minimal pain after surgery.
The following illustration shows the type of incision used with our technique.



1.  Position the patient.
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Position the patient in the supine position on the O.R. table.


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2.  Anesthesia.
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Anesthesis is achieved via a posterior nerve block and sural nerve blockade using equal amounts of 2% xylocaine and 0.5% marcaine without epinephrine.


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3.  Make the incision.
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Mark a 1.0 cm incision approximately 1.5 to 2.0 cm superior to the weight bearing surface and 1.5 cm distal to the medial calcaneal tubercle .  Incise the skin using a #15 blade.

making the incision  
Marking the Incision.

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4.  Create a pathway.
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Create a pathway inferior to the plantar fascia using a curved clamp.  Gently introduce the clamp into the incision, hugging the inferior surface of the plantar fascia.  Extend the sub-ligamentous blunt dissection to the lateral aspect of the foot.
Remove the clamp and introduce the cannula/obturator into the same pathway
Keep the tip of the cannula snugly against the inferior aspect of the plantar fascia.

The ligament fibers are usually palpable as the cannula tip scrapes the plantar fascia.
Figure 3.

When the tip of the cannula is palpable through the skin of the lateral foot, remove the obturator, leaving the cannula in place.

scraping of plantar fascia


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5. Identify the plantar fascia.
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Insert the 4mm endoscope into the cannula to visualize the plantar fascia (Figure 4).
Introduce an absorbent swab into the cannula as needed to remove fluid and improve visualization.

If the fibers of the plantar fascia are not clearly defined, pass the rasp through the cannula several times to remove fat and soft tissue adhering to the fascia.


endoscopic view of plantar fascia
use of the rasp


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6.  Use of depth gauge.
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Estimate the approximate measurement required to transect the plantar fascia by using the depth gauge.  Prior to the endoscopic measurement, an approximate measurement may be taken external to the foot by sliding the depth gauge over the endoscope and then gently depressing the locking lever when the tip of the depth guage contacts the endoscope.

Insert the depth gauge into the cannula to the location at which it is desired to transect the plantar fascia (usually inclusive of the medial band; central band transection is optional).
The intermuscular septa are a useful landmark in determining  
the depth of cut



Position the stop device against the cannula and tighten in place


use of the depth gauge


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7.  Use of the knife.
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The measurement from the depth gauge is replicated on the knife using the stop attachment (Figure 7), and the knife is affixed to the scope in the same manner as was the depth gauge.


Introduce the knife into the slotted cannula.  As the knife is passed in a medial-to-lateral direction, the plantar fascia is divided (Figures 8a and 8b).
Dorsiflexing the toes while cutting, as well as pushing against the cannula from below, are two technical maneuvers that will increase the extent of plantar fascia transection (useful with thick fascia).

Visualization of the abductor hallucis and flexor digitorum brevis muscles confirm adequate transection of the plantar fascia. Multiple passes of the knife may be needed to achieve this.  

Warning:  The disposable knife is for one-time-use. Re-sterilization may result in blade detachment and potentially cause harm to the patient.


use of endoscopic knife


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8.  Confirm adequate release.
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Remove the knife is from the endoscope, and re-introduce the endoscope into the cannula to visualize the divided plantar fascia

 A complete division is accomplished when the overlying muscle is seen without any intervening fibers of the plantar fascia.  



If preserved, the interthenar fascia will be visible above the divided edges of the TCL.  After removing the cannula with the obturator, verify the divided edges of the TCL under direct vision using Ragnell retractors.